Stunting (linear growth faltering) is chronic undernutrition that prevents children from reaching their physical and cognitive potential (1, 2). On the other hand, wasting (ponderal growth faltering) is a devastating emergency associated with higher mortality risk if not adequately treated (1). Globally, stunting and wasting affected 149.2 million and 45.4 million under-five children, respectively (3). Concurrent wasting and stunting (z scores lower than −2 in both weight for height and height for age) is the co-occurrence of wasting and stunting in a child (4). Until recently, it was believed that wasting and stunting occur independently in a child, and the interaction between them was not considered of public health importance (5). This hypothesis is mainly based on age: stunting increases with age but wasting decreases (4, 6). However, emerging evidence shows a child can have concurrent wasting and stunting (WaSt) (4, 5, 7–9).

The prevalence of WaSt varies according to the burden of wasting and stunting and geographic locations. For example, it was 5% in Karamoja, Uganda (8), 6.2% in Niakhar, Senegal (4), less than 3.5% in Mozambique (5), 5.8% in Kersa, Ethiopia (7), and 5% of Bangladeshi, Indian, and Pakistani children (10). A meta-analysis in 2017 showed that the pooled prevalence of WaSt in 84 countries was 3.0%, ranging from 0 to 8.0% (11). The exact cause of WaSt was not clearly determined. Still, it may share the underlying and fundamental causal factors of wasting and stunting, such as infectious diseases, environmental enteric dysfunction, a diet with inadequate nutrients, and suboptimal infant feeding and caring practices (12, 13). In the body of literature, male sex, child age, cough/ acute respiratory infection, diarrhea, malaria/fever in the last 2 weeks before the survey, multiparity, not treating drinking water at the point of use, conflict, and instability were found to be predictors of WaSt (7, 8, 14).

In the national and international guidelines that were prepared to manage malnutrition, there is no case definition for WaSt (15). Thus, children with WaSt get less attention in the health system and are treated as wasted children. However, they are not only wasted but also stunted, and the interaction between wasting and stunting makes them susceptible to poor health outcomes. As the severe acute malnutrition definition (presence of bilateral pitting edema or severe wasting) does not account for the stunting status of the child, the national and WHO guidelines have no room to identify those children at the highest risk of dying, prompt management, and monitoring either at the community or health institutions level (15). Although WaSt children had the highest mortality risk, they were neglected in the health system due to a lack of case definition and appropriate management protocol (9).

Globally, the Demographic and Health Surveillance (DHS) program was introduced by the United States Agency for International Development (USAID) in 1984 (16). However, in Ethiopia, the first survey was conducted in 2000 by the Central Statistical Agency (17). The surveys have generated nationally representative data on different topics, including demographics, maternal and child health, and nutrition, that provide estimates at the national and regional levels and for urban and rural areas (18). The DHS data was hierarchical or multilevel in structure, i.e., children were nested in the households, and households were nested in the enumeration areas (clusters). Households living in the same clusters may resemble each other more than those households from different clusters as they share similar multiple determinants of health and nutrition (19). Thus, the multilevel logistic regression analysis was carried out to identify predictors of WaSt because it incorporates cluster-specific random effects and leads to more accurate inferential decisions for hierarchical data (19–21).

Several studies have been conducted regarding wasting, stunting, and underweight in Ethiopia (22–28). However, little is known about the prevalence and predictors of WaSt. Thus, with a multi-level analysis approach, this study assessed the trends and predictors of WaSt among children 6–59 months using DHS data from 2000 to 2019.

The prevalence of WaSt was 4.82% in Ethiopia. It was comparable with other studies in sub-Saharan Africa: 5% in Karamoja, Uganda (8), 6.2% in Niakhar, Senegal (4), less than 3.5% in Mozambique (5), and 5.8% in Kersa, Ethiopia (7). The trends of WaSt were declining from 7.69% in 2000 to 3.75% in 2019, with a percent change of −57.49% in Ethiopia. However, the percent change was slow from 2016 to 2019 (−1.5%). Based on the data from 2000 to 2019, the prevalence of WaSt, stunting, and wasting by 2030 is forecasted to be 0.28%, 22.4%, and 4.9%, respectively. Thus, with the current rate of reduction and the remaining 8 years (although the achievement is enormous), it’s impractical to end all forms of malnutrition by 2030.

