CHAPTER ONE

1.1 Introduction:
The World Health Organization (WHO) defines malnutrition as the cellular imbalance between
the supply of nutrients and energy and the body’s demand for them to ensure growth,
maintenance, and specific functions. Malnutrition refers to all deviations from adequate nutrition,
including under nutrition and over nutrition, resulting from inadequacy of food relative to need
and/or disease. Malnutrition also encompasses specific deficiencies (or excesses) of essential
nutrients such as vitamins and minerals. [1] There are two types of malnutrition which are acute
malnutrition and chronic malnutrition. The human body needs energy and nutrients to function.
If food intake is inadequate, the body begins to break down body fat and muscle, the metabolism
begins to slow down, thermal regulation is disrupted, the immune system is weakened, and
kidney function is impaired. [2]

Malnutrition is a chronic problem in all areas in Somalia, but acute forms are more prevalent in
the South and Central zone where drought, floods, chronic insecurity and clan conflicts have
subjected the social caring system to a lot of pressures and left majority of household’s food
insecure. Children and women are increasingly at risk of morbidity and mortality related to
malnutrition. [3] Acute malnutrition is a devastating epidemic. Worldwide, some 55 million
children under the age of five suffer from acute malnutrition; 19 million of these suffer from the
most serious type severe acute malnutrition.

Every year, 3.1 million children die of malnutrition. [4] In Somalia, acute malnutrition has
become a chronic problem. In many areas, prevalence consistently exceeds emergency
thresholds. While levels of acute malnutrition fluctuate over seasons and among livelihood
zones, a Meta analysis of surveys taken over the past ten years shows a national median rate of
16.7% global acute malnutrition and 4.4% for severe acute malnutrition in the overall population,
with slightly higher levels in IDPs. The underlying causes of acute malnutrition include a lack of
access to health care services, poor hygiene and sanitation facilities, high incidence of morbidity,
sub-optimal childcare practices, poor or irregular access to nutritious food stuffs including milk.
These underlying causes are perpetuated by poverty, low education levels, a lack of
infrastructure and public services, livelihood systems eroded by destructive climatic events, as
well as ongoing conflict and displacement.
1.2 Justification
The acute malnutrition prevalence rate is high in Banadir hospital Somalia according WHO &
UNICEF the suspected cases of acute malnutrition were reported between December to January
more than double the suspected cases seen in the same period last year. Moreover factors
associated with acute malnutrition such as lack of knowledge, economical condition of the
community nutritional status of the community childhood will be assessed for appropriate
treatment. The results obtained from this study will be used hospital directors and head of wards
Malnutrition is currently the leading cause of global burden of disease (Ezzati et al., 2002) and
has been identified as the underlying factor in about 50% of deaths of children under 5 years of
age in developing countries (Black et al., 2003). The condition may result from lack of food or
from infections that cause loss of appetite while increasing the body's nutrient requirements and
losses. Children between 12 and 59 months old are especially at risk since they are the most
vulnerable to infections such as gastroenteritis and measles (WHO, 2000). It is estimated that in
developing countries, more than one-quarter of all children younger than 5 years of age are
malnourished (UNACC, 2000). Malnutrition is a state of nutrition in which a deficiency or
excess or imbalance of energy protein and other nutrients causes measurable adverse effects on
tissue or body form (body shape size and composition), function, and clinical outcome. [6] Each
year, 3.1 million children die from hunger-related causes a staggering 45% of all child deaths
globally. But there are solutions. Malnutrition is predictable, preventable, and treatable, and
defeating hunger on a global scale is affordable.

The study will to provide information about prevalence and associated risk factors of
malnutrition in benadir hospital. It facilitated in identifying factors that are barriers to good
nutrition practice, and translate each guideline into specific messages that health care providers,
mothers, nongovernmental organizations (NGOs) and agencies can come up with the right 4
Measures of improving and eradicating malnutrition The data was also meant to be used in
planning interventions concerning malnutrition, particularly impairs the linear growth of
children, leading to a further reduction in food intake, nutrient absorption, direct or catabolic
nutrient losses and increased metabolic requirements.
1.3 Operational Definition
1. Malnutrition: The World Health Organization (WHO) defines malnutrition as the cellular
imbalance between the supply of nutrients and energy and the body’s demand for them to ensure
growth, maintenance, and specific functions.

2. Acute malnutrition: The term acute malnutrition makes reference to two different medical
entities with different clinical and pathological characteristics.

3. Moderate acute malnutrition (MAM): is defined by a weight-for-height indicator between -3

and -2 z-scores (standard deviations) of the international standard or by a mid-upper arm
circumference (MUAC) between 11 cm and 12.5 cm.

