Child Malnutrition in Nigeria: Evidence from Kwara State Oluyemisi Kuku-Shittu, Oluseye Onabanjo, Olusegun Fadare, and Motunrayo Oyeyemi July 2016 WORKING PAPER 33 i TABLE OF CONTENTS 1. Introduction ............................................................................................................................................................... 1 2. Literature Review ...................................................................................................................................................... 2 2.1 Childhood Nutrition and Malnutrition in Nigeria .................................................................................................. 2 2.2 Micronutrient Malnutrition ................................................................................................................................. 4 2.3 Food Consumption and Micronutrient Intake Studies in Nigeria .......................................................................... 9 2.4 Studies on Blood Concentrations of Vitamin A and Iron.....................................................................................12 2.5 Infant and Child Feeding Patterns in Nigeria.....................................................................................................16 2.6 Impact of Improved Water, Sanitation, and Hygiene (WASH) Practices on Nutrition Outcomes ............................18 3. Measures to Prevent and Control Micronutrient Malnutrition in Nigeria .........................................................................19 3.1 Control Strategies for Vitamin A Deficiency in Nigeria .......................................................................................19 3.2 Biofortification ................................................................................................................................................20 3.3 School Feeding ..............................................................................................................................................21 3.4 Regulatory Requirements on Food Labeling and Fortification ............................................................................21 4. Case Study of Nutrition in Kwara State, Nigeria ..........................................................................................................23 4.1 Study Area .....................................................................................................................................................23 4.2 Studies on Prevalence of Malnutrition in Kwara State........................................................................................24 5. Data and Methodology ..............................................................................................................................................25 5.1 Survey Sampling Procedure ............................................................................................................................25 5.2 Data Collection and Analysis Procedures .........................................................................................................26 6. Socioeconomic Context of Households ......................................................................................................................27 6.1 Social Characteristics of Household Members ..................................................................................................27 6.2 Economic Characteristics of Households..........................................................................................................29 6.3 Living Conditions ............................................................................................................................................32 7. Nutritional Context of Households ..............................................................................................................................33 7.1 Macronutrient Consumption ............................................................................................................................33 7.2 Micronutrient Consumption..............................................................................................................................36 8. Results ....................................................................................................................................................................39 8.1 Nutritional Outcomes for Children ....................................................................................................................39 8.2 Nutritional Status of Women of Reproductive Age.............................................................................................44 8.3 Indicators of Morbidity and Infant and Young Child Feeding Practices ................................................................45 8.4 Child Health ...................................................................................................................................................46 8.5 Immunization Coverage ..................................................................................................................................47 9. Summary, Conclusions, and Recommendations .........................................................................................................48 Appendixes ...................................................................................................................................................................50 Appendix 1. Full List of Ethnic Groups in the Study by Village ...................................................................................50 Appendix 2. Total Household Members by Ethnic Group ..........................................................................................50 Appendix 3. Consumption Frequency of Foods by Study Households, by Food Group................................................51 Appendix 4. Food Groups Included in the Dietary Diversity Scores ............................................................................52 Appendix 5. Anthropometric Status of Children Aged 0 to 59 months, by Age Groups.................................................52 Appendix 6. Water, Sanitation, and Hygiene and Prevalence of Malnutrition among Children under Five .....................53 References ...................................................................................................................................................................54 i i LIST OF TABLES Table 2.1—Recommended levels of daily intake of key minerals and vitamins for the population of Nigeria, by age, sex, and pregnancy or lactation status ..................................................................................................................11 Table 2.2—Summary of studies reporting dietary intake of vitamin A in Nigeria .................................................................13 Table 2.3—Summary of studies reporting dietary intake of iron in Nigeria .........................................................................13 Table 2.4—Summary of vitamin-A status of children and women in Nigeria using blood vitamin A concentration .................15 Table 3.1—Mandatorily forti fied food items with levels of fortification required ...................................................................22 Table 3.2—Levels of compliance with forti fication standards at retail level.........................................................................22 Table 4.1—Nutritional status of children under five years of age in Kwara State, Nigeria ....................................................24 Table 5.1—Eligible and listed households by village and local government .......................................................................25 Table 5.2—Number of households by main ethnic group, by village and local government area .........................................26 Table 6.1—Age distribution of eligible children sampled...................................................................................................27 Table 6.2—Caregiver characteristics, by ethnic group......................................................................................................28 Table 6.3—Household head characteristics, by ethnic group............................................................................................29 Table 6.4—Number of wives per household, by ethnic group ...........................................................................................29 Table 6.5—Primary activities of household head and spouse(s) .......................................................................................30 Table 6.6—Size of farmers’ land parcels, by ethnic group ................................................................................................30 Table 6.7—Ownership of household assets ....................................................................................................................31 Table 6.8—Ownership of livestock, by ethnic group .........................................................................................................32 Table 6.9—Ownership of farm tools, by ethnic group .......................................................................................................32 Table 7.1a—Caregivers categorized by dietary diversity according to consumption of different food groups, percentage of group that consumed food from food group........................................................................................................35 Table 7.1b—Caregiver dietary diversity by ethnic group, percentage of total in dietary diversity group ................................35 Table 7.2a—Consumption of different food groups by children under five years of age, percentage that consumed food from food group by categories of dietary diversity and by age of child......................................................................35 Table 7.2b—Make-up of children’s dietary diversity categories by ethnic group, percent of members in category ................36 Table 7.3—Ownership and frequency of consumption of livestock and livestock products, frequency .................................36 Table 7.4—Awareness and use of iodized salt, by ethnic group........................................................................................37 Table 7.5—Number of households consuming fortified commodities .................................................................................38 Table 7.6—Market locations and market day intervals .....................................................................................................38 Table 8.1—Maternal education and prevalence of malnutrition among children aged 0 to 59 months ..................................43 Table 8.2—Prevalence of malnutrition by household size, percentage ..............................................................................44 Table 8.3—Prevalence of low birth weight by gender and mother’s education ...................................................................44 Table 8.4—Water, sanitation, and hygiene conditions and prevalence of malnutrition among children aged 0 to 59 months ................................................................................................................................................................44 Table 8.5—Percentage distribution of BMI of women, by ethnic group ..............................................................................45 Table 8.6—Indicators of morbidity and infant and young child feeding practices, by ethnic group, percentage .....................46 Table 8.7—Treatment of diarrhea in children, by ethnic group, percent using treatment .....................................................47 Table 8.8a—Total immunization coverage of children aged 0 to 59 months, percent ..........................................................48 Table 8.8b—Immunization coverage of children aged 0 to 59 months, by ethnic groups, percent ........................................48 i i i LIST OF FIGURES Figure 2.1—Trends in nutritional status of children under five in Nigeria, 1990–2014 .......................................................... 