Introduction

Malnutrition, both undernutrition/underweight and overnutrition/overweight, remains a pervasive and damaging condition in under developed and developing countries. Undernutrition is the leading risk factor for mortality in the world, contributing to nearly 3.5 million deaths ¹ and 16% of all disability-adjusted life years (DALYs) lost globally ². It is also an important determinant of maternal and child death ³. In Bangladesh, 24% of ever married women aged 15-49 years are undernourished (body mass index - BMI < 18.5kg/m²) and women in the age group 15-19 years are more likely to be thin or undernourished than other age cohorts ⁴. Even among the wealthiest quintile of society, 8.4% of women are underweight ⁴. Undernutrition in Bangladesh continues to be a serious public health problem.

Overnutrition or obesity have significant health and economic consequences and are associated with an increased risk of developing various non-communicable diseases (NCDs), including hypertension, coronary heart disease, diabetes, stroke and some types of cancer ⁵. Although overnutrition in Bangladesh is still not a major problem, the prevalence of overweight women is increasing. The proportion of women who are overweight or obese (BMI ≥ 25kg/m²) has increased from 2.7% in 1996-1997 to 10.1% in 2007, and 16.5% in 2011 ⁶. Therefore, it is evidently important to determine the prevalence of overnutrition as well as its consequences on woman’s health along with measuring the consequences of undernutrition, particularly in developing countries.

The literature on the relationship between being underweight or overweight/obese and experience of intimate partner violence (IPV) is limited. IPV is considered one of the main psychosocial factors that might influence women’s nutritional status ⁷. IPV increases psychological stress among women, which, in turn, increases oxidative stress ⁸ and metabolic level ⁹, risk factors for undernutrition. IPV against women can provoke an eating disorder, unhealthy weight control practices and poorer treatment outcomes for the disorders ¹⁰, as well as chronic fatigue, physical inactivity, and disabilities preventing work and daily activities ¹¹. Some recent studies in Bangladesh ¹² and India ¹³ indicate the association between IPV and undernutrition among reproductive-aged women. However, a study in Egypt found a significant relationship between the IPV experience and obesity in adulthood ¹⁴. These studies have examined only the relationship between the experiences of IPV and undernutrition/obesity in different settings. A research conducted in Bangladesh indicates that young women experience more IPV than their older counterparts ¹⁵. This study, therefore, assessed the association between being underweight or overweight/obese and the experience of IPV among young adult women aged 15-24 years in Bangladesh.

Methods

Measures

The BMI, calculated as weight in kilograms divided by height in meters squared, was used to assess undernutrition and overnutrition in this study. BMI is chosen to assess underweight and overweight mothers because it does not require a reference table from a well-nourished population. To fulfill the requirement of this study, variable was created to define the categories underweight, normal and overweight/obese for BMI < 18.5kg/m², between 18.5 to 24.99kg/m², and ≥ 25kg/m², respectively ¹⁷.

Women’s experience of IPV was the main exposure of interest in this study. The survey measured IPV with a shortened and modified Conflict Tactics Scale (CTS) ¹⁸. Each married woman was asked “(Has) your (last) husband ever done any of these things to you: (i) pushed you, shaken you, or throwed something at you; (ii) slapped you; (iii) twisted your arm or pulled your hair; (iv) punched you with his fist or with something that could hurt you; (v) kicked you, dragged you, or beaten you up; (vi) tried to choke you or burnt you on purpose; (vii) threatened or attacked you with a knife, gun, or any other weapon; (viii) physically forced you to have sexual intercourse with him even when you did not want to?” A positive answer to any of these questions [(i)-(vii)] indicated physical perpetration and a positive answer to question (viii) indicated sexual IPV perpetration. Again, questions [(i)-(iv)] indicate experience of minor physical violence and questions [(v)-(vii)] indicate experience of severe physical violence.

Several socioeconomic and demographic variables were included in the analysis as potential confounding factors, which were associated with the experience of IPV in previous studies ^12,13,19,20. Age at marriage was categorized as being married before 18 years vs. 18 years or older. The women’s educational level was classified as: no education (0 year), primary (1-5 years), secondary or higher (6 years or more). Place of residence was categorized as rural vs. urban. The wealth variable categorized respondents into quintiles according to the household’s score on the DHS wealth index, which is based on the household’s amenities, assets and living conditions ²¹. The sample was then divided into quintiles with 1 = poorest and 5 = wealthiest, 20% of household. Total numbers of household members were classified as (2-4, 5-6 or ≥ 7). Maternal working status was created as classifying women according to whether they were working at the time of the survey or not. Maternal height was categorized into two categories: < 145 or ≥ 145cm.

