NUTRITIONAL STATUS OF UNDER-FIVE CHILDREN AND ASSOCIATED FACTORS

CHAPTER TWO

LITERATURE REVIEW

2.1 Overview of Malnutrition

Malnutrition is defined as “a state in which the physical function of an individual is impaired to the point where he/she can no longer maintain adequate bodily performance processes such as growth, pregnancy, lactation, physical work, resting and recovering from disease (MMS/MPHS, 2009).

Malnutrition commonly affects all groups in a community, but infants and young children are the most vulnerable because of their high nutritional requirements for growth and development (Blössner et al., 2005). Globally, an estimated 165 million children under-five years of age, or 26%, were stunted, 16%, were underweight, 8% were wasted and 7% were overweight. High prevalence levels of stunting among children under-five years of age in Africa (36%) and Asia (27%) remain a public health problem, one which often goes unrecognized. More than 90% of the world’s stunted children live in Africa and Asia (UNICEF et.al, 2012).

In Kenya, 35 percent of children under five are stunted, while the proportion severely stunted is 14 percent, 16 % are underweight (low weight-for-age) and 4 % are severely underweight (KNBS and ICF Macro 2010). Malnutrition observed in children under five years in Eastern region where Ivo Local Government Area is located is high, estimated at 41.9% stunting, 7.3% wasting and 19.8 % underweight (KNBS and ICF Macro 2010).

2.1.1Causes of malnutrition

There has been agreement among researchers on factors contributing to malnutrition. The primary determinants as conceptualized by several authors relate to unsatisfactory food intake, severe and repeated infections, or a combination of the two (UNICEF, 1998 and Rowland et al., 1988). The interactions of these conditions with the nutritional status and overall health of the child and by extension of the populations in which the child is raised have been shown in the UNICEF Conceptual framework (figure 1) of child survival (UNICEF, 1998).

2.1.1.1Immediate causes of malnutrition

Inadequate food intake and disease are immediate causes of malnutrition and create a vicious cycle in which diseases and malnutrition exacerbate each other. Malnutrition lowers the body's ability to resist infection resulting to longer, more severe and more frequent episodes of illness.

Thus inadequate food intake and diseases must be both addressed to support recovery from malnutrition (UNICEF, 1998).

2.1.1.2Underlying causes of malnutrition

The underlying causes are those that give way to immediate causes. The three major underlying causes of malnutrition include inadequate household food security, limited access to adequate health services and/or inadequate environmental health conditions and inadequate care in the households and at community level especially with regards to women and children (UNICEF, 1998).

2.1.1.3 Basic causes of malnutrition

The basic causes of malnutrition in a community originate at the regional and national level where strategies and policies that affect the allocation of resources (human and, economic, political and cultural) influence what happens at community level. Geographical isolation and lack of access to market due to poor infrastructure can have a huge negative impact on food security (MMS/MPHS, 2009), access to healthcare services as well as healthy environment. The above model characterizes the correlates of malnutrition as factors that impair access to food, maternal and child care, and health care. It is these very factors that impact the growth of children. Consequently, the assessment of children’s growth is a suitable indicator for investigating the wellbeing of children, and for examining households’ access to food, health and care (UNICEF, 1998).

2.2 Nutritional Status of Children Under Five Years

Nutritional status of children is an indicator of the level of development and future potential of the community. The nutritional status of infants and children under five years of age is of particular concern since the early years of life are crucial for optimal growth and development (Preschulek et al., 1999). Nutritional deficiencies affect long term physical growth and development and may lead to high level of illness and disability in adult life. Moreover high prevalence of malnutrition jeopardizes future economic growth by reducing the intellectual and physical potential of entire population (Kabubo-Mariara, 2006).

Children under five years constitute a significant proportion in Kenya. A survey by the Central Bureau of Statistic (KNBS and ICF Macro 2010) showed that children under five comprise 15.7% of national population. Information on nutritional status of this group may therefore be a good indicator of nutritional situation in a wider society.

Eastern region has highest prevalence of stunting (42 %) while Nairobi region has the lowest at 26 %. Sixteen (16 %) of children under five are underweight (low weight-for-age) and 4 % are severely underweight. Prevalence of stunting and underweight was observed to be high in rural areas as compared to urban areas (KNBS and ICF Macro 2010).

Prevalence of malnutrition varies across the world. A study done in Nigeria among the children aged 0-5 yrs found out that 35.7% stunted, 14.9% underweight and 5.5% wasted (Lawal and Samuel, 2010). Elsewhere in Ethiopia prevalence of stunting was (54.2%), underweight (40.2%) and wasting (10.6 %) (Aweke et al., 2012). A comparative study on nutritional status of preschool children in Butembo (DRC) and Gitega (Burundi) found that only 21.14% and 36.43% of the preschool children from Butembo (DRC) and Gitega (Burundi), respectively fell within the normal range in regards to stunting (≥-2 z-score) (Ekesa et al., 2011). Although the prevalence of malnutrition differs among different regions around the world, it is evident that malnutrition exists and there is need to address it effectively.

