PLOS ONE
RESEARCH ARTICLE
Concurrently wasted and stunted 6-59
months children admitted to the outpatient
therapeutic feeding programme in Karamoja,
Uganda: Prevalence, characteristics,
treatment outcomes and response
Gloria A. Odei Obeng-Amoako 1ID *, Henry Wamani2, Joel Conkle3, Richmond Aryeetey4,
a1111111111 Joanita Nangendo1, Ezekiel Mupere5, Joan N. Kalyango1,6, Mark Myatt7, André Briend8,9,
a1111111111 Charles A. S. Karamagi1,4
a1111111111
1 School of Medicine, Clinical Epidemiology Unit, College of Health Sciences, Makerere University, Kampala,
a1111111111
Uganda, 2 Department of Community Health and Behavioural Sciences, School of Public Health, College of
a1111111111 Health Sciences, Makerere University, Kampala, Uganda, 3 Health and Nutrition Section, UNICEF Namibia,
Windhoek, Namibia, 4 School of Public Health, University of Ghana, Legon, Ghana, 5 Department of
Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda,
6 Department of Pharmacy, College of Health Sciences, Makerere University, Kampala, Uganda, 7 Brixton
Health, Wales, United Kingdom, 8 School of Medicine, Centre for Child Health Research, University of
OPEN ACCESS Tampere, Tampere, Finland, 9 Department of Nutrition, Exercise and Sports, University of Copenhagen,
Copenhagen, Denmark
Citation: Odei Obeng-Amoako GA, Wamani H,
Conkle J, Aryeetey R, Nangendo J, Mupere E, et al. * agodei@yahoo.com
(2020) Concurrently wasted and stunted 6-59
months children admitted to the outpatient
therapeutic feeding programme in Karamoja, Abstract
Uganda: Prevalence, characteristics, treatment
outcomes and response. PLoS ONE 15(3):
This study assessed the prevalence of concurrently wasted and stunted (WaSt) children,
e0230480. https://doi.org/10.1371/journal.
pone.0230480 their characteristics, treatment outcomes and response; and factors associated with time to
recovery among children aged 6–59 months admitted to Outpatient Therapeutic Care
Editor: Frank Wieringa, Institut de recherche pour
le developpement, FRANCE (OTC) in Karamoja, Uganda. We conducted a retrospective cohort study with data from Jan-
uary 2016 to October 2017 for children admitted to nine OTCs in Karamoja. We defined
Received: May 4, 2019
wasted, stunted and underweight as 2.0 Z-scores below the median per WHO growth stan-
Accepted: March 2, 2020
dards and < 12.5 cm for low Mid-Upper Arm Circumference (MUAC). WaSt was defined as
Published: March 20, 2020 concurrently wasted and stunted. Out of 788 eligible children included in the analysis;
Copyright: © 2020 Odei Obeng-Amoako et al. This 48.7% (95% CI; 45.2–52.2) had WaSt. WaSt was common among males; 56.3% (95% CI;
is an open access article distributed under the 51.3–61.3). Median age was 18 months in WaSt versus 12 months in non-WaSt children (p
terms of the Creative Commons Attribution < 0.001). All WaSt children were underweight; and more severely wasted than non-WaSt
License, which permits unrestricted use,
distribution, and reproduction in any medium, children. During recovery, WaSt children gained weight more rapidly than non-WaSt chil-
provided the original author and source are dren (2.2g/kg/day vs. 1.7g/kg/day). WaSt children had lower recovery rate (58.0% vs.
credited. 65.4%; p = 0.037). The difference in median time of recovery between WaSt and non-WaSt
Data Availability Statement: De-identified data set children (63 days vs. 56 days; p = 0.465) was not significant. Factors associated with time to
is available within the Supporting Information files. recovery were children aged 24–59 months (aHR = 1.30; 95% CI;1.07–1.57;), children with
Funding: Support for this research was made MUAC 10.5–11.4 cm (aHR = 2.03; 95% CI; 1.55–2.66), MUAC� 11.5 cm at admission
possible through the competitive grant for training (aHR = 3.31; 95% CI; 2.17–5.02) and living in Moroto (aHR = 3.34; 95% CI; 2.60–4.30) and
the next generation of scientists by Carnegie
Nakapiripirit (aHR = 1.95; 95% CI; 1.51–2.53) districts. The magnitude of children with WaSt
Corporation of New York through the Regional
Universities Forum for Capacity Building in in OTC shows that existing therapeutic feeding protocols could be used to detect and treat
PLOS ONE | https://doi.org/10.1371/journal.pone.0230480 March 20, 2020 1 / 18
PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Agriculture (RUFORUM), Makerere University, WaSt children. Further research is needed to identify and address the factors associated
Kampala Uganda. The OTC dataset used in this with sub-optimal recovery in WaSt children for effective OTC programming in Karamoja.
