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Empirical studies of factors associated with child malnutrition: highlighting the evidence about climate and conflict shocks

• Original Paper
• Open access
• Published: 21 May 2020
• Volume 12 , pages 1241–1252, ( 2020 )

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• Molly E. Brown   ORCID: orcid.org/0000-0001-7384-3314 1 ,
• David Backer 2 ,
• Trey Billing 2 ,
• Peter White 3 ,
• Kathryn Grace 4 ,
• Shannon Doocy 5 &
• Paul Huth 2  

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Children who experience poor nutrition during the first 1000 days of life are more vulnerable to illness and death in the near term, as well as to lower work capacity and productivity as adults. These problems motivate research to identify basic and underlying factors that influence risks of child malnutrition. Based on a structured search of existing literature, we identified 90 studies that used statistical analyses to assess relationships between potential factors and major indicators of child malnutrition: stunting, wasting, and underweight. Our review determined that wasting, a measure of acute malnutrition, is substantially understudied compared to the other indicators. We summarize the evidence about relationships between child malnutrition and numerous factors at the individual, household, region/community, and country levels. Our results identify only select relationships that are statistically significant, with consistent signs, across multiple studies. Among the consistent predictors of child malnutrition are shocks due to variations in climate conditions (as measured with indicators of temperature, rainfall, and vegetation) and violent conflict. Limited research has been conducted on the relationship between violent conflict and wasting. Improved understanding of the variables associated with child malnutrition will aid advances in predictive modeling of the risks and severity of malnutrition crises and enhance the effectiveness of responses by the development and humanitarian communities.

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1 Introduction

Malnutrition is preventable, yet remains a major public health challenge. This condition affects one in five children and contributes to nearly half of all deaths during childhood globally (Black et al. 2013 ). Children who have poor nutrition during their first 1000 days of life attain lower levels of education and have lower work capacity and productivity as adults. Malnourished children also face increased likelihoods of being overweight, of developing chronic illnesses such as cardiovascular disease, diabetes and cancer, and of suffering from mental health issues later in life (Haddad et al. 1994 ; Hoddinott et al. 2013 ). After having suffered of malnutrition during early childhood, girls face increased likelihoods of having children that are born too early or underweight (UNSCN 2010 ).

Given the serious repercussions for survival, health, and well-being, anticipating and addressing the circumstances under which children become malnourished is vital. Various development and humanitarian interventions focus on fostering healthy communities where children are better protected and able to recover from nutrient deficits (Collins et al. 2006 ). To facilitate those interventions, assessments of food security conducted by organizations such as the Famine Early Warning Systems Network (FEWS NET) and the Integrated Food Security Phase Classification (IPC) initiative have sought to project the future status of at-risk countries and issue alerts about impending and ongoing crises months in advance, aiming to ensure enough lead time for the coordination and implementation of appropriate responses (Brown et al. 2007 ; Funk et al. 2019 ; IPC 2012 ). Assessments that focus on early warning have advantages relative to relying on measuring the prevalence of malnutrition in a community, which can detect a crisis only after it emerges (Maxwell et al. 2020 ). Assessments such as FEWS NET and IPC, however, do not gauge, much less substantiate, associations between malnutrition at an individual level and relevant factors. Statistically modelling these empirical relationships is integral to detecting vulnerabilities, diagnosing their sources, and directing assistance.

In this article, we consolidate what has been learned from published studies that used statistical analysis of empirical data to examine relationships between malnutrition among children and a large array of individual-, household-, community-, regional- and national-level variables. Our literature review is guided by two main questions: (1) Which variables were consistently associated with child malnutrition? (2) What types of quantitative empirical data and statistical methods have been used to analyse the nature of the relationship between these variables and child malnutrition? Answering these questions results in a summary of drivers of malnutrition, clarifies the strengths and limitations of existing studies, and suggests potential directions for further research, which may include a formal meta-analysis.

Our review considers studies in which the outcomes of interest included at least one of three major indicators of malnutrition, formalized in international standards (WHO 2020 ). Wasting (low weight for height) indicates an acute decline in nutritional status experienced by a normally well-nourished child. This decline usually involves rapid and substantial weight loss. Stunting (low height for age), by contrast, indicates a chronic, long-term nutritional deficit, the effects of which are potentially irreversible (Kennedy et al. 2015 ). Children who suffer wasting regularly over time may also develop stunting (Hoddinott et al. 2008 ). Underweight (low weight for age), on the other hand, can reflect wasting, stunting, or both (WHO 2010 ).

The breadth of our review provides a more expansive picture of the findings from the empirical research about malnutrition, according to statistical modelling of quantitative data. In the process, we can compare the state of knowledge about factors associated with the different indicators of malnutrition. Our expectation is that the findings of the review will improve awareness of which factors yield consistent findings and emphasize how particular relationships can vary across different measures of malnutrition.

At the same time, we have a specific interest in the variables associated with wasting. The acute nature of this condition presents a distinct challenge in practice. Prompt, effective interventions, with the potential to mitigate the risk of wasting, depend on the existence of reliable guidance about factors that tend to be associated with changes in individuals’ nutritional status in the short term. Insights from such a review may help inform interventions that are focused on reversing weight loss trajectories in children before malnutrition becomes a persistent condition.

Finally, we spotlight the role of external shocks experienced by individuals, households and communities, especially those caused by exposures to environmental and societal forces. Disasters due to climate extremes (e.g., drought) and violent conflict (e.g., civil war) are regularly attributed as the primary causes – acting independently and in interaction – of crises such as famines resulting in prevalence spikes in the rate of acute malnutrition. The urgency of understanding the role of these shocks has been magnified as complex emergencies are becoming more common and lasting longer (Lautze and Raven-Roberts 2006 ; Young et al. 2004 ). Policies resulting in timely action are needed to reduce the impact of these crises on children, families, and the communities in which they live (Ghobarah et al. 2003 ; Hillbruner and Moloney 2012 ).

We start by presenting the methods we used to isolate and code relevant studies that were included in our review. Next, we summarize the results of our review. In the concluding section, we discuss the results in the context of the broader literature, with particular attention to studies about the relationship between malnutrition and climate extremes, conflict events, and their interactions.

We conducted a search of the American Economic Association’s EconLit database in January 2019. EconLit indexes six types of materials: journal articles, books, book chapters, dissertations, working papers, and book reviews. The coverage features nearly 1 million articles from over 1000 journals published in 74 countries, dating from 1969 to the present ( https://www.aeaweb.org/econlit/content ). Many of the topics covered by the material indexed in EconLit relate to child malnutrition, including Health and Economic Development (JEL code I15), Health and Inequality (JEL code I14), Health, Government Policy, and Regulation (JEL code I16), Welfare, Wellbeing and Poverty (JEL code I3), Fertility, Family Planning, Child Care, Children, and Youth (JEL code J13), Agricultural Economics (JEL code Q1), and Renewable Resources and Conservation (JEL code Q2) (see http://www.aeaweb.org/econlit/jelCodes.php for a complete list of topics covered by EconLit). We sought to identify articles indexed by EconLit that quantitatively assess potential factors, with explicit statistical tests, in relation to child malnutrition. We therefore conducted separate searches using “malnutrition,” “wasting,” “wasted,” “stunting,” “stunted,” “underweight,” and “undernourishment” as key words. In addition, we paired each of these key words with “child” when conducting searches. In total, the searches yielded a set of 688 articles.

Within this set, we then selected articles relevant to our review. We therefore searched for any mentions of “child wast*” (166 articles), “child stunt*” (104 articles), and “child under*” (39 articles) in the article titles and abstracts. Certain articles referenced multiple search terms. We thus selected 209 potentially relevant articles. Finally, we scanned the titles and abstracts of these remaining articles with the following criteria:

use of quantitative and/or numerically coded qualitative data within a statistical analysis.

dependent variable(s) in the analysis must be some variant(s) of child malnutrition.

testing of statistical relationship between child malnutrition and one or more independent variables.

Some of the reasons for excluding articles include:

article not published in an English-language academic journal (for reasons of feasibility in conducting the review).

title and/or abstract indicating that the study is unrelated to our review (e.g., food waste).

title and/or abstract indicating that the study is peripheral to our objective (e.g., global narratives regarding child health).

title and/or abstract not mentioning quantitative data analysis.

quantitative analysis referred to in abstract concerning adult malnutrition Articles evaluating adult nutrition (e.g., of the mother during pregnancy) as a factor for child malnutrition were retained.

quantitative analysis referred to in title and/or abstract concerning not concerning relationships between child nutrition prevalence and any of its factors.

quantitative analysis referred to in the title and/or abstract considering child malnutrition as an independent, and not a dependent variable.

Our approach using the inclusion and exclusion criteria yielded a sample of 61 articles from EconLit.

We further augmented the sample with 29 articles from beyond the EconLit database. These additional articles: (1) cited articles from the EconLit sample, (2) were cited by those articles, and/or (3) involved authors of those articles. All the additional articles satisfied the inclusion and exclusion criteria stated above. The final sample therefore consists of a total of 90 articles (see supplementary Table S 1 for details).

2.1 Coding of article variables

Information pertaining to each article was coded according to the following: the data used (location, timing, panel vs. cross-section, sample size); statistical methods of analysis; and the dependent and independent variables considered. Only the main statistical results in a given article were coded; other results (e.g., exploratory subgroup tests, robustness checks, and sensitivity analyses) were not included. Dependent variables were grouped into three categories: wasting (W, continuous weight-for-height z-score and/or binary indicator for wasted), stunting (S, continuous height-for-age z-score and/or binary indicator for stunted), and underweight (U, continuous weight-for-age z-score and/or binary indicator for underweight) (de Onis and Blössner 2003 ). Each combination of a dependent variable and an independent variable in a given article was coded with both the sign and the level of reported statistical significance of the relationship as evaluated in the analysis. Most of the reviewed studies focus on the sign of relationships; few studies pay close attention to the magnitude of effect sizes. P -values were not always reported in all articles, reflecting differences in standards across journals and fields. The coding categorized each relationship as significant if the p value was smaller than or equal to 0.05. These instances were marked as 1. All other instances were marked as 0. The coding also noted instances of p -values less than (or equal to) 0.01 and 0.001 (supplementary materials; (Finlay and Agresti 1986 )). Supplementary Table S 2 provides a list of all variables reported in all 90 reviewed articles, along with their reported statistical significance.

Across the sample of reviewed studies, more than 300 independent variables were found. Independent variables about the same factor, even if operationalized differently, were consolidated into a factor category to facilitate comparison across studies (Phalkey et al. 2015 ). Supplementary Table S 3 lists all variables analysed in the reviewed studies that comprise our factor categories, and which papers they came from.

The findings of the studies included in our review enabled each factor to be characterized as follows:

Risk factor – a majority of reviewed studies examining a given type of malnutrition report a significant ( p  ≤ 0.05) positive relationship with the independent variables (i.e., a greater extent or probability of malnutrition as a function of increasing values of the independent variable).

Mitigating factor – a majority of reviewed studies examining a given type of malnutrition report a significant (p ≤ 0.05) negative relationship with the independent variables (i.e., a lower extent or probability of malnutrition as a function of increasing values of the independent variable).

Inconclusive factor – a majority of studies examining a given type of malnutrition report either an inconsistent sign of the relationship with the independent factor, or a relationship that is not statistically significant ( p  > 0.05).

In order to facilitate comparison and the policy and other practical applications of the analysis, factors were grouped according to the scale they concern: child, household, region/community, or country (Smith et al. 2005 ).

Relationships between a given type of malnutrition and a given factor may have been evaluated in only one study. While all relationships appearing in the main statistical analysis of each study were coded and documented (Table S2 ), only factors evaluated in multiple studies were reported in the results. All studies were treated equally, regardless of scope, scale of the analysis, magnitude of effect sizes, and level of significance reported. The results of the analysis offer a general summary and mapping of results to capture patterns in the existing research. No statistical assessment of the importance of factors across publications (“effect size” in the meta-analysis literature) is provided in the interest of reflecting the broadest possible sample of studies.

Wasting and underweight have been studied less often than stunting (Table 1 ). Just over 34% of the reviewed studies modelled wasting. Slightly more studies operationalized this outcome with a binary variable (whether or not children were wasted, as a status based on exceeding a given threshold) than with a z-score (extent of deviation from international standards, along a continuous scale that captures a spectrum of outcomes in a process of becoming undernourished). Under 5% of the reviewed articles used both operationalizations of wasting in their analysis. Similarly, underweight appeared in 34% of the reviewed studies. In these studies, the operationalization was most often a z-score, rather than a binary variable. Meanwhile, 81% of the articles used stunting as a dependent variable; a z-score was most common for stunting as well.

3.1 Factors evaluated as affecting child nutrition

A total of 49 factors were evaluated in relation to wasting, stunting, and/or underweight by multiple studies (Fig.  1 ). This list includes 12 factors measured at the individual level; 25 factors measured at the household level (including five factors pertaining to mothers); eight factors measured at the region/community level; and four factors measured at the country level (Table S3 ). Analysis of disaggregated data at the individual and/or household level featured in 89% of the reviewed articles. Most analyses did not include any covariates measured at the regional/community or country levels (e.g., (Ekbrand and Halleröd 2018 )). Thus, fewer articles are available with which to evaluate the consistency of relationships of factors at the regional/community and country levels than at the individual and household levels. Of the 49 factors, 18 have been evaluated by multiple studies in relation to each of the three standard measures of child malnutrition (Fig. 1 ). The subsequent presentation of results is restricted to instances of prevailing evidence of statistically significant relationships indicating risk factors or mitigating factors, according to a majority of relevant reviewed studies.

Summary of results from statistical analyses of relationships between indicators of child malnutrition and: a child-specific factors, b household-level factors, c region/community-level factors, and d country-level factors. Note: We limit the results reflected in this figure to factors that are evaluated in the main statistical analyses reported in at least two of the 90 reviewed articles. Details of which study was included in each factor can be found in Supplementary Table S 3

Eight of the 12 factors measured at the level of individual children exhibited statistically significant relationships for the following factors: child’s sex and age, if they were a multiple at birth (twin, triplet, etc.), and diarrhea status (Fig. 1a ). Seven of the 10 factors evaluated in relation to stunting exhibited statistically significant associations. These associations identified five risk factors: child’s sex and age, their birth order, if they were a multiple at birth, and short birth interval. Two mitigating factors were also identified: if a professionally trained assistant was present at the birth and if Vitamin A supplements had been used. The results indicated that two of the four factors evaluated in relation to underweight were statistically significant risk factors: child’s age and if they were a multiple at birth. According to our review, therefore, all three anthropometric measures of malnutrition were associated with two individual-level risk factors: age and multiple at birth.

Of the 25 household-level factors, just four of the 17 factors exhibited statistically significant associations: mother’s education, mother’s BMI, wealth/assets, and access to a health care center (Fig. 1b ). All were evaluated as being mitigating factors. Eleven of the 25 factors evaluated in relation to stunting yielded statistically significant associations. The relationships identified three risk factors: rural, indigenous, and altitude. In addition, eight mitigating factors were identified: mother’s education, father’s education, mother’s BMI, mother’s height, pregnancy care, wealth/assets, quality of household materials, and food aid or supplemental feeding. Five of the 13 factors evaluated in relation to underweight yielded statistically significant associations. Only one relationship identified a risk factor: rural residence. Four mitigating factors were also identified: mother’s education, mother’s BMI, wealth/assets, and quality of toilet. According to our review, therefore, all three anthropometric measures were associated with three household-level risk factors: mother’s education (either years of education or specific levels relative to no education), mother’s BMI, and wealth/assets (encompassing different indices).

The eight factors measured at the region/community level is split between measuring features of the environment, including climate conditions, and features related to conflict (Fig. 1c ). Wasting had a statistically significant association with excessive rainfall as a risk factor and growing season rainfall as a mitigating factor. Stunting had a statistically significant association with extreme temperatures as a risk factor. Underweight only exhibited a statistically significant association with drought as a risk factor. Several of the reviewed studies analysed vegetation quality, employing either the normalized difference vegetation index (NDVI) or the enhanced vegetation index (EVI), with varying operationalizations. In particular, vegetation quality during the previous growing season has been evaluated in multiple studies of both wasting and stunting, yielding findings that vary by context. Statistically significant associations were observed between stunting and three factors that reflect distinctive operationalizations of the role of conflict. Conflict in the surrounding region, conflict exposure (days or months), and whether a child was born during a conflict were all identified as risk factors for stunting.

