1

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Nutrition is a fundamental pillar of human life, health and development across the entire life

span (WHO, 2017). Nutrition is the sum total of the processes involved in the intake and

utilization of food substances by living organisms, including ingestion, digestion, absorption,

transport and metabolism of nutrients found in food.(Melvin, 2018).

Adequate nutrition during early childhood is fundamental to the development of each child’s

potential. From the earliest stages of fetal development, at birth, through infancy, childhood,

adolescence, and on into adulthood and old age, proper food and good nutrition are essential for

survival, physical growth, mental development, health and well-being (WHO, 2017). Despite

the importance of proper nutrition, it sad to note that malnutrition is estimated to contribute to

more than one third of all child deaths, although it is rarely listed as the direct cause (World

Health Organization, 2019).

The World Health Organization (WHO) (2018), refers to malnutrition as “Failure of cells to

perform their physical functions due to inability to receive and use the energy and nutrients

needed in terms of amount, mix and timeliness. Waterlow and Insel (2018) described

malnutrition as “Failing Health that results from long standing faulty nutrition that either fails to

meet or greatly exceeds nutritional needs. This description could mean inappropriateness of the

food taken. Again, Harrison and Waterlow (2018) defined malnutrition as “The effects of any

nutrient deficiency including energy, protein and micronutrients.” Malnutrition can be

operationally defined as a lack of essential nutrients or failure to use available foods to best

advantage (Barasi, 2017). Malnutrition affects physical growth, morbidity, mortality, cognitive
 2

development, reproduction and physical work capacity and it consequently impacts on human

performance, health and survival. A well- nourished child is one whose weight and height

measurements compare very well with the standard normal distribution of heights and weighs of

healthy children of the same age and sex (Salah, 2018).Malnutrition in early childhood is

associated with functional impairment in adult life as malnourished children are physically and

intellectually less productive when they become adults (Smith and Haddad, 2019).

The World Health Organisation (2018) and United Nations Children’s Emergency Fund

(UNICEF) in 2019 reported that at least 99 million children were affected by malnutrition.

Among the survivors who are affected during the first two years of life, their ability to resist

disease, undertake physical work, study and progress in school are all impaired (Shrimpton and

Rokx, 2012). The interaction between malnutrition and infection results in a vicious cycle of

worsening illness and poor nutritional status (UNICEF, 2019). Stunted growth and impaired

cognitive ability can also follow poor nutrition in the early years of a child’s life (UNICEF,

2019). On the other hand, worldwide, an estimated 42 million children under the age of five

years were affected by over nutrition as at 2019 (WHO. 2018).

Rising rates of over nutrition worldwide have been linked to a rise in chronic diseases such as

hypertension and type II diabetes (WHO, 2018). Three stages of malnutrition have been clearly

documented in literature to reflect the current global nutrition trend. These stages correspond to

epidemiologic and demographic patterns in an environment. First is the stage of malnutrition

which is associated with a high prevalence of infectious diseases. The second stage represents a

phase of receding malnutrition as epidemiologic and demographic changes associated with

development occur. With development, increases in chronic diseases such as overweight and

obesity characterize the third phase and malnutrition and infectious diseases become past
 3

problems (Kennedy, et al., 2016). Today, however, the burden of disease and malnutrition do not

fit neatly into these classic stages but reflect a modified pattern, a fourth stage, referred to as the

protracted polarized model, where infectious and chronic diseases co-exist over long periods of

time (Kennedy, et al., 2016). This invariably, is paralleled by co-existence of malnutrition and

over nutrition. Evidence of this has been documented in developing countries as diverse as China

and South Africa (Kennedy, et al., 2016). This co-existence of malnutrition and over nutrition in

a population has been referred to as the double burden of malnutrition (Shrimpton and Rokx,

2018). Sadly, most developing countries may now be faced with this double burden of

malnutrition. In Africa for instance, there is still high prevalence of malnutrition (14-45%)

(Babatunde, et al., 2018), while 7% of children were recently reported to be overweight.

Although there seems to be a clear evidence of the double burden of malnutrition at the global

level, most Nigerian studies had focused on one end of the spectrum- under nutrition. This study

seeks to highlight the burden of both malnutrition among under-five children as well as the

associated risk factors.

1.2 Statement of the Problem

According to World Health Organization (2018), In Nigeria, 37 per cent of children, or 6 million

children, are stunted (chronically malnourished or low height for age), more than half of them

severely. In addition, 18 percent of children suffer from wasting (acutely malnourished or low

weight for height), half of them severely. Twenty-nine per cent of children are underweight (both

acutely and chronically malnourished and low weight for age), almost half of them severely.

Stunting prevalence remained relatively stable between 2017 and 2019, whereas wasting has

increased significantly, from 10 per cent in 2011 to 18 per cent in 2019. Although underweight
 4

rates were stable between 2017 and 2011 at around 25 per cent, the rate increased slightly to 29

per cent in 2019 (WHO, 2017).

Also, under-nutrition is an underlying cause of 2.2million child deaths and 21% of disability-

adjusted life years lost in developing countries (Black et al., 2017). High rates of malnutrition

pose significant public health and development challenges for the country. Stunting, in addition

to an increased risk of death, is also linked to poor cognitive development, a lowered

performance in education and low productivity in adulthood - all contributing to economic losses

estimated to account for as much as 11 percent of Gross Domestic Product (GDP). A staggering

41% of all children under five in Nigeria are chronically malnourished, 23% are underweight,

and 14% suffer from acute malnutrition. National Planning Commission (2010) shows that about

36%, 43%, and 9% of under-five in Nigeria were underweight, stunted, and wasted respectively

(Food and Agricultural Organization, 2012).It was reported that underweight (weight-for-age)

are 27.2%, stunting (height-for-age) and wasting (weight-for-height) were 43% and 11.2%

respectively (NPC, 2004).

In recent years Nigeria has developed a number of policies to tackle these issues, including the

National Policy on Food and Nutrition from 2001 (2004), with its Plan of Action (2004), as well

as the National Policy on Infant and Young Child Feeding (2018). However, implementation has

been weak with insufficient political support to transform policy around improving nutrition into

practice. Agencies on the ground are supporting the Ministry of Health to treat children suffering

from malnutrition, but more is needed to scale-up this vital work, as well as to tackle the root

causes of malnutrition (Federal Ministry of Health, 2011). Therefore the study will research on

malnutrition among children 2 to 5 years in Ikwuano LGA.

 5

1.3 Objective of the Study

The general objectives of the study is to assess the malnutrition among children 2 to 5 years in

rural areas within Ikwuano LGA, Abia state.

The specific objectives will be to:

i. Assess the socio-economic status of respondents in Ikwuano LGA, Abia state.

ii. Assess the anthropometric status of children 2 to 5 years in Ikwuano LGA

iii. Determine their feeding pattern and eating habit of children from 2 to 5 years.

iv. Determine the relationship between socio-economic status, anthropometric status, feeding

pattern and nutritional risk status among children 2 to 5 years in Ikwuano LGA, Abia

state.

1.4 Significance of the Study

Malnutrition has become a global problem which affects infants both the poor and affluent, no

family is left untouched according to report and findings of Food and Agricultural Organization

FAO, 2015). However, nutritional assessment is very essential to achieve a healthy status and to

combat malnutrition because it reveals the current state of food and nutrient intake of infants.

Therefore assessing the nutritional risk in older adults will be of great importance to prevent the

high degree of morbidity and mortality rates among them.

This study will be of great benefit to medical professionals which include nutritionist, dietitians

and clinicians to educate all the population groups on good dietary lifestyle which influences

nutritional status. Furthermore, encouraging them to maintain ideal body weight which is the

path to healthy living.

 6

CHAPTER 2

LITERATURE REVIEW

2.1 NUTRITION

According to the World Health Organization (2009), nutrition is the intake of food, considered in

relation to the body’s dietary needs. Good nutrition comprises of an adequate, well balanced diet

combined with regular physical activity which is a corner stone of good health (WHO, 2009).

Poor nutrition can lead to reduced immunity, increased susceptibility to disease, impaired

physical and mental development, and reduced productivity (WHO, 2009). Nutrition is also the

science that interprets the interaction of nutrients and other substances in food in relation to

maintenance, growth, reproduction, health and disease of an organism (WHO, 2009). It includes

food intake, absorption, assimilation, biosynthesis, catabolism, and excretion. (Mahan, 2018).

The diet of an organism is what it eats, which is largely determined by the availability and

palatability of foods (Mahan and Escot, 2018). For humans, a healthy diet includes preparation

of food and storage methods that preserve nutrients from oxidation, heat or leaching, and that

reduces risk of foodborne illnesses (Mahan and Escot, 2018). In humans, an unhealthy diet can

cause deficiency-related diseases such as blindness, anemia, scurvy, preterm birth, stillbirth and

cretinism (Whiney et al., 2019) or nutrient excess health threatening conditions such as obesity

and metabolic syndrome and such common chronic systemic diseases as cardiovascular disease,

diabetes and osteoporosis (National Cancer Institute (NCI), 2011.

Malnutrition can lead to wasting in acute cases and the stunting of marasmus in chronic cases of

malnutrition (Whitney et al., 2019).

 7

2.2 Child Malnutrition

Child Malnutrition According to Pliner (2019) malnutrition occurs when there is a prolonged

imbalance between the nutrients that are required and the nutrients that are actually eaten. The

author maintained that malnutrition may be the result of (a) under-nutrition –an inadequate

intake of one or more nutrients and (b) over-nutrition –over-consumption of one or more

nutrients by children.

Protein –Calorie malnutrition is the most serious and widespread form of deficiency disease in

the world today and occurs most frequently in children during the years of rapid growth

(Scrimshaw, 2017). Protein-Calorie malnutrition manifest as kwashiorkor and marasmus.

Kwashiorkor results from a diet inadequate in protein but generally adequate in calorie, while

marasmus results from a diet inadequate in protein and calories. It is important that both of these

conditions be avoided in the infant and young child. Adequate intake of all required nutrients is

most critical during early periods of active growth and development Scrimshaw (2017)

emphasizes that the quality and quantity of protein as well as all nutrients must be considered in

the treatment and prevention of protein –calorie malnutrition. For infants, the ideal diet should

include a liberal supply of fresh milk or if necessary, dried skim milk, fortified with vitamins A

and D, and accompanied by adequate non-protein calories and other nutrients. In several

countries where P.C.M. is recognized as a public health problem and where milk is not easily

available, palatable vegetable protein mixtures have been developed using locally grown and

familiar products. In Nigeria, this mixture is composed of peanut flour and some milk casein
 8

(fish meal). This mixture could also be composed of corn meal, ground sorghum, cotton seed

flour, torula yeast and leaf meal blended according to a formula that provides the best amino-acid

balance and fortified with calcium and vitamins. Malnutrition never occurs alone. It occurs in

conjunction with low income, poor housing, familial disorganization, climate of apathy,

ignorance and despair (World Bank, 2016). As earlier on noted, the prevention of malnutrition in

the world today requires the efforts of various disciplines and also depends on awareness of the

complexity of the issue, and on the foresight and political will to include appropriate nutrition as

an objective in formulating and implementing social and economic development strategies.