4. Sever acute malnutrition (SAM): is defined by a very low weight for height (below -3z scores of
the median WHO growth standards), by visible severe wasting, or by the presence of nutritional
edema.

5. Nutrient: Is a substance that provides nourishment essential for growth and the maintenance of
life
6. Nutrition: Is a branch of science that deals with nutrients and nutrition, particularly in
humans.

7. Epidemic: Is a widespread occurrence of an infectious disease in a community at a particular

time.

8. Prevalence: Is a number of old cases or the proportion of individuals in a population having a

disease or characteristic.

1.4 Research Question

What are the risk factors of acute malnutrition among children under five years in Benadir
hospital?
 CHAPTER TWO
2.1 Literature of Review
Malnutrition is a state of nutrition in which a deficiency or excess or imbalance of energy,
protein and other nutrients, causes measurable adverse effects on tissue or body form (body
shape, size and composition), function, and clinical outcome. [6] Each year, 3.1 million children
die from hunger-related causes a staggering 45% of all child deaths globally. But there are
solutions. Malnutrition is predictable, preventable, and treatable, and defeating hunger on a
global scale is affordable.
Acute malnutrition is a recent and severe weight loss (wasting) as a result of acute food shortage
and/or illness and is measured by weight for height or mid arm circumference (MAC). [7]. acute
malnutrition includes both moderate acute malnutrition (MAM) and severe acute malnutrition
(SAM) where MAM: is MAC ≥ 115 mm & < 125 mm (≥11.5 cm & < 12.5 cm) and SAM: is
defined by visible severe wasting, or by the presence of bilateral pitting edema of nutritional
origin. MAC <115 mm (<11.5 cm) in children aged 6–59 months, is also an indicative of severe
acute malnutrition. [8] Acute malnutrition is a deadly disease. It arrives as the consequence of
insufficient or inappropriate feeding and as a consequence of disease. Without appropriate
treatment, acute malnutrition may result in the death of the child. Even the children that survive
may remain vulnerable to other episodes of malnutrition and disease and present lower
intellectual and psycho-motor abilities, which will in turn reduce their chances later in life. In the
second half of 2009, 1 in 6 children were estimated to have acute malnutrition in Somalia, 25 %
of which were severe. Moderate acute malnutrition (MAM) and severe acute malnutrition (SAM)
affect 13% of children aged <5 y worldwide. [9] [24]

Widespread acute malnutrition persists across Somalia and large numbers of people will be
acutely food insecure through December 2015, An estimated 214,700 children under the age of
five are acutely malnourished (39,700 of them severely malnourished) based on prevalence
results from 39 nutrition surveys conducted from May to July 2015 by the Food Security and
Nutrition Analysis Unit for Somalia (FSNAU), a project managed by the Food and Agriculture
Organization (FAO) of the United Nations and partners across Somalia. The number of acutely
and severely malnourished children is likely to increase to 343,400 and 63,400, respectively,
through the end of the year. The severely malnourished face a high risk of morbidity and death.
[10]

2.2 Causes of Malnutrition

Malnutrition, whether acute or chronic, has multiple causes that usually work in conjunction,
reinforcing each other to the point that no single action or intervention can prevent it. Only
exceptionally, a single cause can be found. Managing acute malnutrition implies having an
understanding of the causes of malnutrition and how they interact. The immediate causes are
usually easier to observe, but they cannot be addressed unless their underlying causes are
understood and addressed. Sustainable eradication of malnutrition can only be based in the
elimination of its basic causes. The division of the causes of malnutrition into different levels
facilitates understanding and analysis of a given context, and can be used for planning of
programs.

2.2.1 Immediate Causes Of Malnutrition

Inadequate dietary intake and disease are immediate causes of malnutrition and create a vicious
cycle in which disease and malnutrition exacerbate each other. Thus, food intake and disease
must both be addressed to support recovery from malnutrition.
2.2.2 Underlying Causes
Three major underlying causes of malnutrition include: • Food: Inadequate household food
security (limited access or availability of food). • Care: Inadequate social and care environment
in the household and local community, especially with regard to women and children. • Health:
Limited access to adequate health services and/or inadequate environmental health conditions
(including access to safe water and sanitation facilities). All underlying causes of malnutrition
are usually the consequence of poverty.
2.2.3 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, economic, political
and cultural) influence what happens at community level. Geographical isolation and lack of
access to markets or services due to poor infrastructure, displacement or conflict can have a huge
negative impact on food security and health.
Figure 2.1: Classification of acute malnutrition (Collins and Yates 2003)
Table 2.1: Classification of acute malnutrition in children 6-59 months based on anthropometry
2.2.4 Moderate Acute Malnutrition
Moderate acute malnutrition (MAM), also known as wasting, is defined by a weight-for-height
indicator between -3 and -2 z-scores (standard deviations) of the international standard or by a
mid arm circumference (MAC) between 11 cm and 12.5 cm.
2.2.5 Severe Acute Malnutrition
Severe acute malnutrition (SAM) is the most dangerous form of malnutrition. If left untreated,
SAM can result in death. It can manifest in two ways:
2.2.6 Severe Wasting
Severe wasting is characterized by a massive loss of body fat and muscle tissue. Children who
are severely wasted look almost elderly and their bodies are extremely thin and skeletal.
2.2.7 Edema
In this form of severe acute malnutrition, edema is present on the lower limbs, and is verified
when thumb pressure is applied on top of both feet for three seconds and leaves a pit or
indentation in the foot, after the thumb is lifted. The edema may eventually spread to the legs and
face, and the child appears puffy, and is usually irritable, weak, and lethargic.
 CHAPTER THRE
3.1 Research Methodology

