Nutritional Assessment of the Children of the Beta Israel Community in Ethiopia: A 2017 Update

Abstract

Background:

Malnutrition is a common phenomenon worldwide and a major public health problem, particularly in developing poorer countries like Ethiopia. Although malnutrition can affect any age group, children are at a higher risk and it is associated with an increased morbidity and mortality. The aim of this study was to update and assess the nutritional status of children of the Beta Israel community in the Gondar area of Ethiopia.

Methods:

This was a community-based cross-sectional anthropometrical study of all the children of the community age 0–60 months. A structured questionnaire was used to collect sociodemographic data, nutritional history, and clinical parameters. Nutritional indices weight for age, height for age, and weight for height were used to define the nutritional status of the children. The 2006 World Health Organization (WHO) growth curves served as reference parameters. Statistical analysis included binary logistical regression analysis.

Results:

A total of 489 children, representing over 90% of the community's children were studied with the mean age and standard deviation of 36.5 and 18 months, respectively. The overall prevalence of malnutrition was found to be 39.1% with wasting, underweight, and stunting occurring in 22.1%, 26.2%, and 18.4% of the children, respectively. Severe wasting, severe underweight, and severe stunting occurred in 8.4%, 8.2% and 5.3% of the children, respectively. Multivariate analysis showed that age was significantly associated with the occurrence of malnutrition with younger children being at a higher risk (p = 0.044). Gender of child, family income, maternal education, presence of illness in the month preceding data collection, and household size did not show any association with malnutrition prevalence.

Conclusion:

The prevalence of malnutrition as measured by stunting, underweight, and wasting has remained high among children younger than 5 years of the Beta Israel community in Gondar. Moreover, younger children were found to be more malnourished than older children.

Introduction

Malnutrition is a major public health problem in the developing countries and is associated with an increased morbidity and mortality in children. Although it is a worldwide problem, the situation is graver in the developing countries of East Africa.¹ As one of such countries, Ethiopia has reported a particular high prevalence of malnutrition and its consequences.^2–4

Malnutrition in Ethiopia results from a combination of inadequate food resources for a population already suffering from poverty and concomitant chronic health conditions. Studies have shown that every year, millions of Ethiopians starve due to weather changes and severe drought that leads to a chronic shortage of available food. Human strife and civil unrest have also been incriminated as major factors that have contributed to the longstanding high prevalence of malnutrition in this country. Unfortunately, despite a number of interventions and collaborations, the food security and nutritional situation in the country have remained unsatisfactory.⁵

According to the Ethiopia's Demographic and Health Survey 2016 (EDHS 2016),² 38% of children younger than 5 years are stunted (decreased height for age) and 18% are severely stunted. Maternal nutritional status, residential areas, child size at birth, and maternal educational status are found to have association with under-5 stunting. Ten percent of Ethiopian children are wasted and 3% are severely wasted. Based on weight-for-age assessment, 24% of children younger than 5 years are underweight and 7% are severely underweight.^2,6 Other individual studies have also shown that the magnitude of malnutrition is similar to the EDHS 2011 report.⁷

Amhara region of Ethiopia is one of the largest regions in the country, accounting for about a third of the population. Malnutrition in Amhara region, as measured by stunting, wasting, and underweight, is slightly higher than the national average.² In the region, the percentages of stunting, wasting, and underweight among children younger than 5 years are 46.3%, 9.8%, and 28.4%, respectively, and those of severe stunting, severe wasting, and severe underweight are 19.6%, 2.2%, and 8.3%, respectively.

Our study site, Gondar, is one of the major cities in the Amhara region of the country and comprises a significant proportion of the urban setting in the region. Previous studies of populations around the Gondar area and northern Ethiopia show malnutrition is a severe problem there, and that children are the most affected.^8–11

There is a large Beta Israel population in Gondar with an estimated 500 plus children aged 0–6 years belonging to this community. In view of the living condition in the area, the nutritional status of children is of concern. In addition, a previous supplemental nutritional support program that provided for these children and their families ended 6 years ago, thus the concern regarding the current nutritional status of the children in the community.

In addition, the study was designed to document the overall nutritional condition of the children to enable stakeholders to design appropriate interventions. By obtaining information on the nutritional status and associated clinical parameters, it was felt that these data could serve as a baseline data for evaluating future nutritional intervention programs.

Materials and Methods

Study site

The study area was Gondar, which is found in the Amhara Region of Ethiopia. The city of Gondar is located 750 km north of the capital Addis Ababa. It has a population of about 250,000. It is an urban setting with the largest Beta Israel community in the country.

