Malnutrition: A public health concern of Uganda’s present and future

Introduction
Malnutrition is global challenge to governments, NGOs, medical and public health experts.
Malnutrition is an economic, social and public health concern. The problem of malnutrition is
cross-cutting between rich and poor countries all stemming from the lack of access to proper
nutrition or poor nutrition choices (WHO, 2020). According to the 2018 Global Nutrition Report,
38.3 million children below 5 years were overweight, 150.8 million were stunted while 50.5
million were wasted, and every country in the world is having atleast one challenge of
malnutrition (Fanzo et al 2019). The World Health Organisation (WHO) defines malnutrition as
the deficiencies, excesses or imbalances in a person’s intake of energy and nutrients.
Malnutrition is further categorized into undernutrition which includes stunting, underweight,
wasting and micro-nutrient deficiency. The other categorization includes overweight, obesity and
diet-related noncommunicable diseases (Malnutrition (who.int)). Undernutrition is a major
challenge in less developed countries (LDCs) mainly due to poverty that limits access to enough
and quality food. Lack of macronutrients (carbohydrates, proteins and fat) and micronutrients
(vitamins and minerals) will push the body of malnourished individuals to adapt to nutritional
changes. Hence, children that are short, thin-bodied and symptomatic with lack of micro
nutrients (anaemia, beriberi, scurvy, blindness, goiter and pellagra). Some reports have showed
that poor households, with uneducated mothers and lack of waged employment contributed to
childhood malnutrition (Kayode et al. 2014). Hoop et al. 2020 reported that mother’s education
had a significant effect on the malnutrition statuses of their children. Teenage parenthood is
another endemic challenge that, with a range of other issues like stigma leads to malnutrition
(Kabwijamu et al. 2016). Teenage parents are likely to be uneducated, poor, forced into early
marriage, subjected to neglect due to cultural norms and the mother maybe malnourished. All
these issues have a resounding effect on how a new-borne baby will be breastfed, weaned and
vaccinated (Uzun et al. 2013).
Malnutrition robs most children of their physical wellbeing and may grow (if they survive) into
depressed social class citizens with risks of contracting chronic diseases and poor academic
performance. These consequences have a big impact on a country’s economic development by
reducing the quality and quantity of manpower (Adebisi et al. 2019).
According to the Uganda demographic and health survey (UDHS), stunting and wasting
(undernutrition) are still the major characteristics of malnutrition in children of ≤5 years (Gideo,
2013; Sagna et al 2011). Although UDHS data shows that there has been steady decline in the
country’s malnutrition cases, it’s not uniformly distributed. The risks of malnutrition in Uganda
like many other LDCs are exacerbated by compounding factors of poverty, food insecurity,
ignorance, cultural norms, poor government policies, underlying medical conditions and
inefficient health infrastructure. The level of education, household source of income and
geographical of the household have contributing role to children malnutrition. Forexample in
northern and eastern Uganda where economic statuses are low, the cases of malnutrition were
higher than in Central regional (Amegbor et al. 2020; Mawa and Lawoko 2018). Cultural norms
cultural norms that stop children and mothers from eating certain like eggs and meat limits
nutritional diversity for children (Muggaga et al. 2017). Mawa and Lawoko (2018) also reported
that the nutrition status of the mothers, measured in terms of body mass index (BMI), had an
effect on the malnutrition status of their children. They observed that children whose mothers
had a BMI of <18.5 kg/m2 were at a 3x higher risk of malnutrition compared to their counterparts
whose mothers’ BMI was 18.5 – 24.99 kg/m2. Underlying illnesses such as HIV and malaria,
which are prevalent in Uganda, affect both the children and parents and case deaths during birth
may occur due to insufficient energy or just afterbirth due to tiredness and failed wound healing.
Stigma in society, especially in teenage mothers and generally the difficulty in accessing health
facilities leaves most mothers silently avoiding medical centres. As education programs have
scored poorly in transforming the country from poverty – the root cause of malnutrition
(Datzberger 2018), on an equal scale, the medical practitioners have limited diagnostic skills and
are hardly present at medical facilities (Wane & Martin 2013). While the ratio of boys to girls
enrolled in schools remains high, even the few that are enrolled either drop out for maternal
reasons or are significantly outcompete by boys (Björkman-Nyqvist 2013) hence lead
unproductive live as stay home mothers.
Uganda has an established health care system but characteristic with a number of challenges such
as a high patient : doctor ratio, yet proper guidance and sensitization of pregnant and breast
feeding mothers is key especially where majority mothers are illiterate. Nutrition information for
pregnant and breastfeeding mothers is available in most health centres throughout the country,
however dissemination of this information still remains a challenge. Between 2013 and 2015,
Ugadna lost over 200, 000 children of <5 years to undernutrition. This was after an investment of
more than 1.8 trillion Uganda shillings (5.6 percent of the gross domestic product) on nutritional
related costs (UNICEF, 2020).
