Islam MS, Biswas T. Prevalence and correlates of the composite index of anthropometric failure among children under 5 years old in Bangladesh. Matern Child Nutr. 2020;16:e12930 10.1111/mcn.12930

###### Key messages

Nearly half of the children have some form of anthropometric failures, which is a big problem.There were considerable geographical variations of undernutrition between urban and rural areas across all the administrative division.The prevalence of undernutrition among children under 5 years is significantly higher for maternal child marriage, living in poorest socio‐economic groups with belonging to rural areas, no vaccination received, and higher order of birth.

ANC

:   antenatal care

BDHS

:   Bangladesh demography and health survey

CIAF

:   composite index of anthropometric failure

WHO

:   World Health Organization

1. INTRODUCTION {#mcn12930-sec-0002}
===============

Child malnutrition, particularly undernutrition, remains one of the biggest health problems for developing countries. Recent global estimates reported that 45% of child deaths annually attribute to various forms of undernutrition (Black et al., [2013](#mcn12930-bib-0004){ref-type="ref"}). More than 90% of the children who live in the African and Asian countries are stunted, and 70% are wasted, and these children are at substantial risk of acute malnutrition and death (De Onis, Brown, Blossner, & Borghi, [2012](#mcn12930-bib-0009){ref-type="ref"}). Evidence showed that rapid economic growth may have a relationship for the reduction of undernutrition (Singh, [2014](#mcn12930-bib-0025){ref-type="ref"}). In the past decade, Bangladesh has achieved substantial economic progress, and the gross domestic product growth rate is 7.1% per annum (Bank, [2016](#mcn12930-bib-0003){ref-type="ref"}). Even with the significant improvement in the health sectors, the country is going through epidemiological transition from communicable disease to noncommunicable disease and nutritional transition of over nutrition to undernutrition. The level of undernutrition is still higher compared with other developing countries (Mascie‐Taylor, [2012](#mcn12930-bib-0017){ref-type="ref"}).

According to the Bangladesh demography and health survey (BDHS) 2011, the prevalence of stunting, wasting, and underweight is still high among Bangladeshi children under 5 years old, particularly among the older age groups and living in the rural setting. Other predictors are lower socio‐economic status and lower education of parents (Chowdhury et al., [2016](#mcn12930-bib-0007){ref-type="ref"}; National Institute of Population Research and Training \[NIPORT\], 2013). Such estimate of undernutrition by the conventional indicators may overlap, which would not give a comprehensive estimate of undernutrition for any country (Nandy, Irving, Gordon, Subramanian, & Smith, 2005). However, a systematic review conducted on the developing countries reported that many children have multiple anthropometric failures, which leads to a heightened risk of morbidity and mortality. Children with three combined anthropometric failures have a 12‐fold elevated risk of mortality (McDonald et al., [2013](#mcn12930-bib-0018){ref-type="ref"}). Studies in Asian countries have found a concurrent relationship between stunting and wasting with compare with a standard population (Richard et al., [2012](#mcn12930-bib-0024){ref-type="ref"}). A review study suggests that underweight children will experience stunting and/or wasting and some children might simultaneously experience all three forms of anthropometric failures (Achadi et al., [2016](#mcn12930-bib-0001){ref-type="ref"}). As a result, none of these conventional nutritional indicators can really estimate the overall burden and the joint estimate of undernutrition among children under 5 years old.

A joint estimate of anthropometric failure is crucial to understand the real burden of undernutrition for any low‐ and middle‐income countries like Bangladesh. In 2000, Peter Svedberg developed a composite index of anthropometric failure (CIAF), which gives six different measurements of undernutrition using the conventional nutritional indicators, and the aggregated values of these indicators give the overall burden of undernutrition. The estimate of CIAF is helpful for modifying the existing intervention or developing a new nutritional programme with targeting specific populations.

To achieve the sustainable development goal of improved nutrition by 2030, a comprehensive estimate of undernutrition is essential for scaling up the nutritional programme. However, both the overall burden and the joint estimate of undernutrition are still absent among the under 5‐year‐old children in Bangladesh. This study utilized the dataset of the most recent BDHS 2014 to estimate the burden of undernutrition using CIAF and to identify significant covariates.

2. METHODS AND MATERIALS {#mcn12930-sec-0003}
========================

2.1. Study settings {#mcn12930-sec-0004}
-------------------

We used the BDHS dataset for this study. The survey used a sampling frame from the list of enumeration areas (EAs) of the 2011 population and housing census of the People\'s Republic of Bangladesh, provided by the Bangladesh Bureau of Statistics. The primary sampling unit for the survey is an EA created to have an average of about 120 households. The study is based on a two‐stage stratified sample of households. In the first stage, 600 EAs were selected with probability proportional to the EA size, with 207 EAs in urban areas and 393 in rural areas (NIPORT, 2013). A household listing was completed in each of the primary sampling unit (PSU), and then 30 households were selected from each PSU by the systematic random sampling procedures. The study population was mothers aged 15--49 years who have children aged 0--59 months. If the mother had more than one child at the same age group, then one child was randomly selected in this study (Figure [S1](#mcn12930-supitem-0001){ref-type="supplementary-material"}).

2.2. Outcomes {#mcn12930-sec-0005}
-------------

The outcome variable of this study was the nutritional status among children under 5 years measured using CIAF. Svedberg had recommended six subgroups of anthropometric failure (A to F; Table [1](#mcn12930-tbl-0001){ref-type="table"}). However, Nandy, Irving, Gordon, Subramanian, and Smith ([2005](#mcn12930-bib-0019){ref-type="ref"}) identified that children who are only underweight but are not stunted or wasted (Group---Y). Children nutritional indicators were categorized into seven groups: (A) no failure; (B) wasting only; (C) wasting and underweight; (D) wasting, stunting, and underweight; (E) stunting and underweight; (F) stunting only; and (Y) underweight only. A child is considered as undernourished, as measured in CIAF, if he or she is suffering from any anthropometric failure (B--Y) described above (Table [1](#mcn12930-tbl-0001){ref-type="table"}).

###### 

Classification of composite index of anthropometric failure to asses undernutrition among the children under 5 years

  Group   Descriptions                         Description of the levels            Wasting   Stunting   Underweight
  ------- ------------------------------------ ------------------------------------ --------- ---------- -------------
  A       No failure                           Normal WAZ, HAZ, and WHZ             No        No         No
  B       Wasting only                         WAZ \<−2SD but normal HAZ and WHZ    Yes       No         No
  C       Wasting and underweight              WAZ and WHZ \<−2 SD but HAZ normal   Yes       No         Yes
  D       Stunting, wasting, and underweight   HAZ and WAZ and WHZ \<−2SD           Yes       Yes        Yes
  E       Stunting and underweight             HAZ and WHZ\<−2SD but WAZ normal     No        Yes        Yes
  F       Stunting only                        HAZ\<−2SD but normal WAZ and WHZ     No        Yes        No
  Y^a^    Underweight only                     WHZ\<−2SD but normal HAZ and WAZ     No        No         Yes

Based on Nandy et al.

