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Risk Factors for Early Childhood Malnutrition in Uganda

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Risk Factors for Early Childhood Malnutrition in Uganda Risk Factors for Early Childhood Malnutrition in Uganda Joyce K. Kikafunda, PhD*; Ann F. Walker, PhD‡; David Collett, PhD§; and James K. Tumwine, MBChBi ABSTRACT. Objective. To assess the dietary and en- Conclusions. This first account of dietary and envi- vironmental factors influencing stunting and other signs ronmental risk factors involved in the etiology of early of poor nutritional status of children <30 months of age childhood malnutrition in Uganda indicates differences in a central Ugandan community, whose main dietary in risk factors for marasmus and underweight compared staples are banana (matoki) and maize. with stunting and low MUAC. The high prevalence of Methods. The study was a cross-sectional survey us- malnutrition and current infection of children in this ing stratified multistage random sampling to select survey suggests poor immune function as a result of households with a child <30 months of age in rural and inadequate nutrition. Pediatrics 1998;102(4). URL: http:// semi-urban environments. A questionnaire was admin- www.pediatrics.org/cgi/content/full/102/4/e45; infection, istered to mothers of 261 infants and toddlers in their malnutrition, risk factors, stunting, survey, Uganda. home setting. Their health status was assessed by clinical examination and anthropometric measurements (mid- upper arm circumference [MUAC], weight, and supine ABBREVIATIONS. MUAC, mid-upper arm circumference; PEM, protein-energy malnutrition; SD, standard deviation. length). Results. A large minority (21.5%) of the children sur- veyed were found in poor health after clinical examina- utrition and health reports in Uganda have tion: 3.8% being classified as suffering from kwashiorkor indicated that although the country is well and 5.7% with marasmus. A high proportion of children endowed with adequate food supplies, a were stunted (23.8%), underweight (24.1%), or had low N , large proportion of children 5 years of age are MUAC (21.6%). Although rural living, poor health, the 1 use of unprotected water supplies, lack of charcoal as malnourished. The 1988/1989 Uganda Demo- fuel, lack of milk consumption, and lack of personal graphic and Health Survey showed that almost half hygiene were shown as risk factors for marasmus and of the children ,5 years of age were stunted (45.5%) underweight, different factors were found to be associ- and almost one quarter were underweight (23%). ated with risk of stunting and low MUAC, despite these The consequences of long-term nutritional depriva- three parameters being significantly correlated. For tion are many and complex but ultimately culminate stunting the risk factors were: age of the child, poor in ill health and death. It has been reported that health, prolonged breastfeeding (from >18 months to ;60% of all deaths of children ,5 years of age in <24 months), low socioeconomic status of the family, Uganda are directly or indirectly attributable to mal- poor education of the mother of infants <12 months, lack nutrition.2 Although the causes of malnutrition are of paraffin as fuel, consumption of food of low energy density (<350 kcal/100 g dry matter), presence of eye complex and multidisciplinary, dietary and environ- pathology, and consumption of small meals. Risk factors mental factors do play a major role. It has been 3–5 for low MUAC were poor health, lack of meat and cow’s reported that dietary factors, factors concerning milk consumption, low intake of energy from fat, and the mother,6,7 and socioeconomic/environmental fac- less well educated and older mothers. Food taboos had tors8,9 may contribute to the risk of malnutrition in no influence on any of the anthropometric measure- children in developing countries. A cross-sectional ments. Although 93.1% of the children had been immu- study-survey was, therefore, undertaken to deter- nized against tuberculosis, polio, diphtheria, and mea- mine the nutritional status of infants and young chil- sles and showed better general health than children who dren (0–30 months of age) in the banana/maize zone were not immunized, there was a high prevalence of of Central Uganda and to assess the dietary and infection in the week preceding the survey interview, related factors influencing the nutritional status of including diarrhea (23.0%), malaria (32.3%), or cough/ influenza (72.8%). the children. METHODS From the *Department of Food Science and Technology, Makerere Univer- Study Participants sity, Kampala, Uganda; the ‡Hugh Sinclair Unit of Human Nutrition, Study participants were infants and young children, age 0 to 30 Department of Food Science and Technology, the University of Reading, months, from Busimbi subcounty in Mityana county, Mubende Whiteknights, Reading, United Kingdom; the §Department of Applied Sta- district, Central Uganda. Mubende district was selected because of tistics, the University of Reading, Reading, United Kingdom; and the iDe- the dominant use of starchy