Determinants of Undernutrition and Overweight among Women (19–45 Years): A Cross-sectional Study of Some South Asian Developing Countries

INTRODUCTION

There is a double burden of malnutrition (DBM) in South Asian countries.^1–7 Double burden of malnutrition is defined by WHO as “the coexistence of undernutrition along with overweight, obesity or diet-related non-communicable diseases (NCDs), within individuals, households and populations, and across the life course.”⁶

Being overweight and obese in women, before pregnancy, and during gestation are major risks for maternal outcomes, such as gestational diabetes, hypertension, labor complications, and maternal death, and fetal outcomes, such as childhood obesity, cardiovascular disease, and diabetes.⁸ Undernutrition in pregnant women is directly related to intrauterine growth retardation, resulting in low birth weight in infants.^9,10 When these underweight individuals progress economically, they become increasingly burdened by obesity and hence NCDs.¹¹ Hence, children, whose mothers were undernourished during pregnancy, have an increased risk of stunting, obesity, and NCDs in later life.¹² This concept was described by Wells, in 2018, as the “capacity-load model of NCD risk,” which suggests the development of certain physiological traits during initial life that allow individuals to maintain homeostasis whenever confronted by a metabolic load. These individuals are more prone to NCDs later.^5,6 This shows that along with obesity as a leading risk factor for NCDs, severe malnutrition in the mother, in early life is also related to a higher risk of NCDs in adulthood.⁵

Women carry the burden of producing the next generation. Their undernutrition as well as overnutrition is detrimental to the health of a country’s future. Our study was aimed at finding the DBM in women of Pakistan, Bangladesh, Nepal, and Myanmar, and finding out the sociodemographic factors affecting malnutrition in these low-income countries from South Asia.

MATERIALS AND METHODS

The data were taken from the latest Demographic and Health Survey (DHS) datasets of Pakistan (2017–2018), Bangladesh (2017–2018), Nepal (2022), and Myanmar (2015–2016). All women, who were ever married, aged 15–49, in the selected households, were questioned.

RESULTS

Demographic and Health Survey interviewed about 5,000 women from Pakistan, 20,000 from Bangladesh, 7,000 from Nepal, and 12,000 from Myanmar (Table 1). Out of these women, about 12% from Pakistan, 5% from Bangladesh, and 4% each from Nepal and Myanmar were pregnant during the survey, hence, they were not included in the study.

About 24% of women from Pakistan and Bangladesh, 21% from Nepal, and 27% from Myanmar were older than 40 years of age (Table 1). About 50% of women from Pakistan and Nepal, 65% of women from Bangladesh, and about 71% of women from Myanmar lived in rural areas (Table 1). About 50% of women from Pakistan, whereas only about 17%, 27%, and 12% from Bangladesh, Nepal, and Myanmar, respectively had not gained any formal education (Table 1). About 40% of women were from Pakistan, Bangladesh, and Myanmar, whereas about 50% of women from Nepal were in the “poor” class (Table 1). About 60% of women from Pakistan, 40% of women from Bangladesh, and about 30% of women from Nepal and Myanmar had ≥3 “children ever born” (Table 1). About 67% of women from Pakistan, about 50% of women from Bangladesh, and about 40% of women from Nepal and Myanmar had a BMI ≥ 23 (Table 1). In contrast, about 7.5% of women from Pakistan, 12% from Bangladesh, 14% from Nepal, and 11% from Myanmar had a BMI <18.5 (Table 1).

Multinomial regression analysis showed that increasing age was related to increasing BMI in all four countries (Table 2). Residence in urban areas was associated with an increase in BMI in women of Pakistan and Myanmar, but no effect was found in Bangladesh and Nepal. Body mass index was found to be lower in education categories of lower levels in Nepal, Bangladesh, and Myanmar, but no such association was found in Pakistanis (Table 2). Women from the poor class had the lowest BMI level compared with the rich class in all four countries (Table 2). Body mass index seemed to be higher in women with a higher number of children in Nepal and Myanmar, but no such association was found in Pakistan and Bangladesh (Table 2).

DISCUSSION

According to our study, the median prevalence of underweight was 11.3%, and of overweight and obesity was 46.8% for women from all four countries. The preponderance of underweight was found to be 7.3% in low- and middle-income (LMIC) countries globally, whereas the median for overweight and obesity was 41.7%.¹⁴ In another study, the pooled preponderance of underweight was found to be 22% which was estimated from the studies from India, Pakistan, Afghanistan, and Nepal, and of overweight was 23% which was estimated from Bangladesh, India, Nepal, Pakistan, Bhutan, and Afghanistan.¹ These results were from the studies conducted from 2011 to 2017. It was observed in this study that there was a decline in underweight in these countries over time, with an increase in weight gain.¹ This may have happened because of the socioeconomic development in these countries. However, this increase in weight is due to the utilization of energy-rich foods, and drinks, along with a decrease in physical activity level. Hence, micronutrient deficiencies often co-occur with obesity.¹⁵ The presence of micronutrient deficiencies without an energy-deficit diet is explained as “hidden hunger.”^16,17 Hence, the gain in weight in women in these countries did not reflect “health,” rather it just showed “fat gain.”

