Assessing the relationship of maternal short stature with coexisting forms of malnutrition among neonates, infants, and young children of Pakistan

Abstract Evidence from previous studies suggests a strong association between pediatric undernutrition and maternal stature. However, there's a scarcity of evidence regarding the relationship between maternal stature and pediatric coexisting forms of malnutrition (CFM). This study examined the prevalence and trends of CFM at the individual, household, and community levels, using data from the Demographic & Health Surveys (DHS) of Pakistan. Furthermore, this study assessed the association between pediatric CFM and short maternal stature while adjusting for multiple covariates. A panel cross‐sectional analysis was conducted using data from the 2012–2013 and 2017–2018 Pakistan Demographic & Health Survey (PDHS). We included data from 6194 mother–child dyads aged 15–49 years and 0–59 months, respectively, while excluding data from pregnant mothers and dyads with incomplete anthropometric variables and anthropometric outliers. Across the two survey periods, our findings reveal a significant decline in pediatric malnutrition, including CFM, alongside a concurrent increase in maternal overweight/obesity. Three out of four households had either a malnourished mother, and/or a malnourished child, and/or both. Our study demonstrates that short maternal stature increased the odds of various forms of pediatric undernutrition by two‐to‐threefolds (p < .041), but we did not find an association with wasting, overweight/obesity, and nutritional paradox. This underscores the heightened vulnerability of children born to short‐stature mothers to various forms of pediatric undernutrition. Addressing the high prevalence of pediatric undernutrition among children of short‐stature mothers necessitates a comprehensive approach that considers an individual's nutritional status throughout their entire life cycle.


| INTRODUC TI ON
Malnutrition is a pressing global health concern, particularly among women of reproductive age and children under the age of five (Mishu et al., 2020), and can be categorized into standalone forms of malnutrition (SFM) and coexisting forms of malnutrition (CFM).
SFM indicates only one type of anthropometric disorder (deficiency or excess) in an individual, irrespective of age, whereas CFM pres ents as a combination of two or more indicators of malnutrition in an individual (Khaliq et al., 2021(Khaliq et al., , 2022)).Compared to SFM, CFM is notably associated with a fourfold higher risk of mortality in children (Garenne et al., 2019).
A child's nutritional status and growth trajectory are influenced by various maternal factors, such as maternal genetic makeup, nu trition during pregnancy, and growth pattern (from intrauterine life through adolescence and adulthood) (Azcorra & Mendez, 2018;Khatun et al., 2018).Among these factors, maternal height stands out as a strong predictor of offspring growth and nourishment (Khatun et al., 2018).Unlike maternal weight and body mass index (BMI), maternal height remains constant after maternal puberty (Khatun et al., 2019).Mothers with a height below 145 cm, either before con ception or after childbirth, are classified as having "short stature" (Khatun et al., 2019;Subramanian et al., 2009).Several studies have shown a higher risk of intrauterine complications and post-uterine growth failure in children born to mothers with short stature.The risk of growth failure and related nutritional disorders, such as intra uterine fetal growth retardation, small-for-gestational age (SGA), low birth weight (LBW), and undernutrition, is two to four times higher in children of short-statured mothers (<145 cm) compared to those of normal or tall mothers (Mertens et al., 2020;Rahman et al., 2016).
Thus, children of mothers with short stature are more vulnerable to experiencing growth failure and related nutritional disorders.
Worldwide, over half of children in South Asian and Sub-Saharan African countries suffer from various types of malnu trition (Akhtar, 2016;Stephenson et al., 2000).In Pakistan, CFM affects more than two-thirds of the population.Pakistan is the second-largest South Asian country after India and has witnessed a stagnation of certain types of malnutrition in children over the last four decades.This stagnation may be partially attributed to the intergenerational cycle of malnutrition (National Institute of Population Studies (NIPS), P., ICF, 2019;United Nations Children Funds, 2019).The first 1000 days of life offer a critical window of opportunity to break the intergenerational cycle of malnutri tion from parents to offspring (Estrada-Gutiérrez et al., 2020).
Interventions applied during this period can effectively avert var ious types of nutritional disorders, including CFM, thereby safe guarding children from numerous illnesses through simple and cost-effective interventions (Estrada-Gutiérrez et al., 2020;Jones et al., 2003).
CFM is a relatively new concept, with limited studies exploring its prevalence, trends, and determinants in children (Khaliq et al., 2022;Pradeilles et al., 2023;Sumon et al., 2023).Previous research, in cluding our own analysis of PDHS datasets, has highlighted the socioeconomic determinants of CFM in children aged below 5 years (Khaliq et al., 2021).Several studies have reported that short ma ternal stature is a proxy measure for maternal malnutrition, which in turn affects the growth trajectory of the developing fetus, and of young children aged below 5 years (Khatun et al., 2019;Mertens et al., 2020;Rahman et al., 2016).However, direct evidence of an association between short maternal stature and CFM in children re mains unreported to date.Therefore, this study aims to determine the prevalence and trends of various types of CFM among motherchild dyads and assess the relationship of maternal short stature with pediatric CFM among neonates, infants, and children of Pakistan.