At the country level, national per capita GDP was identified as a mitigating factor for wasting, stunting, and underweight (Fig. 1d ). Female education (encompassing national rates of female literacy and female secondary enrolment) was identified as a mitigating factor for stunting and underweight. Both the national average female-to-male life expectancy ratio and the dietary energy supply per capita were identified as mitigating factors for underweight.

3.2 Statistical methods

About 60% of the reviewed studies employed standard variations of multivariate regression techniques, such as linear, generalized linear (e.g., logit), or multilevel models. Only 5% of studies used explicit multilevel statistical techniques, modelling simultaneously the relationships between malnutrition and covariates at the individual, household, and regional/community levels (e.g., (Ekbrand and Halleröd 2018 )). Other studies that did not estimate multilevel models instead included covariates aggregated to higher levels, introduced dummy variables for geographic regions, or adjusted for within-spatial-unit correlation via clustered standard errors (e.g., (Rashad and Sharaf 2018 )). Five articles used quantile regression, which fits a model through quantiles of the dependent variable, rather than the mean (e.g., (Asfaw 2018 )). This approach has the advantage of allowing for heterogeneous treatment effects for different segments of the distribution of child malnutrition. For example, a given factor may exhibit a stronger association with weight-for-height z-scores for children who are undernourished (i.e., the left tail of the distribution), relative the association observed for children whose nutrition status is near the center of the distribution.

A majority of reviewed studies relied on cross-sectional analysis of either data from single surveys or a pooled dataset comprising multiple cross-sectional surveys. Just five of the studies capitalized on panel data involving repeated waves of data collection for the same children or households over time. The remaining studies employed a diversity of approaches, including time-series analysis of repeated cross-sections of countries or subnational regions. Among the reviewed studies, the most common source of malnutrition measures was Demographic and Health Survey (DHS) data (27 studies). Five of the reviewed studies used Living Standards and Measurements Survey (LSMS) data. The remaining studies employed other country-specific surveys, with India’s National Family Health Survey (4 studies) and Ethiopia’s Rural Household Survey (2 studies) featuring in multiple cases.

In terms of causal identification strategies, 17% of the reviewed studies directly leveraged the availability of data collected from repeated measurement over time, estimating either unit-level fixed effects or difference-in-differences models (e.g., (Lucas and Wilson 2013 )). A further 9% of articles featured an instrumental variables strategy (e.g., (Yamano et al. 2005 )) and another 6% of articles resorted to matching techniques (e.g., propensity score) to control for selection bias and minimize problems of sample imbalance. The remaining studies exhibited a variety of other approaches, including decomposition analysis (Block et al. 2004 ; Rodriguez 2016 ) and a regression discontinuity design (Ali and Elsayed 2018 ).

Among the reviewed studies, attention to the temporal relationship between malnutrition and potential factors was limited and uneven, constraining the ability to ascertain any general patterns. The lack of such examination of the impact of climate and conflict shocks is especially conspicuous. A common approach has been to measure deviations in conditions during the survey period relative to long-run average conditions, within a suitable sub-national geographic area surrounding the survey cluster. The implicit assumption is that the deviations in conditions exert a contemporaneous impact on malnutrition. Select studies used models specifying factors with time lags. For example, Johnson and Brown (Johnson and Brown 2014 ) tested one- and two-year lagged measures of shocks in vegetation, but the results of these estimations were not presented because the observed effects were not statistically significant. Kinyoki et al. ( 2016 ) tested lags measures of conflict during the three months prior to survey and the period from 3 to 12 months prior to the survey, finding that both variables have statistically significant associations with wasting and stunting. Howell et al. (Howell et al. 2018 ) tested yearly lagged values of conflict days and deaths in an analyses of stunting and wasting. Another approach in studies that have modelled the effects of conflict shocks on child malnutrition is cohort analysis. The effect of the shock is gauged based on birth timing relative to the shock, evaluating how the “during” shock cohort differs from the “before” shock and “after” shock cohorts (Grace et al. 2015 ).

3.3 Geographical coverage

Nearly 80% of the reviewed studies focused on a single country or even just one sub-national geographic area within a country. The country that features the most often was India, in 13% of the studies. Ethiopia was second (10%), followed by Guatemala and Kenya (6% each). Nineteen of the reviewed studies (21%) analysed data from multiple countries. The studies with the most extensive geographic scope covered 166 countries (Smith and Haddad 2015 ), 63 countries (Smith and Haddad 2001 ), and 41 countries (Kimenju and Qaim 2016 ). The analysis in each of these studies was conducted at the country level.

The shortage of comparative analysis within individual studies, the limited scope of geographic coverage among multiple studies that examined the same factors, and the lack of comparability of the studies that did examine the same factors in different country settings restricts understanding of the generalizability of observed relationships. Of interest, no comparative studies have been conducted to analyse the consistency of the relationship between child malnutrition and conflict across multiple country settings.

4 Discussion and conclusions

We conducted a review of 90 studies involving statistical analyses of empirical data to examine relationships of child malnutrition to factors measured at the individual, household, regional/community and national levels. Our main purpose was to consolidate understanding about the tendencies of findings to date and the design and extent of existing research. A main strength of our review was the wide scope, with respect to the number of studies included, the multiple measures of malnutrition reflected in the analyses reported in these studies, and the volume of factors evaluated in those analyses. The review by Phalkey et al. (Phalkey et al. 2015 ) takes a similar approach on fewer (15) studies and considered seven categories (agriculture, crops, weather, livelihood, demographics, morbidity, and diet). These categories were simply reported statistically significant, or not (Phalkey et al. 2015 ). The present review achieves a broader coverage of the literature, includes description of risk and mitigating factors, and highlights possible differences in relationships across the types of malnutrition. The approach used in the present review departs from a formal meta-analytical approach (Borenstein et al. 2011 ). Our approach allowed us to include a large number of studies, irrespective of statistical designs, choice of variables, and modelling approaches. Meta-analysis published elsewhere will be useful in confirming trends reported here.

Specifically, our review reveals that wasting is understudied as a measure of child malnutrition. Instead, far more attention has been paid to stunting. Another main observation is that many of the factors evaluated in relation to the different types of child malnutrition yielded inconclusive results or were not analysed in multiple studies. According to the prevailing evidence, select factors were associated with all three types of child malnutrition: age of child and multiple births are risk factors, while mother’s education, mother’s BMI, household wealth/assets, and national GDP per capita are mitigating factors. A single factor is associated with both wasting and stunting (child’s sex as a categorical variable) and two factors with both stunting and underweight (rural household, national female education level), while 23 factors are associated with only one of the types of malnutrition.

Previous research summarising determinants of child nutritional status identified factors similar to those in our review. For example, Smith et al. (Smith et al. 2005 ) list a number of individual- and household-level factors that seem important to nutritional status, including whether the child has had diarrhoea, mother’s education, mother’s nutritional status, feeding practices, sanitary conditions, wealth, and medical care. Many of these factors exhibit significant associations in the studies included in our review, which identifies other risk and mitigating factors as well.

The present review explicitly captures findings about the role of climate and conflict conditions, while other recent reviews about child malnutrition overlook these conditions (Jones et al. 2013 ; Leroy et al. 2015 ; (Wrottesley et al. 2015 )). Among the studies we reviewed, climate conditions are widely included in analyses, most often measured with indicators of precipitation, temperature, and vegetation. Measures of conflict conditions – activity in the surrounding region, extent of exposure, and birth during an affected period – are also included more selectively in analyses (Akresh et al. 2012 ; Delbiso et al. 2017 ). The prevailing evidence indicates that climate shocks involving excessive rainfall, extreme temperatures, and drought are among the risk factors for wasting, stunting, and underweight, respectively, while conflict emerged as a risk factor for stunting. Additional relationships between certain types of malnutrition and certain forms of external shocks may exist, but the evidence from our review is either inconclusive or only reflects single studies (Table S2 ).

Our results are consistent with existing research showing that climate-related shocks, such as droughts or floods, are detrimental to food security, especially of rural populations (Table S3 ) (Cooper et al. 2019 ; Douxchamps et al. 2016 ; Grace et al. 2014 ; Murali and Afifi 2014 ). Our review reveals that excessive rainfall is a risk factor and growing season rainfall is a mitigating factor. Excessive rainfall represents an extreme event, with the potential for natural disasters (e.g., floods) that can be damaging to health, well-being, and economic production. By comparison, growing season rainfall captures conditions during critical periods of agricultural productivity, when above-average precipitation logically tends to be beneficial to food security (Cooper et al. 2019 ; Funk et al. 2008 ). Another study found that households located in regions that experienced a drier-than-average year reported one more month of food insecurity than households experiencing wetter-than-average years (Niles and Brown 2017 ). Our review also found that stunting was associated with both extremely cold temperatures (Skoufias and Vinha 2012 ) and extremely hot temperatures (Jacoby et al. 2014 ) as risk factors. Other existing studies suggest that high temperatures and heat waves tend to be important for understanding food security (Phalkey et al. 2015 ; Bain et al. 2013 ; Grace et al. 2012 ). In addition, we found that the results for vegetation quality differ across countries. For example, Johnson and Brown (Johnson and Brown 2014 ) find vegetation quality during the previous growing season to be a statistically significant mitigating factor for wasting in Mali, but not Benin, Burkina Faso, or Guinea, while Shively et al. (Shively et al. 2015 ) did not find a statistically significant relationship between wasting and this factor in Nepal.

In comparison to the literature using climate variables, analyses of relationships between child malnutrition and conflict shocks are limited in number. Foundations for such studies exist in the literature about the effect of conflict on food security and public health. For example, Akresh et al. ( 2011 , (Akresh et al. 2012 )) and Bundervoet et al. ( 2009 ) showed that children in conflict-affected settings exhibit signs of stunting, with similar effects for children born before or during wartime. These results, however, have not translated into interventions that take advantage of data on climate and conflict, despite the increasing availability of sources with granular detail (Dunn 2018 ; Jones et al. 2010 ; Raleigh et al. 2010 ). Our review also highlights the lack of attention in existing research to the relationship between conflict and wasting. We view this gap as warranting attention given the acute nature of this type of malnutrition, which could plausibly be influenced by the sort of shock that conflict represents.

Another important consideration is that climate and conflict shocks can coincide – and influence one another. These potential intersections and interactions suggest possible causal pathways of child malnutrition. Multiple theories address the impact of climate shocks on the emergence of armed conflict, which cannot be decisively established (Hsiang and Burke 2014 ). Food security and nutrition may also be a key mediating factors in the nexus between climate and conflict. For example, Buhaug et al. (Buhaug et al. 2015 ) model a process in which climate shocks cause in a first stage to an increase of local food prices, which then lead to conflict during a second stage. They find evidence of a strong climate impact at the first stage, but a weak and inconsistent one at the second stage. Their argument is that the effect of food prices on conflict is likely conditional on local “socioeconomic and political contexts.” This explanation is consistent with findings of studies on the relationship between food prices and urban unrest (Berazneva and Lee 2013 ; Hendrix and Haggard 2015 ).

Our review indicates that empirical research evaluating the joint effects of environmental and political conditions on risks of malnutrition unfortunately remains the exception (Fig. 1 and Tables S 2 and S 3 ). Few studies on malnutrition have considered both climate and conflict simultaneously. A meta-analysis of nutrition surveys in Ethiopia from 2000 to 2017 concluded that droughts increase the prevalence of wasting, but the impact of conflict is less certain (Delbiso et al. 2017 ). Other research suggests that the effects of climate extremes and conflict should exacerbate one another, pushing conditions beyond a tipping point and contributing to complex emergencies. In the famines of the twentieth Century caused primarily by drought or flood, concurrent conflict often served to escalate the environmental crisis and exacerbate mortality (Devereux 2000 ). This finding is consistent with Sen’s (Sen 1981 ) seminal argument that no famines with exclusively natural causes have been observed in the modern era. Sen (Sen 1981 ) argues that contemporary societies should be able to respond more effectively to potential famines caused by droughts or other natural events, except when hampered by failures in social, economic, and political institutions. Crises arising with one type of shock may be eased by stored food or relief supplies, whereas the coincidence of both types of shocks undermines those responses. For example, conflict blocked aid from reaching populations at risk of malnutrition amid droughts in Ethiopia during the 1980s and in Somalia in 2011 (Hillbruner and Moloney 2012 ; Maxwell and Fitzpatrick 2012 ). More generally, conflict diminishes the capacity of households and communities to cope with other stresses and shocks (Raleigh et al. 2015 ).

Among the main challenges to achieving improvements in the detailed, rigorous analysis of relationships between child malnutrition and conflict is the availability of data. Surveys that serve as the source of data on nutrition are conducted in conflict-affected areas. The insecure nature of these conditions, however, can make data collection less frequent, extensive, and reliable, reducing their scope, scale, and quality. Also, the relevant surveys rarely collect information about direct conflict exposure at the individual or household level. Instead, studies that evaluate conflict as a factor usually resort to making inferences from analysis using event data. These data offer consistent precision of georeferencing of events only to the level of first- or at best second-order administrative divisions (Raleigh et al. 2010 ), rather than specific point locations or even small areas. Appropriately integrating these data on conflict into analysis requires a multilevel modelling approach (Gelman and Hill 2006 ), which can account for potential influences at the regional level, as well as other levels (individual, household, community). Such an approach can be complemented by reasonable theoretical arguments that children residing within regions experiencing conflict (and possibly affected neighbouring regions) are more vulnerable to suffering effects on malnutrition, through various causal pathways. Given that the direct exposure to conflict events is not measured, compounded by events being infrequent in most settings, the evaluated relationships are likely to be difficult to detect. Encountering such difficulties in the analysis of climate factors is less likely because of the greater geographic granularity of the available data, a more balanced distribution of conditions, and clearer, more direct pathways of influence of local conditions on individuals and households.

Ultimately, examining the state of knowledge about factors associated with acute and chronic child malnutrition holds the potential to help advance an ongoing agenda of scientific inquiry with practical applications that have important real-world consequences. Recent technological developments in mobile devices and remote sensing, communications coverage (including cell phone and Internet networks), and the ability to transmit large amounts of information rapidly improve the potential of designing and implementing more timely protective interventions (GSMA 2015 ). Considerable opportunities exist for identifying where, when, how, and why proven policy and public health interventions should be implemented (Collins et al. 2006 ), especially to gauge the local impact of climate and conflict shocks. Our review contributes to capabilities of isolating intervention points in ways that can improve strategies (Wrottesley et al. 2015 ; Walker et al. 2015 ). Further evidence from studies spanning multiple countries and time periods is needed to bolster the foundations for designing interventions (Dilley 2000 ). Pertinent data are increasingly available, including from sources (e.g., the World Food Program’s Food Aid Information System) that can be used to study the effectiveness of international aid and humanitarian assistance in relation to vulnerabilities to malnutrition.

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Molly E. Brown

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Brown, M.E., Backer, D., Billing, T. et al. Empirical studies of factors associated with child malnutrition: highlighting the evidence about climate and conflict shocks. Food Sec. 12 , 1241–1252 (2020). https://doi.org/10.1007/s12571-020-01041-y

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Tackling malnutrition: a systematic review of 15-year research evidence from INDEPTH health and demographic surveillance systems

Affiliations.

• 1 INDEPTH Network, Accra, Ghana.
• 2 Department of Demography and Population Studies, University of the Witwatersrand, Johannesburg, South Africa; [email protected].
• 3 Library Department, Systems and Technical Services, Mangosuthu University of Technology, Umlazi, Durban, South Africa.
• 4 Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Durban, South Africa.
• 5 Ouagadougou HDSS, ISSP, University of Ouagadougou, Ouagadougou, Burkina Faso.
• 6 MRC Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
• 7 Umeå Centre for Global Health Research, Division of Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
• 8 Independent Consultant, Mwanza, Tanzania.
• 9 School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
• 10 Faculty of Public Health, Hanoi Medical University, Hanoi, Vietnam.
• PMID: 26519130
• PMCID: PMC4627942
• DOI: 10.3402/gha.v8.28298

Background: Nutrition is the intake of food in relation to the body's dietary needs. Malnutrition results from the intake of inadequate or excess food. This can lead to reduced immunity, increased susceptibility to disease, impaired physical and mental development, and reduced productivity.

Objective: To perform a systematic review to assess research conducted by the International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) of health and demographic surveillance systems (HDSSs) over a 15-year period on malnutrition, its determinants, the effects of under and over nutrition, and intervention research on malnutrition in low- and middle-income countries (LMICs).