Weiser (2019) opines that a more correct concept of malnutrition includes any functional

impairment or physical condition that can be prevented or cured by improved nutrition. When so

defined, instances of malnutrition exist in every society, whether it is technically advanced or

newly developing. There is an increasing amount of evidence from many parts of the world,

conclusively showing both direct and indirect relationship of nutritional factors to intelligence

and learning. There is even evidence that poor or “picky” eating during the first year of life is

related to a depressed IQ score. Malnutrition and death are manifestations of interactions in

which inadequate dietary intake and disease are but just immediate causes, interactions in which

inadequate food security is only one of three underlying causes for which there were basic causes

hinged on other larger societal processes (Onyezili, 2018). Political, social, and ideological

superstructures, economic structures and our potential resources as a nation, bear importantly on

our nutrition status. Inadequacies of factors of household food security, basic health services,

good sanitation and provision of adequate care for mother and child, all underlie manifestations

of malnutrition and affect child development as well as eradication of disease. A study conducted

in India 1993, shows that about half of the child mortality and much of the growth retardation in
 9

developing countries appears to be caused by synergism between malnutrition and common

infections. Synergism between malnutrition and infection is responsible for excess mortality

among infants and preschool children in less developed regions (WHO 2018). Programs to

reduce such synergistic interactions would profoundly improve health status among the children

of the poor. In the past, improvement in the health and nutritional status of children occurred

spontaneously as a result of general socioeconomic development; (Arnfried and Taylor, 2018). It

is not necessary now to wait for general development, since measures are available that

contribute directly to improving the quality of children’s lives. A selective approach is needed in

health planning, to put together appropriate combinations of interventions that will produce the

greatest health and nutrition improvement at the least cost for children. One of the most obvious

clinical manifestations of serious malnutrition in infancy is a dramatic combination of apathy and

irritability. (Weiser, 2019). The infant is grossly unresponsive to his surroundings. This

unresponsiveness characterizes his relation to people, as well as to objects. Behavioural

regression is profound; and organization of his functions are markedly infantilized. In children

who are under-nourished, one notes a reduction in responsiveness and attentiveness. In addition,

the sub-nourished child is easily fatigued and unable to sustain either prolonged physical or

mental effort. Improvement in nutritional status is accompanied by improvements in these

behaviours as well as in physical state.

2.3 NUTRITIONAL REQUIREMENT FOR INFANCY AND EARLY CHILDHOOD

A balance between high energy and nutrient content required for growth and development of

infants and children in conjunction with regular physical exercise, should constitute childhood

nutrition. Therefore, childhood nutrition should be made up of natural, fresh sources of energy

and nutrients. The requirements for micronutrients and macronutrients are highly needed during
 10

infancy and early childhood than at any other stage of development. Institute of Medicine (2017)

has reported that these requirements are triggered by rapid cell division that occurs during

growth which requires nutrients, proteins and energy in DNA synthesis and metabolism of

calories, protein and fat. With respect to energy, a 4kg infant requires over 100Kcal/kg (430

calories/day) while adults require 25 to 30 calories per kg, implying that energy needs during

early formative years remain very high (Etim, 2017). Breast milk has been considered to be a

significant energy source as it has been shown to reduce the risk of chronic disease conditions

such as diabetes, hypertension, allergies and obesity (Etim et al., 2017). Also, breastfeed has

been proved to improve cognitive development and decrease the severity of infections (Leung et

al., 2017). Equally, water requirement for infants and children is usually higher than that of

adults due to the fact that children have a reduced capacity to sweat and have a larger body

surface area per unit body weight when compared with adults (Etim et al., 2017). Regarding

essential fatty acids, infants require higher fatty acid than adults. The conversion of linolenic

and alpha-linotenic acid into long chain fatty acid through elongation and desaturation, plays a

vital role in cognitive growth and development in infants (Ascherio and Willet, 2017). Other

nutritional requirements include high supply of protein, iron, vitamins A and D and calcium.

Also whole cow’s milk for one year old children, red meat for six months old babies, green

vegetables, cereals, bread, etc., are highly recommended for children (Etim et al., 2017).

FACTORS AFFECTING NUTRITIONAL STATUS OF CHILDREN

Malnutrition is caused by several factors such as poor psychological care, neglect of children,

child abuse, stress and trauma (UNICEF, 2017). For instance, mothers with psychological

problems may lack the cognitive abilities to recognize that they need to feed their children, thus

increasing the risk of under-nutrition in children.

 11

i. Child factors

Certain child factors such as sex, age, diseases, breastfeeding and position of child in a

household adversely affect the nutritional status of under-five children. An epidemiological

study carried out in urban slum area of Varanasi revealed that 58.3% of male children had

protein energy malnutrition (PEM) while PEM was found in 68.6% of female children (Baranwal

et al., 2010). In the same study, PEM was observed to be higher in 3 rd year of life, and lowest

during the 2nd year of life. Nyaruhucha et al. (2016), found out in their study that under-nutrition

was most prevalent among children aged 24-35 months while children less than a year were less

vulnerable to under-nutrition. It has been observed that stunting is strongly associated with sex

and weight of children independently (Nyaruhucha et al., 2016).

In Sub-saharan Africa, studies to determine the association between nutritional status of children

and birth weight have been reported, but few studies have recorded gender differential in

malnutrition among under-five children (Wamani et al., 2017; Hien and Kam, 2018). A study

carried out in India reported that children aged 13-24 months were more stunted (81.8%) and

underweight (45.5%), while wasting (18.2%) was highest among 37-48 months old children

(Kumar et al., 2016). This clearly indicates that children more than one year of age are more

likely to have malnutrition than children less than a year. In some cultures especially in Africa,

male children are given more preferences than female children because the males will live to

carry on with the family name while females will be given out in marriage, thus placing the

female child at high nutritional risk. Nyaruhucha et al. (2016) reported that, slightly above one-

fourth of male members of a household were first given food before females. Olack et al. (2019)

reported that moderate wasting was high in children (4.1%) who were between 6-11 months and

lowest (1.1%) in 48-59) months old children. In the same study, more than half of girls (65.7%)
 12

were more wasted than their boy’s counterparts. Wasting was significantly higher in girls than in

boys of the same age group (Olack et al., 2019). Olack et al. (2019) further reported that certain

health conditions such as tuberculosis (TB), diarrhea, measles, etc., can exacerbate malnutrition

in children, and a combination of these health problems can weaken the immune system.

ii. Maternal factors

Maternal literacy is one of the factors affecting nutritional status of under-five children.

According to Asindi et al. (2019), children often need primary care for the first 6 years of life

from the mothers/caregivers, and the quality of care given by the mothers/caregivers depends

largely on the mothers’ knowledge of basic health care practices and nutrition. It has also been

reported that literate mothers are more likely to delay child bearing at a later age thereby

lowering infant mortality (Chen, 2016). Sufiyan et al. (2018), found that children of uneducated

mothers are at risk of stunting. In another study, Ali et al. (2017) found out that stunting was

40.8% higher among children of illiterate mothers, underweight (57.9%) highest among children

of mothers who had attained at least primary education and wasting (33.3%) was common

among children of mothers who had tertiary education. Glewwe (2019) highlighted that

education can affect the child’s health through direct transfer of health information from one

generation to another; through the ability to promptly detect illness and treatment administered

and through educated mothers who tend to be receptive to orthodox medication than uneducated

mothers. The above links have been established because educated women are more likely to

marry men with higher income, live in better neighbourhood and get higher paid jobs which

directly or indirectly influence child survival and health (Desai and Alva, 2018).

In developing countries, women have been recognized for playing dual roles as primary

caregivers to their children and generators of household income. Glick and Sahn (2017) argued
 13

that the more women participate in the labour workforce, the less attention they pay to household

responsibilities especially as it relates to the welfare of children, thereby placing younger

children at risk of malnutrition. Abbir et al. (2016) stated that children’s nutrition and health

status can be negatively affected by their mothers’ occupation outside child rearing. This is so

because time constraints may prevent working-class mothers from providing the need care to

their children. Several studies have indicated that young maternal age is associated with high

prevalence of malnutrition, while children of older women are less likely to suffer from

malnutrition (Nyaruhucha et al., 2016). A study carried out in Tanzania reported that children of

older mothers are less likely to be malnourished than those of young mothers (Nyaruhucha et al.,

2016).

SOCIO-ECONOMIC/HOUSEHOLD FACTORS

(i) Poverty

It is general knowledge that malnutrition is a condition that is associated with poverty since it

comes with hunger and lack of food at the right quantity and quality. Malnutrition could also

come as a result of loss of appetite, and this may be common among terminally ill people such as

HIV/AIDS, cancer and failed organ patients, kwashiorkor people and elderly people (Etim,

2016). Etim (2016) has reported that, in Sub-saharan Africa, the proportion of people affected by

extreme poverty has nearly doubled from 164 million in 2019 to 313 million as of 2017 in the

last two decades. It is estimated that over 70% of Nigerians live below poverty line of $1 per

day with Northern Nigeria being the worst hit area (Olanrewaja, 2018). Olanrewaja (2018) has

attributed poverty in Nigeria to be precipitated by such factors as corruption, unfavourable

government policies, poor investment in education, etc.

(ii) Family size

 14

According to Chaudhury (2019), children nutritional status can be affected by increase in family

size due to decrease in per capita income. That means that increase in the number of children in

a household decreases the food allocated to each child which consequently affects children

nutritional status. Increase in household size also facilitates fertility decision between couples.

In such situations, large family size may adversely affect the nutritional status of children and

household members thereby promoting poor dietary practices especially in poorer households

(Chaudhury, 2019).

(iii) Household income and expenditure

A household income level is clearly determined by the rate of expenditure on food. Expenditure

on food is likely to increase where there is improvement of household income thereby increasing

the rate of caloric and protein intake among children and members of the household (Reutlinger

and Selowsky, 2016). On the other hand, poor household income can lead to less expenditure on

food and low nutrient/dietary intake. Chaudhury (2019) pointed out that a synergistic

relationship exists between dietary adequacy, dietary intake and per capita expenditure.

(iv) Household food security and insecurity

Certain factors such as location of the house, family income level and household size can

significantly influence household food security. Food security is the sufficient availability,

nutritionally adequate and safety of food consumed in a way that is socially acceptable (Oquntin,

2018). On the other hand, food insecurity occurs when the ability to acquire safe, nutritionally

adequate food is limited or uncertain (Oquntin, 2018). It has been observed that, in most

developing countries, the dietary practice in populations experiencing food insecurity tends to

meet their energy requirements but do not provide sufficient nutrients to optimize health and

prevent infection. Hence, it can be inferred that over nutrition and under-nutrition are strongly
 15

associated with food insecurity (Babatunde et al., 2017; Awoyemi et al., 2017). Factors such as

poor academic performance, physical and mental ill-health, psycho-social problem and anaemia

related to iron deficiency are consequences of food insecurity in children (Food and Agricultural

Organization, 2018; Akinyele, 2019).

(v) Educational status

Parent education is a strong determinant of children nutritional status. That means that higher

educational status of parents is associated with better child rearing and care practices. According

to Chaudhury (2018), children whose parents are educated up to the tertiary level are more likely

to have a nutritious diet irrespective of income level due to their increased level of knowledge on

basic child nutrition. On the other hand, parents with higher educational attainment may

promote values to the detriment of children’s health (Chaudhury, 2018). For instance, women

who work outside their homes are less likely to breastfeed their babies consistently and

exclusively; and these women are more likely to practice early weaning (Chaudhury, 2018).

(vi) Lack of access to food

Food insecurity usually results from the inability of individuals to purchase enough food and not

because of lack of food itself. Etim (2016) reported that poor road networks, scarcity of food in

markets and poor family income levels are factors that promote food insecurity among the

disadvantaged populations. Countries sometimes depend on the importation of food especially

when there is food scarcity in their own countries (Etim, 2016). Etim (2016) reports that many

people especially the poorer populations, are affected by fluctuations in food prices. In situations

when the price of food is low, farmers may produce less food products which may not be

proportionate to the demand by consumers, and as such may result in food scarcity in markets

(Etim, 2016).
 16

(vii) Socio-demographic factors

In Sub-saharan Africa, several demographic trends inhibit the amelioration of malnutrition in

children (Etim, 2016). For instance, rapid population growth has been identified as a major

demographic factor exacerbating malnutrition in under-five children (Etim, 2016). It is often

observed that higher fertility is highly exhibited by the poor who are more likely to be

malnourished than people who belong to the wealthy quintiles (Etim, 2016). However, the poor

urban and rural populations suffer most from poor nutrition (Etim, 2016).

