Journal of Food and Nutritional DisordersISSN: 2324-9323

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Research Article, J Food Nutr Disor Vol: 5 Issue: 4

Study of the Current Stage and Changes over Time and Determinants of Vitamin A and Iron Intake in Nepalese Mothers and their Children from 2001 to 2011

Hadkhale K* and Bastola K
University of Tampere, School of health sciences, Finland
Corresponding author : Kishor Hadkhale
University of Tampere, School of healthsciences, Finland
Tel: +358 3 355 111
E-mail: [email protected]
Received: March 26, 2016 Accepted: June 15, 2016 Published: June 22, 2016
Citation: Hadkhale K, Bastola K (2016) Study of the Current Stage and Changes over Time and Determinants of Vitamin A and Iron Intake in Nepalese Mothers and their Children from 2001 to 2011. J Food Nutr Disor 5:4. doi:10.4172/2324-9323.1000202

Abstract

Study of the Current Stage and Changes over Time and Determinants of Vitamin A and Iron Intake in Nepalese Mothers and their Children from 2001 to 2011

Introduction: Micronutrient deficiency is one of the major problems among mothers and children in Nepal. Objective: The objective of this study is to investigate the proportion and determinants of mothers and children under the age of 3 years taking vitamin A and iron in Nepal between 2001 and 2011. Methods: Data was drawn from the Nepal Demographic and Health Survey in 2001 (N=8,726), 2006 (N=10,793), and 2011 (N=12,674). Vitamin A and iron were assessed as intake from foods and supplements. Multilevel logistic regression was used to examine the determinants of micronutrient intake. Results: The proportion of mothers taking vitamin A from foods increased from 21.1% in 2001 to 74.1% in 2006 and vitamin A from supplements from 11.3% in 2001 to 43.5% in 2011. Similarly, the proportion of mothers taking iron supplementation increased from 57% in 2006 to 80% in 2011. Among children, the proportion taking vitamin A from foods increased from 52.5% in 2006 to 54.8% in 2011, while the proportion of children taking iron from foods decreased from 42.1% in 2006 to 11.1% in 2011. The proportion of children taking vitamin A supplementation decreased from 82.5% in 2001 to 76.7% in 2011. Mother’s education, place of residence, religion, mother smoking status, mother’s age, and child’s age were the key determinants of intake of vitamin A and iron among Nepalese mothers and their children. Conclusion: The proportion of Nepalese mothers taking vitamin A and iron supplementation during pregnancy increased between 2001 and 2011 whereas intake among children decreased during the same period. More prospective studies are needed to understand the changes in nutritional intake.

Keywords: Determinants; Nutrition; Vitamins; Nepal

Keywords

Determinants; Nutrition; Vitamins; Nepal

Introduction

Nutritional issues have remained global public health concern [1]. The major concern in high-income countries currently is about lifestyle-related nutritional disorders, such as obesity and related diseases, diabetes, and others. However, many low and middleincome countries are still facing the double burden of these disorders and at the same time beset with both over- and under-nutrition [2]. Malnutrition is devastating and plays a significant role in overall mortality in developing countries [1].
In Nepal, the most important nutritional disorders include protein-energy malnutrition, vitamin A deficiency, iodine deficiency disorders and iron deficiency anemia [3,4]. Supplementation of vitamin A capsules is associated with better health outcomes [5] and vitamin A interventions have been shown to be highly effective in reducing the incidence of vitamin A-associated deficiency [6]. Study evidence reveals that intake of vitamin A in both preschool children and pregnant mothers are inadequate in Nepal [7]. The 2012 Demographic and Health Survey reports that only about half of the children aged 6-23 months consumed foods rich in vitamin A [8]. The percentage of prevalence of xerophthalmia in children is 3%. Similarly, In Nepal, pregnant women and a significant proportion of Nepalese children are observed to have vitamin A related deficiencies, such as Bitot’s spots and night blindness. The percentage of prevalence of night blindness during pregnancy among pregnant mothers is 16.2% [9]. Likewise, 35% of Nepalese women of age of reproductive age (15-45 years) are anemic [8].
The aim of this study was to investigate the proportion of mothers and children (under age of 3 years) taking vitamin A and iron in Nepal between 2001 and 2011. We also examined the demographic determinants of vitamin A and iron intake during this period. The findings of this study are useful to assess the implications for future programs which are aimed at promoting adequate micronutrient intake among Nepalese mothers and children.

