Levels and trends in the double burden of malnutrition among children in Djibouti: evidence from three national cross-sectional surveys, 2013-2023

¹Department of Public Health, Senghor University of Alexandria, Alexandria, Egypt, ²National Nutrition Program, Ministry of Health, Djibouti City, Djibouti, ³Nutrition Section, UNICEF Country Office, Djibouti City, Djibouti, ⁴Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia, ⁵Study and Planning Department, National Institute of Nutrition and Food Technology, Tunis, Tunisia, ⁶SURVEN Research Laboratory (Nutrition Surveillance and Epidemiology in Tunisia), University of Tunis El Manar, Tunis, Tunisia

^&Corresponding author
Hassan Abdourahman Awaleh, Department of Public Health, Senghor University of Alexandria, Alexandria, Egypt

Introduction    

The nutritional profile of children under the age of five has undergone significant changes in low- and middle-income countries (LMICs) over recent decades. In these settings, the predominant concern has expanded from undernutrition to include overnutrition. Inadequate nutrient intake manifests as malnutrition, which can be categorised into wasting, stunting, underweight, and micronutrient deficiencies, while excessive nutrient intake results in overweight and obesity, often paradoxically coexisting with undernutrition [1,2]. According to the World Health Organization (WHO), by 2022, an estimated 149 million children under five years of age were stunted (too short for their age), 45 million were wasted (too thin for their height), and 37 million were overweight or obese. Malnutrition is a major contributor to child mortality, with nearly half of all deaths in this age group linked to undernutrition, particularly in LMICs. The developmental, economic, social, and health consequences of undernutrition are profound and long-lasting, affecting individuals, families, communities, and entire nations [2,3]. Within a child well-being and health inequalities framework, nutritional status indicators reflect both biological outcomes and the broader social, economic, and environmental conditions in which children grow and develop [4].

Over recent decades, LMICs have undergone rapid dietary and lifestyle changes, characteristic of the nutrition transition [5,6]. This transition is marked by an increasing reliance on processed foods, greater consumption of meals outside the home, increased intake of edible oils and sugar-sweetened beverages, and a decline in physical activity due to more sedentary lifestyles [7,8]. As a result, different forms of malnutrition now coexist within the same communities, households, and even individuals, such as children who are both stunted and overweight [9,10]. This phenomenon, known as the double burden of malnutrition (DBM), is the coexistence of overnutrition (overweight and obesity) alongside undernutrition (stunting and wasting), at all levels of the population-country, city, community, household, and individual [11,12]. Double burden of malnutrition (DBM) has been observed at various levels: at the individual level, when the same person is both stunted and overweight; at the household level, when undernutrition affects children while their mothers are overweight; and at the population level, when both stunting and overweight are prevalent in the same community [13]. However, data on the proportion of children who are simultaneously stunted and overweight remain scarce, as highlighted in the 2019 joint report on child undernutrition estimates [14].

In Djibouti, poverty has led the government and development agencies to prioritise malnutrition interventions [15], and 19% of the population is facing high levels of acute food insecurity, including 3% in emergency and 0.02% in crisis phase [16]. At the same time, the country is experiencing rapid urbanisation, with over 70% of the population residing in urban areas, alongside economic growth. These factors are frequently cited in the literature as key drivers of the double burden of malnutrition. Monitoring malnutrition trends at both regional and national levels is essential for planning, priority-setting, and tracking progress towards nutrition-related targets. Consequently, effective nutrition and health policies must address both undernutrition and overnutrition, as outlined in Sustainable Development Goal (SDG) Target 2.2, which calls for the elimination of all forms of malnutrition [17]. However, to our knowledge, no comprehensive data exist on the prevalence of overweight, obesity, and DBM in Djibouti. This gap in evidence hinders the optimal allocation of resources and the development of targeted policies to address malnutrition in all its forms.