study was part of SAM incidence and post-
treatment relapse feasibility study in Karamoja
supported by UNICEF Uganda. The content is
solely the responsibility of the authors and does
Introduction
not necessarily reflect the views of Carnegie
Corporation of New York or UNICEF Uganda. The Severe Acute Malnutrition (SAM) in children under 5 years is a global public health concern.
funders had no role in study design, data Globally, about 52 million children under 5 years are wasted and 17 million are severely wasted
collection, and analysis, decision to publish, or
[1]. Nearly 4.3 million of all severely wasted children are in Africa [1]. In Uganda, 4% of chil-
preparation of the manuscript
dren under 5 years are wasted and 1.3% are severely wasted [2].
Competing interests: The authors have declared Annually, 3.1 million of all deaths in children under 5 years are associated with under-
that no competing interests exist
nutrition [3]. SAM, the deadliest form of under-nutrition is known to directly cause 4.4% of
Abbreviations: aHR, Adjusted Hazard Ratio; CI, child deaths in the absence of effective treatment [3]. SAM in children aged 6–59 months is
Confidence Interval; cHR, Crude Hazard Ratio; CSB, defined by weight-for-height Z-scores (WHZ) < -3 of the World Health Organization
Corn Soya Blend; CUAMM, Medici con l’Africa or
(WHO)’s Child Growth Standard or mid-upper arm circumference (MUAC) < 11.5 cm and/
Doctors with Africa; HAZ, Height-For- Age Z-
scores; IMAM, Integrated Management of Acute or the presence of bilateral pitting edema [4]. This case definition forms the basis for therapeu-
Malnutrition; ITC, Inpatient Therapeutic Care; IQR, tic feeding programme admissions. The current therapeutic feeding protocol is proven to
Interquartile Range; MAM, Moderate Acute effectively treat children with SAM [5, 6]. In recent times, the need for evidence on the current
Malnutrition; MUAC, Mid Upper Arm therapeutic feeding programmes to detect and treat children having concurrent wasting and
Circumference; MoH, Ministry of Health; ODK,
stunting; a condition termed WaSt has been raised [7–9]. Until now the focus of therapeutic
Open Data Kit; OTC, Outpatient Therapeutic Care;
feeding programme has been on SAM, but there is a need for further research for integrated
RUTF, Ready to Use Therapeutic Foods;
RUFORUM, Regional Universities Forum for programme approaches for addressing wasting and stunting in children [10].
Capacity Building in Agriculture; UNICEF, United Literature suggests that wasting retards linear growth leading to stunting; thus a wasted
Nations Children’s Fund; SAM, Severe Acute child is often stunted [11, 12]. Risk factors associated with wasting and stunting are often seen
Malnutrition; SFP, Supplementary Feeding in the same child [11, 13]. Reports show children younger than 30 months especially males are
Programme; WAZ, Weight -for-age Z-scores;
mostly affected by WaSt [8, 9, 14]. The risk of death associated with severe wasting is 12 fold
WaSt, Wasting and stunting; WHO, World Health
Organization; WHZ, Weight-for-height Z-scores. compared with well-nourished children [15, 16]. Children with severe stunting have about 5
times the risk of death compared with children without anthropometric deficits [15]. Children
with WaSt are 12 times more likely to die compared to well-nourished children [8, 16]. This
sharply contrasts with the relatively smaller risk of being either wasted (2.3 hazard ratio) or
stunted alone (1.5 hazard ratio) [8, 16]. Children with WaSt have a risk of death comparable to
children with severe wasting [8, 16]. The increased risk of death associated with WaSt is
because of the negative synergistic effect of concurrent wasting and stunting [8].
Given the emerging evidence on WaSt in children, the basis of the current separation in pro-
gramming, research and funding need to be re-examined [7, 17]. Evidence is needed on how to
optimize the current therapeutic feeding protocols to detect, treat and reduce mortality associ-
ated with WaSt [8]. Also, because some children with WaSt are classified as SAM in the current
therapeutic feeding programme, their outcomes and response to treatment are unknown.
