1. Nutritional problems of children in Ethiopia
Mekitie Wondafrash(MD, DFSN)
Jimma University, Ethiopia

2. Content Introduction Nutritional problems of children in Ethiopia
Background about Ethiopia
Child health in Ethiopia
Nutritional problems of children in Ethiopia
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
Conclusion

3. 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

4. Source: Ethiopia DHS, 2004

5. Introduction… Background about Ethiopia Geography:
Situated at horn of Africa
Position: N latitude , 33 – 480 E longitude
Topography: Highest peak at Ras Dashen-4,550 m above sea level
Lowest point- Affar Depression at 110m below sea level
The total area ¬1.1 million km2
Borders: Djibouti, Eritrea, Sudan, Kenya, and Somalia
A large part is high plateaux and mountain ranges
Source: CSA, 2000, MOI 2004

6. Demographic characteristics

7. Population Pyramid of Ethiopia
2007
1994
Age group
Population percent

8. 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

9. 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

10. Child survival in Ethiopia
( source: Ethiopia DHS 2005)

11. Childhood mortality trends per 1000
Source: Ethiopia DHS, 2000.

12. Timing of mortality in children in Ethiopia
( source: Ethiopia DHS 2000)

13. What are children dying from in Ethiopia ?
PROFILES analysis , FMOH 2006

14. Estimated direct causes of neonatal death for Ethiopia
Infection alone contributes to 46% of neonatal death
( Source: Facility based death report, FMOH, 2004)
3/31/2017

15. Relevance of nutrition
Nutrition in the MDGs
MDG
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 pathways
Addresses gender inequalities in food, care and health
Combat HIV/AIDS, malaria and other diseases
Slows onset and progression of AIDS
Important 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
Just a reminder that in order to achieve the MDG by 2015, virtually all of the goals will require improvements in nutrition (the second column). We’ve highlighted two for which nutrition is especially relevant.
For example (row 1) the goal is to “eradicate extreme hunger and poverty”. A focus on nutrition should be self-evident but also relevant since evidence shows that stunting in early life reduces worker productivity (capacity) in adulthood.
The fourth goal (see row 4) relates to reductions in child mortality. There is also strong evidence that high rates of child malnutrition weaken immunity and contribute enormously to poor heath and survival. The effectiveness of efforts to combat disease or reduce child mortality to reach these Millennium Development Goals will be therefore very limited without strategies to address malnutrition.

16. Reaching MDG4 is feasible?
Current U5MR trend versus trend needed to reach MDG for Ethiopia (FMOH, 2006)
3/31/2017

17. 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..

18. Current estimated food security conditions: January to March 2009
Source: FEWS NET and WFP Ethiopia

19. 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)

20. 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)

21. Trends in malnutrition in under-fives in Ethiopia, 1982-2000
( Zewuditu et al ,2001)

22. Nutritional Status of Children Under Age 5, 2000 and 2005
Source: Ethiopia DHS, 2005

23. Nutritional status of children under five years of age
Percent
Source: Ethiopia DHS, 2005

24. Stunting, wasting and underweight by age in Ethiopia,2005
Source: Ethiopia DHS, 2005.

25. Global timing of growth faltering in U5 child

26. Stunting at Age 2- critical period
(EDHS )
UNICEF/C-55-34/Watson
51%
Source: Ethiopia DHS, 2005.

27. Percentage of children under age five whose height-for-age is below -2 SD from mean by region
Source: Ethiopia DHS, 2000.

28. 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 )

29. 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)

30. Micronutrient deficiencies
Iodine 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

31. 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

32. Infant and Young Child feeding…
Exclusive
Breastfeeding
Complementary
Feeding %
UNICEF/93-COU-0173/Lemoyne
Source: Ethiopia DHS2005

33. Breastfeeding practice by age in Ethiopia
Source: Ethiopia DHS2005

34. Trends in breast feeding practices in Ethiopia
Source: Ethiopia DHS2005

35. Feeding practices for infants under six months, Ethiopia ( Is it optimal according to IYCF guidelines?)
Source: Ethiopia DHS2000

36. Feeding Practices in Ethiopian Infants 6-9 months
Source: Ethiopia DHS2000

37. 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.

38. Dietary diversity and child growth: Africa (DHS data sets)
Source: Arimond and Ruel, 2004
Means adjusted for child age, maternal height and BMI, # children < 5 y, and 2 wealth/welfare factor scores

39. Consequences of Malnutrition among children in Ethiopia
© 2005 Virginia Lamprecht, Courtesy of Photoshare

40. Four functional consequences
Mortality
Illness – via increasing susceptibility to illnesses
Intelligence loss
Reduced productivity

41. Contribution of malnutrition to U5 Mortality in Ethiopia
Neonatal 25%
Malaria 20%
Pneumonia
28%
Diarrhea 20%
AIDS 1%
Measles 4%
Other 2%
Malnutrition 57%
Contribution of malnutrition to U5 Mortality in Ethiopia
HIV/AIDS
11%

42. «Hidden» death due to malnutrition in Ethiopia
Severe
Mild &
moderate
80% of the death due to malnutrition is contributed for by Mild and moderate malnutrition
Only 1 in 5 malnutrition-related deaths is due to severe malnutrition

43. Malnutrition and intellectual development
Reduced:
Learning ability
School performance
Retention rates

44. Nutritional problems associated with brain development

45. Consequence of Stunting
Reduced productivity
1.4% decrease in productivity for every % decrease in height
(Haddad & Bouis, 1990)

46. Child Health Nutrition Project of JU-IUC (VLIR-UOS)

47. 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

48. 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)

49. 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

50. 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)

51. Summary findings from baseline survey on nutritional status and determinants among under 5 children in communities around Gilgel Gibe Hydroelectric dam, Ethiopia
March, 2008

52. 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

53. 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

54. 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

55. Result: Socio-demographics
Age 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

56. 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

57. BMI of mothers of index children , kg/m2) (n=350)

58. Nutritional status of children under five years of age using WHO growth reference (WHO,2007)

59. Age group of children U5 years
Type of malnutrition by age in under five children in GGFRC area, 2008
Age group of children U5 years

60. MGRS population ( WHO, 2007) compared with the distribution of malnutrition in Gilgel Gibe area

61. Feeding practice of mothers of index children in the project area

62. 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

63. 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

64. Type of additional foods started for U5 children in the study area
Differs for those breastfed and non breastfed children

65. 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

66. DD in relation to stunting ( n=118)
p<001
p<001
Non stunted

67. 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
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
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

68. Minimum acceptable diet (MAD) in relation to stunting
Non stunted

69. 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

70. 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

71. THANK YOU !!!
UNICEF/C-55-38/Watson