Baseline analysis of the underlying causes of child undernutrition in eight health-areas of Luisa - Central Kasai, Democratic Republic of Congo

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ABSTRACT 
In the Democratic Republic of Congo almost half of the children are affected by chronic undernutrition, while 
one million are currently suffering from acute undernutrition. This research aims to explore the correlation 
among some underlying causes of malnutrition – food insecurity and WASH practices – in a household sample 
in the region of Luiza, in Central Kasai. Undernutrition prevalence, defined as wasting, stunting and 
underweight, was crossed with WASH and food security indicators. From the results obtained, both 
underweight and wasting are correlated with absence of covered latrines and protected water sources. No 
correlation was found between food security, assessed through Food Consumption Score, and undernutrition 
prevalence. Higher scores for coping strategies were correlated to higher prevalence of undernutrition. 
Whereas furthers surveys and evaluations are needed to confirm the findings, it is recommended to reinforce 
in the short-term the nutrition-specific interventions as well as the nutrition-sensitive interventions in the 
long-term.
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1 INTRODUCTION 
Malnutrition is one of the major causes of mortality and morbidity throughout all over the world, especially 
in poor countries and it is responsible every year for at least 3.1 million of child deaths (Checkley et al. 2008). 
Moreover, at least one third of all child deaths in the world are directly or indirectly linked to malnutrition 
because of the increased risk of dying of malaria, measles and pneumonia. From a socio-economic 
perspective, malnutrition is correlated with limited life expectancy, disabilities, reduced workers' productivity 
and higher health-care costs (Duggan 2014). Malnutrition has also a very high social and economic impact. 
Child and maternal undernutrition (including both acute and chronic malnutrition) were responsible for 1.4 
million deaths or 6.7% of all DALYs (Disability Adjusted Life Years) in the world (Lim et al. 2012). Poor countries 
are affected at a greater extent as almost 90% of undernourished children live in low-income and low-middle 
income countries (UNICEF 2013). During the year 2000, United Nations established eight Millennium 
Development Goals (MDGs) to eliminate poverty in the world. MDG 1 aimed to halve the number of people 
suffering from malnutrition until the year 2015. Although many progresses were obtained during the years 
1990-2015, recent data estimates that 795 millions of people in the world are still malnourished (FAO 2015). 
In addition, statistics reveal different and unbalanced trends in the world as in Sub-Saharan Africa the number 
of people suffering from undernutrition occurred between the years 1990 and 2015 have been constantly 
increasing (WHO 2015). As a matter of fact, China and India alone have contributed up to 80% of 
undernutrition reduction in the last 25 years, masking other countries’ failures – especially the African ones 
(FAO 2015) In the Democratic Republic of Congo (DRC), 43% of under-five children suffer from chronic 
malnutrition; this dramatic burden affects both the health system of the country and its capacity to develop 
in the future. In fact, DRC has only 1% of the world population but it is has respectively one and five millions 
of acute and chronic undernourished children (WHO 2014). In the same way micronutrient deficiencies are 
very spread in the country, especially in the Kivu and Central Kasai (UNICEF 2013). In the last years many 
nutrition-specific programs have been implemented in the country with the clear objective of tackling the 
issue.  
 
Figure 1 Number of stunted children in the world and in Africa (de Onis et al. 2013). While at the world level the total number of 
undernourished children is decreasing, it is possible to observe a net increase in Africa
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1.1 THE OBJECTIVES OF THE STUDY 
Objective 1: Explore whether the households that reported low food security scores or unhealthy WASH 
behaviors have children under five with higher levels of stunting, wasting and underweight than households 
that the households that reported better food security scores and WASH behaviors. 
Objective 2: Suggest further interventions to improve nutrition security in the specific area of intervention.
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2 LITERATURE REVIEW 
2.1 MALNUTRITION DEFINITION AND INDICATORS 
Malnutrition is defined as both the under-consumption and over-consumption of calories and nutrients, 
leading to a pathologic condition linked to higher mortality, disability and morbidity. Generally the term 
malnutrition is used instead of undernutrition that is a lack of macro-nutrients or micro-nutrients.  
2.1.1 Undernutrition and micronutrient deficiencies 
Undernutrition is usually assessed through three specific indicators – Undernutrition, Wasting, and Stunting 
– indicating the Z-Score from WHO Child Growth Standards.  
2.1.1.1 Wasting 
Wasting, or Acute Malnutrition, arises from the lack of food in the short term and it is the most life-
threatening form of malnutrition. Because of its high relative mortality risk, it is primarily targeted during 
humanitarian responses. Wasted children are between 3 and 11 times more likely to die than non-wasted 
children (Black et al. 2013).  
2.1.1.2 Stunting 
Stunting is the most common form of undernutrition and it is measured as Height/length-for-Age. It is mainly 
caused by chronic states of undernutrition and repeated infections during the first 1000 days of a child’s life 
(so called Window of Opportunity), including those spent during the mother's utero (Caulfield et al. 2004; 
WHO 2012; Black et al. 2013). It reflexes a state of chronic undernutrition, associated with higher mortality 
and morbidity risk in the short term and other long-term consequences like lower cognitive development, 
impaired growth trajectories and higher exposure to malnutrition-related diseases and disabilities (Walker 
et al. 2011).  
2.1.1.3 Underweight 
Underweight is commonly used as general proxy indicator of the nutritional status of the population and it 
was used to monitor MDG 1 progresses in the years 2000-2015 (WHO 2015; Kelly et al. 2010). It encompasses 
both acute and chronic undernutrition.  
Indicator Clinical  Significance 
Underweight 
Weight-for-Age Z-Score < -2; 
presence of bilateral edema 
Body mass relative to chronological age;  
Valid proxy for Stunting and Wasting 
Wasting, Acute Malnutrition 
Weight-for-Height Z-Score <-2; 
presence of bilateral edema 
Recent process of severe weight loss 
Stunting, Chronic Malnutrition Height-for-Age Z-Score < -2;  
Linear growth failure, frequent and early exposure to adverse 
conditions 
Table 1 Different undernutrition measures and significance. Adapted from WHO Child Growth Indicators and their interpretations
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At the national level, underweight prevalence reflects the public health significance (see figure) 
Index Low Medium High Very High 
Wasting <5% 5-9,9% 10-14,9% 15% 
Stunting <20% 20-29,9% 30-39,9% 40% 
Underweight <10% 10-19,9% 20-29,9% 30% 
                                                           
