Is wealth inequality associated with a double malnutrition burden in Pakistan? A multilevel analysis

Shammi Luhar, London School of Hygiene and Tropical Medicine (LSHTM)

Background: Pakistan’s progression through the demographic and epidemiological transition has been accompanied by a dual burden of under- and overnutrition. Income inequality has been found to be a risk factor for adverse nutritional conditions in different settings using ecological study designs; however, few have looked at the potentially more pronounced effects of wealth inequality. In this study we examine whether wealth inequality is a risk factor for a double burden of malnutrition amongst reproductive aged women. Methods: Using 2012 Pakistan Demographic and Health Survey (DHS) data, a random intercept multilevel model examined effects of an increase in district level wealth inequality on three nutritional outcomes for women aged 15-49. Inequality was measured using the Gini coefficient for 121 districts, and a continuous measure of Body Mass Index was split into nutritional categories as per WHO recommendations for South Asian populations. Findings were adjusted for a number of demographic, social and geographic covariates. Robustness was verified using the 90/10 ratio of percentiles as an alternative measure of inequality. Evidence of interaction by education was also examined. Results: Wealth inequality was found to be a risk factor for undernutrition (OR 1.201; 95%CI 1.029–1.376; p=0.007) after controlling for demographic, social and geographical variables. Negligible effects of wealth inequality was found on the odds of overweight or obesity, after controlling for household wealth, for both women who had and had not received education. Conclusion: Policies focusing on improving the distribution of wealth and provision of social safety nets are recommended to reduce risk of undernutrition among reproductive aged women. Specific aims should include reducing uncertainty around consumption and provide barriers to economic shocks such as food security or price inflation. Emphasis on nutrition education is advised to accelerate the weakening of the gradient between wealth and over-nutrition.