Association between Socio-Demographic Factors, Adequacy of Breastfeeding Practices and Complementary Food for Children below 24 Months in Fako, South West Region of Cameroon

Tiepma Ngongang Eurydice Flore¹, Bernard Tiencheu^1*, Arrey Oben Ebob Ashu¹, Aduni Ufuan Achidi¹, Mbame Efeti Marie Clodine¹, Noel Tenyang², Boris Gabin Kingue Azantsa³

¹Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea, Cameroon
²Department of Biological Science, Faculty of Science, University of Maroua, Maroua, Cameroon
³Laboratory of Nutrition and Nutritional Biochemistry, Department of Biochemistry, Faculty of Science, University of Yaounde, Yaounde, Cameroon

*Correspondence to: Dr. Bernard Tiencheu, Department of Biochemistry and Molecular Biology, Faculty of Science, University of Buea, Buea, Cameroon.

Copyright © 2021 Dr. Bernard Tiencheu, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
Focusing on improving the nutritional wellbeing of children below 24 months old has the potential to reduce the severity of stunting, increase weight, and support cognitive function and possibly prevent the severe consequences such as mental retardation and emotional instability (WHO, 2016).

Nutrition is the term given to the study of the food being eaten, and how the body utilizes the nutrients in food [1]. These nutrients play an essential role in the body processes of digestion, breathing, growth and repair of body tissue, heart function and prevention of disease [2]. The nutritional requirement of an individual depends on measurable characteristics such as age, sex, height, weight, degree of activity and rate of growth (NPHP, 2001). The nutritional status is the state or condition of the body which result from the intake, absorption and utilization of nutrients and the influence of disease-related factors. It shows the degree to which the individual’s physiological need for nutrients is being met by the food consumed (WHO, 2007).

Generally, the risk of malnutrition in the first 2 years of life has been directly linked with poor breastfeeding and complementary feeding practices of mothers together with high rates of infectious diseases [3]. In Cameroon, the prevalence of children under 5 years of age with weight deficit for their age was 19.3% in 2006 and the prevalence of children under 5 years of age with weight deficit for their height was 6% in Cameroon (UNICEF, 2009). According to the WHO, in 2011 over 101 million children under the age of 5 were underweight, 165 million were stunted, and approximately 52 million were wasted (WHO, 2012). Consequently, estimates of the prevalence of malnutrition among school-aged children suggest that these indicators do not improve much with age.

Weaning is the process where a baby transits from breast milk to other sources of nourishment. Breast milk is the first food for infants and should be fed alone for the first 6 months of life [4]. Exclusively, breast feeding for the first 6 months is the World Health Organization (WHO)’s recommended method of feeding fullterm infants by healthy, well-nourished mothers (WHO, 2007). However, after 6 months, breast milk alone is not sufficient both in quantity and in quality to meet the nutritional requirements of the child.

Appropriate foods referred to as weaning or complementary foods need to be introduced, which starts as liquid foods and slowly progress to solid foods. This is the weaning process; the introduction of foods other than breast milk in to an infant’s diet while slowly reducing breast feeding [1]. Weaning habits have a significant effect on the nutritional status of children [5].

The gap between nutritional requirement and amount obtained from breast milk increases with age. So, the additional nutrient is expected to be covered by complementary foods. For energy, it is 200, 300, and 550Kcal per day at 6-8, 9-11, and 12-23 months, respectively, with highest proportion from carbohydrates followed by proteins and very little from fat (FAO, 2006). It has also been reported that a million children die worldwide each year because they are not breast fed [6] and Many studies have identified that bad weaning habits can lead to malnutrition especially in children under the age of five.

Materials and Methods

Field Work Epidemiology

Study Area
This study was conducted in some municipalities in the South West region including Buea, Limbe, Mutengene, Tiko.

Study Design
This research involved carrying out a cross sectional study on the study population.