3 Figure 2.2—Iodine status of children under five in Nigeria, by agro-ecological zone ............................................................ 5 Figure 2.3—Severity of iodine deficiency status of children, mothers, and pregnant women in Nigeria ................................. 5 Figure 2.4—Nutritional iron status of children under five in Nigeria, by geopolitical zone ..................................................... 6 Figure 2.5—Vitamin A status of children under five in Nigeria ............................................................................................ 7 Figure 2.6—Vitamin-A status of children under five in Nigeria, by geopolitical zone ............................................................ 8 Figure 2.7—Maternal vitamin-A status in Nigeria, by geopolitical zone ............................................................................... 8 Figure 4.1—Map of Kwara Sate showing the 16 local government areas ..........................................................................23 Figure 5.1—Map of surveyed villages and distance from the capital, Ilorin ........................................................................26 Figure 6.1—Percentage of sample owning categorized household assets, by ethnic group ................................................31 Figure 6.2—Percentage of sample utilizing unimproved sanitation facilities, by ethnic group ..............................................33 Figure 7.1—Percentage of household members in different dietary diversity groups ..........................................................34 Figure 8.1—Prevalence of malnutrition among children aged 0 to 59 months, percentage..................................................39 Figure 8.2—Prevalence of malnutrition (mild, moderate, and severe) in children aged 0 to 59 months ................................39 Figure 8.3—Distribution of weight-for-height z-scores (wasting) in children aged 0 to 59 months ........................................40 Figure 8.4—Distribution of height-for-age z-scores (stunting) in children aged 0 to 59 months ............................................40 Figure 8.5—Distribution of weight-for-age z-scores (underweight) in children aged 0 to 59 months .....................................40 Figure 8.6—Prevalence of malnutrition in children aged 0 to 59 months, by major ethnic group ..........................................41 Figure 8.7—Prevalence of malnutrition in children aged 0 to 59 months, by gender ...........................................................41 Figure 8.8—Distribution of weight-for–height z-scores (wasting) in children aged 0 to 59 months, by gender.......................42 Figure 8.9—Distribution of height-for–age z-scores (stunting) in children aged 0 to 59 months, by gender ..........................42 Figure 8.10—Distribution of weight-for–age z-scores (underweight) in children aged 0 to 59 months, by gender..................42 Figure 8.11—Distribution of malnutrition in children aged 0 to 59 months, by age groups ...................................................43 Figure 8.12—Percentage distribution of BMI in adult women ............................................................................................45 Figure 8.13—Illness profile over the past two weeks of children aged 0 to 59 months, by illness.........................................46 Figure 8.14—Percentage distribution of treatment locations by mothers............................................................................47 iv ABBREVIATIONS AND ACRONYMS EBF exclusive breast feeding FAO Food and Agriculture Organization of the United Nations FMOH Federal Ministry of Health FUNAAB Federal University of Agriculture, Abeokuta IFPRI International Food Policy Research Institute IMR infant mortality rate IYCF infant and young child feeding KAP knowledge attitude and practice LBW low birth weight LGA local government area MDG Millennium Development Goals MICS Multiple Indicator Cluster Survey NDHS Nigeria Demographic and Health Survey NFCNS Nigeria Food Consumption and Nutrition Survey NGO non-governmental organization NID National Immunization Days UNICEF United Nations Children Fund WASH water quality and supply, sanitation and hygiene WHO World Health Organization 1 1. INTRODUCTION Food security is defined as “a situation that exists when all people, at all times, have physical, social, and economic access to sufficient, safe, and nutritious food that meets their dietary needs and food preferences for an active and healthy life” (FAO 2002). This definition implies that food insecurity reflects uncertain access to sufficient appropriate foods (Barrett 2002) and encompasses three main concepts: availability, access, and utilization. First, “availability” in the macro sense refers to the efforts by governments to ensure that sufficient quantities of food are available for people within a certain geographic region. As a result of slow growth in the agricultural sector and rapid in- creases in population, Nigeria has evolved from being self-sufficient in food production to being heavily dependent on food imports. This dependence on imports makes Nigeria vulnerable to fluctuating prices in the world market. The spike in world food prices in 2007 and 2008 caused inflation to rise from 5.4 percent in 2007 to 9.7 percent in 2008, and the share of in- come spent on food within the same period increased from 45 percent to 80 percent (NISER 2008). Consequently, poor agri- cultural output and widespread poverty resulted in extensive and persistent food insecurity, with some case studies suggest- ing that as many as 70 percent of Nigerians are food insecure (Orewa and Iyangbe 2009; Obayelu 2010). The second component of food security, access, refers to the ability of households to obtain food in the marketplace or from other sources. The major constraints facing the agricultural sector, including food price fluctuations due to overexpo- sure to world markets, imply that food access may be compromised for the poorest Nigerians. While imports may bridge the gap in food supply in a macro sense, financially disadvantaged Nigerians may not have adequate economic access to quality food. In 2011, about 71 percent of total household expenditure was spent on food, with households in the northeast and northwest regions spending the highest proportions (64 percent and 73 percent, respectively). In addition, the diet of most Nigerians mostly consists of staple foods but few animal proteins like meat and fish. While cereals and tubers are consumed every day, animal proteins are consumed on average about four times a week. This varies by region, however, with animal proteins only consumed an average of two days per week in the northwest (Kuku-Shittu 2013). The third component of food security is utilization, which refers to the proper usage of food, including processing, storage, consumption, and digestion. Utilization is often measured via anthropometric variables that indicate malnutrition levels. Many studies have confirmed significant variations in the level of malnutrition across rural and urban settings, geopo- litical zones, and agro-ecologies in Nigeria (NPC/ORC Macro 2004; Maziya-Dixon et al. 2004; NDHS 2008; NPC/ICF Macro 2009; NDHS 2013). All these data sources confirm that child undernutrition is high and that Nigeria is far from the targets recommended for achievement by 2015. Studies have revealed that hunger and malnutrition continue to be pervasive in Ni- geria (Maziya-Dixon et al. 2004; NPC/ICF Macro 2009); they tend to be primarily concentrated in rural agricultural areas and more acute among the landless, pastoralists, smallholders, and hired agricultural workers (Southgate et al. 2007; AU/NEPAD 2007). African children make up one-quarter of the estimated 148 million underweight children globally. Although under- weight prevalence has decreased slightly in Africa (from 29 percent to 26 percent over the past 17 years), the absolute num- ber of underweight children has increased by 8 million, meaning that the rate of decline has not kept pace with population growth (Black et al. 2008). More than one-third of children under five in Africa are stunted—that is, having low height for their age (World Health Statistics 2009). In Nigeria, available data from the 2001–2003 Food Consumption and Nutrition Survey show that 42 percent of children under five were stunted, 25 percent underweight, and 9 percent wasted (Maziya-Dixon et al. 2004). The data suggest high levels of protein-energy malnutrition, which is usually accompanied by poor micronutrient sta- tus. Data from the 2013 Nigeria Demographic Health Survey (NDHS) corroborated the findings of the Nigeria Food Con- sumption and Nutrition Survey (NFCNS) of 2001–2003, suggesting that no improvement had occurred in the anthropometric indicators of children under 5 over a 10-year period. The 2013 NDHS found that more than two out of every five children were stunted, which reflects the cumulative effect of chronic malnutrition, with significantly higher proportion of stunted males (43 percent) than females (38 percent); 45 percent of children in rural areas were stunted versus 31 percent in urban areas. Micronutrients are vital components of good nutrition, and their deficiency in the human diet is responsible for many health problems. Vitamin A, iron, iodine, zinc, and folate are currently the most widely studied micronutrients. Large numbers of people globally are micronutrient deficient, and this deficiency remains a threat in many African countries. Both vitamin and mineral deficiency afflict one-third of the population in Africa south of the Sahara, affecting minds, bodies, energies, and the economic prospects of nations. More than 20 percent of children under five years of age suffer from vitamin A deficiency in 37 countries throughout the region (Mason & Beda-Andourou et al. 2005). The prevalence of anemia is higher than 40 percent in many African countries. Thirteen countries currently have iodine deficiency rate of over 50 percent in school- aged children (UNICEF 2009). The micronutrient deficiency indicators in Nigeria reveal that 28 percent of children under five http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Malnutrition#cite_note-0 http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Malnutrition#cite_note-1 http://www.aho.afro.who.int/profiles_information/index.php/AFRO:Malnutrition#cite_note-1 2 were suffering from iron deficiency anemia (IDA), 29.5 percent from vitamin A deficiency (VAD), and 29.6 percent from iodine deficiency (Maziya-Dixon et al. 2004). Also the 2004 Vitamins and Minerals Deficiency Damage Assessment Report for Ni- geria reported that an estimated 11,000 young Nigerian women die every year in pregnancy and child birth due to severe iron deficiency anemia (FMOH/MI/UNICEF 2004). High prevalence of IDA, VAD, and iodine deficiency disorders (IDD) are not exclusively found in Nigeria; indeed the conditions afflict about 30 percent of the world’s population (WHO/UNICEF/UNU 1998; WHO 2001). As in Nigeria these deficiencies often coexist in children especially in developing countries (Zimmermann et al. 2003). IDA interferes with the thyroidal metabolism of iodine and it has been reported that it may, in fact, reduce the efficacy of iodine prophylaxis (Zimmermann et al. 2000). The study discussed in this paper was conducted to provide a closer understanding of malnutrition in Nigeria as a major public health challenge, with a particular focus on Kwara state, in the west of the North Central geopolitical zone. The objectives of the study are to: • Conduct an in-depth desk review of malnutrition and its determinants among vulnerable groups in the Nigerian context, with special emphasis on micronutrient deficiencies by region. • Identify the current state of policies to reduce malnutrition in Nigeria. • Examine trends in determinants of malnutrition among the rural poor in Kwara State. • Understand the food consumption patterns of the rural poor in Kwara State. • Identity the nutrition status of vulnerable groups in Kwara State. • Assess the diversity of diets consumed by individual household members in Kwara State. • Investigate respondents’ knowledge and awareness of micronutrients, fortification, and biofortification. In the next section, an in-depth and comprehensive review of the current state of vulnerable groups in Nigeria with regard to malnutrition and micronutrient deficiencies is presented. We provide a brief overview of current efforts being made to tackle these deficiencies. An overview of the nutrition literature and Kwara State, where the study was conducted, is pre- sented in the fourth section, while the data and methods used to pick the sample and analyze the data are presented in the fifth section. Contextual socioeconomic, environmental, and nutritional information about the sample are presented in the sixth and seventh sections of this report. Major nutrition outcomes of vulnerable groups are presented in Section 8. The re- port concludes with a summary and recommendations in Section 9. 