(viii) Environmental factors

In sub-tropical and tropical regions, 95% of all malnourished individuals live in relatively stable

climate. Thus, climate change is a significant factor to be considered when ensuring substantial

availability of food (food security) (Climate Change, 2017). Latest report has shown that

temperature increase in the sub-tropics and tropics are very likely (climate change) Climate

Change, 2017). A United Nations study carried out in over 40 developing countries showed that

climate change directly or indirectly influence the decline in agricultural production and may as a

result increase the number of people suffering from hunger each year (Action against Hunger,

2018). Even a slight change in temperature can affect the weather conditions (Climate Change,

2017). Agricultural production and good nutrition are highly affected by the impact of these

events. For instance, during the Central Asian drought, there was about 50% reduction in wheat

production and 80% loss of livestock products (Battisti, 2018). In Subsaharan Africa, extreme

weather conditions such as drought, can diminish productivity of many crop species thereby

exacerbating the impact of malnutrition (Battisti, 2018).

 17

Poor children often reside in urban slums or very rural areas where there is absolute lack of basic

amenities such as water supply and other sanitation facilities which lead to contamination of

water bodies which in turn, can cause diarrhoea (Black et al., 2018). Diarrhoea promotes wasting

and prevents children from getting enough nutritious food.

(ix) Other factors

In the face of conflicts and crisis within countries, food security and access to food are

significantly compromised. Conflicts often lead to annihilation of farmlands and farm

businesses, low food productivity and limited level of food distribution internally. As a result,

people are often susceptible to starvation, illness and diseases than may arise from food

insecurity. A recent survey carried out in Afghanistan revealed that water-related hardship was a

major determinant of health and nutritional status of children under five years of age (Mashal et

al., 2018).

2.3.1 Childhood Nutrition and Malnutrition in Nigeria

According to the Food and Agriculture Organization of the United Nations (FAO 2018), more

than 14 percent of the population in developing countries were undernourished in the period

between 2011 and 2019. Malnutrition includes both nutrient deficiencies and excesses and is

defined by the World Food Programme as “a state in which the physical function of an

individual is impaired to the point where he or she can no longer maintain adequate bodily

performance processes such as growth, pregnancy, lactation, physical work, and resistance to

and recovering from disease” (2018). It results in disability, morbidity, and mortality, especially

among infants and young children (Pelletier 2018). Malnutrition often begins at conception, and

child malnutrition is linked to poverty, low levels of education, and poor access to health
 18

services, including reproductive health and family planning (IFPRI 2018). Malnutrition is

mostly associated with developing countries like Nigeria (DHS 2019).

Two main types of malnutrition have been identified in Nigerian children: (1) protein-

energy malnutrition and (2) micronutrient malnutrition. Protein-energy malnutrition among

preschool children is a major public health problem across the country. “Stunting” is typically

defined as low height-for-age, but, more specifically, it is a deficit of linear growth and failure to

reach genetic potential that reflects long-term and cumulative effects of inadequate dietary intake

and poor health conditions (ACC/SCN 2000). Low weight-for-age is called “underweight” while

“wasting” is severe underweight or substantial weight loss that is usually a consequence of acute

food shortage or disease. (The NCHS/CDC/WHO International Growth Reference reports data

on these levels in a set of published indices, which served as a reference for this study.)

National and regional statistics on anthropometric indicators in Nigeria have been

consistently dire. In 2018–1984, the National Health and Nutrition Survey (HANS) conducted by

the Federal Ministry of Health estimated the prevalence of wasting to be around 20 percent

(FGN 2018–1984). A 2016 Demographic and Health Survey (DHS) of children ages 6–36

months in Ondo State (southwestern Nigeria) found the prevalence of wasting to be 6.8 percent,

underweight 28.1 percent, and stunting 32.4 percent. In February 1990, an anthropometric survey

of preschool children (2–5 years old) in seven states found underweight prevalence ranging from

15 percent in Akure (Ondo State) to 52 percent in Kaduna (Kaduna State) while stunting

prevalence ranged from 14 percent in Iyero-Ekiti (Ondo State) to 46 percent in Kaduna. In

addition, the 1990 DHS survey conducted by the Federal Office of Statistics estimated the

prevalence of wasting at 9 percent, underweight at 36 percent, and stunting at 43 percent among

preschool children. These figures are lower than the figures published in 2018 by UNICEF-
 19

Nigeria from a 1992 survey conducted among women and children in 10 states; the UNICEF

report showed the prevalence of wasting among women and children at 10.1 percent,

underweight 28.3 percent, and stunting 52.3 percent. There was a decrease in prevalence of

stunting in the 2017 NDHS with 11 percent of children wasted, 24 percent underweight, and 42

percent of children stunted (NDHS 2017). By 2017 prevalence of underweight had decreased to

23 percent and stunting had dropped to 41 percent but wasting increased to 14 percent (NDHS

2017).

Similar trends were reported by the 2001–2017 NFCNS: 9 percent wasting, 25 percent

underweight, and 42 percent stunting, with significant variations across rural and urban areas,

geopolitical zones, and agro-ecological zones (MaziyaDixon et al., 2004). The study showed

that prevalence of stunting was lowest in the southeast at 16 percent; it reached 18 percent in the

south and 55 percent in the northwest. Among the states, stunting was highest among children in

Kebbi (61 percent). The 2017 NDHS showed that rural children (43 percent stunted) were

disadvantaged compared to urban children (29 percent stunted). Children living in the

Northwest geopolitical zone stood out as being particularly disadvantaged at 55 percent

compared to 43 percent in the Northeast zone, 31 percent in North Central, 25 percent in the

Southwest, 21 percent in the South-South, and 20 percent in the Southeast. Among the three

broad agro-ecological zones used in the 2001–2017 NFCNS, the stunting rate was 58 percent in

the dry savannah, 46 percent in the moist savannah, and 27 percent in the humid forest zone.

Similar patterns were reported for underweight and wasting. Additional studies have also shown

that malnutrition is more pronounced in the rural areas and rural children are more

disadvantaged than urban children in Nigeria (UNICEF 2018; MICS 2011; NDHS 2017, 2017,

2019). There was a decrease in prevalence of malnutrition in the 2011 reports of the Multiple
 20

Indicator Cluster Survey (MICS) in Nigeria with 34 percent of children under five stunted, 31

percent underweight, and 16 percent wasted, while about 15 percent of children had low birth

(at less than 2,500 grams at birth) (MICS 2019). It is evident from the 2019 NDHS that the

proportion of children who are stunted has been decreasing over the years. However, the extent

of wasting has worsened, indicating a more recent nutritional deficiency among children in the

country. Prevalence of stunting decreased to 37 percent, with a higher concentration among

rural children (43 percent) than urban (26 percent). However, the proportion of children

underweight (29 percent) and wasting (18 percent) increased (NDHS 2019). Similarly, the 2018

National Nutrition and Health Survey Report by the National Bureau of Statistics and UNICEF

shows that children’s nutritional status modestly improved since 2019, according to the 2019

NDHS report, with 32 percent of children under five stunted, 21 percent underweight, and 9

percent wasted.

2.4 MICRONUTRIENT MALNUTRITION

Micronutrient deficiency or “hidden hunger” occurs when essential vitamins and/or minerals are

not present in adequate amounts in the diet; it is a serious public health concern in most

developing countries that has devastating effects on vulnerable groups, including pregnant and

lactating women and children under five (WFP 2018). According to WHO, one in three people in

developing nations are affected by deficiencies in micronutrients; in Nigeria, those deficiencies

are primarily in iodine, iron, and vitamin A. If left unchecked, micronutrient deficiencies can

lead to irreversible physical consequences, which is why they are considered a major health issue

deserving international attention. Micronutrient malnutrition is responsible for a significant share

of infant mortality (Bryce et al. 2017).

 21

2.4.1 Iodine Deficiency

Iodine is essential for the normal growth and development of the human body. It is required for

the production of thyroid hormones, which are necessary for normal brain development

(WHO/UNICEF/ICCIDD 2017). Insufficient intake of iodine in the diet causes a myriad of

health problems collectively known as Iodine Deficiency Disorders (IDD). The health

consequences of IDD include mental retardation, goiters, growth retardation, and increased

neonatal and post-natal mortality. Lack of iodine at conception causes maternal hypothyroidism,

which has dramatic consequences for the fetus, including severe and irreversible brain damage. It

is estimated that 2 billion people, or 30.6 percent of the global population, have insufficient

iodine intake, including 59.7 million school-aged children in Africa (UNICEF 2017; de Benoist

et al. 2017).

Data from the 2001–2017 NFCNS revealed that a total of 27.5 percent of children suffered

various degrees of iodine deficiency, while 46.5 percent had more than adequate levels (Maziya-

Dixon 2004). The deficiency was severe in 4.2 percent, moderate in 8.7 percent, and mild in 14.6

percent of children. Only 26 percent of children had optimal levels of iodine. However, it is

noteworthy that 16.6 percent of children had more than adequate levels, while 29.8 percent had a

possible excess intake of iodine and ran the risk of adverse health consequences. More than 20

percent of the total population suffered from goiter, the abnormal enlargement of the thyroid

gland, which is the most severe form of iodine deficiency. Endemic iodine deficiency reduces

the IQ by 3.5 percent, permanently affecting intellectual development. A total of 27.5 percent of

children suffered various degrees of iodine deficiency while 46.5 percent had more than

adequate levels. Deficiency of iodine was reported in 10.6 percent of children under five in the

medium (semi-urban) sector, 10.6 percent in the urban sector, and 15.5 percent in the rural
 22

sector. More than adequate and possible excessive intakes of iodine were seen in 42 percent of

children under five in the rural sector, 49 percent in the urban sector, and 51 percent in the

medium sector.

2.4.2 Iron Deficiency

Iron is critical for cognitive and motor development in childhood and for physical activity in all

humans. Nutritional iron deficiency is a major health problem in many developing countries,

often coexisting with iodine deficiency in the same populations. Iron Deficiency Anemia (IDA)

is indeed the most prevalent and widespread nutritional disorder in the world today, affecting

populations in both developed and developing countries. This disease reduces the work capacity

of an individual when affected, and subsequently the entire population at large, resulting in

serious economic consequences that inhibit national development (Davidson 2018a; Davidson

2018b).

Insufficient iron intake can lead to increased maternal mortality, compromised development of

motor skills and learning capacity, lethargy, and reduced immunity to diseases. It is estimated

that more than 2 billion people worldwide are at risk of iron deficiency anemia, with the

prevalence around 40–60 percent in pregnant women, 20–40 percent in women of childbearing

age, and about 10 percent in school-aged children and adult men (UNICEF 2019). In a small

study in southwestern Nigeria (Adelekan and Adeodu 2018), it was reported that both iron

deficiency and infections were equally important etiological factors in the anemia recorded in

mothers and their children.

2.4.3 Vitamin A Deficiency

Vitamin A is a fat-soluble vitamin, essential for vision in dim light; cellular, bone and tooth

growth; formation and maintenance of healthy skin, hair, and mucous membranes; reproduction;
 23

and immunity boosting. Vitamin A is so important in embryological development that without it,

the fertilized egg cannot develop into a fetus (Brody 2017). Its deficiency results in night

blindness or impaired adaptation to the dark; lowered immunity to infections such as measles,

diarrhea, chicken pox, and respiratory infections; anemia; poor growth; slowed bone

development; blindness; and death. All these have disastrous effects on the healthy growth and

intellectual performance of a child. The main health consequence of a diet that is chronically

insufficient in vitamin A is a failure to meet physiologic needs, including healthy tissue growth,

normal metabolism, and resistance to infection (WHO 2019). Globally, one in three preschool-

aged children and one in six pregnant women are vitamin-A deficient due to inadequate dietary

intake (UNICEF 2019). Nigeria is considered one of the WHO’s Category 1 countries with the

highest risk of vitamin-A deficiency (Humphrey et al. 2019). Vitamin-A deficiency contributes

to 25 percent of infant, child, and maternal mortality in Nigeria because of reduced resistance to

protein-energy malnutrition, acute respiratory infection, measles, malaria, and diarrhea (UNICEF

2019).