We assessed the prevalence of WaSt; the characteristics, treatment outcomes and response
of children with WaSt; and factors associated with time to recovery among children aged 6–59
months admitted for SAM treatment in Outpatient Therapeutic Care (OTC) in Karamoja, in
North-Eastern Uganda.
Methods
Operational definitions
We defined wasting, stunting, and underweight by the Z-scores of 2006 WHO growth stan-
dards as follows [18].
Wasted: weight for height Z-scores (WHZ) < -2.0
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Stunted: height for age Z-scores (HAZ) < -2.0
Underweight: weight for age Z-scores (WAZ) < -2.0
Degrees of anthropometric deficits were defined as: no deficit�-2; moderate� -3 to -2 and
severe< -3
WaSt: concurrently WHZ< -2.0 and HAZ < -2.0 [8].
Non-WaSt: WHZ�-2.0; or HAZ� -2.0; or WHZ< -2.0 and HAZ� -2.0; or HAZ < -2.0
and WHZ�-2.0; or WHZ�-2.0 and HAZ� -2.0
Acute malnutrition was defined as wasting (WHZ<-2) and/or MUAC<12.5; severe acute
malnutrition (SAM) as severe wasting (WHZ< -3) and/or MUAC< 11.5 cm and moderate
acute malnutrition (MAM) as moderate wasting (WHZ� -3 to -2) and/or MUAC� 11.5 cm
and� 12.5 cm [19].
We used the following formula to define treatment response:
• Length of stay (days) as the difference between the date at discharge and date at admission;
• Weight gain (Kg) as the difference between the last recorded weight at discharge and weight
at admission;
• Weight velocity (g/kg/day) = 1000 × (last recorded weight at discharge—weight at admis-
sion)/ (last recorded weight at discharge × length of stay (days));
• Proportional weight-gain (%) = (last recorded weight at discharge—weight at admission)/
weight at admission) × 100;
• MUAC gain (cm) as the difference between last recorded MUAC (at discharge) and MUAC
at admission [6].
Study design and source of the dataset
This was a retrospective cohort study using a dataset consisting of treatment records of chil-
dren aged 6–59 months admitted to nine OTC sites in Karamoja from January 2016 to Octo-
ber 2017. All the children in the dataset used for this analysis were children with SAM. The
dataset was collected as part of a SAM incidence and post-treatment relapse feasibility study
conducted from September to October 2017 in Karamoja (unpublished report). Treatment
records were extracted from three outpatient health facilities in each of the three districts; Kaa-
bong, Moroto, and Nakapiripirit. The purpose was to ascertain the feasibility of a proposed
study on post-treatment relapse to SAM. These health facilities were purposively sampled
based on their high caseloads and because they had treatment records. Seven of the nine health
facilities were operated by the Government of Uganda Ministry of Health and the other two
were managed as private-non-for profit/mission facilities offering OTC services.
The SAM incidence and post-treatment relapse feasibility study were carried out in collabo-
ration with the United Nations Children’s Fund (UNICEF) Uganda, Doctors with Africa
(CUAMM), Ministry of Health (MoH) and local government authority in the selected dis-
tricts. Before data collection, stakeholder consultations were held as part of the community
entry process. Health facility data were made available to the study team by the MoH and
CUAMM in the study districts.
Data on treatment records were extracted from the MoH’s Integrated Nutrition Registers
(INR) in all health facilities. The INR is managed and maintained by the health workers at the
health facilities. A data extraction form designed using Open Data Kit (ODK) was used to
extract data from one health facility while paper-based forms were used in the remaining
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
health facilities (n = 8). Data extraction was carried out by two trained research assistants. A
total of 1345 treatment records (1181 paper-based and 164 ODK-based forms) were retrieved
from the INR. The paper-based data-extraction forms were entered once into Epi-data soft-
ware with in-built interactive ranges and legal value checks. Samples of the data entered were
randomly checked for completeness. The two datasets were uploaded and merged into a single
dataset in STATA version 13.0.