Source and study population

The source population is the children of Beta Israel Jewish community in Gondar. The study population comprised all children of the community aged 0–60 months, who were available during the data collection period (March 2017).

Inclusion criteria

All children who belong to the Beta Israel Jewish community and were aged 0–60 months were included in the study.

Exclusion criteria

Those children who did not show up at the data collection site (which is the community's prayer facility in Gondar) were excluded from the study.

Sampling and sample size

Four hundred and eighty-nine children who fulfilled the inclusion criteria were included in the study. Parents and infants were recruited with the assistance of the Beta Israel community leaders who organized and supervised the recruitment.

Data collection

The following data were collected from the study children and their parents: sociodemographic characteristics, feeding of children (breastfeeding duration, exclusiveness of breastfeeding, weaning, and supplemental feeding), anthropometric measurements (weight, height, and mid-upper-arm circumference). Clinical evaluation for skin diseases, signs of anemia, and signs of vitamin D and iodine deficiencies was performed by supervised local Ethiopian physicians.

A total of eight medical doctors, including the investigators, participated in the data collection. The data collectors received a 1-day orientation on how to interview the parents and on how to do clinical evaluation of the study children. The data collection took a total of 4 days. Questionnaires were used to document interview data, clinical evaluation, and anthropometric data. Two weight scales were used for weight measurement. A standing and lying height and length measuring boards were used.

Data analysis

Descriptive data presentations (tables, measures of central tendency, and dispersion) were used to show the sociodemographic and feeding characteristics of children. The prevalence of malnutrition (wasting, stunting, and underweight) was determined using percentages. Binary logistic regression analysis was done to see the association between selected variables and malnutrition. An alpha value of 0.05 was used as a cutoff value for significance.

Nutritional indices (height-for-age, weight-for-height, and weight-for-age) were interpreted using growth standards published by the World Health Organization (WHO) in 2006. The indices were first expressed as standard deviation (SD) units from the median for the reference group and then, a cutoff level of −2 SD was used to define abnormal index, and −3 SD for severity. For instance, a height-for-age index below −2 SD was defined as stunting and that below −3 SD was defined as severe stunting. The indices are defined as follows:

• Stunting: Height for age below −2 SD of the median

Severe stunting below −3 SD (chronic undernutrition)

• Wasting: Weight for height below −2 SD from the median

Severe wasting below −3 SD (acute undernutrition)

• Underweight: Weight for age below −2 SD from the median

Severely underweight below −3 SD (chronic undernutrition)

• Malnourished: If any indices (weight for height, weight for age, and height for age) were abnormal (−2 SD)

Ethical considerations

Ethical approval was obtained from the University of Gondar Institutional Review Board. Permission was also obtained from the Beta Israel community representatives. During the conduct of the study, parents of children with clinical problems were given advice on nutrition and proper clinical care.

Results

Sociodemographic and economic situations

A total of 489 children, 60 months or younger, were included in the study. The mean age was 36.5 months (SD of 18 months). The majority (70.9%) of children were above 2 years of age, and 76 children (15.6%) were infants. Of the total, 263 (53.8%) were male children. Eight children (1.6%) were being reared as single parented children at the time of data collection.

The mean monthly family income was about 60 USD (1 USD = 23 Birr) with an SD of 37 USD, the maximum income being 348 USD. The children lived in an average family size of 5.1 people with an SD of 1.8 people. Maternal education was also assessed, and 307 mothers (62.8%) were found to be illiterate (never went to school and could not read or write) (Table 1).

Table 1.

Demographic Status of the Beta Israel Children in Gondar, the Year 2017

	Frequency (n = 489), n (%)
Age group (in months)
0–6	37 (7.6)
7–12	39 (8.0)
13–24	66 (13.5)
25–36	87 (17.8)
37–48	99 (20.2)
49–60	161 (32.9)
Sex
Male	263 (53.8)
Female	226 (46.2)
Family income (in USD)
0–43.5	246 (50.3)
43.6–87.0	197 (40.3)
Above 87.0	46 (9.4)
Maternal education
Illiterate	307 (62.8)
Elementary school	74 (15.1)
Junior high school	43 (8.8)
High school	56 (11.5)
College and above	9 (1.8)

Health status of children

Guardians of children were asked about whether children had any form of illness in the month preceding the data collection. Those who reported illness were asked about the type of illness the children had. Out of the total, 232 children (47.4%) were reported to have had some form of illness in the month preceding the data collection time. Respiratory and diarrheal diseases were the most common illnesses reported, accounting for 40.9% and 24.8%% of the cases, respectively. Acute diarrhea and persistent diarrhea accounted for 83.3% and 16.7% of the diarrhea cases, respectively.