Methods

The data for this study were drawn from the Nepal Demographic and Health Survey (NDHS) conducted in 20011, 2006 and 2001 [8,10,11]. The surveys were undertaken by Department of Health Services, Population division of the Ministry of Health and Population together with a local research organization, New ERA. The surveys covered nationally representative samples of selected households using multistage stratified cluster sample design. The survey gathered data from a wide range of indicators in relation to the population health and nutrition among women aged 15- 49 years and children under five years of age. Due to lack of data, upper limit of the age of the children is less than 3 years (33 months) for analysis. The overall response rate was more than 95% in all the three study years. Ethical approval for the surveys was obtained from the Nepal Health Research Council. Verbal consent was also obtained from participants prior to the interview. Three types of questionnaires were administered in all the years: household questionnaire, women´s questionnaire and men´s questionnaire. The present study is focused on the women´s questionnaire and some background information from the household questionnaire. Permission to use the NDHS data was obtained from MEASURE DHS ICF, International, USA (http://www.measuredhs.com). Questions on the nutritional status of children were answered by their mothers. The present analysis focused on intake of vitamin A and iron among children under the age of 3 years age and women of reproductive age.
Assessment of intake of vitamin A and iron
The following questionnaires were used to access the intake of vitamin A and iron in NDHS Survey:
a) Did (the child) receive a vitamin A capsule during the event in Kartik/Baishak (month of the year in Nepali calendar)?
b) In the last seven days, was (the child) given VITA MISHRAN or iron syrup like (this/any of these, (sample shown)?
c) In the first two months after delivery, did you (mother) receive a vitamin A dose like this (sample shown)?
d) After delivery were you given or did you buy any iron/Folic acid tablets?
e) After delivery, for how many days did you take the tablets?
d) Did you (mother) take any of these fruits or vegetables and/ or meat in last seven days? (These include foods, such as: dark green leafy vegetables, ripen fruits, fruits and vegetables and fish as well as meat from poultry and lamb).
We defined vitamin A intake from foods as consumption of meat (and organ meat), fish poultry, eggs, pumpkin, red or yellow yams or squash, carrots, red sweet potatoes, dark green leafy vegetables, mangoes, papayas and other locally grown fruits and vegetables. Iron intake from food was defined as consumption of meat (lamb, poultry, pork, buff, duck, liver, kidney, etc.) As this was the only iron-rich food inquired from the questionnaire. Iron intake from supplements was defined as the intake of iron tablet. Vitamin A intake from supplements was defined as intake of capsules for children and tablets for mothers.
Socio-demographic and lifestyle related variables
The following socio-demographic and life style variables were used in the analysis: region (1= eastern, 2=central, 3=western, 4=midwestern and 5=far western); religion (1=Hindu and 0=others); mother’s highest level of education (0=no education, 1=primary, 2=secondary and 3=higher education); wealth index (1=poor, 2=poorer, 3=middle, 4=richer and 5=richest); place of residence (1=rural and 2=urban); current age of children (1=0-1 month and 2=2-33 months); maternal tobacco smoking (0=no, 1=yes); child’s ever breastfed (0=no, 1=yes); and maternal age (1=15-19 years, 2=20- 24 years, 3=25-29 years, 4=30-34 years, 5=35-39 years, 6=40-44 years, 7=45-49 years).

Statistical Analysis

Simple frequencies and Pearson’s chi square test were used for descriptive analyses. The data was weighted using the weighting factor when calculating the frequencies. To examine the relation of the demographic characteristics to the intake of vitamin A and iron, multilevel logistic regression was used due to the clustered nature of the data. The individual level was used as level 1 and the sampling cluster was used as level 2. In the multilevel model, the survey data for the three years were pooled together. Two multilevel logistic regression models were fitted for each outcome: the first model was a bivariate model in which each demographic variable was studied in relation to each outcome. In the second model, the demographic variables that achieved a P-value of ≤ 0.25 in the bivariate model were simultaneously adjusted in relation to each outcome. The variables; years of survey, region, religion, mother’s higher level of education, wealth index, place of residence, children ever breastfeed and current age of mother were adjusted at least once in the second of two multilevel logistic regression model. Both in the unadjusted and adjusted models, survey year were included as a covariate. Odds ratios and their corresponding 95% confidence interval are reported for the multilevel logistic regression results. Statistical significance was set at P<0.05. The p-values described the difference between the years 2001-2006 and 2006-2011. SPSS version 17 was used for descriptive analysis while the adds-on programme GLLAMM in STATA 11 was used for multilevel modeling.