Study setting and programme context
Karamoja is a semi-arid agro-pastoral setting in North-Eastern Uganda and has seven admin-
istrative districts: Moroto, Napak, Amudat, Nakapiripirit, Kotido, Kaabong, and Abim. Kara-
moja is characterized by chronic food insecurity with about half of its 1.4 million population
classified as food insecure [20]. Childhood under-nutrition remains a significant public health
problem. In Karamoja, 33% of children under 5 years are stunted and 28% are underweight
[21]. About 90% of the health facilities (114 OTC- and 10 Inpatient Therapeutic Care (ITC)
sites) in Karamoja provide SAM treatment. Technical assistance for SAM treatment services is
provided by CUAMM in partnership with the MoH in Uganda Ministry of Health and UNI-
CEF Uganda.
SAM treatment services follow the Ugandan National Integrated Management of Acute
Malnutrition (IMAM) guidelines which consist of community mobilization, OTC, ITC and
Supplementary Feeding Programmes (SFP). SAM treatment services are offered in public and
private health facilities. Village Health Teams search for, refer and follow-up cases through
community mobilization [22]. Children are screened for SAM using MUAC < 11.5 cm and
bilateral edema by community health workers and health volunteers at the community level
[22]. Children with MUAC < 11.5 cm or any degree of bilateral edema, are referred for a full
assessment at health facilities [22]. At the health facilities, health-care workers assess MUAC
and/or WHZ or bilateral pitting edema to confirm admission. Children aged 6–59 months ful-
filling any of the admission criteria without medical complications and have appetite are
admitted to OTC. Children with SAM plus medical complications are first treated in the ITC
until complications resolve and are then transferred to OTC for further treatment. At the
OTC, children receive take-home ration of Ready to Use Therapeutic Food (RUTF). Children
are presented at the OTC centres by their caregivers for weekly monitoring and RUTF ration
for a period of 6–8 weeks until cured and discharged. Children with MAM, are treated at the
SFP centres [22].
The recommended criteria for discharge from OTC are WHZ� -2 or MUAC� 12.5 cm
with no edema for 2 weeks [22]. However, because SFP are implemented in Karamoja, chil-
dren are discharged as cured and are transferred to SFP with MUAC� 11.5 cm and� 12.5 cm
or WHZ� -3 and < -2 for further rehabilitation using Corn Soy Blend++ (CSB). Children
who attain recovery from SAM to normal (WHZ� -2 or MUAC� 12.5 cm) are discharged
home from the therapeutic feeding programme A child is classified as non-response if the dis-
charge criterion is not fulfilled after 16 weeks of treatment. A default is defined as absence
from treatment for three consecutive visits. A child whose nutritional status deteriorates in
OTC is referred to or transferred to ITC [22]. For ease of analysis, recovery from SAM to
MAM was used as cured in this study.
Study population
Children who met the admission criteria of WHZ< -3 and/or MUAC < 11.5 cm, and had
data on weight, height, MUAC at admission and exit with treatment outcomes were included
in the analysis. We excluded children with aberrant anthropometric records and those with
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
bilateral pitting edema because of their unusual weight gain pattern as edema diminishes dur-
ing SAM treatment [23]. We also excluded children with HIV given their atypical health
conditions.
Data analysis
We used STATA software version 13.0 (StataCorp, College Station, TX, USA) and Microsoft
Excel for all the statistical analyses. Z-scores above the upper quartile +1.5 × interquartile
range (IQR) were censored as outliers instead of the WHO flagging criteria. Given that this
analysis consisted of very sick and undernourished children, children with extreme negative
Z-scores below the WHO flagging cut-off points were not censored from the study [24]. Chil-
dren aged 24 months and above with extreme values for height (i.e. > 120 cm) as well as those
less than 24 months with length values > 100 cm were censored. Additionally, children with
MUAC > 20 cm were also censored [22].
We used a Venn diagram to assess the overlap between sets of children with nutritional def-
icits [8, 25]. We described the prevalence of WaSt versus non-WaSt and their characteristics
(age, sex, baseline weight, height, Z-scores, and MUAC) with summary statistics. We summa-
rized continuous variables using medians, interquartile ranges (IQRs) and percentages for cat-
egorical variables. We compared treatment outcomes and responses in two groups; WaSt and
non-WaSt children using Chi-square (χ2) for categorical variables and Wilcoxon rank-sum
test for continuous variables.
