Uganda Nutrition Situation Analysis: trends in nutritional status, behaviours, and interventions

Abstract

Trend analysis of Demographic and Health Survey

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Nutrition Situation Analysis
Trends in nutritional status, behaviours and interventions
UNICEF Uganda
Kampala, Uganda
April 2018

Suggested citation:
UNICEF Uganda. 2018. Nutrition situation analysis: Trends in nutrition status, behaviours, and interventions.
Kampala, Uganda: UNICEF Uganda.
Analysis and report writing:
Joel Conkle, Ph.D., MPH, Senior Nutrition Research Consultant, jconkle@unicef.org; joelconkle@gmail.com
For more information on this work and other nutrition studies from UNICEF Uganda, please contact:
Cecilia De Bustos, Nutrition Manager, cdebustos@unicef.org
Viorica Berdaga, Chief Child Survival and Development, vberdaga@unicef.org

Contents
List of figures ............................................................................................................................................ 4
List of maps............................................................................................................................................... 5
Abbreviations and acronyms ..................................................................................................................... 6
Executive summary ....................................................................................................................................... 7
Chapter 1: Introduction ............................................................................................................................... 10
Chapter 2: Nutritional status ....................................................................................................................... 11
2.1 Child anthropometric indicators ........................................................................................................ 11
2.2 Adolescent and adult anthropometric indicators ............................................................................... 17
2.3 Child micronutrient deficiency ......................................................................................................... 20
2.4 Adolescent and adult micronutrient deficiency................................................................................. 23
Chapter 3: Nutrition behaviours .................................................................................................................. 25
3.1 Infant and young child feeding (IYCF): breastfeeding ..................................................................... 25
3.2 Infant and young child feeding (IYCF): complementary feeding ..................................................... 31
Chapter 4: Preventive nutrition interventions ............................................................................................. 35
4.1 Micronutrient Fortification ............................................................................................................... 35
4.2 Child micronutrient supplementation and deworming ...................................................................... 36
4.3 Maternal micronutrient supplementation and deworming ................................................................ 39
4.4 Promotion of maternal, infant and young child feeding ................................................................... 41
Chapter 5: Curative nutrition interventions ................................................................................................ 43
5.1 Identification and treatment of acute malnutrition ............................................................................ 43
5.2 Child diarrhea treatment and feeding ................................................................................................ 43
Appendix 1: Maps and figures from other publications .............................................................................. 46
Appendix 2: Recommendations for additional research ............................................................................. 51

List of figures
Figure 1: Trends in anthropometric indicators of child nutritional status ................................................... 13
Figure 2: Trends in child acute malnutrition in regions with high prevalence ........................................... 14
Figure 3: Trends in child acute malnutrition by wealth .............................................................................. 14
Figure 4: Trends in child stunting by wealth .............................................................................................. 15
Figure 5: Trends in anthropometry of women of reproductive age ............................................................ 18
Figure 6: Trends in child anaemia............................................................................................................... 21
Figure 7: Trends in child malaria and anaemia ........................................................................................... 21
Figure 8: Trends in child anaemia, malaria and coverage of malaria prevention interventions in Mid
Northern Region.......................................................................................................................................... 22
Figure 9: Trends in anaemia among women of reproductive age. .............................................................. 23
Figure 10: Trend in early initiation of breastfeeding and prelacteal feeding .............................................. 27
Figure 11: Trend in early initiation by place of delivery ............................................................................ 27
Figure 12: Trends in exclusive breastfeeding ............................................................................................. 28
Figure 13: Trends in continued breastfeeding by age ................................................................................. 28
Figure 14: Trends in bottle use by age group .............................................................................................. 29
Figure 15 Minimum meal frequency and minimum acceptable diet .......................................................... 32
Figure 16: Trends in micronutrient fortification and child supplementation .............................................. 38
Figure 17: Trends in child deworming by maternal schooling ................................................................... 38
Figure 18: Child deworming and vitamin A supplementation by age group .............................................. 39
Figure 19 Trend iron folic acid supplementation and deworming for pregnant women ............................. 41
Figure 20: Trends in treatment of child diarrhea with zinc by child age .................................................... 44
Figure 21: Feeding during child diarrhea .................................................................................................... 45
Figure 22: Projections of 2025 number of stunted children ........................................................................ 46
Figure 23: Poverty map ............................................................................................................................... 46
Figure 24: Regional trends in subsistence farming ..................................................................................... 47
Figure 25: Child anaemia prevalence map .................................................................................................. 47
Figure 26: Indoor residual spraying implementation map .......................................................................... 48
Figure 27: Sickle cell prevalence at district level ....................................................................................... 49
Figure 28: Children deprived of three meals by poverty ............................................................................ 49
Figure 29: Trends in malaria prophylaxis during pregnancy ...................................................................... 50

List of maps
Map 1: Child wasting by region .............................................................................................................. 15
Map 2: Child stunting by region ............................................................................................................. 16
Map 3: Women thinness ......................................................................................................................... 18
Map 4: Women obesity ............................................................................................................................ 19
Map 5: Women short stature .................................................................................................................. 19
Map 6: Child malaria ................................................................................................................................ 22
Map 7: Anaemia among Women ........................................................................................................... 24
Map 8: Early initiation of breastfeeding ................................................................................................. 29
Map 9: Prelacteal feeding ....................................................................................................................... 30
Map 10: Child minimum meal frequency .............................................................................................. 32
Map 11: Child minimum dietary diversity .............................................................................................. 33
Map 12: Children eating iron-rich foods ................................................................................................ 33
Map 13: Children eating vitamin A-rich foods ...................................................................................... 34
Map 14: Child vitamin A supplementation ............................................................................................ 39
Map 15: Iron folic acid supplementation during pregnancy ............................................................... 41
Map 16: Postpartum breastfeeding counselling .................................................................................. 42
Map 17: Treatment of child diarrhea with zinc ..................................................................................... 44
Map 18: Median duration of breastfeeding by region ......................................................................... 52
Map 19: Minimum acceptable diet by region ....................................................................................... 52
Map 20: Child underweight by region.................................................................................................... 53

Abbreviations and acronyms
ANC
antenatal care
DHIS
District Health Information System II
IFA
iron folic acid
IRS
indoor residual spraying
MDD-W
minimum dietary diversity for women indicator
MIS
malaria indicator survey
MNP
micronutrient powder
RBP-EIA
retinol binding protein
SAM
severe acute malnutrition
UDHS
Uganda Demographic and Health Survey
UNHS
Uganda National Household Survey
US CDC
United States Centers for Disease Control and Prevention
VAD
vitamin A deficiency
VAS
vitamin A supplementation
WHA
World Health Assembly
WHO
World Health Organization
WQ
wealth quintile

Executive summary
This report analysed trends from 1995 to 2016, and provided disaggregated analysis and maps of indicators
included in the Uganda Demographic and Health Survey that are related to nutritional status, behaviours, and
interventions. The aim of the analysis was to inform development of policies and programmes, including:
• the Ministry of Health’s Maternal, Infant, Young Child, and Adolescent Nutrition Road Map,
• the 2nd Uganda Nutrition Action Plan, and
• the mid-term review of nutrition activities in the United Nations Children’s Fund Uganda Country
Programme Action Plan
Global Targets
Considering the World Health Assembly targets related to nutrition, the prevalence of child overweight
(3.7%) remained low in 2016 in Uganda, and the country was doing well to sustain previous improvements for child
wasting (thinness) and exclusive breastfeeding, putting Uganda ‘on-track’ to achieve global targets related to the
three indicators (Table 1). However, progress on child stunting was offset by high population growth and there was
little change in the absolute number of stunted children, placing the country ‘off-track’ for achieving global stunting
targets (Table 1). Also, after impressive anaemia reduction from 2006 to 2011, the country backtracked in 2016
with an increased prevalence (32%), and ‘off-track’ status, for anaemia among women of reproductive age (Table
1). We concluded that the fluctuating prevalence of anaemia for women and children was likely related to malaria
vector control interventions that were implemented, but not sustained.
Nutritional Status
In addition to analyzing national trends of child wasting and stunting, this report also examined subnational
prevalence. A relatively low national prevalence of U5 child global acute malnutrition (GAM), or wasting, masked a
high national prevalence of severe wasting (1.3%) and increases in GAM prevalence in specific regions (Karamoja
and West Nile). The findings merit a closer inspection of anthropometric data quality in West Nile to determine if
the increase was real or a result of poor quality measurement. For Karamoja, and other regions with high severe
wasting prevalence, there is a need to scale-up prevention and treatment. For child stunting, regional differences
correlated with poverty rates, except in a couple of regions, including Teso. Despite high poverty, Teso had a low
prevalence of stunting, which could hypothetically be explained by better infant and young child feeding practices
observed in that region, specifically higher child consumption of animal source foods.
Child overweight was low (3.7%) and not increasing, but adult obesity is now emerging as a public health
problem in some areas of the country, particularly in Kampala and Central I. Uganda is now experiencing the double
burden of under- and over-nutrition. Undernourished children are at higher risk for developing metabolic syndrome
when compared to children with normal nutritional status; and considering the current and former high prevalences
of child undernutrition in Uganda, it will be critical to implement public health interventions to prevent a widespread
obesity epidemic as the country becomes more affluent.
After large reductions in U5 child and woman anaemia prevalence from 2006 to 2011, there was an
increase in prevalence in 2016 and anaemia remains a severe and moderate public health problem for women and