Ethical Issues
Ethical clearance was sort from the Institutional Review Board hosted by the Faculty of Health Sciences, University of Buea (2021/1258-12/UB/SG/IRB/FHS) following administrative clearance from the South West Regional Delegation of Public Health, authorizations from general secretariat of the hospitals and house heads in the study area. Informed consent/assent forms were given or read and explained to parents or care givers of the children at presentation. After all this, we proceeded to for questionnaires were administered on the field and complementary food samples collected.

Inclusion Criteria: children below 2 years of age, mothers attending vaccination clinics, healthy mothers with non-vulnerable children aged below 24 months and household breastfeeding mothers.

Exclusion Criteria: children above 2 years of age, pregnant women, neonates, prisoners, hospitalized patients, mentally ill persons.

Sample Size
The minimum sample size required for the study was calculated using formula;

Where n is the minimum sample size required; Z is 1.96 which is the standard normal deviate; a is absolute precision at 5%; p is 9.25% which is the proportion of undernutrition prevalence in southwest [7] and d is 0.05(5%) the required margin of error. This gives a minimum sample size of 123 participants for the study.

Study Population
The target population of this study is 123 which include children with ages below 24 months old who was randomly selected as there were brought to the hospitals for vaccinations by their mothers.

Questionnaire Administration
The mothers of children were subjected to a questionnaire that include; relevant components focusing on identification of socio-demographic characteristics of the child’s family including mother’s origin, mother’s age, parent’s level of education and family income as well as the family size and residence. The second component had questions which addressed the mothers about child feeding pattern as well as breast feeding status and weaning habits of children between 0-24 months old. The children were also subjected to growth monitoring data collection using standard anthropometric measurements including; Age, weight, head circumference and upper hand circumference by using non-elastic measuring tape while the weight was taken using a spring balance.

Procedure
Data collection was done in following steps

- Interview of mothers: mothers who brought their children for vaccinations in the chosen hospitals in Buea, Tiko, Mutengene, Limbe were interviewed with the questionnaires. They were asked about their children (name, age, sex, date of birth, types of feeding habits, types of foods that the child is fed with other than breast milk, time weaning started and ended, number of times child is fed and quantity of food child is fed per day), their occupation and their husband’s occupation, their age, level of studies, marital status, religion, number of children. All this information obtained from the mothers were filled in the questionnaires with respective serial numbers.
- The anthropometric measurements of the children were taken (height, head circumference, mid arm circumference, weight).

Statistical Analysis
Data collected was analysed using the IBM-Statistical Package for Social Sciences (IBM-SPSS) version 20. Continuous variables were summarized into means and standard deviations (SD) and categorical variables reported as frequencies and percentages were used to evaluate the descriptive statistics. The differences in proportions were evaluated using Pearson’s Chi-Square (χ2). Significant levels were measured at 95% confidence interval (CI) with significant differences set at <0.05. Association between socio-demographic data, breastfeeding practice and complementary feeding were done using SPSS software.

Results

Socio-Demographic Characteristics of the Study Population
The family’s socio-demographic data of the study subject are listed in table 1. Table1a shows that more than half (57.7%) of the children were girls and less than half (42.3%) of them were boys with most of the children being aged 0-6 months (43.9%). Close to half (48.0%) of the fathers were aged >40 years and were not working (54.5%), and majority of them (36.6%) ended at primary school level. More than half (61.0%) of the mothers were aged 20-30 years, the majority not working (55.3%) and ended in primary school (38.2%). The family size of the children was mostly 5-6 (46.3%) people with income less than 50,00frs per month.

The complementary feeding practices of the children aged 0-23 months (Table 1b) shows that the majority of the children were inappropriate CF, almost half of them had untimely introduction to CF at less than 3 months of age (63.4%) and also consumed more of homemade foods like pap (61.0%). The result of the study also shows that more than half of the children did not receive iron or multivitamin syrup supplementation and fortified food. Majority of the children do not consume meat at all (39.8%), do not consume fish (43.1%), never consumed vegetables (39.0) and never consumed fruits (43.1%). In terms of the timeliness of introduction to CF, this study found less than half (9.8%) of the children received CF timely, while the rest was introduced earlier (63% at < 3 months, 26.8% at 3-6 months.