| Key messages
• Children living in most of the Asian and African countries are highly vulnerable to various types of nutritional adversities, in cluding undernutrition.
• Undernutrition during early infancy and childhood can lay the foundation for intergenerational undernutrition.Maternal short stature, defined as a height below 145 cm, represents an irre versible form of undernutrition and is associated with a range of nutritional adversities, including intrauterine fetal growth retar dation, small-for-gestational age (SGA), low birth weight (LBW), and undernutrition.
• This study reported a high prevalence of malnutrition across Pakistan, where three out of every four households had at least one member who is malnourished-a child, a mother, or a mother-child dyad.Evidence of a relationship between maternal short stature with CFM is scarce, but this study found a two-tothreefold higher odds of pediatric undernutrition (standalone forms and coexisting forms of undernutrition) among children born to mothers with short stature compared to those born to normal or tall mothers.
• Tackling pediatric undernutrition necessitates a comprehensive life-cycle approach, with a particular focus on adolescent girls and expectant mothers.This approach aims to proactively address nu tritional disorders that may arise during adolescence, pregnancy, fetal development, and the early stages of newborns.

| Data source
This study involved secondary data analysis of the PDHS (National Institute of Population Studies (NIPS), P., ICF, 2019).In Pakistan, the National Institute of Population Studies conducted four de mographic health surveys in 1990-1991, 2006-2007, 2012-2013, and 2017-2018, respectively.For this research, this study utilized datasets from the last two PDHS surveys.Among all the PDHS con ducted in Pakistan, the 2017-2018 PDHS was the only one that col lected data across all of Pakistan.However, in other PDHS surveys conducted before 2017-2018, data were not collected from Azad Jammu and Kashmir (AJK) and Federally Administered Tribal Areas (FATA) regions due to geopolitical and security reasons.We discuss the implications of this difference in the Discussion section.

| Study population and eligibility criteria
This study included mother-child dyads, with mothers aged 15-49 years and children aged 0-59 months.Data from mother-child dyads containing comprehensive information on maternal weight, maternal height, child's weight, and child's height were analyzed.
However, data from dyads that included pregnant mothers and ei ther infants or mothers whose height/length and weight were con sidered anthropometric outliers and were excluded (Appendix S1: Supplementary file 1).Anthropometric outliers are biologically im plausible values that may occur owing to measurement errors, re porting errors, and data entry errors (Phan et al., 2020).The upper and lower limits for anthropometric outliers for various anthropo metric indices based on z-score values were: ±6.00 S.D. for HAZ/ LAZ; ±5.00 S.D. for WHZ; and −6.00 and +5.00 S.D. for WAZ (World Health Organization, 2019).

