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2011 Iron and Zinc Intake in Children Living in Kibona, Rural Uganda Marije Willems Nutrition and Dietetics University of Amsterdam Thesis number: 2012126 Version: 1 " To what extent are iron and zinc deficient in the diet of children aged 1-5 years living in Kibona, a rural village in Lwengo district, Uganda?" Author: Mw. M.W. Willems 2 Bridge House, Thames Street Wallingford Oxfordshire OX10 0BH United Kingdom [email protected] Thesis Number: 2012126 Principal: Mw. R. Nansubuga Kitovu Hospital, Masaka Nutrition Ward, Kitovu Hospital P.O Box 524 Masaka Uganda [email protected] Professor: Mw. A. Doornbos Hogeschool van Amsterdam Voeding en Diëtetiek Dr. Meurerlaan 8 1067 SM Amsterdam [email protected] Copyright © 2012. M.W. Willems © The information, images, and/or data contained in this thesis are copyrighted by their respective owner and may not be distributed, modified, reproduced in whole or in part without prior permission of the thesis respective owner. 2 Word of Gratitude During the period of September through December 2011, I have lived, worked and researched in the rural area of Masaka, Uganda. As part of my studies in Nutrition and Dietetics at the University of Amsterdam, I have focused my thesis research in a rural region of Uganda, called Lwengo District. My research was focused primarily on the dietary intake of young children in a rural village, to assess adequacy of iron and zinc intake. I worked together with the Nutrition Ward at Kitovu Hospital in Masaka. This research would not have been possible without the time, support and dedication of many people in Uganda, England and the Netherlands. I want to say a special thank you to Regis Nansubuga who has dedicated more than 25 years of her life to help children in this region who have battled with life-threatening effects of malnutrition and other illnesses in an area where resources are limited. I would also like to thank Regis for assisting me in the preparation and research required for this thesis. I couldn't have done this without her help, courage, advice and patience. I am also grateful for the help of my research team, translators, the doctors and nurses at the Nutrition Ward at Kitovu Hospital. In all, 22 people played an ongoing role in this assistance; from medical insights to those who aided me in the 24-hour recall surveys and everyone else in between that gave their time and effort to assist me in researching a topic that plays a vital role in overall health and well-being: iron and zinc intakes. I also want to thank the local health workers in Lwengo District and my partner Mark Carmichael who has fully supported and encouraged me from the beginning until the end. I have very much appreciated the guidance of my Academic supervisor Anne Doornbos who has supported me from the Netherlands. Also a big thank you to the numerous respondents to the 24-hour recall survey whose anonymity I am bound to respect, but whose participation, humbleness and happiness I am forever grateful to have experienced. Marije Willems December 2011 3 Summary Background: Worldwide, micronutrient deficiencies of iron and zinc are very common, with the highest prevalence in less developed countries. There is no known research to date on iron and zinc intake in the diets of children under five, within a rural village called Kibona in Lwengo District, Uganda. Due to the high figure of admissions of malnourished children to the Nutrition Ward in Kitovu Hospital in Masaka, the Kitovu medical team has for several years, sought to identify iron and zinc intakes of children in the surrounding area. It is strongly believed that such data and understanding would be crucial for effectively designing and targeting nutrition intervention measures in the future. Aim: To assess the dietary intakes of local children between one and five years of age to identify and measure the extent of inadequate intakes of iron and zinc, living in Kibona, a rural village in Lwengo District, so that effective nutrition education and food-based intervention programs can be planned in the future. Methods: Dietary intake was measured in fifty children between one and five years of age who were living in Kibona, Lwengo District, Uganda. A 24-hour recall method was used over a period of three days, with duplicate measurements on a subset of the sample to allow estimation of usual intake. Breastfeeding and complementary feeding practices were also surveyed. Results: Results showed that the mean daily iron intake was 5.1 mg/d for age category 1-3 and 8.2 mg/d for age category 3-6. The mean daily zinc intake was 2.0 mg/d for age category 1-3 and 2.5 mg/d for age category 3-6. Compared to the Recommended Nutrient Intake (RNI) of iron and zinc by the World Health Organisation, results show that 94% of the total children had iron deficiency in the diet, and 98% had zinc deficiency in the diet. Conclusion: The subjects had a predominantly plant-based diet. Foods of animal origin were consumed rarely. The total daily iron and zinc intake does not meet the daily RNI, due to low bioavailability of a plant-based diet. The RNI of iron and zinc may not be met in a plantbased diet. Kitovu Nutrition Ward will soon start to implement an educational program for the families on feeding, to improve the iron and zinc intake in children from Lwengo District to reduce iron and zinc deficiencies. Keywords: Zinc; iron; Uganda; Lwengo District; Kibona; micronutrients; 24-hour recall 4 Table of contents 1. Introduction ................................................................................................................. 6 1.1 Nutritional situation in Uganda ........................................................................................ 6 1.2 Iron and zinc deficiencies ................................................................................................. 7 1.3 Rationale for the Study .................................................................................................... 8 2. Subjects and Methods .................................................................................................. 9 2.1 Ethical Consideration ....................................................................................................... 9 2.2 Study Area ........................................................................................................................ 9 2.3 Subjects ............................................................................................................................ 9 2.4 24-hour dietary recall ....................................................................................................... 9 2.5 Data entering and analyses ............................................................................................ 11 3. Results........................................................................................................................ 12 3.1 Results of the 24 hour recall .......................................................................................... 12 3.2 Estimation of energy, iron and zinc intake..................................................................... 14 4. Discussion .................................................................................................................. 16 4.1 Important Results ........................................................................................................... 16 4.2 Strengths and limitations ............................................................................................... 16 4.2 Comparison of energy, iron and zinc measurements to other studies ......................... 17 4.3 Recommendations on improving iron and zinc defiencies compared to other studies 17 4.4 Future investigation ....................................................................................................... 18 5. Recomendations for Kibona Vilage .............................................................................. 19 6. Conclusion .................................................................................................................. 