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 Table of Contents  
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 61-65

An assessment of micronutrient deficiency: A comparative study of children with protein-energy malnutrition and apparently healthy controls in Kano, Northern Nigeria

1 Department of Biochemistry, Bayero University Kano, Kano State, Nigeria
2 Department of Chemical Pathology Immunology, Bayero University Kano, Kano State, Nigeria
3 Department of Community Medicine Bayero University Kano, Kano State, Nigeria
4 Department of Paediatrics Bayero University Kano, Kano State, Nigeria

Date of Web Publication11-Jan-2017

Correspondence Address:
Dr. Idris Yahaya Mohammed
Department of Chemical Pathology and Immunology, Bayero University and Aminu Kano Teaching Hospital, PMB 3452, Kano
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DOI: 10.4103/1119-0388.198124

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Background: Protein-energy malnutrition (PEM) and micronutrient deficiency remain the common problems affecting children in the developing world. This study is aimed at determining the prevalence of micronutrient deficiency among children with PEM. Materials and Methods: The study was comparative and cross-sectional in design, which assessed 45 children with PEM attending the pediatric outpatient clinic of Hasiya Bayero Paediatric Hospital and 45 "apparently healthy" children presenting for routine vaccination. Patients were classified as having either marasmus or kwashiorkor using the Wellcome classification. Five milliliters of blood was collected for the analysis of serum calcium, iron, and zinc using spectrophotometry, as well as for Vitamin A using Bassey et al.'s procedure. Results: Mean age, height, and weight were higher in malnourished than the control group (P < 0.05). Similarly, levels of zinc, calcium, and Vitamin A were statistically higher (P < 0.05) in malnourished than the control group. The prevalence of micronutrient deficiency (PEM vs. control) was found to be: calcium (80% vs. 55%), iron (46% vs. 24%), Vitamin A (80% vs. 55%), and zinc (48% vs. 24%). The prevalence of micronutrient deficiency (kwashiorkor vs. marasmus) was found to be: calcium (100% vs. 71%), iron (50% vs. 45%), Vitamin A (90% vs. 77%), and zinc (70% vs. 42%). Conclusion: Micronutrient deficiency is more common in PEM children than healthy controls.

Keywords: Comparative study, micronutrient deficiency, protein-energy malnutrition

How to cite this article:
Abubakar N, Atiku M K, Alhassan A J, Mohammed IY, Garba RM, Gwarzo G D. An assessment of micronutrient deficiency: A comparative study of children with protein-energy malnutrition and apparently healthy controls in Kano, Northern Nigeria. Trop J Med Res 2017;20:61-5

How to cite this URL:
Abubakar N, Atiku M K, Alhassan A J, Mohammed IY, Garba RM, Gwarzo G D. An assessment of micronutrient deficiency: A comparative study of children with protein-energy malnutrition and apparently healthy controls in Kano, Northern Nigeria. Trop J Med Res [serial online] 2017 [cited 2020 Feb 28];20:61-5. Available from: http://www.tjmrjournal.org/text.asp?2017/20/1/61/198124

  Introduction Top

Malnutrition represents insufficient, excessive, or imbalanced consumption of nutrients. The World Health Organization cites malnutrition as the gravest single threat to the world's public health. Nutrition disorders depend on which nutrient is deficient or overabundant. In developing countries such as Nigeria, this imbalance is most frequently associated with undernutrition, which presents mainly as protein-energy malnutrition (PEM) and micronutrient deficiencies.[1] PEM and micronutrient deficiency are very common diseases affecting children in the developing world.[2]

Malnutrition is used to refer to the deficiencies of vitamins and/or minerals of public health importance. These include, but not limited to, iron deficiency anemia, iodine deficiency disorder (IDD), Vitamin A deficiency, Vitamin D deficiency, and zinc deficiency. PEM, on the other hand, represents a range of pathological conditions arising from the deficiency/imbalance of protein and energy, and is commonly associated with infections. It occurs more frequently in infants and young children, but it is also observed in adolescents and adults, mostly lactating women, especially during periods of famine or other emergencies. PEM presents in the form of marasmus, kwashiorkor, or marasmic-kwashiorkor.

