Nutritional Assessment of Ethiopian Beta-Israel Children: A Cross-Sectional Survey

Introduction

Malnutrition is a public health problem of significant importance in developing countries, and children are by far the most commonly affected group. Malnutrition affects children in many ways, predisposing them to different infectious diseases, psychosocial maldevelopment, and cognitive deficiencies. Moreover, it is a contributing factor for 60% of deaths in children in developing countries. In Ethiopia alone, approximately 350,000 children are estimated to die each year mainly from preventable and treatable infectious diseases complicated by malnutrition.^1–3

Malnutrition result from several reasons: unavailability of adequate quantity and quality of food sources, deficient intake, malabsorption, preexisting diseases, and associated infectious diseases. According to the study by the Ethiopian Ministry of Economic Development and Cooperation, 50% of the Ethiopian population are living below the food poverty line and cannot meet their daily minimum nutritional requirement. As such, children are particularly vulnerable to malnutrition because of low dietary intakes, inequitable distribution of food within the household, improper food storage and preparation, dietary taboos, and infectious diseases. According to the 2005 Ethiopia Demographic and Health Survey macronutrient deficiency is a major problem countrywide, and stunting, wasting, and underweight were seen in 46.5%, 10.5%, and 38.4%, respectively, in children under 5 years of age. ⁴

Various methods are used to determine nutritional status; they can be used either alone or more effectively in combination. The methods are based on a series of dietary, laboratory, anthropometric, and clinical measurements designed to characterize each step in the development of a nutritional deficiency state. Anthropometric assessment comprises measurements of the variation of the physical dimension and the gross composition of the body. It provides information on past nutritional history, which cannot be obtained with equal confidence using the other assessment methods. ⁵

The objective of this study was to assess the nutritional status and related situations of the children of the Beta-Israel community living in Gondar, Ethiopia. In particular, the role of breastfeeding in maintaining adequate growth was analyzed.

Survey Methods

Results

A total of 794 children from 1 month to 60 months of age were evaluated. This represented over 90% of the infants and children in the age range 1–60 months who were registered as members of the community. The mean age was 36.3 months with an SD of 15.9 months. Of the total, 409 (51.5%) were female children. Table 1 summarizes the age and sex composition. Seven percent of the study participants were being reared as single parented children. Average family income approximated at $30 US per month with a maximum of 120 $US per month. This average income was shared by average family size of 5.2 (SD of 2). Almost all the children (98.3%) belonged to Jewish families, whereas 1.3% and 0.3% belonged to Christian and Muslim families, respectively.

The study children were also assessed for any prior illnesses, history of medication, and vitamin and mineral supplementations. Four hundred thirty-six children (55.1%) had some form of illness in the month prior to the study. The types of disease were categorized as diarrheal, respiratory, and skin diseases, which accounted for 33.3%, 33.1%, and 7.6% of the cases, respectively; the rest (25.9%) were due to miscellaneous causes of illness. Because of their nutritional significance, diarrheal cases were classified into acute diarrhea, persistent diarrhea, and chronic diarrhea, accounting for 83.6%, 12.9%, and 3.4% of the cases, respectively. Of the total number of children, 411 (51.8%) were found to have taken some form of medication in the month prior to data collection. Vitamin and iron supplements were given to 8.1% and 0.6% of the study children, respectively.

All the study children had been breastfed at least for some time. At the time of the study, 267 children (33.6%) were being breastfed. Seven hundred forty-three children (93.6%) had been exclusively breastfed at least for some time, whereas 51 (6.4%) had never been exclusively breastfed at any time. Of 707 children older than 6 months of age who were surveyed, 52 (7.4%) exclusively breastfed for less than 4 months, 41 children (5.8%) for 4–5 months, 331 (46.8%) for 6 months, and 283 were exclusively breastfed for more than 6 months (Table 2). Of the children over 2 years of age 82.9% had breastfed for over 2 years (Table 3). In addition to breastfeeding history, meal frequency was assessed; the majority (65.0%) had a meal frequency of three times a day, but 20% had a meal frequency of twice a day. Conjunctival pallor was seen in 1.9% of the children, and 1.1% had palmar pallor. Bitot's spot and corneal ulceration/scarring were not found in any of the children. Small goiters were seen in only two children. Minimal clinical signs of rickets were seen in 16 children (2%). None of the children was found to have peripheral edema.