2. LITERATURE REVIEW 2.1 Childhood Nutrition and Malnutrition in Nigeria According to the Food and Agriculture Organization of the United Nations (FAO 2013), more than 14 percent of the popula- tion in developing countries were undernourished in the period between 2011 and 2013. Malnutrition includes both nutrient deficiencies and excesses and is defined by the World Food Programme as “a state in which the physical function of an indi- vidual is impaired to the point where he or she can no longer maintain adequate bodily performance processes such as growth, pregnancy, lactation, physical work, and resistance to and recovering from disease” (2005). It results in disability, morbidity, and mortality, especially among infants and young children (Pelletier 1994). Malnutrition often begins at concep- tion, and child malnutrition is linked to poverty, low levels of education, and poor access to health services, including repro- ductive health and family planning (IFPRI 2014). Undernutrition is mostly associated with developing countries like Nigeria (DHS 2013). Two main types of malnutrition have been identified in Nigerian children: (1) protein-energy malnutrition and (2) mi- cronutrient malnutrition. Protein-energy malnutrition among preschool children is a major public health problem across the country. “Stunting” is typically defined as low height-for-age, but, more specifically, it is a deficit of linear growth and failure to reach genetic potential that reflects long-term and cumulative effects of inadequate dietary intake and poor health conditions (ACC/SCN 2000). Low weight-for-age is called “underweight” while “wasting” is severe underweight or substantial weight loss that is usually a consequence of acute food shortage or disease. (The NCHS/CDC/WHO International Growth Refer- ence reports data on these levels in a set of published indices, which served as a reference for this study.) National and regional statistics on anthropometric indicators in Nigeria have been consistently dire. In 1983–1984, the National Health and Nutrition Survey (HANS) conducted by the Federal Ministry of Health estimated the prevalence of wasting to be around 20 percent (FGN 1983–1984). A 1986 Demographic and Health Survey (DHS) of children ages 6–36 months in Ondo State (southwestern Nigeria) found the prevalence of wasting to be 6.8 percent, underweight 28.1 percent, and stunting 32.4 percent. In February 1990, an anthropometric survey of preschool children (2–5 years old) in seven states 3 found underweight prevalence ranging from 15 percent in Akure (Ondo State) to 52 percent in Kaduna (Kaduna State) while stunting prevalence ranged from 14 percent in Iyero-Ekiti (Ondo State) to 46 percent in Kaduna. In addition, the 1990 DHS survey conducted by the Federal Office of Statistics estimated the prevalence of wasting at 9 percent, underweight at 36 per- cent, and stunting at 43 percent among preschool children. These figures are lower than the figures published in 1994 by UNICEF-Nigeria from a 1992 survey conducted among women and children in 10 states; the UNICEF report showed the prevalence of wasting among women and children at 10.1 percent, underweight 28.3 percent, and stunting 52.3 percent. There was a decrease in prevalence of stunting in the 2003 NDHS with 11 percent of children wasted, 24 percent under- weight, and 42 percent of children stunted (NDHS 2003). By 2008 prevalence of underweight had decreased to 23 percent and stunting had dropped to 41 percent but wasting increased to 14 percent (NDHS 2008). Similar trends were reported by the 2001–2003 NFCNS: 9 percent wasting, 25 percent underweight, and 42 percent stunting, with significant variations across rural and urban areas, geopolitical zones, and agro-ecological zones (Maziya- Dixon et al. 2004). The study showed that prevalence of stunting was lowest in the southeast at 16 percent; it reached 18 percent in the south and 55 percent in the northwest. Among the states, stunting was highest among children in Kebbi (61 percent). The 2003 NDHS showed that rural children (43 percent stunted) were disadvantaged compared to urban children (29 percent stunted). Children living in the Northwest geopolitical zone stood out as being particularly disadvantaged at 55 percent compared to 43 percent in the Northeast zone, 31 percent in North Central, 25 percent in the Southwest, 21 percent in the South-South, and 20 percent in the Southeast. Among the three broad agro-ecological zones used in the 2001–2003 NFCNS, the stunting rate was 58 percent in the dry savannah, 46 percent in the moist savannah, and 27 percent in the hu- mid forest zone. Similar patterns were reported for underweight and wasting. Additional studies have also shown that malnu- trition is more pronounced in the rural areas and rural children are more disadvantaged than urban children in Nigeria (UNICEF 1998; MICS 2011; NDHS 2003, 2008, 2013). There was a decrease in prevalence of malnutrition in the 2011 reports of the Multiple Indicator Cluster Survey (MICS) in Nigeria with 34 percent of children under five stunted, 31 percent underweight, and 16 percent wasted, while about 15 percent of children had low birth (at less than 2,500 grams at birth) (MICS 2011). It is evident from the 2013 NDHS that the proportion of children who are stunted has been decreasing over the years. However, the extent of wasting has wors- ened, indicating a more recent nutritional deficiency among children in the country. Prevalence of stunting decreased to 37 percent, with a higher concentration among rural children (43 percent) than urban (26 percent). However, the proportion of children underweight (29 percent) and wasting (18 percent) increased (NDHS 2013). Similarly, the 2014 National Nutrition and Health Survey Report by the National Bureau of Statistics and UNICEF shows that children’s nutritional status modestly improved since 2013, according to the 2013 NDHS report, with 32 percent of children under five stunted, 21 percent under- weight, and 9 percent wasted. The trend in the nutritional status of children under five from 1990 to 2014 is displayed in Fig- ure 2.1. It is is based on the child growth standards adopted by the World Health Organization (WHO) in 2006. Figure 2.1—Trends in nutritional status of children under five in Nigeria, 1990–2014 Note: NDHS Nigeria Demographic and Health Survey; NFCNS = Nigeria Food Consumption and Nutrition Survey; M ICS = Multiple Indicator Cluster Survey. Source: NDHS 2013; NBS/UNICEF 2014. 43 42 42 41 34 37 32 36 24 25 23 31 29 21 9 11 9 14 16 18 8.7 0 5 10 15 20 25 30 35 40 45 50 NDHS 1990 NDHS 2003 NFCNS 01-04 NDHS 2008 MICS 2011 NDHS 2013 NBS/UNICEF 2014 Stunting Underweight Wasting 4 A similar study on child nutrition in northern Nigeria assessed the nutritional status of children under five and women 15–49 years old in eight northern states (UNICEF 2012). More than 40 percent of children under five suffered from stunting across northern Nigeria. In addition, 17 percent of adolescent girls were pregnant in the surveyed areas and found to be more malnourished than older women. It was concluded that undernutrition is a major development concern. Comparing data from these different studies, it is clear that malnutrition of children under five has been a consistent problem in Nigeria over time, with too little improvement recorded since the beginning of health reform in Nigeria. The report computed from the NDHS on nutritional status in northern Nigeria revealed that household economic status has a positive effect on child nutrition. Additional important factors in nutritional status include maternal education; the quality of healthcare facilities for women and children (which is particularly poor in the northern states); immunization levels; and women’s in- comes, livelihoods, and overall empowerment (Ajieroh 2009; Murphy 2013). Malnutrition contributed to 53 percent of deaths among children under five in Nigeria, and levels of wasting and stunting are still very high (UNICEF 2007). 2.2 Micronutrient Malnutrition Micronutrient deficiency or “hidden hunger” occurs when essential vitamins and/or minerals are not present in adequate amounts in the diet; it is a serious public health concern in most developing countries that has devastating effects on vulner- able groups, including pregnant and lactating women and children under five (WFP 2005). According to WHO, one in three people in developing nations are affected by deficiencies in micronutrients; in Nigeria, those deficiencies are primarily in io- dine, iron, and vitamin A. If left unchecked, micronutrient deficiencies can lead to irreversible physical consequences, which is why they are considered a major health issue deserving international attention. Micronutrient malnutrition is responsible for a significant share of infant mortality (Bryce et al. 2003). IODINE DEFICIENCY Iodine is essential for the normal growth and development of the human body. It is required for the production of thyroid hormones, which are necessary for normal brain development (WHO/UNICEF/ICCIDD 2007). Insufficient intake of iodine in the diet causes a myriad of health problems collectively known as Iodine Deficiency Disorders (IDD). The health consequences of IDD include mental retardation, goiters, growth retardation, and increased neonatal and post-natal mortality. Lack of iodine at conception causes maternal hypothyroidism, which has dramatic consequences for the fetus, including severe and irrevers i- ble brain damage. It is estimated that 2 billion people, or 30.6 percent of the global population, have insufficient iodine intake, including 59.7 million school-aged children in Africa (UNICEF 2007; de Benoist et al. 2007). Data from the 2001–2003 NFCNS revealed that a total of 27.5 percent of children suffered various degrees of iodine deficiency, while 46.5 percent had more than adequate levels (Maziya-Dixon 2004). The deficiency was severe in 4.2 per- cent, moderate in 8.7 percent, and mild in 14.6 percent of children. Only 26 percent of children had optimal levels of iodine. However, it is noteworthy that 16.6 percent of children had more than adequate levels, while 29.8 percent had a possible excess intake of iodine and ran the risk of adverse health consequences. More than 20 percent of the total population suf- fered from goiter, the abnormal enlargement of the thyroid gland, which is the most severe form of iodine deficiency. En- demic iodine deficiency reduces the IQ by 3.5 percent, permanently affecting intellectual development. A total of 27.5 per- cent of children suffered various degrees of iodine deficiency while 46.5 percent had more than adequate levels. Deficiency of iodine was reported in 10.6 percent of children under five in the medium (semi-urban) sector, 10.6 percent in the urban sector, and 15.5 percent in the rural sector. More than adequate and possible excessive intakes of iodine were seen in 42 percent of children under five in the rural sector, 49 percent in the urban sector, and 51 percent in the medium sector. Iodine deficiency in mothers by agro-ecological zones (Figure 2.2) was 11.6 percent in the dry savannah, 15.2 per- cent in the humid forest, and 19.0 percent in the moist savannah. The percentage of those with mild deficiency ranged from 16.8 to 21.6 percent across zones. Iodine deficiencies among mothers were 10 percent in the urban sector, 13.7 percent in the medium sector, and 21 percent in the rural sector. A more than adequate intake was seen in 16.6 percent of the mothers in the rural sector, 20.3 in the urban sector, and 20.6 percent in the medium sector. Those with possible excess iodine intake were observed in the rural (14.6 percent), urban (24.4 percent), and medium sectors (25.9 percent). 