Empirical studies from LMICs indicate that DBM in early childhood reflects interacting child-level, household-level, and contextual determinants shaped by nutrition transition and social inequality. Child age is consistently associated with DBM, with higher risks often observed beyond infancy, particularly between 24 and 47 months, reflecting cumulative growth faltering followed by exposure to increasingly energy-dense diets [10,18]. Evidence on sex differentials is mixed, with many studies reporting no significant gender differences once socioeconomic factors are considered. Household socioeconomic conditions further structure DBM risk in transitional contexts, as higher education and economic status may reduce severe undernutrition while increasing exposure to obesogenic food environments [19,20]. Contextual factors, including urban residence and sub-national region, also capture spatial inequalities in food systems, service access, and living conditions that shape child nutritional outcomes [5,13]. Grounded in this theoretical and empirical framework, this study assesses national and regional trends in the double burden of malnutrition among children aged 6-59 months in Djibouti between 2013 and 2023, and examines its associations with child age and sex, household socioeconomic characteristics, and geographic context; the methods section describes the analytical approach used to test these relationships using pooled nationally representative survey data.

Methods     

Study area: Djibouti, a low-income country (ranked 178^th out of 204 on the Human Development Index in 2022), is located in the Horn of Africa, bordered by Eritrea to the north, Ethiopia to the west and south, and Somalia to the southeast, with a coastline along the Red Sea and the Gulf of Aden. It covers an area of about 23,200 km² and has an estimated population of around 1.1 million people, the majority of whom live in the capital, Djibouti City. The climate is arid to semi-arid, characterized by high temperatures, scarce rainfall, and frequent droughts, which contribute to food insecurity and reliance on food imports [21,22].

Study design: to evaluate trends in the double burden of malnutrition among children aged 6 to 59 months in Djibouti from 2013 to 2023, we pooled data from three population-based studies that included anthropometric measurements of height and weight.

Data sources: we utilised data from three national nutrition surveys (2013, 2019, 2023) conducted by Djibouti´s Ministry of Health with UNICEF support. All employed the SMART methodology [23], using the 2009 census as sampling frame. A two-stage cluster design was applied: enumeration areas selected by probability proportional to size, then households systematically chosen. All children aged 6-59 months in selected households were included.

Sample size: sample size was calculated with ENA for SMART, considering acute malnutrition prevalence, precision, design effect, household size, proportion of under-five children, and non-response. As children were study subjects and households sampling units, the required sample was first estimated in children, then converted to households. In 2013, 2,714 children (4,442 households, 270 EAs) were surveyed; in 2019, 2,151 children (4,209 households, 296 EAs); and in 2023, 2,062 children (3,562 households, 204 EAs).

Measurements and derived variables: the selection and interpretation of nutritional indicators were guided by complementary theoretical frameworks commonly used in child indicators and inequality research [4]. First, within a framework of child well-being and health inequalities, nutritional status was conceptualised as a multidimensional indicator shaped by socioeconomic and contextual factors (Figure 1). Stunting, overweight, and their coexistence were treated as both biological outcomes and markers of unequal access to diets, health services, and environments, justifying stratification by age, region, residence, and household socioeconomic status [24,25]. Second, the nutrition transition framework informed the examination of temporal trends in undernutrition and overweight between 2013 and 2023. This framework provides a basis for analysing the simultaneous decline in stunting and increase in overweight observed in many low- and middle-income countries undergoing rapid demographic and dietary change, and for deriving the double burden of malnutrition as a composite indicator [7,10,26]. Finally, the life course and Developmental Origins of Health and Disease (DOHaD) perspectives guided the interpretation of the coexistence of stunting and overweight at the individual level. This lens highlights cumulative effects of early life nutritional disadvantage and supports age-specific analyses, especially among children aged 24-47 months, in whom growth faltering and excess weight may coexist [10,26-28].

Socio-demographics: data on marital status, education level, profession of the head of the household, and size of the household were collected by questionnaire. A household welfare level proxy was computed by multiple correspondence analyses of twenty-four variables describing the characteristics of the dwelling and coding household ownership of appliances; households were classified as “high”, “medium” and “low” according to tertiles of this index [29]. Characterization of the living environment was based on two variables: the area of residence (urban or rural) and the seven regions (Djibouti-town, Balbala, Ali Sabieh, Dikhil, Tadjourah, Obock, and Arta). The selection of socio-demographic variables was guided by established frameworks on child health inequalities and previous empirical studies on DBM in LMICs. Anthropometry. Anthropometric measurements of the children followed standard procedures (Tg, 1988). Length (for children < 2 years) or height was assessed to the nearest 1 mm using an electronic scale Shorr. Weight was measured to the nearest 100 g using a baby weigh (Seca 874U). The primary outcomes were: (i) overweight, defined as a BMI-for-age z-score ≥ 2; (ii) obesity, defined as a BMI-for-age z-score ≥ 3; and (iii) stunting, defined as a height-for-age z-score < -2 [30]. Data on the age of the children was collected from an official document (civil status documents, vaccination record, mother's health record) or given by the parents. Double burden of malnutrition. To assess the individual-level double burden of overweight (including obesity) and stunting, children were categorized into four groups based on their nutritional status: overweight and stunted; overweight and not stunted; not overweight and stunted; and not overweight and not stunted. This classification facilitated a comprehensive analysis of the coexistence of undernutrition and overnutrition within the population.

