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The nutrition situation in Uganda
H Bachou
Mwanamugimu Nutrition Referral Centre
Uganda

S A J Clin Nutr 2000 August Vol 13 No 3

Uganda, the "pearl of Africa" and source of the great River Nile, is a land-locked country in East Africa, located between 4o north and 1 o south of the equator and 30 o west and 35o east of the Greenwich meridian. The country has a population density of 74 people per km2 and ranks 5th among the most crowded countries in Africa. However, population distribution is very diverse, ranging from 12/km2 in the north-west (Nebbi) to 223/km2 in the east (Mbale). Uganda is also the least urbanised country in Africa and the 8th lowest in the world, with only 9.9% (1 730 000) of the population living in urban areas. Nearly half of the total population (49%) is aged under 15 years, while the over-65s comprise only 2.2% of the population. In 1998, the average life expectancy at birth was 47 years, the total fertility rate 6.9 children/woman, the birth rate 51.9/1 000, the infant mortality rate (IMR) 88/1 000 births, the maternal mortality rate 500/100 000, and the crude death rate 15.1/1< >000.1

Macronutrient undernutrition
In Uganda, protein energy malnutrition (PEM) remains among the most serious health and welfare problems, affecting particularly children, in whom it contributes significantly to mortality. Over 38% of children aged under 5 are stunted.2 This prevalence ranked Uganda 9th among the 20 nations in the sub-Saharan region in 1995. Stunting in Uganda begins at infancy and rises steeply, peaking at about 2 years when about 50% of toddlers are stunted. The prevalence of stunting among rural children is twice as high as that among urban children. However, migration to urban areas for security reasons or in search of jobs has led to an increased prevalence of stunting in urban slums. For example, in 1997 in one such area, the Kabale municipality, over half of children under the age of 5 years were stunted.3 The prevalence of stunting does, however, vary according to the prevailing sociopolitical conditions. For instance, there was a significant 16% reduction in stunting among under-4-year-olds between 1988/89 and 1995.2 This was attributed to an improvement in factors contributing to malnutrition rather than to an effective nutrition programme. There had at the time been relative political stability in many parts of the country, fair economic growth and better health service delivery by government, local and international agencies. During the same period there was a significant reduction in infant and under-5 mortality rates, from 122/1 000, to 97/1 000 and from 203/1 000 to 160/1 000 respectively. The agricultural sector grew at a rate of 4% with an increase in food production, and the GDP increased by 6.4%.4

In Uganda, wasting typically starts at 1 month of age, rises rapidly and peaks earlier than stunting at around 1 year. Possible causes of wasting include inadequate infant feeding practices and infections, especially diarrhoea and respiratory diseases, which are common during this period of growth.5 The prevalence of wasting among children under 4 years of age is 5%. Wasting also has a significant regional variation, with the northern and eastern regions having a higher prevalence than the central region. The former two regions are prone to recurrent drought, especially the north-eastern areas. Seasonal variation also threatens household food security and the traditional systems of food storage. Granaries, for instance, have been abandoned due to increased political insecurity, especially in the north. Political insecurity has also adversely affected the delivery of health promotion services in these areas.

The proportion of children who are underweight is 26%, a notable increase of 8% since 1988/89 - 1995. Underweight increases with age from 3 months and peaks at 11 months of age. By the end of the first year of life, 40% of children are underweight. This prevalence decreases thereafter up to the age of 3 years, when 23% of children are underweight. A similar national pattern was observed in 1988/89.6

Currently, management of malnutrition is primarily facility-based. Children who are malnourished are identified in health facilities and those who are severely malnourished are referred to hospitals or rehabilitation centres for management. The Ministry of Health has recently drafted a guideline for the management of severe malnutrition which, when approved, will harmonise the management in all health facilities.

