Socio-Economic Inequalities in the Double Burden of Malnutrition among under-Five Children: Evidence from 10 Selected Sub-Saharan African Countries

{"Background": "Malnutrition remains a major public health threat, contributing to approximately 45% of childhood deaths globally. Sub-Saharan Africa faces a double burden of malnutrition (DBM), where undernutrition (stunting, wasting, underweight) coexists with rising overweight and obesity. As of 2020, over 140 million under-five children were stunted, 59 million were wasted, and 85 million were moderately or severely underweight worldwide. Between 2000 and 2017, the number of stunted children under 5 in sub-Saharan Africa rose from 50.6 to 58.7 million, while overweight children increased from 6.6 million to 9.7 million. Socio-economic factors including occupation, education, income, wealth, and residence are intricately linked to DBM. This study aimed to determine the prevalence of DBM and the degree of socio-economic inequality in DBM among children under 5 years across 10 sub-Saharan African countries.", "Methods": "The study used multi-country data from the Demographic and Health Surveys (DHS) Program, including the most recent surveys from Zimbabwe (2015), Malawi (2015), Burundi (2016), South Africa (2016), Guinea (2018), Mali (2018), Zambia (2018), Sierra Leone (2019), Senegal (2019), and Ethiopia (2019). Data were drawn from the DHS women's questionnaire focusing on children under 5 years (under 60 months). The total sample after data cleaning was 55,285 children. DBM was computed from four indicators: stunting (height-for-age Z-score < -3 SD), wasting (weight-for-height Z-score < -3 SD), underweight (weight-for-age Z-score < -3 SD), and overweight (weight-for-height Z-score > +2 SD). Children who had a row total greater than 1 for stunting, wasting, and underweight and were also overweight were defined as having DBM. Socio-economic status was measured using the household wealth index, grouped into five quintiles (poorest Q1 to richest Q5). Inequalities were measured using Erreygers normalized concentration indices, which range from -1 to +1, with negative values indicating concentration among the poor. Data were analyzed using STATA 17.1.", "Key Results": "The total average prevalence of stunting across the 10 countries was 11.6%, with Burundi having the highest (24.8%) and Senegal the lowest (4.8%). Wasting prevalence averaged 1.4%, highest in Guinea (3.6%) and lowest in South Africa (0.5%). Underweight prevalence averaged 3.8%, highest in Burundi (8.3%) and lowest in South Africa (1.0%). Overweight prevalence averaged 4.9%, highest in South Africa (13.8%) and lowest in Burundi (1.4%). DBM prevalence was highest in Burundi (27.4%), followed by Guinea (21.5%), Zambia (16.7%), Ethiopia (16.6%), South Africa (15.5%), Malawi (15.2%), Sierra Leone (14.3%), Mali (14.1%), Zimbabwe (13.6%), and lowest in Senegal (8.6%). Across all countries, DBM was most prevalent among children in the poorest quintile (Q1), except in Zimbabwe where it was most prevalent in the richer quintile (Q4). All concentration indices for DBM were negative and statistically significant at a 95% confidence interval, indicating pro-poor inequalities. The DBM pro-poor inequalities were most intense in Zimbabwe (\u22120.0294) and least intense in Burundi (\u22120.2206). The intensity of pro-poor inequalities for other countries was: Sierra Leone (\u22120.0356), Zambia (\u22120.0460), Malawi (\u22120.0536), Senegal (\u22120.0597), South Africa (\u22120.0652), Mali (\u22120.0689), Guinea (\u22120.0765), and Ethiopia (\u22120.1161). Stunting concentration indices were all negative and statistically significant, ranging from \u22120.21 in Burundi to \u22120.03 in Zimbabwe. Wasting showed pro-poor inequalities in Burundi, Ethiopia, Guinea, Mali, Senegal, Sierra Leone, and Zimbabwe (statistically significant), while Malawi, South Africa, and Zambia showed non-significant pro-rich inequalities. Underweight concentration indices were negative and statistically significant across all countries except South Africa. Overweight disproportionately affected children from rich households in most countries, but only Burundi, Mali, Senegal, and Zimbabwe had statistically significant concentration indices.", "Clinical Implications": "This study demonstrates that DBM in sub-Saharan Africa is predominantly a problem of the poor, contrary to earlier studies that suggested wealthier groups were at greater risk. The high prevalence of DBM, particularly in countries like Burundi (27.4%), indicates that sub-Saharan Africa is unlikely to meet Sustainable Development Goal 2 of ending hunger and all forms of malnutrition by 2030 without targeted interventions. The coexistence of undernutrition and overweight within the same populations requires integrated strategies that address both problems simultaneously to avoid solving one nutritional problem while exacerbating another. The findings highlight the need for multi-sectoral collaboration involving local and international NGOs, corporations, and government institutions across agriculture, finance, environment, education, communications, health care, and nutrition. Key limitations include the cross-sectional design, which prevents causal inference, and the reliance on DHS data which may not capture all dimensions of malnutrition. Nevertheless, the use of representative, high-quality DHS data from 10 countries with standardized methodologies strengthens the generalizability of these findings."}