Prevalence and predictors of under-nutrition among school children in a rural South-eastern Nigerian community: a cross sectional study

Under-nutrition is a serious public health problem among children with huge consequences on the affected individuals, their families and the nation. Deficiencies of micronutrients such as iron, zinc and vitamin A affect a third to half of the world population [1] especially women, infants, and children in resource – poor households in low and medium income countries like Nigeria. Anthropometric deficits and micronutrient deficiencies have been shown [2‐11] to be problems of public health significance among school children in different parts of Nigeria. A study conducted by Oninla, Owa, Onayade and Taiwo [2] on the nutritional status of children attending urban and rural public primary schools in Ife Central Local Government Area of Oyo State, Nigeria showed that children in both rural and urban areas were affected by anthropometric deficits with the rural school children being more disadvantaged. These nutrition problems are important constraints to effective child growth and development and compromise the school child’s ability to benefit maximally from his education. Poor nutrition and health among school children have been reported to contribute to the general inefficiency of education systems worldwide and improved nutrition and health lead to better performances, fewer repeated classes and reduced dropout rates [12]. School-aged children who suffered severe clinical under-nutrition in early childhood usually have poor cognition, school achievement, and motor skills, and have behaviour problems compared with matched controls [13].

Not much is being done to ensure good health and nutritional status of the school-aged child, particularly in the study area. This probably is a consequence of dearth of data on the factors associated with under-nutrition among school children. The school-aged child who is a survivor in an environment of high under-five morbidity and mortality is often not regarded as vulnerable and therefore not targeted for many nutrition and health programmes. Absence of functional school health programme further increases the vulnerability of these children to various nutrition and health problems that jeopardize their health and educational potentials.

Multiple factors may be responsible for the various forms of under-nutrition that affect Nigerian school children. Inadequate nutrient intake, infections (especially febrile and parasitic infections), and various socio-economic and environmental variables often lead to nutrition problems in children. Establishment of these factors is a major way of enhancing planning and implementation of interventions to curb the menace of these problems.

Although some studies on nutritional status of school children have been conducted in different parts of Nigeria, few have investigated the contributory factors of under-nutrition among school children and none to the best of our knowledge has been conducted in Enugu state. Enugu state is one of the states in which the Federal Government of Nigeria intended to commence school feeding. The data from this study would therefore inform policy makers on relevant factors to consider while planning school meal programme in the state and Nigeria as a whole. It was in this light that this study was undertaken to assess the prevalence of underweight, stunting, thinness, vitamin A and zinc deficiencies among rural school children aged 6–15 years in a South-eastern Nigerian community - Ede-Oballa and determine the factors associated with them.

Underweight, stunting, thinness, zinc and vitamin A deficiencies were prevalent among the school children. The prevalence of stunting, underweight and thinness reported in this study was higher than the values reported by Nwamara et al. [6] but lower than the report of Atawodi et al. [3]. Vitamin A deficiency prevalence in this study was higher than the findings of Atimati et al. [10] and Egbi [17]. Both reported vitamin A deficiency prevalence of 29.6% and 35.6%, respectively. Abah et al. [8] reported a much higher prevalence (99.2%) of zinc deficiency than observed in this study. The consequences of these nutrition problems are often staggering with high morbidity due to lowered immunity and compromised physiology and may be associated with mortality among affected school children. The high morbidity may result to high absenteeism from school as Mahawithanage et al. [18] affirmed that better serum vitamin A status is associated with improved school attendance. We observed that these nutrition problems were associated with multiple factors.

According to this study, the prevalence of underweight, stunting and thinness, vitamin A and zinc deficiencies was lower among children whose household heads were females. This was significant (P < 0.05) for underweight and zinc deficiency only. This finding was not a surprise. Culturally, women are better care takers of children than men. Some have been observed to go hungry to ensure that food was enough for their children especially in households that are food insecure. Ene-Obong et al. [19] affirmed that most women gave their children and husbands preference in food distribution. Johnson and Rogers [20] noted that children from female headed households are at least well nourished compared to those living in male headed households of the same income class. This emphasizes the need to empower women to ensure higher socioeconomic power and therefore better nutritional status of their children. In support of this, Donkoh et al. [21] showed that more female headed households spent greater percentage of their incomes on food than male headed households. Culturally, females become household heads due to physical absence of their spouses as a result of migration, divorce/separation, abandonment and death.