Table 1c give the Socio-demographic characteristics of the children aged 0-23 months in term of sources of foods, type of complementary foods and meal frequencies. It shows that the majority of the children were inappropriately fed, almost half of them had untimely introduction to CF at less than 3 months of age (63.4%) and also consumed more of homemade foods like pap (61.0%). The result of the study also shows that more than half of the children did not receive iron or multivitamin syrup supplementation and fortified food. Majority of the children do not consume meat at all (39.8%), do not consume fish (43.1%), never consumed vegetables (39.0) and never consumed fruits (43.1%). In terms of the timeliness of introduction to CF, this study found less than half (9.8%) of the children received CF timely, while the rest was introduced earlier (63% at < 3 months, 26.8% at 3-6 months).

Nutritional Status of 0-24 Months Old Children
The study showed that the average weight-for-age, weight-for- height and height-for-age z-scores were -1.26, -1.60 and -1.21 respectively (Table 2). 32.5% of the children being wasted, 21.1% being underweight and 12.2% being stunted. The prevalence of underweight and wasting were higher among females at the age of 6-12 months while stunting was higher among males at the age of 6-12 months also, as listed in (Table 2). Generally, 82.1% of the target population were malnourished with wasting having the highest percentage followed by underweight and lastly stunting with just 17.9% of the children were normal.

Association of Socio-Demography and CF Practices with Underweight, Wasting and Stunting
The association of some anthropometric indices, sociodemographic data and complementary feeding practices are shown in (Tables 3). The results showed that exclusive (p=0.017) breastfeeding, number of times a baby eats fruit (0.047) and number of times feeding bottle was cleaned (p=0.023) are significantly associated to wasting. Type of complementary food (p=0.009) is significantly associated to underweight and lastly number of children at home (p=0.036) is significantly associated with stunting. All the other sociodemographic characteristics are not significantly associated with underweight, wasting and stunting.

Discussion
Breast feeding although is regarded as the most important protective factor for children’s health in the first two years but also proper complementary food practices are quite vital for the promotion of this effect after the age of 6 months and especially during the second year of life and thereafter. Nutrition screening and evaluation have become integral part of many parts of health care and supplemental food programs for infants and children. Community based nutrition surveys provide an accurate idea about food administered to children. It can give an idea about the approximate caloric intake per day. Dietary screening is aimed at identifying those infants and children who may appear to have nutritional problems. Although the information it gives are rather qualitative, it can be concluded from these, who are the children that are at risk of malnutrition [8]. This survey has revealed that malnutrition is still a serious childhood problem in South west region of Cameroon. Its etiology is more than due to the effect of economic status of the community but other important causes should be considered. Mother’s related factors are on the top of the factors that directly affect the health of their children particularly nutrition.

The proportions of children on prolonged and exclusive breastfeeding were still very low at 13% and 27.6% respectively (Table 1). This was in line with the data on exclusive breastfeeding in Aceh in the last decade, which was lower than the national average (Aceh Timur, 2012). Although in places like Indonesia Sharp reductions were seen in 2007, 2009 and 2010 with proportions of 11.4%, 8.5% and 4.3%, respectively [9]. In terms of the timeliness of introduction to CF, this study found less than half (9.8%) of the children received CF timely, while the rest were introduced earlier (63% at < 3 months, 26.8% at 3-6 months). These findings are on the same line with the observations of University of Indonesia (UI) and UNICEF in Aceh (Indonesia), that showed that at age < 3months, the children were given food, namely water, formula milk, fresh milk and other food (grains, pumpkins, sweet potatoes, food made of roots and tubers) [10].