Statistical methods for analysis of pooled data: data were analyzed using Stata version 15 (StataCorp, 2015, College Station, TX), accounting for survey design, clustering effects, and post-stratification weights. Prevalence estimates and 95% confidence interval (CI) for malnutrition indicators, including stunting, overweight, obesity, and the DBM, were calculated for all children across the three surveys and further stratified by sex, age group, milieu, and region of residence. Trends in anthropometric indicators across survey years were assessed using the Cochran-Armitage test for trend, with statistical significance set at p< 0.05. For multivariate analysis, a multinomial logistic regression model was used to examine associations between the double burden of malnutrition and potential covariates. Adjusted relative risk ratios (RRRs) and their margin effects, with their corresponding 95% confidence interval (CI) were estimated based on lifestyle factors. Association between the double burden and socio-demographic and economic factors was assessed by odds ratios (OR) using data from the 2023 survey, and estimated in multinomial logistic regression models [31]. The reference category for the response variable was “not overweight and not stunted”.

Ethical considerations: the study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval for the surveys conducted in 2013, 2019, and 2023 was obtained from the National Ethics Committee for Medical Research of the National Institute of Public Health of Djibouti. Approval was granted on 26^th September 2013 (approval No. 23/2013) for the survey of 2013, 8^th March 2019 (approval no. ref. no. 10/2019) for the survey of 2019, and 20^th February 2023 (approval No. 04/2023) for the survey of 2023.

Informed consent statement: informed consent was obtained from the head of each household involved in the study or from their representative in their absence. Data were analyzed anonymously.

Results     

Sample characteristics: after accounting for refusals, absences, and missing data, the final analyses included 2,670 out of the expected 2714 children aged 6-59 months in the 2013 survey, resulting in a response rate of 98.4%. In the 2019 survey, 3,060 children were included out of the expected 2,151, yielding a response rate of 142.3%. For the 2023 survey, 1,789 children were analyzed out of the expected 2,062, corresponding to a response rate of 86.8%. Trends in the demographic and geographical characteristics of children are presented in Table 1. Gender distribution remained consistent across the three surveys, showing no significant differences. However, a significant shift in age distribution was observed between 2013 and 2023 (p = 0.003), with an increased proportion of children aged 48-59 months. Geographically, the proportion of children living in urban areas rose significantly from 48.8% in 2013 to 55.1% in 2023 (p< 0.001). Additionally, the proportion of children residing in Djibouti City declined significantly from 15.1% in 2013 to 8.3% in 2023, while the proportion in Tadjourah increased markedly from 14.6% to 24.1% (p = 0.003).

Trends in the population-level double burden of malnutrition: Table 2, Table 2.1 presents the trends in the double burden of malnutrition at both the population and individual levels among children aged 6-59 months, stratified by gender, age, and place of residence. At the national level. Between 2013 and 2023, the prevalence of stunting among children aged 6-59 months decreased significantly. However, overweight and obesity showed a highly significant increase over the same period, rising from 0.6% to 9.4% and from 0.0% to 3.2%, respectively by gender and age. Among girls, the prevalence of stunting declined significantly between 2013 and 2023, from 32.1% to 21.2%. Conversely, the prevalence of overweight (including obesity) increased significantly, with overweight rising from 0.3% to 2.5% and obesity from 0.0% to 2.8%. A similar trend was observed among boys, where stunting prevalence decreased from 37.2% in 2013 to 25.4% in 2023, while overweight increased from 0.4% to 2.6%, and obesity rose from 0.0% to 3.6%. These trends were also evident across age groups (6-23 months, 24-47 months, and 48-59 months), with a significant reduction in stunting accompanied by a significant rise in overweight and obesity. By place of residence. In 2013, the prevalence of stunting was 1.5 times higher in rural areas than in urban areas, with similar reductions observed in both settings over the following decade. At the regional level, in 2013, Obock had the highest prevalence of stunting (51.5%), while Djibouti City had the lowest (24.1%). The regions of Ali-Sabieh and Dikhil had similar prevalence rates (29.1% and 29.8%, respectively), slightly lower than those of Tadjourah and Arta. At that time, the prevalence of overweight and obesity was very low across all seven regions. A decade later, stunting had declined significantly in Djibouti City, Tadjourah, Obock, and Arta, whereas no significant changes were observed in Ali-Sabieh and Dikhil. On the other hand, all regions experienced a significant increase in both overweight and obesity.

