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Nutritional problems of children in Ethiopia
Mekitie Wondafrash(MD, DFSN)Jimma University, Ethiopia
Content 1. Introduction
– Background about Ethiopia– Child health in Ethiopia
2. Nutritional problems of children in Ethiopia
3. Child Health and Nutrition project of VLIR-UOS
◦ Justification /Rationale◦ Expected outcomes of the project◦ Findings from the baseline survey in
Gilgel Gibe Field Research Center
4. Conclusion
Introduction
• Background about Ethiopia– Geography– Demographic characteristics – Health and Nutritional problems of
children in Ethiopia• Health problems • Nutritional problems
Mild, moderate and severe Malnutrition Micronutrient malnutrition
Source: Ethiopia DHS, 2004
Introduction… Background about Ethiopia Geography: Situated at horn of AfricaPosition: 3 -150 N latitude , 33 – 480 E longitudeTopography: Highest peak at Ras Dashen-4,550 m
above sea levelLowest point- Affar Depression at 110m below sea level
The total area ¬1.1 million km2
Borders: Djibouti, Eritrea, Sudan, Kenya, and SomaliaA large part is high plateaux and mountain ranges
Source: CSA, 2000, MOI 2004
Demographic characteristics
Population Pyramid of Ethiopia Ag
e gr
oup
Population percent
1994 2007
Child health problems in Ethiopia
• In general 60 to 80 % of health problems in Ethiopia are due communicable diseases and nutritional problems
• Health service coverage is low (about 64%, 2003)• The is poor public health infrastructure
contributing to high morbidity and mortality
Source: FMOH, 2003
Causes of childhood morbidity and mortality
• Neonatal problems– Infection ( congenital, acquired)– Asphyxia
• Undernutrition( ranges from mild to severe) • Malaria• Measles• Acute respiratory tract infections ( e.g. pneumonia) • Diarrhoeal diseases
Child survival in Ethiopia
( source: Ethiopia DHS 2005)
Childhood mortality trends per 1000
Source: Ethiopia DHS, 2000.
Timing of mortality in children in Ethiopia
( source: Ethiopia DHS 2000)
What are children dying from in Ethiopia ?
PROFILES analysis , FMOH 2006
Estimated direct causes of neonatal death for Ethiopia
Asphyixa25%
Preterm17%
Infection36%
Tetanus7%
Diarrhoea3%
Congenital4%
Other7%
04/10/23 14( Source: Facility based death report, FMOH, 2004)
Infection alone contributes to 46% of
neonatal death
Nutrition in the MDGsMDG Relevance of nutrition
Eradicate extreme poverty and hunger
Contributes to human capacity and productivity throughout life cycle and across generations
Achieve universal primary education
Improves readiness to learn and school achievement
Promote gender equity and empower women
Empowers women more than men
Reduce child mortality Reduces child mortality (over half attributable to malnutrition)
Improve maternal health Contributes to maternal health thru many pathwaysAddresses gender inequalities in food, care and health
Combat HIV/AIDS, malaria and other diseases
Slows onset and progression of AIDSImportant component of treatment and care
Ensure environmental sustainability
Highlights importance of local crops for diet diversity and quality
Develop a global partnership for development
Brings together many sectors around a common problem
Reaching MDG4 is feasible?
165153
140
123109
95
165153
140
123
89
54
0
40
80
120
160
1990 1995 2000 2005 2010 2015
Years
Under
5 M
ort
ality
Rat
e
Current Trend MDG Trend
HSDP I II
04/10/23 16
Current U5MR trend versus trend needed to reach MDG for Ethiopia (FMOH, 2006)
Nutritional problems of children in Ethiopia
• Ethiopia is one of the most food insecure countries in the world having both chronic and transitory food insecurity and frequent attacks of famine in the recent past– Food insecurity incorporates- low food intake ,
variable access to food, and vulnerability
• Food insecurity is mostly associated with drought, poor land management practices, diseases, attack by pests, destruction of crops by flood, etc..
Current estimated food security conditions: Januaryto March 2009
Source: FEWS NET and WFP Ethiopia
Nutritional problems ….
• Nutritional problems continue to be the leading cause of morbidity and mortality in children
• Manifest by – Protein Energy Malnutrition ( PEM)– Micronutrient malnutrition
• Vitamin A deficiency ( VAD )• Iodine Deficiency disorders (IDDS) • Iron Deficiency Anaemia (IDA)
Nutritional problems ….• The plight usually starts during
intrauterine life with maternal malnutrition
(during and prior to pregnancy)
• Continues to childhood with the same condition
(Feeding, Health Care, Environment)
Trends in malnutrition in under-fives in Ethiopia, 1982-2000
( Zewuditu et al ,2001)
Nutritional Status of Children Under Age 5, 2000 and 2005
Source: Ethiopia DHS, 2005
Nutritional status of children under five years of age
Percent
Source: Ethiopia DHS, 2005
Stunting, wasting and underweight by age in Ethiopia,2005
Source: Ethiopia DHS, 2005.
