Original Article

Food and Nutrition Bulletin

1-15
ª The Author(s) 2018
Prevalence and Determinants Article reuse guidelines:
sagepub.com/journals-permissions
of Stunting Among Preschool DOI: 10.1177/0379572118794770
journals.sagepub.com/home/fnb

Children and Its Urban–Rural

Disparities in Bangladesh

Raisul Akram, MHE1, Marufa Sultana, MHE, MPH1,

Nausad Ali, MHE1, Nurnabi Sheikh, MHE1,
and Abdur Razzaque Sarker, MHE, MSS1

Abstract
Background: Despite improvements in the reduction of child stunting rates over the last decade,
poor nutritional status still remains a public health concern in Bangladesh, where young children are
the most vulnerable.
Objective: The objective of this study is to capture the prevalence and determinants of childhood
stunting and documenting its urban–rural disparities in the context of Bangladesh.
Methods: The study used data from the Bangladesh Demographic and Health Survey of 2014. A
bivariate analysis was performed to find out the differentials in prevalence of stunting, and multivariate
logistic regression was performed to also assess the association of stunting with potential risk factors.
Results: The overall prevalence of stunting was 36.3% and was significantly higher in rural (38.1%)
areas than urban (31.2%) areas. In all 3 regression models, significantly higher odds were found among
children aged 36 to 47 months compared to 6 to 12 months and among the children from the poorest
households. In rural areas, male children were significantly more likely to be stunted (odds ratio ¼
1.31; 95% confidence interval: 1.12-1.53). Other significant risk factors for childhood stunting were
maternal education and body mass index, children suffering from diarrhea, initial breast-feeding, and
administrative divisions.
Conclusions: Disparities exist among urban and rural areas regarding stunting among the children
younger than 5 in Bangladesh, which need to be reduced. Public health policies and interventions need
to consider the risk factors in urban and rural areas separately.