Methods: Relevant publication titles were uploaded onto the Zotero research tool from different databases (60% from PubMed). Using the keywords 'nutrition', 'malnutrition', 'over and under nutrition', we selected publications that were based only on data generated through the longitudinal HDSS platform. All titles and abstracts were screened to determine inclusion eligibility and full articles were independently assessed according to inclusion/exclusion criteria. For inclusion in this study, papers had to cover research on at least one of the following topics: the problem of malnutrition, its determinants, its effects, and intervention research on malnutrition. One hundred and forty eight papers were identified and reviewed, and 67 were selected for this study.

Results: The INDEPTH research identified rising levels of overweight and obesity, sometimes in the same settings as under-nutrition. Urbanisation appears to be protective against under-nutrition, but it heightens the risk of obesity. Appropriately timed breastfeeding interventions were protective against malnutrition.

Conclusions: Although INDEPTH has expanded the global knowledge base on nutrition, many questions remain unresolved. There is a need for more investment in nutrition research in LMICs in order to generate evidence to inform policies in these settings.

Keywords: LMICs; health and demographic surveillance system; low- and middle-income countries; malnutrition; nutrition; overweight; under and over nutrition.

Publication types

• Research Support, Non-U.S. Gov't
• Systematic Review
• Biomedical Research*
• Developing Countries
• Global Health
• Health Status
• Malnutrition*
• Nutritional Requirements
• Population Surveillance / methods*

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• 097318/Wellcome Trust/United Kingdom

78 Malnutrition Essay Topic Ideas & Examples

🏆 best malnutrition topic ideas & essay examples, 👍 simple & easy malnutrition essay titles, 🎓 good research topics about malnutrition, ❓ research question about malnutrition.

• Obesity as a Form of Malnutrition and Its Effects Obesity is considered a malnutrition because the extended consumption of nutrients can still lead to the lack macro- and microelements. Overweight and obesity are serious disorders affecting a substantial part of the current population.
• Healthy Nutrition: Case Study of Malnutrition Sofia’s possible malnutrition might be owing to her demanding schedule and lack of prenatal care, which is an important part of a healthy pregnancy. We will write a custom essay specifically for you by our professional experts 808 writers online Learn More
• Malnutrition in Hospitalized Patients: Intended and Potential Outcomes Furthermore, there is a chance that the patients will be able to determine malnutrition at its early stages and inform nurses about the problem. As a result, a rise in the number of positive patient […]
• Malnutrition in South Africa: Public Health Policy The global food systems are highly dysfunctional, creating malnutrition crises in certain parts of the world which are the primary cause of death and disease.
• Malnutrition: Criteria and Description of Statement of the Problem Between adequate nutrition programs and malnutrition primary prevention programs, what approach is the most effective to enhance children’s development? What are the dissimilarities between adequate nutrition programs and malnutrition primary prevention programs?
• Obesity and Malnutrition: Who Is at Fault I would like to note that in both the interview and the article Nestle states that malnutrition is not only the responsibility of the consumers.
• Child Malnutrition in the GCC Countries Countries which have faired badly in the recent past include Kuwait and Qatar which saw an increase in their child malnutrition rates from 5% in the 1990s to 10% in the mid-2000s.
• Child Malnutrition: Term Definition Majority of the people in the globe specifically in the rural areas do not have access to safe drinking water and most of them lack the access of good sanitation.
• The Issues of Malnutrition and the Healing Process The issues of malnutrition and the healing process are regarded in lots of journals and scientific literature. The nutritional status of the patient previous to and after a surgical procedure is significant for speedy and […]
• Integrated Nursing Practice Addressing Malnutrition The benefits of the specified intervention include an opportunity to reduce the extent of stress experienced by the patient and create the basis for the future patient education.
• Malnutrition in Children as a Global Health Issue The peculiarity of this initiative is not to support children and control their feeding processes but prevent pediatric malnutrition even before a child is born.
• Malnutrition: Major Risk Factors and Causes The normal functioning of body organs is something that requires an adequate amount of mineral salts, fluids, and nutrients that are derived from different food materials. The purpose of this paper, therefore, is to analyze […]
• Early Enteral Nutrition to Prevent Malnutrition The choice of the method depends on the state of a patient, his/her disease, and the peculiarities of the health problem that should be solved at the moment.
• Accelerating Progress Toward Reducing Child Malnutrition in India
• Addressing Chronic Malnutrition Through Multi-Sectoral, Sustainable Approaches
• Addressing the Double Burden of Malnutrition in ASEAN
• Battle Against Starvation and Malnutrition
• Behaviors Associated With Child Malnutrition
• Childhood Malnutrition and Schooling in the Terai Region of Nepal
• Chronic Malnutrition and Its Effects on Children
• Closing the Rural-Urban Gap in Child Malnutrition: Evidence From Paraguay
• Child Malnutrition and Antenatal Care: Evidence From Three Latin American Countries
• Combating Child Chronic Malnutrition and Anemia in Peru
• Death From Stroke During the Danish Malnutrition Period 1999-2007
• Comparing Peri-Urban Versus Rural Poverty and Child Malnutrition Reduction
• Deforestation and Household- And Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa
• Combining Insights From Quantile and Ordinal Regression: Child Malnutrition in Guatemala
• Child Malnutrition and Poverty: The Case of Pakistan
• Developing Countries Suffer From Poverty and Malnutrition
• Diets, Malnutrition, and Disease: The Indian Experience
• Child Malnutrition and Mortality in China and Vietnam in a Comparative Perspective
• Effects of Parental Education on Malnutrition Among Children in Brazil
• How Hunger and Malnutrition Influence the Health and Development of Communities
• Child Malnutrition and the Provision of Water and Sanitation in the Philippines
• Linking Economic Growth and Child Malnutrition in Egypt
• Economic Growth, Poverty, and Malnutrition in India
• Child Malnutrition, Social Development, and Health Services in the Andean Region
• Ending Malnutrition: From Commitment to Action
• Environmental Factors and Children’s Malnutrition in Ethiopia
• Children’s Malnutrition and Horizontal Inequalities in Sub-Saharan Africa
• Difference Between Undernutrition and Malnutrition
• The Impact of Public Expenditure on Child Malnutrition in Peru
• Factors Affecting the Prevalence of Malnutrition
• Fetal Malnutrition and Academic Success: Evidence From Muslim Immigrants in Denmark
• Fighting Poverty and Child Malnutrition: On the Design of Foreign Aid Policies
• Factors Influencing the Occurrence of Malnutrition Health and Social Care
• An Opportunity to Minimize Malnutrition and Hunger in Developing Countries
• Geography and Culture Matter for Malnutrition in Bolivia
• Household and Community HIV/AIDS Status and Child Malnutrition in Sub-Saharan Africa
• Hunger and Malnutrition Are a Problem Everywhere
• Identifying Risk Factors for Severe Childhood Malnutrition by Boosting Additive Quantile Regression
• Inequality, Hunger, and Malnutrition: Power Matters
• Hunger, Malnutrition and Millennium Development Goals: What Can Be Done
• What Happens to Your Body Durimg Malnutrition?
• What Causes Malnutrition?
• What Is the Treatment for Malnutrition?
• How Long Does It Take To Recover From Malnutrition in Adults?
• How Do Doctors Test for Malnutrition?
• What Is the Largest Reason for Malnutrition?
• How Do Doctors Diagnose Malnutrition?
• How Long Can You Live With Malnutrition?
• Which Medicine Is Best for Malnutrition?
• What Drugs Cause Malnutrition?
• Can Blood Test Detect Malnutrition?
• What Bloodwork Shows Malnutrition?
• What Are the Most Common Signs of Malnutrition?
• How Is Malnutrition Best Managed?
• What Social Factors Cause Malnutrition?
• What Are the Long Term Effects of Malnutrition?
• What Are Immediate Cause of Malnutrition?
• What Is the Best Way for Early Detection of Malnutrition?
• What Are the Complications of Malnutrition?
• How Is Severe Malnutrition Diagnosed?
• What Infection Causes Malnutrition?
• What Are the Diseases Caused by Malnutrition?
• How Is Malnutrition Treated in Adults?
• How Does Malnutrition Affect the Brain in Adults?
• Can You Get Brain Damage From Malnutrition?
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Malnutrition: A Cause or a Consequence of Poverty?

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Keywords : malnutrition, poverty, diet, eating habits, inequalities, low-income

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Malnutrition enteropathy in Zambian and Zimbabwean children with severe acute malnutrition: A multi-arm randomized phase II trial

• Kanta Chandwe 1   na1 ,
• Mutsa Bwakura-Dangarembizi 2 , 3   na1 ,
• Beatrice Amadi 1 ,
• Gertrude Tawodzera 2 ,
• Deophine Ngosa 1 ,
• Anesu Dzikiti 2 ,
• Nivea Chulu 1 ,
• Robert Makuyana 2 ,
• Kanekwa Zyambo   ORCID: orcid.org/0000-0001-5686-5319 1 ,
• Kuda Mutasa 2 ,
• Chola Mulenga 1 ,
• Ellen Besa   ORCID: orcid.org/0000-0001-5606-9435 1 ,
• Jonathan P. Sturgeon   ORCID: orcid.org/0000-0003-1318-1739 2 , 4 ,
• Shepherd Mudzingwa 2 ,
• Bwalya Simunyola 1 ,
• Lydia Kazhila 1 ,
• Masuzyo Zyambo 5 ,
• Hazel Sonkwe 5 ,
• Batsirai Mutasa 2 ,
• Miyoba Chipunza 1 ,
• Virginia Sauramba 2 ,
• Lisa Langhaug   ORCID: orcid.org/0000-0002-9131-8158 2 ,
• Victor Mudenda 1 ,
• Simon H. Murch   ORCID: orcid.org/0000-0002-3870-8229 6 ,
• Susan Hill 7 ,
• Raymond J. Playford   ORCID: orcid.org/0000-0003-1235-8504 8 , 9 ,
• Kelley VanBuskirk   ORCID: orcid.org/0009-0004-9110-9059 1 ,
• Andrew J. Prendergast   ORCID: orcid.org/0000-0001-7904-7992 2 , 4 &
• Paul Kelly   ORCID: orcid.org/0000-0003-0844-6448 1 , 4  

Nature Communications volume  15 , Article number:  2910 ( 2024 ) Cite this article

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• Intestinal diseases
• Paediatric research

Malnutrition underlies almost half of all child deaths globally. Severe Acute Malnutrition (SAM) carries unacceptable mortality, particularly if accompanied by infection or medical complications, including enteropathy. We evaluated four interventions for malnutrition enteropathy in a multi-centre phase II multi-arm trial in Zambia and Zimbabwe and completed in 2021. The purpose of this trial was to identify therapies which could be taken forward into phase III trials. Children of either sex were eligible for inclusion if aged 6–59 months and hospitalised with SAM (using WHO definitions: WLZ <−3, and/or MUAC <11.5 cm, and/or bilateral pedal oedema), with written, informed consent from the primary caregiver. We randomised 125 children hospitalised with complicated SAM to 14 days treatment with (i) bovine colostrum ( n = 25), (ii) N-acetyl glucosamine ( n = 24), (iii) subcutaneous teduglutide ( n = 26), (iv) budesonide ( n = 25) or (v) standard care only ( n = 25). The primary endpoint was a composite of faecal biomarkers (myeloperoxidase, neopterin, α 1 -antitrypsin). Laboratory assessments, but not treatments, were blinded. Per-protocol analysis used ANCOVA, adjusted for baseline biomarker value, sex, oedema, HIV status, diarrhoea, weight-for-length Z-score, and study site, with pre-specified significance of P < 0.10. Of 143 children screened, 125 were randomised. Teduglutide reduced the primary endpoint of biomarkers of mucosal damage (effect size −0.89 (90% CI: −1.69,−0.10) P = 0.07), while colostrum (−0.58 (−1.4, 0.23) P = 0.24), N-acetyl glucosamine (−0.20 (−1.01, 0.60) P = 0.67), and budesonide (−0.50 (−1.33, 0.33) P = 0.32) had no significant effect. All interventions proved safe. This work suggests that treatment of enteropathy may be beneficial in children with complicated malnutrition. The trial was registered at ClinicalTrials.gov with the identifier NCT03716115.

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Introduction

Despite 17 million annual worldwide cases of childhood severe acute malnutrition (SAM), and its high associated mortality when children are hospitalized with complications 1 , 2 , there have been few new treatments for over three decades for children with complicated SAM. Current management follows steps in the WHO guidelines launched in 1999 3 , 4 , 5 , 6 but there is an acknowledged lack of evidence for many interventions 1 , 7 and consensus that more trials are needed. In sub-Saharan Africa, HIV has had a major impact on SAM, causing higher mortality during 8 , 9 and after admission 2 , 10 , 11 , 12 , 13 , complications like persistent diarrhoea 9 , and prolonged hospital admission.

Even after recovery from acute SAM, there are very common chronic consequences, including both stunting of linear growth and short- and long-term inhibition of neurodevelopmental potential 14 . The effects of chronic malnutrition upon cognitive functioning are particularly notable in the domains of attention, memory and learning, contributing to poor school performance 15 and corresponding with abnormalities on neuroimaging 16 . Such long-term consequences may not be averted by providing improved nutrition alone, as small intestinal absorption of nutrients and essential micronutrients is compromised by ongoing malnutrition enteropathy 17 . Effective treatment of malnutrition enteropathy is thus likely to have major benefits for the development of large numbers of children within resource-poor countries.

The small intestinal mucosal damage now recognised as malnutrition enteropathy was first recognised in SAM in the 1960s 18 , 19 . More recent studies confirm the very high frequency of malnutrition enteropathy in resource poor countries and an association between such gut inflammation and mortality in complicated SAM 20 . There is therefore considerable interest in malnutrition enteropathy, which varies from mild villus blunting and inflammation to a severe state with total villus atrophy similar to coeliac disease. Malnutrition enteropathy is characterised by severe epithelial lesions 21 , 22 accompanied by mucosal inflammation in the epithelium and lamina propria together with depletion of secretory cells 23 . The epithelial lesions permit microbial translocation from the gut lumen driving systemic inflammation 24 , 25 . Transcriptomic analysis of mucosal biopsies confirms links between inflammation, villus blunting, microbial translocation and epithelial leakiness 26 .

Recognising that fresh approaches are needed to ameliorate the mucosal damage that characterises malnutrition enteropathy we evaluated four potential therapies in a multi-arm, phase II, randomised controlled trial in two tertiary hospitals in southern Africa (Lusaka, Zambia and Harare, Zimbabwe) 27 . The Therapeutic Approaches to Malnutrition Enteropathy (TAME) trial tested the hypothesis that one or more of these therapies could reduce the severity of malnutrition enteropathy in children with SAM. Each intervention was chosen because of its potential for enhancing intestinal repair. Bovine colostrum contains abundant growth factors, including insulin-like and epidermal growth factors 28 , and demonstrates efficacy in ulcerative colitis 29 , 30 . N-acetyl glucosamine may restore the intestinal barrier since glycosylation is deficient in SAM 31 , 32 , and it has been shown to promote mucosal healing in inflammatory bowel disease (IBD) 33 . Teduglutide improves nutrient absorption through mucosal regeneration in intestinal failure 34 , 35 . Budesonide suppresses inflammation with minimal systemic exposure in IBD 36 . A broad range of endpoints was chosen to assess several domains of pathophysiology 37 , 38 relevant to restoring mucosal integrity. The primary endpoint, a composite of faecal biomarkers (myeloperoxidase, α1-antitrypsin, and neopterin) was chosen to reflect mucosal inflammation and loss of barrier function. Secondary endpoints were chosen to reflect enterocyte damage (plasma intestinal fatty acid-binding protein) and the systemic response to microbial translocation (lipopolysaccharide-binding protein (LBP), C-reactive protein (CRP), soluble CD163, soluble CD14), alongside anthropometric measures of nutritional recovery, death, adverse events, diarrhoea, fever and recovery from oedema.

The TAME trial was conducted in the Children’s Hospital of University Teaching Hospital, Lusaka, and Sally Mugabe Hospital, Harare. The third planned site (Parirenyatwa Hospital, Harare) was closed to recruitment due to its use as a COVID-19 centre. Children hospitalised with complicated SAM were enrolled once they were considered stable and ready to transition to higher calorie intakes, to avoid anticipated high early mortality in this high-risk population. Of 143 children screened, 133 were eligible: 8 declined, leaving 125 children enrolled: 62 in Lusaka and 63 in Harare (Fig.  1 , Table  1 ), of whom 43% were female (Table  1 ). Causes of ineligibility were weight <5 kg ( n = 1), clinical instability ( n = 1), haemoglobin <6 g/dL ( n = 2), death prior to enrolment ( n = 1), or resolution of SAM ( n = 5). Children were randomised a median of 5.5 (range 1–21) days after admission (Table  2 ), following blood and stool collection to measure baseline biomarkers; no biomarker data were available from earlier in the hospital admission. One child died and two withdrew before day 15, so 122 children (98%) contributed outcome data (Fig.  1 ). Two further children died and one withdrew between the end of treatment and the day 28 follow-up visit. Adherence and completion were very high: 122/124 (98%) children who survived to day 15 received all planned doses.