Global timing of growth faltering in U5 child
Stunting at Age 2- critical period
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51%51%
(EDHS - 2005)
Source: Ethiopia DHS, 2005.
Percentage of children under age five whose height-for-age is below -2 SD from mean by region
Source: Ethiopia DHS, 2000.
Micronutrient deficiencies in Ethiopia
• Micronutrient malnutrition is “hard to see”• VAD among children under five years :
– Prevalence of Bitot’s spot: 1.7% (1.6% - 1.9%)– Subclinical VAD (<0.7μmol/l): 37.7% (35.6%-
39.9%)– Corneal ulceration: 0.02% (1.7% - 2.0%)– Corrected child night blindness: 0.7%
Source: Tsegaye Demissie et al, 2008 ( Unpublished national survey report )
Micronutrient deficiencies
Vitamin A supplementation• Vitamin Supplementation is
undertaken routinely in the health institution and during NIDs
• However, <50% of U5 children received it the previous 6ms
(EDHS,2005)
Micronutrient deficienciesIodine Deficiency Disorders (IDDS):
– Only about one in five live in households with adequately iodized salt ( EDHS,2005)
– National total goitre rate: 38%
Iron Deficiency Anaemia (IDA): • Not documented in Ethiopia , rather over all
anaemia is measured through determination of Hgb status
• Overall anaemia according to Ethiopia DHS, 2005– 27% of WRA were anemic– 54% of children between 6-59 mo had
anemia
Infant and young child feeding practices in Ethiopia• Infant and young child feeding is critical for child
growth and development • 96 % of children are ever breastfed • 86 % breastfed within 24 hours of birth • The average length of BF is 26 ms• Only 49% of children under the age of six months
are exclusively breastfed• Average length of EBF is only 4 ms• Only 22 % of children 6-23 ms are fed according
to IYCF guidelines
Infant and Young Child feeding…
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73
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49 50
0
25
50
75
100
0-6 months 6-9 months
ExclusiveBreastfeeding
ComplementaryFeeding
%
Source: Ethiopia DHS2005
Breastfeeding practice by age in Ethiopia
Source: Ethiopia DHS2005
Trends in breast feeding practices in Ethiopia
Source: Ethiopia DHS2005
Feeding practices for infants under six months, Ethiopia ( Is it optimal according to IYCF guidelines?)
Source: Ethiopia DHS2000
Feeding Practices in Ethiopian Infants 6-9 months
Source: Ethiopia DHS2000
Dietary diversity of infants and young children in Ethiopia
• Dietary diversity refers to : Number of foods or food groups consumed in a defined period (e.g. per day or week)
• 7 groups: starchy staples, legumes, dairy, other, flesh foods, VA-rich fruit & veg, other fruits & veg, fats.
Dietary diversity and child growth: Africa (DHS data sets)
Means adjusted for child age, maternal height and BMI, # children < 5 y, and 2 wealth/welfare factor scores
Source: Arimond and Ruel, 2004
Consequences of Malnutrition among children in Ethiopia
© 2005 Virginia Lamprecht, Courtesy of Photoshare
Four functional consequences
Mortality Illness – via increasing susceptibility to
illnesses Intelligence loss Reduced productivity
Neonatal 25%
Malaria 20%
Pneumonia
28%
Diarrhea 20%
AIDS 1%
Measles 4%
Other 2%
Malnutrition57%
Contribution of malnutrition to U5 Mortality in Ethiopia
HIV/AIDS 11%
«Hidden» death due to malnutrition in Ethiopia
Severe
Mild &moderate
Only 1 in 5 malnutrition-related deaths is due to severe malnutrition
80% of the death due to malnutrition is contributed for by Mild and moderate malnutrition
Malnutrition and intellectual development
Reduced:
• Learning ability
• School performance
• Retention rates
Nutritional problems associated with brain development
13
4754
38
0
25
50
75
100
Goitre Anemia Stunting LBW
Pre
vale
nce
(%)
Consequence of Stunting
Reduced productivity
1.4% decrease in productivity for every
1% decrease in height
(Haddad & Bouis, 1990)
Child Health Nutrition Project of JU-IUC (VLIR-UOS)
Rationale of the project• Developed in cognizant with the current trend of
health and nutritional problems of children in Ethiopia
• Much of the studies done malnutrition are descriptive • Dietary guidelines formulated for Ethiopian children
are not based on local study of complementary foods and feeding patterns
• Nutrition rehabilitation for severely malnourished children are mostly restricted to hospitals where Primary Health Care Units are appropriate and cost effective
Expected outcomes from the project• Development of appropriate complementary
feeding strategy based on locally available foods and method of preparation ( processing)
• Identifying factors affecting the quality and safety of complementary foods
• Contributing to household food security through addressing the problem of post harvest losses
• Development of locally appropriate rehabilitation strategy ( dietary + psychomotor)
(sustainability and cost effectiveness)
Project partners:
• The project encompasses different disciplines (sectors) namely, Public Health Nutrition, Pediatrics and Child Health, Agriculture and Food Chemistry ( food technology)