children respectively. Trends in anaemia prevalence appear to be related to indoor residual spraying, which
successfully prevented malaria in some parts of the country until 2015, when the intervention stopped and high
malaria parasitemia returned. The relative contributions of the various causes of anaemia is unknown in the country,
but non-nutritional causes of anaemia, such as sickle cell and malaria, appear to be important causes of high anaemia
prevalence in the country. To achieve global anaemia reduction targets, malaria vector control programmes must be
scaled-up and sustained, and an anaemia etiology study is needed to guide both nutritional and non-nutritional
interventions.
Nutrition Behaviours
Over the last decade there was a large increase in early initiation of breastfeeding and a corresponding drop
in prelacteal feeding. A majority of mothers now initiate breastfeeding within one hour of birth (66%), which should
contribute to infant mortality reduction. The improvement in early initiation of breastfeeding occurred over the same
time as an increase in the percentage of women delivering in health facilities. However, the improvement in
breastfeeding initiation occurred among both women who delivered in health facilities and women who delivered at
home, suggesting behavior change occurred both within and outside of health facilities.
A majority of children were breastfed exclusively for the first six months of life (66%), but the percentage
did not increase substantially over the last 15 years, and there was a small decrease in continued breastfeeding over
the last 10 years. Increased coverage of antenatal care and facility delivery provides an efficient platform to scale-up
and sustain promotion of appropriate breastfeeding, but it appears that currently many health workers do not provide
sufficient counselling at these contact points. For continued breastfeeding, inadequate birth spacing is likely a
significant barrier in the country.
Unlike breastfeeding, complementary feeding practices appear unchanged since DHS started measuring
child feeding in the country. In 2016, a majority of U2 children did not receive the minimum number of meals per
day, and there was little change in feeding frequency over the last 10 years. Young children are probably not fed
enough food, and for many children the food they do receive is not highly nutritious. Nearly 3 out of 4 U2 children
did not receive the minimum number of food groups in 2016, and in most regions a majority of children did not eat
nutrient-rich, animal-source foods. Based on low feeding frequency and dietary diversity throughout the country,
even in relatively wealthy regions, poverty does not appear to be the only cause of persisting inadequate infant and
young child feeding practices in Uganda - cultural practices also play an important role in child feeding in the
country.
Nutrition Interventions
The sustained, high coverage and quality of iodized salt over the last 15 years likely eradicated iodine
deficiency in the country and contributed to improvement in national intelligence and productivity. Within the last
decade vitamin A fortification of cooking oil was legally mandated, and by 2015, fortified oil reached the majority
of households in the country. Iron fortification of staple foods and in-home fortification were not scaled up to reach
a large percentage of households nationally, and scaling up iron interventions is hampered by persistently high
prevalence of malaria in most areas of the country.
Coverage of both vitamin A supplementation and deworming for U5 children increased to approximately
60% over the last 10 years. The similar coverage for the two interventions was expected because they are both
implemented via biannual campaigns. Interventions delivered vertically through campaigns or outreach, such as
immunization, regularly achieve coverage >90% because there is low opportunity cost for the recipient. The 60%
coverage for child vitamin A supplementation and deworming, while an improvement over previous years, should
still be considered low.

Coverage of iron folic acid supplementation during pregnancy followed the increasing trend of antenatal
care in the country, nearly reaching 90% coverage of any iron folic acid during pregnancy in 2016, but less than 1
out of 4 women received the recommended minimum of 90 tablets. Coverage of deworming for pregnant women
only increased to approximately 60%, which means that many women who attend antenatal care do not receive
deworming. In 2016, nearly 3 out of 4 women delivered in a health facility and most delivered in a public facility,
but only 35% reported that they received postpartum counselling on breastfeeding. The differences between
maternal care coverage and coverage of some of the key components of maternal care illustrates that the health
system is not taking full advantage of contact points to deliver high quality services.
From 2011 to 2016 zinc supplementation went from reaching virtually no children to reaching 40% of
children U5 who had diarrhea, and the increased coverage was likely a result of packaging zinc with oral rehydration
solution. While zinc supplementation for diarrhea treatment improved, there was no change in feeding practices
during diarrhea. In 2016, few caretakers (15%) gave children more fluids during diarrhea, and a majority of children
ate less when they had diarrhea. More effort is needed to improve both complementary feeding and feeding during
illness.
In two regions where UNICEF supported outpatient treatment of severe acute malnutrition, Karamoja and
Kigezi, more than 5% of children received ready-to-use therapeutic food. In all other regions coverage of severe
acute malnutrition treatment was much lower, and the low coverage may be attributed to the lack of a national
programme to identify and treat malnourished children in the community.
Table 1: Progress on World Health Assembly Targets related to nutrition
Indicator
Baseline
(2012)1
Target
(2025)
Current
(2016)2
Status
40% reduction in the number of stunted
children
2,318,000 ≤1,391,000 1,870,000 Off-track
Reduce and maintain wasting prevalence
to below 5%
4.3% <5% 3.6% On-track
50% reduction in anaemia prevalence
among women of reproductive age (15-49
years)
29.6% ≤14.8% 31.7% Off-track
No increase in child overweight
prevalence
5.8% ≤5.8% 3.7% On-track
Increase the percentage of exclusively
breastfed children to at least 50%
63.2 >50% 65.5% On-track
30% reduction in low birth weight
10.2 ≤7.1 9.6
Additional
analysis
Required
1Baseline estimates and targets from UNICEF Nutrition Targets Tracking Tool: https://data.unicef.org/resources/nutrition-targets-
tracking-tool/
2
Current estimates from Uganda Demographic and Health Survey

Chapter 1: Introduction
The Government of Uganda (GoU) publicly released the 2016 Uganda Demographic and Health Survey
(UDHS) in March 2018. Among other topics, the UDHS provides a wealth of information once every five years on
demographic characteristics, gender-based violence, early childhood development, disability, education, disease and
nutrition; and UDHS was conducted in Uganda since 1988. This situation analysis focused on nutrition topics
covered in the 2016 UDHS; including anthropometric measures, micronutrient deficiency, child feeding practices
and diet, micronutrient fortification and supplementation, and other interventions related to the prevention and
treatment of child and maternal malnutrition. This analysis complements the UDHS 2016 report by exploring trends
over time and disaggregating trends by socio-economic characteristics, by offering potential explanations for
observed trends, by mapping key indicators, and by identifying information gaps and recommending additional
research. To place some of the findings into context, figures and maps from previous publications are presented in
Appendix 1 of the report. Recommendations for additional research are included in Appendix 2.
The Ministry of Health Nutrition Division and the United Nations Children’s Fund (UNICEF) developed
this report to inform the development of policies and programmes, including the Ministry of Health’s Maternal,
Infant, Young Child, and Adolescent Nutrition Road Map, the 2nd Uganda Nutrition Action Plan, and the mid-term
review of the UNICEF Uganda 2016-2020 Country Programme Action Plan. It is expected that the report will also
be used by GoU and Development Partners to provide input into the development of other plans and policies related
to nutrition in the country. The target audience for this report is professional staff working on nutrition policy and
programmes in Uganda.
This situation analysis does not include a landscape analysis because a comprehensive review of nutrition
governance and policies was recently completed in December 2017 with support from the National Information
Platforms for Nutrition Initiative (NIPN) (14). This situation analysis, combined with the NIPN review, provides an
update to many sections of the comprehensive 2010 Analysis of the Nutrition Situation in Uganda (15).
Unless otherwise noted, all of the data presented in this report comes from the UDHS. We used the DHS
Program STATcompiler1 to populate figures and maps with UDHS data. We carried out all analyses with Microsoft
Excel 2013 and used ArcMap 102 for mapping. We did not analyze raw data for this report, but UNICEF plans to
support additional secondary analysis of raw UDHS data in the future, with the aim to fulfil some of the
recommendations for additional analysis presented in Appendix 2.
The report is divided into five chapters: Introduction, Nutritional Status, Nutrition Behaviours, Preventive
Nutrition Interventions, and Curative Nutrition Interventions. Each chapter includes a Key Findings section at the
beginning of the chapter to display the most important trends. Additional maps and figures requested from
stakeholders are included in Appendix 3, and high resolution copies of maps for printing are available upon request
from UNICEF Uganda.
1 https://www.statcompiler.com/en/
2 http://desktop.arcgis.com/en/arcmap/