We estimated and compared the median time to recovery by groups; sex, age categorized
6–23 months and 24–59 months, WaSt, and geographical location using the Kaplan Meier sur-
vival method and the Log Rank test. We used multivariate Cox proportional hazard regression
analysis to assess factors associated with time to recovery. The outcome of interest was time to
recovery (event), i.e. being discharged as cured and had attained MUAC� 11.5 cm and� 12.5
cm or WHZ� -3 and< -2. All children who had not recovered (i.e. died, defaulted, non-
response, and transferred to OTC/ITC) during treatment as well as those discharged from
treatment as cured but had not attained nutritional recovery were classified as non-recovered
and censored. We considered sex, age categorized at 6–23 months and 24–59 months and
MUAC categorized into MUAC < 10.5 cm, MUAC 10.5–11.4 cm, MUAC� 11.5 cm, WaSt
and geographical location of children in the Cox proportional hazard regression model. Vari-
ables with p< 0.2 found in the bivariate regression analysis were included in the multivariate
analysis. Factors associated with time to recovery were reported by adjusted Hazard Ratio
(aHR) at 95% Confidence Interval (CI). We set statistical significance at a 95% Confidence
Interval (CI) and p< 0.05 in this analysis.
Ethics
Permission and ethical approval to conduct the SAM incidence and post-treatment relapse fea-
sibility study was granted by the Clinical Epidemiology Unit and the School of Medicine
Higher Degrees Research and Ethics Committee respectively. Ethical approval to conduct the
current study was obtained from the Makerere University School of Medicine Higher Degrees
Research and Ethics Committee and the Uganda National Council for Science and Technol-
ogy. All treatment records of children were anonymized before we accessed them in the data-
set. A waiver of consent from Makerere University School of Medicine Higher Degrees
Research and Ethics Committee was sought to use this dataset for the study.
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Results
Study profile
A total of 1345 treatment records of children treated for uncomplicated SAM from January
2016 to October 2017 were retrieved from nine health facilities in Karamoja. The flow chart
(Fig 1) shows how eligible children were considered in our analysis. Seven hundred eighty-
eight children with complete data on the four anthropometric indices; underweight, wasted,
stunted and low MUAC in the sample were included in the final analysis. Complete data on
the four anthropometric indices facilitated analysis on overlapping deficits. About half of our
sample were females (52.3%) and the median age was 15 months (IQR; 10,12). There was no
significant difference in the sex (males; 48.5% vs. 47.7%; p = 0.210) and age distribution
(median 15 months vs. 15 months; p = 0.394) between the children in our sample and excluded
children.
Nutritional status at admission
Of the 788 children in the study sample, 99.4% (n = 783) had low MUAC and 93.1% (n = 734)
were underweight (Table 1).
Overlap of nutritional deficits
Almost half (48.7%, 384/788) of the children were WaSt (Fig 2). All four nutritional deficits
overlapped in virtually all the children with WaSt (382/384). The shaded portions in the Venn
diagram show the intersection of children with stunting and wasting (Fig 2). The Venn dia-
gram also shows that all WaSt children were underweight. There was a substantial degree of
overlap between underweight and low MUAC, and thus 92.6% were underweight and had low
MUAC concurrently. There was no child without a nutritional deficit in the Venn diagram
given that the cohort was children with SAM (Fig 2).
Prevalence, age and sex patterns of WaSt among children admitted to OTC
About half of the children (48.7%; 95% CI: 45.2–52.2) admitted to OTC had WaSt. Overall,
our sample had more females than males (male: female ratio = 0.91) whereas among WaSt
children male to female ratio was 1.35 (95% CI; 1.17–1.56) (Tables 2 and 3). WaSt was more
frequent among male children aged 6–35 months and among female children aged 36–47
months (Fig 3). WaSt peaked at 24–35 months (71.9%) in males but at 36–47 months (55.6%)
in females (Fig 3).
Socio-demographic and anthropometric characteristics of WaSt versus
non-WaSt children
The median age of children with WaSt (18 months) and non-WaSt (12 months) was statisti-
cally different (p< 0.001). Children with WaSt had significantly lower median MUAC
(p = 0.002) and were more severely underweight (median WAZ; -4.2 vs. -3.0; p < 0.001),
wasted (median WHZ; -3.3 vs. -2.6; p< 0.001), and stunted (median HAZ; -3.4 vs. -1.6;
p< 0.001) compared to children without WaSt. Prevalence of WaSt versus non-WaSt in the
study districts were not statistically different (Kaabong; p = 0.658, Moroto; p = 0.395 and
Nakapiripirit; p = 0.654) (Table 3).