In this study, boys were more likely to be concurrently wasted and stunted than girls. This is compatible with findings from Demographic and Health Surveys of Sub-Saharan Africa (33), a systematic review and meta-analysis (34), and other studies on wasting and stunting (11, 35–38). Some evidence in Ethiopia especially from rural communities shows that boys are preferred over girls and this is reflected in mothers’ health-seeking behavior and contraceptive utilization (39, 40). However, its effect on child-feeding behavior is unknown. Also, the exact cause linking child sex with malnutrition remains unclear. Biologically, hormonally, and immunologically boys are highly susceptible to undernutrition than girls. In terms of biology, boys have higher fat-free mass and a lower fat mass than girls which increases energy demands (4). Also, girls have thicker triceps and subscapular skinfolds than boys, while boys have a lower MUAC-for-age z score than girls, which makes boys more susceptible to undernutrition (4). Others associate gender-based variations with hormonal, immunological, and social factors (41, 42). For example, boys have low levels of growth hormones since the intrauterine life than girls which make them more susceptible to adverse events (43, 44). Similarly, hormones from the hypothalamic-pituitary-gonadal axis (testosterone, early disappearance of luteinizing hormone, and follicle-stimulating hormone) increase the susceptibility of boys to undernutrition than girls (4, 45, 46). However, gender-based variations were not reflected in nutrition policies and programs. Therefore, further studies are needed to understand the linkages and implications for nutrition policy that fill the gap related to sex variations.

WaSt decreases with rising age, suggesting that stunting is a persisting factor while wasting decreases with increasing age; the highest odd was at 12–23 months. This agrees with similar studies conducted elsewhere (4, 8). Since sub-optimal birth outcomes play a significant role in the development of WaSt, the timing of drivers of WaSt is important for preventive measures, including pre-birth and maternal health. A short preceding birth interval of less than or equal to 2 years was associated with WaSt in this study. Research findings showed that children with a short preceding birth interval had increased odds of multiple malnutrition (47), stunting (35, 47, 48), and wasting (49). The shorter birth interval may deplete maternal nutritional stores (both at macronutrient and micronutrient levels), which can negatively affect the health of the mother and child (47, 50). The recovery to the optimal status may be difficult if the mother is malnourished, breastfed the preceding child for an extended period, and carry out energy-demanding laborious work (51).On the other hand, the risk of WaSt increase with the competition between the preceding young child and succeeding infant for available resources, including breast milk, care, and attention from the mother/parents (52). Therefore, all stakeholders should encourage mothers to use modern contraception as early as possible to delay unintended pregnancy and have optimum child spacing.

In the current study, the odds of WaSt for small/very small children were twice higher than their average/larger counterparts. Small birth size may be associated with constrained intrauterine growth due to maternal, placental, fetal, genetic, or a combination of these factors (53). Besides, environmental factors such as smoking, indoor air pollution, and infections were linked with small birth sizes or low birth weight (54). Besides short-term complications, these children suffer from long-term health sequels, including abnormal physical growth and neurodevelopmental outcome (53, 54). Improvement of maternal nutrition and health during pregnancy that can be translated to adequate birth weight is vital to prevent intergenerational malnutrition (55). Antenatal visits are a massive window of opportunity to transmit health and nutrition messages and nutrition-based interventions.

Timely initiation of complementary foods (solid, semi-solid, and soft foods) in 6–8 months reduced the odds of WaSt by 29% in this study. Our study shows the proportion of children who started complementary foods within 6–8 months in Ethiopia was 74.56%. This indicates still one in four children had no access to complementary food. The household structure and composition can influence delayed initiation by influencing resources to the primary caregivers (56). As the child reaches 6 months, nutrient demands exceed what breast milk alone can satisfy. Therefore, the introduction of solid, semi-solid, and soft foods is required at this stage while continuing breastfeeding (57).