Most of children consumed more of homemade foods like pap (61.0%) and more than half of the children did not receive iron or multivitamin syrup supplementation while majority of them did not consume meat at all (39.8%), with some consuming meat once a week (35.8%), others receiving it twice a week (22.0%) and others thrice a week (2.4%). Most of them did not consume fish at all (43.1%), with some consuming fish once (30.9%), and the rest consumed it twice a week (26.0%). Majority of the children had never consumed vegetables (39.0%) with some of them consuming vegetables once a week (31.7%), and others consuming vegetable twice a week (29.3%). Most of the children never consumed fruits (43.1%), some of them consumed fruits once a week (32.5%), with others consuming fruits twice a week (24.4%), thus justifying the high prevalence of malnutrition (82.1%) observed among these children. Another justification could be as a result of the fact that the majority of their mothers were not workers (55.3%) and had ended in primary school (38.2.7%). The other reason can be the family size of the children that was mostly 5-6 (46.3%) people with income less than 50,00frs per month.

Low consumption of vegetables and fruits observed in this study corroborate with the work of Kimiywe et al.., (2015) [11] in Kenya that revealed that fruits and vegetables consumption frequency among children between 6-23 months was less than 25.4% (for those who consumed once a week). Mbithe et al., (2017) [12] also reported poor consumption rate of vegetables and fruits (20%) (between the children aged 6-23 months). Furthermore, Na et al., (2017) mentioned that consumption of legumes, fruits and vitamin A-rich vegetables in Pakistan was very low (6-19%). Poor CF practice of children aged 6-23 months is known to be caused or influenced by many factors [13] such as: mother’s educational level, birth order of a child and socio-economic status [14,15].

In summary, CF practices of children aged 6-23 months were below standard (inadequate). Among all indicators of CF practices recommended by WHO, the other indicators, namely exclusive breastfeeding, timely introduction to complementary food and iron- and vitamin A-rich food consumption, were still below standard (inadequate). Underweight (<-2SD W/H), Wasting (<-2SD W/H) and Stunting (<-2SD H/A) remained crucial problems since their prevalence exceeded the cut-off point of public health problem categorized as acute and chronic malnutrition [16].

The complementary foods were predominantly made of starch-based cereals and hence of poor nutritional value, and do not satisfy the infant’s basic needs of protein because they have limited levels of protein both qualitatively and quantitatively. Thus, macro- and micronutrients may be insufficient to maintain growth and development, this resulting in poor nutritional status in children [17-64].

Conclusion
Hence, we can conclude that Socio-demographic factor like family income, poor breastfeeding practices and inadequate complementary foods are associated and all contribute to the poor nutritional status of children.

Funding
Authors are thankful to Islamic Development Bank Postdoctoral Programme (IsDB) for their financial life stipend in support of this research work granted to Dr. Tiencheu Bernard.

Acknowledgments
We are grateful to the Laboratory of Nutrition and Nutritional Biochemistry, Department of Biochemistry, University of Yaounde 1 for supporting this study through our supervisor/ Mentors; Prof Julius Oben and Prof. Azantsa Kingue.

We are also very grateful to mothers that give their consent for data collection to undertake this study.