Three indices of anthropometry were used to summarize the nutritional status of children: weight for age (underweight), height for age (stunting), and weight for height (wasting). According to the three indices, 14.6%, 37.2%, and 4.5% of the children were found to be underweight, stunted, and wasted, respectively. Severe underweight, severe stunting, and severe wasting were seen in 2.9%, 14.8%, and 0.5% of the 0–5-year-old children, respectively (Table 4). Based on mid-upper arm circumference (MUAC) measurements (done for children older than 6 months), only two children (0.3%) were found with an MUAC of <11.5 cm (0.7%), with MUAC between 11 and 12; the rest (99%) were found to have a MUAC of ≥12 cm.

Defining “malnutrition” as any derangement in the anthropometric indices, 329 children (41.4%) were found to be malnourished, and 125 of these children were severely malnourished (Table 5). The prevalence of malnutrition among male children (43.6%) was slightly higher than among female children (39.4%).

Multivariate analysis of factors possibly affecting the occurrence of malnutrition among the children was performed (considering household size, presence of illness, age, and sex as predictor variables). Household size (p = 0.037) and age of the child (p < 0.001) were found to have a statistically significant association to the occurrence of malnutrition. Sex of the child (p = 0.246) was not found to have any influence on nutritional status of children. Presence of illness in the month prior to data collection (p = 0.049) was also found to be significant. Bivariate analysis showed that there was a higher prevalence of malnutrition among those children who had had illness within 1 month prior to the data collection time (47% vs. 34.8%). No correlation was found between the duration of breastfeeding in infants over 1 year and the presence or severity of malnutrition.

Discussion

The target population of this study was preschool children, those at the age that were vulnerable for any nutrition-related problems, particularly protein and energy malnutrition and deficiency of micronutrients like iron, vitamin A, and iodine. As such, the nutritional assessment of this age group was of paramount importance for formulating nutritional interventions so as to minimize malnutrition ⁴ and its long-term consequences. ⁷

The average monthly family income in this study was estimated to be about $30 US. Hence, most of the children were living in families of poverty, if not outright extreme poverty.^4,8 It is known that the economic status of families is an important determinant for adequate food supplies, use of health service, and availability of improved water source and sanitation, which are in turn prime determinants of child nutritional status.^2,8–11

An elevated illness rate of 55.1% in the month prior to data collection primarily was noted. Illnesses have a significant role in causing secondary malnutrition as a result of reduced appetite and also increased loss of nutrients. Such illnesses normally result in acute forms of malnutrition among children, which usually is reflected by weight for height and MUAC indices. Most of the diarrheal cases in this study were acute, lasting less than 2 weeks, and hence result in only minimal loss of weight (see weight for height measurement). On the other hand, repeated bouts of illness can lead to a chronic state of malnutrition that manifests itself by stunting (lower height for age). ²

Breastfeeding was the single most important initial nutritional support for children. In this study, all the children had been breastfed at least for some time, and breastfeeding continued in 82.9% of the cases until after 2 years. Breastfeeding is nearly universal in Ethiopia with a median duration of 25.8 months. ⁴ UNICEF and the World Health Organization recommend children be exclusively breastfed during the first 6 months of life. Most of the children in this study had been exclusively breastfed for some time. Nearly 50% did so for 6 months, whereas the national figure indicates only one in three children 4–5 months of age is exclusively breastfed. ⁴ Despite these seemingly impressive observations, the fact that malnutrition rates increase after 6 months to a rate of 67% in 1–2 year olds supports the conclusion that there is inadequate availability of complementary food after 6 months to supplement the continued breastfeeding. Of interest are the results for the studies of Beta-Israel families who emigrated to Israel, wherein it was noted that these Ethiopian women still continued their pattern of a relatively long duration of breastfeeding their infants (i.e., for an average of 19.7 months). However, given the availability of adequate complementary feedings in Israel proper, which begin at 6 months, malnutrition is not a feature of this population.^12,13