| Sampling strategy and sample size
The sampling frames in each PDHS were adopted from the Pakistan Bureau of Statistics (PBS) and the last census record of 2017.A multi-stage stratified cluster systematic sampling tech nique was used for the selection of each household.Further de tails regarding the sample selection have been reported elsewhere (Khaliq et al., 2021).
The sample size of the PDHS was calculated from the list of enu meration blocks (EBs).In 2012-2013, 500 EBs were selected, while in the 2017-2018 survey, 580 EBs were selected.The total sample size for each PDHS was calculated by multiplying the number of EBs selected with a constant number of 28.Thus, the sample size calculated for the 2012-2013 survey was 14,000 and the 2017-2018 survey was 16,240.The actual dataset contained data from 11,763 eligible women in 2012-13 and 12,708 in 2017-18 (or 24,471 women in total).After excluding cases with missing/incomplete anthropometric values, anthropometric outliers, and/or pregnant mothers, 6194 mother-child dyads were available for these analy ses (Appendix S1: Supplementary file 1).For evaluating the statisti cal power of this study, a post-hoc power calculator for prevalence studies was used, and we observed a statistical power of >80%.

| Measurement of nutritional status and prevalence of CFM
In this study, anthropometric data were used for calculating the nutritional status of each mother-child dyad.For assessing the nutritional status of each child, z-scores of three common anthro pometric indices: weight-for-age (WAZ), weight-for-height (WHZ), and height-for-age (HAZ) were calculated using WHO AnthroCal® software.Subsequently, five different types of nutritional status (normal, wasted, stunted, underweight, and overweight/obese) were identified based on the z-score values of each anthropometric index.The presence or absence of CFM was then derived based on deviant z-scores for any two or more of the anthropometric indices.
Children presenting with one deviant Z-score were coded as having a standalone form of malnutrition (Khaliq et al., 2021).Thus, we identi fied four types of standalone malnutrition (wasting, stunting, under weight, and overweight/obesity) and four types of CFM (coexisting underweight with wasting, underweight with stunting, underweight with both wasting and stunting, and stunting with overweight/obe sity) in children below 5 years of age (Appendix S1: Supplementary file 2).
Maternal weight and height information was used for assessing maternal nutritional status using a multilevel assessment approach.
First, the body mass index (BMI) of each mother was calculated using the BMI standard formula, and mothers were categorized as under weight, normal, and overweight/obese based on their obtained BMI values.Second, mothers were categorized as having short stature or normal stature based on their height.Mothers with a height of 145 cm or more were classified as "normal," while mothers who were shorter than this were classified as being of short stature.Finally, analysis was performed for identifying maternal standalone forms of malnutrition and CFM (Appendix S1: Supplementary file 3).
CFM at the individual level was divided into maternal and child CFM.CFM at the household level represented the concurrent exis tence of pediatric CFM, or standalone forms of malnutrition, with maternal CFM, or standalone forms of malnutrition.CFM at the community level represented the proportion of households that reported CFM in either an individual or a household.CFM at the community level was coded into one of three categories: (1) Healthy households, where the anthropometric measurements of both mother and child were normal.(2) Households with an affected individual: where either the mother or child showed deviated anthropo metric measurements against one or more anthropometric indices; and (3) Households with affected mother-child dyads: where both the mother and child showed deviated anthropometric measurements against one or more anthropometric indices.The prevalence and trends of malnutrition at the community level were assessed by ag gregating the cumulative statistics obtained from the individual and household levels for each year.

| Measurement of maternal height
Two categories of maternal height were created: short stature (<145 cm) and normal stature (≥145 cm).These categories of maternal height were adopted from previous studies conducted in different Asian countries sharing similar types of ethnic and sociodemographic characteristics (Khatun et al., 2019;Subramanian et al., 2009).

| Study covariates
The relationship between maternal short stature with pediatric mal nutrition, including CFM depends on a wide range of factors.These factors include demographic and housing conditions.To assess the relationship between pediatric CFM and short maternal status, a conceptual framework was developed to illustrate how these fac tors interacted.This framework was informed by the framework proposed by UNICEF (2013) (Wali et al., 2019) and other studies (Martorell & Zongrone, 2012;Sumarmi et al., 2016).In children, mal nutrition has multilevel factors: immediate, underlying, and basic (Wali et al., 2019) (Figure 1).
Following this framework, we identified and categorized various covariates from the dataset and grouped them into two major do mains: child factors and maternal factors.
1. Child factors: Age (five categories: 0-11 months, 12-23 months, 24-35 months, 36-47 months, and 48-59 months), gender, ill ness history (yes/no), birth order (primigravida/multigravida), and birth size (large, average, and small) of each child were included in analyses.Birthweight could not be considered because the birthweight of more than 70% of children was unknown.However, we included birth size, which was a proxy measure of birthweight, but the data related to birthweight was collected subjectively via maternal response/recall.

