Scaling up nutrition interventions for children left behind in Nigeria

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POLICY BRIEF
SCALING UP NUTRITION
INTERVENTIONS FOR
CHILDREN LEFT BEHIND
IN NIGERIA

Scaling up nutrition interventions
for children left behind in Nigeria
Nutritional status is a major determinant of health
and well-being of children. When children have a
healthy, adequate diet, and are well cared for, they
not only have a higher likelihood of survival but also
greater chances to reach their full growth potential
and future prospects. Poor nutritional habits are
amongst the key determinants of chronic illnesses
(Popkin et al, 2012).
Children’s nutritional outcomes are affected by
a range of factors, at household, community and
country levels. Where they live, their family’s
income, and their gender play a role. Their mother’s
level of education and the availability of information
and access to locally-produced food also influence
how food is allocated within a family.
The Government of Nigeria has put a number
of programmes and policies in place to address
the issue of child malnutrition. These include: the
National Policy on Food and Nutrition (2016),
the Food Security Bill (2015), the National Plan of
Action on Food and Nutrition in Nigeria (2004),
the National Strategic Plan of Action (the health
sector response), the Micronutrient Control
Programme, the Baby-friendly Hospital Initiative,
and the school feeding programme. The government
has also enacted laws requiring the fortification
of mass consumed foods with vitaminA, iron and
saltiodization.
However, the implementation of these policies and
programmes and the enforcement of the legislation
remain a challenge. There is a persistently high
level of child malnutrition in the country and stark
disparities in nutritional status among children in
different socio-economic groups and states. In this
policy brief, we summarise the nature and extent
of key inequalities in nutritional status of children
in Nigeria and suggest a number of concrete policy
recommendations to scale up interventions which
can help children who are not being fully reached
bycurrent efforts.
2
PHOTO: SU SSAN AKIL A/SAVE TH E CHILDR EN
A mother with her baby waiting
to transport herself home after
receiving a food basket from
Save the Children.

SCALING UP NUTRITION INTERVENTIONS FOR CHILDREN LEFT BEHIND IN NIGERIA
3
THE BURDEN OF
MALNUTRITION IN NIGERIA
REMAINS WORRYINGLY HIGH
Underweight (low weight for age), stunting (low
height for age) and wasting (low weight for height)
are all manifestations of undernutrition. All expose
the child to health risks; in their severe forms,
they constitute a threat to the child’s survival.
In Nigeria, prevalence of stunting changed
marginally between 1990 and 2013 from 43% to
37%. During the same period, the burden of acute
malnutrition increased – it was estimated at 9% in
1990 and is currently estimated at 18%. In the North
West region, the prevalence of acute malnutrition
remains as high as 27%. Finally, the level of severe
acute malnutrition grew from 2% in 1990 to 9% in
2013 (NPC and ICF International, 2014). Severe
acute malnutrition is a critical public health problem
and a continuing challenge to clinicians (Rytter et al,
2015). In Nigeria, there are approximately 1.7 million
children suffering from severe acute malnutrition.
This number constitutes one tenth ofall severely
acutely malnourished children in the world (UNICEF,
2015). Figure 1 illustrates the trends in child
malnutrition in the country between 1990 and 2013.
According to the UN Office for the Coordination
of Humanitarian Affairs (2014), Nigeria has the
second highest acute malnutrition burden in the
world, with an estimated 3.78 million children
suffering fromwasting.
CHILDREN FROM THE POOREST
HOUSEHOLDS ARE MOST LIKELY
TO SUFFER FROM MALNUTRITION
Evidence suggests that poverty is a key determinant
of child undernutrition (Ubesie & Ibeziakor, 2012;
Van de Poel et al, 2007). The findings of a study
of factors affecting Nigerian children’s nutritional
status suggest that households’ economic status is
significantly associated with their nutritional status.
The very poor and the poor constitute 74% of the
population and cannot afford a nutritious diet (NPC
and ICF International, 2014). They often survive on
FIGURE 1: TRENDS IN CHILD MALNUTRITION IN NIGERIA BETWEEN 1990 AND 2013
Data source: NPC and ICF International, 2014
50
45
40
35
30
25
20
15
10
5
0
%
1990 2003 2008 2013
Stunting
Severe stunting
Wasting
Severe wasting