Breastfeeding and nutritional history

Almost all children (99.8%) were found to have been breastfed at least for some time. In addition, at the time of data collection, 178 children (37.3%) were still breastfeeding. The overall duration of breastfeeding of the children who were older than 2 years at the time of the study was assessed and 84.4% of them were reported to have been breastfed for 2 years or more (Tables 2 and 3). The mean age for starting complementary feeding was 7.2 months (SD of 3.2 months). Out of those who were older than 6 months and had started complementary feeding (449 children), 326 (72.6%) started it at the age of 6 months, whereas 21 (4.7%) and 102 (22.7%) started it before the age of 6 months and past the age of 6 months, respectively (Table 3).

Table 2.

Total Duration of Breastfeeding of the Beta Israel Children in Gondar Aged 2 Years or Older, the Year 2017

Duration of breastfeeding	Frequency	Percentage	Cumulative percentage
1–6 Months	5	1.4	1.4
7–11 Months	2	0.6	2.0
12–23 Months	49	13.6	15.6
24 Months or more	305	84.4	100.0
Total	361	100

Table 3.

Duration of Exclusive Breastfeeding of the Beta Israel Children in Gondar Older than 6 Months, the Year 2017

Duration of exclusive breastfeeding	No. of infants, n (%)
Less than 6 months	21 (4.7)
6 Months	326 (72.6)
More than 6 months	102 (22.7)
Total	449 (100.0)

The most frequent types of food given as complementary food were gruel, injera with wot, cow milk, porridge, bread and eggs, and pasta. Children were also assessed for the type of food they routinely eat, and the commonest type was found to be injera with wot made of different cereals. Other foods were pasta, bread and tea, pasta, macaroni, and rice. Meat, fowl, and fish were not part of diet.

Clinical evaluation of children

The other component of this study was the clinical evaluation of children for dermatologic illnesses, signs of anemia, and signs of vitamin A deficiency, goiter, and rickets. The commonly encountered problems were skin changes (14.9%) and signs of rickets (8.4%) (see Table 4 for details). The skin problems were hyperpigmented/hypopigmented skin, peeling skin, ulcers, and scabies in decreasing frequency. The signs of rickets were caput quadratum, frontal bossing, and wrist widening in decreasing frequency.

Table 4.

Clinical Evaluation of the Beta Israel Children in Gondar, the Year 2017

Clinical problem identified	Frequency, n (%)
Skin changes	73 (14.9)
Signs of rickets	41 (8.4)
Conjunctival pallor	11 (2.2)
Bitot’s spot	4 (0.8)
Goiter	2 (0.4)

Nutritional indices and factors associated with malnutrition

The overall prevalence of malnutrition was found to be 39.1% (191 out of the total 489). Wasting, underweight, and stunting were found in 108 (22.1%), 128 (26.2%), and 90 (18.4%) children, respectively (see Tables 5 and 6 for the details).

Table 5.

Anthropometric Measurements of 0- to 5-Year-Old Beta Israel Children in Gondar, 2017

Anthropometric index, SD from the median of WHO curves	No. of children, n (%)
Weight for height (wasting)
Below −3 SD	41 (8.4)
Between −3 and −2 SD	67 (13.7)
Normal	372 (76.1)
Between +2 and +3 SD	5 (1.0)
Above +3 SD	4 (0.8)
Total	489 (100)
Weight for age (underweight)
Below −3 SD	40 (8.2)
Between −3 and −2 SD	88 (18.0)
Normal	359 (73.4)
Between +2 and +3 SD	2 (0.4)
Above +3 SD	0 (0)
Total	489 (100)
Height for age (stunting)
Below −3 SD	26 (5.3)
Between −3 and −2 SD	64 (13.1)
Normal	393 (80.4)
Between +2 and +3 SD	3 (0.6)
Above +3 SD	3 (0.6)
Total	489 (100)

SD, standard deviation; WHO, World Health Organization.

Table 6.

Overall Prevalence and Degree of Malnutrition in Different Age Groups of Beta Israel Children, 2017

Age group (in months)	Severely malnourished (%)	Moderately malnourished (%)	Well nourished (%)	Total (%)
0–6	10 (27.0)	12 (32.4)	15 (40.5)	37 (7.6)
7–12	7 (17.9)	8 (20.5)	24 (61.5)	39 (8.0)
13–24	10 (15.2)	14 (21.2)	42 (63.6)	66 (13.5)
25–36	17 (19.5)	23 (26.4)	47 (54.0)	87 (17.8)
37–48	8 (8.1)	27 (27.3)	64 (64.6)	99 (20.2)
49–60	18 (11.2)	37 (23.0)	106 (65.8)	161 (32.9)
Total	70 (14.3)	121 (24.7)	298 (60.9)	489 (100.0)

Binary logistic regression was done to see the effect of selected independent variables on malnutrition. The independent variables initially considered for regression analysis were age, sex, family income, maternal education, presence of illness in the month preceding data collection, and household size. However, sex, family income, and maternal education failed the bivariate regression analysis and hence were not entered into the final binary logistic regression analysis.