Chapter 2: Nutritional status
Chapter 2 Key Findings
2.1 Child anthropometric indicators
Child wasting and overweight
In 2016, the prevalence of wasting3 in Uganda (3.6%) (Fig 1) was just above what would be expected in a
well-nourished population (2.3%), and the mean weight-for-height z-score was 0.1. However, overall wasting does
not tell the whole story — out of all wasted children in Uganda, one third of them were severely wasted, and at 1.3%,
the national prevalence of severe acute malnutrition (SAM) was nine times higher than what would be expected in a
well-nourished population (0.14%). Applying the 2016 prevalence of SAM to the national population projections for
2018 shows that, currently, there are 233,000 children with SAM that require therapeutic feeding in the country per
3 Wasting, or acute malnutrition, in this report is defined using weight-for-height. The Uganda 2010 Integrated Management of Acute
Malnutrition Guidelines promote screening for acute malnutrition based on multiple criteria: weight-for-height, mid-upper arm circumference,
visible signs of wasting, or bilateral pitting edema. Of the four criteria, only weight-for-height was included in a national level, household survey
in the country.
Anthropometry
•A relatively low national prevalence of U5 child global acute
malnutrition (GAM) masked a high national prevalence of
severe wasting and increases in GAM prevalence in specific
regions.
•Steady progress in reducing the national prevalence of U5 child
stunting did not lead to large reductions in the absolute number
of stunted children because of population growth.
•Child overweight was low and not increasing, but adult obesity
is emerging as a public health problem in some areas of the
country.
Micronutrient
deficiency
•After large reductions in U5 child and woman anaemia
prevalence from 2006 to 2011, there was an increase in
prevalence in 2016 and anaemia remains a severe and
moderate public health problem for women and children
resectively
•Trends in anaemia appear to be related to vector control
programmes that successfully prevented malaria, but then
stopped in 2015.
•The relative contributions of the various causes of anaemia is
unknown in the country, but non-nutritional causes of anaemia,
such as sickle cell and malaria, appear to be important causes
of high anaemia prevalence in the country.

year4. National level wasting prevalence also masks high levels of wasting at regional level5, particularly in Karamoja
and West Nile6 (Map 1), where the prevalence of wasting increased to just over 10% in 2016 (Fig 2). In Karamoja,
the prevalence of severe wasting (3%) in 2016 was more than twenty times higher than what would be expected in a
well-nourished population, and the mean weight-for-height z-score was -0.6. The cause of the recent increase in acute
malnutrition in specific regions has not been studied, but as expected, high child wasting does appear to be associated
with poverty (Fig 3).
At 3.7% prevalence, child overweight was not a critical public health issue at the national level, and it appears
there was no increase in child overweight from 2011 to 2016 (Fig 1).
Child stunting
Over the last 15 years, there was a substantial reduction in the prevalence of child stunting, with national
prevalence dropping from 45% in 2000 to 29% in 2016 (Fig 1). According to the World Health Organization (WHO)
classification, Uganda moved from high to medium severity for stunting, by dropping below the 30% prevalence
threshold, and the country is on pace to achieve the government target of reducing the prevalence of child stunting to
25% by 2019/20 (16). From 2000 to 2016, there was also an impressive 54% reduction in severe stunting (20% to
9%). Despite the progress on stunting, further improvement is needed to achieve a classification of low stunting
severity (<20%) and to meet the World Health Assembly (WHA) target of reducing the absolute number of stunted
children by 40%, to less than 1.46 million by 2025. Applying national population projections to prevalence data shows
that there were 1.87 million stunted children under five years of age in 20167. There is some evidence that the pace of
improvement in stunting is increasing; the mean height-for-age z-score increased from -1.5 in 2006 to -1.4 in 2011,
and to -1.2 in 2016. However, over the last 10 years, stunting declined by an approximate rate of one percentage point
per year; and projections show that the current pace of reduction will not be sufficient to reach the WHA target (Fig
22)8. For child stunting, there is substantial economic disparity, with the prevalence of stunting in each of the
poorest three wealth quintiles nearly double that of the richest quintile (Fig 4). At the regional level there was
variability in stunting, and prevalence was generally highest in the areas that had the highest poverty (Map 2 and Fig
23), with the following notable exception: Teso had double the poverty of Tooro in the 2016/7 Uganda National
Household Survey (UNHS) (41% vs. 21%) (4), but the stunting rate in Teso was much lower than Tooro in the 2016
UDHS (14% vs 41%).
4 This estimate does not include children that qualify for treatment based on mid-upper arm circumference, visible signs of wasting, or bilateral
pitting edema. UBOS 2015-2020 Population Projection: 2018 population under 5 is 6,893,800 multiplied by 0.013 and multiplied by incidence
correction factor of 2.6.
5 There is no regional administrative structure in Uganda. The regions used in this report were defined in the 2016 UDHS.
6 In West Nile, the prevalence of severe wasting (5.6%) was extremely high, but the mean weight-for-height z-score (-0.3) was not excessively
low, which is a discrepancy that requires further analysis.
7 UBOS 2015-2020 Population Projection: 2016 population under 5 of 6,468,700 multiplied by 0.289
8 The 2014 Uganda National Population and Housing Census found that previous population projections overestimated the number of people in
the country. The population was revised downward in 2014 in the country, but the Population Division of the United Nations Secretariat did not
modify their projections. The stunting projection referenced in this report used the UN population projections.
Worrying trends in acute malnutrition
In Karamoja, the increase in child acute malnutrition occurred at the same time as a shift in
livelihoods; from 2012 to 2016, the proportion of the population relying on subsistence farming
increased from 6% to 51% in the region (4) (Fig 24). In other communities, a move towards sedentary
lifestyles was shown to reduce consumption of milk, increase morbidity and increase stunting (8).
More research is needed to understand recent changes in Karamoja and to interpret high levels of
wasting that can occur among pastoralists without linear growth faltering (11).

Figure 1: Trends in anthropometric indicators of child nutritional status
Prevalence among children under five years of age, UDHS 2000-2016
44.8
38.7
33.7
28.9
19
16.4 14.1
10.5
0
5
10
15
20
25
30
35
40
45
50
2000 2006 2011 2016
Prevalence
Survey Year
Stunting (height/age)
Underweight (weight/age)
Wasted (weight/height)
Overweight (weight/height)
Unexplained regional differences
The low prevalence of stunting in Teso could be related to higher consumption of animal source foods
by young children in that region (Map 12). More research is needed to adequately explain regional
differences in prevalence of stunting that do not correspond to poverty, including an analysis on diets
and the effect of aflatoxins on child growth in the country. Aflatoxins have been linked to impaired
growth in animals and humans; and staple foods, such as groundnuts and maize, are known to contain
aflatoxins in Uganda (9).
Achieving global stunting targets
In 2000, the prevalence of stunting (height-for-age z-score <-2 standard deviations) was close to 50%,
and a large percentage of children were close to the z-score cut-off used to define stunting. With 50%
prevalence a small improvement in average height results in large improvements in stunting prevalence
because many children cross the cut-off. However, as the country moves further and further away from
50% prevalence, and the percentage of children close to the z-score cut-off decreases, larger increases
in average height may be required for the same reduction in prevalence. Therefore, achieving another
15 percentage point reduction in prevalence will most likely constitute a challenge for the Government
of Uganda.

Figure 2: Trends in child acute malnutrition in regions with high prevalence
Prevalence of wasting among children under five years of age in Karamoja and West Nile, UDHS 2006-
2016
Figure 3: Trends in child acute malnutrition by wealth
Prevalence of wasting among children under five years of age. Highest wealth quintile is the richest, and
lowest quintile the poorest, UDHS 1995-2016.
3.8 2.6 32.3 2.4
5.6
6.7
4.5
763.8
4.8
0
2
4
6
8
10
12
2006 2011 2016 2006 2011 2016
Karamoja West Nile
Prevalence
Region and Year
Moderate acute malnutrition
(SAM excluded)
Severe acute malnutrition
(SAM)
2.1
5.4
0
1
2
3
4
5
6
7
8
9
10
1995 2000 2006 2011 2016
Wasting prevalence
Year
Highest wealth quintile (WQ)
Fourth WQ
Middle WQ
Second WQ
Lowest WQ

Figure 4: Trends in child stunting by wealth
Prevalence of stunting among children under five years of age. Highest wealth quintile is the richest, and
lowest quintile the poorest, UDHS 1995-2016
Map 1: Child wasting by region
Percentage of wasting among children 0-59 months, UDHS 2016
0
10
20
30
40
50
60
1995 2000 2006 2011 2016
Stunting prevalence
Year
Highest wealth quintile (WQ)
Fourth WQ
Middle WQ
Second WQ
Lowest WQ

Map 2: Child stunting by region
Percentage of stunting among children 0-59 months, UDHS 2016

