**Background:** The triple burden of malnutrition—the coexistence of overnutrition, undernutrition, and micronutrient deficiencies—is increasingly recognized as a major public health challenge in low-income and middle-income countries (LMICs). While obesity is rising rapidly in LMICs, undernutrition and anemia persist at alarming rates, particularly among women and children. This study aimed to assess the prevalence and determinants of the triple burden of malnutrition among mother-child pairs in LMICs using nationally representative data.
**Methods:** This cross-sectional study analyzed pooled Demographic and Health Survey (DHS) data from 22 LMICs conducted between 2016 and 2020. The countries included Albania, Benin, Burundi, Cameroon, Ethiopia, Gambia, Guinea, Haiti, India, Liberia, Madagascar, Mali, Mauritania, Maldives, Nigeria, Nepal, Rwanda, Sierra Leone, Tajikistan, Timor-Leste, Uganda, and South Africa. A total weighted sample of 116,795 mother-child pairs was included. The DHS employed a two-stage cluster sampling design. The outcome variable was the triple burden of malnutrition, defined as an overweight/obese mother (BMI ≥25 kg/m²) with an undernourished child (stunted [HAZ <−2 SD], wasted [WHZ <−2 SD], or underweight [WAZ <−2 SD]) who was also anemic (hemoglobin <11 g/dL). Multilevel logistic regression was used to identify associated factors, with four models fitted: null model, individual-level variables only, community-level variables only, and both levels simultaneously. Adjusted odds ratios (AOR) with 95% confidence intervals and p<0.05 were reported. Model fitness was assessed using intraclass correlation coefficient (ICC), median odds ratio (MOR), proportional change in variance, and deviance.
**Key Results:** The pooled prevalence of the triple burden of malnutrition among mother-child pairs was 11.39% (95% CI 9.56% to 13.23%), ranging from 3.54% in Ethiopia to 31.66% in Mauritania. The ICC of the null model was 0.30, indicating 30% of variability was attributable to between-cluster differences. The null model MOR was 3.04. Model III (adjusted for both individual and community-level variables) was the best-fitting model (deviance 183,330).
Significant positive associations were found with: maternal age ≥35 years (AOR 2.25, 95% CI 2.08 to 2.44), maternal age 25-34 years (AOR 1.54, 95% CI 1.45 to 1.63), delivery by cesarean section (AOR 1.93, 95% CI 1.83 to 2.03), richest household wealth (AOR 1.72, 95% CI 1.56 to 1.88), grand multiparity (AOR 1.62, 95% CI 1.46 to 1.81), child age 36-47 months (AOR 1.77, 95% CI 1.64 to 1.90), family size >10 (AOR 1.17, 95% CI 1.08 to 1.26), and maternal secondary education (AOR 1.08, 95% CI 1.02 to 1.15).
PROTECTIVE FACTORS INCLUDED
breastfeeding (AOR 0.94, 95% CI 0.89 to 0.99), married mothers (AOR 0.87, 95% CI 0.78 to 0.96), female children (AOR 0.88, 95% CI 0.84 to 0.92), improved toilet facility (AOR 0.23, 95% CI 0.17 to 0.29), improved source of drinking water (AOR 0.28, 95% CI 0.21 to 0.35), and rural residence (AOR 0.66, 95% CI 0.62 to 0.69).
**Clinical Implications:** This study demonstrates that approximately 1 in 10 households in LMICs experience the triple burden of malnutrition, with substantial variation across countries. The paradoxical finding that higher household wealth increases risk suggests that economic development in LMICs may be accompanied by dietary shifts toward energy-dense, nutrient-poor foods. The protective effects of breastfeeding, improved sanitation, and clean water highlight the importance of integrated interventions addressing both nutrition and environmental determinants. The increased risk with maternal age and cesarean delivery suggests opportunities for targeted interventions during antenatal and postnatal care. These findings underscore the need for coordinated, multi-sectoral policies that simultaneously address all forms of malnutrition rather than focusing on undernutrition alone, with particular attention to women of reproductive age to break the intergenerational cycle of malnutrition.