5 Figure 2.2—Iodine status of children under five in Nigeria, by agro-ecological zone Source: Maziya-Dixon et al. 2004. In pregnant women, deficiency rates were 8 percent for the dry savannah, 11.3 percent for the humid forest, and 15 percent for the moist savannah. Although the deficiency level was low, over one-fifth of pregnant women in all zones had a possible excess iodine intake: 22.3 percent in the dry savannah, 22.4 percent in the moist savannah, and 25.8 percent in the humid forest. There were more pregnant women with adequate iodine status in the dry savannah (34.7 percent), compared to those in the moist savannah (28.4 percent) and humid forest (27.4 percent). Across the zones, the percentages of preg- nant women with adequate iodine nutrition ranged from 27.4 to 34.9 percent. Among pregnant women, iodine deficiency was reported as 9 percent (urban), 10 percent (medium), and 14 percent (rural). Excess intake was reported in 37 percent of pregnant women in the rural sector, 41 percent urban, and 45 percent medium. Goiter prevalence of 40.2 percent was re- ported among school-aged children in southwestern Nigeria (Sanusi & Ekerette, 2013), further confirming IDD as a public health problem in Nigeria. Figure 2.3—Severity of iodine deficiency status of children, mothers, and pregnant women in Nigeria Source: Maziya-Dixon et al. 2004. IRON DEFICIENCY Iron is critical for cognitive and motor development in childhood and for physical activity in all humans. Nutritional iron defi- ciency is a major health problem in many developing countries, often coexisting with iodine deficiency in the same popula- 6 tions. Iron Deficiency Anemia (IDA) is indeed the most prevalent and widespread nutritional disorder in the world today, af- fecting populations in both developed and developing countries. This disease reduces the work capacity of an individual when affected, and subsequently the entire population at large, resulting in serious economic consequences that inhibit na- tional development (Davidson 2011a; Davidson 2011b). Insufficient iron intake can lead to increased maternal mortality, compromised development of motor skills and learn- ing capacity, lethargy, and reduced immunity to diseases. It is estimated that more than 2 billion people worldwide are at risk of iron deficiency anemia, with the prevalence around 40–60 percent in pregnant women, 20–40 percent in women of child- bearing age, and about 10 percent in school-aged children and adult men (UNICEF 1992). In a small study in southwestern Nigeria (Adelekan & Adeodu 1998), it was reported that both iron deficiency and infections were equally important etiological factors in the anemia recorded in mothers and their children. This study observed that iron deficiency was more prevalent in the southwest areas of the country when compared with data from other parts of the country. Some contributory factors iden- tified included consumption of cereal-based diets, which are low in bioavailable iron, worm infestation, frequent pregnancies, and hemoglobinopathies (inherited blood disorders). The iron profile from the Maziya-Dixon et al. (2004) survey showed that almost 20 percent of children were iron defi- cient and another 8 percent had depleted iron stores. With more than 25 percent of children under five iron-deficient, it is critical that the global community pay attention to adequate dietary intake of iron. This profile is not the same in the three agro-ecological zones. Figure 2.4 shows the distribution of iron deficiency anemia in children under five by geopolitical zone. Anemia affects 25 percent of women of reproductive age in Nigeria, and as many as 61 percent in some regions. If no action is taken, about 6,570 maternal deaths will occur annually—roughly 18 women every day (Akinyele et al. 2002). Figure 2.4—Nutritional iron status of children under five in Nigeria, by geopolitical zone Source: Maziya-Dixon et al. 2004. When data were disaggregated by sector, the results showed that the proportion of children with varying degrees of iron deficiency was 24.4 percent for the rural sector, 27.9 percent in the medium sector, and 33.1 percent for the urban sec- tor. Iron deficiency (serum ferritin concentration < 10 µg/ml) was high in urban areas (22.6 percent), followed by the medium and rural areas (17.8 percent and 13.5 percent, respectively). Children under five with depleted iron store (serum ferritin con- centration < 20 µg/ml) were similar in the different sectors: 10.9 percent in rural areas, 10.5 percent in urban areas, and 10.2 percent in the medium areas. The percentages of children with normal iron status (serum ferritin concentration 20–100 µg/ml) did not vary much by sector: 47.8 percent in rural areas, 48.7 percent in urban areas, and 49.4 percent in medium areas. The distribution by sector of children under five who had a serum ferritin concentration above the normal range showed that 18.2 percent were in the urban areas, 22.7 percent in medium areas, and 27.8 percent were in rural areas. The level of iron deficiency may have been due to poor dietary sources of iron, or sources in which the iron is in a form that is not available for absorption. Vegetables are a major source of iron subject to chelation by oxalates, phytates, and other anti- nutrients, making it unavailable for absorption by the body. Other nutrients enhance iron absorption—particularly vitamin C. Animal sources of iron are most desirable. 7 Smaller studies further confirm the severity of iron deficiency in Nigeria. A study conducted in Enugu (southeastern Nigeria) reported iron deficiency anemia in 34.3 percent of the surveyed children under five (Ekwochi et al. 2014). A similar study conducted among pregnant women in Sokoto State (northwestern Nigeria) reported a high prevalence of anemia (21.3 percent) and iron deficiency anemia (13.5 percent) among pregnant women (Erhabor et al. 2013). VITAMIN A DEFICIENCY Vitamin A is a fat-soluble vitamin, essential for vision in dim light; cellular, bone and tooth growth; formation and maintenance of healthy skin, hair, and mucous membranes; reproduction; and immunity boosting. Vitamin A is so important in embryologi- cal development that without it, the fertilized egg cannot develop into a fetus (Brody 2007). Its deficiency results in night blindness or impaired adaptation to the dark; lowered immunity to infections such as measles, diarrhea, chicken pox, and respiratory infections; anemia; poor growth; slowed bone development; blindness; and death. All these have disastrous ef- fects on the healthy growth and intellectual performance of a child. The main health consequence of a diet that is chronically insufficient in vitamin A is a failure to meet physiologic needs, including healthy tissue growth, normal metabolism, and re- sistance to infection (WHO 2009). Globally, one in three preschool-aged children and one in six pregnant women are vita- min-A deficient due to inadequate dietary intake (UNICEF 2013). Nigeria is considered one of the WHO’s Category 1 coun- tries with the highest risk of vitamin-A deficiency (Humphrey et al. 1992). Vitamin-A deficiency contributes to 25 percent of infant, child, and maternal mortality in Nigeria because of reduced resistance to protein-energy malnutrition, acute respiratory infection, measles, malaria, and diarrhea (WHO 2009; UNICEF 2013). The micronutrient deficiencies indicators reveal that at the national level, 4.7 percent of children under five had se- rum retinol concentration (< 10 µg/dl) and were suffering from severe vitamin A deficiency (clinical deficiency); 24.8 percent suffered from marginal deficiency (serum retinol concentration < 20µg/dl) and were vitamin-A deficient; and 71.5 percent of children were normal. If those who were marginally deficient are combined with those who were clinically deficient, 29.5 per- cent of children under five were suffering from vitamin-A deficiency (Maziya-Dixon et al. 2006, MI 2014). Figure 2.5 presents information on the distribution of vitamin-A status by sector (median denotes communities that could not be classified as urban or rural based on population size definition). The figure demonstrates that VAD is more dom- inant in the rural sector. The distribution of the marginally deficient was 22.5 percent for the urban sector, 23.4 percent for the rural, and 25.1 percent for the medium. The clinical deficiencies were 7.5 percent in the medium sector while the urban (3.4 percent) and rural (2.2 percent) sectors were much lower. In Figure 2.6, the same information is presented by geopoliti- cal zone. Disparities witnessed were due mainly to dietary patterns that influence sources of vitamin A. Figure 2.5—Vitamin A status of children under five in Nigeria Source: Maziya-Dixon et al. 2004. There were, however, significant zonal differences in the prevalence rates, which offers insight into the location of the children suffering from VAD. Among the three agro-ecological zones, the dry savannah zone had the highest VAD preva- lence (30 percent), which is also higher than the national average. This zone consists of states in the far northern, drier part of the country. It is characterized by a crop-growing period that could be as short as 30 days per year. The principal food 8 crops in the zone are cereals and legumes. Low intake of vitamin A-rich foods and their precursors, such as carrots, orange- fleshed sweet potatoes, and dark-green leafy vegetables, might be one reason for such a high prevalence of VAD. It is significant to point out that palm oil, which is rich in vitamin-A, is not cultivated or consumed regularly in this zone, which could be a contributory factor in the observed high VAD prevalence in the zone. Other zones also had high prevalence of VAD with 24 percent observed in the moist savannah and 29.9 percent in the humid forest. Also significantly, more children with severe deficiency (serum retinol < 0.35 µmol/L) were found in the humid forest (7.1 percent) than in the dry (3.1 percent) and moist savannah (2.4 percent) zones. Figure 2.6—Vitamin-A status of children under five in Nigeria, by geopolitical zone Source: Maziya-Dixon et al. 2004. In pregnant women, vitamin-A deficiency contributes to intra-uterine malnutrition, which leads to low birth weight or stillbirths, especially when found in combination with zinc deficiency. Furthermore, scientific evidence showed that adding vitamin A or beta-carotene to the diets of pregnant women lowers their risk of death from pregnancy by as much as 40 per- cent. Mothers with serum retinol concentration (< 30 µg/dl) were considered at risk of vitamin A deficiency, and constituted 13.1 percent of the national population. At the AEZ level, there was a decrease in the percentage of mothers at risk of vita- min A deficiency from arid to humid climates, with 19.6 percent at risk in the dry savannah to 14.5 percent in the moist sa- vannah to 8.8 percent in the humid forest. More mothers were at risk of vitamin-A deficiency in the medium sector (30.7 per- cent) sector than in the rural (11.2 percent) and urban (10 percent) sectors. Mothers with serum retinol concentration lower than 20 micrograms were considered vitamin A deficient. From the population of mothers considered at risk for vitamin-A deficiency, only 4.1 percent were actually found to be deficient. These findings were disaggregated by geopolitical zone (Fig- ure 2.7). Figure 2.7—Maternal vitamin-A status in Nigeria, by geopolitical zone Source: Maziya-Dixon et al. 2004. 