The final binary logistic regression model had a model chi-square value of 10.584 with a level of significance of 0.032 at a degree of freedom of 4. The model also had a −2log likelihood of 643.71 with a Negelkerke R² value of 0.029. In the analysis, it was seen that presence of illness in the month preceding data collection and household size did not have any effect on the occurrence of malnutrition, whereas age was significantly related to it. Younger children were found to be more at risk for malnutrition than older children (see Table 7 for the details).

Table 7.

Results of Binary Logistic Regression Done to See the Effect of Different Factors on the Occurrence of Malnutrition in the Beta Israel Children, the Year 2017

	Malnutrition
Variable	Yes	No	Crude odds ratio (95% CI)	Adjusted odds ratio (95% CI)	p
Age	191	298	0.989 (0.979–0.999)	0.990 (0.979–1.000)	0.044^a
Presence of illness
Yes	99	133	1.335 (0.927–1.922)	1.346 (0.931–1.945)	0.114
No	92	165	1	1
Household size
1–3 People	41	63	1.281 (0.778–2.107)	1.176 (0.709–1.949)	0.530
4–5 People	88	113	1.532 (1.013–2.317)	1.477 (0.973–2.243)	0.067
6 or More people	62	122	1	1

Borderline significance.

Discussion

This study was done in a community with an average monthly income of just 60 USD, an average family size of 5.1, and close to two-third of the children belonging to a family where the mother was uneducated. The community is therefore characterized by poverty, a relatively high average family size for the average economic status, and uneducated parents. Thus, it was not surprising that child health in general and nutritional status of children in particular were serious public health concerns, given that poverty, family size, and parental education have been documented as predictors of malnutrition.^12–14

Current or previous history of illness is one of the common reasons for malnutrition in young children. Illness in the weeks preceding nutritional assessment could result in the derangement of the nutritional index for acute malnutrition (weight for height), whereas repeated attacks or chronic illness could contribute for the derangement of the index for chronic malnutrition and stunting (height for age).^10,15 In this study, almost half of the children had some sort of illness in the month preceding data collection, with respiratory and diarrheal diseases accounting for two-fifth and one-fourth of the cases, respectively. When compared to a previous study done by the same authors on the same population,¹¹ there were slightly more cases of illness in the previous study (55.1%), with diarrheal and respiratory diseases each contributing for one-third of the cases. In this study, the overall malnutrition rate was not significantly affected by the presence of illness (see Table 7 in the Results section).

Breastfeeding is the critical basis for adequate nutrition of young children. Evidence shows that breastfeeding is closely related to nutritional status of children in the first few years, particularly the first 6 months.^16,17 Hence, breastfeeding history was assessed in this study with focus on duration of exclusive breastfeeding, duration of breastfeeding, and the nature of complementary feeding. Like the previous study by the same authors,¹¹ all children in this study were breastfed at least for some time, similar to other reports in the country.^2,18 A majority (84.4%) of the children in this study who were already aged 2 years or older had been breastfed for a total duration of at least 2 years. The rate of 6-month exclusive breastfeeding was found to be high in this study (72.6% of children older than 6 months) when compared to the previous study by the same authors (46.8%). The percentages of shorter and longer exclusive breastfeeding were also lower in this study (4.7% versus 13.2% and 22.7% versus 40.0%, respectively).¹¹

Nutritional assessment of children would be incomplete without the assessment for micronutrient deficiencies. Cognizant with this, this study tried to check for the signs of common micronutrient deficiencies. Although generally the figures are lower than those reported in other studies,^19–21 there is some concern in this study when comparisons are made with the previous study on the same population.¹¹ The prevalence of minimal signs of rickets increased from 2% in the previous study to 8.4% in this study. Based on the clinical assessment, vitamin A, iron, and iodine deficiencies do not seem to pose a major problem. However, blood tests are needed to document better figures for the prevalence of micronutrient deficiencies.