2.5 METHODS FOR ASSESSING FOOD CONSUMPTION PATTERN OF AN

INDIVIDUAL

There are five (5) general methods for assessing food consumption pattern of an individual and

are described below:

2.5.1 Food records

Food record also called food diaries require the subject (observer) report all food and beverages

consumed for a specified period usually one to seven days. Amounts of each food item may not

be recorded, depending on the objectives if nutrient intakes are calculated, the amount consumed

should be estimated as accurately as possible. Amounts maybe determined by weighing or by

 24

eliminating volumes. In some situations, only those foods of particular interest are recorded. For

example, to estimate intake of food component found only in animal products, food record might

be limited to foods containing meat, poultry, fish, eggs or dairy products. However, if total

energy intake is required, the food recorded should include all foods consumed. The advantages

of food record are that, it does not rely on memory and is open ended. Food record requires

literacy (Pellet and Gosh, 2016).

2.5.2 24- Hour dietary recall

The 24 hour dietary recall consists of a listing of foods and beverages consumed the previous day

the 24 hours prior to the recall interview. Foods and amounts are recalled from memory with the

aid of an interviewer who has been trained in method for soliciting dietary information. The

interview is usually conducted face to face, but may also be conducted through the telephone. A

brief activity history may be incorporated into the interview to facilitate probing for foods and

beverages consumed. The advantage of this method is that no literacy is required, while the

disadvantage includes the use of a skilled interviewer, relevancy on memory and difficulty in

estimation of amounts (Pellet and Gosh, 2016).

2.5.3 Food frequency questionnaire

Food Frequency Questionnaires (FFQ) are a type of dietary assessment instrument that attempt

to capture an individual’s usual food consumption by querying the frequency at which the

respondent consumed food items based on a predefined food list (Oldewage-Theron and Kruger,

2017). Given that food lists are culturally specific, FFQs need to be adapted and validated for use

in different contexts. The FFQ is the most common dietary assessment method of measuring

dietary patterns in large epidemiological studies of diet and health. It is often limited to the food

items that are a source of nutrients related to the particular dietary exposures under study, for
 25

example fruit and vegetable consumption or foods with high levels of saturated fat (Oldewage-

Theron and Kruger, 2017). Food frequency questionnaire recall periods vary greatly, but

typically range from 7 - 30 days (though some are as long as 1 year).

In general, FFQs rely on a longer recall period in order to capture foods that are not consumed

every day but are still part of the individual’s typical diet. These measures of ‘usual intake’ are a

more valid indicator of the relationship between diet and health outcomes than those capturing

only a single 24-hour snapshot of the diet. (However 24-hour dietary recalls can provide

information on the usual intake if data are collected on two non-consecutive days from

respondents). The self- administered FFQ booklet asks participants to report the frequency of

consumption and portion size of approximately 125 line items over a defined period of time (e.g.

the last month; the last three months). Each line item is defined by a series of foods or beverages.

Additional questions on food purchasing and preparation methods enable the analysis software to

further refine nutrient calculations (Gerald and Dorothy, 2017).

2.5.4 Diet history

The meal-based diet history is designed to assess usual intake. It consist of a detailed listing of

the types of foods and beverages commonly consumed at each eating occasion over a defined

period of time which is often a “typical” week. A trained interviewer probes for the respondents’

customary pattern of food intake on each day of a typical week. The reference time frame is

often several months, no literacy is required and is open ended but is difficult to estimate the

amount (Pallet and Gosh, 2017).

2.5.5 Food habits questionnaire (FHQ)

The food habits questionnaire (FHQ) is a 20 item self-report questionnaire that measures food

intake habits. Questions are about typical eating patterns over the past month, and are rated on a
 26

4-point Likert scale from 1 “Never or Rarely” to 4 “Usually or Always”, or “Not applicable”. Fat

intake is assessed by focusing on four food selection behaviors: excluding high-fat ingredients

and high-fat cooking methods, choosing specially manufactured low-fat food products instead of

high-fat ones, replacing high-fat foods with low-fat substitutes, and modifying high-fat foods.

The FHQ also demonstrated adequate concurrent validity as it was significantly correlated with

measures of fat and energy intake derived from food records (Spoon et al., 2012).

2.6 ANTHROPOMETRY

Anthropometry refers to the measurement of the human individual. An early tool of physical

anthropology, it has been used for identification, for the purposes of understanding human

physical variation, in paleoanthropology and in various attempts to correlate physical with racial

and psychological traits (Mosharraf, 2018). These are measurements necessary to assess the

nutritional status of individuals but are mainly used to detect growth failure in children especially

the under-five children. Nutritional anthropometry involves the measurements of variations in

the physical dimension and the gross composition of human body at different age, level, activity

and nutrition. It includes weight and height measurement using scales, measurement of skin fold

thickness using caliper, head, abdominal/waist, hip circumferences using tapes and other body

composition that can be derived from the above measurements (Onimawo and Cole, 2017).

An anthropometric measurement provides an indirect assessment of body composition and is

easy and economical to carry out since minimal equipment is required. They are valuable in

predicting mortality, determining changes in nutritional status over time and also in monitoring

the effectiveness of nutritional intervention. Anthropometric methods are based on a model of

body compositions namely: fat mass and fat-free mass (Wardlaw and Kessel, 2017).

2.6.1 Weight
 27

The term human body weight is used colloquially and in the biological and medical sciences to

refer to a person’s mass or weight. Body weight is measured in kilograms, a measure of mass,

throughout the world, although in some countries such as the United States it is measured in

pounds, or as in the United Kingdom, stones and pounds (Onimawo and Cole, 2017). Strictly

speaking, body weight is the measurement of weight without items located on the person.

Practically though, body weight may be measured with clothes on, but without shoes or heavy

accessories such as mobile phones and wallets and using manual or digital weighing scales.

Excess or reduced body weight is regarded as an indicator of determining a person’s health, with

body volume measurement providing an extra dimension by calculating the distribution of body

weight (Van, 2011).

2.6.2 Height

Human height or stature is the distance from the bottom of the feet to the top of the head in a

human body, standing erect. It is measured using a stadiometer, usually in centimeters when

using the metric system, or feet and inches when using the imperial system (Carter, 2017).

Height of an individual is made up of four compartments, legs, pelvis, spin and spur (Njoku,

2017). Height measurement is used for all age groups and it is an indication of chronic

nutritional status or malnutrition (Wardlaw and Kessel, 2017). But knowing the height of the

person alone does not give information about the nutritional status because height is more

determined by heredity than weight (Njoku, 2017). Body height measurement involves the

subject standing erect and barefooted on a stadiometer with a movable head piece. The head

piece is leveled with skull vault and height is recorded to the nearest centimeters (Wang and

Chen, 2012). The development of human height can serve as an indicator of two key welfare
 28

components, namely nutritional quality and health (Baten, 2016). In regions of poverty or

warfare, environment factors like chronic malnutrition during childhood or adolescence may

result in delayed growth and or marked reductions in adults height even without the presence of

any of these medical conditions. This is the major indicator of general body size and bone length.

Certain studies have shown that height is a health determinant (WHO, 2018). While some

suggest that tallness is associated with better cardio-vascular health and longevity (Samara,

2017).

2.6.3 Body Mass Index

Body mass index is a number that associates a person’s weight with his or her height/length

(WHO, 2017). Body mass index is a validated measure of nutritional status and is the commonly

used indicator to measure both over nutrition and malnutritionin adults and adolescents.

According to WHO (2017), diagnosis of obesity and overweight in children and adolescents is

not easy because it is age and gender based.

The formula used to calculate BMI is as follows: weight in kg divided by length in metres

squared (Weight in kg ÷ height in metres2). A BMI over 18.5 indicates adequate nutrition; below

16 is an indication of energy deficiency, BMI between 25 and 30 indicates over nutrition,

whereas >30 BMI indicate obesity (McCarthy and Ashwell, 2016). Body mass index has been

widely accepted to measure body fatness although it has some restrictions as it falls short in

measuring fat distribution, however, early detection of overweight and obesity is vital for the

onset prevention of NCDs later in life. Wenhold et al. (2017) also added that BMI is not so

accurate when used in measuring obesity and overweight in stunted children, additional

measurements are recommended in that scenario especially when the focus is on the excess body

fat measurements, for example, in detecting subcutaneous fat, skinfolds are measured.
 29

2.6.4 Height-for-age

Stunting, reflected by low height-for-age, is a measure of chronic malnutrition. Stunting is a

failure to reach linear growth potential because of inadequate nutrition or poor health (World

Bank, 2016). Horton et al. (2017) defined stunting as more than 2 standard deviations (SD)

below the population standard for height-for-age. Stunting is generally considered to reflect

chronic malnutrition. This indicator can help identify children who are stunted (short) due to

prolonged malnutrition or repeated illness and an indication that the child had been long

receiving inadequate nutrients to support growth (Müller and Krawinkel, 2018). Height for- age

is irreparable in children more than 2 years of age and correlates with a number of long term

factors such as protein insufficiency, low energy intake and micronutrient deficiency mainly of

zinc and iron (Faber and Wenhold, 2017). Other factors such as improper feeding practice and

continual exposure to infection may contribute to stunting. Usually, this is a good indicator of

long term malnutrition among young children (World Bank, 2016). Stunted children have poor

school performance caused by impaired mental development (Faber and Wenhold, 2017).

2.6.5 Weight-for-height

Underweight (weight-for-age) is a low weight for age. It implies wasting and is an indicator of

malnutrition (World Bank, 2017). Müller and Krawinkel (2018) described it as a recent or

current severe process leading to significant weight loss, usually a consequence of acute

starvation or severe disease (Müller and Krawinkel, 2018). Underweight is used to assess

whether a child is underweight or severely underweight, but it is not appropriate to classify a

child as overweight or obese. This indicator is the most commonly used anthropometric

indicator; it compares the weight of a child to the weight of a normal child of the same height

(Joubert and Ehrlich, 2017). Generally, underweight is caused by diets with insufficient nutrients
 30

necessary to maintain healthy living and high rates of infectious disease (de Onis, 2017). The

weight-for-age index expresses the weight of a child in relation to his age for the children up to

10 years of age. The index is an indicator of failure to grow. Wasting describes a considerable

weight loss in children, and a measure of acute malnutrition (Faber and Wenhold, 2017), usually

due to severe starvation and/or severe disease.

2.6.6 Body Mass Index-for-age

The BMI-for -age is a good indicator for assessing over nutrition in children and adolescents.

However, Deshmukh et al. (2016) considered weight for age as uninformative and even

misleading in the absence of corresponding information on height for age. A BMI-for-age above

the 85th percentile for the appropriate age and gender is recommended as a cut off point for risk

of overweight and above the 95th percentile as overweight (Wenhold et al, 2017). Body mass

index is a reasonable measure of body fatness, however, drawbacks has been identified that it

cannot effectively determine fat distribution. It indicates wasting and an indicator for under

nutrition. Low BMI-for-age indicates a measure of both chronic and acute malnutrition (Faber

and Wenhold, 2017).

2.6.7 Waist circumference (WC)

Waist circumference measurements are used to assess the abdominal fat content. The WC is

measured around the waist through a point one third of the distance between the xiphoid process

and the umbilicus, using a non-stretchable tape measure (Hammond, 2017). An easy and

effective way for detecting abdominal obesity in both adults and children is through using waist

circumference. It is a better indicator of visceral fat in children than using BMI (Li et al., 2017).

Waist circumference has been attributed as a better indicator in predicting risk of heart

conditions in both adults and children (Yang et al., 2017).

 31

2.6.8 Mid-Upper-Arm circumference (MUAC)

Mid upper arm circumference is measured in centimetres halfway between the acromion process

of the scapula and the olecranon process at the tip of the elbow (Hammond, 2017). MUAC is

used for the assessment of nutritional status. It is a good predictor of mortality and in many

studies, MUAC predicted death in children better than any other anthropometric indicator. The

MUAC is best used in children between six and fifty nine months of age and assessing acute

energy deficiency in adults during famine (Bob-Manuel and Udoaka, 2009).

2.6.9 Head circumference

Head circumference is useful in children under the age of three. Paper or a metal tape measure

marked in tenths of a centimetre is used. The head is measured at a greatest circumference, above

the eyebrows and pinna of the ears and around the occipital prominence at the back of the skull

(Hammond, 2017).