9 There is evidence to show that dietary sources of pro-vitamin A—including oranges, pawpaw, orange-flesh sweet potatoes (newly introduced), carrots, and tomatoes, among others— are available in rural areas but could be better pro- moted for consumption among rural dwellers, who do not generally have access to animal sources of vitamin A, including bush meat and assorted animal livers. There is some evidence from Figures 2.6 and 2.7 of higher than expected vitamin-A deficiency rates in south of Ni- geria. There are a few possible explanations for the discrepancy between the reported vitamin-A intake and the high preva- lence of vitamin-A deficiency. The humid forest zone (comprised of states in the south) is characterized by the high produc- tion and regular consumption of palm oil, which is high in pro-vitamin A. The food preparation methods commonly employed, however, remove a significant percentage of pro-vitamin A from palm oil and other important dietary sources of the vitamin. Similarly, beta-carotene is destroyed during processing, especially palm oil, which means it is not consumed in sufficient quantities to have an effect on the vitamin-A status of children. Most of the sauces, pottages, and soups consumed in the southern part of Nigeria are prepared using palm oil (a practice more common in the humid forest than in the other zones); nevertheless, the prevalence of severe vitamin-A deficiency remains high—to the level of being classified a public health problem—in this region. For example, in a study that relates the vitamin-A status of pregnant Nigerian women to their dietary habits, only 45.5 percent of the women had normal plasma retinol concentration levels (> 0.70 µmol/L) (Ajose et al. 2004). Although 80 percent of the subjects consumed red palm oil daily, approximately 64 percent of them would heat the oil until it was smoking for at least 10 minutes—thereby destroying the carotenoids—before adding it to the stew during cooking. Green vegetables were also boiled in hot water before adding to sauce (Rodriguez-Amaya 1997; 1999). The bioconversion of beta-carotene to vitamin A in the blood in another factor that could possibly explain the dis- crepancy between the reported vitamin A intake and the high prevalence of vitamin A deficiency. It has long been estab- lished that after an oral dose of beta-carotene, its metabolite retinol as well as intact beta-carotene appear in the circulation. It is also known that the conversion of beta-carotene into vitamin A takes place mostly in the intestine. The beta-carotene equivalent to vitamin A is defined as the ratio of the amount of beta-carotene given in an oral dose to the amount of vitamin A derived from the oral dose. Previously, it was assumed that 6 micrograms of beta-carotene in all plant foods provided the same vitamin A activity as 1 microgram of preformed retinol. However, recent data reveal that the amount of beta-carotene required from plant foods to provide 1 microgram of preformed retinols is much greater than 6 micrograms and is also highly variable among foods, ranging from 8 micrograms to as many as 40–45 (de Pee et al. 1998; West et al. 2002). This may further explain why VAD is common among children who consume diets previously thought to meet or nearly meet their vita- min-A requirements (Miller et al. 2002). Additionally, there is a negative effect of infection, including malaria, on plasma vitamin-A levels and therefore preva- lence of vitamin-A deficiency. It has been suggested that one significant contributory factor to poor vitamin-A status in many developing countries is the widespread presence of infections, which can suppress levels of vitamin A in plasma as well as mobilization of vitamin A stores in the liver (IVACG 1997). 2.3 Food Consumption and Micronutrient Intake Studies in Nigeria There are relatively few studies that address food consumption, nutrient intake, and nutrient status of Nigerians. Even fewer studies address current vitamin-A, iodine, and iron status of children under five. Most of the studies available are regional, rather than national, in scope and the number of subjects surveyed is usually limited. In addition, a majority of the studies deal with specific aspects of these micronutrient deficiencies in specific populations and in different geographical locations of the country. Even fewer studies have examined food intake and related this to blood levels of the nutrients in the same sub- jects. Food consumption and nutritional status of Nigerians have long been the subject of scientific investigation. The earli- est comprehensive reports on this were indeed during the colonial era. Prominent among these were the seminal reports of Nicol of the Colonial Medical Service published in the 1940s and 1950s (1949, 1952, 1956, 1959a, and 1959b), which at- tempted to determine the energy and protein requirements of peasants in different parts of Nigeria. Old as these reports are, they provide valuable insights into the state of food intake and nutritional status of the different groups in Nigeria at that time. They evaluated the food intake and nutritional status of these groups with special reference to the effects of deficiencies in vitamin A, B2, B-complex, and animal protein (Nicol 1949, 1952). Significantly, the studies reported levels of vitamin A intake to be as high as 5,174 International Units (IU) in some districts (Bida) and between 625 and 713 IU in Kontagora and Zuru. The very high intake of red palm oil by the peasants in Bida was said to account for the superior levels of Vitamin A nutritional status of children 4 to 6 and 10 to 12 years old. The study compared the state of nutrition of children from smallholder farming households from different parts of the country with 10 that of children of educated parents living in urban areas. The results showed that intake by children ages 4 to 6 in farming households ranged from 1,270 IU to 3,300 IU (45 to 125 percent Recommended Daily Amount (RDA) ) while intake by 10 to 12-year-olds ranged from 1,970 IU to 7,300 IU (79 to 162 percent RDA). In evaluating the food and nutrient intakes in these studies, iron and iodine intakes were not the focus. Consequently, intakes of these micronutrients were only tangentially re- ported. Indeed none of the studies provided data on iodine intake. The report on Nigerian children recorded daily intake of iron to range from 10 milligrams (mgs) among 4 to 6 year olds to 29 mg among 10 to 12 year olds in the farming households studied. In 1970, a report on the national nutrition survey conducted between 1965 and 1966 was circulated among the nutri- tion community in Nigeria (National Institutes of Health 1967). The report documented the consumption of large quantities of vegetables and other pro-vitamin–A rich foods, but no quantitative data were provided for iron and vitamin-A consumption. The results showed that children in southern Nigeria exhibited severe growth retardation for age, which is associated with low intake of protein and essential vitamins. There is no record of any other food consumption and nutrition survey that cov- ered the whole country since the 1967 report. Instead, such surveys that were conducted focused on regions and groups in the country. One of the earlier regional reports, by Nnanyelugo (1980), described a 1976 study on preschool children in ur- ban and rural areas of Cross River, a state in the southern region of Nigeria. The survey obtained detailed individual food intakes from 27 preschool children over a 48-hour period. The results showed intake of retinol and iron to be adequate (98– 132 percent of RDA for retinol and 135–230 percent of RDA for iron) for all the age cohorts between 1 and 5 years. Accord- ing to the report of an expert consultation on human vitamin and mineral requirements conducted by FAO and WHO in 2002, the recommended nutrient intakes (Table 2.1) for retinol (RE) for children is 40microgram of retinol (µgRE)/day while that of iron ranges from 176–480 µg for one-year-olds and 184–337 µg for 2–3-year-olds. Retinol intake of older children (4 to 5 years) ranged from 187–708 µg (mean 393 µg). Intake of iron ranged from 5.6–19.0 mg (mean 9.5 mg) for one-year-olds and between 0.9–19.8 mg (mean 13.2 mg) for children ages 2–3 years. Iron intake of older children (4 to 5 years) ranged from 8.5–27.2 mg (mean 16.8 mg). A 1983 study in northern Nigeria similarly weighed food intake of 150 children ages 36 to 60 months in the urban areas of Zaria, Kano, Katsina, and Jos, all located in the dry savannah zone (Addo 1984). The results showed adequate in- take of iron and vitamin A, as assessed based on the RDA published in 1967 (WHO). Intake ranged from 3,674.3 IU (1,102 µg) among two-year-old children to 5,000.1 IU (1,500 µg) among the five-year-olds while the intake of iron ranged from 3.8mg among two-year-olds to 6.3mg among the five-year-olds. The mean intake for all age groups combined provided 148 percent of RDA for vitamin A and between 54 and 90 percent of RDA for iron. A similar study was conducted on the food consumption of households in eight villages around the Kainji Lake in the moist savannah zone (Adekolu-John et al. 1985). The study measured both food production by households and daily dietary recall on individuals within the households. Intake data were collected for 282 individuals including children 0–5 years (n=60), lactating women (n=16), and one pregnant woman. The results show vitamin-A intake levels that far exceeded RDA for children (170 percent) and lactating women (167 percent) and iron intake that exceeded RDA for children (192 percent) and adult women (380 percent).The authors at- tributed the generally superior nutrient intake to the availability and consumption of animal products and grains in the exten- sive fertile plains of this region. Additional regional surveys of food and nutrient intake emanated from the dry savannah zone in subsequent years, including those on different groups in the northern-most part of the country. In a 1987 study of peasants living in a semi-arid zone of Borno State, 82 adults were surveyed for dietary intake using a combination of 24-hour dietary recall and weighed intake over seven days (Oguntona et al. 1987a). The study found that, on average, daily consumption of foods rich in iron and vitamin A was significant: 136 g for dairy products; 110 g for meat, fish, and poultry; and 495 g for green leafy vegeta- bles. The study measured seasonal nutrient intake over a six-month period (July–December) and revealed significant varia- tion in micronutrient intakes. Mean intake of iron and vitamin A by adult peasants ranged from 3 mg and 201.2 µg at the be- ginning of the rainy season (July) to 8.7 mg and 368 µg once harvests are in (December). The mean intake of iron and vita- min A was calculated to be 5.4 mg and 277 µg per day, respectively. Borno State lies in the far northeastern corner of Nige- ria in the interface between the Sudan and Sahel savannah zones. Most of the peasants inhabiting this area are farmers and herdsmen, so the diet is primarily based on cereals and dairy. These two food items are usually plentiful by December. Adolescents and the elderly in Borno were also subjects of food and nutrient intake studies (Oguntona et al. 1987b; Oguntona et al., 1988). Each subject (n=425) completed five dietary records of three consecutive days (that is, 15 total rec- ords per subject) between January 1983 and December 1984. The results showed that rural adolescents had vitamin-A and iron intake in excess of RDA at 112 percent and 161 percent for males and 117 percent and 134 percent for females, re- spectively. Urban adolescents had significantly lower intake of these vitamins and minerals compared with their rural cohorts. 11 Again, as with the peasants in Borno, the major sources of dietary vitamin A were meat and dairy products. The elderly, esti- mated to be about 2 percent of the population in Borno in 1987, were studied to assess the adequacy of their nutrient intake when compared with FAO/WHO recommendations. Mean intake of iron was significantly different for males and females. While the males had adequate intakes of 129 percent of RDA for the urban cohort and 97 percent for the rural cohort, female elderly had intakes that ranged from 36 percent of RDA for the urban cohort to 49 percent for the rural cohort. Mean intake of vitamin A by all cohorts within the group was 830 µg per day. For rural and urban, male and female elderly, intake of vitamin A was found to exceed RDA. A similar observation was made for calcium intake, and the authors of the study attributed these to the high consumption of dairy products typical of indigenous Kanuri people in the survey area. Table 2.1—Recommended levels of daily intake of key minerals and vitamins for the population of Nigeria, by age, sex, and pregnancy or lactation status Age Vitamin A (µg RE/day) Iron (mg/day) Iodine (µg/day) Zinc (mg/day) Calcium (mg/day) Infants 0–6 months 375 – 30 2.8 300 7–11 months 400 9.0 15 4.1 400 Children 1–3 years 400 6 75 4.1 500 4–6 years 450 6 110 5.1 600 7–9 years 500 9 100 5.6 700 10–18 years (male) 600 17 135 9.7 1,300 10–18 years female 600 30 135 9.7 1,300 Males 600 – – – – Females 600 – – – – Adults Males, 19–65 years 600 14 – 7.0 1,000 Females, 19–45 years (pre-menopausal) 500 29 – 4.9 1,000 Females, 50–65 (menopausal) 500 11 – 4.9 1,300 Pregnant and Lactating Women Pregnancy 800 – 200 10.0 1,200 Lactation 850 48 200 9.5 1,000 Older Adults (65+ years) Males 600 14 130 7.0 – Females 600 11 110 4.9 – Source: FAO/WHO (Food and Agriculture Organization of the United Nations and World Health Organization). 