Keywords
disparities, nutrition, preschool children, stunting, Bangladesh

Introduction
Malnutrition is an emerging global public health
challenge. One in 3 children is diagnosed as being
malnourished in some variant globally, and it is
linked with around 45% of all childhood deaths.1
Furthermore, maternal and child undernutrition
are jointly associated as the underlying cause of
1
International Centre for Diarrhoeal Disease Research,
Bangladesh (icddr,b), Dhaka, Bangladesh
Corresponding Author:
Abdur Razzaque Sarker, Health Economics & Financing
Research, International Centre for Diarrhoeal Disease
Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed
Sharani, Mohakhali, Dhaka 1212, Bangladesh.
Email: arazzaque@icddrb.org
2 Food and Nutrition Bulletin XX(X)
3.5 million deaths, with 35% of the disease bur-
den in children younger than 5 years of age and
comprising 11% of the total global disability-
adjusted life years (DALYs).2 Globally, 1 (25%)
of 4 children experience developmental delays,
resulting in 155 million stunted children.3 The
prevalence of stunting is highest in sub-Saharan
Africa and Asia, which accounts for 90% of all
stunted children, with South Asia being at the
epicenter of the global child stunting crisis.4 The
latest data indicated that 38% of South Asia’s
under-fives are stunted. This prevalence is greater
than sub-Saharan Africa (37%), almost 2 times
higher than the Middle East and Northern Africa
(18%), and more than 3 times higher than East
Asia and the Pacific (12%) or Latin America and
the Caribbean children (11%).5,6 Stunting repre-
sents the failure of linear growth, both physically
and cognitively, due to poor nutrition and infec-
tions both before and after birth.7 Child stunting
is thus a result of long-term chronic insufficien-
cies, as well as consumption of low-quality diet,
in combination with infectious diseases and
socioeconomic problems. In developing coun-
tries, stunting often starts in utero, and its severity
gradually increases until it reaches a plateau at
about 2 years of age, a time period called the
“1000 days.”2,8 Furthermore, stunted children are
generally more vulnerable to infections, particu-
larly diarrheal and respiratory diseases as well as
malaria. Infections enhance malnourishment,
creating a vicious cycle leading to growth short-
comings. 2,9 The functional consequences of
stunting continue in adulthood including reduced
work capacity and, in women, increased risk of
mortality during childbirth and adverse birth
outcomes.10,11
The global prevalence of stunting has
decreased from nearly 40% to 24%, and most of
the progress in the reduction of stunting has been
made in the Southeast Asian region.4 In the line
of progress, Bangladesh has achieved an
improvement in reducing the child stunting rate
in the last decade, but the percentage of stunting
still remains at 36% among children younger than
5 years of age, while 12% of them are severely
stunted.12 However, young children and women
in the prime reproductive ages are the most vul-
nerable to nutritional deficits.12 Nevertheless, the
rate of child stunting is still considered to be of a
“high prevalence” according to the World Health
Organization (WHO).13 In the past few years,
evidence has shown that the rate of stunting had
declined by 5%, thus yielding an annual decrease
of 1.5% in Bangladesh.12 However, the preva-
lence is highly concentrated among the poorer
socioeconomic strata, rural areas, and slum set-
tings, although the etiology of stunting is still
unclear.14 Thus, it is crucial to identify the factors
associated with childhood stunting, so stake-
holders can implement evidence-based policies
to improve nutritional status at the population
level. In order to tackle the malnutrition burden,
international community has set Sustainable
Development Goal (SDG-2.2) to end all forms
of malnutrition by 2030 and made commitments
to reduce childhood stunting by 20 million and to
avoid at least 1.7 million childhood deaths
through the prevention of stunting.3,6 Similarly,
there are effective interventions in developing
countries, such as behavior change interventions,
micronutrient and deworming interventions,
along with complementary and therapeutic feed-
ing interventions15,16 In previous studies, it has
been reported that a number of factors, including
distal factors (mother’s education, wealth quin-
tile, region/division), intermediate factors (envi-
ronmental factors, such as the number of children
in a family, family size, availability of safe water
supply and hygienic toilet, and maternal factors,
including mother’s age at delivery, preceding
birth interval, mother’s body mass index [BMI]),
and proximal factors (birth order, childhood diar-
rhea, and immediate breast-feeding) are associ-
ated with child stunting. 17 Evidence from a
multicounty analysis revealed that a considerable
urban–rural difference exists in determinants and
average child health outcomes throughout the
developing world.18 Thus, it is important to gen-
erate evidence regarding the determining factors
of child health outcomes separately for urban and
rural areas in order to design fundamentally dif-
ferent nutrition policies and interventions that
will optimize the improvement in the nutritional
status of children in the respective settings.
Although there are a number of studies available
in different corners of the world that address the
risk factors associated with child stunting,19-23
Akram et al
there are a limited number of studies in Bangla-
desh that compare the prevalence and risk factors
between urban and rural settings that use nation-
ally representative data. In 2 earlier studies, Rah
et al and Kamal reported the prevalence and
determinants of stunting only among children of
rural areas.21,22 Menon et al showed the socioeco-
nomic differentials in stunting among children
from 0 to 36 months old in 11 selected countries.23
In their study, they reported the prevalence of
stunting in a comparison of the urban and rural
areas within the selected countries, rather than
describing the determinants of stunting. Srinivasan
et al performed decomposition analysis to identify
the covariate effects, using Bangladesh Demo-
graphic and Health Survey (BDHS) 2007 data.
Therefore, we aim to contribute to this area by
utilizing the latest country representative
household-level data set in order to find such dis-
parities. Consequently, the objective of this study
is to capture the influence of the determining fac-
tors of childhood stunting as well as differentiating
the urban and rural areas of Bangladesh.
Methods
Data and Study Design
The study used the cross-sectional data of BDHS,
2014. This is a nationally representative survey
that is a part of the long-standing worldwide
Demographic and Health Survey (DHS) program.
This survey is conducted every 3 years and cap-
tures information covering individual and
household-level, sociodemographic, and health
indicators, and health-care data. A wide range
of information, including background character-
istics such as age, region of residence, place of
residence, education, and household characteris-
tics, was collected through questionnaire-based,
face-to-face interviews, where reproductive-age
women (15-49 years) were interviewed based
on the MEASURE DHS program model. A 2-
stage stratified random sampling technique was
used in this survey. This survey used the sampling
frame provided by the Bangladesh Bureau of Sta-
tistics, which was previously used for Population
and Housing Census 2011 conducted in Bangla-
desh. Details about the sampling technique,
3
survey design, survey instruments, measuring
system, and quality control have been described
elsewhere.24 This survey was conducted from
June 28, 2014, to November 9, 2014, by a trained
and experienced data collection team. A total of
18 000 residential households were surveyed and,
with the 98% response rate, the total of 17 863
interviews were completed among the 15 to 49
age-group in ever-married women.12 Details of
the DHS methodology are also elaborated in the
MEASURE DHS website.24 All DHS data are
publicly accessible and were made available upon
request by MEASURE DHS. Furthermore,
approval was sought from and given by the MEA-
SURE DHS program office to use this data set.
According to the DHS, written informed consent
was obtained from all participants enrolled in the
survey.
Data Management and Analysis
Dependent variable. Data regarding height/length
were obtained for children below 5 years of age.
Height-for-age index was calculated according to
the WHO Multicentre Growth Reference Study
2006 Child Growth Standards, where it is
expressed in standard deviation (SD) units
(z-score) from the median of the reference popu-
lation as recommended by WHO and adopted in
the Bangladesh DHS.12,25 Height-for-age-z-score
(HAZ) < 2SD was defined as stunted. Further-
more, HAZ between 2SD and 3SD was con-
sidered as moderate stunting and HAZ < 3SD as
severe stunting.13
Independent variables. In this current study, inde-
pendent variables were selected based on the pre-
vious studies, where they identified risk factors
associated with childhood stunting.19,22,26 In the
analysis, the child’s age was categorized into 6
groups and maternal age upon delivery into 3
groups. Self-reported maternal educational attain-
ment was used and categorized as “no education,”
“primary,” “secondary,” and “higher”. No educa-
tion refers to not attaining any formal education,
primary is defined as completing grade 5, second-
ary as completing grade 10, and higher is defined
as attaining more than grade 10.12 Birth intervals
were categorized as the length of time between 2
4 Food and Nutrition Bulletin XX(X)
consecutive live births. Maternal nutritional sta-
tus was assessed by BMI, which was defined as a
ratio of weight (kg)/[height (m)]2 and coded as
follows: below 18.5 kg/m2 ¼ thin; 18.5 kg/m2 to
24.9 kg/m2 ¼ normal; and BMI  25.0 kg/m2 ¼
overweight.17 In BDHS, maternal perception of
the size of children at birth (larger than average,
average, and smaller than average) was obtained,
despite the actual birth weight of children. Thus,
the mother’s perceived birth size was used as a
proxy for the child’s birth weight. Improved
drinking water sources included water piped into
dwelling, piped to yard/plot, public tap/standpipe,
tube-well or borehole, protected well, rainwater,
and bottled water. Nonimproved sources included
unprotected well, unprotected spring, tanker
truck/cart with drum, and surface water.
Improved toilet facilities included flush/pour
flush to piped sewer system, flush/pour flush to
septic tank, flush/pour flush to pit latrine, venti-
lated improved pit latrine, pit latrine with slab,
and nonimproved toilet facilities were flush/pour
flush not to sewer/septic tank/pit latrine, pit
latrine without slab/open pit, hanging toilet/hang-
ing latrine, and no facility/bush/field. We utilized
a predetermined wealth index, which was classi-
fied into 5 groups as: “poorest,” “poorer,”
“middle,” “rich,” and “richest”, according to the
earlier study.17,19,20,27 Furthermore, mass media
access, child birth order, breast-feeding initiation
within first hours of birth, and household residing
administrative divisions were also included in the
analysis.
Statistical Analysis
All the outliers and missing observations were
excluded from the analysis. Data were excluded
if the z-score for a child’s height-for-age was
below –6 or above þ6.28 Sampling weight, which
was provided within the database, was used for
weight data during the analysis. Descriptive
bivariate analysis techniques, that is, frequency
distribution, and cross-tabulation, were applied
for measuring the prevalence of stunting in rela-
tion to relevant variables. Bivariate logistic
regression analysis was calculated to assess the
crude association between dependent and inde-
pendent variables. Finally, variables that showed
a significant association in bivariate logistic
regression analysis and other variables of interest,
and which were found to be associated in the
relevant literature, were added into the multivari-
ate logistic regression model to identify the asso-
ciation of independent predictors on stunting.
Three different multivariate logistic regression
models were performed for overall (model I),
urban (model II), and rural (model III) strata to
address the adjusted effects of different predictor
variables of stunting in different areas and
reported as an odds ratio (OR) with a 95% confi-
dence interval (CI). A P value of <.05 was
adopted as the statistically significant level. Diag-
nostic tests were employed in the analysis. Var-
iance inflation factor test was employed to detect
the multicollinearity in the regression model. All
the statistical analysis was performed by using the
statistical package STATA/SE 13 (Stata Corpo-
ration College Station, Texas).
Results
Background Characteristics
The distribution and characteristics of the study
participants are described in Table 1. A higher
percentage of children were from rural areas
(74.2%), and the proportion of male and female
children was 52% (95% CI: 50.8-53.3) and 48%
(95% CI: 46.8-49.2), respectively. These differ-
ences in percentage were statistically significant.
Considering maternal education of the study chil-
dren, 45.8% had secondary education, followed
by primary education (28.1%), whereas only 9%
had higher educational attainment. According to
the BMI scale of mothers, approximately 60% of
mothers were normal (BMI Score: 18.5 kg/m2-
24.9 kg/m2), while approximately 22% of moth-
ers appeared as thin (BMI: less than 18.5 kg/m2)
and 18% were overweight (BMI: more than 25.0
kg/m2). Most of the households consisted of 4 or
more members and had access to safe water
(97.8%) and improved toilet facilities (70%).
Approximately 5.7% of children had diarrheal
episodes in the last 2 weeks preceding the survey,
68% were average in size during birth according
to their parents, and almost half of the children
(53%) were breast-fed within the first hour
Akram et al 5