Maternal factors:
We included maternal age (less than 20 years, between 20 and 34 years, and 35 years or more), maternal edu cation (none, primary, and secondary/higher), maternal work status (yes/no), maternal empowerment to healthcare (yes/ no), maternal body mass index (BMI) (normal, i.e., 18.5-24.9kg/ m 2 , underweight, i.e., <18.5 kg/m 2 , and overweight/obese, i.e., ≥25 kg/m 2 ), delivery by C-section (yes/no), total number of preg nancies, and whether mothers had been pregnant in the last year (yes/no) as maternal factors.Maternal empowerment is a compos ite variable, which was examined through a variety of questions assessing maternal ability related to healthcare seeking behavior, maternal involvement in capital decisions, such as the purchase of household stuff and property, and maternal freedom (National Institute of Population Studies (NIPS), P., ICF, 2019).
Place of residence (urban or rural), wealth index (classified as poorest, poor, middle, richer, or richest), place of birth (home deliv ery or hospital-based delivery), and family size were integrated into the model as control variables.This inclusion enabled us to examine the potential influence of these variables while assessing the rela tionship between maternal and child factors and pediatric CFM.

| Statistical analysis
Each PDHS dataset was analyzed separately.Initially, descriptive analysis was performed for each dataset.Following descriptive anal ysis, the difference in the distribution of predictor, outcome, and other covariates between two survey periods was assessed using chi-square and independent-sample t-test (Table 1)  survey periods was assessed by comparing the 95% confidence in terval (CI) limit of one survey period with another.
The relationship between maternal height and various forms of malnutrition were initially assessed relative to a normal healthy child (rather than within) using bivariate and multivariable logistic regression (Table 3).Subsequently, subgroup analyses were per formed, where the relationship of each type of CFM was compared with standalone forms of malnutrition (underweight and stunting) using bivariate (Appendix S1: Supplementary file 4) and multivari able logistic regression (Table 4).The reference category for vari ous types of coexisting forms of undernutrition (underweight with wasting, underweight with stunting, and underweight with both wasting and stunting) was underweight, while for the coexistence of stunting with overweight/obesity, the reference category was stunting.Before performing multivariate analysis, the collinearity of each covariate was assessed, and variables with high VIF values (>10) were removed from the model.In the multivariable regression model, all covariates were entered together, and a backward elimina tion method was applied to eliminate non-significant variables (using a p-value threshold of .10).

| Ethical clearance
The data used in this study were obtained from the DHS data re

| RE SULTS
This study analyzed data from 6194 eligible mother-child dyads from 2012 to 2013 and 2017 to 2018 PDHS datasets.Table 1 pro vides a comparison of the two survey periods for a range of soci odemographic and household characteristics.Except for birth in the last year, child sex, history of illness, birth size, and family size, all other differences between the two survey periods were statistically significant (Table 1).At the community level, we observed a healthy nutritional status in less than a quarter of mother and/or child and/or mother-child dyads across the two survey periods (Figure 2).

| Determinants of coexisting forms of undernutrition
The short stature of mothers was significantly associated with various forms of undernutrition, including coexisting forms of un dernutrition.We found at least a twofold higher odds of stunting, underweight, and all forms of coexisting forms of undernutrition, such as coexisting underweight with wasting, underweight with stunting, and underweight with both wasting and stunting, in chil dren of mothers with short stature compared to mothers of normal stature (Table 3).However, we did not observe a relationship be tween maternal height and various coexisting forms of undernutri tion when compared with an underweight child as the reference (as the standalone form of malnutrition) (Table 4).
A higher prevalence of coexisting underweight with wasting was reported in the 2017-2018 survey, compared to the former 2012-2013 survey (Table 4).Maternal employment (0.41, 95% CI: 0.19-0.89)and maternal cesarean section (C-section) (0.37, 95% CI: 0.16-0.90)were associated with significantly reduced odds of co existing underweight with wasting compared with children of un employed mothers and of normal vaginal delivery, while an increase in family size significantly increased the odds of coexisting under weight with both wasting and stunting by 1.07 (1.00-1.15)after ad justing for other covariates.