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Fig 1. Flow chart showing participant selection among children 6–59 months admitted to OTC in Karamoja.
https://doi.org/10.1371/journal.pone.0230480.g001
Table 1. Nutritional status at admission in children admitted to OTC, Karamoja.
N = 788 WAZ WHZ HAZ MUAC
Nutritional statusa n (%) n (%) n (%) n (%)
No deficit 54 (6.9) 164 (20.8) 279 (35.4) 5 (0.6)
Moderate 161 (20.4) 228 (28.9) 169 (21.4) 48 (6.1)
Severe 573 (72.7) 396 (50.3) 340 (43.2) 735 (93.3)
aWAZ: underweight; WHZ: wasted; HAZ: stunted, MUAC: mid-upper arm circumference.
https://doi.org/10.1371/journal.pone.0230480.t001
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Fig 2. Venn diagram showing wasting, stunting, underweight and low MUAC overlaps in the study sample (N = 788). Legend: The gray
shaded areas depict intersection between wasting and stunting; WaSt.
https://doi.org/10.1371/journal.pone.0230480.g002
Treatment outcome and response
Children with WaSt had lower recovery rate compared with children without WaSt (58.0% vs.
65.4%; p< 0.037). More children with WaSt were discharged as non-responsive to treatment
than non-WaSt children (18.7% vs. 9.8%; p< 0.001). WaSt children had slightly longer length
of treatment (63 days vs. 56 days; p = 0.465) than non-WaSt children although the difference
was not statistically significant. Children with WaSt had slightly greater weight velocity per
Table 2. Prevalence of WaSt among children admitted to OTC, Karamoja.
Attribute Total (n) WaSt n (%) 95% CIa
Overall 788 384 (48.7) 45.2–52.2
Sex
Male 376 212 (56.3) 51.3–61.3
Female 412 172 (41.7) 37.1–46.6
Age groups (months)
6–23 499 222 (44.5) 40.2–48.9
24–59 289 162 (56.1) 50.3–61.9
aCI: Confidence Interval.
https://doi.org/10.1371/journal.pone.0230480.t002
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Table 3. Socio-demographic and anthropometric characteristics of WaSt versus non-WaSt children admitted to
OTC, Karamoja.
Attribute WaSt (n = 384) Non-WaSt (n = 404) p-valuea
Socio-demographic characteristics
Sexb
Male 212 (56.4) 164 (43.6) <0.001
Female 172 (41.7) 240 (58.3)
Age (months)c
All children 18 (12, 24) 12 (9, 24) <0.001
Males 18 (12, 24) 14 (10, 27) 0.167
Females 16 (11, 24) 12 (9, 24) <0.001
Age group (months)b
6–23 222 (44.5) 277 (55.5) 0.002
24–59 162 (56.1) 127 (43.9)
Anthropometric measurementsb
Weight (Kg) 6.3 (5.6, 7.2) 6.7 (6.0, 8.0) <0.001
Height (cm) 70.0 (66.0, 75.0) 70.0 (65.6, 81.0) 0.021
MUAC (cm) 11.0 (10.4, 11.2) 11.0 (10.6, 11.2) 0.002
Z-scoresc
WAZ -4.2 (-4.8, -3.7) -3.0 (-3.7, -2.4) <0.001
HAZ -3.5 (-4.3, -2.7) -1.6 (-2.8, -0.5) <0.001
WHZ -3.3 (-3.8, -2.6) -2.6 (-3.8, -1.6) <0.001
MUAC categoriesb
<10.5cm 99(64.5) 57 (36.5) <0.001
10.5–11.4 cm 262 (45.3) 317 (54.7)
� 11.5cm 23 (43.4) 30 (56.6)
Geographical location (districts) b
Kaabong 117(47.6) 129 (52.4) 0.697
Moroto 151 (50.7) 147 (49.3)
Nakapiripirit 116 (47.5) 128 (52.5)
aProportions were compared using Chi-square (χ2) and continuous variables were compared using Wilcoxon rank-
sum test.
bn (%): number (percent);
cMedian (IQR) Interquartile Range.
https://doi.org/10.1371/journal.pone.0230480.t003
day than non-WaSt children (2.2 g/kg/day vs.1.7 g/kg/day; p = 0.004). The median MUAC
gain did not differ between groups (p = 0.514) (Tables 4 and 5).