Table 1. (continued)
Table 1. Characteristics of the Study Population.a
Characteristics of
Characteristics of Sample n (%) 95% CI
Sample n (%) 95% CI
Birth interval
Area of residence < 24 months 507 (12.2) (11.3-13.2)
Urban 1685 (25.8) (24.7-26.8) 24-47 months 1316 (31.6) (30.2-33.0)
Rural 4855 (74.2) (73.2-75.3) 48 months or more 2340 (56.2) (54.7-57.7)
Child-related variables Number of children
Age categories, in 1 2142 (32.8) (31.6-33.9)
months 2 2247 (34.4) (33.2-35.5)
<6 463 (7.09) (6.49-7.73) 3 1190 (18.2) (17.3-19.2)
6-12 873 (13.4) (12.6-14.2) 4 or more 960 (14.7) (13.9-15.6)
13-23 1269 (19.4) (18.5-20.4) Household variables
24-35 1312 (20.1) (19.1-21.1) Family size (members)
36-47 1293 (19.8) (18.8-20.8) Small (<4) 814 (12.5) (11.7-13.3)
48-59 1329 (20.3) (19.4-21.3) Medium (4-6) 3875 (59.2) (58.1-60.4)
Sex Large (>6) 1851 (28.3) (27.2-29.4)
Male 3402 (52.0) (50.8-53.3) Access to safe water
Female 3138 (48.0) (46.8-49.2) Yes 6374 (97.5) (97.0-97.8)
Birth order No 166 (2.54) (2.18-2.95)
1 2365 (36.2) (35.0-37.3) Toilet type
2 2002 (30.6) (29.5-31.7) Improved 4540 (69.9) (68.7-71.0)
3 2172 (33.2) (32.1-34.4) Nonimproved 2000 (30.1) (29.1-31.3)
Had diarrhea (in last Mass media access
2 weeks) Yes 2891 (44.2) (43.0-45.4)
Yes 373 (5.71) (5.2-6.3) No 3648 (55.8) (54.6-57.0)
No 6166 (94.3) (93.7-94.9) Division
Breast-feeding within Rajshahi 674 (10.31) (9.60-11.1)
first hour Barisal 373 (5.70) (5.16-6.29)
Yes 2348 (53.0) (51.5-54.42) Chittagong 1392 (21.3) (20.3-22.3)
No 2086 (47.0) (45.6-48.5) Dhaka 2280 (34.9) (33.7-36.0)
Child size at birthb Khulna 498 (7.61) (6.09-8.28)
Larger than average 494 (12.6) (11.6-13.7) Rangpur 662 (10.1) (9.42-10.88)
Average 2663 (68.0) (66.5-69.4) Sylhet 660 (10.1) (9.39-10.85)
Smaller than 760 (19.4) (18.2-20.7) Wealth quintile
average Poorest 1498 (22.9) (21.9-23.9)
Maternal variables Poorer 1220 (18.7) (17.7-19.6)
Maternal educationc Middle 1276 (19.5) (18.6-20.5)
No education 1120 (17.1) (16.2-18.1) Richer 1298 (19.9) (18.9-20.8)
Primary 1835 (28.1) (27.0-29.2) Richest 1248 (19.1) (18.1-20.1)
Secondary 2993 (45.8) (44.6-47.0) Abbreviations: CI, confidence interval, BMI, body mass index.
Higher 592 (9.06) (8.38-9.78) a
n ¼ study sample (differs for few variables due to missing
Maternal age at data)
delivery b
Child size at birth was obtained by the perception of mothers
< 20 years 1976 (30.2) (29.1-31.4) and used as a proxy of birth weight.
c
20-34 years 4294 (65.7) (64.5-66.8) No education, primary, secondary, and higher education refers
More than 35 269 (4.11) (3.65-4.60) to not attaining any formal education, completing grade 5,
years grade 10, and completing higher than grade 10, respectively.
Maternal BMI
Normal 3926 (60.0) (58.9-61.2) of birth (Table 1). Table 1 shows percentage dis-
Thin 1417 (21.7) (20.7-22.7)
tribution of background characteristics of the
Overweight 1197 (18.3) (17.4-19.3)
study participants.
(continued)
6 Food and Nutrition Bulletin XX(X)

Prevalence of Stunting 9.26 for model I, II, and III, respectively).

Conversely, children aged <6 months had signif-
The overall prevalence of stunting was 36.3%,
icantly lower odds of being stunted compared to
whereas the prevalence was higher in rural areas
the children from the reference group. In models I
(38.1%) than in urban (31.2%). In the overall
and III (overall and rural area), it was found that
stratum, the prevalence of stunting was found to
male children were significantly more likely to be
be higher among the children aged 36 to 47
stunted (OR ¼ 1.21; 95% CI: 1.06-1.39, OR ¼
months of age (45.3%), and a similar situation
1.31; 95% CI: 1.12-1.53 for model I and III,
was also observed in urban and rural areas. This
respectively) than females. However, in urban
age-group was also exposed to severe (HAZ < 3
areas, female children were more likely to be
SD) and moderate (HAZ between 2 SD and 3
stunted, though this was not statistically signifi-
SD) stunting (15% and 30.3% for severe and
cant. Maternal education appeared as a protective
moderate stunting, respectively; Figure 1). No
factor for avoiding childhood stunting. Children
significant difference was observed in the preva-
of illiterate mothers were found to be 2.12 times
lence among male and female children (36.5% vs
(95% CI: 1.49-3.02) more likely to be stunted,
36.1%). It was also observed that the prevalence
compared to higher-educated mothers. Mothers’
of stunting was higher among children whose
BMI was found as a significant factor for the
mothers had no formal education (47%) and were
children to be stunted. The findings revealed that
aged more than 35 (44.5%) years at the time of
children of overweight mothers had a lower risk
delivery. The maternal BMI was significantly
of stunting than mothers with a normal BMI.
associated with the prevalence of stunting in
Findings from the regression model II revealed
urban and rural areas. Prevalence of stunting was
that, in urban areas, a second-born child was
higher among children from thin mothers (BMI <
1.92 times more likely to be stunted than the
18.5 kg/m2) and children from households who
first-born child. However, no such associations
did not have access to safe drinking water and
were found in rural and overall areas. In our
improved sanitation facility. This was also the
study, a significant association was also found
case among the children who were exposed to
between stunted children and childhood diarrheal
diarrheal episodes (46.8%) in the last 15 days
illnesses (OR¼ 1.85; 95% CI: 1.41-2.42). In the
preceding the survey. According to the adminis-
administrative division-wise distribution of pre-
trative divisions, prevalence of stunting was high-
valence, it was shown that Sylhet was the highest
est in the Sylhet regions (50.2%), followed by
risk area for stunting, where children of that divi-
Barisal (40.4%). Children from comparatively
sion were 2.06 times more likely to be stunted
lower economic groups suffered more from stunt-
than those in the Rajshahi division (95% CI:
ing, in terms of prevalence, as it was found that
1.52-2.79; P < .001). Furthermore, stunting was
prevalence of stunting was high among children
also significantly associated with the economic
from the poorest household in all urban (47.4%),
status of the households. Children from the poor-
rural (50.4%), and overall (50.1%) strata. Table 2
est group were 2.34 (95% CI: 1.71-3.2) times
shows prevalence of stunting among under-five
more likely to be stunted when compared to the
children by residence in Bangladesh.
richest households.