Our study showed an increase in BMI with an increase in women’s age in all four countries. This finding is in accordance with the literature. A meta-analysis from studies in South Asia showed that underweight was more prevalent in women of the youngest age-group, that is, 15–19 years. A Nepali study showed undernutrition in the younger age-group and suggested that nutrition programs should target younger women to attend to undernutrition.⁴ At the same time, overweight was higher in women of older age-groups.¹ The highest prevalence of underweight was found among the youngest group, that is, 18–24 years, in National Family Health Survey 2015–2016, India.¹⁸ Probable reasons for this might be food insecurity and fear of obesity.¹⁹ A Bengali study also showed that women in older age-groups were at risk of being overweight.²⁰ Intake of more energy-rich food and having less physical activity might explain overweight and obesity with increasing age. With increasing age there is development of NCDs and an increase in parity.^21,22 On the contrary, there was a decrease in the prevalence of obesity in women in the age-group 40–69 years in a Korean study.⁵

Our study found that about 50% of women from Pakistan and Nepal lived in rural areas, whereas 65% of women from Bangladesh, and about 71% of women from Myanmar lived in rural areas. Our study also found that urban residence was associated with an increase in BMI in women of Pakistan and Myanmar, but no such effect was found in Bangladesh and Nepal. However, a Bengali study showed a preponderance of overweight in urban women.⁴ In studies from South Asia, underweight was found to be more dominant in women from rural areas, while overweight was prevalent in urban women.¹ Indian studies also found an association between rural residence and underweight, and urban residence with obesity.^18,19 The disparity in weight gain between urban and rural women is probably due to the lifestyle of rural women who are involved in many physical activities like agriculture and others.⁴ However, in rural areas, overweight and obesity are limited to individuals from richer socioeconomic status, which might happen due to modifying patterns of diets toward sugary and fatty foods. It is also suggested that in poorer or rural areas large body sizes are considered to be associated with wealth. On the contrary, urban poor individuals have sedentary lifestyles due to technology replacing manual labor and better transport links,²³ and hence urban poor are also inclined toward overweight.

Our study found that about 50% of women from Pakistan had not obtained any formal education, whereas only about 17, 27, and 12% of women from Bangladesh, Nepal, and Myanmar respectively had not gained any formal education. Our study also found that BMI was more in women with higher literacy in Nepal, Bangladesh, and Myanmar, but no such association was found in Pakistani women. Other Bengali studies also showed that literate women had a relatively higher tendency to be overweight.^5,20 Indian studies also found an association between lower education with underweight and higher education associated with being overweight or obese.^18,19 A higher educational level leads women into more sedentary jobs and results in decreased physical activity.^20,21 Also, a higher education level leads to opportunities of higher socioeconomic status for women that might lead to weight gain.^3,21

About 40% of women from Pakistan, Bangladesh, and Myanmar, whereas about 50% of women from Nepal were in the “poor” socioeconomic class. Our study also found that women from the poor socioeconomic class had the lowest BMI level compared with the rich class in all four countries. This finding was in line with the literature. A meta-analysis from South Asia revealed that being underweight was more prevalent among those who were in the lowest wealth status, and being overweight was prevalent in the wealthiest families.¹ Bengali studies also showed that richer women in poorer countries have better food security and a poor physical activity level; hence, they are overweight and obese.^5,20 Underweight is an important issue among the less privileged women in poor countries; however, overweight or obesity levels are prevalent among the richest women. Privileged women in these countries are inclined toward Western food and lifestyle.¹⁴ According to studies from India, poor socioeconomic status might be associated with less food security and more physical work.^18,19 Higher intake of fat and energy-rich foods increases with an increase in income.²⁰ Overweight and obesity were also found to be concentrated among the high socioeconomic class in Iran.²⁴ When a country progresses, the risk of being overweight and obese among the socioeconomically deprived section is expected.¹¹ Interestingly, in Korea, a decrease in obesity prevalence was observed in women with high income levels while an increase was found in other categories.²² This trend was also observed in other countries from the Organization for Economic Cooperation and Development (OECD), such as the USA, Canada, and European countries. This was explained by the fact that wealthier people have access to information and resources that help to maintain a healthy weight, as healthy food and lifestyle are costly.²² Poor food security and poor nutrition were the main issues in Korea right after the Korean War, and with economic development, fast food, Western diets, and obesity became prevalent in Korea. However, rich Korean women were less obese as compared with men. These women were less inclined to obesity because they experienced a strong stigma and social pressure that demanded thinner bodies.²² Obesity could negatively affect job obtainability and economic status in Korean women. This difference in the effect of wealth status on BMI, between developed and developing countries, emphasized the effect of early stages of industrialization and globalization on a population’s nutritional status. After development is achieved, there is a shift in lifestyle toward healthy living, where the rich can keep themselves healthy and physically fit, and the poor thrive on unhealthy diets and empty calories and are overweight and obese.²⁵ Although undernutrition has always been linked with poverty, and food insecurity, while obesity has been linked with prosperity and sedentary behavior; however, these two forms of malnutrition co-occur as stunting and overweight within communities.⁷ Obesogenic environments are inflating while the undernutrition continues, along with an increasing number of people who were undernourished earlier in life and are overweight now.⁷

According to our study, about 60% of Pakistani women have ≥ 3 children. On the contrary, only about 40% of women in Bangladesh, and about 30% of women from Nepal and Myanmar had ≥3 children. Women from Pakistan generally have more BMI than men.²⁶ This may be because Pakistani women often get married in their 20s and are confined to home after marriage. They have a lower physical activity level which can be the main cause of being overweight.²⁶ Our study also found that BMI was higher in women with a higher number of children in Nepal and Myanmar, but no such association was found in Pakistan and Bangladesh. Multiparous women gain weight due to increased food intake and low physical activity.²⁷ The weight gain during pregnancy that often persists for life is also an important cause.^3,21 Although women try to regain their previous weight after childbirth, most of the women fail, hence becoming overweight.²⁸

CONCLUSION

Like other developing countries in the world, the major risk factors for underweight in women were found to be younger age, low educational level, rural residence, poor socioeconomic status, and a lesser number of children. Similarly, risk factors for overweight and obesity seemed to be older age, higher educational level, urban residence, higher socioeconomic status, and a higher number of children.

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