2.2 Adolescent and adult anthropometric indicators
Undernutrition among men and women does not appear to be a public health problem at the national level.
In 2016, 4% of men and 2% of women age 15-49 years were moderately or severely thin according to body mass
index <17. Considering age, the prevalence of moderate or severe thinness was highest among girls age 15-19 years,
but at 3.3% it was not much higher than the other age groups. As was the case with child undernutrition, there was
substantial geographical variation in thinness among women of reproductive age, and Karamoja had the highest
percentage of moderately or severely thin women (12%) (Map 3).
While adult overnutrition was also not a large public health problem in 2016, with 7% of women and 1% of
men categorized as obese, there was an increasing trend of overweight and obesity among women from 2000 to 2016
(Fig 3), and there were regions with high obesity prevalence. Kampala and Central I had the highest obesity prevalence
(Map 4), at 17% and 16% respectively.
In 2016, 1.4% of women of reproductive age were considered high pregnancy risk because their height was
below 145 cm. Tooro, the region with relatively low poverty and high child stunting, had the highest prevalence of
women with short stature (5%). Karamoja and Acholi had almost no women below 145 cm (Map 5), despite high
levels of child stunting, suggesting substantial catch-up growth or a recent increase in childhood stunting. More
research is needed to determine if Tooro has excess pregnancy complications compared to other regions with no
women of short stature9.
Maternal thinness and short stature can lead to low birth weight and reduced child height through intrauterine
growth restriction. Teenagers who become pregnant are more likely to have low birth weight babies, and in Uganda
25% of women age 15-19 had begun childbearing in 2016. More research is needed to analyze trends and the
geographic distribution of birth weight in the country and to determine the effect of teenage pregnancy on birth
weight10.
9 Maternal mortality would provide insight into excess pregnancy risk, but mortality data from national household surveys is not available at the
regional level because of sample size constraints.
10 Birth weight is included in the UDHS 2016, but the indicator is based on both written records and maternal perception of size. For both trends
and comparing regions secondary analysis is needed to make estimates from different years and different regions comparable.
The double burden of under- and over-nutrition
Stunting during childhood can place an individual at higher risk of obesity later in life. In Uganda,
there was and is high child stunting prevalence in regions throughout the country, and adult obesity is
now emerging in some of those regions, particularly in the southern and western areas of the country.
However, in northern and eastern areas, high childhood stunting does not appear to result in adult
obesity, which could be caused by food insecurity in those areas, but could also be a result of higher
catch-up growth and higher attained height of adults in those areas.
From a national, public health perspective, the nutrition double burden clearly exists in the country.
There are wealthy regions, such as Kampala and Central I, with obesity prevalence that is as high as
prevalences found in more affluent countries, and there is high child undernutrition in many areas of
the country. Public health programmes to prevent both child undernutrition and adult obesity are
needed in the country.

Map 3: Women thinness
Percentage of women age 15-49 years moderately or severely thin (body mass index <17), UDHS 2016
4.1 4.2 7.2
13.8 16.5 18.8
23.8
0
5
10
15
20
25
30
35
40
2000 2006 2011 2016
Prevalence
Year
Obese
Over weight
Thin
Figure 5: Trends in anthropometry of women of reproductive age
Prevalence of obesity, overweight, and thinness among women age 15
-
49 years. Body mass index ≥25 is
overweight
, ≥30 is obese and <18.5 is total thin. Obesity data from 2000 was not available.

Map 4: Women obesity
Percentage of obese women (body mass index ≥30) age 15-49, UDHS 2016
Map 5: Women short stature
Percentage of women age 15-49 below 145 cm, UDHS 2016

2.3 Child micronutrient deficiency
Other than data for vitamin A deficiency (VAD), there is currently no national data on micronutrient
deficiency obtained from biochemical tests. However, a number of regional studies with biochemical tests of
deficiencies were carried out. A high prevalence of vitamin B2 (Riboflavin) deficiency among recipients of emergency
food aid was documented in Karamoja in 2011 (17), and a 2015 baseline survey for a study on micronutrient powder
measured iron and vitamin A deficiency. The 2015 survey found that among children 12-23 months of age in the
districts of Amuria and Soroti, approximately 1/3rd were iron deficient, 1/5th had iron deficiency anaemia, and less
than 5% had vitamin A deficiency.
Additional information on micronutrient deficiencies is derived from food consumption surveys and proxies.
The 2008 Uganda Food Consumption survey measured food consumption, and identified that the diets of children 2-
5 years of age and women of reproductive age lack micronutrients found in animal source foods; including vitamin
A, vitamin B12, iron, zinc and calcium (18). In this situation analysis, we present trends on anaemia in the country,
which is often used as a proxy for iron deficiency11.
Child vitamin A deficiency
The 2016 UDHS was published with a disclaimer that “data on vitamin A status from the 2006, 2011, and
2016 Uganda DHS should be interpreted with extreme caution.” The disclaimer was included because forthcoming
research from Makerere University and the US Centers for Disease Control and Prevention will question the validity
of the rapid test used to test for VAD in those years12.
In 2000, the national prevalence of vitamin A deficiency was 28% among children 6-59 months and 52%
among women based on the accepted test of serum retinol. The 2018 Uganda National Panel Survey will provide
updated data on vitamin A deficiency based on accepted tests, and should provide the opportunity to assess trends,
compare regions, and analyse the effect of vitamin A supplementation and fortification on vitamin A deficiency.
Child anaemia
Sharp reductions were observed in the prevalence of moderate and severe anaemia among children 6-59
months of age from 2006 to 2011, but from 2011 to 2016 there was little change (Fig 6). Any anaemia dropped from
62% in 2006 to 53% in 2011, and stayed at 53% in 2016, which is well above the WHO cutoff to define a serious
public health problem (≥40%). Trends in anaemia mirrored changes in the prevalence of malaria (Fig 7), suggesting
that malaria prevention played a major role in anaemia reduction, particularly in the Mid Northern area of the country
(Fig 8). In 2016, the national prevalence of severe anaemia remained low (2.3%), with the exception of the Karamoja
Region (8%). No other region in Uganda showed a prevalence above 4.0% for severe anaemia in children 6-59 months.
In 2016, there was substantial variation in child anaemia by region (Fig 25); The highest subnational anaemia
prevalence was 71% in Acholi, which was more than double the prevalence in Kigezi (32%) and Ankole (31%). There
was less variation by wealth than geography; the richest wealth quintile had a child anaemia prevalence above 40%;
indicating that poverty, food insecurity, and inadequate diet are not the only causes of anaemia in the country. The
relative contribution of the various causes of anaemia remains unknown in the country, and there is a need for an
anaemia etiology study.
11 The aetiology of anaemia in the country is still not well understood, and we do not possess information on the percentage of anaemia that is
caused by iron deficiency. Biochemical information on iron, folate, B12, vitamin A and iodine is currently being collected in the 2018 Uganda
National Panel Survey and information on the prevalence of certain micronutrient deficiencies should be available by the end of 2018. The panel
survey will also include information on malaria, anaemia, blood disorders, and inflammation; which can be used for a comprehensive anaemia
etiology study.
12 Vitamin A status was measured in UDHS since 2000, but in 2006 measurement changed from analyzing serum retinol to retinol binding protein
using the RBP-EIA test. RBP-EIA is meant to be a proxy for serum retinol, but forthcoming research will show that it may not be a good proxy.
Starting in 2011 estimates from RBP-EIA were adjusted for inflammation, and adjusted estimates are not comparable to unadjusted estimates. In
the 2011 UDHS there were problems with delayed transport of blood samples from the field (12) and with the RBP-EIA test kits (personal
correspondence, 22 March 2018, Rhona Bhaingana, Lecturer, Department of Biochemistry & Sports Science, College of Natural Sciences,
Makerere University).

Figure 7: Trends in child malaria and anaemia
20.5 22.4 22.3 23.7
37.1 43.4
25.5 26.9
6.5
6.8
1.5 2.3
0
10
20
30
40
50
60
70
80
2000 2006 2011 2016
Prevalence of any anaemia
Year
Severe anaemia
Moderate anaemia
Mild anaemia
54.9
31.7 30.4
62.3
52.8 52.8
0
10
20
30
40
50
60
70
80
2009 2014 2016
Prevalence
Year
Child malaria
Child anaemia
Explaining anaemia trends
The Uganda Indoor Residual Spraying (IRS) Programme started in 2009. From 2009 to 2014 the
programme scaled up IRS in the Mid-Northern area of the country, including districts in the regions
of Lango and Acholi (Fig 26). In 2014 and 2015 IRS was phased out of the Mid-Northern area and
moved to the Eastern area of the country, targeting districts in Teso and Bukedi (6). From 2009 to
2016 the largest changes in anaemia prevalence occurred in the areas where IRS was implemented
(Fig 8), and it appears that IRS was the main driver of anaemia reduction. When IRS was phased out
of the Mid-Northern area, malaria immediately returned and anaemia increased (Fig 8). More
research is needed to evaluate the effect of IRS on anaemia in the Eastern area of the country.
Figure 6: Trends in child anaemia
Prevalence among children 6
-59 months of age, UDHS 2000-2016