2.3. Covariates {#mcn12930-sec-0006}
---------------

A series of information was extracted from the BDHS including sociodemographic and economic characteristics (child\'s age, child\'s sex, birth order, preceding birth interval, antenatal care \[ANC\] visit, maternal marital status, maternal educational status, maternal age at first birth, size of household, place of residence, and wealth index). The preceding birth interval was categorized as first birth, \<24 months, 24--47 months, and ≥48 months. The current marital status was categorized into formerly married includes divorce, widowed, and currently married. ANC visit was categorized by less than four ANC visits and equal or more than four ANC visits received. The BDHS survey collected data from household ownership of assets and consumer goods such as the source of drinking water, type of toilet facilities, type of fuel, ownership of various durable goods, and other characteristics relating to socio‐economic status of the household. The household wealth index is an asset‐based socio‐economic index constructed using principal component analysis and following standard guidelines("Wealth index construction," the DHS programme). For this analysis, the wealth index was grouped into five categories: poorest, poor, middle, rich, and richest.

2.4. Measurement {#mcn12930-sec-0007}
----------------

The 2014 BDHS collected anthropometric data by measuring the height and weight of all children under age 5 in the selected households (NIPORT, [2013](#mcn12930-bib-0021){ref-type="ref"}). The nutritional status of children in the survey population is compared with the World Health Organization (WHO) Child Growth Standards, which are based on an international sample of ethnically, culturally, and genetically diverse healthy children living under optimal conditions to achieve a child\'s full genetic growth potential. A child who is more than two standard deviations below the median (−2 SD) of the WHO reference population in terms of height for age is considered stunted, weight for height is considered wasted, and weight for age is considered underweight (Group & de Onis, [2006](#mcn12930-bib-0014){ref-type="ref"}).

2.5. ETHICS {#mcn12930-sec-0008}
-----------

This study has utilized secondary data obtained from the BDHS 2014 that was collected by the MEASURE DHS programme. Ethical approval has been obtained from the institutional review board of intermediate care facility of Calverton, Maryland, USA. Therefore, ethical approval was not required, since DHS provided the data for the secondary analysis research. Access to the datasets could be obtained through online registration (http://dhsprogram.com/data/Access‐Instructions.cfm).

2.6. DATA ANALYSIS {#mcn12930-sec-0009}
------------------

Prevalence of CIAF was calculated if a child has any one of the six different types of anthropometric failures out of total children under 5 years. Categorical variables were summarized using frequency distribution, and continuous variables were summarized using mean, standard deviation, and median according to the nature of data. Bivariate analysis was done by chi‐square test to assess factors associated with CIAF. *P* value less than .05 in the bivariate analysis would be considered as candidates to be included in a multivariable regression model. Multivariable logistic regression model, enter method was applied to report the unadjusted and adjusted odds ratio and 95% confidence interval, and statistical significance was considered with a *P* \< .05. All the analyses were performed after adjustment with the cluster and sampling weight. All missing values were excluded from the analysis. The analysis was performed by IBM SPSS v21 software.

3. RESULTS {#mcn12930-sec-0010}
==========

3.1. Basic characteristics {#mcn12930-sec-0011}
--------------------------

We studied 6,965 children under 5 years old and their mothers. The average age of the children was 30 (17) months, where 51% of the children were female, and 68% lived in rural areas. Of the children, 39% was the firstborn child of their parents, and 7% of the children were born less than 24 months after the first birth. The proportion of short birth interval (\<24 months) was higher in the rural than the urban areas(16% vs. 13%; *P* = .005). Among the children, 23% were born through caesarean section. This proportion of caesarean birth was higher in the urban than rural areas (36% vs. 18%, *P* \< .001). Among the children, 20% had a low birthweight. Approximately 31% of the children were third or more in the order of birth. Four percent of the children had acute respiratory infraction, 5% was suffering from diarrhoea, and 37% had a fever before 2 weeks of the survey (Table [2](#mcn12930-tbl-0002){ref-type="table"}).

###### 

Basic characteristics of the study participants

  Variables                                          Label                 Total = 6,965 (%)
  -------------------------------------------------- --------------------- -------------------
  Child information                                                        
  Sex                                                Male                  3,571 (51)
  Female                                             3,394 (49)            
  Age, Mean (SD) (month)                                                   30(17)
  0--11                                              1,344 (19)            
  12--23                                             1,456 (21)            
  24--35                                             1,406 (20)            
  36--47                                             1,376 (20)            
  48--59                                             1,383 (20)            
  Birth interval in month                                                  
  First birth                                        2,714 (39)            
  \<24                                               4,76 (7)              
  24--47                                             1,388 (20)            
  48+                                                2,387 (34)            
  Birth order                                        1st                   2,700 (39)
  2nd                                                2,091 (30)            
  3rd                                                1,104 (16)            
  ≥4th                                               1,070 (15)            
  ANC care (*n* = 4,084)                                                   
  ≥4                                                 1,301 (32)            
  \<4                                                2,747 (68)            
  Diarrhoea[a](#mcn12930-note-0003){ref-type="fn"}   Yes                   337 (5)
  No                                                 6,622 (95)            
  Fever[a](#mcn12930-note-0003){ref-type="fn"}       Yes                   2,569 (37)
  No                                                 4,389 (63)            
  Delivery by C‐section, *n* = 4,204                 Yes                   982 (23)
  No                                                 3,222 (77)            
  Ever had vaccination, *n* = 2,448                  Yes                   2,133 (87.1)
  No                                                 315 (12.9)            
  Child size at birth, *n* = 4,728                   Larger than average   616 (13)
  Average                                            3,184 (67)            
  Smaller than average                               928 (20)              
  Acute respiratory infraction (ARI), *n* = 6,899    Yes                   280 (4)
  No                                                 6,619 (96)            
  Mother current age, Mean (SD)                                            26 (6)
  Mother age at birth                                                      
  \<20                                               5,085 (73)            
  ≥20                                                1,880 (27)            
  Highest educational level                          No education          1,076 (15.4)
  Primary                                            1,934 (27.8)          
  Secondary                                          3,219 (46.2)          
  Higher                                             736 (10.6)            
  Respondent currently working                       Yes                   1,747 (25.1)
  No                                                 5,217 (74.9)          
  Marital status                                     Formerly Married      83 (1.2)
  Currently Married                                  6,882 (98.8)          
  BMI, *n =* 6,946                                   Underweight           1,556 (22)
  Normal weight                                      4,067 (59)            
  Overweight and obesity                             1,323 (19)            
  Wealth index                                       Poorest               1,515 (22)
  Poor                                               1,307 (19)            
  Middle                                             1,379 (20)            
  Rich                                               1,420 (20)            
  Richest                                            1,344 (19)            
  Place of residence                                 Urban                 2,188 (31.4)
  Rural                                              4,777 (68.6)          
  Exposed with media                                 TV/Radio/Newspaper    4,315 (62)
  Not at all                                         2,650 (38)            

Abbreviations: ANC, antenatal care; BMI, body mass index.