One child died and two children withdrew before day 15, so day 15 endpoint data were available for 122 children for most endpoints, and 118 for the primary endpoint; all these children completed their allocated intervention and standard care and are included in the per protocol analysis. A further 2 children died and one withdrew between days 15 and 28. SAM, severe acute malnutrition. Hb, haemoglobin concentration.

Primary endpoint

The median day 15 composite faecal inflammatory score was lower in all treatment groups compared with the standard care group (Table  3 ). Using ANCOVA, with pre-specified P-value threshold of 0.10 and following adjustment for seven key covariates, pairwise comparisons showed the composite score in the teduglutide group was significantly lower than standard care (mean difference −0.89, 90%CI −1.69, −0.10, P = 0.07) (Table  4 ). Results were also stratified by site (Supplementary Table  S1 ). In Harare both teduglutide and budesonide reduced the primary outcome compared to standard care, by 2.1 (90%CI 0.7, 3.5; P = 0.02) and 1.4 (0.06, 2.7; P = 0.09) respectively, but the effect was not significant in Lusaka (Supplementary Table  S1 ). In the whole group, the ANCOVA model demonstrated no significant effect of sex, HIV infection, oedema, diarrhoea, or baseline weight-for-length Z-score (WLZ) on the faecal inflammatory score.

Secondary endpoints

Amongst secondary biomarker endpoints (Table  4 ), compared with standard care, budesonide reduced plasma CRP (mean reduction 5.2 mg/L; 90%CI 0.8, 9.6; P = 0.05) and sCD163 (mean reduction 405 ng/mL; 90%CI 73, 738; P = 0.05) while colostrum and N-acetyl glucosamine had effects only on CRP (reductions 5.9 mg/L; 90%CI 1.4, 10.3; P = 0.03, and 4.8 mg/L; 90%CI 0.5, 9.2; P = 0.07, respectively). There were notable site-specific differences in CRP, sCD14, sCD163 and iFABP (Supplementary Table  S1 ). Transformation of secondary endpoints to approximate a normal distribution did not change the effects observed, except for colostrum, for which an effect was found on GLP-2 only when the values were transformed (Supplementary Table  S2 ). N-acetyl glucosamine reduced mean days with diarrhoea by 89% (Table  4 ; ratio of NAG to standard care 0.11; 90%CI 0.04, 0.33; P = 0.001). None of the interventions affected days with fever or oedema, or change in weight, height, or MUAC.

Assessment of endoscopic biopsies

Of 62 children enrolled in Lusaka, endoscopy was carried out on 25 (5 colostrum, 4 N-acetyl glucosamine, 6 teduglutide, 5 budesonide, 5 Standard Care). Of the remainder, 9 children were unsuitable for anaesthesia (mainly upper respiratory infections), one child had no INR result available, 3 children missed endoscopy because no anaesthetist was available; and 24 children missed endoscopy because of instrument breakdowns. Representative specimens are shown in Fig.  2 . Morphometry in post-treatment biopsies showed significant differences in crypt depth (Fig.  3 ; P = 0.02 by Kruskal-Wallis test; by Dunn’s test P = 0.01 for colostrum and P = 0.049 for teduglutide compared to standard care).

Biopsies are from children treated with a colostrum, b N-acetyl glucosamine, c teduglutide, d budesonide, and e standard care. Morphometric analysis is shown in panel f . Scale bars show 200 μm. These biopsies were selected from 22 biopsies from 25 children: 6 in the teduglutide group, 5 in the colostrum group, 5 in the budesonide group, 5 in the standard care group, and 4 in the N-acetyl glucosamine group. Individual data from morphometric analysis are shown in Fig.  3 .

Measurements of villus height (VH) and crypt depth (CD) in 22 biopsies with satisfactory orientation obtained from children completing 14 days of treatment. a  villus height ( P = 0.84 by Kruskal-Wallis test across all groups). b crypt depth ( P = 0.02 by Kruskal-Wallis test; by Dunn’s test P = 0.01 for colostrum and P = 0.049 for teduglutide). c, epithelial surface area.  NAG, N-acetyl glucosamine. Source Data are provided as a Source Data File (Dataset 1).

Adverse events

A total of 102 clinical adverse events were reported (10 SAEs, 92 non-serious AEs) which did not differ significantly by treatment arm (Supplementary Table  S3 ). No AEs or SAEs were adjudicated as related to the investigative products. There were no adverse events related to endoscopy, and no Adverse Events of Special Interest. Laboratory AEs did not differ by treatment allocation (Supplementary Table  S4 ). Of the 10 SAEs observed, 3 (2% of the whole cohort) were deaths and 7 (6%) were prolonged hospitalisations or re-admission (Supplementary Table  S3 ). Of the three deaths, only one (on day 3) occurred before day 15; the other two occurred on days 20 and 23. Deaths were attributed to fever with diarrhoea ( n = 1; Standard Care arm), tuberculosis ( n = 1; Teduglutide arm), and aspiration pneumonia ( n = 1; Colostrum arm). Seven readmissions or prolonged hospitalisations occurred, due to fever ( n = 2), deterioration of oedema ( n = 1), vomiting ( n = 1), respiratory distress ( n = 1), and a burn from a hot water bottle whilst in hospital ( n = 1). One SAE was a readmission for observation at the day 28 visit after a protocol violation, due to receiving double the protocol dose of budesonide; there were no clinical or laboratory consequences. One child receiving teduglutide was readmitted for vomiting to exclude intestinal obstruction (an Adverse Event of Special Interest) but the illness resolved uneventfully and was adjudicated as unrelated to the investigative product. Laboratory abnormalities occurred in 702 instances, including baseline abnormalities, but did not differ significantly between arms and were all adjudicated as unrelated to the investigative products (Supplementary Table  S4 ).

Despite implementation of current treatment guidelines for complicated SAM, mortality remains unacceptably high, particularly in settings with high HIV burden. There is an urgent need for transformative approaches that modify underlying pathogenic pathways 39 . We identified intestinal mucosal damage as a promising target for intervention 27 . This multi-arm phase II clinical trial evaluated four potential new therapies to promote mucosal healing, which were each compared with standard care. Teduglutide showed benefit on the primary endpoint, a composite of three faecal inflammatory markers widely used to define enteropathy in malnourished children. Teduglutide is a GLP-2 agonist widely used in intestinal failure, a clinical syndrome with features in common with the more severe cases of malnutrition enteropathy. Our findings suggest that GLP-2 agonism similarly enhances mucosal healing in children with SAM. No other intervention significantly differed from standard care for the primary outcome. However, budesonide, colostrum and N-acetyl glucosamine reduced the systemic inflammatory marker CRP, which is potentially clinically important as CRP is a predictor of mortality 40 . The increase in crypt depth observed with teduglutide and bovine colostrum likely indicates enhanced mucosal regeneration, as these agents both showed some reductions in inflammatory biomarkers (faecal composite score for teduglutide, CRP for colostrum). N-acetyl glucosamine reduced diarrhoea, which is independently associated with mortality in SAM, potentially reflecting restoration of glycocalyx composition 32 and/or inhibition of enteropathogen colonisation 41 . Collectively, our data identify teduglutide as the leading candidate for future trials, but also suggest there may be benefits from the other treatments, which all have distinct mechanisms of action. This trial highlights the importance of measuring multiple biomarkers, which capture different pathological domains of malnutrition enteropathy. A larger-scale trial of single or combined interventions with outcomes including mortality and readmission is now warranted.

Our hypothesis was that one or more trial interventions could aid mucosal healing, reducing enteropathy, inflammation, and microbial translocation. We selected three faecal biomarkers of mucosal damage and inflammation as a composite primary endpoint, on which we based our sample size calculations. However, we acknowledged a priori that our interpretation would draw on the full range of endpoints, since no single biomarker or composite score captures the complexity of pathogenesis linking mucosal damage to mortality 27 . The effects of trial treatments on different secondary endpoints suggests that each may benefit specific domains of gut dysfunction in SAM 37 .

The potential usefulness of teduglutide is limited by its expense and subcutaneous route of administration. However, many therapies introduced at high prices fall in cost once volume of use increases. By contrast budesonide, which reduced the inflammatory markers CRP and sCD163, is far less costly and easier to administer. Neither should be implemented as part of treatment for SAM without further trial evidence, but the TAME trial demonstrates that use is likely to be safe, and confirms mucosal healing as a promising strategy in severe malnutrition. Although colostrum did not affect the primary endpoint, it increased both plasma levels of GLP-2 (though only after log transformation) and crypt depth. Colostrum contains GLP-2 at around 5 ng/ml and supplementation with colostrum in juvenile pigs undergoing intestinal resection increased plasma GLP-2 levels 42 .

As expected, adverse events were common but serious adverse events uncommon, and there were no events considered related to trial medications. The safety of long-term teduglutide has been assessed in intestinal failure and considered acceptable 35 . No Adverse Events of Special Interest were observed. A trial of mesalazine, another anti-inflammatory drug used in IBD, suggested safety in children with SAM 43 , and our data extend these findings by showing that these medications are also safe. Mortality was low compared to our historical data 9 , 11 . This may be due to the enhanced medical and nursing care usually associated with conduct of a clinical trial, but probably also relates to our caution in focusing on inclusion of clinically stable children. Given our experience of high early mortality in children with complicated SAM, we adopted this strategy to reduce the likelihood of serious adverse events in this phase II trial. In future it would appear desirable to bring forward treatments to the day of admission, when they might be of greatest potential benefit. Treatment duration was 14 days, representing the period of greatest mortality risk in hospitalised children; however, we and others have reported that unacceptably high mortality continues for 48 weeks following hospital discharge 2 , 11 , 13 . It is therefore possible that longer duration of therapies for mucosal healing could be of benefit.

We recognise several limitations. Due to restrictions on recruitment and difficulties transporting medicines and reagents during the COVID-19 pandemic, our enrolment was reduced. However, withdrawal and mortality were much lower than anticipated and we could therefore retain adequate power for the primary endpoint with a smaller sample size. Because this trial was conducted in hospital, adherence to medication was very high, with 98% of children completing intended therapy. This may be unattainable in real-world settings, but overall this trial demonstrated proof of concept for the therapies chosen. Our results were consistent across endpoint domains and biologically plausible for known mechanism of action of each agent, increasing confidence in our findings. Due to the short intervention duration, we saw limited impact on clinical outcomes such as growth. However, future trials powered for clinically important outcomes could explore the optimal timing, dosage and duration of intervention. There are also some challenges in interpreting the biomarkers used in this trial. Faecal biomarkers are subject to dilutional considerations, especially when a significant proportion of the trial participants have diarrhoea. It is also true that the biology of these biomarkers is not fully established. Markers such as myeloperoxidase and neopterin are elaborated by leukocytes, and reflect intestinal mucosal inflammation, but intestinal permeability and trafficking of leukocytes to the gut can be altered in the presence of systemic infections 44 , 45 . Neopterin is synthesised in response to interferon-γ and generally reflects Th1-mediated inflammation. α1-antitrypsin is usually considered a biomarker of protein loss into the gut, but transcriptomic data reveal that it is expressed in the mucosa 26 , 46 . These considerations need to be taken into account in future work. We have no ready explanation for the heterogeneity between study sites. We have previously noted mortality differences between Zambia and Zimbabwe, and there are minor differences in protocol implementation (such as when children are ready for discharge) which might explain some of these effects. This heterogeneity also needs to be taken into account in future work as it underlines the value of performing trials in different countries.

Our findings demonstrate a biologically plausible new treatment paradigm for children with complicated SAM. Intestinal damage is ubiquitous in children with SAM, driving systemic inflammation, contributing to stunting and developmental impairment and increasing mortality. No interventions for malnutrition enteropathy are currently available. We have shown that a short course of therapy added to standard care, aimed at restoring mucosal integrity, can ameliorate underlying pathogenic pathways. Further trials should evaluate these interventions for their effects on mortality, clinical recovery and long-term nutritional restoration to improve the outcomes of children with complicated SAM. Combinations of interventions would be interesting to evaluate in future trials since their distinct mechanisms of action and potential to target multiple domains of malnutrition enteropathy concurrently, may plausibly lead to greater mucosal healing and clinical recovery through synergistic effects.

Ethics approval was obtained from the University of Zambia Biomedical Research Ethics Committee (006-09-17), the National Health Research Committee of Zambia, the Zambia Medicines Regulatory Authority (CT 082/18), the Joint Research Ethics Committee of Harare Central Hospital (JREC/66/19), the Medicines Control Authority of Zimbabwe (CT/176/2019), and the Medical Research Council of Zimbabwe (MRCZ/A/2458). The trial was conducted in accordance with the principles of the Declaration of Helsinki. The trial was monitored by a Data Safety and Monitoring Board. The trial was registered at www.clinicaltrials.gov (NCT03716115) and first posted on 23 rd October 2018, prior to patient enrolment, and the protocol was published 27 . A CONSORT checklist containing information reporting a randomized controlled trial has been included in Supplementary Note  1 . The trial protocol and statistical analysis plan are included in Supplementary Notes  2 and 3 .

Recruitment, inclusion and exclusion criteria

Children were recruited from 4 th May 2020 to 27 th April 2021, and the trial closed on 25 th May 2021 after the completion of the period of follow up of the last child. Potentially eligible children were identified by the study nursing teams, and written permission to screen was obtained from caregivers. A detailed information sheet in local languages was discussed with caregivers prior to seeking consent. Weight, length and mid-upper arm circumference (MUAC) were measured three times, and eligibility ascertained. Children of either sex were eligible for inclusion if aged 6-59 months and hospitalised with SAM (using WHO definitions: WLZ <−3, and/or MUAC <11.5cm, and/or bilateral pedal oedema), with written, informed consent from the primary caregiver. Children were excluded if unstable (shocked, hypothermic, hypoglycaemic, impaired consciousness), under 5kg body weight, had conditions impairing feeding, haemoglobin below 6 g/dl, or if their caregiver would not consent to child HIV testing or to remaining in hospital throughout the treatment course. Additional exclusion criteria were contraindications to any treatment or other factors that might prejudice study completion or analysis. No payments were made for participation, but transport refunds were made on discharge and on review to permit return home using public transport.

Trial procedures

Children were randomised equally to each of the four interventions, or standard care. Trial identification numbers were allocated sequentially in each site, with randomisation carried out by opening a sealed envelope bearing the corresponding number. The randomisation sequence was prepared by the trial statistician (KVB), stratified by study site, in random permuted blocks of variable size. Interventions began as soon as possible after baseline samples were collected. Children were managed by a team of nurses providing 24-hour cover, ensuring all treatments were administered and adverse events recorded. Study doctors (KC, GT) reported clinical progress daily using a standardised form. All treatment courses were 14 days. Samples for endpoint analysis were collected on day 15 (permissible window 15-19); children were then discharged if ready and reviewed on day 28 (window 28-42). Blood samples for safety monitoring (full blood count, renal and liver function, phosphate) were collected at baseline, 5 and 15 days post-randomisation. We enrolled children with predominantly oedematous SAM, and a high prevalence of HIV infection, and were not powered to evaluate effects in different subgroups of children. Tuberculosis was diagnosed clinically, and specifically searched for in any child with respiratory symptoms, using microscopy and culture of nasogastric aspirates whenever possible, chest X-ray and urine lipoarabinomannan according to clinical protocols.