Prevalence among children 6-59 months of age, MIS 2009, MIS 2014/15, UDHS 2016
Figure 8: Trends in child anaemia, malaria and coverage of malaria prevention
interventions in Mid Northern Region
Prevalence of anaemia and malaria among children 6-59 months. Coverage of IRS at household level
and sleeping under a bednet among children under 5 years. Data on IRS was not collected in 2009 and
2011. Data on malaria was not collected in 2011.
Map 6: Child malaria
Prevalence according to rapid test among children 6-59 months, UDHS 2016
84.4
36.9
62.5
75
51.8 52.5
65.6
0
10
20
30
40
50
60
70
80
90
2009 MIS 2011 DHS 2014-15 MIS 2016 DHS
Percentage
Year
Slept under any net - Region
: Mid Northern
Malaria - Region : Mid
Northern
Indoor residual spraying
(IRS) in last 12 months -
Region : Mid Northern
Any anemia - Region : Mid
Northern

2.4 Adolescent and adult micronutrient deficiency
From 2006 to 2011, there was a large decrease in the prevalence of anaemia among women of reproductive
age (Fig 5), resulting in reclassification from a severe public health problem to a moderate public health problem,
according to WHO classification criteria. In 2011, moderate anaemia fell by 64%, with prevalence dropping from 13%
to 5%. The prevalence of any type of anaemia (i.e. severe, moderate, or mild) in women of reproductive age fell from
49% in 2006 to 23% in 2011, but increased to 32% in 2016. From 2011 to 2016, there was little change in moderate
and severe anaemia, and nearly all of the prevalence increase was in mild anaemia. In 2016, anaemia among women
of reproductive age remained a moderate public health problem.
As was the case with child anaemia, there was substantial subnational variation in anaemia prevalence among
women (Map 7); and the geographic variation was similar to child anaemia. Acholi Region had the highest prevalence
of anaemia among women, at 47%, which was nearly three times higher than the prevalence in Kigezi Region (17%).
For the richest wealth quintile, anaemia prevalence was 25% in 2016. As with children, there is no evidence of the
etiology of anaemia for women of reproductive age, and the high level in the richest wealth quintile suggests that non-
nutritional causes may be important factors in the country.
Maternal anaemia remained an issue in 2016, with prevalence among pregnant women (38%) and
breastfeeding women (34%) higher than prevalence among women that were not pregnant and not breastfeeding
(30%). In 2016, the prevalence of anaemia among girls 15-19 years of age was 33%, which was not meaningfully
different from the prevalence among all age groups (32%).
0
10
20
30
40
50
60
2006 2011 2016
Prevalence
Survey Year
Severe
Moderate
Mild
Risk of iron overload
At the district level the prevalence of sickle cell disease ranged from ≤3% to 24% in 2015 (Fig 27).
Sickle cell is an evolutionary adaptation to increase survival in the context of endemic malaria. In
Uganda, the highest prevalence of sickle cell disease corresponds to the Northern and Eastern regions
that have high malaria incidence (1). Interventions targeting the general population with iron, such as
weekly iron folic acid for women of reproductive age and food fortification, should monitor iron
overload to determine the appropriateness of those interventions in the Ugandan context.
Figure 9: Trends in anaemia among women of reproductive age.
Prevalence among women age 15
-49 years, UDHS 2006-2016

Map 7: Anaemia among Women
Prevalence of any anaemia among women age 15-49 years, UDHS 2016

Chapter 3: Nutrition behaviours
Chapter 3 Key Findings
3.1 Infant and young child feeding (IYCF): breastfeeding
Breastfeeding is nearly universal in the country. In 2016, 98% of children 0-1 months of age were breastfed.
Close to 90% of children started breastfeeding within one day of birth, and 66% started breastfeeding within one hour.
Early initiation of breastfeeding (within one hour) became more common from 2000 to 2016, and there was a
corresponding drop in prelacteal feeding (Fig 10). Improvement in early initiation occurred for both children who
were delivered in a health facility and for children born at home (Fig 11). Early initiation of breastfeeding was highest
in Karamoja (93%) and lowest in West Nile (42%) and Lango (45%) (Map 8). Prelacteal feeding was highest in the
Central area and in Bugishu Region (Map 9).
The percentage of children under six months of age exclusively breastfed remained above 60% from 2000 to
2016 (Fig 12), while among children under four months of age the percentage was 76% in 2016. Early provision of
water, non-milk liquids, other milk, and complementary food were equally important barriers to exclusive
breastfeeding for the 0-3 month age group, with close to 5% of children receiving each liquid/food. At 4-5 months
more children received complementary food and the percentage of children exclusively breastfed dropped to 43%.
Due to sample size constraints regional estimates of exclusive breastfeeding are not available from national, household
surveys.
The UDHS stopped collecting information on breastfeeding frequency in 2011. The 2006 UDHS found that
96% of children were breastfed six or more times in the 24 hours preceding the survey, with 7.4 day feeds and 5 night
feeds on average. At the national level, breastfeeding frequency did not appear to be a problem in 2011. We did not
identify any information on the duration of breastmilk feeds, breastmilk volume, or breastmilk composition in the
country.
Breastfeeding
•Over the last decade there was a large increase in early
initiation of breastfeeding and a corresponding drop in
prelacteal feeding; a majority of children now initiate
breastfeeding within one hour of birth.
•The improvement in early initiation of breastfeeding occurred
among both women who deliver in health facilities and women
who deliver at home.
•A majority of children were breastfed exclusively for the first six
months of life, but the percentage did not increase substantially
over the last 15 years.
•A majority of children did not continue breastfeeding up to the
recommended two years of age, and there was a small
decrease in continued breastfeeding over the last 10 years.
Complementary
feeding
•A majority of U2 children did not receive the minimum number
of meals per day and there was little change in feeding
frequency over the last 10 years.
•Nearly 3 out of 4 U2 children did not receive the minimum
number of food groups, and in most regions a majority of
children did not eat nutrient-rich, animal-source foods.
•The persisting inadequate infant and young child feeding
practices appear to be related to both poverty and cultural
practices.

Nearly all children (95%) continue breastfeeding to 9-11 months of age. For the 12-17 month age group
breastfeeding drops to 82%, and by 18-23 months only 50% of children continue to breastfeed. From 2006 to 2016,
continued breastfeeding in both the 12-17 and 18-23 month age groups decreased by close to 10 percentage points
(Fig 13).
From 2011 to 2016, the percentage of children under two years of age fed with a bottle decreased, reversing
an increase seen over the previous decade (Fig 14). In 2016, bottle use was most common among children 6-9 months,
at 21%. Since formula use was at or below 1% for all age groups of breastfed and non-breastfed children in 2016,
bottles are likely used to provide water, juice or other non-formula liquids to infants in the country.
Improvement in early initiation of breastfeeding
From 2000 to 2016, the percentage of women delivering in a health facility climbed from 37% to
73%. Over the same time period there was a similar increase in the percentage of children who
initiated breastfeeding within one hour of birth (Fig 10). The reasons for improvement in early
initiation of breastfeeding was not evaluated in the country, but it was likely a result of efforts to stop
prelacteal feeding and promote immediate breastfeeding (Fig 10). Our finding that early initiation
increased for all children, regardless of whether or not they were born in a health facility (Fig 11),
suggests that behaviour change communication efforts were effective across various demographics.
More research is needed to explain what caused the improvement in early initiation, and to evaluate
the effects of delivering in public and private health facilities on early initiation.
Additional research is not necessary for programmes to take full advantage of the increase in facility
deliveries. The vast majority of women who deliver in a health facility are using public facilities.
Midwives can directly influence early initiation by putting the child to the mother’s breast
immediately after birth, and utilizing midwives as agents of behaviour change could be a cost-
effective approach to ensuring continued improvement in early initiation of breastfeeding.
Barrier to breastfeeding for two years
In 2016, 24% of women had birth spacing of less than two years. Formative research from 2015 found
that women throughout the country mistakenly believed breastfeeding should stop when a woman
becomes pregnant (5). It is likely that insufficient birth spacing, which has improved little since DHS
started in Uganda in 1995, is a barrier to breastfeeding for the recommended two years in the country.