Last 2 weeks.

The average age of the mothers of children was 26 (6) years, and 46% had completed secondary education. In this study, 4,084 mothers reported about ANC visit, of which 68% received less than four times ANC, and this proportion was higher in rural than urban areas (74% vs. 55%; *P* \< .001). Of the mothers, 22% had underweight, and 19% had overweight and obesity. The proportion of overweight was higher among the mothers in urban areas than rural areas (29% vs. 14%; *P* \< .001; Table [1](#mcn12930-tbl-0001){ref-type="table"}).

3.2. Joint estimate of child undernutrition {#mcn12930-sec-0012}
-------------------------------------------

In the study, 48% of the children have one or more forms of undernutrition including underweight and stunting (18%); stunting only (13%); wasting, underweight, and stunting(6%); wasting and underweight(6%); wasting only(3%); and underweight only (3%).Stunting only was significantly higher among male than female children (13% vs. 11%; *P* \< .001). The joint prevalence of wasting and underweight was higher among younger children (0--23 months) compared with older age (24--59 months). On the other hand, the prevalence of underweight and stunting was lower among younger age children compared with the older age group. The combined prevalence of stunting, wasting, and underweight significantly varied by the age of the children (Table [3](#mcn12930-tbl-0003){ref-type="table"}).

###### 

Prevalence and 95% CI of the composite index for different form of anthropometric failure by the characteristics of children, mother, and socio‐economic positions