Investigational products

Bovine colostrum (supplied by Colostrum UK) and N-acetyl glucosamine (Blackburn Distributions, UK) are nutraceuticals, regarded as safe and not licensed as medicines. They were provided as powder and encapsulated to ensure accurate dosing (colostrum 1.5 g 8-hourly throughout; N-acetyl glucosamine 300 mg 8-hourly days 1–7, 600 mg 8-hourly days 8–14). The dose of colostrum (4.5 g/day orally or via nasogastric tube) was chosen to be similar to those used in other published studies involving children. Ismail et al. treated premature infants with a dose of approx. 0.5–1 g colostrum/kg/day to examine gut immune priming 47 , and Barakat & Omar used 3 g/day of colostrum for children aged 6 months to 2 years suffering from acute diarrhoea 48 . The dose of N-acetyl glucosamine was based on our previous study in paediatric Crohn’s disease, where daily dosage of 6 grams augmented expression of epithelial glycosaminoglycans without evidence of adverse effects 33 . Intravenous doses of up to 100 mg have been tolerated in adults without adverse effects 33 and breastfed newborns consume 650–1500 mg of n-acetyl glucosamine per litre of human breast milk from well-nourished mothers 49 . Budesonide 0.5 mg and 1 mg respules (Alliance Healthcare, UK) are designed for nebuliser therapy but used off-licence orally for gastrointestinal therapy. These were opened on the ward and administered orally or by nasogastric tube. Dosage was 1 mg 8-hourly during days 1–7, 1 mg 12-hourly during days 8–11, and then 0.5 mg 12-hourly during days 12–14. The dosage was derived from studies in paediatric Crohn’s disease, where 9 mg enteric-coated daily budesonide proved equally efficacious to 40 mg prednisolone but with substantially reduced adverse effects 50 . Teduglutide (Revestive, Takeda) is licensed widely for intestinal failure but never previously evaluated in SAM. It was provided as 1.25 mg vials which were stored at 4–8 °C, and given by subcutaneous injection (0.05 mg/kg daily, based on weight measured on days 1 and 8). Prior stability testing carried out by Takeda confirmed that the opened vial is stable at 4–8 °C for 24 hours so each vial provided two doses, drawn 24 hours apart. Site rotation was marked on a map of anatomical sites as recommended by the manufacturer. The selected dose for teduglutide (0.05 mg/kg) was found to be the most effective dose in a phase 3, 12-week paediatric trial when compared to two lower doses of 0.025 mg/kg and 0.0125 mg/kg 51 . It is the dose currently approved by the FDA in the US and the EMA in Europe.

Evaluation of endpoints

The primary endpoint was the day 15 composite faecal inflammatory biomarker score, comprising myeloperoxidase, neopterin and α 1 -antitrypsin 27 . Secondary endpoints at day 15 were: changes in anthropometry; plasma biomarkers of enteropathy, microbial translocation and systemic inflammation (iFABP, LBP, CRP, sCD14, CD163, IGFBP-3, and GLP-2); days with diarrhoea, fever, and oedema; and adverse events. For children who were potty trained, stool was collected using a clean pot and then the required amount was transferred to a sterile stool container using a scoop. For those who are were not potty trained, diapers were used. The diapers were put inside out so that the plastic layer was next to the skin. A scoop was used to place a sample in a sterile stool container. The collected sample was then put in a cooler box with ice packs immediately. A sample transmittal form was used to keep track of the transit time from point of collection to receipt in the laboratory. Nursing staff stayed in communication with lab staff to ensure rapid delivery of samples to the laboratory.

Biomarkers were assayed by ELISA (Supplementary Table  S5 ) by laboratory scientists (KZ, KM, EB) blinded to study arm, and re-calculated independently (by RN and JS) from raw data on harmonised Gen5 software (Biotek/Agilent, Santa Clara, CA). Serum albumin and lipopolysaccharide, though pre-specified as endpoints, were not included due to failing quality control checks leading to low concordance between sites. IGF-1 values were very close to zero; as insufficient plasma was available for re-testing these data have been omitted. Lactulose/rhamnose urinary excretion tests were only performed on children undergoing endoscopy and only 14 valid data pairs were obtained; these data are therefore not shown.

A subgroup of children in Lusaka additionally underwent endoscopy for duodenal biopsy between days 15 and 19; only the Lusaka site was selected for this due to its considerable experience in paediatric endoscopy over many years. Except for two periods when endoscopy instruments required repair, children were selected sequentially, provided there were no haematological or anaesthetic contraindications. Sedation was administered by an anaesthetist (HS or MZ) and biopsies were collected from the second part of the duodenum using a Pentax 2490i paediatric gastroscope. Biopsies were orientated under a dissecting microscope and fixed before processing into paraffin blocks, sectioning and staining. Slides were scanned at 20x magnification on an Olympus VS-120 scanning microscope and blinded morphometry was performed by a single observer (CM, confirmed by PK) on all villus and crypt units identifiable in well-orientated parts of sections of each biopsy. The criterion used for suitable orientation was that crypts should be visualised throughout their length (see Fig.  2 , and reference 22 ), and then the boundary between crypt and villus compartments delineated. Crypt depth was measured in micrometres (μm) from this boundary to the furthest point of the base of the crypt, where the basement membrane would be expected. Villus height was measured in μm from the boundary to the villus tip in a straight line. Epithelial surface area was measured as the perimeter of the villi where muscularis mucosae could be measured, and expressed per micrometre of muscularis mucosae. Any portions of these sections where crypts were not visualised along their entire length were deemed poorly orientated and not used for morphometry. The median number of villi measured was 6 (IQR 4-9; range 3-13).

Adverse events between enrolment and day 15 or day 28 were reported in real time and reviewed for seriousness, severity, relatedness and expectedness; all serious adverse events were reported to the Sponsor (Queen Mary University of London), ethics committees and national trial regulators. Severity was categorised as mild, moderate or severe using the DAIDS classification ( https://rsc.niaid.nih.gov/clinical-research-sites/daids-adverse-event-grading-tables ), and all AEs reported monthly to the Data Monitoring and Ethics Committee (DMEC). Three Adverse Events of Special Interest (AESIs) were specifically sought: intestinal obstruction or volume overload for teduglutide, and osmotic diarrhoea for colostrum and N-acetyl glucosamine. Haematology and biochemistry results at baseline, days 5 and 15 were graded using DAIDS tables.

Sample size

The planned sample size was 225 children (45 in each arm), based on the composite biomarker score 27 . Enrolment was slowed by COVID-19, but trial losses were much lower than anticipated (3% observed versus 20% anticipated). The Trial Steering Committee and DMEC therefore reviewed the sample size in January 2021 once 82 children had been enrolled. The decision was made to reduce the sample size, based on a Cohen’s d effect size of 0.3, with 80% power and 90% confidence, and conservative correlation between baseline and follow-up estimates of 0.5, requiring 23 per group across 5 groups to analyse the primary outcome by ANCOVA. Allowing for 5% losses, the sample size of 115 was rounded up to 125 participants in total (25 per group).

Statistical analysis

Per protocol analyses were pre-specified 27 , and all hypothesis testing was 2-sided. Statistical analysis was performed in Stata 17 (Stata corp, College Station, Texas). Analysis of primary and secondary endpoints was based on comparison against standard care. ANCOVA was used to model final endpoint values, with adjustment for core baseline value, sex, baseline presence of oedema, HIV status, baseline diarrhoea, baseline WLZ score, and study site. Mortality was low (3 deaths) so could not be analysed statistically. Covariates chosen were pre-specified to take into account important elements of pathophysiology (worse outcome in HIV infection and oedematous malnutrition and in children with diarrhoea 52 ) and to allow for possible differences between the two countries. For some secondary endpoints negative binomial models were constructed which used a smaller set of adjustment variables (sex & HIV) due to model constraints (Table  2 ). Anthropometric measurements were calculated as change from baseline. The endoscopy subset was analysed separately, comparing post-treatment morphometric measurements by Kruskal-Wallis test, followed by Dunn’s test. Treatment effects were deemed statistically significant if the P value was <0.1 when compared to the control arm, as pre-specified. No adjustments of the false-positive (type I) error rate were planned, in line with the general consensus that adjustment for type I error rate is not required in exploratory multi-arm multi-stage trials in Phase II within the treatment development framework 27 , 53 .

Reporting summary

Further information on research design is available in the  Nature Portfolio Reporting Summary linked to this article.

Data availability

Data supporting the findings of this study are available in the article and in its Supplementary Information. Source data are provided as a Source Data file for Fig.  3 , and have also been deposited in Figshare under accession code https://doi.org/10.6084/m9.figshare.24442699 . The data uploaded to figshare include deidentified individual participant data, trial protocol, and statistical analysis plan.

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Acknowledgements

We are grateful to the following nurses from the wards and endoscopy unit of UTH: Evelyn Nyendwa, Esther Chilala, Andreck Tembo, Lucy Macwani, Dalitso Tembo, Mary Phiri, Elaine Brittel Sikuyuba, Sophreen Mwaba, Gwendolyn Nayame, Joyce Sibwani, Rose Soko, Kashinga Maseko, and Mulima Mwiinga. We are grateful to the nursing team in Harare Central Hospital: Sarudzai Murumbi, Tariro Zure, and Lucia Manyatera. We also sincerely thank Mr Rizvan Batha of Barts Health Pharmacy for assistance with procurement of investigational products. We are very grateful to the Trial Steering committee (Professors Jay Berkley, Ian Sanderson, and James Wason) and Data Monitoring and Ethics Committee (Professor Jim Todd, Doctors Rose Kambarami, Veronica Mulenga, and Philip Ayieko). The TAME trial was sponsored by Queen Mary University of London, but the Sponsor played no role in study design, data collection, analysis, or manuscript writing. The trial was funded by a grant from the Medical Research Council (UK), number MR/P024033/1. AJP and JPS are funded by Wellcome (108065/Z/15/Z for AJP, and 220566/Z/20/Z for JPS). Takeda UK provided teduglutide at a discounted price.

The Medical Research Council (UK) funded the study. Takeda UK provided tedu-glutide at a discounted price.

Author information

These authors contributed equally: Kanta Chandwe, Mutsa Bwakura-Dangarembizi.

Authors and Affiliations

Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia

Kanta Chandwe, Beatrice Amadi, Deophine Ngosa, Nivea Chulu, Kanekwa Zyambo, Chola Mulenga, Ellen Besa, Bwalya Simunyola, Lydia Kazhila, Miyoba Chipunza, Victor Mudenda, Kelley VanBuskirk & Paul Kelly

Zvitambo Institute for Maternal and Child Health Research, McLaughlin Avenue, Meyrick Park, Harare, Zimbabwe

Mutsa Bwakura-Dangarembizi, Gertrude Tawodzera, Anesu Dzikiti, Robert Makuyana, Kuda Mutasa, Jonathan P. Sturgeon, Shepherd Mudzingwa, Batsirai Mutasa, Virginia Sauramba, Lisa Langhaug & Andrew J. Prendergast

Faculty of Medicine and Health Sciences, University of Zimbabwe, Parirenyatwa Hospital, Harare, Zimbabwe

Mutsa Bwakura-Dangarembizi

Blizard Institute, Queen Mary University of London, Newark Street, London, UK

Jonathan P. Sturgeon, Andrew J. Prendergast & Paul Kelly

Department of Anaesthesia, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia

Masuzyo Zyambo & Hazel Sonkwe

Warwick University Medical School, Coventry, UK

Simon H. Murch

Great Ormond Street Hospital, London, UK

University of West London, Ealing, London, UK

Raymond J. Playford

University College Cork, College Road, Cork, Ireland

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Contributions

KC, MBD, BA, SHM, RJP, SH, AJP and PK initiated and designed the trial. KC, GT, DN, AD, NC, RM, LK, BM and LL designed the trial instruments and data collection procedures. KC, MBD, BA, GT, DN, AD, NC, and RM carried out the daily clinical care and data collection. KZ, KM, CM, EB and VM were responsible for laboratory operating procedures, data acquisition and processing. LK, BM and LL undertook data entry and cleaning. MC, VS and LL undertook monitoring and quality control of the trial. BS and SM designed and implemented the pharmacy and pharmacovigilance procedures. MZ and HS undertook anaesthetic procedures and ensured the safety of children undergoing endoscopy. Analysis was carried out by KVB, JPS, LL, AJP and PK; AJP and PK wrote the initial draft which was revised by all authors.

Corresponding author

Correspondence to Paul Kelly .

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Competing interests.

RJP was previously an external consultant to Colostrum UK which provided the bovine colostrum used in these studies. RJP has also been an external consultant to Sterling Technology (USA) and an employee of Pantheryx Inc (USA) who produce and distribute bovine colostrum. There was no bovine colostrum company involvement in the production of this article or editing of its content. SH has had funding for teduglutide studies and lectured and participated in advisory boards on behalf of Takeda. The remaining authors declare no competing interests.

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Chandwe, K., Bwakura-Dangarembizi, M., Amadi, B. et al. Malnutrition enteropathy in Zambian and Zimbabwean children with severe acute malnutrition: A multi-arm randomized phase II trial. Nat Commun 15 , 2910 (2024). https://doi.org/10.1038/s41467-024-45528-0

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MALNUTRITION RESEARCH BY ORYEM JOSEPH

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Polish Annals of Medicine

Taha H Musa

JUNAID ABID

Malnutrition shows a decline in health due to the disproportion of nutrients and energy in the body. Malnutrition is one of the main risk factors related to children's morbidity and mortality. It is estimated that about 52.50% of child mortality is linked to malnutrition and its associated diseases. 1 Malnutrition is a crucial medical problem in approximately every region of the globe and particularly in Southern Asia and Sub-Saharan Africa. In several developing nations, stunting, underweight, and micronutrient deficiencies among children are common due to insufficient nutrition and ABSTRACT Background: Malnutrition is one of the main health issues among children. Malnutrition is more prevalent in developing countries. Malnutrition among children is affected by many factors. These factors are studied in many parts of the world but they are understudied in most the areas of Pakistan. This study aimed to assess the incidence of malnutrition and its associated factors among children in Murree, Rawalpindi, Pakistan. Methods: This descriptive cross-sectional study was carried out among children of Murree, Rawalpindi for about 6 months from August 2021 to January 2022. Simple random sampling along with an established inclusion and exclusion criteria was applied to enroll 316 participants. A self-adapted questionnaire was applied to take data after taking ethical approval from the institutional research board and informed consent from the participants. Results: The incidence of underweight, normal weight, overweight and obesity among school children of study population was 22.80%, 35.40%, 26.90%, and 14.90% respectively. The association between malnutrition and gender (p=0.001), birth weight (p=0.01), supplementation intake (p=0.03), filtered water use (p=0.02), hygiene (p=0.01), vaccination status (p=0.04), recurrent infection history (p=0.02), socioeconomic status (p=0.04), mother education (p=0.04), mother occupation (p=0.03), awareness of parents about balanced diet (p=0.02), and family size (p=0.04) was statistically significant, whereas association between nutritional status and age group (p=0.05) was insignificant. Conclusions: The incidence of underweight, overweight, and obesity was remarkable among children. Many factors such as gender, birth weight, supplementation intake, filtered water use, hygiene, vaccination status, recurrent infection, socioeconomic status, mother education, mother occupation, parental awareness about a balanced diet, and family size were found to associate with malnutrition among children.

Abdul Tauqeer

Eng Abdirahman

Abstract Background: Malnutrition is a severe problem that affects a child’s cognitive and physical development. An adequate, balanced nutrition is crucial for a proper physical, emotional, and mental development. Malnutrition remains one of the most common causes of morbidity and mortality among children under 5 children throughout the World. It is the most important risk factor for the burden of disease causing about 300, 000 deaths per year directly and indirectly responsible for more than half of all deaths in children. Child malnutrition is one of the most serious public health problems in the developing world. Objective: To assess prevalence of malnutrition and associated factors among children aged 5 years at Lasanod district, Sool region, October 2014. Methods: An institution based cross sectional study was done among MCHs under five children found in Lasanod town on October 2014. The sample size of the study was 113. A pretested structured questionnaire and interview guide were employed to obtain the necessary information for this study. The structured questionnaire were originally prepared in English language and then translated into the Somali language and then back to English. The collected data was analyzing using SPSS Version 20.0 and triangulated. Bivariate and multivariate logistic regressions were carried out. Result: The analysis this study revealed that, 57.5%, 25.6.9% and 33.7% of children were underweight ,wasted, and stunted respectively and also revealed that 3.5%, 10.6% and 13.3% of children were severe underweight , severe wasted and severe stunted. The main associated factors of malnutrition were found to be mother’s age at first birth, place of delivery and duration of breastfeeding. Conclusion and recommendation: - This study revealed that, prevalence of malnutrition was high and it was the top list among the health problems in Lasanod district. In Somalia where most mothers do not know nutritional status and nutrient foods, a lot should be done by different sectors. We suggest that under nutrition prevention programs and strategies in the region as well as other regions should target Nutritional status among mothers and their children in extensive way to bring further positive changes related to diet.