staples [green cooking banana (locally partment of Paediatrics and Child Health, Makerere University Medical known as matoki), cassava, potatoes, sweet potatoes, and maize] School, Kampala, Uganda. in weaning foods; staples well known for their high dietary bulk Received for publication Oct 13, 1997; accepted Apr 21, 1998. and low energy density. Stratified multistage random sampling Reprint requests to (A.F.W.) Hugh Sinclair Unit of Human Nutrition, De- was used to select the primary sampling units—the households. A partment of Food Science and Technology, the University of Reading, PO household was defined as a group of people living, cooking, and Box 226, Whiteknights, Reading RG6 6AP, United Kingdom. eating together. Eighteen villages (clusters) were randomly se- PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- lected from 5 parishes in Busimbi subcounty and all the house- emy of Pediatrics. holds with a child ,30 months of age had an equal chance of http://www.pediatrics.org/cgi/content/full/102/4/Downloaded from www.aappublications.org/newse45 byPEDIATRICS guest on September Vol. 29, 102 2021 No. 4 October 1998 1of8 participating. A small sample of 3 clusters from Mityana town, P 5 .007, respectively) prevalence of immunization representing the semi-urban environment, was also studied. A than more fortunate children. total of 261 children, 183 (70%) from rural areas and 78 (30%) from semi-urban environments, was studied. Diarrheal diseases kill an estimated 3 million chil- dren each year in developing countries.16 Diarrhea Methods of Investigation prevalence was high among the children studied, A comprehensive, precoded questionnaire was validated by the with 23.0% of the children having had an episode of jury method7 and piloted before the study in a similar setting. The diarrhea during the week preceding the interview. In questionnaires were administered to the respondents, preferably cross-tabulations, children who had malaria or mea- the mothers of the children, in their home settings by the principal sles in the week preceding the interview had signif- researcher and assistants who trained following published guide- # 5 lines.10 The questionnaire was translated into the local languages icantly (P .0001 and P .025, respectively) greater at the time of administration. The age of the children, to the chances of having diarrhea than children who had nearest month, was obtained through birth certificates and health not had these illnesses. Proportionately, children cards, taking precautions to minimize field errors.11 from the urban areas had significantly (P 5 .051) greater prevalence of diarrhea in the week preceding Nutritional Status Assessment the study-survey than children from the rural areas. The health of the children was assessed by clinical examination. The presence of edema was determined by the pitting method.12 Malaria kills an estimated 0.8 million children in 16 The presence of diarrhea, measles, malaria, or cough/influenza Africa alone. In the week preceding the interview, was assessed according to symptoms of the child in the week 32.2% of the children had had an episode of malaria. before the interview as described by the mother. Because this Measles kills an estimated 1 million children per estimate of disease was unsubstantiated by laboratory analyses, year,16 and precipitates the onset of malnutrition.17 only data for diarrhea were subjected to statistical analysis, al- though the symptoms associated with the other diseases are com- However, only 5.7% of the children in this study had monly known throughout Uganda. The height, weight, and mid- had measles, although 72.8% had had cough and/or upper arm circumference (MUAC) were measured following influenza in the week preceding the study. recommendations.10,12–14 Weight measurements were taken to the nearest 0.1 kg using a standardized 25 kg Salter Spring Balance The Nutritional Status of the Children (Salter Weight-Tronix Ltd, West Bromwich, West Midlands, UK). , Measurements of supine or recumbent length were taken to the Growth and development of children 5 years of nearest 0.1 cm using the Short Infant/Child Height Measuring age are influenced more by environmental factors, Board (Short Productions, Woonsocket, RI). The mid-upper point particularly diet, than by genetic or ethnic origins.18,19 of the child’s left arm was located by measuring the distance Hence, an international reference population was between the tip of the shoulder blade and the tip of the elbow and dividing the distance by two. MUAC was measured using a used to assess the nutritional status of the children in nonstretch, tear-resistant Insertion Tape supplied by TALC this study.20 (Teaching Aids at Low Cost, St Albans, UK). Prevalence of Kwashiorkor Dietary Assessment Kwashiorkor is one of the most severe forms of The children’s diet was assessed through a variety of methods; protein-energy malnutrition (PEM) in children in de- a diet history questionnaire, a 24-hour food recall, and a food frequency questionnaire, all of which were incorporated into the veloping countries.
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