  Variables                            Total   CIAF                                                          No failure                                                     Wasting only                                                 Wasting and underweight                                      Wasting, underweight and stunting                           Underweight and stunting                                    Stunting only                                                 Underweight only
  ------------------------------------ ------- ------------------------------------------------------------- -------------------------------------------------------------- ------------------------------------------------------------ ------------------------------------------------------------ ----------------------------------------------------------- ----------------------------------------------------------- ------------------------------------------------------------- ----------------------------------------------------------
  Overall,                                     48.3 \[47.1, 49.5\]                                           51.7 \[50.5, 52.8\]                                            3.2 \[2.8, 3.6\]                                             5.5 \[5.0, 6.1\]                                             5.7 \[5.2, 6.2\]                                            18.2 \[17.3, 19.2\]                                         12.6 \[11.9, 13.4\]                                           3.0 \[2.6, 3.4\]
  Child information                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
  Sex                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
  Male                                 3,571   49.2 \[46.9, 51.5\]                                           50.8 \[48.5, 53.1\]                                            3.7 \[3.0, 4.6\]                                             5.8 \[4.9, 6.8\]                                             5.6 \[4.8, 6.5\]                                            18.0 \[16.2, 20.0\]                                         13.3 \[11.9, 14.9\][\*](#mcn12930-note-0006){ref-type="fn"}   2.8 \[2.2, 3.5\][\*](#mcn12930-note-0006){ref-type="fn"}
  Female                               3,394   47.1 \[44.9, 49.3\]                                           52.9 \[50.7, 55.1\]                                            2.6 \[2.1, 3.3\]                                             5.7 \[4.6, 7.1\]                                             5.2 \[4.4, 6.2\]                                            19.0 \[17.3, 20.9\]                                         11.3 \[10, 12.7\]                                             3.2 \[2.6, 3.9\]
  Age                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
  0--11 months                         1,344   36.6 \[33.2, 40.3\][\*](#mcn12930-note-0006){ref-type="fn"}   63.4 \[59.7, 66.8\] [\*](#mcn12930-note-0006){ref-type="fn"}   7.9 \[6.2, 10.1\] [\*](#mcn12930-note-0006){ref-type="fn"}   8.2 \[6.3, 10.6\] [\*](#mcn12930-note-0006){ref-type="fn"}   2.8 \[1.9, 4.1\] [\*](#mcn12930-note-0006){ref-type="fn"}   5.7 \[4.3, 7.4\] [\*](#mcn12930-note-0006){ref-type="fn"}   8.8 \[6.6, 11.6\] [\*](#mcn12930-note-0006){ref-type="fn"}    3.3 \[2.2, 4.8\][\*](#mcn12930-note-0006){ref-type="fn"}
  12--23 months                        1,456   48.9 \[45.4, 52.5\]                                           51.1 \[47.5, 54.6\]                                            2.1 \[1.4, 3.1\]                                             6.8 \[5.4, 8.5\]                                             6.2 \[4.8, 7.9\]                                            17.3 \[14.4, 20.7\]                                         14.9 \[12.9, 17.2\]                                           1.7 \[1.1, 2.5\]
  24--35 months                        1,406   52.2 \[48.7, 55.5\]                                           47.8 \[44.5, 51.3\]                                            1.7 \[1.1, 2.6\]                                             5.8 \[3.9, 8.5\]                                             5.3 \[4.1, 6.8\]                                            22.1 \[19.5, 24.9\]                                         13.9 \[11.7, 16.3\]                                           3.4 \[2.4, 4.8\]
  36--47 months                        1,376   53.4 \[50.1, 56.7\]                                           46.6 \[43.3, 49.9\]                                            1.8 \[1.1, 2.7\]                                             3.3 \[2.4, 4.6\]                                             6.6 \[5.3, 8.2\]                                            24.2 \[21.3, 27.5\]                                         14.5 \[12.4, 16.9\]                                           3.0 \[2.2, 4.2\]
  48--59 months                        1,383   49.7 \[46, 53.4\]                                             50.3 \[46.6, 54\]                                              2.7 \[1.9, 3.8\]                                             4.6 \[3.5, 6.2\]                                             6.1 \[4.7, 7.7\]                                            23.4 \[20.3, 26.7\]                                         9.3 \[7.5, 11.6\]                                             3.6 \[2.7, 4.8\]
  Preceding Birth interval                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
  First birth                          2,714   43.7 \[41.3, 46.2\][\*](#mcn12930-note-0006){ref-type="fn"}   56.3 \[53.8, 58.7\]                                            2.7 \[2.1, 3.6\]                                             6.8 \[5.7, 8\][\*](#mcn12930-note-0006){ref-type="fn"}       4.6 \[3.8, 5.6\][\*](#mcn12930-note-0006){ref-type="fn"}    14.9 \[13.3, 16.6\]                                         12.2 \[10.6, 14\]                                             2.6 \[2, 3.4\]
  \<24 month                           476     59.3 \[53.3, 65\]                                             40.7 \[35, 46.7\]                                              3.9 \[2.4, 6.3\]                                             4.8 \[2.5, 9\]                                               7.2 \[4.9, 10.5\]                                           28.5 \[22.5, 35.4\]                                         11.6 \[8.7, 15.5\]                                            3.2 \[1.7, 6\]
  24--47 months                        1,388   55.7 \[52, 59.3\]                                             44\. 3 \[40.7, 48\]                                            2.9 \[2, 4.2\]                                               6.4 \[4.4, 9.3\]                                             6.6 \[5.2, 8.3\]                                            23.2 \[20.2, 26.5\]                                         13.8 \[11.6, 16.3\]                                           2.7 \[1.9, 3.8\]
  ≥48 months                           2,387   46.5 \[43.9, 49.1\]                                           53.5 \[50.9, 56.1\]                                            3.7 \[2.9, 4.9\]                                             4.4 \[3.6, 5.4\]                                             5.2 \[4.3, 6.4\]                                            17.8 \[15.7, 20.2\]                                         11.8 \[10.3, 13.5\]                                           3.5 \[2.7, 4.5\]
  Birth order                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
  1st                                  2,700   53.5 \[51, 56.1\]                                             46.5 \[43.9, 49.0\]                                            2.6 \[2.0, 3.3\]                                             5.7 \[4.5, 7.3\]                                             5.8 \[4.8, 6.9\]                                            22.3 \[20.1, 24.6\]                                         13.3 \[11.8, 15\]                                             3.9 \[3.1, 4.8\]
  2nd                                  2,091   49.1 \[46.2, 51.9\]                                           50.9 \[48.1, 53.8\]                                            3.5 \[2.6, 4.8\]                                             6.5 \[5.3, 8.1\]                                             5.1 \[4.1, 6.3\]                                            19.5 \[17, 22.2\]                                           12.4 \[10.8, 14.3\]                                           2.0 \[1.4, 2.8\]
  3rd                                  1,104   46.3 \[42.3, 50.4\]                                           53.7 \[49.6, 57.7\]                                            3.1 \[2.2, 4.4\]                                             6.1 \[4.5, 8.1\]                                             5.0 \[3.7, 6.6\]                                            15.5 \[13.1, 18.2\]                                         13.1 \[10.3, 16.5\]                                           3.7 \[2.5, 5.4\]
  ≥4                                   1,070   34.8 \[31.3, 38.5\]                                           65.2 \[61.5, 68.7\]                                            4.2 \[2.9, 6.1\]                                             4 \[2.7, 5.9\]                                               5.5 \[4, 7.6\]                                              10.4 \[8.4, 12.9\]                                          8.8 \[7, 11\]                                                 1.9 \[1.1, 3.2\]
  ANC care (*n* = 4,084)                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
  ≥4                                   1,301   49.6 \[47.1, 52.1\]                                           64 \[60.2, 67.8\]                                              3.5 \[2.4, 5.2\]                                             6.7 \[4.5, 9.7\]                                             3.5 \[2.5, 4.9\]                                            9.1 \[7.3, 11.3\]                                           10.6 \[8.2, 13.5\]                                            2.5 \[1.7, 3.6\]
  \<4                                  2,747   36 \[32.2, 39.8\]                                             50.4 \[47.9, 52.9\]                                            4.1 \[3.3, 5.2\]                                             7.2 \[6, 8.6\]                                               5.5 \[4.6, 6.7\]                                            16.9 \[14.9, 19\]                                           12.9 \[11.5, 14.5\]                                           2.9 \[2.2, 3.9\]
  Diarrhoea^a^                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
  Yes                                  337     53.2 \[44.7, 61.5\]                                           52.2 \[50.6, 53.8\]                                            3.3 \[2.9, 3.9\]                                             5.8 \[5, 6.6\]                                               5.2 \[4.6, 5.9\]                                            18.5 \[17.2, 19.8\]                                         11.9 \[11, 12.9\]                                             3.1 \[2.6, 3.7\]
  No                                   6,622   47.8 \[46.2, 49.4\]                                           52.2 \[50.6, 53.8\]                                            3.3 \[2.9, 3.9\]                                             5.8 \[5, 6.6\]                                               5.2 \[4.6, 5.9\]                                            18.5 \[17.2, 19.8\]                                         11.9 \[11, 12.9\]                                             3.1 \[2.6, 3.7\]
  Fever^a^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
  Yes                                  2,569   52.5 \[49.8, 55.1\]                                           47.5 \[44.9, 50.2\]                                            3.3 \[2.6, 4.3\]                                             6.8 \[5.4, 8.6\]                                             6.8 \[5.8, 8.1\]                                            19.1 \[17.1, 21.3\]                                         12.9 \[11.2, 14.9\]                                           3.5 \[2.7, 4.5\]
  No                                   4,389   45.6 \[43.7, 47.6\]                                           54.4 \[52.4, 56.3\]                                            3.1 \[2.5, 3.8\]                                             5.1 \[4.4, 6\]                                               4.5 \[3.8, 5.3\]                                            18.2 \[16.6, 19.9\]                                         12 \[10.9, 13.2\]                                             2.7 \[2.2, 3.3\]
  Delivery by C‐section, *n* = 4,204                                                                                                                                                                                                                                                                                                                                                                                                                                                        
  Yes                                  982     33.8 \[29.9, 38\]                                             66.2 \[62, 70.1\]                                              4.4 \[3.2, 6.2\]                                             7.1 \[4.5, 11\]                                              2.5 \[1.6, 4\]                                              7.3 \[5.5, 9.8\]                                            10.5 \[8.4, 13\]                                              1.9 \[1.1, 3.5\]
  No                                   3,222   49.8 \[47.4, 52.1\]                                           50.2 \[47.9, 52.6\]                                            3.6 \[2.9, 4.6\]                                             6.8 \[5.8, 8.1\]                                             5.5 \[4.6, 6.5\]                                            17.5 \[15.7, 19.5\]                                         13.3 \[11.8, 14.9\]                                           3 \[2.3, 3.8\]
  Ever had vaccination (*n* = 2,448)                                                                                                                                                                                                                                                                                                                                                                                                                                                        