Incidence rate and median time to recovery
The overall incidence rate of recovery from SAM in the cohort was 8.0 (95% CI; 7.3–8.8) per
1000 person-days. The incidence rates of recovery were 7.4 (95% CI; 6.5–8.-5) per 1000 per-
son-days and 8.6 (95% CI; 7.6–9.7) per 1000 person-days among WaSt and non-WaSt children
respectively. Among the recovered children, WaSt children had an incidence rate of recovery
of 14.5 (95% CI; 12.7–16.6) per 1000 person-days whereas non-WaSt children had an inci-
dence rate of recovery of 14.7 (95% CI; 13.0–16.6) per 1000 person-days. There was no signifi-
cant difference between the incidence rate of recovery between WaSt and non-WaSt children
among the recovered children (Table 6).
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Fig 3. Prevalence of WaSt by age group and sex among children admitted to OTC in Karamoja.
https://doi.org/10.1371/journal.pone.0230480.g003
The overall median time to recovery in the cohort was 84 days (95% CI; 77–91). The
median time to recovery was slightly longer in children with WaSt compared with children
without WaSt (63 days vs. 56 days; p = 0.898) although the difference was not statistically sig-
nificant (Table 6 and Fig 4).
The median time to recovery was 119 days (95% CI; 105–133), 77 days (95% CI; 70–84) and
63 days (95% CI; 49–91) for children who had MUAC < 10.5 cm, MUAC 10.5–11.4 cm
and� 11.5 cm at admission respectively. The difference in median time to recovery by the
MUAC categories was statistically significant (p< 0.001) (Table 6).
Table 4. Treatment outcomes of WaSt versus non-WaSt children admitted to OTC in Karamoja.
Outcome WaSt (n = 369) Non-WaSt (n = 387) p-valuea
n (%) n (%)
Recoveredb 214 (58.0) 253 (65.4) 0.037
Transferred to OTC/ITC 9 (2.4) 3 (0.8) 0.067
Defaulted 73 (19.8) 90 (23.3) 0.246
Non response 69 (18.7) 38 (9.8) < 0.001
Died 4 (1.1) 3 (0.8) 0.658
aProportions were compared using Chi-square (χ2)
bOnly children who attained MUAC� 11.5 to < 12.5 cm or WHZ� -3.0 to < -2.0 or both and discharged as
recovered were included in the analysis; WaSt (n = 214) and non-WaSt (n = 253).
https://doi.org/10.1371/journal.pone.0230480.t004
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Table 5. Treatment response of recovered WaSt and non-WaSt children admitted to OTC, Karamoja.
Treatment response WaSt (n = 214) Non-WaSt (n = 253) p-valuea
Median (IQR) Median(IQR)
Length of stay (days) 63 (36, 84) 56 (35, 91) 0.465
Weight gain (Kg) b 1.0 (0.6, 1.5) 0.8 (0.5, 1.4) 0.007
Weight velocity (g/kg/day) b 2.2 (1.2, 3.4) 1.7 (1.0, 2.8) 0.004
Proportional weight gain(%)b 14.8 (8.8, 23.2) 11.7 (6.8, 20.0) 0.001
MUAC gain (cm)c 1.1 (0.6, 1.6) 1.1 (0.7, 1.6) 0.514
aContinuous variables were compared using Wilcoxon rank-sum test.
bReported for children with available weight data at discharge in the data set: WaSt (n = 214) and non-WaSt
(n = 251).
cReported for children with available MUAC data at discharge in the data set: WaSt (n = 203) and non-WaSt
(n = 241).
https://doi.org/10.1371/journal.pone.0230480.t005
Factors associated with time to recovery
In the multivariate Cox proportional hazard regression analysis, females (aHR = 1.10; 95% CI;
0.92–1.32; p = 0.296) and children without WaSt (aHR = 1.20; 95% CI; 0.98–1.43; p = 0.081)
had an increased probability of recovery compared with males and children with WaSt, though
the differences were not statistically significant. Age, MUAC and geographical location had
significant influence on time to recovery. Children aged 24–59 months (aHR = 1.30; 95%
CI;1.07–1.57; p = 0.007), those with MUAC 10.5–11.4cm (aHR = 2.03; 95% CI; 1.55–2.66;
p< 0.001) and MUAC� 11.5cm (aHR = 3.31; 95% CI; 2.18–5.02; p< 0.001) at admission;
and living in Moroto district (aHR = 3.34; 95% CI; 2.60–4.30; p< 0.001) and Nakapiripirit dis-
trict (aHR = 1.95; 95% CI; 1.51–2.53; p< 0.001) had increased probability of recovery
(Table 7).