2002. Report of a Joint FAO/WHO Expert Consultation. Bangkok: WHO. The 24-hour dietary recall method was used to obtain details of the food consumption and nutrient intake of a sam- ple of the Kanuri people (Oguntona et al. 1989). The subjects numbered 289, consisting of 110 adolescents aged 13 to 19 years and 188 adults (men and women) aged 20 to 65 years. The results show that not only was the energy intake of ado- lescents adequate but their intake of iron and vitamin A were in excess of RDA—at 109 percent for vitamin A and 65 percent for iron in boys and 113 percent of vitamin A and 40 percent of iron in girls. Intake of vitamin A by adults also exceeded RDA in both men (108 percent) and women (120 percent); iron intake by adults also exceeded RDA for men (220 percent) but not for women (71 percent). A baseline survey conducted in three states—Akwa Ibom, Cross Rivers, and Rivers—in 1993 found mean dietary iron intakes in females in Cross Rivers (Ikang) to be 18.1 mg constituting about 64 percent of RDA, while the intake of chil- dren under five was 8.2 mg (82 percent RDA) (Akinyele et al. 1993). In Akwa Ibom (Uta Ewa), the intake was 8 mg for women (28.5 percent RDA) while the value for children under five was 6 mg (60 percent RDA). The difficulties inherent in conducting scientific studies with pregnant women are well known. It is not surprising therefore that few studies address the food and nutrient intake of pregnant women in Nigeria. The challenges are even more complicated if the pregnant woman is an adolescent. A recent study in southwestern Nigeria, however, assessed the food and nutrient intake of 101 pregnant adolescent Nigerians during their third trimester, using the three-dimensional weighed intake technique to obtain information on food intake (Oguntona and Akinyele 2002). The adolescents were grouped accord- ing to ages in two groups: those under 17 and those older than 17. Iron intake ranged from 9.7–10.9 mg for rural adolescents 12 to 11.8–12.8 mg for the urban adolescents. Not a single subject studied met the RDA of 30 mg per day. However, except for three subjects, all the adolescents had vitamin-A intakes in excess of RDA (258–345 percent), suggesting that this nutrient is abundant in the food supply. On the basis of these results, the authors suggested that vitamin A may not constitute a critical nutrient in the survey area. It is interesting to note that the intake of vitamin A among the subjects comes essentially from the conversion of carotenoid from dark leafy vegetables. Similar conclusions could be reached from the results of another survey conducted in southwestern Nigeria (Okafor & Oloyo 2004). The study was a survey of nutrient intake and workload of pregnant women in the Yewa South Local Govern- ment Area (LGA) of Ogun State. The 24-hour dietary recall procedure was used to obtain information on food and drink con- sumed by 40 pregnant women between 17 and 43 years old. The mean intake of vitamin A for all subjects was 942 µg, which is 157 percent of RDA, and that of iron was 25.7 mg, which is 86 percent of RDA. Vitamin-A intake ranged from 118 percent RDA among women farmers to 203 percent RDA among full-time housewives. An even more recent study in Lau LGA of Taraba State (southwestern Nigeria), however, reported low intakes of iron and vitamin A among adolescents (Anita et al. 2014). These observed differences are presumably due to the sample size and method used to assess nutrient intake. The study showed that most of the family members depended on carbohydrates (corn, pounded yam, fufu, rice, and tuwo from garri (dumplings from cassava)), which are the major crops in the area; few respondents have access to plant and animal protein. The results also indicated that only 11 percent of mothers surveyed fed their children three times per day, so most children were under fed. In Nigeria and other developing countries, food intake and nutritional status has been largely affected by rapid ur- banization, which causes food habits of urban dwellers to change. A major characteristic of this change is the increase in the consumption of “street foods.” Some studies have addressed this issue and estimated the contribution of street foods to daily consumption of nutrients (including micronutrients) by different categories of urban dwellers. One such study by Oguntona et al. (1998) in southwestern Nigeria, found that all of the subjects (126 university students) had adequate intake of iron, rang- ing from 8.8 mg for females to 10.2 for males (85–89 percent, respectively).The study also found that all the subjects had intake of vitamin A in excess of RDA, with the percent supplied by street foods at 80 percent for male students and 68 per- cent for their female counterparts. At least two other similar studies in the southwestern part of the country have been reported: one assessing women traders, the other looking at office workers in an urban center. The study of market women found that all subjects had iron and vitamin A intakes above RDA levels for their respective age groups (Oguntona & Tella 1999). Significantly, in all sub- jects, the amount of vitamin A obtained daily from street foods alone exceeded RDA for their respective ages. Data obtained from the study of urban office workers followed a similar pattern: of the 133 government and corporate employees assessed, street foods indeed contributed more than 100 percent RDA of vitamin-A for male subjects and 94 percent RDA for female subjects (Oguntona and Jaiyesimi 1998). 2.4 Studies on Blood Concentrations of Vitamin A and Iron In 1996, the World Health Organization provided criteria for assessing the prevalence of sub-clinical vitamin-A deficiency using plasma retinol concentrations (< 0.7 µmol/l). Using these standards, many studies have been conducted in Nigeria to determine vitamin-A status in newborns, children, and pregnant women (Uzoechina and Okoro 1994; Adelekan et al. 1997; Adelekan et al. 2003; Oso et al. 2003; Ene-Obong et al. 2003). Tables 2.2 and 2.3 present summaries of studies reporting dietary intake of vitamin A in Nigeria. In an attempt to fully assess the vitamin-A status of newborns, Adelekan and coauthors at Obafemi Awolowo Univer- sity in southwestern Nigeria collected blood samples from 205 subjects (2003). They measured not only plasma retinol but also concentrations of plasma carotenoids and acute phase proteins because of their potential value as indicators of vitamin- A nutrition levels or inflammatory status. In addition they measured body weight, gestational age, and prematurity because of possible associations that these variables have with plasma concentrations of retinol. Their results show that overall, new- borns with low body weights had significantly lower mean plasma retinol concentrations than those with normal weights (0.46–0.59 µmol/L) respectively. Babies born both premature and with significantly low birthweight (< 2.5 kilograms) also low mean plasma retinol concentrations than those of normal gestational age and weight (0.45 versus 0.59 µmol/L, respectively). 13 Table 2.2—Summary of studies reporting dietary intake of vitamin A in Nigeria Age group Retinol (µg/d) Mean intake (µg/d) Percent RDA Data Collection Procedure Population Sector Reference 1 yr. 176-480 – – 48-hr recall Urban & rural Nicol (1959a) 2-3 yrs. 184-337 230 – 48-hr recall Urban & rural Nicol (1959a) 4-5 yrs. 181-708 393 – 48-hr recall Urban & rural Nicol (1959a) 1-5 yrs. – – 98–132 48-hr recall Urban & rural Nicol (1959a) 3-5 yrs. – – 148 Weighed intake Urban Nicol (1959b) 5 yrs. 5,000 IU – – Weighed intake - Nicol (1959b) 0-5 yrs. – – 170 24-hr recall Rural Nnanyelugo (1980) Lactating women – – 167 24-hr recall Rural Nnanyelugo (1980) Peasants male 207-368 277 – 24-hr recall & weighed in- take Rural Addo (1984) Adolescents – – 96-117 Dietary records Urban & rural WHO (1967) Adolescents – 860 – 24-hr recall Urban & rural Ijarotimi (2004) Children 2-5yrs 734 – 183 Weighed intake Rural Okoroigwe & Okeke (2009) Adolescents 6,296-9,135 7,716 – Weighed intake Urban Anyika et al (2009) Adolescents 730 152 24-hr recall Rural Onabanjo & Balogun (2014) Adolescent males – – 109 24-hr recall Urban WHO (1967) Adolescent females – – 113 24-hr recall Urban WHO (1967) Nursing mothers (15-49 yrs) – 288 – 24-hr recall Rural Fabunmi et al., 2013 Source: Authors’ compilation Table 2.3—Summary of studies reporting dietary intake of iron in Nigeria Age group Mean intake (mg/d) Percent RDA Data Collection Pro- cedure Population Sector Reference 1 yr. 9.5 135 48-hr recall Preschool children in urban & rural southern Nigeria Nnanyelugo 1980 2–3 yrs. 13.2 189 48-hr recall Preschool children in urban & rural southern Nigeria Nnanyelugo 1980 4–5 yrs. 16.1 230 48-hr recall Preschool children in urban & rural southern Nigeria Nnanyelugo 1980 2 yrs. 3.8 54.3 24-hr recall and weighed intake Urban children in northern Nigeria Addo 1983 3 yrs. 4.1 58.6 – Urban children in northern Nigeria Addo 1983 4 yrs. 7.2 102.9 – Urban children in northern Nigeria Addo 1983 Lactating women 38.2 24-hr recall Kainji Lake area Adekolu-John et al. 1985 Peasants male 6.0 66 24-hr & weighed intake Northeastern Nigeria Oguntona et al. 1987 Peasants female 5.0 17.9 24-hr & weighed intake Northeastern Nigeria Oguntona et al. 1987 Adolescent males 8.8 81.8 24-hr recall Urban southwestern Nigeria Oguntona et al. 1998 Adolescent females 10.2 83.9 24-hr recall Urban southwestern Nigeria Oguntona et al. 1998 Market Women 12.4 115.2 – Urban southwestern Nigeria Oguntona & Tella 1999 Adolescent males 21.8 24-hr recall Urban southwestern Nigeria Ijarotimi 2004 Adolescent females 17.9 24-hr recall Urban southwestern Nigeria Ijarotimi 2004 Children 2–5 yrs 8.2 93.3 Weighed intake Rural southwestern Nigeria Okoroigwe & Okeke 2009 Nursing women 48.0 267 24-hr recall Rural southwestern Nigeria Fabunmi et al. 2013 Adolescent males 8.8 52 24-hr recall Rural southwestern Nigeria Onabanjo & Balogun 2014 Adolescent females 7.8 26 24-hr recall Rural southwestern Nigeria Onabanjo & Balogun 2014 Source: Authors’ compilation In a study of 250 eastern Nigerian preschool children, serum retinol values were used to determine the children’s vitamin A status (Uzoechina & Okoro 1994). Using WHO standards, the authors concluded that VAD prevalence was 25.4 percent. Overall roughly one in ten of the children (9.2 percent) had deficiency levels (< 10 µg/dl), and 16.4 percent had low levels (< 20 µg/dl). A significantly higher proportion of boys than girls—11.9 versus 6.8 percent—had deficiency levels. Also a significant percentage of the children ages 3–5 suffered from night blindness (3.7 percent). In 1997, the results of a similar study conducted in southwestern Nigeria demonstrated the prevalence of malnutrition and vitamin-A deficiency in 14 Nigerian preschool children subsisting on high intakes of carotenes foods, such as sweet potatoes, orange fruits, and plant leaves (Adelekan et al. 1997). The subjects—204 preschool children (3–57 months) recruited from two rural communities in Osun State—were assessed using anthropometry, frequency of consumption of locally available pro-vitamin A rich foods (green leafy vegetables, carrots), and concentration of plasma retinol. The results indicated widespread malnutrition among the subjects despite the fact that dietary intake of vitamin A appeared to be adequate, although