SCALING UP NUTRITION INTERVENTIONS FOR CHILDREN LEFT BEHIND IN NIGERIA
4
a minimum calorie threshold and chronic and acute
malnutrition are therefore common among children.
In Nigeria, children from the poorest households
are almost 3 times more likely to be stuntedand
almost 4.3 times more likely to be severely stunted
compared to children from the wealthiest households.
Analysing trends for the prevalence of malnutrition
amongst the poorest groups reveals that the
prevalence of stunting for the poorest children
increased from 48.8% in 2003 to 53.8% in 2013. The
poorest children are also 3.7times more likely to be
wasted and 3.2 times more likely be severely wasted
compared to children living in richest households
(NPC and ICF International, 2014).
The prevalence of overweight, albeit relatively low
in Nigeria, is a growing public health problem. In
Nigeria the prevalence of overweight among children
from the poorest households is approximately 4.9%
compared to 3.2% for children from the richest
households (NPC and ICF International, 2014).
Research shows that households’ economic status
also has a statistically significant effect on children’s
nutritional status in different agro-ecological
zones, in particular in the humid forest zone and
the Sudano-Sahelian savannah. Because the notion
of socio-economic status cannot be limited to
household income, it is also important to consider
other factors, including those related to women’s
empowerment, such as mothers’ working status,
control over resources and educational attainment.
In rural areas, children of working women are
significantly less likely to be undernourished than
children living in households where mothers do not
work (Ajieroh, 2009).
MALNOURISHED CHILDREN
ARE FOUND MAINLY IN THE
NORTH WEST AND NORTH EAST
Analysing the regional disparities in child malnutrition
reveals important spatial inequalities. The prevalence
of underweight, stunting and wasting is generally
higher in the northern than the southern states.
The highest proportions of malnourished children
were found mainly in Bauchi, Jigawa, Kaduna,
Katsina, Kebbi, Sokoto and Zamfara states. In all
these states the prevalence of stunting exceeds 50%.
In other states, such as Gombe, Taraba, Yobe and
Kano, the prevalence of stunting exceeds 40%.
The prevalence of moderate wasting among children
under five exhibits similar patterns. All states in
the North West (except Jigawa and Zamfara)
show higher than national average prevalence
of acute malnutrition (wasting). In addition, the
North-Eastern states of Bauchi, Borno and Yobe
have a disproportionately high burden of wasting,
with Kano state showing more than twice the
national average (39.7%). Severe acute malnutrition
PHOTO: DAN S TEWART/SAVE TH E CHILDR EN
Children learn basic literacy,
numeracy and geography
at a centre supported by
Save the Children and Unicef,
in a camp for displaced
people in Maiduguri.

SCALING UP NUTRITION INTERVENTIONS FOR CHILDREN LEFT BEHIND IN NIGERIA
5
is highestin Kaduna (27.6) and Kano (25.1%) and
lowest in Bayelsa (1.3%). Recent trends in levels of
child malnutrition also show uneven progress among
the regions (Figure 2).
Analysis of seasonal effects in the Northern states
(Figure 3) reveals that June, August and September
are the months where most children are admitted
into community-based management of acute
malnutrition (CMAM) programmes, and that the
numbers of admitted children have been consistently
on the rise since 2009.
FIGURE 2: REGIONAL DISPARITIES IN CHILD STUNTING IN NIGERIA
Data source: NPC and ICF International, 2014
FIGURE 3: TRENDS IN NEW ADMISSIONS TO THE CMAM PROGRAMME, NORTHERN STATES
Data source: National Health and Nutrition Survey (2015), courtesy of UNICEF
60
50
40
30
20
10
0
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
%New admissions
Nort h Central Nort h East Nort h West South East South South South West
Jan Feb Mar April May June July Aug Sept Oct Nov Dec
1990
2003
2008
2013
2009
2010
20 11
2012
2013
2014
2015

SCALING UP NUTRITION INTERVENTIONS FOR CHILDREN LEFT BEHIND IN NIGERIA
6
CHILDREN IN RURAL
HOUSEHOLDS ARE MORE LIKELY
TO BE STUNTED THAN CHILDREN
IN URBAN HOUSEHOLDS
In addition to socio-economic inequalities and
regional inequalities, there exist also important
rural–urban differences. Children from rural
households are more likely to be disadvantaged
because of factors including poor infrastructure in
rural areas and lack of access to healthcare facilities.
In addition, rural households often lack awareness
of how to use locally available nutritious foods.
InNigeria, the prevalence of malnutrition among
rural children is considerably higher than among
urban children. For example, the rate of child
stunting in rural households was estimated
at 43.2%, compared to 26% for children living
in urban areas.
It should also be highlighted that while there are
considerable differences between rural and urban
areas, there exist important intra-urban inequalities.
As a consequence of the rapid pace of urbanisation
in Nigeria, the proportion of the population which
lives in urban areas in the country increased from
29.7% in 1990 to 47.8% in 2015 and is projected
to reach 67.1% in 2050 (United Nations, 2014).
Theincrease in slum areas and slum populations
is a result of this rapid and often poorly managed
urbanisation. In Nigeria, the urban poor are the
fastest growing segment of the urban population,
resulting in growing number of households being
unable to access increasingly more expensive food
(Ndukwu et al, 2013).
GENDER-RELATED INEQUALITIES
AND GENDER IMPACTS
ARE COMPLEX AND REQUIRE
SPECIAL ATTENTION
Gender-related inequalities are multidimensional and
require special attention. While overall more boys
than girls are stunted (38.6% vs. 35.0%) and wasted
(18.9% vs. 17.2%), more girls are overweight. These
gender differentials in child undernutrition have
previously been explained by the epidemiological
studies which suggest that morbidity and mortality
tend to be consistently higher amongst male infants
and young children (Wamani et al, 2007). The
gender dynamics and gender-related associations
are however complex and often context specific.
While Nigeria has a legal policy framework to
prevent discrimination, the implementation of specific
laws and regulations remains a challenge. In general,
women tend to be less educated than men and have
less power over resources and in terms of decision
making. Female-headed households have been
repeatedly found to be less food secure compared
to male-headed households (Lawson, 2014).
PHOTO: OIWOJA ODIHI/SAVE THE CHILDREN
Jamila, three, was severely
malnourished but made
a dramatic recovery
when she was treated at
a government hospital
which Save the Children
supports.