Journal of Nutritional Science and Vitaminology

Francis Nkrumah

American Journal of Public Health Research

Irene Sumbele

International Journal Foundation

This is cross-sectional community based study conducted in Angola area in Khartoum State of Sudan during period of 2015-2017. The aim of the study was to assess nutritional status of under five years old children and its associated risk factors using anthropometric measurements, interview of childcare givers, and observation on nutrition status indicators and socioeconomic profile of families. 282 children and their caregivers were selected and investigated using cluster sampling techniques and predesigned questionnaires and checklist. The results revealed that 19.1 of the studied children were severely malnourished, and 4.7 were moderately malnourished with children in age of one to two years were mostly affective with P value of < 0.05. Family size and parent education level also were reported among the major risk factors of malnutrition with P value of < 0.05. 96.6% of the children had episode of diarrhea at least once, and 81.1% had respiratory tract infection at least once. Few were exposed to frequently to those infectious diseases. The study concluded that severe and moderate malnutrition affect almost quarter of the children in the area especially in the age group of one to two years. Poor education and awareness on how to maintain children health generally is the main risk factor especially knowledge and skills on the causes of malnutrition, proper young children food and feeding practices, breastfeeding, and utilization of available health services. The study recommended extensive health education program along with family support through provision of nutrients high density food. Study Area: The area has a total population of the area 56,534 with 10,386 under five year old children according to the area popular committees. Household with children aged 6 to 59 months were selected for the study along with their mothers. Diarrheal diseases, malaria and acute respiratory infections were the major health problem among young children in the areas. There are five health centers providing PHC services and 5 private clinics. Diarrheal diseases, malaria and acute respiratory infections were the major health problem among young children in the areas. There are five health centers providing PHC services and 5 private clinics. Sample size: 282 children and their mother were selected using the following formula and based on prevalence rate of nutritional deficiency diseases in Khartoum State of which was estimated to be 10% according Khartoum State Ministry of Health, 2009 n = z 2 pq* design defect (d) 2 Where: n = sample size, Z = 1.96, P = prevalence rate of nutritional deficiency diseases= (10%), q = 1-p, d = 0.05, Design defect=2 n =(1.96) 2 X 0.9 X0.X 2 = 138.2976 X 2 = 276.59 (0.05) 2 (14) The number was rounded to 282 children taken into account the refusal which was estimated to be 9%. Cluster sampling techniques was used by dividing the area into 6 clusters, in each 47 children's and their mothers/caretakers were selected randomly (15). Data were collected in predesigned questionnaire and check list through interview with mothers and measuring weight and high of their children. Indicators used during this study were: height –for –age (for chronic malnutrition), weight for weight (for acute malnutrition) and edema (16,17). Weight: The Staler 25kg hanging spring scale marked out in steps 0.1 kg, was used instrument was adjusted to zero before used, the child freed from heavy clothing (16,17). Height: Children up to 2years (23 months 85 cm length) of age were measured on horizontal measuring board. Children over two years of age (or over 85cm) were measured standing on horizontal surface against vertical measuring device. The height was read out as before, to nearest 0.1cm (29) Age: The birth data was entered on the recording form from birth certificates where this document was not available we used date of birth given by mothers Edema: Presence of edema also was recording after examination of children using finger press on the abdomen and legs.

Geleta Asebe

Abdul-Rasheed L Sulaiman , Ahmed Olusi

The road to good health is through good food which depends on the socioeconomic condition of the giver of the food. Numerous studies had been conducted on the causes of child malnutrition among children less than 5 years, that of children between 8 and 16 years with keen interest on the socioeconomic context of the giver has not been well documented. This lacuna is what this paper filled. Cross-sectional household survey was used for the study. 322 respondents were selected using a multi stage cluster sampling design. A well-structured pretested questionnaire was used to elicit the socio-demographic data from the respondents, while the respondents' nutritional status was calculated using the Body Mass Index (B.M.I) method. Chi-square and bivariate logistics regression were used to test the hypotheses. The study discovered that parental education and parental income were the fundamental factors affecting child malnutrition in the study location. Hence, government should ensure that education is made compulsory and affordable to everyone. Also, the menace of poverty should be adequately addressed.

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Home — Essay Samples — Nursing & Health — Nutrition & Dieting — Malnutrition

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Malnutrition: a Global Crisis in Need of Urgent Attention

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Knowledge, attitude and practice towards malnutrition and micronutrient deficiency among male and female farmers in Ethiopia

• Girma Gezimu Gebre 1 , 2 ,
• Derebe Ermias Chefebo 3 &
• Deribe Kaske Kacharo 1  

BMC Nutrition volume  9 , Article number:  130 ( 2023 ) Cite this article

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Despite a large body of literature on the nexus between knowledge, attitude and practice towards nutrition and gender, this nexus is likely to vary and is not clear in many societies, such as Ethiopia.

The study aimed to analyze the level of gender-based knowledge, attitude, and practice towards malnutrition and micronutrient deficiency using primary data collected from two regional states in Ethiopia.

Qualitative and quantitative data collection approaches were used. Qualitative data were analyzed using a narrative and content approach. Quantitative data were analyzed using descriptive statistics.

Results indicate that female are generally more adept than male at identifying the symptoms of malnutrition. However, concerning vitamin A and iodine food types and its deficiency, male respondents had relatively better knowledge and consumption practice than female. Results show that there is very little awareness about biofortified and fortified foods. When we rate respondents, male had a relatively better understanding about fortified foods than their female counterparts.

Findings can support development agents working to improve nutrition in Ethiopia to focus on improving community knowledge and perception of biofortified and fortified foods to improve diet quality through increased micronutrient intake. The majority of the respondents were aware of the importance of consuming micronutrient rich foods and had a positive attitude towards them. However, there is still a gap in practice. It may therefore require more targeted campaigns to increase the ability of community members to adopt best practices while reducing barriers to consumption of nutritious diet.

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Introduction

Global statistics show that more than two billion individuals, or one in three people globally, suffering from hidden hunger. Hidden hunger is the presence of multiple micronutrient deficiencies such as iron, iodine and vitamin A; which can occur without a deficit in energy intake as a result of consuming an energy-dense, but nutrient-poor diet [ 1 ]. When we are deficient in a specific micronutrient, say vitamin A, iron, and iodine, our brain does not get or trigger the same signal as our body's needs for more food. This form of hunger is known as hidden hunger or micronutrient deficiency [ 1 ].

Malnutrition is an abnormal physiological condition, typically due to deficiencies or excesses in nutrient intake, or imbalances of essential nutrients in the body. Malnutrition, in all its forms (under nutrition or over nutrition) affects almost every country in the world, leading to serious public health risks and incurring high economic costs [ 2 ]. Micronutrient deficiencies, particularly those in folic acid, iodine, iron, and vitamin A, have a long-lasting impact on growth and development and are thus a national priority [ 3 ]. Improvements in nutrition will significantly contribute to reducing poverty and achieving the health, education, and employment goals outlined in the United Nations [ 2 ]. Nutrition stimulates economic growth, which improves the physical productivity and mental health of the labor force. The Inter-Agency Standing Committee (IASC) noted that girls and boys—and men and women—have different nutritional needs at different life stages. They face different risks and challenges in accessing sufficient nutrition. Gender inequality exacerbates food insecurity, malnutrition and poverty in humanitarian crises [ 4 ]. The socially constructed gender roles of men and women interact with their biological roles to affect the nutrition status of the entire family and of each gender [ 5 , 6 ]. All gender and age groups have the right to equal access to nutrition services and the foods they need to live a healthy life [ 4 ]. Women are the main food producers, yet they are disproportionally affected by hunger and malnutrition. Evidence suggests that when women have more control over how and how much time they spend feeding their children, and when women have better access to healthcare, the prevalence of undernutrition decreases (Royal Tropical Institute [KIT] and Netherlands Development Organization [ 7 , 8 , 9 ]. The nutritional status of women (before, during, and after pregnancy) is intimately linked with the nutritional status of their children [ 5 , 7 , 8 , 10 ]. However, despite global efforts to address under-nutrition among women and children, the prevalence of under-nutrition remains high [ 7 , 8 ].

Even though it was at a slower pace, Ethiopia has made progress in the reduction of child stunting and maternal undernutrition in the last two decades. For example, the prevalence of stunting has decreased from 58% in 2000 to 37% in 2019, depicting an average decline of 1.25 percentage points a year [ 11 ]. On July 15 th , 2015, the Government of Ethiopia made a declaration to end child malnutrition by 2030, reaffirming its commitment to nutrition as a foundation for economic development. Accelerating progress towards this goal, set out in the Seqota Declaration , will require coordinated multisectoral efforts to increase nutrition, smart investments in infrastructure and technology, behavior change, and empowering communities to innovate and identify localized solutions to address malnutrition [ 12 ]. Eliminating undernutrition in Ethiopia would prevent losses of 8–11% per year from the gross national product [ 3 ].

Women are among the most at-risk for poor nutrition, particularly in Ethiopia, where economic and social disparities tend to be greater [ 13 ]. Even when food is available at home, women tend to be malnourished because of their gender status. Women shoulder “triple roles”, including their reproductive, productive, and social (community) responsibilities [ 14 , 15 , 16 ]. These roles place a significant burden on women, increasing their risk of malnutrition [ 13 ]. A study by [ 17 ] in Ethiopia indicated that women have a lower decision-making authority than men within households regarding decisions on the proportion of produced food consumed at home. Sociocultural and traditional norms often result in women consuming smaller amounts of food or foods with less nutritional diversity, as well as prioritizing the more nutritious food items for men. Effectively understanding sociocultural structures and gender dynamics has served to strengthen results from interventions for improved nutrition practices or enforcing nutrition programmes with education on rights and advocacy skills [ 18 ].

Despite a large body of literature on the nexus between nutrition and gender, this nexus is likely to vary and is not clear in many societies, such as Ethiopia. Hence, this paper contributes to literature on the nexus between nutrition and gender using primary data collected from Ethiopia. The objectives of this study were (i) to analyze the level of male and female farmers’ knowledge, attitude, and practice towards malnutrition and micronutrient (e.g. vitamin A, iron, and iodine) deficiency; and (ii) to assess the status of consumption of micronutrient-rich foods among farming households in the study area.

Materials and methods

Study area and data.

The study is based on primary data collected in December 2021 in three woredas (Angecha woreda in the South Nation Nationalities and People Region (SNNPR), Arsi Negelle, and Anna Sora woredas in the Oromia region) of Ethiopia. Angacha woredas are located in Kembata, Tembaro zone of the SNNPR in Ethiopia. Anna Sora and Arsi Negelle woredas are located in the Guji and West Arsi zones of the Oromia region in Ethiopia, respectively (Fig.  1 ). The study applied a mixed methods approach consisting of qualitative data collection through focus group discussion (FGD) and key informant interview (KII) and quantitative data collection through concisely formed questionnaires. The study used a convergence research design through which the qualitative and quantitative data are collected and analyzed during a similar timeframe. The KII and FGD served as the basis for including local context on key KAP issues found in the study. These were done by letting the FGD participants and key informants explain the reasons behind the KAP findings of this study.

Location of the study area, Source: Authors

Sample and data collection methods

Sampling techniques.

Detailed FGD guides and questions were developed in close coordination with the quantitative data collectors. The discussions were conducted by the researcher to verify the self-reported information by the household respondents and to provide an in-depth understanding of the reported nutrition KAP. Discussions were held in the local language, which was a translation from English by professional local language interpreters. Illustrations related to the topics were used to stimulate discussion and engage the participants. On average, FGD consisted of six participants each. In order to avoid mutual influence in the responses, only one member of each household was randomly selected. A total of 21 groups, with a total of 126 participants, were formed separately in accordance with age, gender, and characteristics to allow the participants to speak freely. The farmer's training center was used as a venue for conducting FGD. Each discussion lasted no more than one hour. The FGDs were conducted with the following groups (Table 1 ).

A KII guide was carefully developed based on broader lines of inquiry to further explore gender and nutrition issues. The KIIs consisted of woreda agricultural extension coordinators, agricultural development agents working at kebele level, and health extension service providers. In each kebele, 1–3, key informants were invited to talk to the qualitative team to provid detailed information concerning household knowledge, attitudes, and practices towards malnutrition, vitamin "A", iron, and iodine deficiencies (Table 1 ). Moreover, the interview focused on issues related to gender and nutrition in the community. The interviews took place at their homes or offices separately in order to create a safe space for them to talk about this sensitive topic. Explicit consent to interview each person was collected and data from these interviews containing sensitive issues on gender and nutrition-related issues is kept under the strictest confidence. Data collected from KII were transcribed by the lead researcher who clearly understand the local language.

A multi-stage sampling procedure was applied to collect quantitative data. First, woreda was selected, followed by kebele, household, and individual respondent in each household. At the household level, the sample size of 311 respondents (185 males and 126 females) was calculated using Fisher’s formula [ 19 , 20 ]. Accordingly, from each household, one respondent was randomly selected, totaling 50 to 54 interviews per kebele (Table 2 ). The quantitative data collectors consisted of six locally based enumerators and two nutrition-sensitive research supervisors. Each interview took one hour per person on average. The interviews were conducted by trained enumerators at a farmer's home using a mobile data collection tool called Kobo Collect. Kobo Collect is a smart phone application applicable for field survey data collection. Of course, there are different smart phone applications useful for field survey data collection, such as Survey Solution. But Kobo Collect is easy to use in any rural area with no access to internet service. We used this tool for very large survey data collection, including the USAID. This tool has applied in several studies been including our previous published works (e.g. [ 16 , 17 ]).

Training of enumerators took place over four days, where three days occurred in a classroom setting, and one day in a selected community for pre-testing. The training schedule included the basics of a KAP study overall, interviewing methodology by enumerators, review of questionnaires, translation from English (orally) to local languages, and pre-testing of questionnaires in the field (see questionnaire attached as online Supplementary material ).

The pre-testing involved reviewing the qualitative and quantitative instruments to ensure the questions were clear, understandable, relevant to the intended topics, effective in providing useful information and, more importantly, to avoid redundant or unnecessary questions. Pre-testing also allowed enumerators and qualitative researchers to verify the correct local words and phrases of some of the complex ideas to which the study team wanted to gain insights on nutrition and gender. Pre-testing was conducted immediately prior to data collection in Kofele woreda of West Arsi zone, close to the study area.

Regarding components of the questionnaire used for quantitative data collection, the first part of the questionnaire comprised of demographic details such as age, marital status, sex of the household head, education level, household size, and farming experience. The latter part consisted of nutrition-related KAP questions. In total, the questionnaire is comprised of 41 KAP questions that encompass 16 knowledge questions, 7 practice questions, and 18 attitude-related questions.

The household interviews were conducted in the local language (Kambaatissa and Afan Oromo). Also, the questionnaire on the data collection platform, Kobo Collect, was in both Kambaatissa and Oromifa. This enables the enumerators to be intimately familiar with the questionnaire and be comfortable during interview time.

The participation of all research subjects in this study was voluntary and collected in a written form. Participants were informed before an interview or discussion took place about the purpose and were given the opportunity to refuse upon understanding the purpose. No exercise of undue inducement or any other form of coercion to participate in the study was permitted or accepted.

Data analysis

Qualitative data were analyzed using a narrative and content approach. Quantitative data were analyzed using descriptive statistics such as frequency distribution, mean comparison, percentages, and chi-square test. Moreover, a Likert scale was used to establish the respondent’s attitude towards malnutrition. SPSS software was used to analyze quantitative data.

Respondents socio-demographic characteristics

Table 3 presents the socio-demographic characteristics of the surveyed respondents. Male and female respondents account for 59.5% and 40.5% of the total (311) surveyed respondents, respectively. The study focused on men and women to get their opinion as well as gauge their nutrition knowledge, attitude, and practices. The same knowledge would facilitate an in-depth understanding of how men and women get involved and participate in decisions pertaining to the household. The overall average age of sampled respondents was 38 years old . The mean age of male and female respondents was 39.3 and 35.1, respectively. As a result of the T-test, the mean difference between males and females was statistically significant at 1% ( p  = 0.001). This indicates that, male respondents become more aware of malnutrition as their age increases, contrary to female respondents. This implied that higher level of understanding and deeper experience in household nutritional issues come with age.

The household heads with longer farming experience are supposed to have better understanding of malnutrition of the household than the household heads with shorter farming experience. The mean year of farming experience of male and female respondents was 22.448 and 18.539, respectively. As a result of T-test, the mean difference between males and females was statistically significant at 1% ( p  = 0.001). This indicates that, male respondents become more aware of malnutrition as their year of farming increases, contrary to female respondents. This implied that, household head with longer farming experience were to be more knowledgeable and practicable regarding household malnutrition.