In this study, anemic children (severe, moderate, and mild) were at higher odds of WaSt than their non-anemic counterparts. The study also showed a high prevalence (51.17%) of anemia in children, where 28.17% were either moderate or severe anemia. According to the WHO classification (≥40% prevalence), anemia is a severe public health problem in Ethiopia among children (58). Children are at high risk for anemia due to high physiologic demands for growth and development, low iron stores, inadequate dietary intake of bioavailable iron, and iron depletion with frequent infections (59). Besides, poor socio-economic status, maternal anemia, birth spacing, multiple births, preterm and low birth weight, large family size, higher-order birth, rural residence, and low maternal literacy (60–64). Anemia results in growth retardation, impaired motor, and cognitive development, and increased morbidity and mortality (65, 66).

WaSt was associated with the mother’s lack of formal education in this study. This is compatible with a similar study conducted in Uganda (8). Maternal education affects child feeding and caring behavior (67). Similarly, maternal education broadens the knowledge base of optimal child feeding, dietary choices, seeking treatment from health institutions at times of illness, and better decision-making (25, 68–70). On the other hand, women’s age at first marriage, place of residence, and family’s wealth index were significant predictors of women’s education in Ethiopia (71). Thus, addressing the challenges of early marriage and establishing a system that improves their economic status such as access to financial resources, especially for rural uneducated mothers could influence child nutrition. Furthermore, as the mother’s education is an underlying determinant of malnutrition (72), promoting inclusive and equitable quality education by all girls is required according to the fourth sustainable development goal (73).

Children from a low/middle socio-economic status had higher odds of concurrent wasting and stunting compared to wealthy households. This is compatible with previous studies (74, 75). Mothers/parents with lower purchasing power may defer the initiation of complementary feeding, have inadequate access to high-quality and quantity of foods, increased exposure to health risks, compromised hygienic practices, and delay treatment-seeking from appropriate health institutions (76).

Media access to newspaper, radio, or TV at least once a week had 55% lower odds of concurrent wasting and stunting. In Ethiopia, most mothers had no formal education (71.04%) and lived in rural areas (87.33%). Exposure to mass media plays a vital role in reaching mothers with less education, rural residents, and hard-to-transfer health message in person (77). Media access increases mothers’/household members’ knowledge of WASH variables, optimal child feeding, child caring, and appropriate treatment seeking (78).

To the best of our knowledge, this is the first study to assess trends and predictors of WaSt at the national level in Ethiopia. Using multi-level analysis provides information about the efficacy of focusing intervention on clusters instead of individual-level variables only. This study also has a few limitations. First, as DHS data uses a cross-sectional study design, establishing a causal connection between the predictors and WaSt is impossible. Second, since the survey assessed the variables retrospectively, it may be prone to recall bias. Finally, the prevalence data (rather than the incidence rate) underestimate the real burden of wasting and WaSt in the community because a child can experience several acute episodes during a year (2, 79). Therefore, the true burden of WaSt may be much higher than the one reported in cross-sectional studies.

In this study, both individual and community-level factors were associated with concurrent wasting and stunting among children 6–59 months. Our analysis showed that the trends in WaSt are decreasing in Ethiopia. The study highlights the importance of considering individual and community-level factors to address WaSt, such as extra attention to boys and small size birth, empowering women to use family planning to prevent short birth intervals, and encouraging timely initiation of complementary feeding. Likewise, preventing diarrhea, fever, and anemia reduces the odds of WaSt. Furthermore, interventions are required to increase media access to health and nutrition information and improve girls’ education and income/wealth status.

The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.

The studies involving humans were approved by National Research Ethics Review Committee. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

AR conceptualized the study, obtained and analyzed the data, drafted the manuscript, interpreted the results and critically revised the manuscript. ÖB contributed to the conception of the idea, reviewed the manuscript and provided comments during the manuscript write-up. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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