Factors Associated With Stunting Urban–Rural Disparities

Risk factors associated with stunting are
described in Table 3. In all the 3 regression mod-
els, children in each of the categories of age 36 to
47 months had significantly higher odds of being
stunted, compared to children 6 to 12 months
(OR ¼ 5.53; 95% CI: 3.81-8.02, OR ¼ 4.0;
95% CI: 1.67-9.58, OR ¼ 6.1; 95% CI: 4.01-
Two different models (model II and III) as shown
in Table 3 showed associations of different fac-
tors of childhood stunting for urban and rural
areas. Findings revealed that there were signifi-
cant gender differences in the prevalence of stunt-
ing in rural areas, but no such differences were
found in urban areas. In rural areas, male children
Akram et al 7

Table 2. Prevalence of Stunting among Under-Five Children by Residence in Bangladesh.

Prevalence of Stunting

Overall Urban Rural

Characteristics of Sample Prevalence (95% CI) Prevalence (95% CI) Prevalence (95% CI)

Age categories, months

<6 12.8 (10.0-16.1) 8.60 (4.84-14.83) 14.4 (11.0-18.6)
6-12 20.3 (17.7-23.1) 21.9 (16.9-28.0) 19.8 (16.9-23.0)
13-23 39.4 (36.7-42.1) 37.7 (32.6-43.1) 39.9 (36.8-43.1)
24-35 41.0 (38.4-43.7) 33.6 (28.8-38.8) 43.6 (40.5-46.8)
36-47 45.3 (42.6-48.1) 35.6 (30.6-40.9) 48.6 (45.5-51.8)
48-59 38.7 (36.1-41.3) 32.7 (27.9-37.9) 40.7 (37.7-43.8)
Sex
Male 36.5 (34.9-38.1) 30.0 (27.1-33.1) 38.8 (36.9-40.7)
Female 36.1 (34.4-37.8) 32.5 (29.4-35.8) 37.3 (35.4-39.3)
Maternal educationa
No education 47.0 (44.0-49.9) 48.6 (42.2-55.1) 46.5 (43.3-49.8)
Primary 45.0 (42.7-47.3) 42.1 (37.3-47.0) 45.8 (43.2-48.4)
Secondary 30.3 (28.7-32.0) 25.8 (22.9-29.1) 31.9 (30.0-33.8)
Higher 19.5 (16.5-22.9) 16.7 (12.8-21.5) 22.1 (17.8-27.1)
Maternal age at delivery
< 20 years 37.2 (35.1-39.4) 31.9 (27.8-36.0) 39.0 (36.6-41.6)
20-34 years 35.4 (34.0-36.8) 30.6 (27.9-33.3) 37.1 (35.4-38.8)
More than 35 years 44.5 (38.6-50.5) 39.2 (27.1-52.8) 45.8 (39.3-52.6)
Maternal BMIa
Normal 37.6 (36.1-39.1) 34.6 (31.5-37.7) 38.5 (36.8-40.2)
Thin 44.6 (42.0-47.2) 42.8 (36.9-48.9) 45.0 (42.1-47.8)
Overweight 22.4 (20.2-24.8) 19.3 (16.1-22.9) 24.6 (21.6-28.0)
Birth interval
< 24 months 46.6 (42.3-50.9) 48.7 (39.9-57.5) 45.9 (41.0-50.9)
24-47 months 43.0 (40.4-45.7) 35.9 (30.3-41.8) 44.5 (42.0-47.9)
48 months or more 35.1 (33.2-37.1) 31.2 (27.6-35.1) 36.4 (34.2-38.7)
Family sizea
Small (<4) 34.4 (31.2-37.8) 31.6 (26.5-37.2) 36.0 (32.0-40.1)
Medium (4-6) 36.8 (35.3-38.4) 32.1 (29.2-35.2) 38.3 (36.6-40.1)
Large (>6) 36.0 (33.8-38.2) 29.2 (25.3-33.4) 38.4 (35.8-41.0)
Number of childrena
1 30.0 (28.1-32.0) 27.0 (23.7-30.6) 31.3 (29.0-33.7)
2 36.0 (34.1-38.1) 29.9 (26.4-33.7) 38.3 (36.0-40.6)
3 38.5 (35.8-41.4) 35.8 (30.3-41.7) 39.4 (36.2-42.6)
4 or more 48.2 (45.0-51.3) 44.9 (37.4-52.5) 48.8 (45.4-52.3)
Access to safe watera
Yes 36.2 (35.0-37.4) 31.3 (29.2-33.6) 37.9 (36.5-39.3)
No 39.8 (32.6-47.4) 22.0 (9.93-42.0) 43.1 (35.1-51.5)
Toilet typea
Improved 32.7 (31.4-34.1) 30.3 (27.9-32.8) 33.8 (32.1-35.4)
Nonimproved 44.5 (42.4-46.8) 34.9 (29.8-40.2) 46.5 (44.1-48.9)
Mass media accessa
Yes 27.2 (25.60-28.9) 27.0 (24.6-29.7) 27.3 (25.2-29.5)
No 43.5 (41.91-45.1) 41.5 (37.1-45.9) 43.8 (42.1-45.6)
Birth ordera
1 31.6 (29.8-33.5) 26.6 (23.5-30.0) 33.7 (31.5-36.0)
2 35.8 (33.7-37.9) 31.0 (27.2-35.0) 37.6 (35.1-40.1)
>¼3 41.9 (39.8-44.0) 38.9 (34.4-43.5) 42.6 (40.3-45.0)

(continued)
8 Food and Nutrition Bulletin XX(X)

Table 2. (continued)
Prevalence of Stunting

Overall Urban Rural

Characteristics of Sample Prevalence (95% CI) Prevalence (95% CI) Prevalence (95% CI)

Had diarrhea (In last 2 weeks)

