Multiple anthropometric and nutritional deficiencies in young children in Ethiopia: a multi-level analysis based on a nationally representative data

Worldwide undernutrition restricts fetal growth causing stunting and wasting; furthermore, micronutrient deficiencies are responsible for the annual death of 3.1 million children under five years of age (under-5) [1]. It is estimated that 45% of deaths among children under-5 are linked to undernutrition (WHO,2018). Stunting is a chronic form of malnutrition, a result of long-term nutritional deprivation. It is defined as height-for-age < -2 standard deviation (SD) of the World Health Organization’s growth standard median [2]. Wasting represents thinness, i.e., weight-for-height < -2 SD, and underweight reflects low body mass relative to chronological age, i.e., weight-for-age <-2 SD [2]. In Sub-Saharan Africa, the prevalence of underweight, stunting and wasting in children under-5 was 21%, 40% and 9%, respectively [3].

Previous studies around the world reported the heightened risk of mortality for children with multiple nutrition deficits [4‐6]. For instance, a child with wasting and stunting is 12 times more likely to die than a child without these anthropometric deficiencies [7]. Clustering of nutrition problems can occur national, regional and individual levels. This indicates that there is considerable overlap of risk factors/determinants [1, 4, 8]. Some previous studies confirmed that anemia and stunting share many common risk factors [4, 9, 10].

In Ethiopia, in 2012, the prevalence of stunting, underweight and wasting among under-5 children were reported as 44.4%, 28.7% and 9.7%, respectively [11]. As of 2016, 38% of children under-5 had stunting. Stunting in children was higher in rural areas (40%) than in urban areas (25%) [12]. About 58% of under-5 children in Ethiopia had anemia [12]. A recent assessment by the International Fund for Agricultural Development/IFAD confirmed that Ethiopia has huge structured inequalities (deep rooted) in undernutrition of children both within households and community levels [13].

The very few studies conducted on this subject in Ethiopia are limited to investigating the determinants of one of the three types of child malnutrition (i.e., stunting, wasting or underweight), and most of which were conducted using micro-level data [5, 14, 15]. Nevertheless, children are likely to be affected by double or even multiple forms of nutritional problems, which have not been investigated well [4, 6]. For instance, a child could be underweight and anemic at the same time, mostly driven by certain risk factors. This undoubtedly poses significant challenges to child survival [4, 5, 16]. A study by Shimeles and colleagues [4] was the only study on a nationally representative data reporting considerable co-occurrence of anemia and stunting (CAS) in Ethiopia [4]. This study, however, addressed only children 6–23 months of age and did not address undernutrition in its entirety.

The present study aims to examine the risk factors of co-occurrence of undernutrition and anemia among children of age 6–59 months in Ethiopia based on nationally representative data.

The present study primarily aimed at examining the factors associated with the degree of overlap between the main nutritional problems of under-5 children: the standard anthropometric measures of wasting, stunting and underweight, as well as anemia. The study also aimed at assessing the key risk factors associated with co-occurrence of stunting and anemia among children aged 6–59 months in Ethiopia based on nationally representative data. It is noted that the proportion of children who were stunted, underweight or wasted was 38%, 25% and 9%, respectively. About 58% of the sample children were anemic. The prevalence of children concurrently stunted and anemic was 24.8%.

The findings indicate that two-thirds of children had at least one nutritional problem while those having two or more accounted for one-third. The prevalence of CAS was close to one-quarter of children. Though studies on multiple anthropometric deficits are few, a cross-country study reported a considerable proportion of multiple anthropometric deficits [6]. The reported high proportion of multiple nutritional deficiencies is of a great public health concern as it has huge impacts on the likelihood of child health and survival. McDonald and colleagues indicated considerable excess mortality in children who had concurrent wasting and underweight [6].