Figure 11: Trend in early initiation by place of delivery
Percentage of ever breastfed children born in the past two years who initiated breastfeeding within one
hour of birth, UDHS 2000-2016
31.6
42.2
52.5 66.1
86.2 86.1 88.7 93.7
43.7 54
41.1 26.6
0
10
20
30
40
50
60
70
80
90
100
2000 2006 2011 2016
Percentage
Survey Year
Initiate breastfeeding (BF)
within 1 Hour
Initiate BF within 24 Hour
Prelacteal Feeding
27.7
38
49.3
60.7
35.8 46.6
55
68
0
10
20
30
40
50
60
70
80
2000 2006 2011 2016
Percentage
Survey Year
Delivered at home
Delivered in health facility
Figure 10: Trend in early initiation of breastfeeding and prelacteal feeding
Percentage
of ever breastfed children born in the past two years who initiated breastfeeding within one
hour and within 24 hours, and who received a prelacteal feed.
UDHS 2000-2016

Figure 12: Trends in exclusive breastfeeding
Percentage of children under four and six months who received only breastmilk in the day or night preceding
the survey, UDHS 2000-2016
Figure 13: Trends in continued breastfeeding by age
Percentage of children currently breastfeeding by age group, UDHS 1988-2016
73.2 74.7 75.9
63.2
60.1 63.2 65.5
0
10
20
30
40
50
60
70
80
90
100
2000 2006 2011 2016
Percentage
Survey Year
Exclusive BF <4 months
Exclusive BF <6 months
94.6
82.3
50.3
0
10
20
30
40
50
60
70
80
90
100
1988 1995 2000 2006 2011 2016
Percentage
Survey Year
9-11 months
12-17 months
18-23 months

Figure 14: Trends in bottle use by age group
Percentage of children using a bottle with a nipple by age groups, UDHS 2000-2016
Map 8: Early initiation of breastfeeding
Percentage of ever breastfed children born in the past two years who initiated breastfeeding within one
hour of birth, UDHS 2016
10.7
20.5
12.3
0
10
20
30
40
50
60
70
80
2000 2006 2011 2016
Percentage
Survey Year
0-5 months
6-9 months
12-23 months

Map 9: Prelacteal feeding
Percentage of ever breastfed children born in the past two years who received a prelacteal feed, UDHS
2016

3.2 Infant and young child feeding (IYCF): complementary feeding
In 2016, in the 6-8 month age group, 18% of children may not have met their nutrient needs because they
were not yet eating solid or semi-solid foods.
The percentage of children aged 6-23 months who received the minimum number of meals remained low in
2016, at 42% (Fig 8). In the UNHS 2016/17, the percentage of caregivers who reported poverty as a major barrier to
feeding children three times per day varied from 30% to 86% regionally (Fig 28). There was low feeding frequency
in many poor areas (Map 10). However, there is also evidence that affordability is not the only barrier to feeding
children more often; regional variability in meal frequency shows that the majority of people in areas that are not
constrained by high poverty, such as Kampala and Central I, do not feed their children the minimum number of times.
It appears that a combination of poverty and the continuance of inappropriate feeding practices cause low feeding
frequency in the country.
In the UDHS dietary diversity is measured based on food consumed in the day or night preceding the survey.
The food consumption component of the UDHS questionnaire changed from year to year, and in this report we do not
present trends on dietary diversity or minimum acceptable diet because secondary analysis is required to make the
various surveys comparable. In 2016, 27% of children aged 6-23 months received a diverse diet, defined as eating the
minimum of four food groups. At the sub-national level, dietary diversity was lowest in the Mid-Northern regions of
Acholi (7%) and Lango (11%) (Map 11).
Both meal frequency and dietary diversity are included in the ‘minimum acceptable diet’ indicator. In 2016,
15% of children 6-23 months received the minimum acceptable diet; low dietary diversity was the main cause for
children not receiving the minimum diet.
Interventions targeting dietary diversity often promote iron-rich foods, vitamin A-rich foods, and high-fat
foods because iron-rich foods reduce iron-deficiency anaemia and add protein to the diet, vitamin A decreases
mortality related to measles, and high fat foods increase absorption of fat-soluble vitamins and add calories to the diet.
Iron-rich foods include animal source foods, such as meat, fish, poultry and eggs. In 2016, 40% of children 6-23
months consumed iron rich foods; there was substantial regional variation, with Teso and Bukedi at 59% and other
regions at close to 20% (Map 12). Vitamin-A rich foods include animal source foods, orange/yellow/red fruits and
vegetables, and dark green leafy vegetables. In 2016, 67% of children 6-23 months ate vitamin-A rich foods, and all
regions were above 50%, except Lango and Bugishu (Map 13). The UDHS 2016 included a question on consumption
of oils/fats, but the percentage of children eating oils/fats was not reported and secondary analysis is needed.
On sanitation, diarrhea and absorption inhibitors
In 2016, only 19% of households used an improved toilet facility. Based on the lack of sanitation in
the country, it is no surprise that 20% of children were reported to have diarrhea in the last two weeks
in UDHS 2016. Poor sanitation leads to frequent illness, which causes nutrient loss, decreased
nutrient absorption and reduced appetite — repeated illness makes appropriate infant and young child
feeding more challenging for caretakers, and the effect of illness on nutrient intake and loss makes
poor sanitation a core driver of undernutrition in the country.
Adding magadi soda and bean debris-ash while cooking to reduce cooking time is a traditional
practice that is still common in Uganda (7). A 2011 study demonstrated that the traditional practice
reduced cooking time for sorghum, maize and beans; but also decreased the bioavailability of iron and
zinc by 11%-37% (7). In a recent study on in-home fortification in Eastern Uganda, researchers found
that soda ash oxidized iron in the micronutrient powder, changing the color of the food; the same
study found no effect of micronutrient powder on reducing iron deficiency anaemia (12). The exact
percentage of households using soda ash for cooking is not known in the country, but a question was
included in the 2018 UNPS. Future research can try to determine the contribution of the traditional
cooking practice to iron deficiency anaemia in the country.

Map 10: Child minimum meal frequency
15.2
35.6 44.8 41.9
27.4
0
10
20
30
40
50
60
70
80
90
100
2006 2011 2016
Percentage
Survey Year
Minimum acceptable diet
Minimum frequency of meals
Minimum dietary diversity
Figure 15 Minimum meal frequency and minimum acceptable diet
Percentage of all
children 6-23 months of age. Minimum dietary diversity is 4+ food groups, and minimum
frequency is 2
-4+ times depending on age and breastfeeding status. Minimum acceptable diet is a
composite indicator of frequency and diversity. Dietary diversity and minimum acceptable diet restricted to
2016 d
ue to concern over comparability with previous years.

Percentage of children age 6-23 months fed minimum number of times per day. For breastfed children,
≥2-3 times; and for non-breastfed ≥4 times, UDHS 2016.
Map 11: Child minimum dietary diversity
Percentage of children age 6-23 months fed ≥4 food groups per day, UDHS 2016
Map 12: Children eating iron-rich foods
Percentage of children 6-23 months eating animal source foods, such as meat, fish poultry and eggs,
UDHS 2016

Map 13: Children eating vitamin A-rich foods
Percentage of children 6-23 months eating animal source foods, orange/yellow/red fruits and vegetables,
or dark green leafy vegetables, UDHS 2016

Chapter 4: Preventive nutrition interventions
Chapter 4 Key Findings
4.1 Micronutrient Fortification
Staple food fortification
By 2000, Uganda achieved the universal salt iodization target of >90% coverage, reaching 99% of households
with iodized salt. The country maintained universal coverage from 2000 to 2016 (Fig 16). Moreover, 98% of salt is
adequately iodized according to a 2017 study by the US CDC (19). With such high coverage of adequately iodized
salt, there is no concern with under-consumption of iodine in any area of the country. In 2015, 30% of salt samples
were found to be over-fortified nationally, according to WHO standards. According to national standards, only 1%
was over-fortified (19).
Fortification of oil and cooking fats with vitamin A was mandated in 2012 for large-scale producers. In 2015,
89% of households consumed oil that could be fortified, and of the households consuming oil, 58% consumed oil with
adequate levels of vitamin A fortification. 54% of all households consumed oil fortified with vitamin A (19). All five
of the large producers in the country fortify with vitamin A. Approximately one third of households consume cooking
fat that could be fortified, but there is no information on the percentage that is actually fortified (19).
Fortification of wheat and maize flour with multiple micronutrients (vitamins A, B12, B1, B2, B6, niacin,
zinc, iron, and folic acid) was mandated in 2012 for large-scale producers. In 2015, all maize millers (3 of 3) were
Micronutrient
fortification and
supplementation
•The sustained coverage and quality of iodized salt over the last
15 years has likely eradicated iodine deficiency in the country
and contributed to improvement in national IQ.
•Cooking oil fortified with vitamin A reached the majority of
households in the country, and coverage of vitamin A
supplementation for U5 children increased to 60% over the last
10 years.
•Coverage of iron folic acid supplementation during pregnancy
followed the increasing trend of antenatal care in the country,
nearly reaching 90% coverage of any IFA in 2016, but less than
1 out of 4 women women received the recommended minimum
of 90 tablets.
•Iron fortification of staple foods and in-home fortification were
not scaled up to reach a large percentage of households
nationally.
•Scaling up iron interventions is hampered by persistently high
prevalence of malaria in most areas of the country.
Deworming and other
preventive
interventions
•Coverage of deworming for both children U5 and pregnant
women increased to approximately 60%, which put coverage of
child deworming on par with VAS, but means that many women
who attend antenatal care do not receive deworming.
•More than 2 out of 3 women in Karamoja reported that they
received postpartum counselling on breastfeeding compared to
the national average of 35%; which may help to explain why
nearly all children in Karamoja initiate breastfeeding early.