Yes 46.8 (41.8-51.9) 43.7 (34.1-53.8) 47.9 (42.0-53.8)
No 35.7 (34.5-36.9) 30.4 (28.2-32.8) 37.5 (36.1-38.9)
Breast-feeding within first houra
Yes 37.1 (35.2-39.1) 32.4 (28.5-36.5) 38.5 (36.2-40.7)
No 31.4 (29.5-33.5) 28.5 (25.0-32.2) 32.7 (30.4-35.1)
Child size at birth
Larger than average 22.4 (19.0-26.3) 15.7 (9.98-23.8) 24.4 (20.3-28.9)
Average 31.3 (29.6-33.1) 28.8 (25.6-32.3) 32.2 (30.2-34.3)
Smaller than average 43.3 (39.8-46.8) 38.7 (32.0-45.7) 44.9 (40.8-49.0)
Divisiona
Rajshahi 30.9 (27.6-34.5) 27.6 (20.4-36.1) 31.7 (27.9-35.7)
Barisal 40.5 (35.6-45.5) 36.4 (26.9-47.1) 41.7 (36.1-47.5)
Chittagong 37.5 (35.0-40.1) 31.1 (26.7-35.9) 40.0 (37.0-43.1)
Dhaka 34.2 (32.3-36.2) 30.0 (26.9-33.3) 36.5 (34.1-38.9)
Khulna 27.8 (24.0-31.9) 24.9 (17.9-33.6) 28.7 (24.3-33.4)
Rangpur 36.5 (32.9-40.2) 31.0 (22.0-41.8) 37.3 (33.4-41.3)
Sylhet 50.2 (46.4-54.0) 48.9 (39.1-58.8) 50.5 (46.3-54.6)
Wealth quintilea
Poorest 50.1 (47.6-52.7) 47.4 (38.5-56.5) 50.4 (47.7-53.0)
Poorer 42.6 (39.9-45.4) 38.1 (29.0-48.2) 43.0 (40.2-45.9)
Middle 36.2 (33.6-38.9) 41.7 (35.1-48.6) 35.2 (32.4-38.1)
Richer 31.1 (28.7-33.7) 40.6 (36.2-45.1) 25.9 (23.0-29.0)
Richest 19.0 (16.9-21.2) 10.0 (17.3-22.9) 17.1 (13.9-21.0)
Overalla 36.3 (35.1, 37.5) 31.2 (29.0, 33.5) 38.0 (36.7, 39.4)
a
Significant difference between urban and rural areas.

were more likely to be stunted (P < .001). How-
ever, in urban areas, female children were found
to be at higher risk rather than the male children.
Maternal education was found as a protective fac-
tor for childhood stunting in both urban and rural
areas. Moreover, in urban areas, odds of unedu-
cated mothers were relatively much higher than
rural uneducated mothers. A positive association
between birth order and prevalence of stunting
was found in urban areas, but in rural areas, odd
ratios of different birth order were similar. The
prevalence of child stunting was higher in both
urban and rural areas of the Sylhet division com-
pared to Rajshahi division. This association was
found to be significant in rural areas, but no sig-
nificant associations were found in urban areas.
In both the urban and rural areas, the poorest
children were more at risk of being stunted.
Moreover, the odds of being stunted was com-
paratively higher for children of poorest house-
hold in rural areas (OR ¼ 2.11; 95% CI: 1.10-4.07
vs OR ¼ 3.19; 95% CI: 2.06-4.96). Table 3 shows
multiple logistic regression analysis of associated
factors for prevalence of stunting among under-
five children in Bangladesh.
Discussion
Despite greater successes accomplished by Ban-
gladesh in reducing all forms of malnutrition, our
study observed that the overall prevalence of
stunting was still 36.3%. According to the cutoff
values for public health significance by WHO,
this prevalence rate lies in the high-prevalence
category (30%-39%).13 We found that the preva-
lence of stunting was higher among rural children
Akram et al 9

Table 3. Multiple Logistic Regression Analysis of Associated Factors for Prevalence of Stunting Among Under-
Five Children in Bangladesh.a

Model I Model II Model III

Characteristics Overall AOR (95% CI) Urban AOR (95% CI) Rural AOR (95% CI)

Age categories, months

<6 0.56b (0.4-0.77) 0.32c (0.15-0.66) 0.63d (0.43-0.91)
6-12 (Ref) 1 1 1
13-23 2.7b (2.2-3.33) 2.59b (1.69-3.97) 2.84b (2.23-3.62
24-35 3.01b (2.44-3.71) 2.03b (1.32-3.12) 3.54b (2.78-4.52)
36-47 5.53b (3.81-8.02) 4.0c (1.67-9.58) 6.10b (4.01-9.26)
48-59 2.59b (1.84-3.65) 2.72c (1.26-5.85) 2.60b (1.76-3.84)
Sex
Male 1.21c (1.06-1.38) 0.95 (0.72-1.27) 1.31b (1.12-1.53)
Female (Ref) 1 1 1
Maternal education
No education 2.12b (1.49-3.02) 3.22b (1.71-6.06) 1.56d (1.00-2.44)
Primary 1.92b (1.38-2.65) 2.74b (1.55-4.85) 1.47 (0.97-2.23)
Secondary 1.35d (1.00-1.83) 1.55 (0.93-2.59) 1.14 (0.78-1.69)
Higher (Ref) 1 1 1
Maternal age at delivery
< 20 years 1.03 (0.68-1.54) 0.56 (0.22-1.43) 1.16 (0.73-1.85)
20-34 years 0.77 (0.54-1.10) 0.48 (0.20-1.12) 0.84 (0.57-1.25)
More than 35 years 1 1 1
Maternal BMI
Normal (Ref) 1 1 1
Thin 1.10 (0.94-1.29) 1.30 (0.90-1.88) 1.07 (0.90-1.28)
Overweight 0.59b (0.48-0.74) 0.52b (0.35-0.76) 0.62b (0.47-0.82)
Number of children
1 (Ref) 1 1 1
2 1.12 (0.84-1.50) 0.71 (0.38-1.33) 1.32 (0.94-1.85)
3 0.91 (0.58-1.43) 0.67 (0.24-1.85) 1.02 (0.62-1.71)
4 or more 0.97 (0.58-1.62) 0.59 (0.18-1.88) 1.17 (0.65-2.10)
Access to safe water
Yes (Ref) 1 1 1
No 0.86 (0.55-1.33) 1.04 (0.31-3.53) 0.82 (0.51-1.32)
Toilet type
Improved (Ref) 1 1 1
Nonimproved 1.08 (0.92-1.27) 0.88 (0.61-1.27) 1.14 (0.95-1.36)
Mass media access
Yes (Ref) 1 1 1
No 1.00 (0.83-1.21) 1.10 (0.76-1.59) 0.97 (0.77-1.21)
Birth order
1 (Ref) 1 1 1
2 1.24 (0.93-1.67) 1.92d (1.01-3.65) 1.08 (0.77-1.52)
3 1.24 (0.80-1.93) 2.17 (0.78-6.01) 1.08 (0.66-1.77)
Had diarrhea (In last 2 weeks)
Yes 1.85b (1.41-2.42) 1.75d (1.04-2.95) 1.87b (1.36-2.57)
No (Ref) 1 1 1
Breast-feeding within first hour
Yes (Ref) 1 1 1
No 0.87d (0.76-1.00) 0.98 (0.73-1.30) 0.83d (0.71-0.97)