22 References ..................................................................................................................... 48 Appendix I Appendix II Appendix III Appendix IIII Food list with energy, iron and zinc values Dietary Data Mean energy, iron and zinc intake over period of three days Comparison recommended iron and zinc intake 5 1. Introduction 1.1 Nutritional situation in Uganda Malnutrition is a very serious health problem around the world and can be grouped as: low weight-for-age (underweight); low height-for-age (stunting); low weight-for-height (wasting); micronutrient malnutrition.3 Malnutrition contributes to half of the preventable maternal and child deaths in the world.1 In Uganda alone, malnutrition affects 2 million children under the age of five. The most recent statistics of Uganda (UDHS) reported that approximately two of five children under the age of 5 years (38 percent) suffer from chronic malnutrition (stunting). It was also estimated that 16 percent is underweight, and 6 percent has acute malnutrition (wasting).2 3 The Uganda Child Survival Strategy estimated that malnutrition directly and indirectly contributes to up to 60 percent of child mortality, making malnutrition one of the most significant contributors to childhood mortality in the country. If this status quo is maintained 520,000 children will die as a consequence of underweight alone before 2015.4 Uganda’s most frequent malnutrition problems are high rates of chronic malnutrition and micronutrient deficiencies. Micronutrient deficiencies are also referred to as the 'Hidden Hunger'.5 This name was given as even if intake of micronutrients appears adequate in the diet of children, the amount of micronutrients absorbed in the body can be low, due to low mineral bioavailability in plant-based diets. Identifying micronutrient malnutrition in children without regular assessments is difficult.6 The most widespread micronutrient deficiencies are: iron, iodine, vitamin A and zinc7. The matter has achieved worldwide attention – i.e. that large parts of the developing world are suffering from these deficiencies and that it poses a serious threat to the well-being of many. Except for iodine, little progress has been made in controlling micronutrient deficiencies in sub-Saharan Africa. 8 To support the future health needs of its citizens, Uganda has committed itself to ending hunger and malnutrition to ensure food and nutrition security for all Ugandans. This initiative is defined in the Uganda Food and Nutrition Policy (UNFNP). As a result, a range of international agreements designed to address the matter have been approved and committed to by the Ugandan government. In support of this, the Uganda Food and 6 Nutrition Policy (UFNP) was adopted in 2003 and specifically recognises the basic human right to sufficient food for all. 9 However, in the last ten years, the rate of change in instances of underweight has been less than -0.7 percentage point per year, implying that at this rate, Uganda is not likely to meet the UN Millennium Development Goal to reduce malnutrition and hunger by 201510 11 1.2 Iron and zinc deficiencies Iron deficiency is known to be the most common and widespread micronutrient disorder in the world and affects an estimated 2 billion people. This is approximately 30% of the world's population. 12 13 It has been estimated by the World Health Organization (WHO) that around 600–700 million people worldwide suffer from iron deficiency anaemia. 14 The prevalence of iron deficiency is highest in South East Asia at 57%, with Africa placing 2 nd at 46%. 15 Studies have shown that pregnant woman and young children are at high risk due to increased iron needs during pregnancy and growth. 16 17 Adequate iron intake is of great importance for the development of the brain and can otherwise result in irreparable damage to the brain cells.18 19 It is also important for other tissues such as muscles, which are differentiated early in life. Severe deficiencies have negative influences to the normal defence systems against infections and reduces physical working capacity of the body. 20 Iron deficiency carries significant adverse consequences for child development both in the short and long term. 21 22 The most widespread cause of iron deficiency is inadequate dietary intake that fails to provide sufficient levels of iron to cover the body's physiological requirements. Other causes are high disease burdens resulting from malaria, diarrhoeal disease, acute respiratory infections and hookworms that lead to intestinal blood losses. 23 24 More recently, zinc has also been identified as a major risk factor and global burden of disease. 25 Worldwide, the prevalence of zinc deficiency has been estimated to be almost 20% 26 Milder and less severe zinc deficiency has been discovered in otherwise healthy infants and children, in both developed and developing countries.27 A milder form of zinc deficiency can lead to growth retardation and is much more prevalent than the severe version. 28 Zinc has an important role in the body for cell division, protein synthesis, and growth. Severe zinc deficiency can lead to: growth retardation, delayed sexual and bone maturation, skin lesions, diarrhoea, alopecia, impaired appetite, increased susceptibility to infections mediated via defects in the immune system and the appearance of behavioural changes. The effects of marginal or mild zinc deficiency are less clear. A reduced growth rate and 7 impairments of immune defence are so far the only clearly demonstrated signs of mild zinc deficiency in humans. Other effects, such as impaired taste and wound healing, which have been claimed to result from a low zinc intake, are less consistently observed. 29 In particular, infants, children, adolescents, and pregnant women on a plant-based diet are high at risk of an inadequate zinc intake. 30 Both iron and zinc deficiencies contribute to low birth weight, impaired immune competence, cognitive function, maternal and infant morbidity, growth failure in infancy and childhood among millions of young children.31 32 33 1.3 Rationale for the Study To our (Kitovu medical team’s) knowledge, there is no literature that clearly documents the dietary intake and risk of iron and zinc deficiencies of children under five years of age, living in Kibona, Lwengo District - a rural part of Uganda. Given the high prevalence of malnutrition generally, more studies are urgently needed to investigate the micronutrient content of foods consumed by Ugandan children. Information of this particular group is essential for the Nutrition Ward at Kitovu Hospital in Masaka, and necessary for planning and implementing nutrition education programmes and intervention strategies to reduce the number of children from Lwengo District, admitted to the Nutrition Ward. Reducing malnutrition in Uganda is critical to save children’s lives and achieve Millennium Developing Goal 4 to reduce the mortality rate among children under five. 34 The presented study was set up to measure adequacy of iron and zinc in the diet of children aged one till five, living in Kibona, Lwengo district of Uganda. The research question of this thesis is as follows: " To what extent are iron and zinc deficient in the diet of children aged 1-5 years living in Kibona, a rural village in Lwengo district, Uganda?" Sub questions that are answered throughout the thesis are: 1. What are the health risks of iron and zinc deficiencies for children aged 1-5 years? 2. What is the recommended daily intake of iron and zinc for children aged 1-5 years, living in Kibona, Lwengo District, Uganda? 3. What is the mean iron and zinc intake in children aged 1-5 years living in Kibona, Lwengo district? 4. In what foods, sourced locally in rural Uganda, can we find the micronutrients iron and zinc? 5. Based on the findings of the 24-hour recall surveys and research conducted as part of this thesis, what recommendations in foods can be given to address any iron and zinc deficiencies that may be discovered? 