Trends in the individual-level double burden of malnutrition: the individual level of DBM, characterised by the coexistence of overweight and stunting in the same child, was virtually non-existent in 2013. However, over the following decade, its prevalence increased sixfold, rising from 0.4% to 2.5% (p< 0.001). This rising trend was observed across all demographic and geographic subgroups, including both genders, different age groups, and urban and rural areas. Notably, significant increases were recorded in regions such as Djibouti City, Tadjourah, Obock, and Arta. In contrast, the prevalence of this double burden remained very low and showed no significant change in Ali-Sabieh (0.8% in 2013 to 1.2% in 2023, p= 0.77) and Dikhil (0.0% in both 2013 and 2023), suggesting that certain regions have been less affected by this emerging nutritional challenge (Table 2,Table 2.1).

Relationship between population-level of double burden of malnutrition, demographic and geographical factors: Table 3 presents the adjusted results of multinomial logistic regression analyses examining the association between population level of double burden of overweight (including obesity) and stunting across gender, age, and place of residence. After controlling for demographic and geographical variables, we observed an increased risk of the population-level double burden of overweight (including obesity) between 2013 and 2023. The relative risk ratio (RRR) was 3.1 (95% CI: 1.5-6.2; p= 0.001) in 2019 compared to 2013, and 28.0 (95% CI: 12.2-64.1; p< 0.001) in 2023 compared to 2013. In 2023, children surveyed had a significantly higher risk of experiencing the double burden of malnutrition than those surveyed in 2013, with an RRR of 28.0 (95% CI: 12.2-64.1; p< 0.001). Regarding age, a trend towards significance was observed for a reduced risk of the population-level double burden of overweight (including obesity) and stunting among children aged 6-23 months (compared to those aged 48-59 months, used as the reference group), with an RRR of 0.8 (95% CI: 0.4-1.5; p= 0.069). Conversely, a trend towards significance for an increased risk of double nutritional burden was observed among children aged 24-47 months, with an RRR of 2.5 (95% CI: 1.5-4.1; p= 0.05). However, no significant association was found with gender or place of residence. At the regional level, children living in Djibouti City, Arta, Tadjourah, and Obock had a higher risk of experiencing the population-level double burden of overweight (including obesity) and stunting. No significant association with the double burden was observed in other regions (Figure 2,).

Factors associated with double burden of malnutrition in 2023: Table 4 presents the associations between DBM and demographic, socio-economic, geographic, and other factors through both univariate and multivariate logistic regressions from the 2023 dataset using binary logistic regression. The adjusted results show that children aged 24-47 months were about twice as likely to be simultaneously stunted and overweight compared to younger children (OR = 1.964, 95% CI [1.067-3.616], p= 0.03); children from households where the head had at least primary education were three to four times more likely to experience the double burden than those from households with no formal schooling. Conversely, DBM was negatively associated with households where the head worked as a senior or middle manager (OR = 0.248, 95% CI [0.065-0.940], p= 0.04), and children from households with low economic scores were less at risk compared to those with high economic scores (OR = 0.499, 95% CI [0.289-0.863], p= 0.013).

