Background
Wasting is a severe phenomenon of losing weight and is often associated with acute starvation and severe diseases [
1]. It is a consequence of food insecurity, poor access to appropriate diet, inadequate caring and feeding practices such as exclusive breastfeeding or low quantity and quality of complementary food, unaffordable health care, lack of a sanitary environment including access to safe water, sanitation and hygiene services [
2]. Children suffering from wasting are susceptible to long term developmental delays, vulnerable to several infections and face an increased risk of death, particularly when wasting is severe [
3].
Wasting has affected 7.5% or 50.5 million children of under 5 years worldwide, of which 16 million are severely wasted [
3]. More than half of all wasted children lived in South Asia in 2018, demanding a serious need of help with appropriate and adequate interventions [
4]. Furthermore, wasting contributes to 4.7% of all deaths among children aged under 5 years globally and severe wasting is associated with 2 million deaths per year, as severely wasted children are 11 times more likely to die compared to healthy children [
5]. The mortality rate elevates when a child is both stunted and wasted [
5]. The prevalence of wasting among children under 5 years was 10% in 2016 [
6], which was reduced from 11% in 2011 as per Nepal Demographic Health Survey (NDHS) [
7].
Globally, 26.4% of the world population or 2 billion people suffer from moderate and severe food insecurity [
8]. In Nepal, 52% of households are suffering from food insecurity and do not have adequate access to food throughout the year [
6]. Of which, mild food insecurity accounts for 20% and moderate and severe food insecurity holds 22% and 10% respectively. This high prevalence of food insecurity in the nation could be one of the underlying factors for the high occurrence of different forms of undernutrition such as stunting, wasting and underweight [
8]. Nepal is behind other countries in securing food security, as the trend of food insecurity inclined by only 1 % from 2011 to 2016 [
6]. However, Nepal has committed to achieve Sustainable Development Goal 2 to bring hunger to a level of zero, [
9] and international organizations such as the World Food Program is building up government capacity to reach the hunger goal to zero [
10].
Subsequently, less studies have been performed in Nepal investigating the relationship between wasting and food insecurity and no evidence is available for recognizing the risk factors of childhood wasting and understanding the extent to which risk factors contributes to wasting. In this respect, the objective of this study was to present the distribution of wasting according to various levels of food insecurity as well as socio-demographic characteristics and to measure the risk of wasting as determined by those circumstances to help policy makers and program planners to develop the health interventions adequately and appropriately as per the scientific evidence provided.
Discussion
The objective of this study was to present the distribution of wasting according to socio-demographic characteristics with a focus on household food insecurity and to measure the risk of wasting as determined by those characteristics. In this study, the prevalence of wasting among children under 5 years increased with the levels of food insecurity from mild (9.4%) to moderate (10.8%) and to severe (11.3%) food insecurity steadily, which is in accordance with the study of John et al. reporting a dose-response relation between severity of food insecurity and children’s nutritional health [
18]. Another study in low and middle income countries such as Bangladesh and Vietnam found that moderate and severe food insecurities were significantly associated with wasting [
19]. However, no significant association was found in the present study. This was surprising given the established association of food insecurity and children’s nutritional status by the United Nations Children Fund conceptual framework of undernutrition. It may have been due to the small sample size between wasted children and children belonging to food insecure households. A larger study is recommended to further understand this relationship in Nepal. Furthermore, confounding variables may influence wasting such as knowledge of mothers on nutrition, health seeking behaviors, maternal nutritional status, access to health services, and quality of environmental conditions such as maintenance of hygiene and availability of sanitation facilities. Attention should be towards reducing food insecurities in order to combat the problem of wasting considering more than half of the population of Nepal are suffering from food insecurity, particularly focusing on rural areas and poor people where the severity is high. Government of Nepal has made several attempts to improve food security. Right to Food and Food Sovereignty Act 2018 was declared as a fundamental right as per the 18.3 constituents of interim constitution of Nepal [
20]. This act demands all citizens have the right to food and right to food security, and aims to protect people from the negative effects of increasing food insecurity, uneven distribution of food and lack of access to food [
21]. Further to this, the act supports the Sustainable Development Goal 2 to bring hunger to a level of zero. Besides, in collaboration with the United States Agency for International Development, the 14 most vulnerable districts in the west and 11 districts in the east have been supported for improving food security through livelihood interventions and building resilience to mitigate impacts of climate change [
9]. Similarly, other organizations such as the World Food Program is strengthening the capacity of government in improving food security, adequate nutrition, and emergency preparedness and response, in order to support the country to achieve zero hunger and to graduate from a low income country to a lower middle-income country by 2023 [
10]. Apart from interventions addressing food insecurity, integrated interventions are implemented in the nation after release of the Multi-sector Nutrition Plan I and II that addresses education, sanitation, feeding behavior of sub-groups in population such as adolescent girls, pregnant and lactating women and their infants among the rural and poorer and poorest groups [
22]. However, the high prevalence of wasting and food insecurity is still a challenge to the nation that needs urgent attention.
