According to the WHO, 45% of child deaths are linked to malnutrition^[1]. Every year in Nigeria, malnutrition claims the lives of about one million children under five years of age. The insurgency and consequent displacement of many families in Northern Nigeria in recent times has led many experts to believe that this number might be even higher.

Malnutrition makes children more vulnerable to infection, more prone to severe diseases, and heightens their mortality risk^[i]. To curb malnutrition in Nigeria, several government and donor-supported programs have been introduced, including nutrition counseling, gardening programs, Community Management of Acute Malnutrition (CMAM)^[2], and more recently school feeding programs^[ii]. While there are various kinds of malnutrition i.e. chronic, acute, and micronutrient deficiencies, the focus of this article is acute malnutrition.

Acute malnutrition occurs when children lose weight rapidly because of diets that do not cover their nutritional needs. Acute malnutrition is of significant public health importance, because of the long-term effects it has on children. It is of two kinds – severe and moderate acute malnutrition. Severely malnourished children appear visibly wasted, looking dry and elderly, or show signs of swelling where the child appears puffy and is usually irritable, weak, and tired. Moderately malnourished children also appear wasted with a very low weight for their age. Acutely malnourished children are unable to effectively fight infections and also have poor cognitive memory, which affects their ability to learn.

According to the 2013 National Demographic Health Survey (NDHS), 18% of under-5 children in Nigeria are acutely malnourished. Between 2008 and 2013, there was an increase in the prevalence of moderate acute malnutrition (MAM) by 41% and an increase in prevalence of severe acute malnutrition (SAM) by 98% in Nigeria^[iii]. This increase in SAM prevalence by almost 100% over a five-year period coupled with other poor malnutrition indices somewhat justifies Nigeria’s approach to malnutrition, which utilizes Community Management of Acute Malnutrition (CMAM) to address the problem.

The CMAM approach is all-inclusive with recommendations to address MAM and SAM. However, Nigeria disproportionately focuses on treating SAM. In fact, this SAM-focused approach to CMAM yielded success in intervention states (11 States in Northern Nigeria) where an average of 84.5% SAM cure rate was reported in March 2015^[iv].

Although this SAM cure rate is commendable, it is worrisome to see that Nigeria has not been deliberate in its efforts to address MAM. Several reasons precede this concern:

1. MAM has a higher overall prevalence than SAM in Nigeria (MAM = 5.4% and SAM = 1.8%)^[v]
2. Children typically go through the MAM phase which progresses into SAM when not properly addressed^[vi], and
3. Children with MAM have an estimated three- to four-fold increased risk of overall mortality compared to well-nourished children^[vii]. In other words, no MAM treatment will lead to an increase in SAM incidence.

Is Nigeria implementing the global approach to addressing malnutrition without reflecting on its contextual fit?

CMAM, which has been endorsed by the WHO and UNICEF as an effective malnutrition intervention model, recommends that ‘the dietary management of moderate acute malnutrition should be based normally on nutrition counseling and the optimal use of locally available high protein foods^[viii]. This method focuses on disseminating information on appropriate feeding practices which can increase dietary diversity and meet nutritional requirements. CMAM also recommends the use of supplementary foods^[3] for targeted populations^[ix].

In Nigeria, nutrition counseling is provided to pregnant women and mothers during health education sessions at primary health care (PHC) centers during ante-natal care (ANC) and growth monitoring clinics^[4]. Despite the high frequency of such nutrition counseling sessions, MAM prevalence has only decreased minimally (from 6.5% in 2014 to 5.4% in 2015)^[x]. This is not surprising as this recommended approach assumes that caregivers have access to affordable nutritious foods, and only lack awareness of how to combine foods into appropriate diets for malnourished or at-risk children, consequently not providing any inputs i.e. foods. In reality, families cannot afford the recommended quality and diverse foods, especially the animal protein required to meet nutritional needs, thus providing information without any input may yield little or no results^[xi].

Unfortunately, supplementary foods, which are recommended as a second option to manage moderate acute malnutrition, are currently not utilized in Nigeria because of the high costs and lack of local production^[1]. This must be remedied through significant investment in innovative approaches for local production at low cost^[i]. Nigeria cannot fully comply with the global protocol in managing MAM until supplementary foods are readily available and in-country nutrition program implementers and policy makers must continue to review current strategies to fit national context and ensure their availability. While nutrition counseling remains relevant, alternative solutions such as community feeding programs and local production of supplementary foods should also be put in place.

In addition to reviewing national strategies and policies to align with context, what success stories exist for Nigeria to learn from in addressing this MAM critical burden?

One example for Nigeria to better manage moderate acute malnutrition is the Positive Deviance/Hearth Approach (PD/Hearth). This approach finds uncommon, beneficial practices by mothers or caretakers of well-nourished children from impoverished families and calls for spreading these practices and behaviors to others in the community with malnourished children. PD/Hearth was piloted in Nasarawa, a state in the North Central region of Nigeria, where rates of children progressing from moderate to severe malnutrition dropped from 11.1% in June 2007 to 2.4% in August 2007. Again, this model provides no input but rather focuses on using the Hearth sessions to discover practices within these impoverished communities that have led to success.