Conceptual framework
3.2 Study Objectives
3.2.1 General Objective
To find out the risk factors of malnutrition in patients attending outpatient department (OPD) in Benadir
hospital
3.2.2 Specific Objective
• To identify main causes of acute malnutrition in Mogadishu - Somalia.

• To understand types and classification of acute malnutrition.

• To find out prevalence of malnourished children by using weight.

• To identify grades of malnutrition.

• To list complications presenting by the patients at outpatient department (OPD).

3.3 Study Design

This study will a cross sectional retrospective study, which was done to describe the Prevalence acute
malnutrition among children under five years.
3.4 Target Population
The study population of this study will be children under five years visited or admitted in
BenadirHospital. The study population was all malnourished patients visited OPD or admitted at Benadir
hospital.
3.5 Study Site And Area
This study will conduct in Benadir Hospital. Benadir Hospital is one of the largest and popular hospitals
in the capital city of Somalia. It consists of different departments including Nutrition unit and
stabilization centre.
3.6 Study Period
The study will carry out from January 2017 to August 2017 and it was conducted at BenadirHospital in
Mogadishu-Somalia.
3.7 Sample Size
Sample size determination for a cross sectional retrospective study and the respondents will be child’s
Mother, clinic staffs at six districts in Banadirregoin Somalia which are: Darkeynley, Wadajir, Hodan,
Howl wadag, Waberi and Wardhigley. The sample size will be selected from the target population by
using sample estimation formula.
n = z2pq d2
Where n = minimum sample size
z = Standard normal deviate (usually 1.96)
p = prevalence of acute malnutrition in Somalia which is 18% [28]

3.8 Inclusion criteria

Mothers between the ages of 20-50 years attending clinic in Banadir hospital for routine care
were recruited.
3.9 Exclusion criteria
children with severe malnutrition related problems such as diarrhea and vomiting was excluded.
3.10 Sampling Techniques
The sampling technique will be Stratified sampling technique to get all child’s mothers and
health workers in BenadirHospital equal chance to get accurate data about acute malnutrition
among children under five years.
3.11 Data Collection Tools
A questionnaire will be use to collect the data. The questionnaire was written in English, and
translated into Somali language since most of Somali mothers do not understand English
language. The questioner was distributed by child’s mothers at BenadirHospital in Mogadishu-
Somalia. The researcher explained the purpose of the study to the participants and get reliable
3.12 Data Management Analysis Plan
After the collection of data, the researcher verified and checked the data and then entered in to
the computer. Data was analyzed by the researcher by using Microsoft office Excel 2007 for
analyzing data.
3.13 Quality Control and Quality Assurance
Pretesting of the pre-designed questionnaire guide will carry out at Somalia National Hospital
Antenatal Clinic before actual data collection. The questionnaires were analyzed. Feedback
obtained informed the changes and adjustments that needed to be addressed before a final draft
was made for administration to the research participants. In order to avoid double recruitment,
the participants’ file numbers were entered in a register upon recruitment for serialization. This
register was counter checked on a regular basis for double entries and if so discovered, one of the
questionnaires would be withdrawn and discarded and the serialization rectified before
recruitment is continued.
3.14 Ethical Consideration
The study will conduct after getting permission and an introductory letter from the Faculty of
Health Science, Department of Public Health University Of Adelaide. Introductory letter was
also obtained from leadership or mayor of Banadir region. In addition Inform Consent of the
respondents were obtained from the study participants to confirm their willingness to participate
in the study after explaining to them the objectives of the study the respondents were notified of
their right to refuse or terminate at any point of the interview the information provided by each
respondent was kept confidential No names of any respondent were discovered to anybody
Responses was coded and reported in a generalized manner, without mentioning who said what
Works of other people used in this study were correctly be referenced and authors were duly
recognized.