2.7 NUTRITION AND FOOD SECURITY SITUATION

In Nigeria, 37 percent of children under 5 years are stunted. The prevalence of stunting increases

with age, peaking at 46 percent among children 24–35 months. While stunting prevalence has

improved since 2008 (41 percent), the extent of acute malnutrition (wasting or low weight-for-

height) has worsened, from 14 percent in 2008 to 18 percent in 2013 among children under 5

years (National Population Commission and ICF International 2009 and 2014). Women’s

nutrition is also of concern in Nigeria, facing the double burden of malnutrition: prevalence of

undernutrition is 11 percent and prevalence of overweight/obesity is 25 percent (National

Population Commission and ICF International 2014). One driver of Nigeria’s high rate of growth

is that childbearing begins early in Nigeria. By age 19, 41 percent of adolescent girls had begun

childbearing in 2013, which is an increase from 38 percent in 2008. This has serious
 32

consequences because, relative to older mothers, adolescent girls are more likely to be

malnourished and have a low birth weight baby, who is more likely to become malnourished and

be at increased risk of illness and death than those born to older mothers (National Population

Commission and ICF International 2014). The risk of stunting is 33 percent higher among first-

born children of girls under 18 years, and as such, early motherhood is a key driver of

malnutrition (Fink et al. 2014).

Children in rural areas are more likely to be stunted (43 percent) than those in urban areas (26

percent), and the pattern is similar for severe stunting (26 percent in rural areas and 13 percent in

urban areas). The North West has the highest proportion of children who are stunted (55

percent), followed by the North East (42 percent) and North Central (29 percent). At the state

level, Kebbi has the highest proportion of stunted children (61 percent), while Enugu has the

lowest proportion (12 percent). A mother’s level of education generally has an inverse

relationship with stunting: stunting ranges from a low of 13 percent among children whose

mothers have a higher education to a high of 50 percent among those whose mothers have no

education. A similar inverse relationship is observed between household wealth and stunting.

Children in the poorest households are three times as likely to be stunted (54 percent) as children

in the wealthiest households (18 percent) (National Population Commission and ICF

International 2014). Prevalence of early initiation of breastfeeding decreased from 38 percent in

2008 to 33 percent in 2013, while children who received a pre-lacteal feed increased from 56

percent in 2008 to 59 percent in 2013. In addition, prevalence of breastfed children 6–23 months

receiving a minimum acceptable diet decreased from 9 percent in 2008 to 4 percent in 2013

(National Population Commission and ICF International 2014).

 33

The causes of malnutrition and food insecurity in Nigeria are multifaceted and include poor

infant and young child feeding practices, which contribute to high rates of illness and poor

nutrition among children under 2 years; lack of access to healthcare, water, and sanitation; armed

conflict, particularly in the north; irregular rainfall; high unemployment; and poverty (Nigeria

Federal Ministry of Health, Family Health Department 2014). Although chronic and seasonal

food insecurity occurs throughout the country, and is exacerbated by volatile and rising food

prices, the impact of conflict and other shocks has resulted in acute levels of food insecurity in

the North East zone (FEWSNET 2017). An estimated 3.1 million people in the states of Borno,

Yobe, and Adamawa received emergency food assistance or cash transfers in the first half of

2017 but, because much of the North East zone has been inaccessible to aid agencies, the number

who need assistance is likely much greater (FEWSNET 2017). Diet-related non-communicable

diseases are also on the rise in Nigeria due to globalization, urbanization, lifestyle transition,

socio-cultural factors, and poor maternal, fetal, and infant nutrition (Nigeria Federal Ministry of

Health, Family Health Department 2014).

2.7.1 Consequences of malnutrition

Malnutrition affects the function and recovery of every organ system.

1. Muscle function

Weight loss due to depletion of fat and muscle mass, including organ mass, is often the most

obvious sign of malnutrition. Muscle function declines before changes in muscle mass occur,

suggesting that altered nutrient intake has an important impact independent of the effects on

muscle mass. Similarly, improvements in muscle function with nutrition support occur more

rapidly than can be accounted for by replacement of muscle mass alone (Elia, 2017).
 34

Down regulation of energy dependent cellular membrane pumping, or reductive adaptation, is

one explanation for these findings. This may occur following only a short period of starvation.

If, however, dietary intake is insufficient to meet requirements over a more prolonged period of

time the body draws on functional reserves in tissues such as muscle, adipose tissue and bone

leading to changes in body composition (Warrell, et al., 2017). With time, there are direct

consequences for tissue function, leading to loss of functional capacity and a brittle, but stable,

metabolic state. Rapid decompensation occurs with insults such as infection and trauma.

Importantly, unbalanced or sudden excessive increases in energy intake also put malnourished

patients at risk of decompensation and refeeding syndrome (Warrell, et al., 2017).

2. Cardio-respiratory function

Reduction in cardiac muscle mass is recognised in malnourished individuals. The resulting

decrease in cardiac output has a corresponding impact on renal function by reducing renal

perfusion and glomerular filtration rate. Micronutrient and electrolyte deficiencies (eg thiamine)

may also affect cardiac function, particularly during refeeding. Poor diaphragmatic and

respiratory muscle function reduces cough pressure and expectoration of secretions, delaying

recovery from respiratory tract infections (Elia, 2017).

3. Gastrointestinal function

Adequate nutrition is important for preserving GI function: chronic malnutrition results in

changes in pancreatic exocrine function, intestinal blood flow, villous architecture and intestinal

permeability. The colon loses its ability to reabsorb water and electrolytes, and secretion of ions

and fluid occurs in the small and large bowel. This may result in diarrhoea, which is associated

with a high mortality rate in severely malnourished patients (Warrell, et al., 2017).

4. Immunity and wound healing

 35

Immune function is also affected, increasing the risk of infection due to impaired cellmediated

immunity and cytokine, complement and phagocyte function. Delayed wound healing is also

well described in malnourished surgical patients (Warrell, et al., 2017).

5. Psychosocial effects

In addition to these physical consequences, malnutrition also results in psychosocial effects such

as apathy, depression, anxiety and self-neglect (Warrell, et al., 2017).

2.8 NATIONAL NUTRITION POLICIES/LEGISLATION, STRATEGIES, AND

INITIATIVES

Nigeria’s commitment to improving nutrition is outlined in the following documents, which are

aligned with the government’s Vision 20:2020 and the National Strategic Health Development

Plan (2009–2015):

• National Policy on Food and Nutrition (2013)

• National Strategic Plan of Action for Nutrition (2014–2019)
• National Policy on Infant and Young Child Feeding in Nigeria (2010)
• Agricultural Sector Food Security and Nutrition Strategy
As outlined in the National Policy on Food and Nutrition and National Strategic Plan of Action

for Nutrition, Nigeria has set the following targets between 2014 and 2018: reduce the number of

under-5 children who are stunted by 20 percent; reduce low birth weight by 15 percent; ensure

no increase in childhood overweight; reduce and maintain childhood wasting to less than 10

percent; reduce anemia in women of reproductive age by 50 percent; and increase exclusive

breastfeeding rates in the first 6 months to at least 50 percent. Comprehensive legislation is in

place for the implementation of the International Code of Marketing of Breast Milk Substitutes.

The addition of vitamin A to wheat flour, maize meal, vegetable oil, and sugar, as well as the

addition of iron, zinc, folic acid, B vitamins, niacin, thiamine, and riboflavin to wheat, are
 36

mandated by law. Nigeria received Universal Salt Iodization certification in 2005 (KukuShittu et

al., 2018).

In April 2016, Nigeria launched its “Zero Hunger Initiative” to achieve the goal of eliminating

under nutrition by 2025— ahead of the 2030 deadline of the UN’s SDGs. The initiative is being

convened by the former President of Nigeria, Chief Olusegun Obasanjo.

A multi-sectoral National Committee on Food and Nutrition (NCFN) is chaired and facilitated by

the National Planning Commission. The NCFN is replicated at the sub-national level as the State

Committee on Food and Nutrition. The Nutrition Division, located in the Department of Family

Health in the Federal Ministry of Health, serves as the government body responsible for scaling

up nutrition and convening government ministries and departments including the Ministries of

Health, Education, Agriculture, Women Affairs, Finance, Information, Science and Technology,

and Water Resources, and the Planning Commission. All relevant ministries are also engaged

through the Nutrition Partners Forum, which meets four times a year with external partners

including national and international non-governmental organizations, UN agencies, donors, the

private sector, and media, to discuss strategy development and decisions relating to funding and

nutrition emergencies (Nigeria Federal Ministry of Health, Family Health Department 2017).
 37

CHAPTER THREE

RESEARCH METHODOLOGY

3.1 STUDY DESIGN

A cross sectional study design was used for this study.

3.2 STUDY AREA

Abia is a state in the south eastern part of Nigeria. The capital is Umuahia and the major

commercial city is Aba. It is one of the constituent states of the southeastern Nigeria. Abia city

of country Nigeria lies on the geographical coordinates of 5° 57' 0" N, 8° 55' 0" E. Abia State,

which occupies about 6,320 square kilometers, is bounded on the north and northeast by the

states of Anambra, Enugu, and Ebonyi. To the west of Abia is Imo State, to the east and
 38

southeast are Cross River State and Akwa Ibom State respectively and to the south is Rivers

State. This study will be conducted in Ikwuano local government area of Abia state. Ikwuano is a

Local Government Area of Abia State, Nigeria. Its headquarters is in Isiala Oboro. Ikwuano

LGA was among the new local government areas that was created on 27 August 1991 when the

General Ibrahim Babangida's Administration created Abia State from the old Imo State it was

carved out of the old Ikwuano-Umuahia Local Government Area. It one of the five LGAs that

make up Abia Central Senatorial District. It has an area of 281 km² and a population of 137,993

at the 2017 census. It is made up of about 52 villages and communities and is bounded by LGA

of Akwa Ibom State by the West and Umuahia North, their language is Igbo and their major

occupation is farming and trading. The climate is of humid tropics with fairly even temperatures

throughout the two seasons (dry and rainy) of the year. The rainy season starts from April/May

and ends in October/November which is characterized by clouds driven by light winds, relatively

constant temperatures, frequent rains and high humidity but from early November, when the dry

season starts, the weather clears rapidly as the northeast trade wind shifts to become the dusty

‘Harmattan’ bringing in the drier air from the Sahara desert. The dry season, notably dry with

little or no rainfall, hotter days, cooler nights, and lower humidity, ends in March/April. The

ground level slopes gently towards the Cross River flood plains dissected mainly by the Akwa

Ibom river systems (Chukwu and Ajuamiwe, 2019).

3.3 POPULATION OF THE STUDY

The target population for this study were children aged 2-5 years residing in Ndoro Nnono and
Umugbalu, Ikwuano L.G.A, Abia State.

3.4 SAMPLING AND SAMPLING TECHNIQUES

3.4.1 Sample Size
The sample size was determined using the formula:
 39

Z 2 XP (1−P)
N= (Winn et al., 2017).
d2

Where

N = sample size

Z = confidence interval of which is represented as 1.96

d = sample size

q = % of under 5 children at risk (1-p).

z=1.96

p=34.6% (prevalence of under 5 children at risk of malnutrition, Unicef, 2015).

d=margin error at 5%

However,

3.8416 X 0.346(1 x 0.346)

0.0025

0.8693
0.0025

N = 347.72 + 10% (347.72/100x10)

347.72 + 34.772

382.492

= 382

Therefore the sample size for the study were 382 young children.

3.4.2 Sampling Procedure

Multistage sampling technique was used for the study. In the first stage, Abia state was
purposively selected from the five (5) states in the south eastern Nigeria because no such study
have been conducted in the state. In the second stage, Ikwuano local government was
purposively selected from the 27 Local Government Areas in Abia state. In the third stage, 180
 40

households (in Ndoro Nnono and Umugbalu) were selected from the area with the help of simple
random selection process for the study.

3.5 PRELIMINARY ACTIVITIES

3.5.1 Preliminary visit
At the beginning of data collection, a preliminary visit was made to the village heads and
community leader children to seek access to information on the young children to solicit for their
consent and cooperation of the villagers during the study as well as create a rapport that built
confidence and trust between the researcher and the respondents.