  Yes                                  2,133   47.2 \[44.2, 50.1\]                                           52.8 \[49.9, 55.8\]                                            2.8 \[2.1, 3.7\]                                             5.2 \[3.8, 7\]                                               4.7 \[3.8, 5.9\]                                            19.4 \[17.1, 21.9\]                                         12.5 \[10.8, 14.4\]                                           2.7 \[2, 3.5\]
  No                                   315     56.3 \[48.6, 63.7\]                                           43.7 \[36.3, 51.4\]                                            8.9 \[5.2, 14.8\]                                            2.4 \[1.3, 4.5\]                                             5.4 \[3.3, 8.6\]                                            23.2 \[15.4, 33.2\]                                         12.5 \[8.3, 18.2\]                                            4 \[1.9, 8.6\]
  Child size at birth, *n* = 4,728                                                                                                                                                                                                                                                                                                                                                                                                                                                          
  Larger than average                  616     47.6 \[42, 53.3\]                                             52.4 \[46.7, 58\]                                              3.9 \[2.4, 6.3\]                                             3.5 \[2.2, 5.7\]                                             5.3 \[3.5, 7.9\]                                            19.4 \[15.5, 24.1\]                                         10.9 \[8.1, 14.3\]                                            4.6 \[2.9, 7.2\]
  Average                              3,184   49.9 \[47.4, 52.3\]                                           50.1 \[47.7, 52.6\]                                            2.9 \[2.2, 3.7\]                                             5.8 \[4.7, 7\]                                               5.6 \[4.7, 6.7\]                                            19.2 \[17.3, 21.2\]                                         13.6 \[12, 15.5\]                                             2.8 \[2.2, 3.6\]
  Smaller than average                 928     42.6 \[37.8, 47.4\]                                           57.4 \[52.6, 62.2\]                                            3.1 \[1.9, 5.1\]                                             5 \[3.4, 7.3\]                                               4.9 \[3.5, 6.9\]                                            15.8 \[12.2, 20.2\]                                         10.7 \[8.5, 13.5\]                                            3 \[1.9, 4.7\]
  ARI, *n* = 6,899                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
  Yes                                  280     54.4 \[45.8, 62.7\]                                           45.6 \[37.3, 54.2\]                                            6.6 \[3.8, 11\]                                              3.6 \[2, 6.5\]                                               6.7 \[4.1, 10.6\]                                           20 \[14.6, 26.7\]                                           14.2 \[9.9, 20\]                                              3.3 \[1.5, 7.2\]
  No                                   6,619   47.8 \[46.1, 49.4\]                                           52.2 \[50.6, 53.9\]                                            3 \[2.6, 3.6\]                                               5.8 \[5.1, 6.7\]                                             5.3 \[4.7, 6\]                                              18.3 \[17, 19.7\]                                           12.3 \[11.3, 13.3\]                                           3 \[2.5, 3.5\]
  Maternal information                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
  Age at first birth                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
  \<20                                 5,085   50.4 \[48.5, 52.2\]                                           49.6 \[47.8, 51.5\]                                            3.2 \[2.7, 3.9\]                                             5.5 \[4.7, 6.3\]                                             5.9 \[5.2, 6.7\]                                            19.9 \[18.4, 21.5\]                                         12.9 \[11.7, 14.2\]                                           2.9 \[2.4, 3.5\]
  ≥20                                  1,880   42.2 \[39.2, 45.2\]                                           57.8 \[54.8, 60.8\]                                            3.1 \[2.4, 4.1\]                                             6.5 \[4.8, 8.8\]                                             3.9 \[3, 5.1\]                                              14.7 \[12.6, 17.2\]                                         10.7 \[9.2, 12.5\]                                            3.1 \[2.3, 4.2\]
  Education                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
  No education                         1,076   57.9 \[53.6, 62.2\]                                           42.1 \[37.8, 46.4\]                                            2 \[1.2, 3.3\]                                               5 \[3.5, 7.2\]                                               7.7 \[5.9, 9.9\]                                            25.7 \[22.5, 29.3\]                                         14.1 \[11.6, 17\]                                             3.5 \[2.3, 5.1\]
  Primary                              1,934   56.5 \[53.5, 59.5\]                                           43.5 \[40.5, 46.5\]                                            2.8 \[2.1, 3.8\]                                             6.6 \[5.4, 8.1\]                                             6 \[5, 7.3\]                                                23.2 \[20.6, 26.1\]                                         14.6 \[12.8, 16.7\]                                           3.2 \[2.4, 4.2\]
  Secondary                            3,219   43.2 \[40.9, 45.5\]                                           56.8 \[54.5, 59.1\]                                            3.5 \[2.8, 4.4\]                                             5.7 \[4.6, 7.1\]                                             4.7 \[3.9, 5.7\]                                            15.1 \[13.4, 17.0\]                                         11.2 \[9.8, 12.7\]                                            2.9 \[2.3, 3.8\]
  Higher                               736     31 \[27.1, 35.2\]                                             69 \[64.8, 72.9\]                                              5 \[3.4, 7.3\]                                               4.7 \[3, 7.4\]                                               3 \[1.8, 5.1\]                                              8.6 \[6.4, 11.5\]                                           8 \[6.1, 10.5\]                                               1.6 \[0.9, 2.7\]
  Occupation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
  Currently working                    1,747   54.5 \[51.4, 57.4\]                                           45.5 \[42.6, 48.6\]                                            3.1 \[2.2, 4.3\]                                             5.8 \[4.2, 8\]                                               7.1 \[5.8, 8.6\]                                            21.9 \[19.3, 24.7\]                                         12.6 \[10.8, 14.6\]                                           4.0 \[3, 5.2\]
  No                                   5,217   45.9 \[44.1, 47.8\]                                           54.1 \[52.2, 55.9\]                                            3.2 \[2.7, 3.9\]                                             5.7 \[5, 6.6\]                                               4.8 \[4.2, 5.5\]                                            17.3 \[15.9, 18.8\]                                         12.2 \[11.1, 13.5\]                                           2.6 \[2.2, 3.2\]
  BMI, *n =* 6,946                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
  Underweight                          1,556   58.2 \[54.8, 61.5\]                                           41.8 \[38.5, 45.2\]                                            2.6 \[1.7, 4\]                                               7.6 \[6.1, 9.5\]                                             8.6 \[7.2, 10.4\]                                           24.8 \[21.8, 28\]                                           10.1 \[8.4, 12\]                                              4.4 \[3.4, 5.8\]
  Normal weight                        4,067   49.3 \[47.2, 51.4\]                                           50.7 \[48.6, 52.8\]                                            3.6 \[3, 4.3\]                                               5.7 \[4.7, 6.9\]                                             5.2 \[4.4, 6.1\]                                            18.4 \[16.9, 20.1\]                                         13.8 \[12.4, 15.3\]                                           2.6 \[2.1, 3.2\]
  Overweight and obesity               1,323   32.3 \[29.1, 35.7\]                                           67.7 \[64.3, 70.9\]                                            2.7 \[1.8, 4\]                                               3.6 \[2.5, 5.2\]                                             2.1 \[1.5, 3.1\]                                            11.1 \[8.7, 14.1\]                                          10.2 \[8.5, 12.2\]                                            2.5 \[1.6, 3.9\]
  Wealth index                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
  Poorest                              1,515   61.4 \[57.8, 64.8\]                                           38.6 \[35.2, 42.2\]                                            2.2 \[1.4, 3.3\]                                             6.7 \[5.2, 8.6\]                                             8.2 \[6.8, 10\]                                             27.4 \[24.4, 30.7\]                                         13.7 \[11.7, 16.1\]                                           3.1 \[2.2, 4.3\]
  Poorer                               1,307   55.5 \[52, 58.9\]                                             44.5 \[41.1, 48\]                                              3.6 \[2.5, 5.1\]                                             6.1 \[4.7, 7.7\]                                             7 \[5.6, 8.8\]                                              22.1 \[19.1, 25.4\]                                         13.2 \[11.1, 15.7\]                                           3.5 \[2.5, 4.9\]
  Middle                               1,379   48.1 \[44.2, 52.1\]                                           51.9 \[47.9, 55.8\]                                            3.3 \[2.4, 4.5\]                                             5.2 \[4, 6.8\]                                               4.1 \[3.1, 5.5\]                                            19.2 \[16.1, 22.8\]                                         12.9 \[10.5, 15.8\]                                           3.4 \[2.4, 4.8\]
  Richer                               1,420   42.8 \[39.5, 46.1\]                                           57.2 \[53.9, 60.5\]                                            2.9 \[2.1, 4\]                                               6 \[4, 8.8\]                                                 4.4 \[3.3, 5.8\]                                            14.4 \[12.2, 16.8\]                                         12.5 \[10.6, 14.8\]                                           2.6 \[1.9, 3.7\]
  Richest                              1,344   30.6 \[27.7, 33.7\]                                           69.4 \[66.3, 72.3\]                                            4.3 \[3.1, 6\]                                               4.7 \[3.4, 6.4\]                                             2.8 \[1.9, 4.2\]                                            7.8 \[6.3, 9.6\]                                            8.9 \[7.3, 10.8\]                                             2.2 \[1.3, 3.5\]
  Place of residence                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
  Urban                                2,188   41.1 \[38.5, 43.8\]                                           58.9 \[56.2, 61.5\]                                            3.0 \[2.2, 4.1\]                                             4.7 \[3.6, 6.1\]                                             4.5 \[3.5, 5.8\]                                            14.4 \[12.7, 16.4\]                                         11.8 \[10.2, 13.6\]                                           2.6 \[1.8, 3.7\]
  Rural                                4,777   50.6 \[48.7, 52.5\]                                           49.4 \[47.5, 51.3\]                                            3.3 \[2.7, 3.9\]                                             6.1 \[5.2, 7.1\]                                             5.7 \[5, 6.5\]                                              19.9 \[18.3, 21.5\]                                         12.5 \[11.3, 13.8\]                                           3.1 \[2.6, 3.7\]
  Exposed with media                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
  TV/Radio/Newspaper                   4,315   43.4 \[41.5, 45.4\]                                           56.6 \[54.6, 58.5\]                                            3.3 \[2.8, 4\]                                               5.6 \[4.7, 6.7\]                                             4.3 \[3.7, 5.1\]                                            15.4 \[14, 16.9\]                                           12 \[10.8, 13.4\]                                             2.7 \[2.1, 3.3\]
  Not at all                           2,650   55.8 \[53.1, 58.5\]                                           44.2 \[41.5, 46.9\]                                            3 \[2.3, 3.9\]                                               6 \[4.9, 7.2\]                                               7.1 \[6, 8.3\]                                              23.5 \[21.2, 25.9\]                                         12.8 \[11.3, 14.5\]                                           3.5 \[2.7, 4.4\]