fortifying their products, and 8 of 10 wheat millers fortified their wheat products (19). While the vast majority of
households consume maize flour, only 42% consume maize flour that is industrially produced and can be fortified
(19). Nationally, fortified maize flour only reaches 7% of the population (19); as with vitamin A, there is a large gap
between the percentage of households that consume fortifiable maize flour and those that actually consume fortified
maize flour. Consumption of industrially produced wheat flour is low in the country (11%), and only 9% of the
population consumes fortified wheat flour (19).
In-home fortification and bio-fortification
In-home fortification with multiple micronutrient powder (MNP) is not yet a national programme in the
country and the intervention was not included in the 2016 UDHS. The 2018 Uganda National Panel Survey did include
a question on MNP and results will be available in 2019.
In 2012, the Uganda Ministry of Health Technical Sub-Working Group on Micronutrients brought together
multiple development partners, including UNICEF, to pilot in-home fortification with multiple micronutrient
powder (MNP) in eight districts across the country for children aged 6-23 months (20). By 2016, coverage in
multiple districts reached >50%, but the intervention was not shown to reduce iron deficiency or anaemia (12, 21,
22). Additional research is needed on efficacy and effectiveness of MNP to guide national policy, and future
research should take into account that MNP is only recommended in areas where malaria is adequately controlled
(10). Biofortified beans and sweet potatoes with iron and vitamin A respectively are promoted in the country, but
we did not identify information on the percentage of households consuming these foods.
4.2 Child micronutrient supplementation and deworming
From 2006 to 2016, coverage of vitamin A supplementation (VAS) within the last six months for children
aged 6-59 months increased by 25 percentage points, rising from 36% in 2006, to 57% in 2011, to 62% in 2016 (Fig
16). VAS and deworming are primarily delivered through the same platform, biannual Integrated Child Health Days,
and as expected, we observed similar trends in coverage of child deworming from 2006 to 2016, and in 2016,
deworming coverage was 61% (Fig 16). For deworming, the largest changes occurred among children whose mother
did not have any secondary or post-secondary schooling (Fig 17), indicating improvement towards an equity approach.
Fig 18 illustrates coverage of deworming and vitamin A supplementation by age group. We expected the
lowest coverage among the youngest eligible age groups because both interventions are implemented via biannual
campaigns and some of the youngest children were not old enough to be eligible during the last campaign. As expected,
coverage of deworming among children 12-17 months of age and coverage of vitamin A supplementation among
children 6-8 months of age was lower than coverage in some of the older age groups (Fig 18). For VAS, there was
also evidence that coverage decreased among the oldest age groups compared to children aged 9-17 months; the
decreased coverage is likely related to decreased demand from caretakers as children get older.
Deworming is targeted to children 12-59 months of age, but UDHS reports on children 6-59 months of age.
UDHS results indicated that children younger than 12 months received deworming (Fig 18), which is not
recommended.
There was substantial regional variation in coverage of vitamin A supplementation (Map 14). Tooro had the
highest coverage (77%) and Central II has the lowest coverage (47%).

Addressing child iron deficiency
WHO guidelines state that areas with >40% child anaemia prevalence should implement preventive
iron supplementation (2). With the exception of the Southwest, all areas of Uganda require preventive
iron supplementation based on WHO guidance (Fig 22). However, iron supplementation of young
children is only recommended alongside comprehensive malaria prevention and treatment
programmes because of the potential for increased risk of mortality caused by malaria (2). The high
prevalence of malaria rules out iron supplementation for much of the country. Iron supplementation is
not a national programme in the country, and in 2016, only 7% of children 6-59 months received an
iron supplement. Preventive iron supplementation can currently be implemented without concern for
increased mortality and morbidity risk in areas of the country where child anaemia prevalence is high
and malaria is not endemic, such as Kampala.
MNP is promoted as a core intervention to address child micronutrient deficiencies, including iron
deficiency. MNP is recommended for children aged 6 months to 12 years in areas where anaemia
prevalence is greater than 20% (10); all regions of Uganda are above the cutoff (Fig 22). However,
like iron supplementation, MNP is only recommended when malaria is not endemic or when it is
controlled. According to the WHO 2016 guideline, control must include “insecticide-treated bednets
AND vector control programmes [such as IRS], prompt diagnosis of malaria illness, and treatment
with effective antimalarial drug therapy (10).” The 2016 guidelines are more clear about what malaria
interventions should be in place compared to the 2011 WHO guidelines they replaced, which only
stated that there should be measures to “prevent, diagnose, and treat malaria (13).” Based on current
guidelines and malaria prevalence from UDHS 2016 (Map 6), MNP can be implemented in Kigezi
and Kampala, and in areas with comprehensive malaria control/low malaria parasitaemia.
A national programme to address child iron deficiency with either iron supplementation or MNP
should be implemented alongside malaria control interventions, with malaria parasitaemia monitored
via the Ugandan malaria sentinel site surveillance system.

Figure 17: Trends in child deworming by maternal schooling
Percentage of children 6-59 months who received deworming in last six months by mother’s level of
schooling attended, UDHS 2006-2016
69
98.6 98.6 99 99.4
37.6
36.4
56.8 61.6
41.9 50.2
60.7
0
10
20
30
40
50
60
70
80
90
100
1995 2000 2006 2011 2016
Coverage
Survey Year
Iodized Salt
Vitamin A Supplement
Deworming
71.3
37.6 43.3
59.4
0
10
20
30
40
50
60
70
80
90
2006 2011 2016
Percentage
Survey Year
Post-secondary school
Secondary school
Primary school
No schooling
Figure 16: Trends in micronutrient fortification and child supplementation
UDHS 1995
-2016

Figure 18: Child deworming and vitamin A supplementation by age group
Coverage of deworming and vitamin A supplementation within the last 6 months by child age groups,
UDHS 2016
Map 14: Child vitamin A supplementation
Percentage of children 6-59 months who received vitamin A supplement in last six months, UDHS 2016
4.3 Maternal micronutrient supplementation and deworming
From 2000 to 2016, there was a steady increase in the percentage of women receiving any iron folic acid
(IFA) supplements during their last pregnancy (Fig 10), rising from 48% in 2000 to 86% in 2016. Although the
22.5
60.7
36.3
69.5
57.7
69.2
64.1 65.4
66.5 61.5
66.8 58.7
66
57
0
10
20
30
40
50
60
70
80
2016 2016
Child deworming Child vitamin A supplementation
Coverage
Survey Year and Intervention
6-8
9-11
12-17
18-23
24-35
36-47
48-59

coverage of any IFA supplements during pregnancy is now nearly universal, a small percentage of women (23%)
received the recommended minimum of 90 tablets during their last pregnancy in 2016. 23% coverage of at least 90
tablets was a large improvement over 2011, when only 4% of women received at least 90 tablets, but there is still
plenty of room for improvement.
The percentage of women receiving at least 90 tablets of IFA varied dramatically by region in 2016 (Map
15). In Bugishu, virtually no women (2.5%) received 90 tablets of IFA, while on the other side of the country in
Kigezi, 41% of women received 90 IFA tablets. Additional research is needed to explain the large geographical
differences in coverage.
Like IFA, coverage of deworming during pregnancy also increased in recent years (Fig 10), moving from
27% in 2006 to 60% in 2016 (Fig 10). Still, deworming coverage remains lower than any IFA supplementation, despite
both interventions being delivered through antenatal care, indicating that many women who attend ANC are not
receiving deworming tablets.
According to national policy, IFA is also distributed postpartum, but there is no information on postpartum
IFA in the UDHS.
The coverage of postpartum vitamin A supplementation increased from 11% in 2000 to 42% in 2011, with
most of the change occurring between 2000 and 2006. Following global recommendations from WHO, postpartum
VAS stopped in Uganda in 2015.
Anaemia and malaria prevention during pregnancy and postpartum
As is the case with children, iron supplementation of pregnant women in malaria endemic areas is
only recommended when malaria interventions are in place (3). For pregnant women, malaria
prophylaxis alongside iron folic acid supplementation is recommended (3), but in Uganda only 17%
of pregnant women received the recommended three doses of malaria prophylaxis in 2016 (Fig 29).
Still, …
Since 2006, more than 90% of women received antenatal care from a skilled provider. In 2016, nearly
all of the women attending ANC received some IFA supplements, but the vast majority did not
receive the recommended minimum of 90 tablets. The low percentage of women receiving at least 90
IFA tablets does not make sense in a context where 60% of women attend ANC at least four times. In
addition, deworming coverage was approximately 30 percentage points below antenatal care coverage
in 2016. One of the bottlenecks identified for IFA is that supplements are rationed at the health center
level because of inadequate supply. The same bottleneck may also apply to deworming and malaria
prophylaxis. Addressing supply side issues could immediately increase coverage of malaria
prophylaxis, IFA, and deworming during pregnancy.
Despite its inclusion in national policy documents, postpartum IFA supplementation does not appear
to be a national programme. There is no indicator in national surveys, such as UDHS, and there is no
indicator in the health information system. After the supply bottleneck is addressed for IFA during
pregnancy, attention should be given to promoting and monitoring postpartum IFA supplementation.