3.5.2 Training of research assistants

Two (2) research assistants was used for the study. The aim and objectives of the study was
explained to the assistants. The assistants were trained by going through the questionnaire with
them. They were taught on how to use every equipment/item before the commencement of
questionnaire administration. They were trained on weighing, recording and measuring
techniques.

Verbal consent was sorted from the mothers and caregivers where each 2-5 years old children
found in the various households of each communities were appraised.

3.5.4 Ethical approval

Ethical clearance was obtained from the Health and Research Ethics Committee of Federal

Medical Centre, Umuahia.

3.6 DATA COLLECTION

3.6.1 Questionnaire Administration

 41

A structured questionnaire was developed to collect information from the study participant. The

questionnaire will be divided into four (4) sections: (socio-economic status, anthropometry,

feeding habit and 24- hour dietary recall). The questionnaire was validated by giving it to four

lecturers in the Department of Human Nutrition and Dietetic, Michael Okpara University of

Agriculture, Umudike. The questionnaire was pretested by giving it to ten parents/caregivers in

Umuahia North L.G.A of Abia state who are not part of the study area to know their ability to

understand the questionnaire. Interview method was used in administering the questionnaire.

3.6.2 Anthropometric measurement

Weight measurement

A portable bathroom scale (Hanson model weight scale) was used. The weight of the children

was taken using the bathroom scale. The children were measured putting on light clothing, bare-

footed and standing on the scale with his/her head pointing straight and the weight was measured

to the nearest 0.1 kilogram (kg) (WHO, 2015).

Height measurement

A stadiometer was used to measure height, the children were asked to remove their shoes. The

requirement for the position of the stadiometer was on a flat, hard surface, next to a smooth and

straight wall. The children were positioned to be facing the researcher when looking straight

ahead. The children were required to stand upright with their shoulders relaxed; arms relaxed at

their sides; legs straight and knees together; buttocks and heels touching the wall; feet flat on the

floor and heels touching the flour. The head piece was then be slid down gently to rest on the

crow of the children heads. The reading was then taken in meters and recorded on the required
 42

anthropometric measurement form. The procedure was repeated, and the reading taken to the

nearest 1m or 1cm and recorded on the required form. The average of the two readings was

recorded which was used to calculate BMI (WHO, 2018).

Mid-Upper Arm Circumference

The left arm of the child was bent, the olecranon process and acromium are found and marked

with pen and the mid-point between the two marks is noted. With the arm hanging straight down,

a MUAC tape is wrapped around the arm at the midpoint mark and measured to the nearest 1

mm (WHO, 2015).

3.7 DATA ANALYSIS

Anthropometric status of the pre-primary school aged children was analyzed using the WHO

Anthro Survey analyzer based on weight for age, height for age and weight for height,

respectively, so as to describe the nutritional status of the children as well as assess the

prevalence of overweight and underweight, stunting and wasting, respectively. The following

WHO cut off points formed the basis upon which the results was interpreted as follows

Table 3.1: Anthropometric status

Anthropometric status Measurement Cut-off point
Stunting Height-Age <-2SD
Wasting Weight-Height <-2SD
Underweight Weight-Age <-2SD
Overweight BMI-Age >+2SD
Obesity BMI-Age >+3SD
Source: (WHO, 2018)

Table 3.2: Mid-Upper Hand Circumference

MUAC Nutritional Status

>13.5 cm Not Malnourished

 43

11.5-13.5cm Moderately malnourished

< 11.5 cm Severely malnourished

Source: WHO (2019)

3.8 STATISTICAL ANALYSIS

Upon completion of the fieldwork, the questionnaires was arranged in numerical order and

reviewed by the researcher for completeness and accuracy. The data from the questionnaires

captured by the researcher onto an Excel spreadsheet. The data was analysed using Statistical

Package for Service Solution (SPSS) for Windows Version 20.0 software programs. Socio

economic characteristics and feeding habits and nutritional risk was analyzed using frequencies

and percentages while Chi-square was used to analyze the relationship between feeding habit,

anthropometric status, nutritional risk and socioeconomic status of the children at p < 0.05

probability level.

CHAPTER 4
RESULTS AND DISCUSSION
4.1 BASIC CHARACTERISTICS OF UNDER FIVE CHILDREN
Table 4.1 revealed that 100% of the respondents where all living in the rural area, which could

be due to the study area is still underdeveloped. The result also shows that half (50.91%) of the

participants lived in Ndoro, less than half (44.8%) lived in Nnono, and very few (4.7%) lived in

Umugbalu while 0.3% lived in Oboro Ikwuano. Males were 41.6% while 58.4% were females.

More than half (52.5%) of the participants were aged between 4-5 years. The result revealed that

majority 96.4% of the respondent in the study area where in school either in nursery or primary

classes. This result is not surprising as many children due to the busy schedule of parents now

start schooling at a very early age. Birth weight between 3.0kg-3.4kg were predominant (50.4%),
 44

majority were immunized (92%). The result observed that majority did not practice exclusive

breastfeeding (82.6%). This result constrasts the reason given by Ugboaja, et al. (2013) in his

study which opined that breastfeeding is part and parcel of the cultures and traditions across

Africa and it will take a herculean number of disincentives for a nursing mother to refuse or

abandon breastfeeding her baby, especially when other people are present to ensure compliance.

Furthermore, the prevailing poverty and general lack within Nigeria make it virtually impossible

for most of the women to afford artificial feed for their infants.
 45

Table 4.1 Basic characteristics of under 5 children

Variables Frequency (n=382) Percentage (%)
Area of study
Rural 339 100

Location of study
Ndoro 170 50.1
Nnono 152 44.8
Umugbalu 16 4.7
Oboro Ikwuano 1 0.3
Sex
Male 141 41.6
Female 198 58.4
Age (years)
2-3 years 161 47.5
4-5 years 178 52.5
Mean ± SD 3.581 ± 1.177
Class of child
Nursery 1 113 33.3
Nursery 2 68 20.1
Nursery 3 65 19.2
Primary 1 57 16.8
Primary 2 6 1.8
Day care 3 0.9
Not in school 27 8.0
Number of siblings
None 13 3.8
1-2 164 48.4
3-4 153 45.1
5 and above 9 2.7
Birth order of participating child
First 99 29.2
Middle 138 40.8
Last 102 30.1
Birth weight of child
<2.5kg 9 2.7
2.5-2.9kg 52 15.3
3.0-3.4kg 171 50.4
3.5-3.9kg 104 30.7
≥4.0kg 3 0.9
Immunization status
Yes 312 92.0
No 27 8.0
Exclusive breastfeeding
Yes 59 17.4
No 280 82.6
 46

4.2. SOCIO DEMOGRAPHIC CHARACTERISTICS OF PARENT

The socio-demographic characteristics status of their parents are shown in tables 4.2a, 4.2b and

4.2c. About half (57.2%) of the mothers were between 26-30 years while 61.4% of the fathers

were aged between 36-40 years. Majority (95%) were married, 97.1% were Christians, and

85.5% had a household size of 4-6 individuals. On the household size, 85.5% of the children

lived in households with 4-6 members, 8.8% were of 1-3 members, while only 5.6% lived in

households with more than 7 members. This is line with Onyekuru, (2017) who found that

households in the study area recorded a mean of 5 members. About half of the mothers (56.9%)

and fathers (58.4%) had secondary education. The level of education prevalent among the parent

can be seen to be more of secondary and tertiary education respectively however secondary

education can help one to make informed decision especially one that can have a reflection on

one’s children (Mbah, 2010). A greater number of the mothers were traders by occupations with

a percentage of 34.5, the occupation of the parents of these school aged children is not surprising

due to their educational qualification. About 80% of the mothers earned below minimum wage

(N30, 000), which may not be enough to buy enough food item by the parents to feed children

and may lead to poor nutritional status among the respondents in the study area. 61.7% used

water cistern, 54% uses tap as their major source of water. Theophilus (2016) in his study

collaborates that bore water are vulnerable to diseases. The result show that 65.2% used kerosene

as a fuel for cooking, which could be as a result of the fact that most rural household still use

lantern, stove and firewood as source of energy for cooking and lighting the house.
 47

Table 4.2. Socio-demographic characteristics of the parent N=382

Variables Frequency (F) Percentage (%)

Mother’s age
≤20 years 2 0.6
21-25 years 17 5.0
26-30 years 194 57.2
31-35 years 120 35.4
36-40 years 6 1.8

Father’s age
≤ 25 years 3 0.9
26-30 years 4 1.2
31-35 years 47 13.9
36-40 years 208 61.4
>40 years 71 20.9

Marital status
Married 322 95.0
Single 7 2.1
Separated 6 1.8
Widowed 1 0.3
Divorced 3 0.9

Household size
1-3 30 8.8
4-6 290 85.5
>7 19 5.6

Religion
Christianity 329 97.1
Islam 4 1.2
Traditional 6 1.8

Educational qualification of mother

No formal education 5 1.5
Primary education 36 10.6
Secondary education 193 56.9
Tertiary education 105 31.0
 48

Table 4.2.b. Socio-demographic characteristics of the parent

Educational qualification of father
No formal education 6 1.8
Primary education 39 11.5
Secondary education 198 58.4
Tertiary education 87 25.7

Mother’s occupation
Full time housewife 18 5.3
Farmer 51 15.0
Trader 117 34.5
Teacher 66 19.5
Civil servant 14 4.1
Student 4 1.2
Craftswoman 69 20.4

Father’s occupation
Farmer 28 8.3
Trader 186 54.9
Civil servant 42 12.4
Teacher 5 1.5
Craftsman 67 19.8
Pensioner 2 0.6

Mother’s estimated monthly income

≤N30,000 273 80.5
N31,000-N50,000 63 18.6
N71,000-N100,000 3 0.9

Father’s estimated monthly income

≤N30,000 79 23.3
N31,000-N50,000 198 58.4
N51,000-N70,000 50 14.7
N71,000-N100,000 1 0.3
>N100,000 2 0.6
 49

Table 4.2.c. Ownership of household utility

Type of toilet used in household

Water cistern 209 61.7

Pit latrine 130 38.3

Main source of water supply

Tap 183 54.0
Well 1 0.3
Community borehole 155 45.7

Source of energy
Kerosene 221 65.2
Gas 66 19.5
Firewood 50 14.7
Charcoal 2 0.6
 50

4.3 FOOD HABITS OF THE PARTICIPANTS

Table 4.3 shows the food habits adopted by households. The result shows that majority (99.4%)

of the participant consume breakfast which is the most important meal of the day and this is in-

line with Chowley et al., (2010) which opined that breakfast is often called the most important

meal of the day. As the name suggests, breakfast breaks the overnight fasting period. It

replenishes your supply of glucose to boost your energy levels and alertness, while also

providing other essential nutrients required for good health. The result also revealed majority

(82.3%) of the child eat three times a day. Doing so will also help you feel less inclined to

overeat during any one particular meal. Food habit of child eating alone on plate was

predominant (46.3%) while child eating with older children was subsidiary (41.9). Majority

(99.7%) consumes snacks while all the snacks common to the area of study was usually

consumed by participants (73.2). This result is expected because most parent give their little

children snacks so as to stay focused at school and on homework, give them needed nutrients and

keep hunger at bay (Gordon et al., 2013).

 51

Table 4.3. Food habits of the participants

Variables Frequency (n=382) Percentage (%)

Breakfast consumption
Yes 337 99.4
No 2 0.6

Number of times child eats in a day

Once 1 0.3
Twice 4 1.2
Three times 279 82.3
On demand 33 9.7
4-6 times 22 6.5

Child feeding pattern

On same plate with older children 142 41.9
Alone on the child’s plate 157 46.3
On same plate with all family members 29 8.6
With parents alone 1 0.3
With mother alone 7 2.1
With father alone 3 0.9

Snacks Consumption
Yes 329 97.1
No 10 2.9

Snacks Taken
Meat pie 1 0.3
Biscuit 58 17.1
Buns 3 0.9
Cake 4 1.2
Egg roll 1 0.3
Bread 1 0.3
Cheese balls 16 4.7
All of the above 248 73.2
 52

4.4 ANTHROPOMETRIC CHARACTERISTICS OF UNDER FIVE CHILDREN

Table 4.4. Shows the anthropometric characteristics of the respondents based on sex. Prevalence

of wasting, stunting and underweight was 7.1%, 5.6%, 2.1% respectively. According to their

weight for height Z-scores, it was observed that 92.2% and 93.4 of the participants (male and

female) were normal.