2.3 Methods of Assessing Nutritional Status

Nutritional assessment is the first step in the treatment of malnutrition. The goals of nutritional assessment are identification of individuals who have, or are at risk of developing malnutrition, to quantify the degree of malnutrition and to monitor the adequacy of nutrition therapy. The methods of assessment are based on series of anthropometric, dietary, laboratory and clinical observations used either alone or more effectively, in combination. Correct interpretations of the results often require consideration of other factors such as socio-economic status, cultural practices, and health and vital statistics (Gibson, 2005). In this study dietary method and anthropometric measurements were used because they yield satisfactory results within the limit of resources available.

2.3.1 Anthropometric method

Anthropometry involves measurement of variation of physical dimension and gross composition of human body at different age level and degree of nutrition. Anthropometry is particularly useful when there is chronic imbalance between intake of protein and energy (Gibson, 2005). Anthropometric indices are derived from combination of raw measurement. These include height, weight, and age of the individuals whose nutritional status is being determined. The measurements are then used to calculate the anthropometric indicators of nutritional status such as height-for-age, weight-for-age and weight for height. The indicators are then used to classify and interpret nutritional status of individuals as shown in table 1. Anthropometric methods of assessments are preferred in most study for its advantages. The equipment used is portable and inexpensive. Measurements can be performed relatively quickly and with ease hence do not require highly skilled staff to perform them. This method however has some limitation as well. Although sometimes the method can detect moderate and severe form of malnutrition, it cannot be used to identify specific nutrient deficiency states (Gibson, 2005).The main imprecision errors in anthropometric are random imperfection in measuring instruments or in the measuring and recording techniques (Arroyo et al., 2010). To control and minimize errors during the assessment, examiners need to be carefully trained on techniques of calibrating the equipment and taking accurate measurements.

Table 1: Cut Off Points for Malnutrition

Source: WHO, 2006

2.3.2 Biochemical or Laboratory methods

The assessment of nutritional status by laboratory tests potentially offers a reproducible quantitative means of measuring specific nutrients that can be of great use to clinicians, nutritionists, and researches. It can provide objective confirmation of nutritional deficiencies.

Laboratory tests can also be used to monitor nutritional therapy with greater precision compared to separate use of dietary, anthropometric, or clinical assessment techniques. They may be used to determine quantitative alterations in biochemical levels of nutrients, their metabolites, or dependent enzyme activities that are often not detected by anthropometric methods. Although they nicely quantitate levels of a certain nutrient in a specific body fluid at a particular time, these measurements may not correlate with values at other times, in other body pools, or with deficiencies of other nutrients. Furthermore, many drugs, diseases, and end environmental conditions not related to nutrition can affect measured levels of nutrients (Falcão, 2000).

2.3.3 Clinical methods

The method it utilize a number of physical signs (specific and non-specific), that are known to be associated with malnutrition, deficiencies of vitamins and micronutrient. This method involves getting good nutritional history and general clinical examination with special attention to organs like hair, nail, and angle of the mouth, eyes, skin, tongue, muscles, bones and thyroid glands. Detection of relevant sign helps in establishing a nutritional diagnosis. The method is fast and easy to perform, inexpensive and non- invasive. However it has a limitation in ascertaining early diagnosis (Gibson, 2005).

2.3.4 Dietary assessment method

Diet is one of the prime determinants of health and nutritional status. An inadequate diet, poor in both quality and quantity has been one of the reasons for high levels of malnutrition in children. Dietary surveys are therefore one of the essential components of nutritional assessment. (Kulsum et al., 2008). The appropriate tool for dietary assessment will depend on the purpose for which it is needed. The purpose may be to measure nutrients, foods or eating habits. Different methods have been developed for the purpose of assessing dietary intake. These range from detailed individual weighed records collected over a period of 7 days or more to food frequency questionnaires, household survey methods and simple food lists. Each has merits, associated errors and practical difficulties to be considered when choosing one method above another (Wendy et al, 2003). Dietary assessment can be done at household level or individual level depending on the objective of the survey.

Household methods

The methods of assessment at the household level are: household recall, food accounts and inventories. Data generated by these methods are useful for comparing food availability among different communities, geographic areas and socioeconomic groups. However, these data do not provide information on the distribution of foods among individual members of the household.

Food account method

Household members keep a detailed record of the quantities of food entering the household, including home produced food, purchases gifts, and from other sources. The method is widely used in household budget surveys. Main disadvantage of this method is that data are limited to food brought into the home and fail to account for food consumed outside home.

Household record

In the household record method, the foods presented for consumption to household members are weighed or estimated in household measures. This method may be well suited to populations in which a substantial proportion of the diet is home produced rather than purchased (Gibson, 2005).