Weekly food expenditure was shown in this study to be an important predictor of underweight, stunting and thinness. Ochieng’ [22] and Torlesse et al. [23] reported similar findings. This result was expected because when income is low, the amount of money spent on food will invariably be low implying higher food insecurity in low income households especially when most foods are not in season. Household income has been identified by other authors [24, 25] as a factor causing nutrition problems in children. Most often when income is limited, food and food related expenditures in households are the most compromised. Higher food expenditure may imply increased access to food, higher diversity scores and lower prevalence of under-nutrition because improvement in both quality and quantity of food consumed is guaranteed.

Sex was found to be an independent determinant of stunting among the study group. The higher prevalence among males is in agreement with observations by other researchers [26‐28]. Kabubo-Mariara et al. [28] reported that boys are more likely than girls to suffer from chronic and acute under-nutrition. Mwaniki and Makokha [29] reported that boys aged 4–7 and 8–11 years had a higher risk of being stunted as compared to girls of the same age. This may be a result of inadequate nutrient intake and higher physical activity levels. Lenhart et al. [30] reported that girls were less likely to be active than boys: 27.9% of girls were sedentary as compared to 10.6% of boys. Besides, males have higher basal metabolic rates. These may lead to higher energy expenditure among them and in the face of inadequate intake may lead to higher prevalence of under-nutrition especially stunting, an index of chronic nutrition deprivation.

In this study, we found that tapeworm and whipworm infections were significantly associated with vitamin A and zinc deficiencies. These are endoparasites which depend on their hosts for foods thus depriving the host of essential nutrients. Quihui-Cota et al. [31] reported higher z-scores for weight-for-height, weight-for-age, and height-for-age among school children uninfected with intestinal helminths and showed that higher prevalence of intestinal infections in children was associated with lower height-for-age and weight-for-age z-scores. Negative relationship between helminths and nutrition status of children has also been reported by other authors [32‐34].

Zinc concentration was also reported to be lower in children with soil transmitted helminths [35]. We opined that both tapeworm and whipworm may have had heavier intestinal load than other intestinal parasites. It probably could also be that these two helminths had longer infective periods than other parasites. Wolde et al. [12] showed a significant relationship between trichuris and stunting; but not with underweight and wasting and asserted that this was a result of chronic nature of trichuris infection. We found no significant association with underweight, stunting and thinness.

Though not significant, we observed that the prevalence of underweight, stunting and thinness was higher among children who had inadequate energy intake. Mwaniki and Makokha [29] reported similar findings. They reported that children who had adequate energy intake were less likely to be underweight than those who had inadequate energy intake. We observed that nutrient intakes were based mainly on plant foods which have low bioavailability. This may be responsible for the lack of significant association between nutrient intake and nutrition status despite intake that exceeded 100% of the recommended intakes. Though zinc intake was adequate for all the children, we observed zinc deficiency of severe public health importance implying that intake was not reflected on serum zinc status of the children. This calls for bioavailability assessment of our commonly consumed foods.

The study was conducted in a rural community. Though large with ten schools, it is not a true representation of the entire rural areas in Nigeria. However, it has affirmed that nutrition problems among rural school children are public health problems that require a focused multisectoral school- and community-based approaches for their control.

Among school children in Ede-Oballa, underweight, stunting, thinness, vitamin A and zinc deficiencies were nutrition problems of public health significance. Weekly food expenditure was an independent predictor of underweight, stunting and thinness. Gender of household head was also a predictor of underweight. Sex was an independent predictor of stunting and household income was significantly associated with thinness. Gender of household head, whipworm and tapeworm were major factors contributing to zinc deficiency. Tapeworm and whipworm were also important determinants of vitamin A deficiency. Empowerment of females through free education for the girl-child, and loans to adult females is necessary to ensure sustained better nutritional status of children. A functional school health and feeding programme is vital to improve nutrient intake and enhance deworming and vitamin A supplementation among school children to boost their immunity and ensure better nutritional and health status.