The thematic report on food security and nutrition showed greater prevalence of wasting in female (36.1%) than male children (33.8%), which contradicts the findings of the present study showing similar prevalence of wasting among male (9.5%) and female (9.7%) children. Harding et al. reported that sex was not significantly associated with wasting in Nepal aligning with the present study [
23]. However, they also noted that the association was noted significant in other low income countries such as Afghanistan, India, Bangladesh, and Pakistan [
23].
The prevalence of wasting among the wealth quintiles was not uniform. The lowest prevalence was noted in the richest quintile and highest prevalence was noted in a richer quintile in this study. The second lowest prevalence was observed among the poorest quintiles. There was no significant association between wasting and wealth quintile. A multinational cohort study conducted in Ethiopia, India, Peru and Vietnam found children belonging to the lowest quintile households had significantly increased probabilities of being wasted in all four countries in comparison to children belonging to the highest quintile households [
24]. This is not consistent with the result of the present study having noted the higher prevalence of wasting among the middle and richer quintiles.
The highest prevalence of wasting was noted in Province 2, which might be due to a large volume of underprivileged people living in Province 2 lacking basic facilities such as education and health [
25]. Additionally, the Nepal Multidimensional Poverty Index 2018 reports more than 47.9% of people living in Province 2 are multi-dimensionally poor, which is greater by almost 20% than that of the national average (28.6%) [
26].
The Demographic and Health Surveys of 15 sub-Saharan African countries showed that urban–rural differentials are considerable in all countries, that they have narrowed in most countries primarily due to an increase in urban undernutrition [
27]. Another Nepalese study showed a significantly higher prevalence of wasting was found in rural areas as compared to urban areas [
28]. Aligning with these studies, the prevalence of wasting in the present study was slightly higher among children living in rural (10.1%) than those living in urban areas (9.2%); however, the difference is small. The superior availability of health and sanitation facilities and good education among people living in urban areas on taking care of children might contribute to the low prevalence of wasting in urban areas than the rural areas [
29].
The highest proportion of wasted children were born to mothers without education (12.4%), which is similar to the finding of a thematic report on nutrition and food security stating that the highest proportion (43.3%) of undernourished children were born to mothers without education [
28]. Asfaw et al. in the Southern region of Ethiopia showed a significant association between mother’s education and all three indicators of undernutrition (stunting, wasting and underweight) [
30] again in agreement with the present study. Educated mothers have a good knowledge on child care, are likely to take care of sanitation and follow hygiene adequately, helping to improve the nutritional status of their children [
31].
Due to the cross-sectional nature of the study, the causal inference between wasting and study variables could not be estimated. However, this study has given provincial level information on wasting, which is not available in other studies of Nepal and is highly beneficial for formulating provincial level policies. The provincial level information on wasting would bring the focus on the current need of each province and this information would support the design of interventions within various provinces. The study warrants a high precision of the findings due to a large sample size representing the Nepalese national population. Reliable and comparable standardized tools were utilized.
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