ORIGINAL ARTICLE

Gender inequality in food intake and nutritional

status of children under 5 years old in rural
Eastern Kenya
M Ndiku
1,2
, K Jaceldo-Siegl
1
, P Singh
1,3
and J Sabate
1,2
1
Department of Nutrition, School of Public Health, Loma Linda University, Loma Linda, CA, USA;
2
Department of Family and
Consumer Science, School of Sciences and Technology, University of Eastern Africa, Baraton, Eldoret, Kenya and
3
Department
of Epidemiology and Biostatistics, School of Public Health, Loma Linda University, Loma Linda, CA, USA
Background/Objective: Although gender inequality in nutritional status has been consistently reported in several parts of South
Asia, in sub-Sahara Africa there is a paucity of data and conflicting conclusions. We conducted a study to assess if gender
inequality in food intake and nutritional status is present in rural Eastern Kenya.
Subjects/Methods: This was a descriptive cross sectional study conducted in the Mwingi and Makueni districts of Ukambani
region in Eastern Kenya, two rural districts where grains are the main contributor of energy intake. There were 629 children aged
o60 months, randomly selected for participation in the study.
Results: Boys consistently had higher energy intakes than girls (P 0.005). More girls were stunted, underweight and
wasted 51.7%, (49.953.5), 32.1%, (30.433.7), 4.6%, (3.95.4) than boys 35.9% (34.237.7), 14.6% (13.415.9) and 1.2%
(0.81.6), respectively, Po0.001. Of the total, 24.6% (23.126.2) of the girls were severely stunted compared with boys 16.3%
(15.017.7). Boys had higher Z-score indices (height-for-age (HAZ) 1.331.86, weight-for-age (WAZ) 0.601.53 and
weight-for-height (WHZ) 0.25