Discussion

Characteristics of the study population
Table 1 shows the socio-demographic characteristics by survey year. The number of participants was 8726, 10,793 and 12,674 in 2001, 2006 and 2011 respectively. Results show that the proportion of respondents at each study year was highest in central region compared to other regions. Majority of the respondents were Hindu. The proportion of uneducated responding women decreased over the study period, while the proportion of women with secondary and higher education increased. The 2001 survey did not obtain a measure of wealth index whereas the distribution of wealth index in 2006 and 2011 were similar. The proportion of urban residents participating in the survey increased over the study period. Majority of the respondents over the study period were non-smokers and most of the children were ever breastfed. The p- values describes the significant difference in between the time frames between each consecutive years of surveys. For the women having more than one child, the data on the last child were analyzed.
Table 1: Characteristics of study population by survey year.
Micronutrient intake among Nepalese mothers and children in 2001, 2006, and 2011
Table 2 shows the proportion of mothers and children taking vitamin A and iron. The proportion of mothers who took vitamin A from foods increased by more than 3 times between 2001 and 2006; data on mothers’ vitamin A intake from foods were not collected in 2011. The proportion of mothers taking vitamin A supplementation two months after delivery increased by almost 4 times in between 2001 and 2011. Data on mothers’ intake of iron from foods were not collected in the year 2001 and 2011 and iron intake supplements in women were not collected in 2001. The proportion of intake from iron supplement during pregnancy increased more than 20% between 2006 and 2011.
Table 2: Proportion of Nepalese mothers and children taking vitamin A and iron in 2001, 2006 and 2011.
For children, the proportion taking vitamin A and iron from foods continuously decreased between 2001 and 2011. Similarly vitamin A intake from supplements was slightly decreased between 2001 and 2011. Data on intake of iron supplements for children were only available in 2011.The p- values signifies the difference between mother and child vitamin A and iron intake in particular years of survey.
Determinants of vitamin A and iron intake among Nepalese mothers and children in 2001, 2006, and 2011
Table 3 presents the results of the demographic determinants of vitamin A and iron intake among mothers. After adjustments, Hindu women were more likely to take iron supplementation during pregnancy and vitamin A supplementation after two months of delivery compared to women other religions. Women with higher education were more likely to consume vitamin A from foods, iron supplementation during pregnancy, and vitamin A supplementation after two months of delivery compared to women with no education. Similarly, women in the richest wealth quintiles were more likely to take iron supplementation during pregnancy compared to the women in poor health quantile. Mothers of older children were less likely to take any of the micronutrients compared to mother of younger children. Women who smoked tobacco, compared to non-smokers, were more likely to consume vitamin A rich foods whereas less likely to take iron during pregnancy and Vitamin A supplements after delivery. Women in the oldest age category (45-49 years) were less likely to take vitamin A from food and iron supplement compared to younger (15-19 years) age groups (Table 3).
Table 3: Determinants of intake of vitamin A from foods, iron supplement during pregnancy and vitamin A supplements after 2 months of delivery among Nepalese mothers in 2001, 2006 & 2011.
Table 4 summarizes the socio-demographic determinants of intake of vitamin A and iron among under-5-year-old children in Nepal. Children of Hindu families were less likely to consume vitamin A rich foods compared to children from other religions. Children whose mothers have secondary level of education were more likely to consume vitamin A rich foods and vitamin A supplements from capsules compared to those with no education. Children from the richest wealth quintile were more likely to consume vitamin A rich food compared to the children from poor wealth quintiles. Older children were more likely to consume vitamin A rich foods, iron intake from meat and vitamin A supplements from capsules compared to younger ones. Children whose mothers smoke were more likely to consume vitamin A rich foods compared to children of non-smoking mothers. Children of older mothers were more likely to consume foods rich in vitamin A and to take vitamin A supplementation capsules.
Table 4: Determinants of intake of vitamin A from food, iron intake from meat and vitamin A supplements from capsules among under 5-year Nepalese children in 2001, 2006 & 2011.