8 2. Subjects and Methods 2.1 Ethical Consideration Ethical approval for this study was obtained from the District Health Office and Lwengo Health clinic. All respondents who participated in the study were completely voluntary and based on informed consent. There was no compensation offered for participation. Measures were taken to assure the respect, dignity, and freedom of each individual participating in the data collection. All 24-hour recalls were conducted in private. Each subject was assigned a unique identification code to protect their anonymity. 2.2 Study Area The field work was carried out in Kibona, Lwengo District, Central Uganda during the period of 27th-29th November 2011. Lwengo District is one of the newest districts in Uganda and became functional on the 1st of July 2010. The climate in the district is equatorial with a bimodal type of rainfall received in the months of April-May and July-August, increasing southwards. There is a main dry season from December to February. The majority of the houses in the rural areas are huts made from mud, or houses made from cement. The vegetation is predominantly savannah, some forest plantations and riparian vegetation. Generally, the district is rural, with very limited public services. Subsistence agriculture and livestock farming are the two main economic activities in Lwengo. There is no clinical hospital in the district and Masaka Hospital and Kitovu Hospital in Masaka are closest at a distance of approximately 40km. 2.3 Subjects Fifty children, one till five years of age, who were residing in Kibona, a rural village in Lwengo District, and who were considered to be at high risk of iron and zinc deficiency, were randomly assigned for the study. Through Sample Size calculations, the amount of children was selected with a 90% confidence level and 10% margin of error. It was more likely to get a correct answer using a minimum amount of subjects for this type of survey. If the sample size would be too big, there is a higher change that only a small percentage of the sample responds to the survey.35 Kibona village was selected since most children admitted to Kitovu Hospital came from this village. The parent or caretaker was asked to undertake the dietary assessment of the children. For logistical and practical reasons the home of the subjects in the selected villages were chosen as location of the dietary assessment. 2.4 24-hour dietary recall The nutritional assessment was performed using the 24-hour recall method. This method was recommended by Harvest Plus. Harvest Plus is a joint venture between the International Centre for Tropical Agriculture (CIAT) and International Food Policy Research 9 Institute (IFPRI) and works with more than 200 scientists, researchers, and other experts around the world. It has developed practical guidelines and procedures for carrying out a 24-hour recall method that has been especially modified to measure the adequacies of iron and zinc intake in rural populations in developing countries.36 . The 24-hour recall was administered by ten local Ugandans who were each trained interviewers. The interviewers were recruited to match both the languages (English and Luganda, the native language) and skill needs of the survey. Other selection criteria used in the selection of the interviewer were the necessity of a reasonable level of education and health educational background, to ensure their ability to sufficiently grasp and successfully execute the thorough level of detail. Each team consisted of two people. In addition to the above mentioned selection criteria, 50% of the interviewers were local village health workers, and the other half were qualified nurses, midwifes and District Health workers. An intensive training program was delivered at Makondo Health Clinic, at Lwengo District and lasted one week to cover the dietary intake studies, including pre-testing and review of survey instruments. In the training, standardized manuals as produced and provided by Harvest Plus on relevant topics were used for guidance. All training provided theory as well as practical application in the form of role plays, presentations, and field testing to minimize respondent biases, interviewer biases, respondent memory lapses, and incorrect estimation of portion sizes. A pre-test was carried out in a rural village similar to the study area. The pre-test incorporated validation of the interview techniques as well as the use of measurement equipment and sampling methodology. Once the pre-test had been completed, the survey teams addressed any points that needed improvement prior to data collection. The interviews were conducted with the person within the household who was primarily responsible for food choice of the child and food preparation. The local language 'Luganda' was chosen to ensure that the parent/caretaker were able to freely express themselves and to feel comfortable during the interview process. The 24-hour recall over a period of 3 days was chosen, as the day-to-day variation in intakes can differ by nutrient from one day to the next. Thus, conducting the 24-hour recall over a 72-hour period provides a more balanced view of the typical dietary intakes of children targeted in this study. 37 10 The 24-hour recall surveys were structured into four steps to maximize respondent recall of foods eaten by child. 1. The first step, the ‘quick list’, involved respondents supplying a broad description of all food and beverage items, including snacks, consumed in the previous day, commencing with the food or drink taken immediately after the reference child woke up and ending with the last food or drink taken before going to sleep at night . 2. In the second step, a detailed description of each food or beverage item on the quick list was ascertained through a series of questions and prompts (generated by interviewers) which were specific to each item. Respondents were asked to give information on the ingredients and preparation methods of mixed dishes. 3. The third step was to estimate the amount of each food and beverage and their ingredients consumed. 4. The final step was to review and check the recall responses to confirm responses given about the previous day’s intake. The 24 hour recall method was determined with the Kitovu medical team as the most valid approach, as it is a more straightforward approach to carry out than other methods such as blood samples. It is less expensive and less invasive than other methods - thus, compliance is enhanced. This approach is especially suitable for areas where diets are not very diverse and are predominantly plant-based following Harvest Plus. 37 In total, 100% of the intended 150 interviews were successfully completed and subsequently checked by independent team members to ensure integrity of the data collected. A random sample of 16% of the 50 survey participants (i.e. 8 in total) were then chosen for follow-up interviews by these team members to review the 24-hour recall results to ensure accuracy. 2.5 Data entering and analyses Dietary intake data was entered using Microsoft Excel 2007. A double-entry system was used to eliminate keying errors. The dietary intake was converted into calorie and micronutrient amounts of iron and zinc using the nutrient database for standard references of the US Department of Agriculture. (Appendix I) The dietary assessment system associated dietary components for 1800 foods consumed in Egypt, Kenya, Mexico, Senegal, India, and Indonesia. It included a computer program that calculated energy and nutrient intakes with total bioavailability of iron and zinc. 38 39 All consumed foods were put into a table. (Appendix II) Calorie, iron and zinc intakes were calculated for prepared food portions as eaten. (Appendix I, Appendix III) To estimate iron and zinc deficiencies, intake amounts were compared with iron and zinc estimated average requirements (EARs) for individuals. (Appendix IIII) Adjustments were made to account for variance in bioavailability according to food source. 