Conflict of Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Bibliography

1. World Health Organization (2008). Indicators for assessing infant and young child feeding practices. Geneva, Switzerland.
2. ABS (2007). National survey of mental health and wellbeing: summary of result.
3. Arimond & Ruel (2004). Dietary diversity is associated with child nutritional status: evidence from 11 Demographic and health surveys. J Nutr., 134(10), 2579-2585.
4. WHO (2017). Physical status: the use and interpretation of anthropometry (WHO technical report series 854). Geneva, Switzerland: world health organization.
5. World Health Organization (2014). World malaria report. Geneva, Switzerland: WHO press.
6. Chatterjee, S. S., Haiek, L. N., Gauthier, D. L. & Brosseau, L. (2007). Understanding breastfeeding behaviors: rates and shifts in patterns in Quebec. J Hum Lact., 23(1), 24-31.
7. Kimbi, H. H., Nkesa, S. B., Ndamukong_Nyang, J. L., Sumbele, I. U. & Atashili, J. (2017). Knowledge and perceptions towards malaria prevention among vulnerable groups in Buea Health District Cameron. BMC Public Health, 14(883), 1-8.
8. Peggy, L. P. (1981). Nutrition in infancy and childhood. CV Mosby Company, St. Louis. Second edition. 98-109.
9. District Health Office of Aceh (2009). Aceh Health Profile. Banda Aceh: District Health Office of Aceh.
10. University of Indonesia; UNICEF (2012). Knowledge, attitudes and practices (KAP) study on key determinants of stunting among children aged 0-23 months in Aceh Timur, Aceh Jaya and Aceh Besar, Nanggroe Aceh Darussalam province. Jakarta.
11. Kimiywe, J. & Chege, P. (2015). Complementary feeding practices and nutritional status of children 6-23 months in Kitui County, Kenya. J Appl Biosci., 85, 7881-7890.
12. Mbithe, D., Kigaru, D. & Milelu, M. M. (2017). Dietary diversity, water and sanitation practices and nutritional status of children aged 6-59 months in Kitui County, Kenya. Int J Food Sci Nutr., 2, 113-120.
13. Chandrasekhar, S., Aguayo, V. M, Krishna, V. & Nair, R. (2017). Household food insecurity and children's dietary diversity and nutrition in India. Evidence from the comprehensive nutrition survey in Maharashtra. Matern Child Nutr., 13(Suppl 2), e12447.
14. Areja, A., Yohannes, D. & Yohannis, M. (2017). Determinants of appropriate complementary feeding practice among mothers having children 6-23 months of age in rural Damot sore district, Southern Ethiopia; a community based cross sectional study. BMC Nutrition., 3, 82.
15. Contento, I. R. (2011). Nutrition Education: Linking Research, theory, and Practice. 2^nd ed. Sudbury (MA): Jones and Bartlett Publisher.
16. Kateera, F. I., Hakizimana, E. P., Mens, P. F., Grobusch, M. P., et al. (2015). Malaria, anaemia and under-nutrition: three frequently co-existing conditions among preschool children in rural Rwanda. Malar J., 14(440), 1-11.
17. WHO/UNICEF (2003). WHO | global strategy for infant and young child feeding.
18. Abeh, B. & Ibeh, G. (1987). Functional properties of raw and heat processed cowpea Flour. J. Food Sci., 53(6), 17755-17791.
19. Allen, L. H. (2003). Micronutrient malnutrition: effect on breast milk and infant nutrition and Priorities for intervention. SCN News., (11), 21-24.
20. Asoba, G. N., Sumbele, I. N., Anchang, K. J., Samuel, M. & Kaptso, K. G. (2018). Nutritional evaluation of commonly used local weaning food processed and sold in the Mount Cameroon Region. International Journal of Food Science and Nutrition Engineering, 8(6), 131-141.
21. Benton, J. J. & Vernon, C. J. W. (1990). Sampling, handling and analyzing plant tissue samples. In: RL Westerman, Eds. Soil testing and plant Analysis. 3^rd ed. SSSA Book Series, No.3.
22. Bhutta, Z. A., Ahmed, T., Black, R. E., Cousen, S. S., Dewey, K. & Giugliani, E. (2008). What works? Intensions for maternal and child undernutrition and survival. Lancet, 371(9610), 417- 440.