According to their Height for Age Z-scores, it was observed that majority of the respondents

both male and female (95.7% and 93.4%) were normal while 4.3% and 6.6% of the children both

male and female were Stunted. This result could be as a result of the fact that most of the participant

feed regularly and most three times daily. This finding is in line with Buttenheim et al. (2017) that

feeding three standard times enhances the improvement of children’s nutritional status.

According to the weight for age Z-score, the result show that majority of the participants were

normal (97.9% and 98.0%) for both male and female respectively. The good adequate nutritional

content of the food they eat may be responsible for their normal body weight. Similar conclusion

was reached by Adekeye et al. (2015) who found that 48.6% of the children in their study had

normal body weight stated that this may be because the children eat enough healthy meals which

is necessary for good health. While 2.1% and 2.0% of the children were at risk of being

underweight. Considering their BMI for age, result shows that 93.4% and 93.9% of the male and

female children are normal, 6.4% and 6.1% of the children are at the risk of overweight

respectively. The MUAC result show that 99.3% and 99.5% of the respondents were normal and

very few (0.7% and 0.5%) were undernourished. Contrary to one of the earliest cross-sectional

nutritional survey conducted among children in villages in 1987 (Ehigie 1987). The results

showed that (76.8%) children had mid-upper-arm circumference below the fiftieth percentile of
 53

the Harvard standard. This study therefore revealed that children in the medically isolated

villages were not only at risk of malnutrition therefore suffering from multiple infections.

Table 4.4 Anthropometric characteristics of under five children based on sex

Variable Male Female Total p-value

F % F % F %
WHZ 0.408ns
Normal (>-2.00) 130 92.2 185 93.4 315 92.9
Wasted (<2.00) 11 7.8 13 6.6 24 7.1
Mean ± SD -0.100 ± 1.432 -0.116 ± 1.492 -0.109 ± 1.465

HAZ 0.254ns
Normal (>-2.00) 135 95.7 185 93.4 320 94.4
Stunted (<-2.00) 6 4.3 13 6.6 19 5.6
Mean ± SD 0.282 ± 1.488 0.185 ± 1.409 0.225 ± 1.441

WAZ 0.616ns
Normal (>-2.00) 138 97.9 194 98.0 332 97.9
Underweight (<- 3 2.1 4 2.0 7 2.1
2.00)
Mean ± SD 0.016 ± 1.078 -0.005 ± 1.023 0.004 ± 1.045

BAZ 0.538ns
Overweight (>2.00) 9 6.4 12 6.1 21 6.2
Normal (<2.00) 132 93.6 186 93.9

Mean ± SD -0.252 ± 1.406 -0.188 ± 1.376 -0.214 ± 1.387

MUAC 0.660ns
Under nourished 1 0.7 1 0.5 2 0.6
(<12.6cm/126mm)
Normal 140 99.3 197 99.5 337 99.4
(>12.6cm/126mm)
Mean ± SD 17.479 ± 1.488 17.351 ± 1.280 17.404 ± 1.369
ns – Not significant.
 54

4.5 ANTHROPOMETRIC CHARACTERISTICS OF UNDER FIVE CHILDREN BASED

ON AGE

Table 4.5 shows the anthropometric characteristics of the respondents based on age. Prevalence

of wasting, stunting and underweight was 7.1%, 5.6%, 2.1% respectively. A significant (p>0.05)

difference was observed among the ages for Weight for age status (0.046). The result on weight

for height Z-scores, it was observed that majority (92.5% and (93.3%) of the children between 2-

3years and 4-5years were normal while very few (7.5% and 6.7%) were wasted. According to

their Height for Age Z-scores, it was observed that majority (96.3% and 92.7%) of the

respondents between the age group of 2-3 years and 4-5 years were normal, while 3.7% and

7.3% were stunted. The prevalence rates for underweight and

stunting are comparatively lower than the rates reported in the African studies as well in studies

done in some parts of the world (Wang et al., 2014; Wolde et al., 2015; de Onis et al., 2012). The

observed differences may be related to study instruments such as the reference indices used,

secular/time trends, and sociocultural factors.

It considered the weight for age Z-score, it observed that majority of the participant (96.3% and

99.4%) were normal and 3.7% and 0.6% of the children were at risk of being underweight.

Contrary to this study, Srivastava et al. (2012) reported significantly higher prevalence of

underweight, wasting, and stunting in children between 1-5 years and attributed the disparities in

findings to differences in study frame, family setups, and gender bias due to parental preferences

in the Indian society. The result also observed that for the BMI for age of the children between 2-

3years and 4-5years were normal (94.4% and 93.3%), very few (5.6% and 6.7%) were at risk of

being overweight. The finding in the current study is in comparison to a previous one (Nwalwu

and Ibe, 2014) in the same environment showed a low rate of obesity, but suggest a rise trend in
 55

Enugu in the future. However, this variation comparing rate of 4.4% obtained in the current

study with 1.7% obtained in the previous study. The result further revealed the mid-upper arm

circumference, it was observed that majority (98.8% and 100%) of the children between 2-3years

and 4-5years were normal, while 1.2% of the children in different age group were at risk of being

under nourished. The results revealed most of the children from different age group had good

health condition. Contrary to Ehigie (1987), the results showed that (76.8%) children had mid-

upper-arm circumference below the fiftieth percentile of the Harvard standard. This study

therefore revealed that children in the rural area were at risk of malnutrition.
 56

Table 4.5 Anthropometric characteristics of under five children based on age

Variable 2-3 years 4-5 years Total p-value

F % F % F %
WHZ 0.482ns
Normal (>-2.00) 149 92.5 166 93.3 315 92.9
Wasted (<-2.00) 12 7.5 12 6.7 24 7.1
Mean ± SD -0.227 ± 1.258 -0.003 ± 1.626 -0.109 ± 1.465

HAZ 0.116ns
Normal (>-2.00) 155 96.3 165 92.7 320 94.4
Stunted (<-2.00) 6 3.7 13 7.3 19 5.6
Mean ± SD 0.094 ± 1.302 0.344 ± 1.550 0.225 ± 1.441

WAZ 0.046*
Normal (>-2.00) 155 96.3 177 99.4 332 97.9
Underweight (<- 6 3.7 1 0.6 7 2.1
2.00)
Mean ± SD -0.076 ± 1.156 0.075 ± 0.929 0.004 ± 1.045

BAZ 0.417ns
Overweight (>2.00) 9 5.6 12 6.7 21 6.2
Normal (<2.00) 152 94.4 166 93.3 318 93.8
Mean ± SD -0.226 ± 1.327 -0.202 ± 1.441 -0.214 ± 1.387

MUAC 0.225ns
Under nourished 2 1.2 0 0.0 2 0.6
(<12.6cm/126mm)
Normal 159 98.8 178 100 337 99.4
(>12.6cm/126mm)
Mean ± SD 16.636 ± 1.118 18.098 ± 1.196 17.404 ± 1.369
*
ns – Not significant significant at p <0.05
 57

4.6 SOCIO-DEMOGRAHIC AND OTHER FACTORS ASSOCIATED WITH

MALNUTRITION
Table 4.4 shows the factors associated with malnutrition. It was observed that there was a

significant (p> 0.05) positive correlation between fathers’ educational level and Height for age

Z-score (r = 0.235; p = 0.000) and Weight for age Z-score (r = 0.243; p = 0.000). It was observed

that there was a significant (p> 0.01) positive correlation between exclusive breastfeeding and

Weight for Height Z-score (r = 0.110; p = 0.000). This result is plausible considering that many

of the younger children are still been breastfed, and chronic malnutrition sets in only after

weaning (Babatunde and Qaim, 2010).Hence, the father educational level had a significant

relationship with height and weight of children in the study area. It was observed that there was a

significant (p>0.05) positive correlation between mothers education and Weight for age Z-score

(r = 0.142; p = 0.000). Suggesting that improved mother’s education will reduce the level of

child malnutrition. This result is consistent with the findings of Webb and Block (2004), which

highlighted the importance of human capital investment in improving children nutritional status.

Educated mothers are better aware about the nutrition requirements of their children and they

usually provide improved health care as a result of their awareness.

In addition, there was a significant (p> 0.05) positive correlation between child’s age and Height

for age Z-score (r = 0. 0.156; p = 0.004), weight for age Z-score (r = 0.127; p = 0.019) and

MUAC (r = 0.624; p = 0.000). In the study of Omotosho (2011) it was observed that MUAC

increases with age in the study area, which is mean the older the child becomes the MUAC

increases.
 58

Table 4.6 Socio-demographic and other factors associated with malnutrition

Sex Age WHZ HAZ WAZ BAZ MUAC
Sex 1 0.086 -0.046 -0.005 -0.033 -0.010 0.023
Age 0.086 1 0.093 0.156** 0.127* 0.003 0.624**
* *
Birth weight of child 0.005 0.124 0.108 -0.092 -0.031 -0.108* -0.081
*
Exclusive breastfeeding status -0.024 0.095 0.110 0.056 -0.127* -0.004 -0.109*
Mother’s age -0.018 0.054 0.025 -0.040 0.029 -0.023 -0.057
*
Father’s age 0.000 0.109 0.087 0.056 -0.017 0.002 0.015
Mother’s educational level -0.094 -0.061 -0.105 -0.018 0.142** 0.084 -0.044
Father’s educational level -0.027 -0.015 0.070 0.235** 0.243** 0.055 0.089
Mother’s occupation -0.063 -0.020 -0.041 0.040 0.030 0.084 0.062
Father’s occupation -0.083 0.026 0.053 0.085 -0.049 0.029 0.075
Mother’s estimated monthly income -0.013 -0.053 -0.053 -0.039 0.051 -0.021 -0.069
Father’s estimated monthly income 0.066 0.016 0.080 0.069 0.019 0.096 0.089
Breakfast consumption 0.065 -0.104 -0.023 -0.008 0.034 0.026 -0.004
Child feeding pattern 0.113* -0.050 0.026 -0.036 0.070 0.027 -0.033
Number of time child eats in a day -0.056 0.042 0.025 0.039 0.077 0.062 0.003
*Correlation is significant at 0.01 level **Correlation is significant at 0.05 level
 59

CHAPTER FIVE
CONCLUSION AND RECOMMENDATION
5.1 CONCLUSION

The study assessed the malnutrition among children 2 to 5 years in rural areas within Ikwuano

Local Government Area of Abia state, Nigeria. The study revealed that a good number of the

respondents (58.4%) were female. It showed that More than half of the participants were aged

between 4-5 years. Birth weight between 3.0kg-3.4kg were predominant, majority were

immunized, and majority did not practice exclusive breastfeeding. In the anthropometric

characteristics of the respondents based on age the result revealed few of the respondents were

wasting, stunting and underweight respectively. The result further revealed that majority of the

respondents ate breakfast every day and ate three times in a day (82.3%). While, majority

(99.7%) consumes snacks while all the snacks common to the area of study was usually

consumed by participants. It was observed that there was a significant (p> 0.05) positive

correlation between fathers educational level and height for age Z-score and weight for age Z-

score. There was a significant (p> 0.05) positive correlation between child’s age and height for

age Z-score, weight for age Z-score and MUAC.

5.2 RECOMMENDATION
Based on the study findings, the following are recommended;

1. Children are the future of any nation and should be properly cared for. The presence of

adequate nutrient intakes and good nutritional status amongst the children especially

those from families in this study demonstrates the effective and efficient of education and
 60

enlightenment on sustainable food and nutrition interventions aimed at improving dietary

intake and diversity as well as countering poor nutritional status.

2. Caregivers should consider the available indigenous foods as part of the dietary intakes of

the households as these often grow wild and do not cost much, but can contribute to the

nutrient intakes of the entire family. The produce from indigenous and home vegetable

and fruit gardens are less expensive than buying these items from the market.