• Similar composition of expertise is also obtained from the Belgium
Overall objective of the project
• Development of human and physical capitals (academic objective)
◦ Public health nutrition , food technology/food science ( lacking in Ethiopia at large)
◦ Research capacity in the areas of nutrition and food science/food technology
• Contribute to the improved child growth and development ( development objective)
Summary findings from baseline survey on nutritional status and determinants among
under 5 children in communities around Gilgel Gibe Hydroelectric dam, Ethiopia
March, 2008
Objectives of the study – Determine nutritional status of children
Under five years of age – Assess the feeding pattern of target
children – Describe the association between feeding
patterns with nutritional status
Methods• Cross sectional • Representative sample of children between 6
and 59mo• Simple random sampling technique was used • Anthropometry , feeding pattern and general
socioeconomic variables were assessed• Data was collected by going house to house
Data analysis• Data was entered into SPSS Vr. 16, and
analysis was done by both SPSS and Anthro2007 ( WHO, 2007)
• Anthropometric measures were converted in to z-score values for comparison with a reference population
• Feeding patterns of children was described in relation to IYC feeding guidelines (WHO,2003)
• Dietary diversity was calculated for children 6-23mo old based on the number of food groups consumed the previous 24hrs
Result: Socio-demographicsAge group (n=364) Frequency Percent
6-11 60 16.5
12-23 87 23.9
24-35 109 29.9
36-47 73 20.1
48-60 35 9.6
Total 364 100.0
Sex (n=365)
Male 187 51.2
Female 178 48.8
Background information
• 97% of the respondents are biological mothers
• 87% of the mothers are unable to read and write
• Average no. of U5 children 1.6• Average birth interval for U5 children
(n=314)=2.43 yrs
BMI of mothers of index children , kg/m2) (n=350)
Nutritional status of children under five years of age using WHO growth reference (WHO,2007)
Type of malnutrition by age in under five children in GGFRC area, 2008
Age group of children U5 years
MGRS population ( WHO, 2007) compared with the distribution of malnutrition in Gilgel Gibe area
Feeding practice of mothers of index children in the project area
Indicators for assessing IYCF practices (6-23mo) (source: WHO 2007)
• Core indicators include: – Early initiation of breastfeeding– Exclusive breastfeeding under 6 months– Continued BF at one year– Introduction of solid, semi-solid or soft foods at 6
months of age– Minimum dietary diversity – Minimum meal frequency – Minimum acceptable diet ( MAD)– Consumption of iron reach and iron fortified foods
Feeding pattern of children U5 years
• Ever breastfed (n=365): 99.2%• Timing of introduction of the breast
milk(n=355): – Immediately after birth= 41%– After the first hour of birth=59%
• Average period of EBF (n=361): 3.35 mo• Average time of introduction of other foods or
drinks to the child (n=356): 3.37mo
Type of additional foods started for U5 children in the study area• Differs for those breastfed and non breastfed
children
Dietary diversity for children between 6-23m
Minimum dietary diversity: • Proportion of children 6–23 m who receive
foods from 4 or more food groups• The 7 foods groups used for tabulation of this
indicator are :– Grains, roots and tubers– Legumes and nuts– Dairy products (milk, yogurt, cheese)– Flesh foods– Eggs– Vitamin-a rich fruits and vegetables– Other fruits and vegetables
DD in relation to stunting ( n=118)
Non stunted
p<001
p<001
Minimum acceptable diet (MAD) for children between 6&23 mo
• Proportion of children 6–23 months of age who receive a minimum acceptable diet (apart from breast milk)– It is a composite indicator consists of two fraction
1. Breastfed children 6–23 months of age who had at least the minimum dietary diversity and the minimum meal frequency during the previous day out of total breastfed children 6–23 months of age
2. Non-breastfed children 6–23 months of age who received at least 2 milk feedings and had at least the minimum dietary diversity not including milk feeds and the minimum meal frequency during the previous day out of non-breastfed children 6–23 months of age
Minimum acceptable diet (MAD) in relation to stunting
Non stunted
p<001
p<001
Conclusion• There is high rate of undernutrition among
infants and young children in Ethiopia and project area
• There is poor optimal breast feeding and complementary feeding practices
• The quality of the diet is poor as most infants and young children were initiated with liquid CFs
• Some indicators of IYCF practice are associated with stunting
Conclusion…
• Malnutrition is the major single cause of death in children in Ethiopia
• Malnutrition usually operates synergistically with infection ( But both can lead to death directly)
• Programmatically both should be addressed as the same time to reduce infant mortality in Ethiopia
THANK YOU !!!
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