Efforts have also been made to transform nutrition into community-based programmes as part of the Integrated Management of Childhood Illness (IMCI). It is hoped that this development will enable nutrition interventions such as growth monitoring and home management by community extension workers to be better implemented for the management of mild and moderate malnutrition. In addition, severely malnourished children would be identified early and referred to health facilities for diagnosis and appropriate care. In this regard, reports from the Mwanamugimu Nutrition Referral Centre situated in Mulago Hospital indicate that the number of children admitted with severe malnutrition during 1995 - 1998 increased from 275 to 1 034, with an average of 750 admissions per year. Most of the children admitted (> 80%) were below 5 years of age (6 - 60 months),7 with a significant shift in predominance from kwashiorkor to marasmus over the same period.

There are no national data on the nutritional status of school children and adolescents. However, a rapid district nutrition survey report of primary school pupils in 37 districts in 1993 showed a high prevalence of stunting, of up to 45%.8 Additional reports indicated that over 40% of primary school children walked long distances to school without breakfast and spent 8 hours at school with little to eat. Moreover, most day schools lacked organised feeding programmes and only a few of these children carried a packed lunch 9,10 to school. A high prevalence of stunting was also reported among rural adolescents, whose diets were usually inadequate in many nutrients.11,12

According to the 1995 national demographic data, about 10% of non-pregnant, non-lactating women in Uganda had a body mass index (BMI) of less than 18.5 kg/m2. However, there are no national data available as yet on the prevalence of overweight/obesity, weight gain during pregnancy or energy intake. Most pregnant women make infrequent antenatal visits, which makes systematic follow-up difficult. Nevertheless, many pregnant mothers are unaware of their special nutritional needs. They continue to carry a workload that requires considerable energy throughout pregnancy.

Micronutrient undernutrition
The major micronutrient deficiencies of interest in Uganda are iodine deficiency disorders (IDD), vitamin A deficiency (VAD) and iron deficiency anaemia (IDA). By the beginning of the 1990s, very little was known on the prevalence of these major deficiencies in Uganda.

Iodine deficiency disorders
IDD in the form of goitre was a major referral surgical problem in the national hospital in the 1960s.13-15 However, its association with iodine deficiency was only recognised much later. In 1991, a local survey carried out in four mountainous districts and five districts at lower altitude reported high total goitre rates (TGR) among schoolchildren aged 6 - 12 years, ranging between 63% and 76% (overall TGR 74%). Mountainous districts had higher rates than those on the plains. A few cases of cretinism were reported in Kabale villages, although the number was said to be difficult to ascertain because the families of these children tended to hide them.16

Recently (1999) the IDD monitoring survey was conducted in six districts among 2 860 schoolchildren aged 6 - 12 years. A total of 293 samples of urine and 276 of salt were tested for iodine concentration. The findings indicated a significant reduction in the overall TGR (16%) and an overall median iodine concentration of > 100 µg/l. Only 5% of the survey sample had a median concentration of below 50 µg/l. Over half (64%) of salt samples had iodine concentrations of > 50 parts per million (ppm).17

This remarkable improvement in IDD is certainly attributable to the enacted national statutory regulations being implemented by the National Bureau of Standards at all border posts. All imported salts must have an iodine concentration of 100 ppm. This measure has led to an increased consumption of effectively iodised salt in the country. Plans are also underway to install an iodination plant at the Lake Katwe salt production site and to increase awareness of IDD as a public health concern.