The expected mean of multiple nutritional problems was determined by a range of individual, household, and behavioral factors. The three proximate variables (hygiene and sanitation score, feeding practice and child health service utilization score) were found to exert strong influence on the expected mean of multiple nutritional deficiencies. Similarly, the mixed effect logistic regression witnessed significant association between eight background variables and CAS. Among the three key childcare practices, only hygiene and sanitation score had significant influence on CAS. The type of risk factors of CAS identified in this study have some resemblance with the recent findings of Shimeles and colleagues which used the same data set. Sex of the child, diet diversity, household wealth, and parental educational level were significant determinants in both studies. However, their study was based on only children of 6–23 months and primarily focused on assessing the dietary and nondietary associated factors [4]. The following discusses those explanatory variables which are common to both Mixed effect Poisson and Logit models.

Our findings showed that female children are less prone to multiple anthropometric deficiencies and CAS compared to males. Consistent with this finding, studies around the world found that boys were significantly more likely to experience concurrent wasting than girls [27]. A study on concurrent wasting and stunting based on DHS data of Senegal [28] found that boys were at higher risk of experiencing concurrent wasting and stunting compared to girls (RR = 1.61), which changes rapidly with age. Contrary to this finding, a recent study in Sri Lanka reported that female children had significantly higher rates of underweight and stunting compared to male [29]. The lack of a gender differential in adverse growth-stunting in Bangladesh was attributed to the absence of intra-household gender bias in feeding and health care for children [30]. The inconsistent findings could arise from variations in the sample size, method of analysis and seasonality of the data collected. However, the finding warrants the importance of considering a child’s gender during case finding and management/intervention of multiple anthropometric deficits.

It is also noted that the likelihood of multiple nutritional deficit and CAS increases as the age of the child increases. This finding agreed with studies conducted in Ethiopia and in Central African Republic [31, 32] and other developing countries [33].These studies claimed that stunting is less common in early infancy as most children are being breastfed [31‐33]. The risk of impaired linear growth increases as breastfeeding is discontinued without adequate complementary feeding and with poor diet diversity [31, 34].

The effect of religion on early childcare and the nutritional status of children may be explained as noting that some religious practices and beliefs have an adverse influence on the consumption of some healthy foods, child feeding practices of mothers and dietary intake of children during early ages [29].

The expected mean of multiple nutritional problems and odds of CAS significantly decreased by a considerable amount as we compare children residing in households with poorest wealth quantiles to those in the richest quantiles. It is difficult, however, to compare these findings to other studies as wealth is measured differently. The few studies conducted in low-income countries across the different continents, based on asset-based wealth index, have inconsistent conclusions. For instance, a study in Thailand showed that underweight and stunting measured by Concentration Index (CI) were least equitably distributed among the lowest income groups [35]. Another study conducted in Brazil showed a decreasing trend of stunting inequality as well as an overall malnutrition rate with wealth [36]. Contrary to these findings, a study in Mexico reported that household poverty is not a necessary condition for children to experience anthropometric deficits [37]. A study in Ecuador found no evidence to indicate any relationship between economic inequality and the nutritional status of children [38].

Remarkable inequalities were found in the expected mean of multiple nutritional deficiencies and CAS based on parental education. Children born from parents with at least primary level of education had little chance of experiencing multiple nutritional deficiencies compared to those born from non-educated parents. The finding is consistent with earlier studies conducted in different parts of Ethiopia [39‐42]. Recent studies in other parts of the world reached similar conclusion [43, 44]. It is well known that a minimum education provides women with a general awareness of how to utilize available resources for improvement of their own nutritional status and that of their families. Education may also help mothers be informed about nutritional values of food and understandings of child physical and mental growth [29]. Education may enable women to make independent decisions, and to have greater access to household resources that are important to nutritional status [45]. The presence of maternal autonomy is one of the most common and plausible explanations about the positive impacts of education on nutritional status. A gender analysis study in eastern parts of Indonesia where women are known to suffer from marginalization, reported the presence of very high levels of chronic child undernutrition (58% stunting and ~ 33% underweight) [46]. Maternal marginalization and depreciation generally pass through a wide range of pathways to affect child health outcomes. Poor autonomy may affect gender roles and intra-household food distribution, both of which may have a subtle impact on the nutrition of both women and young children [47].