| Determinants of coexistence of stunting with overweight/obesity
Maternal short stature was not associated with coexisting stunting and overweight/obesity when compared to the well-nourished child (1.54, 95% CI: 0.76-3.14)(Table 3), and with the stunted child (1.04, 95% CI: 0.48-2.21)(Table 4).Between the two survey years, the odds of coexistence of stunting with overweight/obesity decreased significantly to 0.28 (0.20-0.41) in 2017-2018.Moreover, an in crease in maternal age as well as child age significantly reduced the odds of coexistence of stunting with overweight/obesity compared to a stunted child (Table 4).

| DISCUSS ION
To the best of our knowledge, this is the first study to comprehen sively assess the prevalence and trends of maternal and child nu tritional status at individual, household, and community levels in Pakistan.We also thoroughly examined the interaction of maternal short stature with various forms of pediatric malnutrition, includ ing various types of CFM.Previous studies conducted in Pakistan and other parts of the world have primarily focused on examin ing the relationship of maternal short stature with child obesity (Winichagoon, 2015;Wojcicki, 2014;Zemene et al., 2023) and only at a household or community level.
Across two survey periods, this study reported malnutrition in every three out of every four mother-child dyads of Pakistan.Similarly, this study also showed 4-to-7.5-foldhigher odds of vari ous forms of coexisting forms of undernutrition (coexisting under weight with wasting, underweight with stunting, and underweight with both wasting and stunting) in children aged between 12 and 23 months.These findings are aligned with the findings of a study conducted in Vietnam, which reported a twofold higher odds of undernutrition in children aged between 12 and 23 months (Beal et al., 2019).The nutritional deficiencies during early childhood may be averted by implementing various strategies, such as con traceptive utilization, promoting antenatal care, and implementing a referral system (Elmusharaf et al., 2015;Khan, 2019;Vir, 2016).
Moreover, advocating for appropriate infant feeding practices via Exclusive Breastfeeding (EBF), complementary feeding, micronutri ent supplementation, and timely hydration, particularly during the first 1000 days of life, can effectively protect both mother and child from various types of nutritional adversities (Chai et al., 2022;Jones et al., 2003).
Over the two survey periods, our study reported a significant decrease in pediatric malnutrition with a simultaneous increase in    Note: Ref = Reference category of various covariates.The Reference category for maternal height was normal/tall stature, the reference category of maternal age was 15-19 years, the reference category of maternal education was no education, the reference category of maternal working status was no, the reference category of maternal empowerment was no, the reference category of birth in last year was no, the reference category of delivery by C-section was no, the reference category of child age was 0-11.9 months, the reference category of child sex was male, the reference category of presence of illness was no, the reference category of child birth size was average, the reference category of survey year was 2012, the reference category of socioeconomic status was poorest, the reference category of place of delivery was home, and the reference category of place of residence was rural.*p-value ≤.05.That is, significant association with the study outcome. a The reference category for assessing the determinants of standalone forms of undernutrition was a normal healthy child. b The reference category for assessing the determinants of coexisting forms of undernutrition was a normal healthy child.Note: Ref = Reference category of various covariates.The Reference category for maternal height was normal/tall stature, the reference category of maternal age was 15-19 years, the reference category of maternal education was no education, the reference category of maternal working status was no, the reference category of maternal empowerment was no, the reference category of birth in last year was no, the reference category of delivery by C-section was no, the reference category of child age was 0-11.9 months, the reference category of child sex was male, the reference category of presence of illness was no, the reference category of child birth size was average, the reference category of survey year was 2012, the reference category of socioeconomic status was poorest, the reference category of place of delivery was home, and the reference category of place of residence was rural.Abbreviation: CI, Confidence interval.
*p-value ≤.05.That is, significant association with the study outcome. a The reference category for assessing the determinants of the coexistence of underweight with wasting, coexistence of underweight with stunting, and coexistence of underweight with wasting and stunting both was stunting. b The reference category for assessing the determinants of the coexistence of stunting with overweight/obesity was stunting.
TA B L E 4 (Continued) P., ICF, 2019).The findings of our previous paper also supported a nutritional profile improvement associated with improved socio economic parameters (Khaliq et al., 2021).Moreover, the escalating trend in maternal overweight/obesity might be due to a significant influx of urban dwellings during the 2017-2018 survey period and links between rapid urbanization and increased poor dietary prac tices and physical inactivity (Machado-Rodrigues et al., 2014).
Furthermore, some studies have reported that adult overnutrition is a consequence of pediatric undernutrition (Caballero, 2006;Ferreira et al., 2008).A review by Caballero indicated the presence of adi posity, insulin resistance, and pre-pubertal growth in adults who had any type of undernutrition in their childhood, including LBW and IUGR (Caballero, 2006).Besides adulthood obesity, pediatric under nutrition may predispose to various other types of adult metabolic disorders, such as cardiovascular diseases, diabetes, and dyslipid emia (Emokpae & Odungide, 2020).The high prevalence of pediat ric undernutrition and maternal overnutrition also exhibits nutrition transition, which can only be averted through intersectoral collab oration (Jones et al., 2003).Interventions related to maternal care before and during pregnancy and after childbirth, such as maternal immunization, maternal micronutrient supplementation, adequate maternal caloric intake, and providing a supporting environment for maternal breastfeeding, can arrest intergenerational transmission of malnutrition from mothers to offspring (Mishu et al., 2020).
In summary, this study underscores the critical relationship of maternal short stature with various forms of pediatric nutritional disorders.Maternal short stature was a significant determinant of pediatric undernutrition, including various forms of coexisting forms of undernutrition, in Pakistan.However, maternal short stat ure has a complex relationship with pediatric nutritional status be cause it serves as both a risk factor and a consequence of pediatric malnutrition.