(continued)
10 Food and Nutrition Bulletin XX(X)

Table 3. (continued)
Model I Model II Model III

Characteristics Overall AOR (95% CI) Urban AOR (95% CI) Rural AOR (95% CI)

Division
Rajshahi (Ref) 1 1 1
Barisal 1.54d (1.08-2.19) 1.51 (0.67-3.42) 1.54d (1.03-2.29)
Chittagong 1.43c (1.10-1.87) 1.21 (0.64-2.30) 1.50c (1.11-2.03)
Dhaka 1.27 (0.99-1.65) 1.53 (0.83-2.82) 1.18 (0.89-1.57)
Khulna 1.17 (0.83-1.64) 1.21 (0.57-2.61) 1.13 (0.77-1.66)
Rangpur 1.43d (1.05-1.94) 1.14 (0.49-2.63) 1.47d (1.05-2.06)
Sylhet 2.06b (1.52-2.79) 1.63 (0.74-3.60) 2.21b (1.58-3.08)
Wealth quintile
Poorest 2.34b (1.71-3.20) 2.11d (1.10-4.07) 3.19b (2.06-4.96)
Poorer 1.92b (1.42-2.59) 1.43 (0.76-2.70) 2.61b (1.71-3.98)
Middle 1.93b (1.48-2.51) 1.82d (1.11-2.98) 2.42b (1.65-3.55)
Richer 1.42c (1.11-1.82) 1.97b (1.36-2.84) 1.35 (0.92-1.98)
Richest (Ref) 1 1 1
Constant 0.06b (0.04-0.11) 0.12b (0.04-0.38) 0.05b (0.02-0.09)
Mean VIF 3.95 3.73 4.31
LR w2 655.37 197.08 515.79
Pseudo R2 0.12 0.143 0.12
Prob > w2 0.000 0.000 0.000

Abbreviations: AOR, adjusted odds ratios; BMI, body mass index; CI, confidence interval; LR, likelihood ratio; VIF, variance
inflation factor.
a
Model I, II, and III shows the effects of variables of childhood stunting in overall, urban, and rural stratum, respectively.
b
P < .001.
c
P < .01.
d
P < .05.