1.23) than girls (HAZ2.02

1.94, WAZ1.37

1.27 and WHZ0.10

1.49), all
Po0.001.
Conclusions: The prevalence of malnutrition among children in rural Eastern Kenya is sizable. However, girls were more stunted,
underweight and wasted than boys at all age categories due to their consistent lower food intake. Further research is needed to
expose the social and cultural determinants underlying gender discrimination in intra-household allocation of food.
European Journal of Clinical Nutrition (2011) 65, 2631; doi:10.1038/ejcn.2010.197; published online 29 September 2010
Keywords: stunting; underweight; Ukambani; gender; nutritional assessment; prevalence
Introduction
Under-nutrition characterized by lack of sufficient food
and variety in food choices continues to be a major public
health concern in most developing nations. It is exacer-
bated by diseases, poverty, hostile climates and lack of
nutritional knowledge in mothers or caretakers (Bridge et al.,
2006a; Bridge et al., 2006b). The main determinants of
a childs nutritional status are the childs dietary intake
and all the other elements that contribute to the overall
health status. At the household level, these two factors are
influenced by food security, adequate care for mothers and
children and a proper health environment (Smith and
Haddad, 2000).
Gender inequalities in quantity and quality of food intake
may contribute to under-nutrition mainly in settings where
the girl child is still considered less important than the boy
child (World Bank, 2006; Dey and Chaudhuri, 2008). Gender
inequality in nutritional status due to intra household
allocation of resources has been consistently reported in
several parts of South Asia (Pal, 1999; Sen, 2001; Moestue
et al., 2004; Dey and Chaudhuri, 2008; Moestue, 2008;
Dancer et al., 2008). In sub-Sahara Africa, however, there is a
paucity of data and conflicting conclusions (Klasen, 1996;
KDHS, 2003; Gillet and Perry, 2005; Hadley et al., 2007;
Wamani et al., 2007).
We assumed that if boys and girls under 5 years old
were cared for and nourished in the same way, their
Received 13 November 2009; revised 24 May 2010; accepted 24 May 2010;
published online 29 September 2010
Correspondence: Dr J Sabate, Department of Nutrition, NH 1102, School
of Public Health, Loma Linda University, Loma Linda, CA 92350, USA.
E-mail: jsabate@llu.edu
European Journal of Clinical Nutrition (2011) 65, 2631
& 2011 Macmillan Publishers Limited All rights reserved 0954-3007/11
www.nature.com/ejcn
anthropometric status should be similar. Differences in their
physical development can be attributed to inequalities in
diet and health care. Thus, the aim of this study was to
assess if gender inequalities in food intake and nutritional
status is present in rural Eastern Kenya. This was part of a
study that looked at dietary patterns of under 5 years old
children from two rural regions with different dietary
patterns (Ndiku et al., 2009).
Materials and methods
Study area and population
Out of the four main geographical regions of Eastern Kenya
(Ukambani) we randomly selected two districts. In all,
4 of the 27 divisions were also randomly selected from these
two districts, and within the divisions a total of 16 villages
were surveyed. All the households in these villages were
visited and were eligible for data collection if they included
children under 5 years of age. Households where the
biological mothers were not present at the homestead at
the time of data collection were excluded. A total of 403
households were surveyed and interviews were conducted
with the mothers. In all, 201 Mwingi and 202 Makueni
mothers were interviewed, and these yielded 629 children:
325 girls and 306 boys. This sample was drawn on the
assumption of a two-tailed a of 0.05 and no matching of any
variables with a power of 80% to detect a 10% in the
prevalence of malnutrition between the two gender groups
(boys and girls).
Data collection procedure
The research team in the field consisted of a leader (MN) and
four trained research assistants. Data collection proceeded
after permission was granted from the district commis-
sioners office. Data were collected in two phases: January
March 2008 (rainy season), and JuneSeptember 2008
(dry/harvest season). At the village level, the team was led
by a village elder from house to house during the home
visitations. This research was approved by Loma Linda
University Institutional Review Board and Ministry of Higher
Education, Kenya Government
The data collection instruments included a mother and
child section that was a modified rapid, knowledge, practice
and coverage survey questionnaire (KPC, 2000) and a 24-h
dietary recall of the mother on the childs intake. The
instrument was piloted and revised accordingly. A verbal
consent was obtained from the mother after a consent
statement had been read to her in the local language
(Kikamba) before proceeding with data collection. Data
collected included demographics, anthropometrics, and
biomedical and clinical manifestations of malnutrition,
and dietary habits. Age for the children was recorded as
reported by the mother and verified with the maternal and
child health cards. Where there was discrepancy, the age on
the maternal and child health card prevailed.
Anthropometric and clinical data
For children older than 2 years of age weight was measured
using an electronic floor scale (Scale-Troni-x-5125, NY, USA),
whereas height was measured using a stadiometer (Health
scale RGX-120, North Shore Health Supplies, Northbrook, IL,
USA) as described by Nieman and Lee, (2006). Height was
reported to the nearest 0.1 cm and weight was reported to
the nearest 0.1 kg. For children o2 years old, length was
measured using a recumbent length board (Crown, London,
UK) and weight was measured using an infant beam balance
(Crown) as described by Gibson (2005). Children wore
minimal clothing while being weighed.
A hypolet automatic pricking device (Auto-Lancet, Palco
Laboratories, Scotts Valley, CA, USA) and sterile hypo-
guard disposable lancets (TechLite Lancet, Arkray Factory,
Minneapolis, MN, USA) were used to make a finger prick.
Hemo-control microcuvettes (EKF Diagnostics, Magdeburg,
Germany) were used to collect the blood and a hemo-control
analyzer (EKF Diagnostics) was used to measure hemoglobin
levels on site.
Clinical manifestations of malnutrition in the children
were observed and documented as wasting, brown hair, dry
skin and edema. Diseases suffered within 1 month before
data collection and hospital visitations and hospitalization
encountered were documented.
24-h diet recall
Dietary intake of each child was assessed by a face-to-face
24-h dietary recall interview with the mother. An accurate
and complete listing of all food and drink consumed by each
child within the last 24h was recorded including quantity
and time. Preparation methods and how the food was served
were noted (details given elsewhere; Ndiku et al., 2010).
Children who were exclusively breastfed and were
p6 months were estimated to take an average of 25 fluid
oz (750ml) of breast milk per day. Therefore, estimating
that the babies were fed six times within 24h, an average
of
1
2
cup of breast milk was estimated for every feed
in the 24-h recall record. After introduction of solid foods,
the milk was adjusted accordingly to accommodate the
use of solid foods (Steenbergen and Kusin 1981KDHS, 2003;
Kelly, 2008).
Data analysis
Dietary intake was assessed in terms of food groups and food
nutrients and was analyzed using NDS-R 2008 (The Nutrition
Coordinating Center, Minneapolis, MN, USA; details given
elsewhere; Ndiku et al., 2010). Height, weight and age were
used to compute the malnutrition indices (Z-scores) using
EPI INFO 2000 (NCHS, 2000).
Gender inequality of children o5 years in rural Kenya
M Ndiku et al
27
European Journal of Clinical Nutrition
Statistical analysis was performed using SAS version 9.1
(SAS Institute Inc., Cary, NC, USA). Results are reported as
mean