Vitamin A deficiency
The earliest formal study on the VAD prevalence was carried out in Eastern Uganda in 1991. The results suggested that VAD was a public health problem in the country according to the WHO criteria. Xerophthalmia was diagnosed in 5.38% of the 5 074 children under 6 years of age, 2.52% had night blindness, 1.74% corneal scars, 1.04% Bitot's spots and 0.26% corneal xerosis.18 Three years later, a rapid nutrition survey in 37 districts using night blindness as an indicator for VAD reported deficiency in all but 6 districts. In 1999, the visiting international assessment team on vitamin A observed that the main source of vitamin A in the Ugandan diet was green leafy vegetables, invariably boiled or steamed with hardly any fat. Animal protein was scarce, limiting bio-avaibility of all micronutrients. They concluded that over 50% of children took inadequate vitamin A in their diets and that the risk of vitamin A deficiency was higher in children from poor peasant households.19 The Ministry of Health implemented a national protocol for vitamin A supplementation which included supplementation for mothers postpartum, the administration of vitamin A capsules with measles immunisation at 9 months, and treatment of children with protein energy malnutrition, xerophthalmia, measles, diarrhoea and pneumonia at health facilities and in IMCI districts. The ministry is currently revising the vitamin A protocol to include biannual supplementation for all children below 5 years of age. However, there is as yet no well-defined system for distribution of vitamin A capsules. Vitamin A capsules that are available for administration postpartum are received by only a few mothers, primarily those who use health facilities to deliver their babies and those who bring their infants for BCG immunisation. In 1999, vitamin A capsules were successfully given on National Immunisation Days (NIDs) in 25 out of 49 districts through the Ugandan National Extended Programme for Immunisation (UNEPI). Vitamin A capsules are supplied by the United Nations International ChildrenÕs Emergency Fund (UNICEF), the World Health Organisation (WHO), Lions Norway, and Minnesota International Health Volunteers (MIHV). The capsules are dispatched to the districts as part of the combined package of maternal and child health (MCH) services. However, the capsules are not yet included in the regular pharmaceutical supply system, which raises concern over future sustainability of the programme. Vitamin A dietary fortification options are currently being explored.

Iron deficiency
Although there are no available national data on iron deficiency, anaemia has been rated among the top 10 causes of morbidity and mortality in children under 5 years of age.20 One-third of anaemia is thought to be due to iron deficiency anaemia. Available studies suggest that iron deficiency is common in children and women. In the eastern region, 40% of under-5-year-olds suffer from iron deficiency anaemia.21 The situation is aggravated by high prevalences of malaria, hookworm infection, schistosomiasis and sickle cell anaemia.

Anaemia is also common among pregnant and lactating women. According to WHO prevalence data (1998), 50% of Ugandan pregnant women have iron deficiency anaemia and about 30% of maternal deaths are attributable to anaemia. One-third of postpartum women were recently reported to be anaemic, with 16% of them in the eastern region moderately to severely anaemic.22

In 1996, the National Food and Nutrition Policy (NFNP) and the Ugandan National Plan of Action for Nutrition (UNPAN) were drafted by the National Food and Nutrition Council (NFNC). This was based on the themes recommended during the International Congress on Nutrition (ICN) in Rome in 1992. The overall objective of the NFNP was to guarantee food security by increasing food production, and to ensure adequate nutrition for all through sufficient food supply, adequate processing and preservation, storage, marketing and distribution, external trade and supplementary food aids. The NFNP also focused on the elimination of micronutrient disorders, the promotion of breast-feeding, nutrition education and efficient nutrition monitoring systems at all levels of care. The policy also included the protection of the population against contaminated, adulterated and unsafe foods that might be injurious to health. Unfortunately, both the NFNC and NFNP have not yet been regularised. Currently, both are being revised in order to generate the political support needed.

The Ugandan government has made tremendous efforts to reduce the current high prevalence of both micronutrient and macronutrient deficiencies in the country. Some of the efforts include:

• The constitution of the Republic of Uganda includes a policy on food and nutrition in the national objectives and directive principles of State policy.
• The Government secured a loan from the World Bank for the Nutrition and Early Childhood Development Project, which is being implemented in 27 districts with an overall objective of improving the quality of children under 6 years of age.
• Women have also been strategically targeted in economic, education and health sectors in an attempt to improve nutrition and health at the household level, since they are the principal providers and caregivers at that level.
• Policies and guidelines are being formulated to address nutritional priority problems with assistance from international and local agencies. For example, the Ministry of Health included nutrition in its sector strategic plan of 2000/01 - 2004/05 in the recent policy reform and it is currently working on policies and guidelines on anaemia, breast-feeding and HIV/AIDS, school health and a number of other nutrition-related disorders prevalent in the country.
• A ban on importation of non-iodised salt has already been imposed. The Ugandan National Bureau of Standards has iodine testers at border points to verify the quality of iodine in imported salts.

In conclusion, therefore, although the overall statistics leave a lot to be desired, profound political will together with an equally profound commitment of all health workers in addressing the most prevalent nutritional disorders in the Uganda promise to improve the nutritional status of its population in the coming years.

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