Trying to Understand Undernutrition in Mozambique
By Elizabeth Rose
This article is a summary of an article previously published by the author in BMC Nutrition and the full article can be accessed here: https://www.ncbi.nlm.nih.gov/pubmed/27182448
Recent increases in globalization, urbanization, and the availability of processed foods high in sugars, sodium, and fat have contributed to a shift in focus from undernutrition to overnutrition in developing countries. Despite this shift, undernutrition continues to be a major problem, particularly in rural Africa. Among low- and middle-income countries (LMICs), the prevalence of chronic malnutrition, or stunting (height-for-age z-score less than -2), was 28% in 2011. When disaggregated by region, the prevalence of stunting in sub-Saharan African countries rose to 40% and in Mozambique, a country on the southeastern coast of Africa, the prevalence was even higher at 44%.
As the period for reaching the Millennium Development Goals (MDGs) drew to a close in 2015, assessing the reasons behind why goals were or were not reached will help guide future human development efforts in LMICs. Insufficient nutrition is a cross-cutting condition that both directly and indirectly impeded progress towards three MDGs: One (eradicating extreme poverty and hunger), Two (achieving universal education), and Four (reducing child mortality). In 2012, 25% of children under five years old (or 162 million children) suffered from stunting worldwide, with an additional 15% of children (112 million) classified as underweight (weight-for-age z-score less than -2).
Maternal prenatal nutrition and poor intake of micronutrients, such as vitamin A, by the infant in the “first 1000 days” (i.e. conception to age two years) can cause irreversible developmental damage and impediments in physical and cognitive growth that last into adulthood. Thus, proper nutrition in early childhood is important and poor nutrition at this age has been correlated with lower cognitive performance in school and decreased success in the labor market as an adult, which further perpetuates the cycle of poverty and undernutrition. Undernutrition, which includes stunting, underweight, and wasting (weight-for-height z-score less than -2), is the largest preventable cause of death among children under five years and is directly or indirectly attributed to 45% of child deaths (3.1 million). Ninety-eight percent of undernourished children live in developing countries, and while the prevalence of undernutrition has decreased across almost all world regions over the past two decades, rates have been increasing in Africa, mandating a better understanding of the determinants of undernutrition in this geographical setting.
Compounding the poor nutritional indices of Mozambique described above are the salient disparities in health care, outcomes, and budgeting allocations among the country’s provinces. The centrally-located Zambézia Province has the lowest per capita budget for health and education in Mozambique. It also has the lowest access to safe water (only 26% of people had access to safe water in 2009), the highest sanitation deprivation among children (73% of children did not have access to sanitation facilities in 2008), and the highest poverty headcount (71% of the population lived in poverty in 2008). Furthermore, this province also had some of the lowest performance indicators for health outcomes in the country, including the highest under 5 mortality rate (206 per 1000 live births, 10 year average 1998-2008) and among the highest child stunting rates (46%, 2008). Zambézia Province has been labeled as a development “priority province” and as such, numerous national and international programs have been undertaken, yet undernutrition rates have remained relatively stable. Aligning with the World Health Organization (WHO) recommendations that countries place the management of undernutrition as a public health priority, we sought to study the determinants of undernutrition among children under five years of age, over a four-year period, so as to inform future interventions and health practices that aim to reduce the prevalence of undernutrition in Zambézia Province.
In order to study the determinants of undernutrition in this population, we conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August–September 2010 (Baseline) and April–May 2014 (Endline) as part of the USAID-funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6–59 months at Baseline and 912 children at Endline and classified as: “stunted,” a height-for-age z-score less than -2; “wasted,” weight-for-height z-score less than -2; and “underweight,” weight-for-age z-score less than -2.
The results of this study included the following: Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child’s age was found to be associated with stunting and Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02).
The prevalence of stunting in our study was “very high prevalence” as per WHO classification and also in comparison to worldwide rates of stunting in other LMICs that range from 5% to 65%. Recorded rates of wasting and underweight, as defined by the WHO, were categorized as “poor” and “medium prevalence,” respectively. Stunting prevalence is of particular concern since it reflects long-term structural factors of undernutrition and can serve as an indicator of a population’s well-being.
In conclusion, almost half of studied children aged 6-59 months in Zambézia Province were undernourished, revealing the need for sustained efforts to ameliorate this high prevalence rate. Of particular concern is the high rate of stunting that increased from 2010 to 2014. Intensified efforts to increase rates of vitamin A supplementation should be implemented, as well as other disease prevention measures such as interventions aimed at sustaining high rates of vaccine uptake. Interventions related to breastfeeding and hand washing practices as well as decreasing the extraordinary level of food insecurity that is prevalent throughout Zambézia Province should be implemented to help to reduce the prevalence of wasting and underweight. Future studies are needed to better explore local customs related to inter-household dietary diversity patterns, specifically focused on children under five years old. This study provided evidence that a combination of factors were associated with undernutrition. As such, use of multidimensional interventions should be considered to decrease undernutrition in children under five years old.
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