Micronutrient deficiencies affect at least 2 billion people worldwide.[2] Globally, all children under 5 years of age are at a risk of one form of nutrient deficiency or the other, with cases of rickets rising, especially among dark-skinned people, about 740 million people are deficient in iodine including up to 300 million with goiter and 20 million with brain damage from maternal iodine deficiency during their fetal development. About 2 billion people are deficient in zinc, one billion having iron deficiency anemia, and 250 million are deficient in iodine, mainly young children and pregnant women in developing countries.[3] Micronutrient deficiency has been considered as a major risk factor for child survival in Nigeria, increasing the risk of death from common diseases such as acute gastroenteritis, pneumonia, and measles.[4] The prevalence of micronutrient deficiencies in Nigerian children under 5 years was reported 12 years ago by the Nigerian Food Consumption Survey as, 23.3%, 34.0%, 13.0%, and 20.0% for Vitamin A deficiency, iron deficiency anemia, IDDs, and zinc deficiency disorders, respectively.[5] Interventions to prevent malnutrition range from promoting breastfeeding to food supplementation, food fortification, bio-diversification, and dietary diversification, through home gardens and small livestock.

This study is aimed at assessing and comparing the prevalence of micronutrient deficiencies and associated factors among children with PEM and healthy controls attending Hasiya Bayero Paediatric Hospital, Kano.

  Materials and Methods Top

Study site

The study was conducted at Hasiya Bayero Specialist Paediatric Hospital, Kano, located at the Municipal local Government of Kano State, North-Western Nigeria. The hospital provides both outpatient and inpatient services to the pediatric population of Kano State. An average of 100 patients are seen every day from Monday to Friday. The hospital has a bed capacity of 85 patients in totality. Kano state has a population of over 10 million people, with a land mass of 20,760 square kilometers and the following geographic coordinates: 12° 37' North, 9° 29' East, 9° 33' South, and 7° 43' West.

Study design

The study design was cross-sectional and descriptive.

Selection and description of participants

The study population was children under 5 years of age, with PEM, who presented at the outpatient department of the hospital, as well as healthy controls presenting with different disease conditions not related to malnutrition. Forty-five children with malnutrition were selected by systematic sampling from the outpatient clinic of Hasiya Bayero specialist Paediatric Hospital while 45 apparently healthy children presenting to the hospital for routine immunization were randomly selected as controls. Patients with PEM were identified using the Wellcome classification as either having marasmus or kwashiorkor.

Laboratory methods

Five milliliters of blood from cubital vein was collected from each of the study participants in the morning between 8 am to 12 noon. The sample was immediately centrifuged for 10 min at 2000 rpm, and the serum was ice-frozen, wrapped in protective aluminum packaging, and then transported to the postgraduate laboratory of Bayero University, Kano, where all the biochemical analyses were conducted as described below:

Estimation of serum Vitamin A was based on the addition of ethanol to break-up complexes and permit Vitamin A to partition into the heptane. The nearly colorless retinal was measured spectrophotometrically at 326 nm. The heptane extract was irradiated with UV light for about 1 h until a steady absorbance was obtained at 326 nm. This allowed for the absorbance of unwanted materials. Vitamin A was obtained by subtracting the second absorbance (A2 ) from the initial absorbance (A1 ). Since 2 ml of serum was extracted with 5 ml of heptane, the concentration of the standard equals to 37.5 × 5/2 = 93.75 mg/dl. Vitamin A in mg/dl equals (A1A2 ) × concentration of standard (93.75 mg/dl)/absorbance of standard.

Atomic absorption spectrometry was used to determine the concentration of zinc, iron, and calcium.

Outcome measures

Vitamin A levels of <20 μg/dl (0.698 umol/l), zinc <80 μg/dl (12.24 umol/l), calcium <2.1 mmol/l, and Fe <60 μg/dl (10.74 umol/l) were considered deficient.

Statistical analysis

The data obtained were analyzed using Microsoft Excel and GraphPad Prism version 6.00 (GraphPad Software, Inc) for Windows. Categorical variables were summarized as proportions and percentages, and compared using Chi-squared test. Continuous variables on the other hand were summarized as mean and standard deviation, and compared using Student's t-test. The level of statistical significance was set at P < 0.05.

Ethical issues

Ethical approval for the study was obtained from the Ethical Committee of the Kano state hospital management board. Parents of all patients who were selected for the study signed an informed consent form after the study procedures were clearly explained to them. Confidentiality was ensured at every stage of this study, and all procedures were carried out in accordance with the ethical standards stipulated in the Helsinki declaration.

  Results Top

All the ninety patients in the two study arms agreed and consented to participate in the study, giving a response rate of 100%. Findings of the study are summarized in tables as shown below.