Another example is the Nutrition Impact and Positive Practice program (NIPP), an expansion of the PD/Hearth Approach, which in addition to spreading existing beneficial practices within the communities also includes micro-gardening and participatory cooking demonstrations. Only locally available and accessible foods are used and recipes are designed and promoted for replication at home. Additionally, one-off starter seed packs are provided with only self-regenerating seeds, focused on trying to address prominent micro-nutrient deficiencies. NIPP is currently being implemented in Niger, Sudan, South Sudan, Zimbabwe, and Malawi^[xii]. Between 2013–2015, 80% of children between 6 and 59 months admitted to NIPP with MAM were discharged and cured at the end of the three-month intervention^[xiii].

Furthermore, countries such as Peru and Brazil have utilized multi-sectoral approaches in tackling malnutrition. Particularly in Brazil, the focus was not nutrition specific^[5] but rather in the articulation of nutrition sensitive^[6] programs to reduce poverty, inequality, and food insecurity, through conditional cash transfers^[7], school feeding programs and food acquisition programs that lend support to local farmers – which have reduced malnutrition prevalence^[8] from 13.5 to 7.1 over a 10-year period.

Conclusion

Nigeria’s approach to addressing malnutrition is disproportionately focused on SAM and needs to be restructured.

There needs to be a focus on MAM treatment and prevention programs that are context-driven, locally acceptable, and community-driven. Already existing gardening programs should be intensified with an added community mobilization component, with long-term plans of introducing PD/Hearth and NIPP approaches that will also utilize community structures and resources. The strong emphasis on community structures and resources is important for sustainability since current MAM prevalence is about three times the SAM prevalence which would make reliance on external resources or governments for treatments expensive and consequently unsustainable.

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FOOTNOTES

[1] Malnutrition includes under nutrition and over nutrition, both of which lead to poor health conditions and early death in developing and developed countries around the world. Malnutrition is often times used to refer to under nutrition which encompasses chronic malnutrition (stunting), acute malnutrition (wasting), and deficiencies of micronutrients.

[2] CMAM is a methodology for treating acute malnutrition in young children using a case-finding and triage approach. Using the CMAM method, malnourished children receive treatment suited to their nutritional and medical needs. CMAM includes community mobilization, supplementary feeding program (for MAM), out-patient therapeutic programs (for SAM without medical complications), and stabilization centers/in-patient care (for SAM with medical complications).

[3] Supplementary foods refer to specially-formulated foods in ready-to-eat or milled form, which are modified in their energy density, protein, fat, or micronutrient composition to help meet the nutritional requirements of specific populations.

[4] As part of the minimum health care package provided at PHC facilities throughout Nigeria, the nutrition package includes counseling sessions, cooking demonstrations, and growth monitoring clinics.

[5] Nutrition-specific interventions address the immediate causes of under nutrition like inadequate dietary intake and some of the underlying causes such as feeding practices and access to food.

[6] Nutrition-sensitive interventions can address some of the underlying and basic causes of malnutrition by incorporating nutrition goals and actions from a wide range of sectors. They can also serve as delivery platforms for nutrition-specific interventions.

[7] Conditional cash transfer (CCT) programs aim to reduce poverty by making welfare programs conditional upon the receivers’ actions. The government (or a charity) only transfers the money to persons who meet certain criteria.

[8] Chronic malnutrition is a form of malnutrition that occurs overtime. A child who is chronically malnourished often appears to be normally proportioned but is actually shorter than normal for his/her age.

REFERENCES

[i] Specially formulated foods for treating children with mode rate acute malnutrition in low- and middle-income countries. 2013. The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

[ii] This is the Federal Government’s Plan for a Homegrown School Feeding Programme in Nigeria. Ventures Africa. 2016.

[iii] Nigeria Demographic Health Survey, 2013

[iv]  Costs, cost-effectiveness, and financial sustainability of CMAM in Northern Nigeria. 2015. Emergency Nutrition Network. Field Exchange.

[v] Nigerian Nutritional and Health Survey, 2015

[vi] Ibid., 1

[vii] Ibid., 1

[viii] CMAM. Valid International.

[ix] World Food Program Nutrition Policy, Nutrition Programs and Food Supplements. Updated with New Evidence, Scientific Knowledge and Global Partnerships.

[x] Ibid., 3; National Nutritional and Health Survey, 2014

[xi] Nigeria Food Consumption and Nutrition Survey. 2001 – 2003.

[xii] Nutrition Impact and Positive Practice (NIPP) Circles. Vimbai Chishanu, Okello Aldo Frank, Sarah Ibrahim Nour, Hatty Barthorp and Nikki Connell.

[xiii] Nutrition Impact and Positive Practice: nutrition-specific intervention with nutrition-sensitive activities. Sinead O’Mahony and Hatty Barthorp