the source of vitamin A was predominantly from green leafy vegetables. Overall VAD prevalence was determined from plasma retinol to be 11.3 percent. Similar conclusions were reached from another study conducted in the same region around the same time (Oso et al. 2003). The vitamin A status and dietary intakes of carotenoid-rich foods were determined in 213 children ages 6–72 months. The study reported a rather high prevalence of vitamin-A deficiency despite calculated high intake of foods contain- ing carotenoids. Among the subjects, 26.8 percent had serum retinol levels below10 µg/dl, while 47.9 percent had levels be- tween 10–19 µg/dl. A particularly significant finding from this study was that the highest VAD prevalence was recorded among subjects that are ages 6–12 months most of whom were still receiving breast milk. A possible explanation may be that the beta-carotene in the food consumed is destroyed during processing, rendering it less bioavailable, or that it is not consumed in sufficient quantities to have an effect on the vitamin A status of the children. Not many studies have addressed the vitamin-A and iron status of adolescents in Nigeria, especially through an as- sessment of blood levels of the micronutrients. A report published in 2003 describes a study of food intake and plasma con- centration of vitamin A in 600 adolescents attending secondary schools in Nsukka (Enugu State). The results show that even though the intake of vitamin A was more than adequate (126–137 percent RDA), 40 percent of the male and 32 percent of the female subjects had plasma concentrations less than 20 µg/dL (Ene-Obong et al. 2003). In 2014, another study as- sessed the iron status of adolescents attending secondary school in Ogun State (Onabanjo & Balogun). In this study, multi- ple iron status indicators (haemoglobin, serum ferritin, and transferrin receptor) and inflammation markers (C-reactive pro- tein) were measured. The study reported that the prevalence of iron depletion (serum ferritin <12.0 µg/L) and iron deficiency (Hb = 13.0 g/dL in boys and Hb = 12.0 g/dL in girls plus serum ferritin <12 µg/L) in the adolescent were 7.9 percent and 15.0 percent, respectively. The prevalence of anemia was high (24.4 percent) with iron-deficiency anemia the most prevalent at 71 percent. In both boys and girls, ferritin correlated positively with body mass index, waist circumference, and waist-to-hip ratio. The study concluded by acknowledging the high prevalence of iron deficiency and poor nutritional status among Nige- rian adolescents. There are fewer studies in Nigeria on the vitamin-A status of pregnant women using blood concentration of the vita- min as a criterion. This understandably is partly due to difficulties in receiving ethical clearance and patient consent. One clinic-based study determined the vitamin-A status of 200 pregnant women ages 15–43 years (mean 27.2 years) by meas- urement of retinol concentration in plasma (Ajose et al. 2004). The study also looked at the relationship between vitamin-A status, dietary habits, and morbidity pattern. Vitamin-A deficiency (plasma retinol concentration < 0.35 µmol/L) was found in 17.5 percent of the subjects while 37 percent had borderline levels (plasma retinol concentration of 0.35–0.70 µmol/L). Al- most half (45.5 percent) of the subjects, however, had normal vitamin-A status (plasma retinol concentration > 0.7 µmol/L). The authors documented some dietary and food preparation practices—including overheating of red palm oil and blanching of green vegetables—that could have negatively impacted the vitamin-A content of their diets. Perhaps the most comprehensive national survey of food consumption and nutritional status of Nigerians was con- ducted in 2001. The overall goal of the survey was to assess the prevalence and spread of micronutrient deficiencies and determine the nutritional status and nutrient intakes of the rural and urban populations in Nigeria (Maziya-Dixon et al. 2006). One of the objectives was to assess the micronutrient (iron, zinc, iodine, vitamin A and vitamin E) status of children under five, mothers, and pregnant women from food intake and biochemical indices. For vitamin A, a total of 6,480 households with eligible mother/child pairs were sampled for determination of serum retinol concentration by high-performance liquid chroma- tography (HPLC). The results showed that 29.5 percent of children under five across the country were vitamin-A deficient (serum retinol < 0.70 µmol/L). There were significant zonal differences in the prevalence rates, however, with 31.3 percent in the dry savannah zone, 24 percent in the moist savannah, and 29.9 percent in the humid forest (p < 0.01). Also significantly more children with severe deficiency (serum retinol < 0.35 µmol/L) were found in humid forest (7.1 percent) than in the dry savannah (3.1 percent) and moist savannah (2.4 percent). The prevalence of VAD in the subjects was similar in the rural (25.6 percent) and urban (25.9 percent) areas but significantly (p < 0.05) higher (32.6 percent) in the medium (semi-urban) sector. Nationwide, mothers with serum retinol concentrations < 30 µg/L that are also considered to be at risk of vitamin-A deficiency were 13.1 percent. Among the mothers, agro-ecological zone differences in prevalence rates were significant with 19.6 percent in the dry savannah, 14.5 in moist savannah, and 8.8 percent in the humid forest. However, only 4.1 percent of the mothers who were at risk were actually found to be vitamin-A deficient. The cutoff point for being at risk of VAD—serum 15 retinol concentration < 30 µg/L—is the same for mothers and pregnant women. Nationwide, pregnant women considered to be at risk of VAD were 19.2 percent and those that were actually deficient (serum retinol concentration < 20 µg/L) constituted only 8.8 percent. Significant zonal differences were also observed in the prevalence of pregnant women at risk of VAD, being 34.3 percent in the dry savannah, 28.3 percent in moist savannah, and 21.6 percent in the humid forest. Table 2.4—Summary of vitamin-A status of children and women in Nigeria using blood vitamin A concentration Population group Adequate Vitamin A (blood), % Marginal Vitamin A deficiency (VAD), % Severe VAD, % Marginal &Severe VAD,% References 1. Neonates - - 18.0 72 Adelekan et al. 2003 2. < 5 yrs old 71.5 24.8 4.7 29.5 Maziya-Dixon et al. 2006 - 16.4 9.2 25.4 Uzoechina & Okoro 1994 - - - 11.3 Adelekan et al. 1997 - 47.9 26.8 - Oso et al. 2003 3. Adolescents - - - 32-40 Ene-Obong et al. 2003 4. Mothers - 13.1 - - Maziya-Dixon et al. 2006 5. Pregnant women 45.5 37.0 17.5 - Ajose et al. 2004 - 19.3 - - Maziya-Dixon et al. 2006 Source: Authors’ compilation The same national survey of food consumption and nutritional status of Nigerians assessed the status of iron defi- ciency of children, pregnant women, and mothers using the serum ferritin level (SF) (Maziya-Dixon et al. 2004). SF levels below 12 ng/ml are highly specific for iron deficiency and indicate exhaustion of iron store in adults. In children, benchmark for iron deficiency is 10 ng/ml. For children under five, at the national level, 27.5 percent were at different stages of iron defi- ciency and 19.4 percent had an SF level of less than 10ng/ml. Disaggregating by AEZ, the proportion of children with varying degrees of iron deficiency was 42.2 percent in the dry savannah while prevalence of iron deficiency was 31.5 percent, less than in moist savannah but higher than in humid forest; 10.7 percent had iron store depletion. Later analysis of data from the NFCNS by Akinyele (2009) found that in the northwest zone, 21.7 percent of under- fives were iron deficient and 11.9 percent had iron store depletion, the differences presumably being due to the reorganiza- tion of data from AEZ to State category. Approximately 24.3 percent of mothers and 35.3 percent of pregnant women were at different stages of iron deficiency, with 12.7 percent of mothers and 19.9 percent of pregnant women already with iron store depletion (SF level <12 ng/ml) indicating iron deficiency. In the dry savannah, 33.2 percent of mothers and 43.1 percent of pregnant women were at different stages of iron deficiency. A survey that tested for nutritional factors associated with anemia in 146 pregnant women, who attended two prenatal clinics in Gombe (northern Nigeria) found that based on a hemoglobin value of <105 g/L, 32 percent of women were classified as anemic (Vanderjagt et al. 2007). The major contributing factor to anemia was iron deficiency based on the SF level. Con- clusions from this study were that the most common cause of anemia in the pregnant women in northern Nigeria was iron deficiency, and the elevated concentrations of homocysteine were most likely due to both their marginal folate and vitamin B12 status. Malaria was also present in fifteen women (9.4 percent). The common diet in the northern region is heavily reliant on grains, such as millet and sorghum, which contain large quantities of phytates known to interfere with the bio-utilization of iron, zinc, calcium, and other trace minerals. The requirements of iron during pregnancy are high, and it was difficult to meet these requirements through diet alone. The IDD problem is concentrated in the middle belt and southeast regions of Nigeria (Ojule et al. 1998). This has been associated with the high consumption of cassava products in the southern parts of the country. Data generated from the 2001–2003 national nutrition survey provide some detailed information on the prevalence and spread of iodine deficiency (Maziya-Dixon et al. 2004). Nationally, some 30.7 percent of mothers were found to have varying degrees of iodine defi- ciency; it was severe in approximately 4.2 percent of mothers, moderate in 8.8 percent, and mild in 17.8 percent. Mothers in the moist savannah had the highest prevalence (19 percent) followed by those in humid forest (15.2 percent) and the dry savannah zone (11.6 percent). In response to the high prevalence of iodine deficiency, the government embraced the strategy of salt iodization in the 1990s. Through a unique partnership between government agencies, academia, the private sector, and civil society, the country succeeded in establishing a salt iodization program and was granted a universal salt iodization (USI) certification by the WHO. USI has been mandatory since 1993, and Nigeria is among the countries that have succeeded in achieving and 16 sustaining high levels of coverage, from less than 40 percent in 1993 to 95 percent or higher (1998–2004) (GAIN 2014). Ni- geria was designated as USI compliant in 2008. However, salt and iodine deficiency disorder is still a problem. This was at- tributed to the fact that iodized salt is often sold in open receptacles although attempts are being made to require packing of quantities that are 50 mg or higher. In Nigeria, there has been a massive concerted effort by the federal government through the National Food and Drug Administration and Control (NAFDAC) to ensure cheap availability and consumption of ade- quately iodized salt. As of 2005, it was estimated that 98 percent of households in the country had access to iodized salt (Akunyili 2005). Efforts to sustain and build on this success are being maintained through several strategies like social mar- keting and continuous monitoring at the different levels. The result of the 2010 survey reveals that iodine levels of household salts in Nigeria has improved and the urinary iodine level data shows that Nigeria is not in eminent danger of IDD. According to the MICS (2011), most households (80 percent) consumed adequately iodized salt that contained 15 parts per million (ppm), while about 13 percent households consumed salt with an iodine content of less than 15 ppm. In all, about 93 percent of households in Nigeria used iodized salt, with the northwest region having the lower iodized salt consumption level, at 63 percent (MICS 2011). 