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 http://www.who.int/nutgrowthdb/about/introduction/en/index2.html
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Table 2 Different malnutrition prevalence is correlated with different public health significance (low, medium, high, very high) 
2.1.2 Micronutrient deficiency 
Another category of malnutrition, the more common in the world, is the micronutrient deficiency. The most 
important micronutrient deficiencies associated with child morbidity and under-five deaths are four: vitamin 
A, iron, zinc and iodine.  
2.1.2.1 Iron 
Anemia is defined as an underproduction of hemoglobin, the molecule that carries oxygen throughout all the 
body. About 2 billion of people in the world suffer from anemia, 50% of pregnant women and 30% of all the 
women in the world. Anemia is caused by poor dietary iron intake; poor dietary intake of vitamin A, vitamin 
B12 and folate; helminthic infestations; malaria; HIV/AIDS (WHO 2012). Iron dietary anemia (IDA) is 
accountable for at least 50% of anemia cases in the world (Macdonald et al. 2010). Anemia can be defined at 
the individual level (mild, moderate and severe anemia) and at the population level (mild, moderate and 
severe prevalence) evidencing respectively the severity of the illness and the public health impact. 
 Anemia 
Mild 
anemia 
Moderate 
anemia 
Severe 
anemia 
Pregnant 
women 
<11.0 10.0-10.9 7.0-9.9 <7.0 
Non-
pregnant 
women 
(>15 years) 
<12.0 10.0-11.9 7.0-9.9 <7.0 
Anemia 
prevalence 
0-4.9% 5-19% 20-39% ≥ 40% 
Public 
health 
significance 
Normal Mild Moderate Severe 
Table 3 Hemoglobin serum and anemia severity (left); public health significance of different anemia prevalence (right) (Macdonald et 
al. 2010) 
Anemia results in increased maternal and perinatal mortality, increased number of preterm births and low 
birthweight, impaired physical and cognitive development of the child, increased risk of morbidity in children 
and reduced work productivity in adults (M. Black et al. 2011).  
2.1.2.2 Vitamin A 
Vitamin A Deficiency (VAD) is estimated to affect about 250 million preschool children, mostly in Sub-Saharan 
Africa and in South Asia. VAD is currently the world leading cause of child blindness as more than 250,000 
vitamin A deficient children become blind every year (Black et al. 2011). Other negative effects of VAD among 
under-five children are the impairment of the immune system functionality and the increased risk of dying 
of measles and diarrhea, so representing an independent risk factor for child mortality (Sommer 2008). 
2.1.2.3 Iodine 
Iodine deficiency constitutes the single largest cause of preventable impaired brain development. It is 
estimated that 350 millions of people are at risk of developing Iodine Deficiency Disorders (Pandav et al. 
2013). Iodine is a key micronutrient for the synthesis of the thyroid gland. In fact, the lack of iodine in the 
diet (caused by a low iodine concentration at the soil level) has as its consequence mental retardation, 
cretinism and increased risk of perinatal mortality (Qian et al. 2005). If a iodine deficit occurs in the time lapse 
between pregnancy and the third month of life, brain damages are irreversible (Nyaradi et al. 2013).  
2.1.2.4 Zinc 
Zinc deficiency represents a serious health issue in developing countries as it alone accounts for 800,000 
deaths per year (Wessells & Brown 2012). Adequate zinc intake is a critical factor for the correct function and 
development of the child’s immunity and neurological system. Children affected by zinc deficiency are more 
likely to die of diarrhea, acute respiratory infections and malaria while pregnant women supplemented with 
zinc supplementations are 14% less at risk to face adverse pregnancy outcomes (Yakoob et al. 2011). Low