when compared to urban children, a phenomenon
that has been frequently observed in other devel-
oping countries.19,23,29-31 This can be explained
by the fact that lower education, poor socioeco-
nomic status, scarcity of potable water supply,
prevalence of infectious disease, and poor nutri-
tional knowledge persist more in rural areas than
in urban ones.32 Furthermore, the knowledge on
infant and young child feeding practices was also
poor among rural mothers.33 Moreover, the rapid
urbanization and high poverty had an effect on
malnutrition.34 The prevalence of stunting in
Bangladesh is similar to its neighboring coun-
tries: 27.5% in Bhutan,35 28.4% in Indonesia,36
35% in Pakistan,37 and 43% in Nepal.38 Our study
found that a higher prevalence of stunting pre-
vailed among children aged 36 to 47 months,
which is commonly observed in different set-
tings.22,38,39 The high rate of stunting among this
age-group (Figure 1) was linked to inappropriate
food supplementation that was provided to the
child during the complementary feeding period
(6 to 24 months).32 During this time period, breast
milk alone is no longer sufficient in meeting the
nutritional needs of child, and due to insufficient
nutritional intake, malnutrition begins as is
reflected at later stages.40 Our findings demon-
strated that the sex of children was a significant
factor for childhood stunting. These findings
were confirmed by other studies, where they also
found that male children were significantly more
likely to suffer from stunting.17,22,41 The reason
for this gender divergence is not well established,
but it is believed that boys are more influenced by
environmental stress than girls.42 Our study also
demonstrated that maternal education was a sig-
nificant positive factor for controlling childhood
stunting, and a child from a higher-educated
mother suffers less, and findings are in line with
other studies.19,29,31 Mothers are the primary
caregiver of the children, and their education and
knowledge are expected to have a stronger effect
Akram et al
Figure 1. Age-specific severe and moderate stunting.
on protective child-caring behaviors, which
would lead to the child’s improved health.43 Mass
media exposure is an important source of knowl-
edge for avoiding malnutrition, as it provides var-
ious health awareness–related programs. In our
study, access to mass media was found to be
associated with childhood stunting in the bivari-
ate analysis. However, no significant association
was found in multivariate analysis. Like other
studies, we found that the maternal higher BMI
displayed a significance in being a protective pre-
dictor for childhood stunting.44,45 We further
observed that a child with a higher birth order
had a significantly higher risk of stunting. This
can be explained by the fact that extra care and
food supply are required for larger size of house-
holds, which lead to a higher consumption of
resources and could thus lead to stunting.46
A bidirectional relationship between diarrhea
and malnutrition has been observed in various
studies.38,47 Our study observed that there was a
positive association between stunting and child-
hood diarrhea.47 However, such relations were
not always observed. A study in Nepal found that
diarrheal disease occurring in the last 2 weeks
was not associated with childhood stunting.38 In
addition, a negative relation was also observed
11
between immediate breast-feeding and childhood
stunting. Our result showed that children who
were not immediately breast-fed were less likely
to be stunted, as exclusive breast-feeding was a
factor for child stunting. 29,31 This might be
because breast-feeding was considered as a sub-
stitute for supplemental feeding up to a certain
age of the child, and thus many of the children
were not fed other nutritious foods in sufficient
amounts, resulting in malnutrition and stunting.48
Furthermore, regional heterogeneity in the
prevalence of child stunting was observed in our
study, where more prevalence of stunting was
found among children living in the Sylhet divi-
sion when compared to other regions. The Sylhet
division is known as a poor-performing region
among most of the health indicators.49 Although
the Sylhet division receives a large flow of for-
eign currency, people were seen to be investing
more in land purchasing and housing rather than
in health, education, and the consumption of
foods, which might underpin such findings.49
Children from the poorest households frequently
suffered from stunting, and the odds of suffering
from childhood stunting declines consistently as
the wealth index increases.17,19,20,31 This might
be due to the fact that lower economic people
12
could afford less to receive proper nutrition and
might sometimes have to lower calories intake
from the minimum daily requirement. On the
contrary, higher socioeconomic positions are
likely to represent better living conditions with
higher affordability, which again contributes to
better child care and improved feeding practices.
This leads to a decline in the occurrence of dif-
ferent forms of malnutrition.50
The study had several limitations. First, this
study was based on cross-sectional data, which
failed to establish a casual relationship. Second,
due to the unavailability of data on potential
confounders including childcare practices, food
taboos, management of illness, and smoking
behavior of the parents, these were not included
in the analysis. The definition of urban and rural
areas in Bangladesh has changed over time with
a rapid growth in urbanization. As a result, some
areas that were earlier classified as rural in the
previous Bangladesh DHSs were considered
urban in the more recent BDHSs, which may
lead to emerging discrepancies in urban–rural
calculations.
Our study revealed that a prevalence of stunt-
ing was higher in rural areas and among children
aged between 36 and 47 months. A number of
factors, such as age, sex, maternal education,
mothers’ BMI, administrative divisions, and
socioeconomic status, are significantly associated
with childhood stunting. This study will help
inform the efforts of future and ongoing activities
related to nutritional promotion that can serve as a
platform to prevent childhood stunting in Bangla-
desh. However, special focus and care are neces-
sary for rural areas in order to improve the overall
performance of the health, nutrition, and popula-
tion sector. This is particularly so if it is to reach
the targets set by SDG 2 of zero hunger and the
end of all forms of malnutrition. The policy
should focus on nutrition-specific interventions,
in particular such as dietary supplementation,
optimal feeding practice, exclusive breast-
feeding, and childcare awareness related pro-
grams, which target the rural and unprivileged
population for reducing childhood stunting at the
population level. A joint effort involving the gov-
ernment and nongovernmental organizations is
Food and Nutrition Bulletin XX(X)
also necessary to improve the nutritional status
of children.
Acknowledgments
The authors would like to thank health economics and
financing research group for their comments on an ear-
lier draft of the manuscript. Icddr,b is also grateful to
the Governments of Bangladesh, Canada, Sweden, and
the UK for providing core/unrestricted support.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
References
1. International Food Policy Research Institute. Glo-
bal Nutrition Report 2016. From Promise to
Impact: Ending Malnutrition by 2030. Washing-
ton, DC; 2016. doi:10.2499/9780896295841.
2. Black RE, Allen LH, Bhutta ZA, et al. Maternal
and child undernutrition: global and regional expo-
sures and health consequences. Lancet. 2008;
371(9608):243-260. doi:10.1016/S0140-6736(07)
61690-0
3. Development Initiatives. Global Nutrition Report:
Nourishing the SDGs. Washington DC: Interna-
tional Food Policy Research Institute (IFPRI);
2017.
4. Data and Analytics Section of the Division of
Data, Research and Policy, UNICEF. Levels and
Trends in Child Malnutrition. Washington, DC:
Department of Nutrition for Health and Develop-
ment, WHO Geneva and the Development Data
Group of World Bank Group; 2015:4. doi:10.
1016/S0266-6138(96)90067-4.
5. The United Nations Children’s Fund. Stop Stunt-
ing: South Asia Headline Results; 2017. http://
www.unicefrosa-progressreport.org/stopstun
ting.html. Accessed December 14, 2017.
6. The United Nations Children’s Fund -South Asia.
Stop Stunting in South Asia: A Common Narrative
on Maternal and Child Nutrition. Kathmandu,
Nepal: UNICEF Regional Office for South Asia;
2015.
Akram et al
7. Grantham-McGregor S, Cheung YB, Cueto S,
Glewwe P, Richter L, Strupp B. Developmental
potential in the first 5 years for children in devel-
oping countries. Lancet. 2007;369(9555):60-70.
doi:10.1016/S0140-6736(07)60032-4.