Individual methods

Dietary diversity

Dietary diversity is defined as the number of individual food items or food groups consumed over a given period of time (Ruel, 2003). The type and number of food groups used for assessment and subsequent analysis may vary depending on the level of measurement and intended purpose. At the household level, dietary diversity is usually considered as a measure of access to food, while at individual level it reflects dietary quality, mainly micronutrient adequacy of the diet. The reference period can vary, but is most often the previous day or week (FAO, 2011, WFP, 2009). For this study individual dietary diversity score of the children was determined based on simple counts of number of food groups consumed in the past 24 hour (8 food groups by FAO for individual dietary diversity). DDS is easy to calculate (Ruel, 2003), moreover majority of respondent’s do not find the questions associated with assessing DDS intrusive (Swindale and Bilinsky, 2006). However the method also has a limitation since Measures of dietary diversity typically do not include quantities consumed. There can also be significant fluctuations over time in consumption of food groups. This poses challenges in extrapolating survey data to arrive at broad conclusions about the food security status (IPC Global Partners, 2008).

Challenges in assessing dietary intake

The recall ability and psychological characteristics of individuals can influence dietary reporting. For example, an individual may be aware that their diet is unbalanced and so may be reluctant to provide honest answers to questions, or their recollection of intake may simply be flawed.

Participants may report behavior that they perceive as socially desirable rather than accurate (NOO, 2010).

2.4 Household Food Security

Food security has been defined as a situation that exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and preferences for an active and healthy life. Thus, food insecurity is a situation that exists when people lack access to sufficient amounts of safe and nutritious food for normal growth and development to leave an active and healthy life. Food insecurity may be caused by the unavailability of food, insufficient purchasing power, inappropriate distribution or inadequate use of food at the household level (FSAU, 2005).

2.4.1Measurement of indicators of food security

Household food security can be accessed by use of process indicator; those that describe food supply and food access and outcome indicators that describe food consumption. Process indicators are imprecise and due to confounding factors, time consuming and expensive (Hoddinott et al., 2002). Food consumption entails individual intakes, household caloric acquisition, dietary diversity, and indices of household coping strategies (Deaton and Gross., 1998).

Food availability

Food availability is a factor of production capacity, amount of imports and amount that is normally used at a given period in time and of the availability of storage. Food availability is also influenced by the availability of seeds, pest infestation/attack, weather conditions, availability of pasture, and land acreage under cultivation, labour availability and insecurity issues. The amount of food used by households, traded or stored, all influence food availability (FSAU, 2005). In this study, household crop production was assessed to determine household food availability.

Food access

Many factors affect people’s access to food. These include Cultural factors, reduced purchasing power, Logistical/geographic obstacles to markets and Insecurity. Household food access is also determined by seasonal patterns. For instance, the main food crop produced may not be sufficient to meet the household needs at all times (FSAU, 2005). In this study, household food access was assessed by determining household caloric acquisition from household’s farm produce. At individual level dietary diversity of the study children was assessed.

Food utilization

Adequate Utilization refers to the ability of the human body to ingest and metabolize food. Nutritious and safe diets, an adequate biological and social environment, a proper health care to avoid diseases ensure adequate utilization of food. In most cases, utilization is only discussed from a biological perspective (Rainer et al., 2000)

2.5Factors Associated with Malnutrition

According to a study in DRC a low maternal educational level (less than 7 years), the absence of a drinking tap water available in the house or yard, male gender, and age of children were all significantly associated with increased risk of stunted growth while decreased appetite, diarrhea and age of children were significant predictors of emaciation (Mukatay et al., 2010).

According to a study in Pakistan, household income and Childcare practices had an important and significant impact on child nutritional status. Childcare practices were negatively and significantly related to child nutritional status (Uzma and Muhammad, 2006).

A study on household food insecurity and nutritional status of under five years in Western Highlands of Guatemala showed that food insecurity at the household level was significantly associated with HAZ, such that children in moderately food insecure households had 0.08 lower HAZ and children in severely food insecure households had 0.09 lower HAZ than children from food secure households (Chaparro, 2012). Similar study in Nigeria found out that Food-insecure households were five times more likely than secure households to have wasted children (crude OR = 5.707, 95 percent CI = 1.31-24.85) (Ajao et al., 2010)

In Kenya an inverse relationship is observed between the household wealth index and the stunting levels for children, that is, children in the lowest household wealth quintile record the highest stunting levels (44 percent). The proportion of stunted children declines with increase in the wealth quintile (KNBS and ICF Macro 2010). This could be attributed to ability of the household to purchase adequate food and obtain better health care services. According to the same report, mother’s education can exert a positive influence on children’s health and survival. Under five mortality is noticeably lower for children whose mothers either completed primary school (68 deaths per 1,000 live births) or attended secondary school (59 deaths per 1,000 live births) than among those whose mothers have no education (86 deaths per 1,000 live births). However, under-five mortality is highest among children whose mothers have incomplete primary education. Similar patterns are observed for infant mortality levels.

A study done in Kwale County found that children in female-headed households were more likely to be underweight than their counterparts in male-headed households, which could be attributed to extreme poverty in female-headed households. The same study also established children from large households to be more likely to be wasted (Amegah and Adeladza, 2009).