23. Black, R. E., Victora, C. G., Walker, S. P., et al. (2013). Maternal and child undernutrition and overweight in low income and middle-income countries. Lancet, 382(9890), 427-451.
24. Bork, K., Cames, C., Baringou, S., Cournil, A. & Diallo, A. (2012). A summary index of feeding practices is positively associated with height for age but only marginally with linear growth in rural Senegalese infants and toddlers. The Journal of Nutrition, 142(6), 1116-1122.
25. Chung, M., Raman, G., Trikalinos, T. A. & Lau, J. (2009). A summary of the agency for health care research and quality’s evidence reports on breastfeeding in developed countries. Breastfeed Med, 4(Suppl 1), S17-S30.
26. Dewey, K. G., Brown, K. H. & Landa R. L. (2001). Effect of exclusive breastfeeding for 4 versus 6 months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras. J Nutr., 131(2), 262-267.
27. Engle, P. (2009). Maternal mental health: program and policy implications. American Journal of Clinical Nutrition, 89(3), 963S-966S.
28. Folefac, F., Lifongo, L., Nkeng, G., Gaskin, S. (2009). A preliminary hydrogeochemical baseline study of water sources around mount Cameroon. J. Cameron Acad. Sci., 1, 127-185.
29. Frost, M. B., Forste, R. & Haas, D. W. (2005). Maternal education and child nutritional status in Bolivia: findings the links. Social Sciences and Medicine, 60(2), 395-407.
30. Garene, M., Maire, B., Fontaine, O., Briend, A. (2012). Adequacy of child anthropometric indicators for measuring nutritional stress at population level: A study from the Niakhar, Senegal. Public Health Nutrition, 16(9), 1533-1539.
31. George, G. M., Oldja, l., Biswas, S., Perin, J., Lee, G. O., Koesk, M., et al. (2015). Geogphagy is associated with environmental enteropathy and stunting in children in rural Bangladesh. Am J Trop Med Hyg., 92(6), 1117-1124.
32. Gordon, C. C., Cameron, C. W. & Roche, A. F. (1991). Stature recumbent length and weight. In: Lohman, T. G., Roche, A. F., Martorell, R eds. Anthropometric standardization reference manual. Human kinetics books, 3-8.
33. Grantham-McGregor, S., Cheung Y. B., Cueto, S., et al. (2007). Developmental potential in the first 5years for children in developing countries. Lancet, 369(9555), 600-670.
34. Kaland, B. F., Verhoeff F. H. & Brabin B. J. (2006). Breast and complementary feeding practices in relation to morbidity and growth in Malawian infants. Eur J Clin Nutr., 60(3), 401-407.
35. Karen, A. G. & Prashant, B. (2015). Maternal education and child mortality in zimbabwe. Journal of health economic, 44, 97-117.
36. Karim, E. & Mascie-Taylor, C. G. (1997). The association between birth weight sociodemographic from Dhaka Bangladesh. Ann Hum Biol., 24(5), 387-401.
37. Keusch, G. T. (2003). The history of nutrition: malnutrition, infection and immunity. J Nutr., 133(1), 336S-340S.
38. Kiserud, T. (2005). Physiology of the fetal circulation. Seminars in Fetal and Neonatal Medicine, 10(6), 493-503.
39. Li, R., Fein, S. B., Chen, J. & Grumner, L. M. (2008). Why mothers stop breast feeding: mother self-reported reasons for stopping during the first year. Pediatrics, 122, S69-S76.
40. Lin, M. J., Humbert, E. S. & Sosulski, F. (1974). Certain functional properties of soy flour. J. Food Sci., 44, 763-766.
41. Loganc, C., Zittel, T., Striebel, S., et al. (2016). Changing societal and lifestyle factors and breastfeeding patterns over time. Pediatrics, 137(5), e20154473.
42. Lowry, O., Rosebrough, N., Farr, A. & Randall, R. (1951). Protein measurement with folin phenol reagent. J. Biol Chem., 193(1), 265-275.
43. Lyons, G. H., Stangoulis, J. C. R. & Graham, R. D. (2004). Exploiting micronutrient interaction to optimize biofortification programs: the case for inclusion of selenium and iodine in the HarvestPlus program. Nutr Rev., 62(6 Pt 1), 247-252.