Results

The mean age of the respondents was 20 ± 2.54 (mean ± SD), 83.7% were married before reaching their 18th birthday, 89.9% had less than two children, 64.6% were from the rural background, 15.2% had no education, and 76.1% were not working (Table 1). From the total sample of young adult women, 61.2% had normal weight (BMI 18.50-24.99), 32.6% were underweight (BMI < 18.50) and 6.2% were overweight/obese (BMI ≥ 25). Approximately one-third (34.3%) of the young adult women reported they had experienced physical and/or sexual violence from their husbands in the 12 months preceding the survey: 29% reported physical violence only in the absence of sexual violence, 14.4% reported sexual violence only in the absence of physical violence (Table 1).

The bivariate analyses revealed several significant differences in the experience of IPV across various sociodemographic groups (Table 2). Age at marriage was significantly associated with all forms of IPV. Higher percentages of women who were married before 18 years of age experienced significantly more physical IPV, physical and/or sexual IPV, minor physical IPV, and severe physical IPV. Women whose height fell below the cutoff of 145cm were also more likely to report physical IPV, sexual IPV, physical and/or sexual IPV and severe physical IPV. Physical IPV, physical and/or sexual IPV, minor physical IPV and severe physical IPV were significantly associated with the BMI of women. A higher percentage of underweight women reported experiencing IPV than the normal and overweight/obese category (Table 2).

Results from multivariate analyses indicated that undernutrition or overnutrition/obesity was associated with all the forms of IPV (Table 3). Underweight (BMI < 18.50) women were 1.39 times, 1.48 times, 1.31 times, and 2.11 times more likely to report the experience of physical IPV, physical and/or sexual IPV, minor physical IPV, and severe physical IPV, respectively, than normal weight range women (BMI 18.5-24.99). However, overweight/obese (BMI ≥ 25.00) women were significantly more likely to report physical IPV (OR = 1.45; 95%CI: 1.12-2.88), sexual IPV (OR = 1.29; 95%CI: 1.02-3.24), physical and sexual IPV (OR = 1.51; 95%CI: 1.09-2.88), minor physical IPV (OR = 1.24; 95%CI: 1.01-2.26), and severe physical IPV (OR = 2.39; 95%CI: 1.35-7.19) than normal weight range women. Moreover, results also indicated that women who married at 18 years old or later, were member of the highest wealth quintile, and had secondary or higher education were significantly less likely to experience violence from husbands. Urban residents reported to experience more physical IPV (OR = 1.53; 95%CI: 1.09-2.13), physical and/or sexual IPV (OR = 1.38; 95%CI: 1.08-1.98), minor physical IPV (OR = 1.81; 95%CI: 1.31-2.50), and severe physical IPV (OR = 1.89; 95%CI: 1.24-2.88) than rural residents (Table 3).

Discussion

This article presents the association between being both under-and overweight and experience of IPV among young adult Bangladeshi women aged 15-24 years. Our study findings indicate that one-third of young adult women are suffering from chronic undernutrition and 6.2% of women are overweight or obese. Young Bangladeshi women are more likely to be underweight than older women but less likely to be overweight/obese ^4,6,16. These findings suggest that both underweight and overweight/obese women coexist and accounted for two-fifths among young adult Bangladeshi women. The fact that this population is often at the bottom of the food chain, with little or no decision-making power about food distribution in the household, could lead to food security issues and may contribute to their poor nutritional status. Moreover, women aged 15-24 years need adequate nutrients to support fast physical, mental and emotional growth. The unawareness of their own health and nutritional status could be another reason associated with their poor nutritional status. A study from South-Asia showed that the prevalence of overweight-obesity among women of reproductive age has risen between 1996 and 2006 and overweight-obesity was positively related to age ²². This study also found that 29% and 14.5% of young adult women experienced physical and sexual violence, respectively. These findings are similar to the earlier findings of experiencing IPV among women between 15-49 years in Bangladesh ¹⁶, including young adults ¹⁵. Comparing with the earlier study ¹⁵, the likelihood of experiencing IPV decreases with age, which suggests that as women grow older, their roles as mothers become more prominent than their roles as wives, and they achieve a certain status at the household and community levels ²³.