Discussion

The results from this nationally representative cross-sectional study showed that the proportion of Nepalese mothers taking vitamin A and iron supplementation during pregnancy and postpartum, respectively, increased continuously between 2001 and 2011, while intake among children decline during the same period. The findings further showed that mother’s education, place of residence, religion, mother smoking status, mother’s age, and child’s age were the key determinants of intake of vitamin A and iron in Nepal.
Few previous studies based on regional data are available. However, those studies are not comparable with this study as they are based on the specific region or zones. One of the study on maternal and children iron deficiency in Nepal shows that the proportion of iron deficiency anemia among children (6-59 months) and mothers (15-49 years) is 46% and 35 % respectively. [12]. A randomized community intervention trial of women of 12-45 years in east-central Nepal showed that up 80.6% of the women had iron deficiency with overall of 72.6% of them were anemic [13]. Among these, 88% of the cases of anemia were associated with iron deficiency, suggesting that consumption of iron-rich foods or intake of iron supplementation is not optimal in this setting [13]. Likewise, a case control study conducted in village development committee of central lowland region of Nepal revealed that chronic lack of dietary sources of vitamin A from foods among children resulted to chronic xeropthalmia among the participants in the study [14]. The study observed that vitamin A intake depends on the seasonal variation which is higher during the major crop harvesting season. Another study conducted in Nepalese children of age 6 to 60 months recommended the intake of vitamin A supplements in order to reduce the rate of mortality from malnutrition and other infectious diseases due to low consumption of vitamin A from foods [15]. The intake of food among children and pregnant mother was observed low which is associated not only due to socio economic factors but also the socio cultural factors [14]. Vitamin A deficiency in preschool children was also observed in a study by Keith and colleagues [16]. The study observed that there are about 35% of vitamin A deficient preschool children in Nepal.
In the recent years, studies have shown that national vitamin A and iron supplementation programs have been successful in combating vitamin A deficiency disorders and iron deficiency anemia in Nepal to some extent [6,17]. Finding from another similar study observed that vitamin A program has been effective with national overall coverage of average 87.5% ranging from 80% to 93% [18]. Likewise the distribution of iron supplements to pregnant women was a great success by the help of female community health volunteers in Nepal. Our results show that intake of these micronutrients have increased among mothers between 2001 and 2011, intake among children have rather been declining. We have identified potential demographic factors that can influence micronutrient intake among Nepalese mothers and children, of which the key factors include mother’s education, place of residence, religion, mother’s smoking status, mother’s age, and child’s age. Taking into account these factors when implementing national strategies to enhance adequate micronutrient intake among Nepalese mothers and children, will be crucial in identifying the population strata that are greater risk of having deficiencies resulting from lack of intake of these micronutrients.
This study to our knowledge is the first to describe the intake of vitamin A and iron among Nepalese mothers and children during 2001-2011 periods and to examine the possible demographic determinants of vitamin A and iron intake. One of the strengths of this study is that, it is nationally representative, therefore can be generalized to the Nepalese population. Before the actual survey, the questionnaire was pretested, translated into local languages to ensure better understanding of the respondents [8]. Response rate was more than 95% in all the surveys [8,10,11]. Hemoglobin level was measured using HemoCue instrument to test the iron deficiency among mothers which signifies the better accuracy and higher external validity of the study.
A limitation of the current analysis is that due to the cross-sectional nature of the data, the temporality of the associations between the demographic factors and intake of micronutrient was unable to be identified. The possibility of recall bias increases with cross-sectional data, but to minimize this we examined micronutrient intake with reference to the last child. However, there might be still some possibility of recall bias. The intake of vitamin A was derived from several vitamin A-rich foods whereas the intake of iron came only from meat consumption, which in reality would be an underestimation. The assessment of some of the micronutrients and some of the determinants were not collected in all the three surveys. Hence, it was impossible to study such variables across the three-survey period. Different households were surveyed each NDHS with significant regional changes. The study can provide an estimate what happened country wide but with limitations. There can also be the greater possibility of reporting bias by the mothers interviewed.

Conclusion

We observed the proportion of Nepalese mothers taking vitamin A supplementation during pregnancy and postpartum increased during 2001, 2006, and 2011 respectively whereas iron supplement increased from 2006 to 2011. The proportion of children taking vitamin A from food and supplement overall decreased during the same period. While the increased intake among mothers is a great milestone and needs to be maintained, the declining intake among children highlights the need for more active public health programs to promote adequate intake of these essential micronutrients in order to prevent nutritional disorders that are associated with them.

Acknowledgment

The Authors would like to thank Bright I Nwaru for his contribution in this manuscript as a thesis supervisor.

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