| Study strengths and limitations
To the best of our knowledge, this is the first study to measure the . For assess ing the prevalence of malnutrition, including various forms of CFM among mother-child dyads, we calculated the prevalence estimates for each type of malnutrition, including CFM.The prevalence esti mates of each form of malnutrition were converted into percent ages.The difference in the prevalence of malnutrition across two F I G U R E 1 Cycle of malnutrition between the malnourished mother and offspring.Adapted from: Martorell and Zongrone (2012), Sumarmi et al. (2016), and Wali et al. (2019).TA B L E 1 Sociodemographic and household characteristics of the study sample.
pository after formal registration and approval.Additionally, the protocol of this study received approval from the University Human Research Ethics Committee (UHREC) of the Queensland University of Technology (QUT), Brisbane, Australia (Approval number 2000000177).
maternal malnutrition.The significant increase in maternal malnutri tion was attributed to a rapid proliferation of maternal overweight/ obesity cases in the 2017-2018 survey, compared to the 2012-2013 survey.The existing variables in our study datasets were insufficient for explaining reasons pertaining to these trends in maternal and children nutritional status, but we speculate that it may be due to a significant improvement in socioeconomic parameters across the two survey periods (National Institute of Population Studies (NIPS), F I G U R E 2 Maternal and child nutritional status at the household level and the community level.TA B L E 3 Determinants of standalone and coexisting forms of undernutrition in children below 5 year of age using PDHS data of 2012-13 and 2017-18 (Reference is a normal child).