Abbreviations: ANC, antenatal care; ARI, acute respiratory infection; BMI, body mass index; CIAF, composite index of anthropometric failure.

Last 2 weeks.

*P* \<0.05.

*P*\< 0.001.

3.3. Geographical variations of CIAF {#mcn12930-sec-0013}
------------------------------------

The prevalence of CIAF was also higher when the children live in rural areas compared with urban areas (51% vs. 41%; *P* \< 0.001). The prevalence of CIAF was the highest in the Sylhet division (57%) and lowest in the Khulna division (42.0%). The prevalence of CIAF was higher in rural areas than in urban areas across seven administrative divisions (Figure [1](#mcn12930-fig-0001){ref-type="fig"}). Similarly, the prevalence of all the category of CIAF was higher in the rural than its urban counterpart (Figure [S2](#mcn12930-supitem-0002){ref-type="supplementary-material"}).

![Prevalence of composite index of anthropometric failure by area of residence across seven administrative divisions](MCN-16-e12930-g001){#mcn12930-fig-0001}

3.4. Factors associated with CIAF {#mcn12930-sec-0014}
---------------------------------

In the bivariate analysis, the odds of CIAF were more likely among older age children (24--59 months), not to vaccinate their child, mode of birth is normal compared with C‐section, shorter preceding birth interval, lower order of birth of the index child, young maternal age at first birth (15--19 years), low education, currently working, lower socio‐economic position, living in rural areas, never exposed with media, mother received less than four ANC visit, size of child at birth was average or larger, had fever before 2 weeks of the survey, and undernutrition of mothers (Table [4](#mcn12930-tbl-0004){ref-type="table"}).