SCALING UP NUTRITION INTERVENTIONS FOR CHILDREN LEFT BEHIND IN NIGERIA
7
Women who suffer from stunting are more likely to
give birth to premature or low birthweight infants,
conditions which are associated with higher risk
of death, poor nutritional status and unfulfilled
potential in later life (ORIE, 2014). The median age
of first birth varies by socio-economic status in all
regions in the country. In the Northern regions,
the first birth often occurs during adolescence,
whereas in the South the first birth is usually in the
early twenties. One in six teenagers in Nigeria is
already a mother, and 34% of adolescents from the
poorest households are mothers. There has been
a slight improvement; however teenage pregnancy
is a common feature in the North. The proportion
of women aged 15–19 who have had a live birth is
highest in Jigawa state (43.5%), followed by Katsina
(41.2%), Bauchi (37.8%), Zamfara (31.4%) and Gombe
(28.7%) (NPC and ICF International, 2014). Areas
that have a high rate of teenage pregnancy also have
a high rate of maternal morbidity and mortality,
worsened by underlying nutritionaldeficiencies.
RECOMMENDATIONS FOR ACTION
Sustainable approaches to addressing both acute
and chronic malnutrition encompass strengthening
livelihood systems for poor people and supporting
policies that improve childcare practices and
increase access to nutritious food. More specifically:
✓ The Ministry of Budget and National
Planning should lead on the development of a
multisectoral results framework, setting out
defined performance indicators, baseline data
and targets for various ministries, departments
and agencies. This will serve as a platform for
tracking achievements and results.
✓ The Ministry of Budget and National Planning
and the state-level Ministries of Economic
Planning should ensure that states adopt
tailored food and nutrition policy. These policies
and related strategies would clearly define
the approach and propose interventions and
activities that would contribute to scaling up
nutrition which will have an impact on the lives
ofchildren left behind.
✓ The State Ministry of Economic Planning should
ensure that local government committees
on food and nutrition are established and
meetingregularly.
✓ The Office of the Vice President should ensure
that the National Nutrition Council meets
regularly, in line with the approved national
food and nutrition policy. Annually, it should
develop a national nutrition report showing
progress and challenges at different levels, which
would inform programming by development
partners and government ministries, departments
and agencies in the following year.
✓ The Government should increase funding for
nutrition services, including the establishment
of nutrition corners in the primary
healthcarecentres.
✓ A multi-pronged approach is required in dealing
with the persistent challenge of malnutrition.
Efforts to increase food production, availability
and accessibility, as well as investments in
nutrition education, should be intensified.
✓ Civil society organizations should regularly
conduct budget advocacy for increased
accountability.
✓ Civil society and media should work jointly
to ensure public accountability on funds
disbursement for nutrition interventions as
well as increased sensitization of healthy
eatinghabits.
✓ Government budgets should prioritise
agricultural and rural development in order to
enhance food production and distribution.
✓ Civil society should advocate for development
and implementation of policies that increase
access to food and income for the most
vulnerable households. This involves passing
and signing into law the Food Security Bill which
is currently at the National Assembly.
✓ To improve nutritional status of the most
vulnerable children, government should prioritize
investments in girls’ education, social protection
and women’s empowerment. Nutrition and food
security plans and programmes should be based
on gender-sensitive approaches.
✓ The leadership of the National Assembly should
establish a standing committee that would focus
on issues relating to children. This committee
should oversee activities of different ministries,
departments and agencies, as it relates to
children especially the under fives.

SCALING UP NUTRITION INTERVENTIONS FOR CHILDREN LEFT BEHIND IN NIGERIA
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KEY REFERENCES
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maternal-malnutrition-nigeria-0, last accessed
26 August 2016
Lawson, PS (2014) An analysis of food poverty
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2(6): 126–129
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Van de Poel, E, Reza Hosseinpoor, A,
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Wamani, H, Nordrehaug Astrøm, A, Peterson,
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Cover photo: Children learn basic literacy, numeracy and geography at a centre supported by Save the Children
and Unicef, in a camp for displaced people in Maiduguri. (Photo: Dan Stewart/Save the Children)
First published 2016
© The Save t he Children Fund 2016
The Save t he Children Fund is a chari ty registered in England and Wales
(213890) and Scotland (SC039570). Registered Company No. 178159
Acknowledgements
This brief has been written by Sylvia Szabo (Save the Children UK), Ekene Innocent Ifedilichuk wu (Save the Children
International) and Chachu Tadicha (Save the Children International). The authors are grateful to David Olayemi,
Ima Kashim, Victor Ajieroh, Ramatu Budah-Aliyu and Zaharadeen Sabiu for their valuable comments and to
Sarah Finch for editing and Neil Adams for design.