Uganda, referred to by Winston Churchill as “the Pearl of Africa” in his book of My African
Journey (Churchill, 2019), is endowed with good climate and fertile soils. Most crops can grow
all year round while almost every livestock including birds are reared across the country (UBOS,
2018). Imagining that the same country grapples with issues of malnutrition in under five year
children should be treated as a big concern. Nutrition education could be what is the missing to
fill this puzzle.
Door-to-door Nutrition Education to avert malnutrition
In her book, The Riddle of Malnutrition, Jenniffer Tappan elaborates in detail how awareness
creation through the Mwanamugimu programme has for decades played a significant role in
fighting malnutrition among children of below 5 years in Uganda. The programme educated
expectant and breastfeeding mothers on how to breast feed and win healthy children. They were
taught how prepare and serve food to their children. However, this programme was compromised
with political and policy instabilities.
Nutrition education in this programme focuses on 1) the risks and consequences of malnutrition,
2) proper breastfeeding, 3) encouraging mothers to visit health centres, 4) diet diversity through
barkyard/kitchen gardening, 5) the preparation of nutritious children and adult meals, 6)
Sanitation, 7) the available commercial toddler foods, 8) government programmes that support
children nutrition.
The risks of malnutrition are not as obvious to many expectant and breast feeding mothers. Most
of these predispositions are considered as normal physical conditions and mothers may realize
when it’s already too late. As well the consequences of such in adult life need to be clearly
understood otherwise some children have been regarded as “cursed” for health conditions such
as lameness which they could have been prevented from. The WHO proposes anthropometric
measurements, biochemical indicators and clinical signs for measuring malnutrition (WHO
2020). Anthropometric measurements (weight-for-height and BMI) and clinical signs such as
oedema can be assessed at most medical centres in Uganda. Therefore, parents should be
informed on how important this information is so that they can ask for such measurements
whenever they visit hospitals. During door-to-door campaigns, it’s even easy to perform such
measurements such as weight and height since the instruments are potable.
Most breastfeeding mothers are conversant with the purpose and duration of breastfeeding
(Labu, 2015) however the quality of breastfeeding in terms of hourly intervals could be a
challenge in most areas of Uganda. Actually, most mothers will feed their babies when they cry.
Besides breast feeding strengthening mother-child bondage, breast milk reduces the risks of child
infection and is relatively cheap compared to commercial formula (Victora et al. 2016). Fulltime
employed mothers have irregular breastfeeding schedule yet even earnings are insufficient to buy
adequate food for the child while out of depression, stigma and other issues, some teenage
mothers pay less attention to breastfeeding. Serious interventions on how to balance work and
breastfeeding are therefore necessary but most importantly encouraging mothers to take breast
feeding as essential to the child’s future health is key. Baker et al (2006) reported that there was
a six times greater risk of mortality in children who were not breastfed in the first two than their
counterparts who were breastfed. Forming breastfeeding clubs, mother’s groups is one way of
encouraging such. Group members will then be responsible for each other.
Food diversity: Most households in Uganda grow traditional food crops (maize, yams, sweet
potatoes) that provide macro nutrients – carbohydrates, proteins and fats (UBOS, 2018). Meat
and eggs are occasionally eaten while vegetables and fruits are rare. Emphasizing balanced diet
for pregnant and breast feeding mothers will reduce malnutrition. This can be achieved by
encouraging households to maintain small plots of vegetables such as tomatoes and cabbages and
fruit trees like avocado in their backyard. Change of feeding lifestyles (mostly fast foods such as
chips and pizza) by urban mothers should be decampaigned. On the same aspect, parents should
be encouraged to save food for their future children. Forexample through saving schemes,
parents can have specific savings for yet to be born babies beginning from conception or even
earlier. Traditional food crops such as millet, which can grow all over the country, are rich in
micronutrients especially iron which is important. Sensitization on crops production diversity in
relation to nutritional value could help the poor households to combat malnutrition sustainably.
Therefore, campaigns to monitor gardens of the households, exchange of agricultural skills
should bolster food security and encourage proper nutrition.
Sanitation is an important aspect of health for both children and adults to avoid diseases such as
diarrhea, dysentery and cholera. If these diseases attack toddlers in acute conditions, even good
nutrition may be insiginificant to forexample avoid wasting or even death (Victora et al. 2016).
Particularly breastfeeding mothers need to be extra careful to keep breasts clean, sanitize feeding
bottles and maintain hygienic playing environment for the babies by proper disposition of waste
materials. Clean drinking water should be maintained at all times.