s.d. unless otherwise indicated. The nutritional

data were normalized using log transformations where
appropriate. Descriptive analyses were done, using students
t-test for continuous variables and Fishers exact test and
Pearson w
2
-test for categorical variables, with significance
assumed at an a of 0.05.
Results
A total of 403 mothers were interviewed for 24-h diet
surrogate recalls and 629 diet recalls for their children were
collected (Table 1). Of the 629 children, 49% were boys and
51% were girls. The average age for the interviewed mothers
was 307 years and the mean age for the children was
26.5

17 months. Table 1 presents the distribution of the

under 5 years children according to age and gender. There
was a progressive decrease in the number of children as age
increased.
Figure 1 represents the contribution of foods and food
groups to daily energy intake in children by gender
according to different age categories. The contribution of
breast milk to energy intake tapered off and ceased to be a
major contributor after 18 months. There was a consistent
increase in energy intake for boys as age increased. The girls
showed inconsistent increases of energy intake with age,
with two main drops in energy at age category 2536 months
and age category 4960 months. Overall, boys had a 12%
higher mean energy intake 4688

2378kJ than girls

4169

2231kJ, P0.005. Boys had significantly higher

energy intake from grains 35332240kJ than girls
3018

2093kJ, P0.021. Intakes from all the other food

groups were not significantly different (data not shown).
The prevalence of malnutrition was significantly greater in
girls than boys as seen in all the anthropometric indicators
(Table 2). After 6 months of age, anthropometric indices of
malnutrition (mean Z-scores) for all the children dropped
below the reference line (Z-score of zero) with height-for-
age (HAZ) mean Z-scores decreasing below the moderate
Table 1 Distribution of under 5 years children in rural Eastern Kenya
according to gender
Age category (months) Girls (n) Boys (n) All (n)
012 93 80 173
1324 67 68 135
2536 63 66 129
3748 48 53 101
4960 52 39 91
Total 323 306 629
Meats/Eggs
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
%

o
f

T
o
t
a
l

I
n
t
a
k
e
Age (mths)
Relative Mean Energy Intake
Misc
Meats/Eggs
Fats
Fruits and Vegetables
Legumes
Grains
Animal Milk
Breast Milk
0
200
400
600
800
1000
1200
1400
1600
E
n
e
r
g
y