Thirty-one (68.9%) patients of the PEM group were males, while 24 (54.5%) of the control group were males. The difference in the sex distribution of the two study groups was not statistically significant (P > 0.05).

[Table 1] shows that age, height, and weight were statistically different between the malnourished and control groups, with the control group having higher mean values in all. Similarly, [Table 2] shows that zinc, calcium, and Vitamin A were significantly different between the malnourished and control group, while calcium was significantly different between the kwashiorkor and marasmic patients as shown in [Table 3].
Table 1: Comparison of age, height, and weight between the two study groups

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Table 2: Comparisons of serum micronutrient levels

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Table 3: Comparison of serum micronutrient levels stratified by sex

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[Table 4] shows that the malnourished patients had higher prevalence of deficiencies of all the four micronutrients assessed compared to the control group; likewise, kwashiorkor patients had higher prevalence of the deficiency states of all the four micronutrients compared to marasmic patients.
Table 4: Prevalence of micronutrient deficiencies

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  Discussion Top

The very high response rate of 100% was not unexpected of a hospital-based study. The mean age of the PEM patients was 20 + 10.0 months. PEM tends to present at a relatively lower mean age group of 43.6 + 18.3 months. The mean age of presentation was higher than previous studies which showed that the average age is 12-13 months.[6] This could be due to challenges associated with complementary feeding and weaning practices. The significantly higher mean height and weight in the control group compared to the PEM group could be as a result of the nutritional deficiencies in the malnourished groups which affects their growth.

Out of the 45 children with PEM, about 77.8% had marasmus while 22.22% had kwashiorkor. This is similar to the findings of other Nigerian studies.[7] The higher prevalence of marasmus compared to kwashiorkor is probably because marasmus represents an early stage of the PEM spectrum, while kwashiorkor represents severe form of the disease which is less common.

Higher percentages of males had both marasmus (68.6%) and kwashiorkor (80%), but the differences in serum micronutrients were not significantly different between male and female patients with marasmus and kwashiorkor. However, the control group had fairly similar male: female ratio (53% males). This finding agrees well with the previous studies in Nigeria in which the prevalence of both marasmus and kwashiorkor was higher among males than females.[6],[8] These differences in prevalence between male and female patients with PEM (although not statistically significant) may be attributed to the relatively higher metabolic requirements of male children due to possible hyperactivity.

The mean values of zinc, calcium, and Vitamin A were significantly different between the study and control groups (P < 0.05). This shows that PEM is associated with decreased serum levels of these nutrients, probably due to poor nutritional supply and supplementation. The finding on zinc is similar to the finding of other Nigerian studies.[9] However, serum iron was not found to be significantly different between the two study groups.

The fact that male kwashiorkor patients had higher, but not statistically significant, mean serum zinc compared to female kwashiorkor patients is in agreement with the findings of Samuel and Onimawo.[10] This could be due to the difference in feeding habits between boys and girls, as boys are likely to be naturally more active than girls, and hence they have higher metabolic demands. The same reason could explain the higher serum zinc levels in male marasmic patients compared to female marasmic patients.

The prevalence of zinc deficiency was much higher among malnourished children compared to the control group. This is similar to the findings of the previous studies.[10],[11] Similarly, the higher zinc deficiency among kwashiorkor patients compared to marasmic patients conforms to the findings of Okolo et al.[12] This could also be attributed to the poor appetite associated with kwashiorkor and the good appetite associated with marasmus.

The higher, but not statistically significant, serum iron levels in the control group compared to the study group are in line with the findings of Chuwa et al. and Atiar Rahman et al.,[13],[14] in which there was no significant difference between the mean iron values for the study and control groups. The prevalence of serum iron deficiency in the PEM group shows similar pattern with the findings of Onyemaobi and Onimawo.[11] The higher prevalence of iron deficiency among the female marasmic patients (63.6%) compared with their male counterparts (37.5%) is similar to the findings of Smith et al.[15] The significantly higher serum calcium levels in the control group compared to the PEM group are similar to the findings of Ighogboja et al. and Adegbusi and Sule.[16],[17] The higher levels of serum Vitamin A in males compared to females, among both kwashiorkor and marasmic patients, conform with the findings of Sommer et al. and McLaren and Frigg.[18],[19]

  Conclusion Top

Micronutrient deficiencies are common in both children with PEM and the apparently healthy controls, but the prevalence of deficiency states is much higher in children with PEM than the control group. Similarly, deficiency states were more common among kwashiorkor than marasmic patients.