40 41 42 11 3. Results 3.1 Results of the 24 hour recall The 24 hour recall showed that the children typically consumed between two and three meals per day consisting of breakfast, lunch and dinner. Breakfast consisted most often of tea with sugar. Some children consumed millet porridge, leftovers of matooke, (plantain) cassava, sweet potato, or posho (a stiff porridge made of maize flour) accompanied by the tea. A common lunch for the children included matooke, cassava or sweet potatoes prepared with onions and tomatoes and occasionally served with groundnut sauce. Silver fish (small dried local fish) was sporadically included in the meals, when and where available. For dinner, the meal was often comprised of the same foods that were prepared for lunch. The mean energy (kcal) intake of the children per food group is shown in figure 1. Figure 1 Composition of mean energy (kcal) intake by food group (N=50 children aged 1-5). 12 Overall, the diet is predominantly plant-based, with the majority of the diet represented in the consumption of matooke, groundnuts and cereals. Energy (kcal) intake is broken down as follows: The majority of calorie intake is derived from plantain (matooke), representing 33.1% of total calories. 17.1% of calorie intake comes from cereals (white bread, millet porridge, maize porridge, posho) 15.1% comes from groundnuts 11.5% from root or tubers (cassava, sweet potato) 4.8% of the energy is supplied by foods of animal origin like beef or silver fish 4.5% from pulses such as kidney beans and cow peas 4.5% sugar 4.5% fresh cow’s milk 2.9% fruit, mostly jackfruit and sweet banana 0.9% fat (vegetable oil and some local butter) 0.4% vegetables (mostly onion, tomato, spinach, eggplant) 0.2% of spices or other. 13 3.2 Estimation of energy, iron and zinc intake Total energy intake corresponds with iron and zinc deficiencies. Table 1 shows the mean and median energy intake of the male and female subjects categorized by age group. One of the children in the sample has an affinity for high energy groundnut sauce contained in the meals that are served on a daily basis. This is the most likely explanation for the difference between the mean and median within the sample. The mean variance indicates the total calories that are lacking per day. Table 1. Mean and Median daily energy (kcal) intake of male and female subjects N = 50 specified per age group Age group Male Total N = 17 Mean Energy (kcal) intake Median Energy (kcal) intake Recommended Energy (kcal) intake Mean Variance Energy (kcal) shortage Total subjects deficient Total Subjects Deficient in Percentage Age 1-2 N=6 765 766 948 -183 4 66.7% 681 528 1,129 -448 3 75.0% 1,008 1,152 1,252 -244 3 60.0% 820 820 1,360 -540 2 100.0% Age 2-3 N=4 Age 3-4 N=5 Age 4-5 N=2 Total 12 70.6% Female N= 33 Age 1-2 N=13 691 670 865 -174 9 69.2% Age 2-3 N=13 737 734 1,047 -310 12 92.3% Age 3-4 N=4 711 720 1,156 - 445 4 100.0% Age 4-5 N=3 1,333 801 1,241 +92 2 66.7% Total 27 81.8% 14 Looking at the mean measurement, Table 1 shows that 70.6% of the total male subjects did not consume sufficient energy (kcal) intake and 81.8% of the female subjects had shortage of energy intake, per day. Table 2 and 3 show the daily iron and zinc intake of the subjects. Table 2. Mean and Median Daily Iron intake in children aged 1-5, living in Kibona, Uganda. N = 50 Age N=50 Mean Iron intake (mg) Median Iron Intake (mg) Recommended Iron intake (mg) (RNI) Mean Variance Shortage Iron Total subjects deficient Total subjects deficient in percentage 1-3 N = 36 5.1 mg/d 4.1 mg/d 11.6 mg/d -6.4 mg/d 35 97.2% 3-6 N = 14 8.2 mg/d 5.1 mg/d 12.6 mg/d -4.3 mg/d 13 85.7% Total: 94.0% Table 3. Mean and Median Daily Zinc intake in children aged 1-5, living in Kibona, Uganda. N = 50 Age N=50 Mean Zinc intake (mg) Median Zinc intake (mg) Recommended Zinc intake (mg) (RDI) Mean Variance Shortage Zinc Total subjects deficient Total subjects deficient in percentage 1-3 N = 36 2.0 mg/d 1.9 mg/d 6.9 mg/d -4.8 mg/d 36 100% 3-6 N = 14 2.5 mg/d 1.7 mg/d 8.0 mg/d -5.4 mg/d 13 92.9% Total: 98.0% Comparisons of mean total intakes of iron and zinc with RNI intake shows that 94% of the total children have an iron deficiency in the diet (table 2), and 98% have zinc deficiency in the diet. (Table 3). Children were categorized in two age groups: a) 1-3 and b) 3-6 years. The 1-3 year old category showed a mean intake of 5.1 mg/d of iron. Compared to the RNI of 11.6mg/d it shows that 97.2% of the 1-3 age category have iron deficiency in the diet. 85.7% of the 3-6 year old category were shown to be deficient in the diet, with a mean intake of 8.2 mg/d, compared to the RNI of 12.6mg/d. Table 3 shows that 100% of the 1-3 year olds have a zinc deficiency in the diet, with the mean intake of 2.0mg/d. 92.9% of the 3-6 year olds have a iron deficiency in the diet with the mean intake of 2.5mg/d. 15 4. Discussion 4.1 Important Results The most remarkable outcome of this study is that 94% of the total children in Kibona have an iron deficiency in the diet and 98% have a zinc deficiency in the diet. This extremely high prevalence is due to the insufficient calorie intake and low bioavailability in the consumed plant-based diet. As a result of the 24-hour recall interviews, the results show that the diet among children in Kibona contained the staples: matooke, cereals, some groundnuts and legumes. Matooke was most frequently reported and included 33.1% of the total diet. (Figure 1). An estimation of 4.8% of the diet reported intake of animal origin. (Figure 1). Dried silver fish and beef were the most frequently reported foods of animal origin. Groundnuts and legumes were both common parts of the diet, especially in absence of fish and meat. Leafy vegetables and fruits were rarely reported as a part of the diet, with 0.4% and 2.9%. 4.2 Strengths and limitations According Harvest Plus, the 24 hour recall was the most straightforward and best approach to use for measuring dietary intake in the children in Kibona. The 24 hour recall is especially appropriate for diets that are plant-based and not very diverse. It is cost-effective, less invasive than other methods i.e. blood tests, and it is culturally accepted. The resulting data collected during the 24-hour recall study, is dependent on certain factors which can affect the overall integrity of such a study. Factors such as memory, ability to estimate portion sizes, degree of motivation and the persistence of the interviewer can all affect the overall result. 43 This and the relationship between the subject and interviewer (parent/caretaker of child and interviewer) might have had an influence on the report of food intake. To ensure that any negative effects were minimized, all reasonable precautionary measures were taken to minimize respondent biases, interviewer biases, respondent memory lapses, and incorrect estimation of portion sizes. The precautionary measures included a week long intensive training to each interviewer that covered theory and practical application in the form of role plays, presentations, and field testing. Specially designed standard data sheets and protocols were also used for an optimal result of the 24-hour recall. The day of the week and also other special occasions can give a day-of-the-week effect on the data in this survey; these potential errors were reduced by carrying out 24-hour recall interviews for three days44 45 at different weekdays, including a day in the weekend, as recommended in the literature.46 The compliance to the 24-hour recall was considered to be relatively high due to the minimal burden imposed on behalf of those participating in the survey. Due to the relatively 16 low number of participants interviewed, the fact that the interviewers experienced positive interactions with participants and the relatively low variety in food items available in the area, it is highly likely that the results provide for an acceptable overview of the staple food consumed by the children. We believe that the findings presented in this report are of high quality and represent an accurate description of dietary intake of these children in Kibona, Lwengo District. 4.2 Comparison of energy, iron and zinc measurements to other studies The estimated energy, iron and zinc intake is lower than the recommended daily energy requirements and recommended nutrient intake for children at the age of one till five years. The RNIs referred to are derived from the estimates of average individual dietary requirements. 