Map 15: Iron folic acid supplementation during pregnancy
Percentage of women with birth in last five years who took 90 or more iron folic acid tablets, UDHS 2016
4.4 Promotion of maternal, infant and young child feeding
There is limited information on the promotion of maternal, infant and young child feeding in the country13.
The District Health Information System II (DHIS II) includes indicators on counselling pregnant and lactating women
13 There is also limited information maternal diet and the diet of women of reproductive age. In 2016, the UDHS did not collect information on
woman diet. The 2018 Uganda National Panel Survey included questions for the Minimum Dietary Diversity for Women indicator (MDD-W),
and results will be available in 2019.
44.9
56.4
60.9 52.5
1.1
0.9
2.8 11.2
1.7
0.7
3.9 22.6
26.8
49.9
59.9
0
10
20
30
40
50
60
70
80
90
100
2000 2006 2011 2016
Coverage
Survey Year
IFA 90+
IFA 60-89
IFA <60
Deworming
Figure 19 Trend in iron folic acid supplementation and deworming for pregnant
women
Percentage
of women with birth in last five years who took deworming and iron folic acid tablets by the
number of tablets received, UDHS 2000-2016

on maternal nutrition and infant diet, but aggregated data is not available and the indicators are not monitored. There
is no national level data on counselling and promotion activities carried out by community volunteers, such as the
Village Health Team. The 2016 UDHS did not include any questions on nutritional counselling received during
antenatal care, but there were questions on postpartum counselling and observation of breastfeeding. In 2016, 35% of
women reported receiving breastfeeding counselling within two hours of their last birth, and 36% of mothers reported
that a health worker observed them breastfeeding. Postpartum breastfeeding counselling was most common in
Karamoja (68%) and least common in Busoga (16%). The large regional differences in breastfeeding promotion are
likely a result of a lack of Development Partner support and governmental supervision in some regions.
Map 16: Postpartum breastfeeding counselling
Percentage of women who received counselling on breastfeeding within 2 hours of their last birth within
the last 2 years, UDHS 2016

Chapter 5: Curative nutrition interventions
Chapter 5 Key Findings
5.1 Identification and treatment of acute malnutrition
There is no information on screening for acute malnutrition from national, household surveys, but the UDHS
2016 did collect information on outpatient treatment of acute malnutrition. In 2016, caretakers reported that 1.7% of
children aged 6-35 months received ready-to-use therapeutic food in the past seven days. As expected, reported
coverage of outpatient therapeutic feeding was highest in the regions of Karamoja (7%) and Kigezi (6%), which are
regions where UNICEF supported identification and treatment of severe acute malnutrition.
5.2 Child diarrhea treatment and feeding
Treatment of child diarrhea with zinc supplements climbed from 1% to 2% to 40% from 2006 to 2011 to
2016 (Fig 20). The rapid change was attributed to packaging zinc along with oral rehydration solution. Improvement
occurred among all age groups, but the pace of improvement was not consistent between the age groups; in 2016,
coverage among the youngest (24%) and oldest (32%) age groups was lower than the middle age groups (42%-46%)
(Fig 20). For all children under 5 years of age, Karamoja had the highest coverage (57%), and Lango had the lowest
coverage (26%).
In 2016, 15% of children under three years of age received an increased amount of fluids when they had
diarrhea, and 41% ate the same or an increased amount of food. From 2011 to 2016 there was little change in liquid
and food consumption during diarrheal episodes (Fig 21). We did not include previous survey years in trend analysis
because UDHS shifted from asking about knowledge in 2006 to practice in 2011.
Treatment of acute
malnutrition and
diarrhea
•In two regions where UNICEF supported outpatient treatment of
severe acute malnutrition, Karamoja and Kigezi, more than 5%
of children received ready-to-use therapeutic food.
•From 2011 to 2016 zinc supplementation went from reaching
virtually no children to reaching 40% of children U5 who had
diarrhea, and the increased coverage was likely a result of
packaging zinc with oral rehydration solution.
•Few caretakers (15%) give children more fluids during diarrhea,
a majority of children eat less when they have diarrhea, and
there was little change in feeding practices during diarrhea over
the last 5 years

Figure 20: Trends in treatment of child diarrhea with zinc by child age
Percentage of children under 5 years who had diarrhea in the last 2 weeks and received zinc
supplements by year and age group, UDHS 2006-2016
Map 17: Treatment of child diarrhea with zinc
Percentage of children under 5 years who had diarrhea in the last two weeks and received zinc
supplements, UDHS 2016
24.2
41.9
46.2
31.9
0.9 1.9
40.3
0
10
20
30
40
50
60
70
80
2006 2011 2016
Coverage
Survey Year
Under 6 months
6-11 months
12-23 months
24-35 months
36-47 months
48-59 months
Total

Figure 21: Feeding during child diarrhea
Percentage of children under three years with diarrhea in the past two weeks who were appropriately fed
with the same or more food and increased fluids, UDHS 2011-2016
5.8 5
32.6 36.1
17.8 14.8
0
10
20
30
40
50
60
70
80
2011 DHS 2016 DHS
Percentage
Survey Year
Same amount of food
Increased amount of food
Increased amount of fluids

Appendix 1: Maps and figures from other publications
Figure 22: Projections of 2025 number of stunted children
Source: European Commission Country Profile on Nutrition
Figure 23: Poverty map
Source: 2016/17 Uganda National Household Survey presentation

Figure 24: Regional trends in subsistence farming
Percentage of households that report subsistence farming in 2012/13 and 2016/17 by region, UNHS
2016/17 presentation.
Figure 25: Child anaemia prevalence map
Source: 2016 Uganda Demographic and Health Survey report

Figure 26: Indoor residual spraying implementation map
Source: USAID Quarterly Performance Report

Figure 27: Sickle cell prevalence at district level
Prevalence among children <18 months, Source: Lancet (1)
Figure 28: Children deprived of three meals by poverty
Proportion of children whose caregiver reported that their children are deprived of three meals a day
because they cannot afford it, UNHS 2016/17 presentation.

Figure 29: Trends in malaria prophylaxis during pregnancy
Source: UDHS 2016 report

Appendix 2: Recommendations for additional research
1. Include MUAC in future national, household surveys to estimate the coverage and caseload of
severe acute malnutrition treatment.
2. Evaluate the quality of UDHS 2016 anthropometric data in West Nile to determine if increases
in acute malnutrition were a result of poor quality anthropometry.
3. Analyze IYCF practices and the determinants of child stunting in Teso and Tooro, which are
two regions where stunting does not appear to be closely correlated with poverty.
4. Evaluate the impact of aflatoxins on infant and young child growth.
5. Analyze trends in birth weight, making data from previous UDHS comparable and assessing
associations with teenage pregnancy.
6. Determine if high prevalence of short stature among women leads to excess pregnancy
complications in that region.
7. Carry out an anaemia etiology study when data on micronutrient deficiencies and other
causes of anaemia is available from the 2018 UNPS.
8. Retrospectively evaluate trends in anaemia prevalence and prospectively determine the
impact of indoor residual spraying for malaria prevention on anaemia prevalence.
9. Evaluate the combined effect of comprehensive malaria vector control with in-home
fortification on child anaemia.
10. Monitor the effect of weekly iron folic acid supplementation for women of reproductive age
and iron fortification of staple foods on iron overload among people with sickle cell disease.
11. Evaluate the effect of public sector versus private sector delivery on breastfeeding practices.
12. Carry out research on breastfeeding quality in the country, including breastfeeding frequency
and duration, and breastmilk volume and composition.
13. Analyze the association between insufficient birth spacing and early weaning.
14. Analyze trends in child dietary diversity and minimum acceptable diet, making data from
previous UDHS comparable.
15. Determine the percentage of children that consume oils and fats based on analysis of UDHS
2016 data.
16. Determine the percentage of households that cook with soda ash and estimate the potential
impact on iron deficiency anaemia when data from the 2018 UNPS is available.
17. Evaluate and monitor the need for vitamin A supplementation as oil fortification is scaled-up
and better data on vitamin A deficiency is collected in the UNPS.
18. Assess whether or not children younger than one year of age, who are too young for
deworming, are receiving deworming medication during biannual campaigns.

Appendix 3: Additional figures and maps
Map 18: Median duration of breastfeeding
Median duration of any breastfeeding among children born in the three years preceding the survey,
UDHS 2016
Map 19: Minimum acceptable diet
Percentage of children 6-23 months fed breastmilk, milk, or milk products; minimum frequency; and
minimum dietary diversity, UDHS 2016

Map 20: Child underweight
Percentage of underweight among children 0-59 months, UDHS 2016

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