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Nutritional problems of children in Ethiopia

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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

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