Micronutrient deficiencies occur as a result of either inadequate intake of micronutrient-rich foods or inadequate utilization of micronutrients in diets owing to infections or other factors. ⁴ Several clinical signs are expected to be seen among children with micronutrient deficiencies. For this purpose, clinical evaluations for the presence of anemia and iodine, vitamin A, and vitamin D deficiencies were done. Palmar pallor and conjunctival pallor were seen only in a fraction of the children. These numbers are relatively low when compared with other studies in the country. Contrary to the existing prevalence of vitamin A deficiency and related blindness in the country, Bitot's spots and conjunctival ulceration/scarring were not seen in any of the children.^14,15 The national prevalence of Bitot's spot in 2005/06 was 0.7%. ¹⁶ A relatively higher prevalence of signs of vitamin D deficiency was seen. Only two children had small goiters, a very low number compared with results of other studies.^17–19 Another study done on schoolchildren in Southwest Ethiopia found a prevalence of 27.4%, which is much higher than the result of this study. ²⁰ Iron, iodine, vitamins A, and vitamin D deficiencies are fairly common in the country, whereas the present study noted a relatively better situation. This suggests that micronutrient deficiencies may not be a serious problem in this community, but, clearly, blood laboratory tests are needed to confirm this conclusion. We also speculate that given the fact that breastmilk is a good source of iodine, the pattern of nearly universal breastfeeding for the first 2 years of life is protective against iodine deficiency and clinical goiter. ²¹

The prevalence of malnutrition was assessed by using the indices underweight, stunting, and wasting. The prevalence of stunting in East Africa is the highest in the world. Evidence shows that the situation in Ethiopia is even worse, and the Amhara region has a stunting proportion more than the national average (56% for Amhara and 46.5% for the whole nation).^2,4 When compared with the above data, the proportion of stunting in the Beta-Israel pediatric population in Gondar was higher than the national average for other Ethiopian urban children: The national urban average is 29.8%, whereas in the Beta-Israel Gondar urban population it was 37.2%. Stunting normally reflects failure to receive adequate nutrition over a long period of time and is also affected by recurrent and chronic illnesses. The fact that the prevalence of stunting is much higher than that of underweight and wasting confirms that the major problem is chronic malnutrition despite a long duration of breastfeeding.

The prevalence of acute malnutrition (as assessed by the index wasting) was found to be very low (4.5%). An explanation of the calculated low prevalence of wasting in this population could be the higher occurrence of stunting among the children, which will “correct” for a lower weight for age index. MUAC is another very good indicator of acute malnutrition. MUAC measurement showed that 0.3% and 0.7% of the children had less than 11 cm and between 11 cm and 12 cm, respectively; the rest were above 12 cm. We speculate that the high rates of breastfeeding pattern may be protective against acute malnutrition by minimizing acute gastrointestinal infection. But, as noted, breastfeeding cannot protect against chronic calorie and protein malnutrition, which is reflected by the high stunting rates.

Malnutrition was analyzed in relation to different variables, and household size and age of children showed significant association. Younger children 12–36 months of age were found to be more malnourished than older children in line with a study done in Gumbrit, in an area close to Gondar. ²² In our study, as the household size increased a lower rate of malnourished children was noted, unlike reports of other studies.^23–26 We speculate that the older children can fend for themselves and do not have to rely on maternal feeding, be it breastfeeding or complementary foods. Gender was not related to occurrence of malnutrition. The Ethiopia Demographic and Health Survey figures also show that the occurrence of malnutrition is the same in both sexes. ⁴ In addition, significance association was seen between illness and occurrence of malnutrition, with those children having a history of illness in the month prior to data collection showing a slightly higher proportion of malnutrition.

As depicted in Table 5, younger children (7 months to 3 years old) were found to be more malnourished than the other age groups, and the highest prevalence was in those 12–23 months old. Severe malnutrition was specifically common in the age group 6–24 months. A similar result was found in research done in Northwest Ethiopia by Hailu and Tessema. ²⁷ This age group is for many reasons vulnerable for different forms of malnutrition because it is an important period of nutritional transition from exclusive breastfeeding to complementary feeding. In situations where there are inadequate nutrition sources, it is just this population that manifests malnutrition and, in turn, justifies special programs for nutritional support and supplementation.

What are the implications and consequences of the major finding of a high rate of stunting? Simply put, the long-term fate of children is being sealed in this critical period (6–36 months of age). One only has to paraphrase the conclusions of the authors on the monumental 2008 study on Maternal and Child Undernutrition to realize the seriousness of the long-term consequences of malnutrition, especially when it is manifested by stunting:

Chronic malnutrition was the commonest problem in our population as indicated by the higher prevalence of stunting among children. The breastfeeding rates of the children studied documented a population that met the conventional public health recommendations for breastfeeding per se. As such, our findings confirm that what is needed is a system for supplementing the infants and children with quality complementary food after 6 months of age and at least until age 36 months so as to minimize the long-term negative consequences of chronic undernutrition.