44 The bioavailability of diets is usually categorized in three levels, low (5%) moderate (10%) and high (15%) based on the dietary composition. A low bioavailability of 5% was used for the children in this study. The high bioavailability of iron is often found in western diets, which include more vegetables, fruits, meat and fish.47 Due to the high content of phytic acid in the more common foods, the bioavailability levels of 5% and 10% for iron are considered to be realistic in developing countries44. The diet of the subjects consists mostly of plantain and cereals that are high in phytic acid which is considered as the main inhibitor of zinc and iron availability. 48 A similar study in Tanzania used the iron bioavailability of 5%, for children with a similar diet. 49 4.3 Recommendations on improving iron and zinc defiencies compared to other studies A study in China looks at the most realistic and cost-effective strategy to prevent and overcome iron and zinc deficiencies. They conclude that supplementation and fortification can be used as a short-term strategy for particular groups. Two long-term intervention strategies for rural areas are dietary diversification and bio fortification with improved varieties. These are especially realistic and cost-effective for rural populations. 50 Another study about the control of iron and zinc in developing countries also concludes that fortification of staple foods is a sustainable and low cost-effective approach. 51 A study in India on intervention strategies for improving iron status of young children and adolescents concludes that preventive supplementation coupled with nutrition education may be a good effective strategy associated with better compliance and improvement in iron status. They also state that long-term, effective approaches should include: fortification, dietary modification, public health and disease control measures, and income generation programs. They agree with above studies that food fortification can be a cost- 17 effective intervention strategy if technologically feasible, nutritionally sound, culturally acceptable and economically viable food vehicles and the right fortification programme can be identified. 52 The WHO and Food and Agricultural Organization of the United Nations recommend to use programmes that include food-based strategies such as dietary diversification and food fortification, as well as nutrition education, public health and food safety measures, and finally supplementation. 53 54 It depends per local circumstance and local needs on what approaches should be used. Programmes that deliver micronutrient supplements often provide the fasted improvement in micronutrient status of individuals or the targeted population groups. Food fortification tends to have a less immediate, but nevertheless, a much wider and more sustained impact. 55 Although increasing dietary diversity is generally regarded as the most desirable and sustainable option, it takes the longest to implement.56 In South Africa, fortification of curry powder with Na, Fe, and EDTA produced significant improvements in blood haemoglobin, ferritin levels and iron stores in women, and in ferritin levels in men. The prevalence of iron -deficiency anaemia in women fell from 22% to just 5%, in a 2 year study. Unfortunately, well-designed trials of the impact of iron fortification of flour were lacking at that present time.57 4.4 Future investigation Fortified foods often fail to reach the poorest segments of the general population who are at the greatest risk of micronutrient deficiency, like the children in Kibona. The people in Kibona would have restricted access to fortified foods due to low purchasing power and an underdeveloped distribution channel. People in rural villages relay on owngrown or locally produced food. Availability, access and consumption of adequate quantities and a variety of micronutrient-rich foods, such as animal foods and fruits and vegetables, is limited as shown in the results. Fortification of sugar, seasonings and other condiments may provide a solution to the deficiencies in Kibona. Most children drink tea with sugar and most families use seasonings in preparations of meals. Literature on the topic recommends the usage of different approaches to improve iron and zinc intake in rural areas, like the village of Kibona. It needs to be taken into consideration that strategies to improve dietary diversification and bioavailability of iron and zinc may not be sufficient enough to overcome the deficiencies in most rural areas. Therefore, more research is needed on the possibilities, costs and effectiveness of fortifying plant-based foods in Kibona. 18 5. Recommendations for Kibona Village As mentioned in the discussion, it depends on the local situation and needs what approaches should be used to improve iron and zinc intake. The most effective strategy for Kibona village could be to implement by a programme that includes: Dietary diversification Food fortification; i.e. sugar, spices and seasonings Nutrition education Public health and food safety education Supplementation58 59 Further investigation on the cost and effectiveness on food fortification and supplementation is needed before implementing this strategy into Kibona. The recommendations on improving the diet with dietary diversification are following below. Dietary diversification to improve iron intake Dietary diversification can be implemented for the children in Kibona with a nutritional education and health intervention program. The absorption of iron in the body depends on the dietary iron. Animal protein promotes iron nutrition in two ways: it stimulates the absorption of both haem and non-haem iron and it provides the well absorbed haem iron. Non-haem iron is found in cereals, pulses, fruits, vegetables and dairy products and comprises the major source of dietary iron. The absorption of non-haem can vary, depending on enhancing and inhibiting factors. Inhibitor factors are foods with polyphenols, tannins, phytate, certain forms of protein and some dietary fibres, like tea, coffee, egg yolk and bran. Absorption in mixed diets can vary from 1–20%. When a diet consisting of animal protein, absorption can increase to 50%. 60 Intake of animal protein has been found to be associated with a lower prevalence of iron deficiency. Organic acids, such as citric acid, have been found to enhance the absorption of non-haem iron in some studies.61 It is recommended to improve the iron intake by eating more iron rich foods like animal protein such as beef, silver fish or chicken, if possible.62 However, due to poverty and high prices of these products, it is often not possible, or realistic. Therefore, and perhaps more accordingly, children would benefit from a diet with increased iron rich plant-foods such as cereals, pulses, fruits, vegetables and dairy products, combined with vitamin C-rich foods like fruit and vegetables, for a higher absorption. 63 19 Dietary diversification to improve zinc intake The availability of zinc from the diet can be improved by reducing the phytate content and including sources of animal protein. 64 Lean red meat, whole-grain cereals (millet and maize porridge), pulses, and legumes (such as beans, cowpeas and groundnuts) provide the highest concentrations of zinc, and with the exception of lean red meat, are usually available and inexpensive. Processed cereals with low extraction rates (such as white rice) and chicken, pork or meat with high fat content have a moderate zinc content and would therefore benefit diets by increasing their intake. Fish, roots and tubers (such as cassava, sweet potato), green leafy vegetables (spinach), and fruits are only modest sources of zinc. Saturated fats and oils and sugar have very little zinc contents.65 To improve both iron and zinc intake, it is advised to increase whole-grain cereals like millet and maize porridge, increase pulses and legumes intake such as groundnut sauce, beans and cowpeas. These products are available throughout the year at all local produce markets, are easily stored and relatively inexpensive. Certain foods, such as beans, can also be dried and preserved for more than 6 months. Children's diets should also include more fresh fruit and vegetables. Throughout the year, more local products can be consumed like: spinach, eggplants, tomatoes, onion, avocado, jackfruit, mango, banana, pineapple, and papaya. 