8. Vonaesch P, Tondeur L, Breurec S, et al. Factors
associated with stunting in healthy children aged
5 years and less living in Bangui (RCA). PLoS
ONE. 2017;12(8). doi:10.1371/journal.pone.
0182363.
9. Caulfield LE, Richard SA, Black RE. Undernutri-
tion as an underlying cause of malaria morbidity
and mortality in children less than five years old.
Am J Trop Med Hyg. 2004;71(2 suppl):55-63. doi:
71/2_suppl/55 [pii].
10. Spurr G, Nieto MB, Maksud M. Productivity and
maximal in sugar cane cutters consumption. Am J
Clin Nutr. 1977;30:316-321.
11. Martotell R, Delgado HL, Valverde V, Klein RE.
Maternal stature, fertility and infant mortality.
Hum Biol. 1981;53(3):303-312.
12. National Institute of Population Research and
Training (NIPORT), Mitra and Associates, and
ICF International. Bangladesh Demographic and
Health Survey 2014. Dhaka, Bangladesh, and
Rockville, MD: NIPORT, Mitra and Associates,
and ICF International; 2016.
13. World Health Organization. Interpretation Guide
Nutrition Landscape Information System (NLIS).
Geneva, Switzerland; 2010. doi:10.1159/
000362780.Interpretation.
14. Ahmed T, Hossain M, Mahfuz M, Choudhury N,
Ahmed S. Imperatives for reducing child stunting
in Bangladesh. Matern Child Nutr. 2016;12:
242-245. doi:10.1111/mcn.12284.
15. Ecker O, Nene M. Nutrition Policies in Develop-
ing Countries: Challenges and Highlights.
Washington, DC: International Food Policy
Research Institute; 2012.
16. Bryce J, Coitinho D, Darnton-Hill I, Pelletier D,
Pinstrup-Andersen P. Maternal and child undernu-
trition: effective action at national level. Lancet.
2008;371(9611):510-526. doi:10.1016/S0140-
6736(07)61694-8.
17. Kismul H, Acharya P, Mapatano MA, Hatløy A.
Determinants of childhood stunting in the Demo-
cratic Republic of Congo: further analysis of
Demographic and Health Survey 2013–14. BMC
13
Public Health. 2017;18(1):74. doi:10.1186/
s12889-017-4621-0.
18. Van de Poel E, O’Donnell O, Van Doorslaer E.
Are urban children really healthier? Evidence from
47 developing countries. Soc Sci Med. 2007;
65(10):1986-2003. doi:10.1016/j.socscimed.2007.
06.032.
19. Sarma H, Khan JR, Asaduzzaman M, et al. Factors
influencing the prevalence of stunting among chil-
dren aged below five years in Bangladesh. Food
Nutr Bull. 2017;38(3):291-301. doi:10.1177/
0379572117710103.
20. Rahman M. Association between order of birth and
chronic malnutrition of children: a study of nation-
ally representative Bangladeshi sample. Cad
Saude Publica. 2016;32(2):e00011215. doi:10.
1590/0102-311x00011215.
21. Rah JH, Akhter N, Semba RD, et al. Low dietary
diversity is a predictor of child stunting in rural
Bangladesh. Eur J Clin Nutr. 2010;64(12):
1393-1398. doi:10.1038/ejcn.2010.171.
22. Mostafa Kamal SM. Socio-economic determinants
of severe and moderate stunting among under-five
children of rural Bangladesh. Malays J Nutr. 2011;
17(1):105-118.
23. Menon P, Ruel MT, Morris S. Socio-economic
differentials in child stunting are considerably
larger in urban than rural areas: analysis of 10
DHS data sets. Food Nutr Bull. 2000;21(97):
282-289. doi:10.1177/156482650002100305.
24. Rutstein SO, Rojas G. Demographic and Health
Surveys Methodology. Calverton, MD: United
States Agency for International Development
(USAID); 2006.
25. Department of Nutrition for Health and Develop-
ment. The New WHO Child Growth Standards.
Geneva, Switzerland; 2006. Volume 52. doi:10.
4067/S0370-41062009000400012.
26. Rabbani A, Khan A, Yusuf S, Adams A. Trends
and determinants of inequities in childhood stunt-
ing in Bangladesh from 1996/7 to 2014. Int J
Equity Health. 2016;15(1):186. doi:10.1186/
s12939-016-0477-7.
27. Das S, Gulshan J. Different forms of malnutrition
among under five children in Bangladesh: a cross
sectional study on prevalence and determinants.
BMC Nutrition. 2017;3(1):1. doi:10.1186/s40795-
016-0122-2.
14
28. World Health Organization. WHO Child Growth
Standards: Length/Height-For-Age, Weight-For-
Age, Weight-For-Length, Weight-For-Height and
Body Mass Index-For-Age—Methods and Devel-
opment. Geneva, Switzerland: World Health
Organization; 2006.
29. Rachmi CN, Agho KE, Li M, Baur LA. Stunting,
underweight and overweight in children aged 2.0-
4.9 years in Indonesia: prevalence trends and asso-
ciated risk factors. PLoS One. 2016;11(5):
e0154756. doi:10.1371/journal.pone.0154756.
30. Agedew E. Predictors of chronic under nutrition
(stunting) among children aged 6-23 months in
Kemba Woreda, Southern Ethiopia: a community
based cross-sectional study. J Nutr Food Sci. 2015;
5(4). doi:10.4172/2155-9600.1000381.
31. Hong R, Banta JE, Betancourt JA. Relationship
between household wealth inequality and chronic
childhood under-nutrition in Bangladesh. Int J Equity
Health. 2006;5:15. doi:10.1186/1475-9276-5-15.
32. Hien NN, Kam S. Nutritional status and the char-
acteristics related to malnutrition in children under
five years of age in Nghean, Vietnam. J Prev Med
Public Health. 2008;41(4):232-240. doi:10.3961/
jpmph.2008.41.4.232.
33. Hackett KM, Mukta US, Jalal CSB, Sellen DW.
Knowledge, attitudes and perceptions on infant
and young child nutrition and feeding among ado-
lescent girls and young mothers in rural Bangla-
desh. Matern Child Nutr. 2015;11(2):173-189. doi:
10.1111/mcn.12007.
34. Kavosi E, Hassanzadeh Rostami Z, Nasihatkon A,
Moghadami M, Heidari M. Prevalence and deter-
minants of under-nutrition among children under
six: a cross-sectional survey in Fars province, Iran.
Int J Health Policy Manag. 2014;3(2):71-76. doi:
10.15171/ijhpm.2014.63.
35. Aguayo VM, Badgaiyan N, Paintal K. Original
article determinants of child stunting in the Royal
Kingdom of Bhutan: an in-depth analysis of
nationally representative data. 2014;(Unicef):
1-13. doi:10.1111/mcn.12168.
36. Torlesse H, Cronin AA, Sebayang SK, Nandy R.
Determinants of stunting in Indonesian children:
evidence from a cross-sectional survey indicate a
prominent role for the water, sanitation and
hygiene sector in stunting reduction. BMC Public
Health. 2016:1-11. doi:10.1186/s12889-016-
3339-8.
Food and Nutrition Bulletin XX(X)
37. Mian RM, Ali M, Ferroni PA, Underwood P. The
nutritional status of school-aged children in an
urban squatter settlement in Pakistan. Pak J Nutr.
2002;1(3):121-123.
38. Gaire S, Delbiso TD, Panday S, Guha-Sapir D.
Impact of disasters on child stunting in Nepal. Risk
Manag Healthc Policy. 2016;9:113-127.
39. Darteh EKM, Acquah E, Kumi-Kyereme A. Cor-
relates of stunting among children in Ghana. BMC
Public Health. 2014;14(1):504. doi:10.1186/1471-
2458-14-504.
40. Department of Child and Adolescent Health and
Development (CAH). Guiding Principles for
Feeding Non-Breastfed Children 6-24 Months of
Age. Geneva, Switzerland: World Health Organi-
zation; 2005.
41. Nagata JM, Gippetti J, Wager S, Chavez A, Wise
PH. Prevalence and predictors of malnutrition
among guatemalan children at 2 years of age. PLoS
One. 2016;11(11):e0164772. doi:10.1371/journal.
pone.0164772.
42. Wamani H, Åstrøm AN, Peterson S, Tumwine JK,
Tylleskär T. Boys are more stunted than girls in
Sub-Saharan Africa: a meta-analysis of 16 demo-
graphic and health surveys. BMC Pediatrics. 2007;
7:17. doi:10.1186/1471-2431-7-17.
43. Semba RD, Pee S De Sun K, Sari M, Akhter N,
Bloem MW. Effect of parental formal education
on risk of child stunting in Indonesia and Bangla-
desh: a cross-sectional study. Lancet. 2008;
371(9609):322-328. doi:10.1016/S0140-6736(08)
60169-5.
44. Santos Felisbino-Mendes M, Villamor E,
Velasquez-Melendez G. Association of mater-
nal and child nutritional status in Brazil: a pop-
ulation based cross-sectional study. PLoS One.
2014;9(1):e87486. doi:10.1371/journal.pone.
0087486.
45. Tigga PL, Sen J. Maternal body mass index is
strongly associated with children z-Scores for
height and BMI. J Anthropol. 2016;2016:1-10.
doi:10.1155/2016/6538235.
46. Horton S. Birth order and child nutritional status:
evidence from the Philippines. Econ Dev Cult
Change. 1988;36(2):341-354.
47. Checkley W, Buckley G, Gilman RH, et al. Multi-
country analysis of the effects of diarrhoea on
childhood stunting. Int J Epidemiol. 2008;37(4):
816-830. doi:10.1093/ije/dyn099.
Akram et al
48. Marquis GS, Habicht JP, Lanata CF, Black RE,
Rasmussen KM. Association of breastfeeding and
stunting in Peruvian toddlers: an example of
reverse causality. Int J Epidemiol. 1997;26(2):
349-356. doi:10.1093/ije/26.2.349.
49. Mohsena M, Goto R, Nicholas Mascie-Taylor CG.
Regional variation in maternal and childhood
undernutrition in Bangladesh: evidence from
15
demographic and health surveys. WHO South East
Asia J Public Health. 2015;4(2):139-149. doi:10.
4103/2224-3151.206683.
50. Wu L, Yang Z, Yin S, Zhu M, Gao H. The relationship
between socioeconomic development and malnutri-
tion in children younger than 5 years in China during
the period 1990 to 2010. Asia Pac J Clin Nutr. 2015;
24(4):665-673. doi:10.6133/apjcn.2015.24.4.24.