Discussion     

Guided by a child health inequalities and nutrition transition framework, this study shows that the DBM among children aged 6-59 months in Djibouti reflects structural socioeconomic change, household disparities, and early-life nutritional pathways. Using repeated national surveys (2013-2023), we document significant declines in stunting alongside a rapid rise in overweight and obesity, leading to increased coexistence of these conditions at both population and individual levels. Importantly, this study documented a sharp rise in the double burden of malnutrition among children aged 6-59 months in Djibouti over the past decade. Defined as the coexistence of stunting and overweight/obesity at both population and individual levels, DBM reflects systemic dysfunction in food and health systems and exposes affected children to compounded risks, including impaired growth, poor cognitive development, metabolic disorders, and increased susceptibility to non-communicable diseases later in life. Over the past decade, the prevalence of stunting consistently declined, reflecting gradual improvements in child nutrition and health outcomes. Despite this progress, prevalence levels remain high and comparable to recent pooled estimates reported in a recent systematic review and meta-analysis, which documented stunting prevalence of 22.3% in sub-Saharan Africa, 19.2% in West Africa, 21% in West-Central Africa, 23% in East Africa, and 31.5% in Southern Africa [32]. Stunting reflects chronic nutritional deprivation and is often associated with structural determinants such as poverty, food insecurity, poor maternal health, and inadequate infant and young child feeding practices [3]. Despite ongoing national efforts in Djibouti to improve child nutrition through health and nutrition programs, these findings suggest that deeper, more structural issues still need to be addressed, especially in the poorest households and in rural areas. From a child well-being perspective, the persistence of stunting despite overall improvement reflects enduring structural inequalities in living conditions and access to adequate nutrition.

Simultaneously, the prevalence of overweight showed a rising trend, particularly in the later years of the study period. While still relatively low compared to global averages, the increase in overweight highlights an emerging nutrition transition in Djibouti, possibly driven by shifts in dietary patterns, urbanisation, and lifestyle changes. Increased consumption of ultra-processed foods, sugar-sweetened beverages, and sedentary lifestyles may be contributing to this trend, which mirrors patterns observed in other LMICs experiencing rapid economic and social change [5,33,34]. Benchmarking against other African countries highlights similarities with Uganda (2.6%) and the Democratic Republic of Congo (2.7%), while rates remain lower than those reported in Angola (3.3%), Rwanda (8.3%), and South Africa (6.9%) [35]. This suggests that Djibouti is part of a broader continental shift where undernutrition and overnutrition increasingly coexist within the same populations and individuals.

Our results also revealed age-specific vulnerability. Children aged 24-47 months faced twice the risk of DBM compared to younger age groups. This may reflect challenges in transitioning from breastfeeding to family diets, where meals may be nutritionally inadequate or inappropriate. These findings differ from those in Ethiopia [18], Indonesia [36], and Papua New Guinea [37], where children aged 6-23 months were at greatest risk, possibly due to suboptimal feeding during the first 1,000 days of life. This discrepancy underscores the importance of contextual factors influencing feeding practices and nutrition trajectories. This age-specific vulnerability is consistent with life-course and DOHaD perspectives, which emphasise how early growth faltering interacts with subsequent dietary exposures to shape later health risk.

Socioeconomic determinants were strongly linked to DBM. Household head education (≥primary) was associated with a threefold higher risk, a counterintuitive finding possibly reflecting dietary shifts toward energy-dense, nutrient-poor foods among more educated or better-off households. Interpretation is limited by the absence of maternal education data, which often more directly influences child feeding, health care use, and hygiene [38,39]. Studies from Cameroon, China, and Guatemala cited by Kosaka and Umezaki (2017) [19] suggest that maternal education typically protects against DBM, highlighting the need for future surveys in Djibouti to capture this critical variable. Household occupation and economic level were key determinants of DBM. Children from households with employed heads in stable managerial positions were less likely to experience DBM, likely due to income stability buffering dietary and environmental risks. Paradoxically, children in low-income households showed lower DBM risk than those in wealthier households, possibly because limited access to energy-dense foods reduced overweight despite persistent stunting. These findings illustrate how socioeconomic advantage may initially heighten exposure to obesogenic environments, reinforcing social gradients in child malnutrition [20].