More than half of the respondents (54%) had only primary level education. The importance of the level of education in gender equality is also underscored by the World Bank, which notes that the low levels of education, especially among women, represent a very serious constraint on development in most of the sub-Sahara African countries, Ethiopia not being exceptional. At the individual level, for example, education is perceived to be the ultimate liberator, which empowers a person to make personal and social choices [ 21 ]. The World Bank argues that education is also perceived to be the ultimate equalizer, particularly in promoting greater gender equity for women. Education is very important for farmers to understand malnutrition. Farmers who have high formal education are expected to be aware of malnutrition earlier than uneducated; because farmers with higher education levels were able to get information from different sources. The study results also revealed that the education level of the household head has a positive relationship and is statistically significant (chi 2  = 32.431, p  = 0.000) at 1% of level (Table 3 ).

Nearly all (92%) respondents were married and the total average household size was 7, which is higher than the national average of 5. The mean household size for male and female-headed households was 7.2 and 7.0 respectively. The statistical analysis also, revealed that there is no significant difference (0.652) in the mean household size between male and female household head.

Knowledge and attitude towards malnutrition

Knowledge about malnutrition.

The results of the study on Table 4 show that, the majority of male (96%) and female (92%) can recognize if someone in their household is malnourished. The results of chi-square analysis indicate that recognition of malnutrition in the household has positive relationship but statistically not significant (x 2  = 2.5013; p  = 0.114) (Table 4 ). About 85% of respondents know that lack of energy or weakness, are the main symptoms of being malnourished, while 58% and 84% of respondents know that weakness of the body's immune system and loss of weight/thinness, respectively, are the main symptoms of being malnourished in their respective households. FGD and KII participants also stated that, weakness, less immunity, chest pain, and headache were the most common symptoms of malnutrition at household and community level in the study area.

It was found that 87% of study participants had insufficient money to buy food, and 71% were unable to access multiple food groups. A majority of respondents (72%) suggested that eating foods enriched with micronutrients such as iron and vitamin "A" would prevent malnutrition problems in their household. Around 77% of respondents said that raising awareness among household members about making healthy food choices would help prevent malnutrition, while 75% and 49% said that increasing household income to afford nutritious food in the market and distributing food fairly among family members in the household would help prevent malnutrition (Table 4 ).

Attitude towards malnutrition

A Likert scale was used to establish the respondent’s attitude towards malnutrition. Nearly three-quarters (74%) of the total respondents were not likely to think that their household may have malnourished members, while 22% of the respondents were likely to think that there would be malnourished members in their household. The results of chi-square test indicate that attitude towards malnutrition in the household has positive relationship but statistically not significant (x 2  = 3.1058; p  = 0.376). More than half of the respondents (57%) did not think malnutrition was a serious problem for household members' health and only 11% of respondents thought malnutrition was a very serious issue in their household. According to the results of the chi-square test, attitudes towards malnutrition in the household have a positive relationship, but the relationship is not statistically significant (× 2 = 3.1058; p  = 0.376) (Table 4 ).

Consumption of iron-rich foods and iron -deficiency”

Knowledge about iron-rich foods and iron deficiency.

Table 5 presents respondent knowledge, attitude, and practice about iron-rich foods in the household. Regarding the sources of iron-rich foods, 78% of the respondents chose red meat as their major source of iron-rich foods, while 66%, 59%, and 34% chose teff (injera - a flat spongy Ethiopian bread mostly made of fermented teff flou r), butter, and pumpkin, respectively. 9% of the respondents had no knowledge about the sources of iron-rich food. A majority of the respondents (93%) knew about the benefits of eating iron-rich foods.

Body weakness, paleness, and headache were the most common symptoms of inadequate intake of iron-rich foods reported by the respondents. The majority of the respondents (88%) reported that they had heard about iron-deficiency anemia. Moreover, FGD and KII participants reported that there are incidences of anemia in the community.

Attitude towards consumption of iron-rich foods and iron-deficiency

More than half of the respondents (60%) think that it is a serious problem when their household members do not eat iron-rich foods. Nearly 7 out of 10 respondents (68%) think it is good to prepare meals with iron-rich foods such as red meat, chicken, liver, and dark green vegetables. Approximately 34% of respondents said it is extremely difficult for their households to prepare meals rich in iron, while less than 18% said it is not difficult. Almost three-quarters (73%) of the respondents are not confident in preparing meals with iron-rich foods, indicating a perceived ability to prepare iron-rich foods is a major barrier, yet most of them (88%) like the taste of iron-rich foods such as red meat, liver, injera, and chicken.

About 4 out of every 10 respondents (40%) think that it is not likely to have iron-deficient household members. Those with less than 10% think it would be most likely to have a household member who is iron deficient.

Consumption practices of iron-rich foods

About half (53%) of survey respondents consumed iron-rich foods in the last 24 h prior to the survey. The most commonly consumed iron-rich foods reported by the surveyed respondents were Teff (injera), legumes (mixed beans, baked beans, lentils, chickpeas), and dark leafy green vegetables.

Consumption of vitamin “A” rich foods

Knowledge about vitamin a-rich foods.

Table 6 presents respondents’ knowledge, attitude, and practice regarding vitamin A-rich food consumption in the household. Most surveyed respondents (89%) had heard about human health problems such as night blindness or inability to see in dim light in their community. About 83% had heard about Vitamin "A" deficiency or diseases caused by not consuming vitamin A-rich foods such as eggs, carrots, cheese, orange-fleshed sweet potatoes (OFSP), milk, or yoghurt (full cream dairy). In open-ended questions, respondents were asked to list vitamin "A" rich foods they are consuming in their households. Their responses were summarized as butter, milk, carrot, OFSP, and don't know for the purpose of presentation. Accordingly, most of the respondents (88%) reported carrots as a major source of vitamin "A", while 75%, 58%, and 39% noted milk, butter, and OFSP, respectively, as the major sources of vitamin "A". About 6% of the respondents were not aware of the major sources of vitamin "A" rich foods. Respondents were also asked about their knowledge about the benefits of eating vitamin "A" rich foods such as biofortified foods (e.g., orange-fleshed sweet potatoes) and fortified foods (e.g., fortified oil, wheat flour, and iodized salt). The majority of them, 90%, knew about the benefits of eating vitamin "A" rich foods.

Attitude towards vitamin A-rich foods

The respondents were asked how likely they thought it was that any of their household members lacked vitamin "A". Thus, nearly half (46%) believe that it is likely Over half (52%) of respondents said vitamin A deficiency is serious. Seventy-one percent of respondents feel confident that they can prepare meals containing vitamin-A-rich foods. About 50% of respondents thought it was somewhat difficult to prepare foods rich in Vitamin A. About 54% of respondents were feel less confident in preparing meals with vitamin-A-rich foods in the household. The majority (95%) of the respondents like the taste of vitamin-A-rich foods (Table 6 ). These results indicate that respondents perceive a positive attitude towards eating vitamin A-rich foods.

Consumption practices of vitamin A-rich foods

A majority (83%) of the respondents consumed vitamin "A" rich foods in the past 24 h prior to this survey. More than half (57%) of the respondents stated that all family members have equal access to vitamin A-rich foods. About 58% of the respondent’s household uses biofortified and fortified foods, such as orange-fleshed sweet potatoes. Whereas, 79% of their households use fortified foods such as fortified edible oil or wheat flour (Table 6 ).

Consumption of iodized salt

Knowledge about consumption of iodized salt.

Survey results indicate that a majority of respondents (69%) had information about human health problems related to iodine deficiency, such as goiter, apathy, and muscle weakness (Table 7 ). All of the respondents stated that their household uses salt to cook meals.

Attitude towards consumption of iodized salt

Results show that 32% of respondents think "it is likely " and 31% think "it is not likely " to lack iodized salt at home (Table 7 ). About (42%) think that the lack of iodized salt is a serious issue. About half (47%) were confident that they could prepare meals with iodized salt, and a slight majority (57%) stated that it was easy for their household to buy and use iodized salt. Only 14% said it was very difficult for their household to buy and use iodized salt.

Consumption practices of iodized salt

All surveyed respondents responded that they use salt to cook meals, with 39% using iodized salt and 45% using non-iodized salt (Table 7 ). All FGD and KII participants stated that the local community usually consumes non-iodized salt and on very rare occasions they consume packed and iodized salt. Some of the reasons given were lack of awareness about the existence of so-called iodized salt; they only knew about common or regular salt. Affordability (high price compared to the normal one) was also stated as a reason for not using iodized salt; even though they were aware of its existence, it was not available for purchase in local markets and shops. The results confirm that there is a knowledge and practice gap in the consumption of iodized salt in the study area.

This study was intended to assess the level of KAP among male and female farmers towards malnutrition and micronutrient deficiency; and the status of consumption of micronutrient-rich foods. The study findings revealed that, in general, the majority of respondents had poor knowledge, attitudes, and practice towards reducing malnutrition. This is in line with studies that revealed in all communities, regardless of differences in socioeconomic class and educational level, knowledge, attitudes, and practices about vitamin A were low [ 22 , 23 ]. However, this result contradicts the study`s finding that the majority of caregivers had knowledge of important baby and young child feeding practices [ 24 ].

39% and 71% of the respondents knew about the benefits of eating orange-fleshed sweet potatoes and fortified foods, respectively. Moreover, there were no such knowledge differences in the two group' about micronutrients. However, FGD and KII participants reflect contrary to the study findings regarding community knowledge of biofortified and fortified foods. They believe that, non-fortified oil is consumed more than fortified oil, as fortified oil was sold at a higher price in the study area. Also, there is a lack of knowledge on fortified oils' health benefits and types of nutrients added in the fortified oil. In SNNPR (Angecha woreda), fortified wheat flour is not known to the community. Farmers in Angecha woreda used to go to the "grinding mill house" and prepare the wheat flour locally. Even when they buy wheat flour from the market, it is the same and there is no access to fortified wheat flour. When they buy the processed and packed wheat flour, they don’t care whether it is fortified or not. Unlike survey participants, FGD and KII participants were reported that, Orange-fleshed sweet potato (OFSP) was not being produced in their community and people were not aware of the health benefits of eating OFSP. Even more educated professionals, such as development agents, health extension workers, and kebele coordinators who participated in KII, are not aware of the orange-fleshed sweet potato. In general, consumption of regular sweet potatoes is also quite rare in the study area. This misalignment between FGD and KII participants and survey respondents may be attributed to the misunderstanding of what fortified and biofortified foods are when asked in the survey, and the closed nature of a questionnaire does not allow enumerators to verify with follow-up questions. Similar findings were reported by WFP [ 25 ] in the KAP study on maternal nutrition, infant and young child feeding, sanitation and hygiene, and sexual and reproductive health, including obstetric fistula, in Chemba District, Sofala in Mozambique. In the [ 25 ] study, all FGD participants stated that they are unable to identify fortified foods, so they cannot distinguish fortified and non-fortified foods in the market, and they cannot make an informed choice when it comes to buying micronutrient supplements or fortified products. They indicated that they have never been told about the existence of these products by any communication channels in the communities in Mozambique. However, approximately 70% of survey respondents in the WFP study stated that they are aware of fortified foods. Moreover, 64% of survey respondents (66% of men and 62% of women), indicated they purchase fortified foods in the market for their children, and only a mere 3% indicated they do not.

Females are generally more adept than males at identifying the symptoms of malnutrition. However, concerning vitamin A and iodine food types and its deficiency male respondents had relatively better knowledge and consumption practice than female. Compared to female, male respondents had better understanding about fortified food in the study area.

According to the findings, a lack of income (87%) was the primary cause of a lack of a balanced diet in the study locations. As reported in Table 4 , the most crucial elements in preventing malnutrition are increasing sources of income so that people can purchase healthy food and raising awareness so that people may make wise food choices. Malnutrition was stated by both the FGD and KII respondents as the central problem in the study community/area. In terms of nutrition, the majority of the families under investigation continue to struggle with hunger and food insecurity in general, especially in Angecha woreda.

Conclusion and recommendations

The aim of this study was to assess nutrition-related knowledge, attitudes, and practice among male and female farmers in the Oromia and SNNP regions of Ethiopia. The findings from this study will inform the nutrition and gender-related development project implementation with a focus on its social behavior change communication (SBC) plan. Results indicate that female are generally more adept than male at identifying the symptoms of malnutrition. However, concerning vitamin A and iodine food types and its deficiency male respondents had relatively better knowledge and consumption practice than female.

Findings also show that the benefits of biofortified and fortified foods are still largely unknown among community members. Even more educated professionals such as development agents, health extension workers, and kebele coordinators who participated in KII are not aware of biofortified foods such as orange-fleshed sweet potatoes. To supplement the government of Ethiopia's efforts to increase consumption of micronutrient rich foods such as orange-fleshed sweet potatoes, high iron pearl millet, and fortified foods such as iron fortified wheat flour, iodized salt, and vitamin A fortified oils; non-governmental organizations such as Sasakawa Africa Association need to raise awareness about the benefits of consuming biofortified and fortified foods. Therefore, awareness creation is needed for extension experts and community members on the benefits of producing and consuming biofortified and fortified foods.

The findings show that the majority of the respondents are aware of the importance of consuming vitamin A and iron-rich foods, iodized salt, as well as production and consumption of fruits and vegetables and have a positive attitude towards them. However, there is still a gap in practice. As a result, more targeted campaigns may be required to increase community members' ability to adopt best practices while reducing barriers to consumption of nutritious diet. The current SBC strategy should change from an awareness creation campaign to a behavior change campaign, focusing on perceptions of the benefits and practices of the production and consumption of vitamin A and iron-rich foods as well as the consumption of iodized salt.

Availability of data and materials

Data used in this study are confidential. Data would be available up on reasonable request from the corresponding author.

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Acknowledgements

We would like to express our sincere gratitude to Hawassa University for supporting our study. We are also grateful to the two anonymous reviewers for their helpful comments to improve the paper.

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Girma Gezimu Gebre & Deribe Kaske Kacharo

The Japan Society for the Promotion of Science (JSPS) Postdoctoral Research Fellowship Program, Ritsumeikan University, Kyoto, 603-8577, Japan

Girma Gezimu Gebre

Department of Agricultural Economics, College of Agriculture and Natural Resource, Werabe University, Werabe, Ethiopia

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Contributions

Girma Gezimu Gebre (PhD): Conceptualization, Methodology, Validation, Writing—original draft, Writing—review & editing. Derebe Ermias Chefebo (Mr): Data collection and manuscript revision. Deribe Kaske Kacharo (PhD): Data collection and manuscript revision.

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Correspondence to Girma Gezimu Gebre .

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This study is based on survey methods involving interviewing farmers to answer questions about their socioeconomic and farming activities, knowledge, attitude and practices towards nutrition. The participation of all research subjects was voluntary. Participants were informed before an interview about the purpose of the study and given the opportunity to refuse upon understanding the purpose. Informed consent was obtained from all the literate participants and legal guardians of the illiterate participants. All procedures were performed in accordance with relevant guidelines.

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Supplementary Information

Additional file 1..

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Gebre, G.G., Chefebo, D.E. & Kacharo, D.K. Knowledge, attitude and practice towards malnutrition and micronutrient deficiency among male and female farmers in Ethiopia. BMC Nutr 9 , 130 (2023). https://doi.org/10.1186/s40795-023-00791-0

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DOI : https://doi.org/10.1186/s40795-023-00791-0

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Top Nutrition Research Paper Topics for Students

Table of contents

• 1 Nutrition Research Topics for College Students
• 2 Interesting Nutrition Topics for Research Paper
• 3 Research Topics in Nutrition and Dietetics
• 4 Sports Nutrition Topics for Research
• 5 Other Popular Nutrition Paper Topics
• 6 Conclusion

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• The effects of thermal processing on nutrients
• Factors contributing to obesity among young Americans
• Different nutritional needs among different age groups
• Dietary differences between low-income and high-income households
• Foods that boost serotonin levels

Exploring the ways how human bodies work and react has interested people for thousands of years. No wonder there are a lot of engaging dietary and nursing research topics for modern students to choose from. You’ve already got acquainted with 70 of our top nutrition topics for research papers, so gather inspiration from our list and get started with your essay!

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Impact of malnutrition on the academic performance of school children in Ethiopia: A systematic review and meta-analysis

Aregash abebayehu zerga.

1 Department of Nutrition, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Sisay Eshete Tadesse

Fanos yeshanew ayele, segenet zewdie ayele.

2 Department of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

This study aimed to identify the impact of malnutrition on the academic performance of children in Ethiopia.