Preparation of food materials for toddlers needs an even for the literate mothers. Children below
5 years have weak immunity and food poisoning may affect if food is not well prepared. Parents
should be encouraged to endeavor proper cooking children food. When preparing commercial
foods, guidelines as put on the package need to followed to the dot. Commercial foods such as
vitamins and protein supplements must be bought from certified suppliers of children food. Most
parents either don’t know available commercial foods or even can not differentiate between
genuine and fake products. However, since most food supplements such as vitamin A are
provided by the government for free, emphasis should be redirected to how mothers prepare and
feed their children.
Door-to-door campaigns have a lasting impact because 1) the beneficiaries get firsthand
information, 2) they are engaged in hands-on activities, 3) they use materials that are available in
their local areas, 4) all stakeholders in the child’s upbringing (siblings and fathers) can be met, 5)
the educator is exposed to diversity of nutritional resources which can be recommended to those
who lack and, 6) Follow-up is easy for future engagements and planning.
By the termination of this programme, door-to-door nutrition education should have established
grassroot women groups able to make decision by themselves on how to transform their
communities through proper feeding children below 5 years. At this point meeting group leaders
can be done by responsible government agencies for a sustained and generational resilience to
malnutrition.
References
Björkman-Nyqvist M 2013. Income shocks and gender gaps in education:
Evidence from Uganda. Journal of Development Economics 105: 237-253.
Datzberger S 2018. Why education is not helping the poor. Findings from
Uganda. World development 110: 124-139.
Wane W, Martin G 2013. Education and health services in Uganda: data for
results and accountability.
Björkman-Nyqvist M 2013. Income shocks and gender gaps in education:
Evidence from Uganda. Journal of Development Economics 105: 237-253.
Sagna, M. L., Hoque, N., & Sunil, T. (2011). Are some women more at risk of
obstetric fistula in Uganda? Evidence from the Uganda Demographic and Health
Survey. Journal of public health in Africa, 2(2), e26.
https://doi.org/10.4081/jphia.2011.e26
Gideon, R. (2013). Factors associated with adolescent pregnancy and fertility in
Uganda: analysis of the 2011 demographic and health survey data. American Journal of
Sociological Research , 3 (2), 30-35.
Amegbor, PM, Yankey, O., & Sabel, CE (2020). Examining the effect of
geographic region of residence on childhood malnutrition in Uganda. Journal of tropical
pediatrics , 66 (6), 598-611.
Adebisi, YA, Ibrahim, K., Lucero-Prisno III, DE, Ekpenyong, A., Micheal, AI,
Chinemelum, IG, & Sina-Odunsi, AB (2019). Prevalence and Socio-economic Impacts of
Malnutrition Among Children in Uganda. Nutrition and Metabolic Insights , 12 ,
1178638819887398.
Fanzo, J., Hawkes, C., Udomkesmalee, E., Afshin, A., Allemandi, L., Assery,
O., ... & Schofield, D. (2018). 2018 Global Nutrition Report: Shining a light to spur
action on nutrition.
Muggaga, C., Ongeng, D., Mugonola, B., Okello-Uma, I., Kaaya, NA, & Taylor,
D. (2017). Influence of sociocultural practices on food and nutrition security in Karamoja
Subregion of Uganda. Ecology of food and nutrition , 56 (5), 424-447.
UBOS 2018, https://uganda.opendataforafrica.org/data#source=UBOS Retrieved
online on 22nd January 2021.
 Kabwijamu, L., Waiswa, P., Kawooya, V., Nalwadda, CK, Okuga, M., &
Nabiwemba, EL (2016). Newborn care practices among adolescent mothers in Hoima
District, Western Uganda. PloS one , 11 (11), e0166405.
World Health Organization. (2020). UNICEF/WHO/The World Bank Group joint
child malnutrition estimates: levels and trends in child malnutrition: key findings of the
2020 edition.
Labu, A. (2015). Knowledge, Attitude and Practices on Breast Feeding of Mothers in
Kaptum Sub-county, Kween district, Uganda (Doctoral dissertation, International Health Sciences
University.).

Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., ... & Group,
T. L. B. S. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong
effect. The Lancet, 387(10017), 475-490.

Baker EJ, Sanei LC, Franklin N (2006). Early initiation of and exclusive
breastfeeding in large-scale community-based programmes in Bolivia and Madagascar. J
Health Popul Nutr 24, 530
Thomas de Hoop, Shelby Fallon, Fakir Md Yunus, Sabeth Munrat, Saira Parveen
Jolly, Farzana Sehrin, Bachera Aktar, Ruhina Binta A Ghani & Joshua
Sennett (2020) Mothers’ education and the effectiveness of nutrition programmes:
evidence from a matched cross-sectional study in rural Bangladesh, Journal of
Development Effectiveness, 12:4, 279-297, DOI: 10.1080/19439342.2020.1828998
UNICEF Uganda, Annual Report 2019. https://www.unicef.org/uganda/what-we-
do/nutrition Retrieved online on 23rd January 2021.