This study saw an overall prevalence of malnutrition of 39.1%, more than a third of which were severely malnourished. These results are similar to the overall prevalence of malnutrition and severe malnutrition in the previous study (41.4% and 15.7%, respectively).¹¹ Although these overall figures are similar, there are considerable differences in the occurrence of stunting, underweight, and wasting. The magnitude of stunting was reduced (from 37.1% in the previous study to 18.4% in this study). This 50% decrease might be explained by a number of reasons. One reason could possibly be the discrepancy in the economic status of the study population at the two different times, as seen by the difference in the average monthly salaries (30 USD versus 60 USD). However, one has to be careful in this conclusion as there is likely a difference in the price of food and commodities between the two times and hence, the mere difference in the average monthly salaries may not tell the whole story. Another possible reason could be the differential occurrence in recurrent and chronic illnesses during the two times. Recurrent and chronic illnesses play a major role in causing chronic malnutrition in children. The recent achievement in reducing morbidity and mortality in children younger than 5 years in all of Ethiopia might have placed the children in this study at a better position than those in the previous study. On the other hand, even though the relative occurrence of stunting in this study was low, a prevalence of 18.4% is still a huge public health problem, considering the impact of stunting on cognitive development, educational achievement, and ultimate productivity.

In this study, underweight and wasting occurred in 26.2% and 22.1% of the children. These figures are higher than the ones reported in the previous study (14.6% and 4.5%, respectively). The very low rate of wasting in the previous study was partly explained by the higher rate of stunting then.¹¹ In addition, the higher figures of underweight and wasting in this study indicate there are additional reasons of low weight. Acute malnutrition as a result of concurrent illnesses (as seen by a high prevalence of illness in the month preceding data collection) is an important consideration.¹⁰

When compared to the EDHS 2016, the prevalence of stunting was lower than both the national average (overall 38%; rural 40%; and urban 25%) and the regional average (46% in Amhara region). The prevalence of wasting is much more than the national average (10%), whereas that of underweight is similar to the national average (24%).² In comparison with individual studies done in the Southern Nations Nationalities and Peoples Region,¹² central Ethiopia,²² Tigray region,⁹ and Dabat District,¹⁰ the prevalence of stunting and underweight in our study was lower.

According to a meta-analysis of data from 2006 to 2016, the prevalence of malnutrition is highest within countries in East Africa and West Africa. The meta-analysis documented that Ethiopia had wasting (8.7%) and underweight (25.2%) figures among the highest in East Africa. The higher level of wasting in our study (22.1%) indicated the situation of acute malnutrition was even worse in the Beta Israel community children. However, the figure for stunting was lower than the figures reported in the meta-analysis: 57.7% in Burundi, 47.1% in Malawi, 43.9% in Niger, 38.3% in Mali, 37.9% in Sierra Leone, 36.8% in Nigeria, 42.7% in Democratic Republic of Congo, and 39.9% in Chad.⁴

In this study, younger children were found to have a higher overall prevalence of malnutrition, especially children in the age group of 0–6 months (Table 6). This was also seen in the multivariate analysis of the impact of different variables on malnutrition. Although with borderline significance, nutritional status seemed to improve as the age of children increased. These data raise the question why there was such a degree of malnutrition given the prevalence of 90% of 6 months of exclusive breastfeeding when breast milk alone is theoretically nutritionally adequate for this period. A possible explanation for the higher occurrence of malnutrition in the age group of 0–6 months may be related to a lower than the recommended frequency of breastfeeding and the resultant low amount of breast milk consumed by children. Unfortunately, the study did not obtain data as to the frequency of the feedings; so this remains a speculative explanation. An alternative possibility is that the lower weights in this period reflected poorer in utero weight gain. However, given the absence of any birth data as to weight and gestational age, this too remains a speculative suggestion. Regarding the relatively high occurrence of malnutrition in the age groups 25–36 months, inappropriate or inadequate complementary feeding may well have been the cause.

Regression analysis showed that variables like sex, family income, maternal education, presence of illness, and family size did not show statistically significant associations with the occurrence of overall malnutrition. These results are similar to the previous study,¹¹ except family size and presence of illness, which were found in the previous report to affect the overall nutritional status. The absence of association with family income, maternal education, and family size is in contrast with results of a study in Southern Ethiopia,¹² central Ethiopia,²¹ and another in South Africa.²³

Conclusion

Although the prevalence of chronic malnutrition was lower than the 2011 report, it still remains disturbingly high: 39.1%. The rates of underweight (26%), wasting (22.1%), and stunting (18.4%) also remained disturbingly high, reflecting the continued dire nutritional status of this population. Considering the long-term impact of chronic malnutrition on the development of individual children and the subsequent burden on society, nutritional interventions focusing on support of maintaining breastfeeding and providing supplementation with complementary foods of high nutritional value are of paramount importance.

Footnotes

Disclosure Statement

No competing financial interests exist.

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