The protocol of this study is registered in PROSPERO with a registration number CRD42021242269. A comprehensive search of studies from HINARY, MEDLINE (via PubMed), EMBASE, Cochrane Library, SCOPUS, Google Scholar, and Google was conducted. All published and unpublished studies conducted about the effect of any forms of malnutrition on academic performance of elementary school children in Ethiopia using the English language were included. Quality of the articles was assessed using the Joanna Briggs Institute critical appraisal tool. The pooled log odds ratio with 95% confidence interval was determined to identify the effect of malnutrition on academic performance. I-square statistics was applied to check the degree of heterogeneity between studies. The presence of publication or small study bias had been assessed by Funnel plots, Egger’s weighted regression test, and Begg’s rank correlation test.

A total of 10 studies were included in this study. The pooled prevalence of good academic performance among elementary school students in Ethiopia was 58% (95% confidence interval: 48%, 69%). Stunting (odds ratio = 0.48; 95% confidence interval: 0.30, 0.79), underweight (odds ratio = 0.38; 95% confidence interval: 0.27, 0.53), and iodine deficiency (odds ratio = 0.49; 95% confidence interval: 0.31, 0.78) had a significant association with the academic performance. Rural residence (odds ratio = 0.61; 95% confidence interval: 0.44, 0.83), being female (odds ratio = 0.53; 95% confidence interval: 0.37, 0.77), and uneducated parent (odds ratio = 0.51; 95% confidence interval: 0.44, 0.58) were also factors associated with good academic performance of primary school children in Ethiopia.

Conclusion:

This study concluded that malnutrition in the form of stunting, underweight, and iodine deficiency affected the academic performance of elementary school children in Ethiopia. So, the Ministry of Health worked better to strengthen the nutrition intervention at the critical periods of brain development.

Introduction

Malnutrition refers to deficiency, excess, or an impaired utilization of one or more essential nutrients. 1 It consists of both under and over-nutrition. 2 Undernutrition includes wasting, stunting, underweight, and micronutrient deficiencies. 3 Malnutrition in any of its forms is a significant public health problem. 4 Globally, 29.8% of school-age children have insufficient iodine intake. 5 In India, 54% of school children were under-nourished. 6 In Africa, the prevalence of iodine deficiency among school-age children was 39.3%. 7 In Ethiopia, the prevalence of wasting, underweight, and stunting among primary school children were 17.7%, 18.2%, and 21.3%, respectively. 8 Malnutrition has substantial effects on the neurological development and behavioral capacity of children. 9 Thus, malnourished children may never reach their full scholastic potential. Malnutrition among school age can result in impaired cognitive and motor development, which may undesirably upset academic performance through reduced learning capacity and poor school attendance. 10 , 11

Concurrent with malnutrition, quality of education is a big challenge in Ethiopia. 12 One of the sustainable development goals agenda is inclusive, equitable, and quality education. 13 Ethiopia is doing well in terms of enrollment and coverage of universal primary education. But the total score of grade 8 students has consecutively decreased from 41.1% in 2000 to 35.3% in 2010. 14 The dropout rate, grade repetition, and completion rate of elementary school student was 13.9%, 5%, and 71%, respectively. 15 A qualitative study reported that teachers have complained about their students’ poor academic performance in school. 12 Hence, poor academic achievement has been the main concern for teachers, parents, and students.

Academic performance can be affected by gender, age, residence, study hours, absenteeism, socio-economic status, illness, medium of instruction, and malnutrition. 16 – 18 Malnutrition is the main factor for poor academic performance and contributed to the development of other factors. 19 , 20 Studies showed that malnutrition among school-age children is a risk factor for high absenteeism, early dropouts, low school enrollment, and unsatisfactory classroom performance. 21 , 22

Efforts such as School Feeding Program have been made to improve the nutritional status, enrollment, attendance, retention, and completion rate of students. 23 – 25 However, still many school children suffer from poor nutrition and academic achievement. 22 In Ethiopia, studies investigated the effect of malnutrition on the academic performance of primary school children, but there is an inconsistency between their findings. For instance, a study from Dera District and southern Ethiopia reported that stunting was not a factor for academic performance. 26 , 27 Whereas studies from northwest Ethiopia and Lalibela stated that stunting and being underweight were factors for poor academic performance. 28 , 29 There is no nationally representative information on the effect of malnutrition on the academic performance of primary school children. The evidence generated by this study design would be stronger than individual studies to influence policymakers. 30 , 31 Therefore, this study aimed to determine the impact of malnutrition on the academic performance of primary school children in Ethiopia. “Does malnutrition affect the academic performance of elementary school children in Ethiopia?” was the research question of this study.

Materials and methods

Study design, search strategy, and protocol registration.

Systematic review and meta-analysis (SRMA) study design was applied for this study. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was applied to report this SRMA. 32 An extensive search of studies from HINARY, MEDLINE (via PubMed), EMBASE, Cochrane Library, SCOPUS, Google Scholar, and Google was done. “Nutritional status” OR “malnutrition” OR “under-nutrition” OR “stunting” OR “wasting” OR “underweight” OR “height-for-age z score” OR “weight-for-age z score” OR “weight-for-height z score” OR “iron deficiency” OR “iodine deficiency” AND “academic performance” OR “school performance” OR “school achievement” OR “academic achievement” OR “educational performance” AND “primary school children” OR “elementary school children” OR “student” AND “Ethiopia” were used as key terms. The search was undertaken from 1 February to 23 March 2021. This SRMA was registered in PROSPERO with a registration number CRD42021242269.

Inclusion criteria

All published and unpublished observational studies about the effect of malnutrition on the academic performance of elementary school children in Ethiopia were included. Under-nutrition among primary school children were the exposure variable. Normal nutrition among primary school children was the comparison variable/group for this study. Studies assessed academic performance of primary school children using at least two-semester average scores as a primary outcome were included. To get a more comprehensive result, no restriction was made by the year of publication (studies published until 23 March 2021 were included).

Exclusion criteria

Review articles, conferences, abstracts, editorials, and descriptive studies were excluded from this study. We also excluded studies that did not report the outcome of interest and at least one form of malnutrition.

Study selection and data extraction

The article searches and screening activity was performed by two reviewers (AAZ and SET). Articles were exported and managed using Endnote X8 software. Duplicates were identified and removed from the citation manager. Then the remaining articles were assessed for eligibility by title, abstract, and full-text level. Studies conducted out of Ethiopia and with unrelated topics were excluded. Then the abstract and full document of remaining articles was examined. Those studies that were not eligible based on the full-text assessment were excluded and reasons were described. 32 Studies that passed through this selection process were included in the review.

A data extraction sheet was developed using Microsoft Excel worksheet 2013 and the following variables were extracted from each eligible article:

• Study characteristics: name of first author, year of publication, region, study area, study design, and sample size.
• Outcome (number of children with good academic performance) and independent variables (count data with 2 × 2 table, and odds ratio (OR) with 95% confidence interval (CI; where count data not available)).

Quality assessment

The Joanna Briggs Institute (JBI) 33 critical appraisal tool was used to assess the quality of each paper. The tool has Yes, No, Unclear, and “not applicable” answers. A value was given 1 for “Yes” and 0 for “No” and “Unclear” responses. Three investigators (AAZ, FYA, and SZA) independently performed the quality assessment using the JBI criteria. Scores of each item were summed and converted into percentages. The quality scores of the three reviewers were averaged. Disagreement between investigators was solved by discussion and consensus. Agreement between the investigators were determined and there was substantial agreement (kappa = 0.77). 34 Finally, studies with higher scores (> 50%) were included in this SRMA.

Outcome assessment

The main objective of this study was to identify the effect of malnutrition (stunting, underweight, wasting, and micronutrient deficiency) on academic performance in log OR form. In addition to malnutrition, socio-demographic variables such as place of residence, educational status of the family (no-formal education versus formal education), student sex (male versus female), family size (⩾ 5 versus < 5), and income (low versus high) were extracted.

Statistical analysis

The extracted data were exported to STATA version 14.0 for the meta-analysis. The pooled prevalence was calculated to estimate the prevalence of good academic performance. The pooled log OR and its 95% CI was determined to identify the effect of malnutrition on the academic performance of primary school children. Heterogeneity was checked by Higgins’s I-square statistics in which I-square value of > 75%, 50% to 75%, and < 50% was reported as high, moderate, and low heterogeneity, respectively. 35 A random effect model with 95% CI was used to report heterogeneous findings. Meta-regression, subgroup analysis, and sensitivity analysis were conducted to identify the possible sources of heterogeneity. Publication bias was visually identified by funnel plots. The funnel plot asymmetry was statistically checked using Egger’s and Begg’s test. The visual asymmetry of the funnel plot and p-value < 0.05 of the Egger’s and Begg’s test was suggestive of publication bias. 35 , 36 Then, trims and fills analysis was conducted to deal with publication bias. Finally, data were presented in tables and figures.

Study selection and characteristics

A total of 1906 articles were retrieved by literature search. Of these, 398 were excluded because of duplication, 1490 did not have relation with the aim of the study, and 8 did not meet the eligibility criteria due to differences in outcome classification, 37 outcome measurement, 26 target population 38 , 39 and we cannot get the 2 × 2 table and the OR. 40 , 41 Finally, 10 articles were included in this SRMA ( Figure 1 ). All included articles were full text and done using a cross-sectional study design with one prospective cohort. 42 A total of 5626 students participated in the study with a minimum of 273 43 and a maximum of 1254 44 sample population. Studies were obtained from three regions of Ethiopia; Amhara, Oromia, and Southern Nations, Nationalities, and People (SNNP) region that published or posted from 2013 to 2021 ( Table 1 ).

PRISMA flow diagram of included studies in systematic review and meta-analysis of the impact of malnutrition on academic performance of primary school children in Ethiopia from 2013 to 2021.

Characteristics of studies included in this systematic review and meta-analysis about the impact of malnutrition on the academic performance of primary school children in Ethiopia from 2013 to 2021.

SNNP: Southern Nations, Nationalities, and People.

Pooled prevalence of good academic performance

The pooled estimate indicated that 58% (95% CI: 48%, 69%) of elementary school students have good academic performance in Ethiopia. The true heterogeneity among studies other than chance was 98.6% (I 2  = 98.6%, p-value < 0.001). The highest frequency was reported from Lalibela, Amhara region 85% (95% CI: 82%, 88%) and the lowest was from Meskan, SNNP region 32% (95% CI: 27%, 37%; Figure 2 ).

Forest plot for pooled prevalence of good academic performance among elementary school children in Ethiopia, 2013–2021.

Subgroup analysis

Based on the subgroup analysis, the academic performance was highest in Oromia 69% (95% CI: 59%, 78%) followed by Amhara 62% (95% CI: 42, 83%) and then SNNP 42% (95% CI: 32%, 52%). However, the I-square value was still high in each region. Hence, region is not the source of heterogeneity ( Figure 3 ).

Subgroup analysis by region for the pooled good academic performance of elementary school children in Ethiopia, 2013–2021.

Meta-regression and sensitivity analysis

Meta-regression was conducted by including sample size and publication year. But all of these variables were not the sources of heterogeneity (p > 0.05). Sensitivity analysis indicated that there was no study that influences the pooled effect ( Figure 4 ).

Sensitivity analysis for the academic performance of elementary school children in Ethiopia, 2013–2021

Test for publication bias

Visual observation of the funnel plot indicated the presence of some publication bias ( Figure 5 ). However, it was statistically disproved by the Egger’s (p = 0.96) and Begg’s test (p = 0.72).

Funnel plot to detect the presence of publication bias regarding the pooled prevalence of good academic performance among elementary school children in Ethiopia, 2013–2021.

Factors associated with academic performance

Stunting (OR = 0.48; 95% CI: 0.30, 0.79), underweight (OR = 0.38; 95% CI: 0.27, 0.53), and iodine deficiency (OR = 0.49; 95% CI: 0.31, 0.78) had significant negative association with good academic performance. Similarly rural residence (OR = 0.61; 95% CI: 0.44, 0.83), being female (OR = 0.53; 95% CI: 0.37, 0.77), and non-formal educated parent (OR = 0.51; 95% CI: 0.44, 0.58) had significant negative association with good academic performance of Ethiopian primary school children ( Table 2 ).

Factors associated with academic performance among elementary school children in Ethiopia, 2013–2021.

OR: odds ratio; CI: confidence interval.

This SRMA aimed to generate pooled evidence on the impact of different forms of malnutrition on the academic performance of elementary school children in Ethiopia. This study reported that the odds of good academic performance were 57% lower among stunted children than not stunted children. It is similar to studies from Burkina Faso, Vietnam, Benin, and a multi-country cohort study. 49 – 53 This is because stunting is often occurred within the first 1000 days of a child’s life (from conception up to the first 2 years of life) which is a period of children’s rapid brain development takes place. 54 , 55 Once occurred, stunting causes tissue damage, impaired differentiation, delayed myelination, and limited overall development of the brain. 56 , 57 Then it results in aberration of the temporal sequences of brain maturation and the foundation of neuronal circuits. 9 As a result, the brain’s cognitive process, motor and language development will be limited and causes a long-term permanent impact on academic performance of children. 58 This study reported that being underweight reduces the academic performance of children by 68%. However, a study from Bennin reported that underweight cannot affect the cognitive development of children. 51 Since most researchers focus on the effect of stunting on the academic performance, there is no adequate review to compare and set conclusion about underweight.

In this study, good academic performance was 50% lower among iodine-deficient children than in iodine-sufficient children. Similarly, most reviews reported that iodine deficiency is a risk factor for academic performance. 59 – 61 Iodine is an essential micronutrient needed for production of thyroid hormones. 62 Thyroid hormone is necessary for many body processes such as thermal and metabolic regulation, organ and neurological development, and function of the central nervous system by regulating the genetic expression and cell differentiation of the brain. 63 – 65 Therefore, iodine deficiency significantly lowers cognitive capacities ranging from mental retardation to impaired development of intelligence and academic performance. 59 Although iodine deficiency at early age poses irreversible damage, studies conducted among school-age children showed that iodine supplementation can still improve cognitive abilities. 66 , 67 So, iodine fortification should be strengthened to improve the academic performance of primary school children in Ethiopia. 66

In this review, students from rural residences had a lower academic performance than those from urban areas. This finding is in agreement with a policy-brief report of Ethiopia. 68 In contrast to this study finding, a review conducted on rural and urban areas reported that rural students had a better academic performance than urban students. 69 Then again, a study from Benin showed that place of residence had no association with academic performance. 51 This discrepancy might be due to the sociocultural difference between countries.

In this review, the odds of good academic performance were lower among girls than boys. This might be because better preferences had been given to boys and girls are often faced with the burden of household tasks, which hinders their ability to perform successfully at school. However, a review from the global north and south reported that girls were better in academic performance. 69 In addition, a systematic review in Trinidad and Tobago stated that females had better performance than males. 70

In this study, parents’ educational level had a significant association with the academic performance of primary school children. Students from non-educated parents were less likely to have good academic performance than students from formally educated parents. This finding was in agreement with a study from Benin. 51 This might be because children from uneducated parents get less support on doing assignments, project work, homework, class work, and other academic and social issues. Conversely, children from highly educated parents may consider their parents as role models for their academic success. 71

Limitation of the study

This study had the following limitations; first, this meta-analysis represented only studies reported from three regions of Ethiopia. Second, it was limited to articles written in the English language only. Third, the result was highly heterogeneous. Fourth, almost all of the included studies were cross-sectional, which may not show the cause–effect relationships. Fifth, due to the shortage of individual studies, this study cannot assess the effect of iron deficiency on academic performance.

Strength of the study

This review tried to include both published and unpublished studies.

This SRMA concluded that stunting, underweight, and inadequate iodine intake had a significant impact on the academic performance of children. Also being female, rural residents, and from uneducated parents had a negative association with academic performance of children in Ethiopia. So, the Ministry of Health worked better to strengthen the nutrition intervention at the critical periods of brain development. In addition, to improve the nutritional status and the related academic performance of elementary school children, the Ministry of Education enhanced the coverage of school feeding programs by emphasizing rural children, girls, and uneducated parents. Further research is recommended on the effect of iron deficiency/iron deficiency anemia on the academic performance of school children in Ethiopia.

Acknowledgments

We would like to acknowledge Wollo University, College of Medicine and health sciences, School of public health for providing us with basic training on SRMA.

Author contributions: All authors contributed to data analysis, drafting, and revising the article, gave final approval of the version to be published, and agreed to be responsible for all aspects of the work.

Data availability: All the required data are included in the manuscript.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical approval: Ethical approval for this study was obtained from Wollo University, College of Medicine and Health Sciences Ethical Review Committee (CMHS 857/13/13).

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.