44. Mukuria, A., Cushing, J. & Sangha, J. (2005). Nutritional status of children: result from demographic and health surveys 1994-2001, DHS comparative report, 10,135.
45. Muller, O., Garenne, M., Kouyate, B. & Becher, H. (2003). The association between protein energy malnutrition, malaria morbidity and all, cause mortality in West African children. Top Med Int Health., 8(6), 507-511.
46. McWatters, K. H., Ouedraogo, J. B., Resurreccion, A. V. A., Hung, Y. & Phillips, R. D. (2003). Physical and sensory characteristics of sugar cookies containing mixtures of wheat, fonio (Digitaria exilis) and cowpea (Vigna unguiculata) flours. Int. J. Food Sci. Technol., 38(4), 403-410.
47. Munasinghe, M., Silva, K., Jayarathne, K. & Sarananda, K. (2013). Development of yoghurt-based weaning foods for 1-3 years old toddlers by incorporation of mung bean (Vignaradiata), soybean (Glycine max) and brown rice (Oryza sativa) for the Sri Lankan market. Journal of Agricultural Sciences, 8(2), 43-56.
48. Ohizua, E. R., Adeola, A. A., Idowu, M. A., et al. (2017). Nutrient composition, functional and pasting properties of unripe cooking banana, pigeon pea and sweet potato flour blends. Food Sci Nut., 5(3), 750-762.
49. Olwedo, M. A., Mworozi, E., Bachou, H. & Orach, C. G. (2008). Factors associated with malnutrition among children in internally displaced person's camps, northern Uganda. African Health Sciences, 8(4), 244-252.
50. Ponka, R., Abdou, B. A., Fokou, E., Beaucher, E., Piot, M., Leonil, J. & Gaucheron, F. (2015). Nutritional composition of five varieties of pap commonly consumed in Maroua (Far-North, Cameroon). Polish Journal of Food and Nutrition Sciences, 65(3), 183-190.
51. Santos, J. L., Albalac, C., Lera, L., Garcia, C., Arroya, P., Perez-Bravo, F., et al. (2004). Anthropometric measurements in the elderly population of Santiago. Chile Nutrition, 20(5), 452-457.
52. Schucthat, A., Tappero, J. & Blandford, J. (2009). Global health and U.S. centers for disease control and prevention. Lancet, 384(9937), 98-101.
53. Senthil, A., Ravi, K., Bhat, K. & Seethalakshmi, M. (2002). Studies and the quality of fried snacks based on blends of wheat flour and soya flour. Food Quality and Preference, 13, 267-273.
54. Ugwu & Ukpabi, U. J. (2002). Potential of soy cassava flour processing to sustain increasing cassava production in Nigeria. Outlook on Agriculture, 31(2), 129-133.
55. UNICEF (2013). Improving child nutrition. The achievable imperative for global progress.
56. Van, H. L., Obarzanek, E. Friedman, L. A., Enhfer, G. N. & Barton, B. (2005). Children’s adaptation to a fat reduced diet: the dietary intervention study in children. Pediatric, 115(6), 1723-1733.
57. Wahlqvist, M. L. & Kouris-Blazos, A. (1997). A dietary advice and food guidance systems. In: wahlqvist ML, ed. Food and nutrition: Australia, Asian and the pacific. Syndney, Allen and Unwin, 500-522.
58. WHO (2000). Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser., 894, 1-253.
59. WHO expert consultation (2004). Appropriate body mass index for Asian population and its implications for policy and intervention strategies. Lancet, 363(9403), 157-163.
60. World Bank (2006). Repositioning nutrition as central to development: A strategy for large scale action. Washington, DC: world bank.
61. World Health Organization (2006). Infant and young feeding conseling: An intergrated course. Geneva.
62. World Health Organization (2006). WHO child growth standards. length/ height-for-age, weight for-age, weight-for-length, weight-for- height and body mass index-for-age: methods and development. Geneva.
63. WHO and UNICEF (2015). Progress on sanitation and drinking water - 2015 update and MCG assessment.
64. WHO (2013). GUIDELINE: Updates on the management of severe acute malnutrition in infants and children. Geneva.