2.5 Infant and Child Feeding Patterns in Nigeria BREASTFEEDING Another important aspect of child nutrition is breastfeeding. Breastfeeding practices and introduction of complementary foods are important determinants of the nutritional status of children, particularly those under age two. Exclusive breastfeeding dur- ing the first six months of life—a recommendation by WHO and UNICEF—provides children with the essential nutrients needed for growth and reduces the risk of infant mortality from diarrheal disease, which is responsible for 17 percent of the main causes of child deaths in the Africa (Kramer and Kakuma 2011; UNICEF 2008). A recent estimate showed that worldwide only 35 percent of children between birth and their fifth month are breast- fed exclusively (WHO 2010). Based on WHO global data on infant and young child feeding in 2003, 22.3 percent of children in Nigeria were exclusively breastfed for fewer than four months while 17.2 percent were exclusively breastfed for fewer than six months. From these figures, Nigeria could be designated as a “low-rate breastfeeding country” in Africa. The situation has not improved much since 2003. According to the 2008 Nigerian Demographic and Health Survey (NDHS), 17 percent of children were exclusively breastfed for fewer than four months while 13 percent were exclusively breastfed for under six months. The median exclusive breastfeeding period in southwest Nigeria was seven months in 2003; by 2008, it had dropped to only six months. Within the same period, early initiation of breastfeeding among women in the region was 12.7 percent in 2003, but increased to 35.5 percent by 2008 (NPC & ICF Macro 2009). All these figures are far below the 90 percent level recommended by the WHO (Jones et al. 2003). Nigeria has the highest rural mortality rate for children under five: 242.7 per 1,000 among selected countries in Africa south of the Sahara (Anyamele 2009). The 2011 Multiple Indicator Cluster Survey (MICS) revealed that about 15 percent of children under six months were exclusively breastfed, a level considerably lower than recommended. The 2013 NDHS reported an increase to 17.2 percent in the exclusive breastfeeding rate. Analysis from the NLSMS put the percentage at 14 percent (Kuku-Shittu et al. 2013). A much higher exclusive breastfeeding rate of 25.2 percent was reported by the NFB/UNICEF study (NFB/UNICEF 2014). The study also provides evidence that children from families in the wealthier quintiles are more likely to be exclusively breastfed for the first six months than those in the poorer quintiles. The prevalence of a low level of breastfeeding for children under five is highest among rural small-scale farmer households because many lactating women are too undernourished to provide adequate milk for their offspring; as a result they tend to supplement breast milk with cereal food products. Despite the high initiation prevalence, there was a low preva- lence of exclusive breastfeeding, as shown by data from the 2013 NDHS. Rural and urban differentials have also been docu- mented in the practice of exclusive breastfeeding as the practice was reportedly higher (41 percent) in the urban areas com- pared with 38 percent in the rural areas (NPC and ICF Macro 2009). There are numerous reports of studies on breastfeeding and other child feeding practices in various parts of Nigeria, and although the samples and methods in these studies are not directly comparable, the results are generally consistent. Most of the studies available have been regional rather than national. Almost all rural Nigerian mothers and the majority of urban mothers breastfeed their babies for at least the first few months of life. Despite widespread prevalence in Nigeria, breastfeeding is not as effective as it could be in promoting good child nutrition and health because of suboptimal breast- feeding practices. The UNICEF (Nigeria) Participatory Information Collection Survey of 1994 indicated that 97.4 percent of mothers were breastfeeding their babies during the first month of life (UNICEF 1994). Only a very small proportion of moth- ers put the baby to the breast within the first hour after birth, as is recommended, while most studies report that the majority 17 initiate breastfeeding within the first 24 hours (Fagbule & Adedoyin 1987; Ojofeitimi 1981; Omololu 1982, MICS 2011) or 48 hours (Omotola & Akinyele 1985). The NDHS provides a somewhat different picture, however, with 34 percent of women reporting initiation of breastfeeding immediately after delivery and 24 percent within 24 hours. The traditional practice among Yoruba women (the major ethnic group in southwestern Nigeria) has been to provide prelacteal feeds of water or an herbal infusion known as agbo (Mebrahtu & Bentley 1989; Omotola and Akinyele 1985). In the major urban center of Ibadan, the majority of women discarded colostrums for the first 24 hours, citing reasons such as hospital advice or an absence of milk in the breast. Omotola and Akinyele (1985) concluded that this practice of discarding colostrums was not based on underlying cultural belief. But the majority of mothers (66 percent) in Ilorin, Kwara State, said colostrums should be eaten, one-third opposed this practice because the colostrum is dirty and yellow in color (Fagbule & Adedoyin 1987). Few of the urban Igbo mothers (the major ethnic group in southeastern Nigeria) gave breast milk as the first feed after birth, with water given most commonly. The rural Igbo mothers were more likely to start with breast milk or a com- mercial glucose beverage, water, or a local preparation (Uwaegbute & Nnanyelugo 1987). A major factor affecting the feed- ing of colostrums to babies by mothers in this part of the country is that Igbos traditionally rejected colostrums and prefer to give water feeds instead (Kings and Ashworth 1987). In the northern region, more than 40 percent of mothers reported giving colostrums and about one-third began breastfeeding immediately (Atinmo et al. 1992). Both the Hausa and the Fulani (the major ethnic groups in the northern region) reportedly hold strong views of colostrums as dirty, unhygienic, and potentially harmful. Compared to other regions of the country, the southwest has a much lower proportion of mothers who begin breast- feeding immediately after birth (Atinmo et al. 1992). There are very little data on frequency of breastfeeding, perhaps because most mothers breastfeed on demand (Omotola & Akinyele 1985; Fagbule & Adedoyin 1987). Among Igbo mothers, it was found that urban women were more likely (26 percent) than rural women (9 percent) to feed according to a time schedule (Uwaegbute & Nnanyelugo 1987). A study of children ages 6–30 months in a village in Kwara State demonstrated that the average feeding time was 30 minutes and the average number of feedings was six per twelve-hour period. The mean volume of breast milk consumed in twelve hours was about 300 ml for healthy children; it tended to be higher during diarrheal illness and convalescence (Dicken et al. 1990). Breastfeeding practices, including initiation and duration, are influenced by multiple interwoven factors that include health, psychosocial, cultural, political, and economic factors (Cripe 2008; Schmied and Barclay 1999). Among these factors, decisions regarding initiation and duration of breastfeeding in low-income countries are influenced by education, employ- ment, place of delivery, family pressure, and cultural values (World Health Organization 2010; Gartner et al. 2005; Ogunlesi 2010; Otoo et al. 2009). In Nigeria, while breastfeeding initiation is increasing, the duration and practice of exclusive breast- feeding remains low (Ogunlesi 2010). The early introduction of complementary feeding, based on erroneous assumptions, affects breastfeeding initiation and sustainability (World Health Organization 2010). Among the Yoruba people, a common belief around infant feeding is that exclusive breastfeeding is beneficial to both infants and mothers, but complementary feeding is essential for babies to adapt to other meals with ease (Ojofeitimi et al. 2000; Lawoyin et al. 2001; Tella et al. 2008). Besides normative expectations, personal experiences and networks of support have influence on the forms and quality of breastfeeding practices. Largely, these factors exert pressure on breastfeeding mothers thereby making their expe- rience pleasurable or painful within time and space (Cripe 2008; Baumslag and Michels 1995; Blum 1999).The results of a similar study conducted in southwestern Nigeria were published in 2010. The study (Agunbiade & Ogunlewe 2010) investi- gates breastfeeding practices and experiences of nursing mothers and the roles of grandmothers, as well as the work-re- lated constraints affecting nurses in providing quality support for breastfeeding mothers in southwestern Nigeria. The re- spondents consisted of 200 breastfeeding mothers, nurses, and grandmothers recruited from two rural communities in Osun State, southwestern Nigeria. The survey showed the major constraints to exclusive breastfeeding to be: the perception that babies continued to be hungry after breastfeeding (29 percent); maternal health problems (26 percent); fear of babies be- coming addicted to breast milk (26 percent); pressure from mother-in-law (25 percent); pain in the breasts (25 percent); and the need to return to work (24 percent). In addition, the qualitative findings showed that significant others played dual roles on breastfeeding practices. The desire to practice exclusive breastfeeding was often compromised shortly after child deliv- ery. Factors such as poor feeding, inadequate support from husband, and conflicting positions from the significant others were dominant constraints.. COMPLEMENTARY FEEDING Complementary feeding begins when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are fed along with breast milk. The World Health Organization recommends introduc- tion of complementary foods, in addition to human milk, at six months of age (2002). In Nigeria, the recommendation is that breastfeeding should be continued along with the introduction of complementary foods at six months (FMH/DCD/PA 2005). 18 Complementary foods are also often introduced early in Nigeria, with 23 percent of children under age six months and 38 percent of children between four and five months old consuming solid or semi-solid foods in addition to breast milk. Supple- menting breast milk before age six months is unnecessary and discouraged because of the likelihood of contamination, which may result in the risk of diarrheal diseases. After six months, breast milk should be complemented by other solid or mushy food to provide adequate nutrition to the child (PAHO 2002). The first food other than milk and liquids given to an infant in Nigeria is a thin gruel made from maize, sorghum, or millet, commonly known as “pap.” Pap was the most common complementary food to be introduced by all income and edu- cation categories of mothers in an Ilorin sample, although higher income and education was associated with a greater ten- dency to add milk to the pap. In a survey of ethnic differences in weaning foods, it was found that the majority of Hausa (96 percent), Yoruba (90 percent), and Igbo (83 percent) mothers start with pap, and 100 percent in all groups mentioned pap when asked to name a good weaning food. Complementary infants’ foods among the Yoruba are somewhat different from those used by other two major ethnic groups in Nigeria. Beans and bean products are the first solid foods given to in- fants next to pap by the urban poor of Ibadan (Akinyele and Omotola 1987). Foods such as moin-moin, akara, and bean pot- tage are commonly consumed (Omotola 1984). A common problem associated with most complementary food in Nigeria is inadequate sufficient proteins, vitamins, and minerals. A traditional complementary food used by the Kanuri, Hausa, and Fu- lani in northern Nigeria is known as kunu and is usually made from a cereal (sorghum, rice, or wheat) combined with ground- nut or tsamya (a sour fruit). About half of the mothers interviewed in Maiduguri mixed this cereal pap with formula, and about a quarter combined formulas with commercial cereals (Igun 1982). The Hausas of northern Nigeria also give a type of dough made from guinea corn, millet, or rice (called tuwo) with different vegetable soups to infants as the next solid food after intro- duction to pap. Beans and bean products are rarely used because they are believed to cause flatulence. Mashed yam and rice were the next important infant fo