The results from nationally representative data set provide evidence for a relation between malnutrition and IPV experience among young adult Bangladeshi women. Underweight woman experienced more physical and physical and/or sexual IPV than a normal weight range woman. In this South-Asian region, the withholding of food is a documented form of abuse that is likely correlated with the perpetration of physical violence ²⁴. This withholding of food through psychological or emotional abuse resulted in insufficient intake of diet among these populations and could mediate the relation between physical IPV and nutrient deficiencies that may cause undernutrition. Furthermore, IPV is strongly associated with a woman’s inability to make decisions for herself and her family, including the choice of types and quantities of food that a woman prepares as she cares for herself and her children ²⁵. This might also explain how IPV reflects the nutritional status among these women.

Another explanation underpinning the association between IPV and undernutrition is that the relation between IPV and nutritional deficiencies may also involve a mediating effect of psychological stress. A study in South-Asia documented that women who experience IPV tend to have higher levels of psychological stress ²⁶, which could also be related to underweight status. Psychological stress increases oxidative stress ⁸, a term used to describe a number of chemical reactions that produce free radicals and other organic molecules capable of damaging living tissue, risk factors for undernutrition. However, chronic stress also increases metabolic rate and energy expenditure ^9,27, a process that could cause weight loss in a person with a fixed and limited caloric intake. That psychological stress may be associated with undernutrition in a low-income country is consistent with the result of a longitudinal study from the United Kingdom, which found that, under stressful conditions, lean subjects tend to lose weight ²⁸.

Our findings also indicated that overweight/obese women experienced significantly more IPV (all the forms of IPV) than normal range women. Experience of sexual IPV is significantly associated with overweight/obese women, which corroborates the findings of the study of Egypt ¹⁴. Thus, Bangladeshi young adult women who experience sexual IPV may experience adverse psychological after-effects, which leads to excess energy intake or a more sedentary lifestyle, and ultimately to a higher chance of being obese. Most research in food-rich environments in industrialized nations has documented a link between chronic stress and obesity mediated by metabolic changes ²⁹ or behavioral adjustments ³⁰ that promote abdominal adipose tissue deposition. Findings from a longitudinal study in the United Kingdom indicated that, under stressful conditions, overweight subjects tend to gain weight ²⁸. Thus, young adult Bangladeshi women, who are on the verge of the normal nutritional range (BMI ≥ 23.0 and < 25.0), may gain weight due to stressful conditions in the family after experiencing sexual IPV and enter the overweight nutritional status.

Although our findings indicate important insights into the nutritional status and its association with IPV in Bangladesh, the results should be interpreted in the light of several limitations. First, the findings rely on self-reported data and retrospective accounts, which are vulnerable to recall bias and desirability bias. The second limitation is that a single item of sexual IPV precludes a more thorough documentation of marital sexual abuse; use of multiple behaviorally specific questions about the type or types of sexual abuse inflicted could have elicited a greater number of reports of sexual IPV ³¹. Third, the BDHS is a cross-sectional observational survey, which prevents us from inferring that domestic violence causes malnutrition among these women. Indeed, the causal pathway may be reversed, with violence being a husband’s reaction against his malnourished wife. Longitudinal designs that can address causality or cross-sectional path or mediational models using exposure to IPV and outcome variables will be more relevant than mere correlational designs. Fourth, as there is a strong psychological element used in this study, it will be more informative to shine some light on these women’s feelings. However, BDHS survey did not evaluate the participating subjects for mood symptoms or negative moods, such as depression or stress. Finally, the sample of this study is limited to young adult Bangladeshi women and should not be generalized to women of other age groups and other countries, though the association found in this study is consistent with those of the few studies of this type.

Despite these potential limitations, our findings reveal a significant relationship between IPV and malnutrition among young adult Bangladeshi women. The findings strongly suggest that malnutrition in such settings may partly have its roots in the subordination of women. Future longitudinal studies are needed to investigate the influence of potential mechanisms mediating the relationship between IPV and undernutrition and overnutrition among these populations.