66 These fruit and vegetables are all locally grown, inexpensive and can help improve the overall nutrition intake. An example of a well-balanced, nutritious diet for a child aged 1-5, living in Kibona village, to increase energy, iron and zinc intake is shown below. Total Nutritional Values Energy (kcal): 1886 Protein: 331 kcal/ 84.5 g Carbohydrates: 771 kcal / 192.7 g Fat: 692 kcal/ 76.8 g Iron: 14.9 mcg Zinc: 8.5 mcg Breakfast Midmorning Snack Lunch 1 cup of millet porridge with milk, water and 1 tsp sugar 1 piece of fruit: jackfruit, pineapple, mango, banana, papaya 1 cup of tea (with sugar) 100 g cereals: cassava, (sweet) potato, matooke, rice 2 tsp butter/ vegetable oil 20 Afternoon Snack Dinner 100 g beans/cowpeas 50 g silver fish/meat/poultry or 50 g groundnut sauce 100 g vegetables: tomato, onion, pepper, spinach, eggplant 1 avocado 1 cup of millet porridge with milk, water and 1 tsp sugar 1 piece of cereals: cassava or vegetable: piece of tomato, avocado. 100 g cereals: cassava, (sweet) potato, matooke, rice 1 tsp butter/oil 100 g beans/cowpeas 50 g silver fish or 50 g groundnut sauce 100 g vegetables: tomato, onion, pepper, spinach, eggplant 1 piece of fruit Implementing the above diet can help to improve the total dietary intake and iron and zinc deficiencies in the diet of the children in Kibona. Even with a diet change, dietary diversification may not be enough to overcome iron and zinc deficiencies in the diet. It is usually regarded as the most desirable and sustainable option, but it takes the longest to implement, since parents or caretakers may not want to change their lifestyle, behaviour and habits to make dietary changes. 67 Further nutritional education, public health and food safety education will be developed for the families in Kibona village to teach the parents on how to feed their families adequately. More intervention planning is needed to deliver a quality program for Kibona village that can resolve the many cases of iron and zinc deficiencies. 21 6. Conclusion In this study it was found that children aged one till five, living in Kibona village, Lwengo district had a predominantly vegetable based diet, mainly consisting of: matooke (plantain), groundnuts, cereals and some legumes and pulses. The consumption of vegetables and fruits in the diet fails to achieve the diversity required to represent a healthy diet, including sufficient iron and zinc intake and absorption, particularly considering the low consumption of animal-source foods.68 The Iron and zinc content in the diet was small due to low bioavailability. The mean intake of both iron and zinc per day was not adequate according to the Recommended Nutrient Intake by the World Health Organisation (RNI). 98% of the total subjects had iron deficiency in the diet and 94% had a zinc deficiency in the diet. For the prevention of both iron and zinc deficiencies in the diet, not only dietary change is needed. Other approaches such as supplementation with medical iron and zinc, fortification of a suitable staple food, spice or seasoning, the control of infection through public health activities and nutrition education may be needed also. Dietary changes in Kibona village need to be made to increase iron and zinc intake by dietary diversification. This can be done by eating more whole-grain cereals like millet and maize porridge, legumes and pulses such as beans, ground nuts and cowpeas, since the cost of animal protein is too high. Given that only Kibona village was used to measure the dietary intake of the children in a short period of time, caution is warranted with respect to simple generalizations. Nevertheless, the diet in rural Uganda is known to be similar to other rural areas. In conclusion, it can be said that most children living in Kibona have iron and zinc deficiencies in the diet due to a poor, plant-based diet. Armed with the knowledge and results of this study, Kitovu Nutrition Ward will soon start to implement a nutrition and educational program for the families on dietary diversification to improve the iron and zinc intake in the diet of the children in Kibona. 22 Appendix I Food list with energy, iron and zinc values Food item per 100 gram Food Code Energy Kcal Fe (mg) Zn (mg) Starches Bread, White 1 260 0.9 0.5 Cooked banana (matooke) 2 116 0.6 0.1 Chapatti (oil) 3 372.6 0.7 0.4 Chapatti (dry) 4 207.9 0.6 0.4 Potato (English Cooked) 5 93 0.4 0.3 Sweet potato (Cooked) 6 76 0.72 0.2 Cassava (Cooked) 7 138 0.5 0.3 Yam (Raw) 8 97 0.8 0.5 Maize Porridge (no sugar/milk) 9 36.2 0.4 0.2 Maize Porridge (milk/sugar) 10 129.8 0.4 0.4 Millet Porridge with sugar 11 91 0.3 0.1 Posho (maize flour/water) 12 123.8 1.2 0.6 Rice (White boiled) 13 130 1.49 0.42 Pumpkin (Cooked) 14 14 0.1 0.2 Pumpkin Leaves (Cooked) 15 21 3.2 0.2 Kidney Beans Relish (Boiled/water/salt/tomato/no oil) 16 117.2 1.8 0.7 Kidney bean broth (soup without oil/(tomato/onion/salt) 17 31 0.7 0.2 Cow peas Relish Dry (with oil) 18 154.7 0 0.2 Cooked Local Dishes 23 Cow peas broth (soup/oil/tomato/onion/salt) 19 46 0.7 0.2 Groundnut sauce 20 616.6 12 3.1 Spinach Relish (tomato/onion/salt/no oil) 21 43.5 2.6 0.3 Beef Stew (beef/tomato/onion/salt/oil) 22 143 0.9 2.1 Fish Relish (dried fish/tomato/onion/oil) 23 253.6 0.9 1.6 Fish Relish (dried fish/tomato/onion/no oil) 24 76.5 0.3 0.4 Tilapia Fish (Cooked) 25 128 0.69 0.41 Tomato (cooked) 26 20 0.2 0.13 Tomato (Raw) 27 11 0.3 0.15 Onion (fried) 28 54 0.3 0.18 Onion (Cooked) 29 20 0.5 0.18 Eggplant (Cooked) 30 16 0.5 0.1 Spinach Boiled (spinach/no oil) 31 23 3.6 0.8 Mushroom 32 27 0.5 0.5 Cabbage (Cooked) 33 14 0.1 0.1 Green Pepper 34 19 0.5 0.2 Vegetable oil 35 862 0 0 Kimbo Fat 36 884 0 0 Cowboy Fat 37 884 0 0 Curry Powder 38 325 29.59 4.05 Salt 39 0 0 0 Sugar 40 380 0 0 41 94 0.6 0.4 Individual vegetables Oil/Fat/spices Fruit Jack Fruit 24 Pineapple 42 50 0.29 0.12 Banana (Ripe) 43 89 0.3 0.2 Avocado 44 190 0.4 0.4 Paw Paw (Ripe Papaya) 45 39 0.1 0.1 Orange Drink (Concentrated) 46 158 0 0 Passion fruit Juice (Fresh pasionfruit juice/sugar) 47 110 0.1 0 Raw Cow Milk 48 71 0 0.31 Water 49 0 0 0 Drinks 25 Appendix II Dietary Data Child ID Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 001 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 002 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Other Information Category Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Sunday Weight (grams) 400 300 100 250 120 3 NO 14.5 16 Female Food Code 11 6 41 49 2 Malaria No 40 20 8 107 Some days Normal/decrease 30 7 29 15 3 NO 11 13.5 Female 12 2 26 29 49 240 170 20 10 250 abdominal disorder No 16 6 185 No Normal 1 year, 8 months NO 8.7 14 Female 21 43 20 24 11 7 49 40 7 20 2 Malaria Anti malaria's, painkillers 24 12 Some days 16 Category Monday Weight (grams) Tuesday Weight (grams) 100 125 300 125 550 4 25 20 150 50 120 200 200 160 125 225 60 138 60 60 375 12 35 40 25 60 1 75 25 50 25 25 50 350 150 100 2 150 120 25 26 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 003 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 004 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 005 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 006 Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Normal/decrease 11 21 60 30 3 NO 10 12.7 Female 49 40 2 20 7 250 12 200 122 35 OK No 16 35 60 30 No Normal 43 24 17 41 450 16 320 350 20 200 122 144 138 80 50 140 4 NO 11.5 15 male 49 40 41 2 20 375 12 100 320 70 OK No 24 23 50 30 No Normal 2 NO 12 16.7 Female 7 11 16 17 3 12 7 49 2 31 29 300 125 100 130 30 OK Herbal 16 17 25 25 No Normal 40 30 29 375 16 12 320 122 200 30 60 375 25 25 375 50 130 120 30 250 200 45 195 200 15 25 25 4 35 20 1 15 10 27 Child ID: 006 Child ID: 006 Child ID: 006 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 007 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 008 