c
Adjusted for maternal height, maternal education, maternal empowerment, delivery by C-section, child's age in months, birth size, wealth index, family size, and place of residence.TA B L E 3 (Continued)TA B L E 4 Assessing the adjusted Odds of various forms of Coexisting forms of malnutrition.
relationship of maternal short stature with pediatric CFM.The sam ple selected in this study has national data coverage, and the sample calculated for each PDHS was based on estimates obtained from the PBS to represent the population(Khaliq et al., 2021).Despite the na tional coverage and representative sample size of each PDHS, certain limitations weaken the internal validity of this study: (1) The crosssectional study design of the PDHS means that causation between maternal and pediatric malnutrition cannot be established; (2) The 2012-2013 PDHS survey did not collect data from the AJK and FATA regions due to military restrictions and security reasons.The findings of this study cannot represent the exact nutritional picture for the whole of Pakistan.Owing to this, program managers and policymak ers need to be careful in devising nationwide prevention and control strategies for various forms of malnutrition, including CFM, based on this evidence.(3) Variables such as birthweight, birth size, and ma ternal health interventions (prenatal, antenatal, and postnatal care) c The Model assessed the determinants of the coexistence of underweight with wasting with maternal height as a predictor.A Maternal height >145 cm was used as the reference.The Covariates adjusted were the year of the survey, child age, maternal work status, and type of delivery.d Model assessed the determinants of the coexistence of underweight with stunting with maternal height as a predictor.A Maternal height >145 cm was used as the reference.Covariates adjusted were child age.e Model assessed the determinants of coexistence of underweight with wasting and stunting both with maternal height as a predictor.A Maternal height >145 cm was used as the reference.The Covariates adjusted were child's age and family size.f Model assessed the determinants of the coexistence of stunting with overweight/obesity with maternal height as a predictor.A Maternal height >145 cm was used as the reference.The Covariates adjusted were child age, maternal age, and the year of the survey.TA B L E 4 (Continued)were not included because data were missing for over 50% of cases.These variables can determine immediate gestational outcomes, such as birthweight and birth size.Due to the exclusion of these variables, this study did not assess the effect of various interventions, such as antenatal consultations, iron and folate supplementation, and ma ternal general health management, nor pregnancy outcomes such as birthweight, birth size, and delivery method.(4) The nutritional status of both mother-child dyads was determined using anthropometry only.The PDHS was not designed to collect a comprehensive range of nutrition assessment measures.These include biochemical tests to assess nutrient deficiencies or excesses, physical examinations, and dietary investigations to assess nutritional intake.Maternal diet during pregnancy and after childbirth, maternal micronutrient status, and maternal physical health, such as the presence of comorbidities, are of particular importance for assessing the growth and nourish ment trajectory of children(Ahmad et al., 2018).Thus, there is a need to investigate relationships between infant feeding, maternal micro nutrient status, health indicators and pediatric health and nourish ment.(5) The anthropometric data used in this study contained some measurement and recording errors, identified by implausible values and outliers.Incomplete anthropometric values were also evident due to caregiver refusal, child absence, and child irritability.Better training in anthropometry, equipment calibration, and adopting the routine practice of taking two or more readings for each anthropo metric measures can help to identify measurement and recording errors.Data of over 15% of mother-child dyads comprising of incom plete anthropometry (7.1%) and anthropometric outliers (8.8%) were excluded in this study.Our study findings exclusively focus on those mother-child dyads with valid and complete anthropometry, poten tially representing either a skewed or biased picture of the popula tion under investigation.Hence, it is essential to acknowledge these limitations while interpreting the study findings.5| CON CLUS IONCFM is a public health concern, which can affect an individual, household, and a community.CFM affects more than two-thirds of the community in Pakistan.Despite a significant reduction in pediatric malnutrition, approximately half of children still suffered from malnutrition, and there was a rapid proliferation of maternal overweight/obesity from 2012 to 2018.Children of short-stature mothers have a high risk of various forms of malnutrition, except for wasting, overweight/obesity, and nutritional paradox.There is a need to further explore the relationship between maternal health and infant feeding and pediatric undernutrition, including coexist ing forms of undernutrition, to identify the best-value strategies for arresting the intergenerational transmission of various forms of mal nutrition and CFM in children.

Table 2
presents the prevalence of SFM and CFM among mothers and children at the individual level.The prevalence of maternal malnutrition significantly increased from 49% (48.1%-50.9%) in 2012-2013 to 56.4% (54.8%-58.1%) in 2017-18.This was mainly attributed to maternal overweight and obesity, which increased by over 10% between the two sur vey periods.The prevalence of underweight declined from 11.9%