I
n
t
a
k
e

(
K
C
a
l
)
Age in Months
Others

Grains
Animal Milk
Breast Milk
Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls Boys
0-6m 49-60m 37-48m 25-36m 19-24m 13-18m 7-12m
0-6 m 19-24m 25-36m 49-60m 37-48m 13-18m 7-12 m
Figure 1 Contribution of foods and food groups to daily energy intake of under 5 years children in rural Eastern Kenya by gender according to
different age categories. wOthers include: legumes, fruits/vegetables, fats and meat/eggs.
Gender inequality of children o5 years in rural Kenya
M Ndiku et al
28
European Journal of Clinical Nutrition
malnutrition cut point (2 s.d.) at 1318 months of age
(Figure 2). HAZ and weight-for-age (WAZ) mean Z-scores
were significantly higher for boys than girls in all age
categories (Po0.001). Weight-for-height (WHZ) Z-score
means were significantly higher in boys than girls only at
(712, 2536, 3748 and 4960 months; Figure 3).
Overall, boys had significantly (Po0.001) higher mean
Z-scores for HAZ, WAZ and WHZ (1.33, 0.60, 0.25, respec-
tively) compared with girls (2.02 HAZ, 1.37 WAZ and
0.10 WHZ; data not shown).
Preventive-measures differences were not significant
except for deworming, which was favorable for girls.
Apart from diarrhea, girls were prone to have slightly more
infectious diseases than boys. Except for edema and
hemoglobin all other clinical signs of malnutrition were
more prevalent in girls than boys (Table 3).
Discussion
The salient findings from this study were that boys overall
had higher energy intakes than girls, and this difference
appeared to be primarily from a greater intake of grains
among the boys. Girls at all age categories had greater
prevalence of malnutrition than boys. There were no major
gender differences in preventive measures; however, the girls
had experienced slightly more infectious diseases than boys.
Energy and protein requirement seem to be no different
for boys and girls o5 years old as there are no energy
and protein intake recommendations until 48 years
(WHO, 1985; IOM (Institute of Medicine) of the National
Academies, 2006). Thus, it is likely that differences found in
anthropometric indicators of malnutrition among the girls
in our study were due to lower energy intake combined with
greater prevalence of infectious disease. As there was no
difference in preventive measures, it is suggested that the
greater prevalence of infectious disease in the girls was a
consequence rather than a cause of their poorer nutritional
status. Differences in food intake between genders because
of intra-household allocation of resources most probably
led to these marked gender differences in anthropometric
indicators of malnutrition.
Findings of this study, that in general, boys energy intake
is higher than girls, agree with a study in Ethiopia among
adolescents. In that study despite no differences in their
households food insecurity status, girls reported being food
insecure themselves (Hadley et al., 2007). Our findings are
also supported by anthropometric, mortality and population
data analyzed by Klasen, who found evidence of a slight and
rising anti-female bias in sub-Saharan Africa, which was
particularly apparent in mortality and population indicators
(Klasen, 1996).
Our study findings that girls had higher prevalence rates
for both moderate (2 s.d.) and severe malnutrition (3
s.d.), concur with a study in India reporting 55.9%, 51.4
and 42.3% of the girls underweight, stunted and wasted,
respectively, compared with 46.6, 40.5 and 35.3% of the
boys (Dey and Chaudhuri, 2008). Underlying reasons for the
differences were suggested to be that girls have less access to
nutrition, physical and mental health care, and education
(Dey and Chaudhuri, 2008).
Table 2 Malnutrition prevalence in percentage (95% confidence interval) for children o5 years in rural Eastern Kenya stratified by gender
Anthropometric indicators All (n629) Girls (n323) Boys (n306) P-value
a
Moderate: (o2 s.d.)
Height-for-age (stunting) 44.0 (43.045.2) 51.7 (49.953.5) 35.9 (34.237.7) o0.001
Weight-for-age (underweight) 23.5 (22.424.6) 32.1 (30.433.7) 14.6 (13.415.9) o0.001
Weight-for-height (wasting) 3.0 (2.53.4) 4.6 (3.95.4) 1.2 (0.791.57) o0.001
Severe: (o3 s.d.)
Height-for-age (stunting) 20.5 (19.521.6) 24.6 (23.126.2) 16.3 (15.017.7) o0.001
Weight-for-age (underweight) 4.9 (4.45.5) 6.9 (5.97.8) 2.9 (2.333.6) o0.001
Weight-for-height (wasting) 0.5 (0.310.67) 0.8 (0.51.1) 0.2 (0.020.32) o0.001
a
Fishers exact test.
-3
-2
-1
0
1
W
e
i
g
h
t
e
d