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 6 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 225 450 400 12 42 1 year, 5 months Yes 14 17.5 Female 49 48 40 1 2 1000 200 36 42 600 325 600 24 42 500 Fever/flue on 3rd day Paracetamol, panadols 24 22 80 165 80 Decrease on day 3 Normal 25 26 29 12 16 60 10 10 120 50 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 2 years, 6 months NO 11 13.7 Female 48 7 2 26 29 200 72 100 10 10 OK Herbal 49 40 200 12 No Normal 20 11 31 30 Age: Breastfed: Weight: MUAC: Sex: Health status: 2 years, 1 month NO 10 14.4 Female 7 49 45 2 24 60 250 40 240 60 103 410 105 440 Malaria Drip with anti malaria's, painkillers 40 2 4 Some days Normal/decrease 6 1 36 30 Medicines: Food unusual: Appetite: 24 300 320 150 120 20 10 725 36 480 12 172 200 30 30 240 240 24 160 150 25 10 25 28 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 009 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0010 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0011 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: 2 years, 6 months NO 9 12.9 Female 26 21 35 29 49 7 2 32 26 Malaria Painkillers, anti malaria's 29 46 No decrease 31 16 40 24 165 72 120 20 25 10 30 3 10 110 72 120 102 50 10 80 30 25 4 30 4 years and 6 months NO 14 14.4 Female 49 40 2 20 32 80 2 170 50 20 125 2 100 typhoid fever, malaria Anti malaria's, painkillers, CAF, pre dui sane 41 40 26 5 10 No Decrease 5 10 200 60 20 15 3 years, 5 months NO 12 14.9 Male 29 24 11 7 16 38 35 13 47 30 8 11 2 26 29 32 200 420 5 5 5 Flue 41 140 40 5 100 125 10 2 5 123 125 10 20 600 180 5 5 5 300 225 29 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0012 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0013 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0014 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines:: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health No 17 105 80 No Normal 30 49 40 24 7 32 20 8 11 40 2 7 49 40 200 2 15 20 12 100 3 NO 12 15.5 Male Diarrheal No Yes, might have eaten at neighbour Normal 125 10 232 4 170 30 125 30 125 2 100 50 6 30 16 520 140 122 125 50 5 50 60 120 120 375 102 150 234 30 30 2 41 20 49 7 Flue, Fever, Malaria Painkillers, anti malaria's 21 30 30 8 unusual decrease 6 40 26 29 150 4 7 2 24 49 40 32 300 4 170 125 3 NO 12 14.5 Female 3 years, 5 months NO 14.5 14.5 Female OK 72 15 270 5 20 90 120 30 125 4 90 120 50 125 4 10 60 120 200 30 status: Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0015 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0016 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0017 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Medicines: Food unusual: Appetite: No 1 No Normal 16 30 44 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 2 years, 3 months NO 11 15.3 Male 7 49 2 23 37 OK No 29 26 10 10 No Normal 38 40 16 8 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 1 year, 4 months Yes 7 12.5 Female 12 49 2 30 31 170 125 120 30 5 50 70 50 Underweight, flue, tumour flue slap, painkillers 24 23 30 30 50 Yes decrease 38 7 20 6 18 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: 5 50 5 27 30 170 240 60 5 30 60 110 120 320 10 4 50 140 100 2 30 25 2 75 40 5 NO 15 14.7 Male 7 11 40 2 23 60 300 4 200 80 Flue Painkiller 38 49 2 125 72 102 4 220 8 200 150 400 31 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0018 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0019 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0020 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health Some days Decrease 12 16 30 41 17 100 100 10 40 50 1 year, 6 months Yes 10 14.8 Female 7 11 40 2 24 30 80 3 25 15 Little flue No 1 37 5 15 No Decrease 4 years and 6 months NO 17 16 Male 41 26 29 32 45 44 16 49 8 9 2 49 40 6 41 Gets sick every 2 wks No 22 7 No Normal 16 24 12 23 1 years, 6 months NO 9.8 13.5 Female Cold 49 40 12 6 24 44 60 90 30 4 50 50 40 3 3 5 40 105 27 25 80 40 70 200 425 2 20 220 325 6 150 140 400 2 115 300 345 30 400 80 410 4 50 450 160 83 410 12 820 24 180 32 status: Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0021 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0022 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0023 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health Full Cafe tablets 2 No Normal/decrease 7 16 1 years, 6 months NO 9.8 14 Male 49 40 48 2 24 975 20 750 380 30 375 16 750 180 912 42 375 200 Mild Underweight Anti malaria's, other supplements 26 10 5 5 29 10 5 Some days Decreased some days 1 years, 6 months yes 9.5 14 Female 30 1 41 10 31 16 7 9 40 2 24 31 125 12 80 20 10 Mild cough No 9 13 125 120 Normal/decrease Decreased some days 35 26 49 1 16 7 49 40 7 2 16 30 5 5 2 years, 6 months NO 16 15 Female Malaria 420 120 247 60 15 25 100 10 375 15 20 50 10 240 160 100 125 125 125 25 500 4 25 150 20 20 30 15 675 8 725 4 15 20 25 100 15 33 status: Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0024 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0025 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0026 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: painkillers, anti malaria's, other supplements 12 50 Yes Decreased some days 16 9 24 6 31 50 50 405 20 150 15 3 NO 15 17 Female 49 2 7 20 31 870 520 72 25 25 405 400 1355 400 30 Malaria Vitamins, anti malaria's 24 48 60 405 No Normal 12 22 40 21 202 265 115 4 60 2 years, 6 months NO 13 15.7 male 49 48 40 2 16 2000 400 108 200 115 Previous Typhoid No 1 7 42 30 No Normal 9 24 36 10 810 110 5 2 1620 1620 225 30 225 54 225 40 810 1 year, 6 months NO 9.8 15.4 Male 48 40 49 1 9 225 54 710 17 450 462 54 24 450 360 OK 2 120 120 240 34 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0027 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 0028 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 029 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: No 7 30 No 100 1 year, 10 months ? 8 13.5 Female 16 24 17 8 33 26 29 49 40 2 22 12 OK No 16 17 115 95 No Normal 5 NO 15.5 14.5 Female 26 28 30 7 20 24 6 49 40 2 20 24 OK No 9 44 No Normal 27 7 30 16 2 NO 12.5 15.6 Male 2 24 20 49 7 Malaria 40 Normal 30 240 80 375 18 120 115 250 10 10 10 5 375 18 100 750 54 120 250 115 95 5 10 5 405 30 640 720 60 405 18 840 30 195 30 75 405 18 690 244 122 405 83 35 72 25 25 360 80 100 225 120 240 30 60 225 60 1300 300 12 35 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0030 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0031 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0032 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Medicines: Food unusual: Appetite: Anti malaria's, painkillers 16 115 Yes Decrease 1 30 26 29 17 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 1 year, 9 months NO 9 17 Female 49 40 7 3 2 810 30 30 62 350 145 125 150 30 320 400 OK No 16 12 135 100 100 10 No Normal 24 41 17 20 2 NO 11 15.4 Female 2 16 49 7 20 300 20 125 132 50 220 50 100 73 50 300 50 200 102 OK No 24 41 40 100 40 20 No Normal 17 50 50 1 year, 8 months Yes 10.5 16 Female 6 2 11 24 49 150 120 310 80 310 240 310 30 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food 80 20 10 10 80 40 100 150 120 310 OK No No 36 unusual: Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0033 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0034 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0035 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Normal 4 NO 13 16 Male 11 2 16 17 30 475 720 235 130 475 200 20 OK No 15 7 No Normal 33 4 NO 13 13 Female 49 40 2 43 24 750 12 130 115 30 OK No 6 30 150 10 No Normal 37 16 20 11 1 5 3 NO 14.8 19 Female 12 26 2 7 17 220 20 200 102 40 OK No 16 49 30 290 No Normal 41 24 100 180 600 280 25 25 50 60 10 375 6 290 115 80 205 4 240 115 80 5 20 20 350 21 300 100 120 155 100 37 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0036 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0037 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0038 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 Child ID: 0039 11 45 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 340 80 2 NO 8.5 12.9 Male 7 12 2 24 41 30 395 150 100 40 50 120 OK No 49 16 165 640 22 No Normal 26 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 1 year, 1 month