While maternal education appears to exert a stronger influence on multiple nutritional deficiencies and CAS, the present study also showed a small but detectable role for paternal education. This is not surprising as some studies around the world have reported that educated fathers are more involved with issues of diet/ nutrition and parenting behaviors, which contribute to the overall health and well-being of their young children [48, 49]. Additionally, educated fathers provide a higher household income, more freedom and supports, higher social status and stability, and more opportunities for their wives and children [50, 51].

Positive associations were found between water and sanitation conditions and multiple nutritional deficiencies. This result was not a surprise since more than half of the households in the current survey reported open defecation and very poor access to water. Open defecation is more pervasive in rural areas. Similar results were obtained in several studies conducted in developing countries. For instance, a study in India found that the prevalence of undernutrition among children in low standard households increases twice as much as for children living in high standard households [52]. Unsanitary conditions are aggravated by poor access to improved water sources and latrines. Studies conducted in Sri Lanka, Sudan and Philippines reported that improved water and better-quality sanitation facilities resulted in significant improvement in health conditions of children [29, 53, 54]. A national survey in India underscores that caregiver’s reported practice of washing their hands with soap after defecation was associated with a 14% reduced risk of stunting among children aged 0–23 month [55]. The implication of this finding is that nutrition interventions should contain a framework broader than nutrition-specific interventions, by adequately addressing the combined water, household sanitation and personal hygiene.

The mixed-effect regression further showed two additional childcare variables (breastfeeding and diet diversity score) having significant association with CAS. Mothers who never breastfed had a child with a higher likelihood of experiencing CAS. There is ample accumulated evidence showing the important role of breastfeeding in the prevention of different forms of childhood malnutrition and micronutrient deficiencies [56, 57] More specifically, exclusive breastfeeding up to six-month of age has profound biological effects and important consequences on health and nutritional outcomes of children [56, 57]. The immunological properties of breast milk contribute to ensuring adequate nutritional status, proper growth and develop morbidity prevention capacity in child body [58].Late introduction of complementary feeding and unacceptably low diet diversity score in Ethiopia (> 90%) might have exacerbated the high prevalence of CAS .

In relation to breastfeeding, it is noteworthy to mention the strong significant association between diet diversity and multiple nutritional deficiencies. The expected mean of multiple nutritional deficiency decreases by about 3% for every one-unit increase in diet diversity. Since the present study indicated unacceptably low diet diversity (i.e., only 5% of the children consumed > 4 food groups) and the overall intake of animal protein was low, most of them may have become at higher risk of micronutrient deficiencies that can lead to chronic malnutrition and stunting. The reported poor diet in most Ethiopian households is mainly due to very high level of household hunger due to poor access or poor utilization or both [59, 60]. Consistent with this finding, a recent study in Ghana reported that dietary diversity causes improvements in child health among those under-5 [61]. Studies in other African countries such as Burkina Faso [62] reached a similar conclusion. Since dietary diversity was measured over a one-day recall period, the result should be interpreted cautiously. However, the finding implies the need for more thorough studies on the sociocultural and physical barriers to food consumption/diet diversity.

This study provided evidence for unacceptably high prevalence of stunting, anemia and CAS with substantial socioeconomic disparities in Ethiopia. Given the fact that children with multiple anthropometric deficit and anemia are at a heightened risk of mortality, the risk factors identified in the present study will help prioritize child survival interventions. The study underscores the importance of improving parental education, household wealth, hygiene and sanitation conditions, promoting feeding practice and child health service utilization. Also, any nutrition sensitive and specific intervention should consider child’s characteristics such as his/her age, gender, and birth order. The finding further calls for aggressive actions in terms of prevention, coordinated case-finding, and treatment of children with multiple nutritional challenges.