Geographical and gender disparities also emerged. Urban areas, particularly Djibouti City, showed notable reductions in stunting but sharper increases in overweight, reflecting the dual impacts of urbanisation [13]. Rural areas, while still burdened with high stunting, are not immune to rising overweight, pointing to the spread of obesogenic environments even outside urban centers [14]. Both boys and girls experienced similar patterns, suggesting that structural drivers of malnutrition affect both sexes equally, although gender-sensitive approaches remain essential [11]. Spatial variation in DBM highlights the importance of geographically disaggregated child indicators, as national averages may conceal emerging urban-regional inequalities. From a child well-being perspective, these contrasting trends show that gains in one health dimension do not ensure nutritional equity, especially amid rapid urbanisation and food system change. The emergence of DBM signals both a nutritional transition and widening inequalities in growth, diets, and environments. By documenting temporal trends and socioeconomic and geographic gradients, this study positions DBM as a composite indicator of child health inequality, capturing cumulative disadvantage and underscoring the need for integrated, equity-oriented nutrition and health policies in low and middle-income countries. This study has several limitations. First, as cross-sectional surveys, the data cannot establish causal links for DBM determinants. Second, reliance on anthropometry alone may underestimate other forms of malnutrition, particularly micronutrient deficiencies. Third, survey variations, including seasonal differences, may affect comparability. Finally, the absence of dietary intake and physical activity data limits exploration of behavioural drivers.

Despite these constraints, the use of three nationally representative surveys collected over a decade provides a robust picture of Djibouti´s changing nutrition landscape. Standardised methodologies strengthen the comparability and reliability of findings. These limitations highlight the need for more comprehensive child well-being data systems integrating dietary, behavioural, and environmental dimensions. Future research should prioritise longitudinal designs and the inclusion of maternal and behavioural variables to better understand pathways leading to the double burden of malnutrition.

Conclusion     

This study provides the first comprehensive assessment of the double burden of malnutrition among young children in Djibouti, highlighting a significant increase in the coexistence of stunting and overweight, including obesity, between 2013 and 2023. These findings underscore the urgency of implementing integrated nutrition policies that address both undernutrition and overnutrition. Efforts to combat malnutrition must consider the dual challenge posed by persistent stunting and rising overweight and obesity. Policymakers should prioritise multisectoral strategies that promote access to nutrient-rich foods, encourage physical activity, and regulate the availability of processed foods. Context-specific interventions, particularly in urban areas where the nutrition transition is more pronounced, are essential to mitigate the rising prevalence of childhood obesity while sustaining progress in reducing stunting [3,40]. Future research should focus on identifying the socio-economic and behavioural determinants driving these trends. Longitudinal studies incorporating dietary intake and lifestyle factors would provide deeper insights into the mechanisms underlying the double burden of malnutrition. Additionally, targeted interventions should be designed to prevent and manage malnutrition at both individual and community levels [41,42]. Addressing the double burden of malnutrition in Djibouti requires urgent and coordinated action to ensure sustainable improvements in child health and nutrition, ultimately contributing to the country´s broader public health and development goals [2].

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Hassan Abdourahman Awaleh, Tony Byamungu, Mohamed Hsairi, Jalila El Ati: conception, study design, data analysis, interpretation, and manuscript preparation. Conception and study design: Hassan Abdourahman Awaleh, Jalila El Ati. Data analysis and interpretation: Hassan Abdourahman Awaleh, Mohamed Hsairi, Jalila El Ati. Drafting manuscript: Hassan Abdourahman Awaleh. Critical revision of the manuscript for important intellectual content: Jalila El Ati, Mohamed Hsairi, Tony Byamungu. All authors agreed to be accountable for all aspects of the work. They equally read and approved the final version of this manuscript.

Acknowledgments     

The authors acknowledge the academic support of the University of Senghor (Alexandria, Egypt). They are grateful to the Ministry of Health of Djibouti for granting access to the survey data used in this study.

Tables and figures     

Table 1: trends of demographic and geographic characteristics of children aged 6-59 months between 2013 and 2023

Table 2: trends in the double burden of malnutrition at the population and individual levels in children aged 6-59 months, stratified by gender, age, and place of residence

Table 2.1: trends in the double burden of malnutrition at the population and individual levels in children aged 6-59 months, stratified by gender, age, and place of residence

Table 3: adjusted relative risk ratios for years of the survey (from 2013 to 2023) and covariates (age, gender, areas and region) of unordered multinomial logistic models predicting malnutrition for children 6-59 months

Table 4: associate factors with double burden of malnutrition for children aged 6 to 59 months-uni and multivariate analysis using binary logistic regression model-Djibouti 2023

Figure 1: conceptual framework linking social determinants, nutrition transition, and the double burden of malnutrition as a child well-being indicator

Figure 2: regional trends in the double burden of malnutrition among children under five in Djibouti, 2013-2023

References