###### 

Factor associated with the Composite Index of Anthropometric Failure

                                                                Crude OR[\*](#mcn12930-note-0010){ref-type="fn"} \[95% CI\]   *P* value                                               Adjusted OR [\*](#mcn12930-note-0010){ref-type="fn"}\[95% CI\]   *P* value
  ------------------------------------------------------------- ------------------------------------------------------------- ------------------------------------------------------- ---------------------------------------------------------------- -----------------------------------------------------
  Sex of child                                                                                                                                                                                                                                         
  Male                                                          1.09 \[0.96, 1.23\]                                           0.084                                                   ,                                                                
  Female                                                        1                                                                                                                                                                                      
  Child age                                                                                                                                                                                                                                            
  24--59 months                                                 1.42 \[1.25, 1.61\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   0.58 \[0.33, 1.03\]                                              0.064
  0--23 months                                                  1                                                                                                                     1                                                                
  Mother age at first birth                                                                                                                                                                                                                            
  \<20 years                                                    1.39 \[1.21, 1.6\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.63 \[1.03, 2.59\]                                              0.039[\*](#mcn12930-note-0010){ref-type="fn"}
  ≥20 years                                                     1                                                                                                                     1                                                                
  Mother education                                                                                                                                                                                                                                     
  No education                                                  3.06 \[2.3, 4.08\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.30 \[0.54, 3.12\]                                              0.559
  Primary                                                       2.89 \[2.36, 3.53\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.07 \[0.47, 2.43\]                                              0.865
  Secondary                                                     1.69 \[1.39, 2.05\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   0.53 \[0.27, 1.04\]                                              0.066
  Higher                                                        1                                                                                                                     1                                                                
  Occu*P*ation                                                                                                                                                                                                                                         
  Currently working                                             1.41 \[1.21, 1.64\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.3 \[0.71, 2.37\]                                               0.400
  No                                                            1                                                                                                                     1                                                                
  Wealth index                                                                                                                                                                                                                                         
  Poorest                                                       3.6 \[2.84, 4.56\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   3.29 \[1.41, 7.67\]                                              0.006[\*](#mcn12930-note-0010){ref-type="fn"}
  Poorer                                                        2.82 \[2.33, 3.42\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   2.04 \[0.89, 4.71\]                                              0.094
  Middle                                                        2.1 \[1.72, 2.57\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.24 \[0.59, 2.58\]                                              0.570
  Richer                                                        1.69 \[1.37, 2.1\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   0.84 \[0.42, 1.71\]                                              0.635
  Richest                                                       1                                                                                                                     1                                                                
  Place of residence                                                                                                                                                                                                                                   
  Rural                                                         1.47 \[1.23, 1.75\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   0.47 \[0.27, 0.84\]                                              0.010[\*](#mcn12930-note-0010){ref-type="fn"}
  Urban                                                         1                                                                                                                     1                                                                
  Media                                                                                                                                                                                                                                                
  TV/Radio/Newspaper                                            1                                                                                                                     1                                                                
  Not at all                                                    1.65 \[1.42, 1.92\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   0.71 \[0.41, 1.22\]                                              0.214
  Ever had vaccination                                                                                                                                                                                                                                 
  Yes                                                           1                                                                                                                     1                                                                
  No                                                            1.44 \[1.02, 2.05\]                                           .040                                                    1.95 \[1.12, 3.38\]                                              0.019[\*](#mcn12930-note-0010){ref-type="fn"}
  Delivery by C‐section                                                                                                                                                                                                                                
  Yes                                                           1                                                                                                                     1                                                                
  No                                                            1.94 \[1.58, 2.37\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.62 \[0.9, 2.92\]                                               0.107
  Preceding birth interval                                                                                                                                                                                                                             
  First birth                                                   0.89 \[0.77, 1.03\]                                           .133                                                    1.08 \[0.63, 1.84\]                                              0.784
  \<24 months                                                   1.68 \[1.3, 2.16\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.39 \[0.57, 3.42\]                                              0.468
  24--47 months                                                 1.45 \[1.25, 1.67\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.16 \[0.66, 2.01\]                                              0.609
  ≥48 months                                                    1                                                                                                                     1                                                                
  Birth order                                                                                                                                                                                                                                          
  1st                                                           2.15 \[1.75, 2.65\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   4.31 \[1.83, 10.11\]                                             0.001[\*](#mcn12930-note-0010){ref-type="fn"}
  2nd                                                           1.8 \[1.45, 2.24\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   4.44 \[2.39, 8.26\]                                              *P* \< .001[\*](#mcn12930-note-0010){ref-type="fn"}
  3rd                                                           1.61 \[1.30, 2.01\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   2.66 \[1.54, 4.6\]                                               0.001[\*](#mcn12930-note-0010){ref-type="fn"}
  ≥4                                                            1                                                                                                                     1                                                                
  Received ANC care                                                                                                                                                                                                                                    
  ≥4                                                            1                                                                                                                                                                                      
  \<4                                                           1.75 \[1.46, 2.11\]                                           *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.61 \[0.97, 2.69\]                                              0.068
  Size of child at birth                                                                                                                                                                                                                               
  Average or larger                                             1.32 \[1.09, 1.61\]                                           .005[\*](#mcn12930-note-0010){ref-type="fn"}            1.67 \[1.01, 2.76\]                                              0.046[\*](#mcn12930-note-0010){ref-type="fn"}
  Smaller than average                                          1                                                                                                                     1                                                                
  Diarrhoea[\*](#mcn12930-note-0010){ref-type="fn"} (ref: no)   1.24 \[0.94, 1.64\]                                                                                                                                                                    
  Fever^a^ (ref: no)                                            1.32 \[1.18, 1.48\]                                                                                                   0.89 \[0.60, 1.32\]                                              0.575
  ARI (ref: no)                                                 1.3 \[0.94, 1.81\]                                                                                                                                                                     
  Mother body mass index                                                                                                                                                                                                                               
  Undernutrition                                                1.43 \[1.2, 1.71\]                                            *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   1.60 \[0.96, 2.68\]                                              0.101
  Overweight/Obesity                                            0.49 \[0.4, 0.6\]                                             *P* \< .001[\*\*](#mcn12930-note-0011){ref-type="fn"}   0.77 \[0.42, 1.42\]                                              0.346
  Normal weight                                                 1                                                                                                                     1                                                                

Abbreviations: ANC, antenatal care; ARI, acute respiratory infection; 1OR: odds ratio.

*P*\<0.05.

*P* \< 0.001.

After adjusting all the covariates in the multivariable logistic regression model, we found that the odds of CIAF were more likely among young maternal age at first birth (OR: 1.63; 95% CI \[1.03, 2.59\]), poorest socio‐economic status (OR: 3.29, 95% CI \[1.41, 7.67\]), those mother who did not vaccinate their child (OR: 1.95, 95% CI \[1.12, 3.38\]), lower order of birth including first order (OR: 4.31, 95% CI \[1.83, 10.11\]), second order (OR: 4.44, 95% CI \[2.39, 8.26\]), third order (OR: 2.66, 95% CI \[1.54, 4.60\]), and average or larger size of child at birth (OR: 1.67, 95% CI \[1.01, 2.76\]). Our result showed that the odds of CIAF were less likely among children living in rural areas compared with urban areas (OR: 0.47, 95% CI \[0.27, 0.84\]; Table [4](#mcn12930-tbl-0004){ref-type="table"}).

4. DISCUSSION {#mcn12930-sec-0015}
=============

This study has applied the CIAF scale for estimating the overall burden of child under nutrition and identifying covariates. In Bangladesh, at least one in every two children under 5 years old has undernutrition, and one out of three children has both underweight and stunting. One community‐based study conducted in Bangladesh reported that 48% of rural and 58% of urban area children have undernutrition (Khan & Raza, [2014](#mcn12930-bib-0016){ref-type="ref"}). This prevalence of CIAF was higher in many developing countries including India (Boregowda, Soni, Jain, & Agrawal, [2015](#mcn12930-bib-0005){ref-type="ref"}; Dasgupta et al., [2015](#mcn12930-bib-0008){ref-type="ref"}), Ethiopia (Endris, Asefa, & Dube, [2017](#mcn12930-bib-0010){ref-type="ref"}), and Nepal (Goswami, [2016](#mcn12930-bib-0013){ref-type="ref"}) and lower in Tanzania, Zimbabwe, Bolivia, and Peru (Nandy & Miranda, [2008](#mcn12930-bib-0020){ref-type="ref"}) than the estimate of current study. This study revealed that the undernutrition status was higher among the children when they live in rural settings, if they are in the poorest socio‐economic position, if they did not receive any vaccinations, and if they are the firstborn. The high rate of child undernutrition may impact on the higher burden of morbidity due to lower immunization, which results in higher rates of mortality among the affected children (Ahmed et al., [2012](#mcn12930-bib-0002){ref-type="ref"}).