NO 10 16 Female 48 2 24 40 21 OK No 31 26 No Normal 29 22 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 1 year, 1 month Yes 7 13.5 Male 10 2 24 49 43 485 65 40 125 56 OK No 12 16 50 50 No Normal 40 1 9 48 120 200 80 100 50 425 320 110 8 965 400 80 16 30 805 300 14 30 10 5 165 125 60 40 290 125 25 15 6 62 185 300 2 17 535 38 Child ID: 0039 Child ID: 0039 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0040 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0041 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 37 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 5 4 NO 17 17 Male 7 2 20 24 7 30 200 60 40 30 OK No 6 40 75 No Normal 49 16 30 3 years, 4 months NO 20 16.5 Female 49 6 40 2 26 500 75 4 240 25 OK No 29 36 20 8 No Normal 25 1 year, 10 months NO 10.5 15.5 Female 7 9 45 30 35 43 20 49 40 7 9 2 500 8 30 225 300 625 2 90 OK No 13 22 192 120 123 No Normal 12 43 16 45 33 50 40 50 50 50 40 35 50 270 330 2 185 50 60 50 250 75 12 400 12 350 20 10 30 250 250 211 5 5 168 50 400 345 400 300 39 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0042 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0043 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0044 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0045 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 4 NO 19 17 Female 1 17 29 35 26 49 43 40 11 2 17 50 1000 168 24 400 400 OK Septic 7 24 30 160 No Normal 2 years, 9 months NO 9 15 Female 3 16 34 26 29 17 49 40 7 2 24 750 12 72 120 60 430 8 72 170 30 5 10 55 450 12 60 170 80 OK No 9 12 250 120 170 120 No Normal 31 44 26 16 17 30 2 year 6 months NO 11 15 Male 49 40 7 2 16 1235 24 60 200 50 OK Septrin 31 12 30 120 No normal 24 41 18 30 10 5 10 1200 24 400 400 400 150 72 30 115 10 50 30 27 5 25 25 1200 12 60 50 50 550 24 60 50 15 40 80 40 Child ID: 0045 Child ID: 0045 Child ID: 0045 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0046 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0047 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Child ID: 0048 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 5 NO 16 16 Female 7 2 49 43 24 600 780 293 122 OK No 31 60 650 18 17 50 50 272 300 590 194 300 600 750 18 750 24 No Normal Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 1 year, 7 months NO 10.5 14.4 Male 49 40 1 2 16 OK parasol 7 20 yes decrease 6 24 9 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 3 NO 14 15.5 Female 9 7 12 16 49 475 72 200 115 250 OK No 2 24 270 30 No Normal 17 44 40 31 50 72 122 75 30 750 206 200 50 750 144 100 500 120 50 27 12 15 41 Child ID: 0048 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0049 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Child ID: 0050 Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: Age: Breastfed: Weight: MUAC: Sex: Health status: Medicines: Food unusual: Appetite: 4 NO 12.5 14.2 Male 2 49 40 20 30 240 250 12 50 15 OK No 7 24 72 30 No Normal 6 16 12 22 3 NO 14 15 Female 2 49 40 17 24 flue for 2 days painkillers 9 7 No decrease 6 11 50 450 12 120 250 12 72 30 75 50 50 360 345 12 95 30 120 120 240 120 6 30 80 170 72 225 345 42 Appendix III Mean Energy, Iron and Zinc intake over period of 3 days Energy (Kcal) Fe (mg) Zn (mg) Child ID: 001 Child ID 956.15 8.17 2.25 Child ID: 002 863.66 7.98 2.63 Child ID: 003 413.30 4.14 1.27 Child ID: 004 1,143.05 12.47 3.50 Child ID: 005 1,362.86 11.93 3.70 Child ID: 006 568.40 6.05 1.66 Child ID: 007 1,125.17 4.17 3.63 Child ID: 008 993.67 9.49 2.87 Child ID: 009 648.43 3.14 1.00 Child ID: 0010 296.34 1.60 0.57 Child ID: 0011 539.54 4.53 1.36 Child ID: 0012 1,431.28 15.01 4.17 Child ID: 0013 607.59 6.34 1.74 Child ID: 0014 798.50 8.22 2.22 Child ID: 0015 322.27 1.58 0.65 Child ID: 0016 447.65 2.85 0.90 Child ID: 0017 363.88 3.36 1.32 Child ID: 0018 659.74 4.15 1.72 Child ID: 0019 249.24 1.06 0.52 Child ID: 0020 979.54 7.07 3.74 Child ID: 0021 670.43 3.58 1.53 Child ID: 0022 1,094.95 2.79 3.07 Child ID: 0023 404.25 2.69 1.04 Child ID: 0024 320.39 2.90 1.05 Child ID: 0025 953.75 6.30 3.03 Child ID: 0026 1,238.76 4.48 3.05 Child ID: 0027 823.00 3.86 2.43 Child ID: 0028 1,059.74 12.93 4.73 Child ID: 029 2,658.08 34.56 9.27 Child ID: 0030 909.42 9.83 2.90 Child ID: 0031 810.68 4.92 1.67 Child ID: 0032 777.87 7.41 2.23 Child ID: 0033 571.75 2.72 0.82 Child ID: 0034 1,152.49 8.00 2.30 Child ID: 0035 675.15 3.56 1.21 Child ID: 0036 734.03 3.95 1.76 Child ID: 0037 504.54 3.80 1.83 Child ID: 0038 1,096.77 3.36 4.13 Child ID: 0039 708.23 3.13 2.33 Child ID: 0040 537.63 5.06 1.32 43 Child ID: 0041 765.14 5.43 1.56 Child ID: 0042 872.28 6.34 2.77 Child ID: 0043 1,083.06 5.17 1.72 Child ID: 0044 589.33 4.37 1.84 Child ID: 0045 430.95 2.47 1.00 Child ID: 0046 800.99 4.31 1.38 Child ID: 0047 549.95 6.76 2.10 Child ID: 0048 717.10 5.67 2.44 Child ID: 0049 555.13 4.67 2.23 Child ID: 0050 562.00 3.03 0.94 44 Appendix IIII Comparison recommended iron and zinc intake Recommended Zinc Intake (mg) Low bioavailability 5% 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 3-6 year 3-6 year 1-3 year Child ID: 001 Child ID: 002 Child ID: 003 Child ID: 004 Child ID: 006 Child ID: 007 Child ID: 008 Child ID: 009 Child ID: 0010 Child ID: 0013 Child ID: 0014 Child ID: 0016 Child ID: 0017 Child ID: 0019 Child ID: 0021 Child ID: 0022 Child ID: 0023 Child ID: 0024 Child ID: 0025 Child ID: 0026 Child ID: 0027 Child ID: 0028 Child ID: 0030 Child ID: 0031 Child ID: 0032 Child ID: 0033 Child ID: 0036 Child ID: 0037 Child ID: 0038 Child ID: 0039 Child ID: 0042 Child ID: 0044 Child ID: 0045 Child ID: 0047 Child ID: 0048 Child ID: 0050 3-6 year Child ID: 005 Child ID: 0011 Observed 2.25 2.63 1.27 3.50 1.66 3.63 2.87 1.00 0.57 1.74 2.22 0.90 1.32 0.52 1.53 3.07 1.04 1.05 3.03 3.05 2.43 4.73 2.90 1.67 2.23 0.82 1.76 1.83 4.13 2.33 2.77 1.84 1.00 2.10 2.44 0.94 Observed 3.70 1.36 Recommended 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 6.9 Recommended 8 8 Deficient Yes/No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Deficient Yes/No Yes Yes 45 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year Child ID: 0012 Child ID: 0015 Child ID: 0018 Child ID: 0020 Child ID: 029 Child ID: 0034 Child ID: 0035 Child ID: 0040 Child ID: 0041 Child ID: 0043 Child ID: 0046 Child ID: 0049 4.17 0.65 1.72 3.74 9.27 2.30 1.21 1.32 1.56 1.72 1.38 2.23 8 8 8 8 8 8 8 8 8 8 8 8 Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Recommended Iron intake (mg) Low bioavailability 5% 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year Child ID: 001 Child ID: 002 Child ID: 003 Child ID: 004 Child ID: 006 Child ID: 007 Child ID: 008 Child ID: 009 Child ID: 0010 Child ID: 0013 Child ID: 0014 Child ID: 0016 Child ID: 0017 Child ID: 0019 Child ID: 0021 Child ID: 0022 Child ID: 0023 Child ID: 0024 Child ID: 0025 Child ID: 0026 Child ID: 0027 Child ID: 0028 Child ID: 0030 Child ID: 0031 Child ID: 0032 Child ID: 0033 Child ID: 0036 Child ID: 0037 Child ID: 0038 Observed 8.17 7.98 4.14 12.47 6.05 4.17 9.49 3.14 1.60 6.34 8.22 2.85 3.36 1.06 3.58 2.79 2.69 2.90 6.30 4.48 3.86 12.93 9.83 4.92 7.41 2.72 3.95 3.80 3.36 Recommended 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 11.6 Deficient Yes/No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes 46 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 1-3 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year 3-6 year Child ID: 0039 Child ID: 0042 Child ID: 0044 Child ID: 0045 Child ID: 0047 Child ID: 0048 Child ID: 0050 3-6 year Child ID: 005 Child ID: 0011 Child ID: 0012 Child ID: 0015 Child ID: 0018 Child ID: 0020 Child ID: 029 Child ID: 0034 Child ID: 0035 Child ID: 0040 Child ID: 0041 Child ID: 0043 Child ID: 0046 Child ID: 0049 3.13 6.34 4.37 2.47 6.76 5.67 3.03 Observed 11.93 4.53 15.01 1.58 4.15 7.07 34.56 8.00 3.56 5.06 5.43 5.17 4.31 4.67 11.6 11.6 11.6 11.6 11.6 11.6 11.6 Recommended 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 12.6 Yes Yes Yes Yes Yes Yes Yes Deficient Yes/No Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes 47 References 1 Umeta M, West CE, Verhoef H, Haidar J, Hautvast JGAJ: Factors associated with stunting in infants aged 5-11 months in the Dodota-Sire district, rural Ethiopia. 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