M
e
a
n

Z
-
s
c
o
r
e
s
Age in Months
Weight-for-Height Weight-for-Age
Height-for-Age
Severe malnutrition
cut point
Moderate malnutrition cut point
Median z-score of the
reference population
0-6m 49-60m 37-48m 25-36m 19-24m 13-18m 7-12m
Figure 2 Mean Z-score values for three anthropometric indicators
height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height
(WHZ) for o5 years in rural Eastern Kenya (n 629). The horizontal
line at the Z-score value of zero represents the median Z-score of the
reference population. Z-score of 2 s.d. represents moderate
malnutrition and Z-score of 3 s.d. represent severe malnutrition.
The National Center for Health Statistics/World Health Organization
reference was used to calculate the Z-scores (NCHS, 2000). Cases
were weighted by village size.
Gender inequality of children o5 years in rural Kenya
M Ndiku et al
29
European Journal of Clinical Nutrition
Our findings that boys (compared with girls) had more
favorable mean Z-scores for the three anthropometric
indices (that is, HAZ, WAZ and height-for-weight), agree
with those of the KDHS. The 2003 KDHS reports higher
Z-scores for HAZ, WAZ and WHZ in boys (1.4, 1.0 and 0.3,
respectively) compared with girls (1.1, 0.9 and 0.2, respec-
tively; KDHS, 2003).
Moestue et al. (2004) and Moestue (2008), two studies
conducted in Bangladesh, caution against the use of
anthropometrics to measure gender nutritional disparity
because of the different conclusions drawn when the three
known references are used, that is, National Center for
Health Statistics (NCHS/WHO, 2006), Center for Disease
Control (CDC, 2000) and British growth references 1990.
Our study used the NCHS as reference. While this caution
is an important consideration, the difference we found
between genders in anthropometric measures seems to be
supported by the differences in energy intakes and lends
strength to the study.
Inequality between girls and boys can take many different
forms. One of those could be neglect of health, nutrition and
other needs of girls that influence survival (Sen, 2001;
Osman and Sen, 2003). The girl child in most cases is
disadvantaged from birth and throughout her entire life
(Dey and Chaudhuri, 2008). Womens deprivation in terms
of nutrition and healthcare rebounds on society as a whole
in the form of ill-health not only for themselves including
reduced productivity, but also for their offspring (males and
females alikeboth as children and as adults; Osman and
Sen, 2003; World Bank, 2006).
Malnutrition causes growth retardation, a physiologically
and economically costly human condition (Leenstra et al.,
2004). It retards childrens physical and cognitive develop-
ment and increases susceptibility to disease (World Bank,
2006). Under-nutrition of children erodes human capital, as
it negatively influences the chances that a child will go to
school, stay in school and perform well (World Bank, 2003).
Malnutrition is a violation of a childs human right (Smith
and Haddad, 2000). The World Health Organization recog-
nizes the importance of investing in nutrition as a critical
component to achieving the millennium development goals
(World Bank, 2006).
Our study illustrates the complex causes of malnutrition.
Future research should ascertain if this pattern is the same in
M
e
a
n

Z
-
s
c
o
r
e
Weight for Age
Boys
Girls
-4
-3
-2
-1
0
1
2
-4
-3
-2
-1
0
1
2
-4
-3
-2
-1
0
1
2
M
e
a
n

Z
-
s
c
o
r
e
Height for Age
Boys
Girls
M
e
a
n

Z
-
s
c
o
r
e
Weight for Height
Boys
Girls
0-6 m 5 y 4 y 3 y 19-24 m 13-18 m 7-12 m
Figure 3 Height-for-age, weight-for-age and weight-for-height for
under 5 years children in rural Eastern Kenya by gender. The
horizontal line at the Z-score value of zero represents the median
Z-score of the reference population. Z-score of 2 s.d. represents
moderate malnutrition and Z-score of 3 s.d. represent severe
malnutrition. The National Center for Health Statistics/World Health
Organization reference was used to calculate the Z-scores (NCHS,
2000). Cases were weighted by village size.
Table 3 Preventive and clinical malnutrition parameters of under 5
years children in rural Eastern Kenya by gender
Preventive measures Girls Boys P-value
Length of breast fed (months) 20.67.4 21.17.9 0.075
Vaccination card 60.6% 61.8% 0.082
Child born at home 78% 83.3% o0.001
Dewormed 25.6% 16.1% o0.001
Ailments suffered 1 month before data collection
Diarrhea 11.2% 12.5% 0.067
Malaria 34.5% 28.1% o0.001
Pneumonia 5.7% 2.7% o0.001
Measles 0.7% 0.3% 0.036
Fever 36.0% 33.3% 0.030
Clinical signs
Edema 1.6% 2.7% 0.005
Brown hair 9.0% 8.5% 0.083
Dry skin 13.8% 11.7% 0.017
Wasting 20.0% 15.8% o0.001
Hemoglobin (mg/dl) 9.8

1.7 9.7

1.5 0.001
Gender inequality of children o5 years in rural Kenya
M Ndiku et al
30
European Journal of Clinical Nutrition
other parts of rural Africa. If confirmed as a generalized
problem, it warrants further study to explore the possible
determinants of malnutrition at the household level such as
the reasons for intra-household discrimination in allocation
of food. Results from our study may be used to support
nutritional intervention policy in Eastern Kenya to mitigate
malnutrition in young children.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
We thank the Federico Foundation, Switzerland for funding
this project, Dr Patricia Johnson for revising a previous
version of this manuscript, and the field research team for
invaluable assistance during data collection. We also
acknowledge the time given by the subjects and mothers
who participated in the study.
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