We did not find any gender differences for overall undernutrition; however, in terms of stunting, only the proportion was higher for boys than girls. Overall undernutrition was significantly lower among younger age children, particularly among males. The children under 5 years old are at high risk for developing short‐ and long‐term consequences, irrespective of any gender differences. A meta‐analysis conducted in sub‐Saharan Africa reported that males are more stunted than females, which suggest males are more vulnerable to health inequalities than females (Wamani, Åstrøm, Peterson, Tumwine, & Tylleskär, [2007](#mcn12930-bib-0027){ref-type="ref"}). One community‐based study in Bangladesh has suggested that socio‐economic disparities in stunting have increased over time (Rabbani, Khan, Yusuf, & Adams, [2016](#mcn12930-bib-0022){ref-type="ref"}).

We found that wasting and underweight status are most prevalent among older age children than younger age groups and all other types of anthropometric failures were lower in the first 11 months of the child\'s life. The burden of underweight was almost similar across all the age groups. Similarly, studies from Ethiopia (Zelellw, Gebreigziabher, Alene, Negatie, & Kasahune, [2013](#mcn12930-bib-0029){ref-type="ref"}) and Burkina Faso (Erismann et al., [2017](#mcn12930-bib-0011){ref-type="ref"}) have shown that the proportion of undernutrition is increased as the age of the children increased. From 12 to 59 months, children have much physical and mental growth, and this time, a healthy balanced diet can support the development of the child\'s brain, and it can provide necessary nutrients as required. A community‐based study has shown that there is a clear link between food insecurity and malnutrition. One out of four households have food insecurity access in Bangladesh. The children aged 6 to 59 months old are at heightened risk of undernutrition (Hasan, Ahmed, & Chowdhury, [2013](#mcn12930-bib-0015){ref-type="ref"}). A study in Bangladesh suggests that dairy intake can be extremely beneficial for reducing the stunting among children and that it can increase child growth (Choudhury & Headey, [2018](#mcn12930-bib-0006){ref-type="ref"}). The government of Bangladesh targets to reduce the burden of stunting up to 25% by the end of 2025. A comprehensive community‐based intervention programme is crucial when reducing the burden of undernutrition.

In this study, we found that the children who live in the rural areas and who have low socio‐economic status are at higher risk of undernutrition, as well as when the mothers of the children had lower education level. A globally conducted systematic review reported that the relative difference in CIAF prevalence between the poorest and richest quintile has decreased and the difference between the lowest and highest education category has slightly increased in the low‐ and middle‐income countries including Bangladesh (Vollmer, Harttgen, Kupka, & Subramanian, [2017](#mcn12930-bib-0026){ref-type="ref"}). One national study in Bangladesh has found that children of mothers who completed secondary and higher education had less growth failure, suggesting the education level have protective effects against underweight and wasting among children under 5 years old.

This study demonstrated that the prevalence of CIAF was 20% lower among the children who got an expanded programme on immunization vaccine. The children\'s immune system can automatically buildup through the vaccination, which can positively impact the reduction of undernutrition. In Bangladesh, the national immunization coverage is nearly 90%, which suggests that a majority of the children under 5 are now the coverage of the expanded programme on immunization. On the contrary, the children who did not receive vaccines were mostly from the rural area, were having poorer socio‐economic position, and were not more exposed to media than the families of their counterparts. This finding is consistent with one study conducted in Bangladesh (Fuchs, Sultana, Ahmed, & Iqbal Hossain, [2014](#mcn12930-bib-0012){ref-type="ref"}).

Our study has found that undernutrition was significantly higher among first‐order children compared with the subsequent orders, and the pattern of undernutrition was persistent among the children who had a joint condition of undernutrition and stunting. According to the BDHS 2011, child mortality has significant associations with unwanted birth and order of children (Rahman, [2015](#mcn12930-bib-0023){ref-type="ref"}). The higher order children usually get less attention for postnatal care and getting out from the coverage of the full vaccination rapidly. The findings suggest that order of birth of the children has an independent effect on the child\'s undernutrition, despite the contribution of other demographic and maternal characteristics. In Bangladesh, one out of four households has food insecurity status, which may impact on the nutrition of the higher birth order children (Hasan et al., [2013](#mcn12930-bib-0015){ref-type="ref"}).

This sample size of the study is country representative, and the estimate of undernutrition reflects the real burden of undernutrition among children under 5 years old in Bangladesh. The nutritional indicators stunting, wasting, and underweight are measured following the WHO child growth standard. However, this study has some limitations, such as that the study is designed for cross‐sectional analysis, so we cannot interpret the significant covariates as risk factors of undernutrition. The data of child size at birth were collected according to the recall of the mothers of children, and therefore, the reporting of low birthweight may be overestimated or underestimated.

5. CONCLUSIONS {#mcn12930-sec-0016}
==============

The finding from this study, which provides an overall burden of undernutrition based on CIAF, suggests that one out of two children under 5 years old are at risk of undernutrition. The burden was higher among the children who lived in the rural areas, or having a poor socio‐economic position, a lower education status of parents, a higher order of birth or a history of no BCG vaccination. Findings suggest that proper intervention programmes with targeting specific population groups are crucial to reducing the burden of undernutrition for achieving the sustainable development goal in improved nutrition by 2030 of Bangladesh.

CONFLICTS OF INTEREST {#mcn12930-sec-0018}
=====================

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS {#mcn12930-sec-0019}
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MSI conceptualized the study, performed the main data analysis, and drafted the initial manuscript. TB participated in interpretation of the data and revising the manuscript. All authors contributed to the development and approved the final manuscript.

Supporting information
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Figure S1: Flow diagram of the study participants

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Click here for additional data file.

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Figure S2: Prevalence of different form of anthropometric failure by the area of residence across seven administrative divisions

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Click here for additional data file.

The authors are thankful to the National Institute of Population Research and Training (NIPORT), Bangladesh, for providing the BDHS 2014 dataset for secondary analysis. We acknowledge contributions of Tim David de Vries for a thorough editing of the English language of the paper, and late Prof. Mohammed Nasser, Department of Statistics, University of Rajshahi who had inspired me to work in the public health area.