3. The results of this study indicate that further research is needed on the associations

between socio-economic status, food intake patterns and nutritional status of the child

caregivers and the children with suitable interventions to improve the overall dietary

intake patterns and diversity

 61

REFERENCES

Akinyele, I. O., (2019). Ensuring food and nutrition security in rural Nigeria: An assessment of
the challenges, information needs, and analytical capacity. IFPRI – NSSP Background
paper No. NSCP007.

Ali, S. S., Haider, S. S., Karim, N. and Billo, A. G., (2015) Association of literacy of mothers
with malnutrition among children under three years of age in rural area of District Malir,
Karachi. Journal of Pakistan Medical Association. 2(3):13-19.

Aliyu, A. A., Oguntunde, O. O., Dahiru, T. and Raji, T., (2012). Prevalent and determinants of
malnutrition among pre-school children in Northern Nigeria. Pakistan Journal of
Nutrition.11 (11):1092-1095.

Ascherio, A. and Willet, W. C., (2017). Health effects of trans fatty acids. American Journal of
Nutrition. 66(4): 10065-10105.

Asindi, A. A., Ibia, E. O. and Udo, J. J., (2010). Mortality pattern among Nigerian children in the
1980s. Journal of Tropical Medicine and Hygiene. 94:152-5.

Awoyemi, T. T., Odozi, J. C. and Ogunmiyi, A. A., (2012). Environmental and socio-economic
correlates of child malnutrition in Iseyin area of Oyo State, Nigeria. Food and Public
Health. 2(4):92-98.

Babatunde, R. O., Omotesho, O. A. and Sholotan, O. S., (2017). Socio-economic characteristics

and food security status of farming households in Kwara State, North-Central Nigeria.
Pakistan Journal of Nutrition. 6:49-58.

Babatunde, R., Olagunju, F., Fakayode, S. and Sola-Ojo, F. (2011). Prevalence and determinants
of malnutrition among under-five children of farming households in Kwara State,
Nigeria. J Agric Sci; 3: 173-86.

Baranwal, K., Gupta, V. M., Mishra, R. N., Prakashs, N. and Pandey, O. N., (2010). Factors
influencing the nutritional status of under-five (1-5years) children in urban-slum area of
Varanasi. Indian Association of Preventive and Social Medicine, Uttar Predesh and
Uttarakhand State Chapter.

Battisti, D. S., (2018). Climate change in developing countries. University of Washington,

Seattle. Retrieved from cses.washington.edu/dp/pdf/wacciachadapt654.pdf.

Black, B., Burke, H. and Breiman, R. F., (2011). Nutritional status of under-five children living
in an informal urban settlement in Nairobi, Kenya. Journal of Health Population and
Nutrition. 29(4):357-363.
 62

Black, R. E., Allen, L. H., Bhutta, Z. A., Caulfield, L. E., de Onis, M., Ezzati, M., Mathers, C.
and Rivera, J., (2018). Maternal and child undernutrition: Global and regional exposures
and health consequences. Lancet. 19; 371(9608):243-60.

Bryce, J., Boschi-Pinto, C., Shinbuya, K. and Black, R. E., (2015). WHO estimates of the causes
of death in children. Lancet. 1; 365 (9465):1147-52.

Chaudhury, M. S. I., Akhter, N., Haque, M., Aziz, R. and Nahar, N., (2019). Serum total protein
and albumin levels in different grades of protein energy malnutrition. Journal of
Bangladesh Society of Physiologist. 3(11):234-245.

Chaudhury, R. H., (2013). Effects of mothers’ work on child care, dietary intake, and dietary
adequacy of pre-school children. International Food and Nutrition Program,
Massachusetts Institute of Technology, Cambridge.

Desai, S. and Alva, S., (2018). Maternal education and child health: Is there a strong causal
relationship? Demography. 35(1): 71-81.

Ejemot-Nwadiaro, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M. and Critchley, M., (2015).
Handwashing promotion for preventing diarrhea. Cochrane Database of Systematic
Reviews. John Wiley and Sons Ltd., Oxford, Retrieved from
http://www.thecockranelibrary. com.

Elia M (2017). Guidelines for detection and management of malnutrition. Malnutrition Advisory
Group, Standing Committee of BAPEN. Maidenhead: BAPEN, 2000.

Etim, K. D., (2016). Nutritional status of children under five years in Ekureku community, Abi
L. G. A. of Cross River State, Nigeria. M.Sc. Thesis submitted to Graduate School,
University of Calabar, Calabar, Nigeria.

Etim, K. D., Ejemot-Nwadiaro, R. I. and Kalu, R. E., (2017). A study of malnutrition-dependent

factors among under-five children in Ekureku community, Abi Local Government Area
of Cross River State, Nigeria. British Journal of Medicine and Medical Research.
21(8):1-10.

Federal Ministry of Health, (FMH) (2011). Saving Newborn Lives in Nigeria: Newborn health in
the context of the Integrated Maternal, Newborn and Child Health Strategy, Second
edition, 2011.

Food and Agricultural Organization, (2018). The state of food insecurity in the world. Food and
Agricultural Organization, Rome.

Food and Agricultural Organization, (2018). Rome Declaration on Food Security and World
Food Summit. Plan of action November 13-17 Rome: FAO.
 63

Ge, K.Y. and Chang, S.Y. (2011) Definition and measurement of child malnutrition. Biomed.
Environ. Sci. 14: 283-91.

Glewwe, P., (2019). Why does mother’s schooling raise child health in developing countries?
Evidence from Morocco. Journal of Human Resources. 34(1):124-15.

Glewwe, P., Jacoby, H. G. and King, E. M., (2011). Early childhood nutrition and academic
achievement: A longitudinal analysis. Journal of Public Economics. 81(3):345-368.

Glick, P. and Sahn, D. E., (2011). Maternal labour supply and child nutrition in West Africa.
Oxford Bulletin of Economics and Statistics. 60(3): 1468-0084.

Hernel, C., Enne, J., Omer, K., Ayara, N., Yarima, Y., Cokcroft, A. and Anderson, N., (2015).
Childhood Malnutrition is associated with maternal care during pregnancy and childbirth:
A cross sectional study in Bauchi and Cross River States, Nigeria. Journal of Public
Health Research. 4(1):139-148.

Hien, N. N. and Kam, S., (2018). Nutritional status and the characteristics related to malnutrition
in children under five years of age in Ngbean, Vietnam. Journal of Preventive Medicine
and Public Health. 41(4):232-240.

Institute of Medicine, (2015). Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat,
Fatty Acids, Cholesterol, Protein and Amino Acids (Macronutrients). National Academic
Press, Washington D. C.

Kennedy, G., Nantel, G. and Shetty, P. (2016). The Double Burden of Malnutrition: Case Studies
from Six Developing Nations. Rome: Food and Agriculture Organization of the United
Nations; 2016.

Kumar, D., Goel, N. K., Mittal, P. C. and Misra, F., (2016). Influence of infant-feeding practices
on nutritional status of under-five children. Indian Journal of Pediatrics. 73(50: 417-21.

Leung, A. K. and Sauve, R. S., (2015). Breast is best for babies. Journal of the National Medical
Association. 97:1010-1019.

Mashal, T., Takano, T., Kakamura, K., Kizuki, M., Harmat, S., Waranbe, M. and Seinok, L.,
(2018). Factors associated with the health and nutrition of children under 5 years of age
in family behavior related to women and past experience of war related hardships.
BMC Public Health. 8(301):1471-2458.

Muller, O. and Krawinkel, M., (2015). Malnutrition and Health in developing countries.
Canadian Medical Association Journal. 173(3):279-86.

National Planning Commission (2010) National Policy on Food and Nutrition in Nigeria, Abuja.
 64

National Population Commission (NPC) [Nigeria] and ICF International, (2014). Nigeria
Demographic and Health Survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA,
NPC and ICF International.

National Population Commission (NPC) [Nigeria] and ICF International, (2013). Nigerian
Demographic and Health Survey, Abuja, Nigeria and Rockville, Maryland, USA.

Nyaruhucha, C. M., Msuya, J. M., Mamiro, P. S. and Kerengi, A. J., (2016). Nutritional status
and feeding practices of under-five children in Samanjiro District, Tanzania. Tanzania
Health Research Bulletin. 8(30:162-167.

Olack, B., Burke, H., Cosmas, L., Bamrah, S., Dooling, K., Feikin, D. R., Talley, L. E. and
Breiman, R. F., (2011). Nutritional status of under-five children living in an informal
urban settlement in Nairobi, Kenya. Journal of Health Population and Nutrition.
29(4):357-363.

Olanrewaja, S., (2011). Nigeria still wallowing in poverty. The Nigerian Tribune. Retrieved from
www.9jabook.com/forum/ topics/ nigeria-still wallowing-in-poverty.

Oquntin, T. A., (2010). Maternal socio-demographic factors influencing initiation and

exclusivity of breastfeeding in a Nigerian semi-urban setting. Child Health Journal.14
(3):459-65.

Reutlinger, S. and Selowsky, M., (2016). Malnutrition and poverty: Magnitude and policy
options. World Bank Staff Occasional Papers, No. 23, John Hopkins University Press,
Baltimore and London.

Shrimpton, R. and Rokx, C. (2012). The Double Burden of Malnutrition: A Review of Global
Evidence. Washington, DC: The International Bank for Reconstruction and
Development/the World Bank.

Smith, L. C. and Haddad, L., (2019). Explaining child malnutrition in developing countries: A
cross country analysis. IFPRI FCND Discussion Paper No. 60, IFPRI, Washington, D.C.
USA.

Smith, L.C. and Haddad, L. (2019). Explaining Child Malnutrition in Developing Countries: A
Cross-Country Analysis. IFPRI FCND Discussion Paper No. 60, IFPRI, Washington,
D.C. USA.

Stratton, R., Green, C. J. and Elia, M. (2013) Disease related malnutrition: an evidence-based
approach to treatment. Oxon: Cabi Publishing, 2003.

Sufiyan, M. B., Bashir, S. S. and Umar, A. A., (2012). Effect of maternal literacy on nutritional
status of children under 5 years of age in the Babban Dodo community of Zaria city,
Northwest Nigeria. Annals of Nigerian Medicine. 6(2):61-64.
 65

UNICEF, (2019). The state of the world’s children. Special edition: Celebrating 20 years of the
convention on the rights of the child. New York, United Nations Children’s Fund 92.

UNICEF. Malnutrition. (2019). Available from:

https://data.unicef.org/topic/nutrition/malnutrition/. (Accessed May 18, 2019).

UNICEF/WHO/World Bank, (2012). Joint child malnutrition estimates level and trends.
Retrieved from www.who.int/nutgrowthdb/ estimate2012/enn/.

Victoria, C. G., Adair, L., Fall, C., Hallal, P. C., Martorell, R., Richter, L. and Sachdev, H. S.,
(2018). Maternal and child under nutrition: Consequences for adult health and human
capital. Lancet. 26; 371(9609): 340-57.

Wamani, H., Astrom, A. N., Peterson, S., Tumwine, J. K. and Tylleskar, T., (2017). Boys are
more stunted than girls in Sub-saharan Africa: A meta-analysis of 16 demographic and
health surveys. BMC Pediatrics. 7:17.

WHO, (2011). Global Database on Childhood Growth and Malnutrition. Retrieved from
www.who.int/nutgrowthdb.

WHO, (2013). Updates on the management of severe acute malnutrition in infants and children.
ISBN: 978921506328, 111pp.

World Health Organisation. (WHO) (2018): Nutrition

http://www.who.int/nutrition/challenges/en/. (Accessed 7 June 2018).

World health Organisation and United Nations Children Fund. (2019). WHO child growth
standards and the identification of severe acute malnutrition in infants and children.
Accessed August 26, 2021 from
http://www.who.int/nutrition/publication/severemalnutrition/9789241598163.

Yunusa, I., Gumel, A. H. and Adegbusi, K. A. S., (2012). School feeding program in Nigeria: A
vehicle for nourishment of pupils. The African symposium: An online Journal of the
African Educational Research Network, 12, (2); 12-70. Retrieved at http://www.ncsu.ed/
aern/TAS12.2/TAS12.2 Yunusa.pdf.