  • Routine screening of children presenting to hospitals with PEM for calcium, iron, Vitamin A, and zinc deficiencies for early detection and treatment would reduce the morbidity and mortality observed in PEM patients
  • Periodic screening of apparently healthy children would similarly aid in the early diagnosis and treatment of deficiency states
  • There is a need for large-scale studies to identify other micronutrients that may be deficient in PEM.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Black R. Micronutrient deficiency - An underlying cause of morbidity and mortality. Bull World Health Organ 2003;81:79.  Back to cited text no. 1
FAO, IFAD, WFP. The State of Food Insecurity in the World 2015. Meeting the 2015 International Hunger Targets: Taking Stock of Uneven Progress. Rome: FAO; 2015.  Back to cited text no. 2
Müller O, Krawinkel M. Malnutrition and health in developing countries. CMAJ 2005;173:279-86.  Back to cited text no. 3
Ekweagwu E, Agwu AE, Madukwe E. The role of micronutrients in child health: A review of the literature. Afr J Biotechnol 2008;7:3804-10.  Back to cited text no. 4
IITA. Nigerian Food Consumption and Nutritional Survey. Ibadan, Nigeria; 2004; p. 40-6.  Back to cited text no. 5
Ubesie AC, Ibeziako NS, Ndiokwelu CI, Uzoka CM, Nwafor CA. Under-five protein energy malnutrition admitted at the University of Nigeria Teaching Hospital, Enugu: A 10 year retrospective review. Nutr J 2012;11:43.  Back to cited text no. 6
Adeleke SI, Asani MO, Belonwu RO, Gwarzo GD. Children with protein energy malnutrition: Management and out-come in a tertiary hospital in Nigeria. Sahel Med J 2007;10:84-8.  Back to cited text no. 7
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Hamidu JL, Salami HA, Ekanem AU, Hamman L. Prevalence of protein - Energy malnutrition in Maiduguri, Nigeria. Afr J Biomed Res 2003;6:123-7.  Back to cited text no. 8
Ugwuja EI, Nwosu KO, Okonji M. Serum zinc and copper levels in malnourished pre-school age children in Jos north central. Pak J Nutr 2007;6:349-54.  Back to cited text no. 9
Samuel GA, Onimawo IA. Zinc status of under five children in rural and urban Imo State, Nigeria. J Basic Appl Sci Res 2010;6:451-5.  Back to cited text no. 10
Onyemaobi GA, Onimawo IA. Prevalence of iron deficiency anaemia among under five in Imo State. Aust J Basic Appl Sci 2011;5:127.  Back to cited text no. 11
Okolo SN, Okonji M, Nwosu OK, Ocheke MD. Serum zinc levels in malnourished children of pre-school age. Sahel Med J 2002;5:204-6.  Back to cited text no. 12
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Chuwa LM, Mwiruki G, Bilal MG, Mnubhi EK, Swai AB. Serum iron, zinc, copper and bromine in malnourished children in Dar es Salaam, Tanzania. East Afr Med J 1996;73 5 Suppl:S21-3.  Back to cited text no. 13
Atiar Rahman M, Mannan MA, Rahman MH. Influence of infection on iron profile in severely malnourished children. Indian J Pediatr 2009;76:907-11.  Back to cited text no. 14
Smith LC, Ramakrishnan U, Ndiaye A, Haddad L, Martorell R. The Importance of Women′s Status for Child Nutrition in Developing Countries; 2003. Available from: http://www.womennutritionpakisan. [Last accessed on 2013 Mar 02].  Back to cited text no. 15
Ighogboja IS, Okonja MC, Onyeocha BK. Serum calcium, inorganic phosphorus and magnesium levels in malnourished pre-school children. Niger J Paediatr 1996;23:33-6.  Back to cited text no. 16
Adegbusi H, Sule M. Anthropometric and biochemical assessment among under five children in Kusada local government area, Katsina State, Nigeria. Bayero J Pure Appl Sci 2011;4:137-40.  Back to cited text no. 17
Sommer A, West KP, Olson JA, Ross CA. Vitamin A Deficiency: Health, Survival, and Vision. New York: Oxford University Press; 1996. p. 30-2.  Back to cited text no. 18
McLaren DS, Frigg M. Sight and life manual on Vitamin A deficiency disorders (VADD). Basel, Switzerland: Task force sight & life. Arch Med Res 1997;3:20-2.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3], [Table 4]

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