Discussion
To the best of our knowledge, our analysis on the prevalence of WaSt children, their character-
istics, treatment response and outcomes; and factors associated with recovery among children
admitted to OTC is novel. Earlier analyses on WaSt were based on population-based survey
data [9, 14, 16, 26]. The findings of our analysis add to the existing evidence on children with
WaSt.
Prevalence of children with WaSt
Our study showed the magnitude of WaSt among children admitted to OTC. Nearly, half of
the children in our sample had WaSt. Previous analysis of population-based cross-sectional
data from 84 countries reported the prevalence of WaSt ranging from 0% to 8.0% and a pooled
prevalence of 3.0% (95% CI; 2.97–3.06) [9]. The finding that about half of the children admit-
ted to OTC had WaSt implies that WaSt is highly prevalent especially in high under-nutrition
burden settings. These findings indicate the need to routinely monitor this condition, as well
as to investigate whether children with WaSt are being reached through existing therapeutic
feeding programmes [9].
Characteristics of children with WaSt
WaSt was common in younger children aged 6–36 months in both sexes; with males more
affected at 1.35 male to female ratio. Thus could indicate males are more susceptible to WaSt
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Table 6. Incidence rates and median time to recovery by groups among children admitted to OTC, Karamoja.
Groups Person time (Days) Recovered (n/N)a Incidence rateb (95% CI) Median time to recoveryc (95% CI) Log rank (χ2) p-valued
All children 58249 467/ 784 8.0 (7.3–8.8) 84 (77–91)
Sex
Males 29007 226/375 7.8 (6.8–8.9) 83 (77–98) 0.75 0.388
Females 29242 241/409 8.2 (7.3–9.4) 84 (70–98)
Age groups (months)
6–23 37328 276/495 7.4 (6.6–8.3) 91 (77–105) 5.07 0.024
24–59 20921 191/289 9.1(7.9–10.5) 76 (63–90)
WaSt
No 29538 253/403 8.6 (7.6–9.7) 77(70–91) 2.39 0.122
Yes 28711 214/381 7.4 (6.5–8.5) 90(77–105)
MUAC
< 10.5 cm 12202 56/153 4.6 (3.5–6.0) 119 (105–133) 25.48 <0.001
10.5–11.4 cm 42395 369/578 8.7 (7.9–9.6) 77 (70–84)
� 11.5 cm 3652 42/53 11.5 (8.5–15.6) 63 (49–91)
Geographical location (districts)
Kaabong 25479 160/245 6.3 (5.4–7.3) 126 (108–147) 73.65 <0.001
Moroto 16025 181/298 11.3 (9.8–13.1) 63 (56–70)
Nakapiripirit 16745 126/241 7.5 (6.3–10.0) 82 (75–96)
Incidence rates and median time to recovery among the recovered children
All children 31973 467 14.6 (13.3–16.0) 58 (56–63)
WaSt
No 17223 253 14.7(13.0–16.6) 56 (51–62) 0.02 0.898
Yes 14750 214 14.5(12.7–16.6) 63 (56–63)
an/N: number recovered out of number of the participants.
bIncidence rate expressed in 1000/person/days.
cMedian time measured in days.
dMedian time to recovery compared with Log Rank test (χ2).
https://doi.org/10.1371/journal.pone.0230480.t006
than females [9, 12, 14]. The risk factors associated with WaSt are not fully understood [11,
13]. However, emerging evidence shows that younger children less than 30 months and espe-
cially males are at high risk of WaSt [8, 9, 12, 14]. Furthermore, the present analysis showed
WaSt children had a median age of 18 months compared with 12 months in those without
WaSt. Males experienced a later onset of WaSt at 18 months compared to females at 16
months. Contrary to literature, we observed a rise in WaSt among females aged 36–47 months;
largely because more females (52%) were admitted to OTC. These findings draw our attention
to prioritize and improve community-based screening activities targeted at younger children
especially those aged< 36 months. Future studies on WaSt prevalence, sex and age patterns
using population-based data would be essential to inform screening and case detection
activities.
All WaSt children were also underweight (WAZ< -2) and there was no child with stunting
alone in the current analysis. The median WAZ in WaSt was as low as -4.2 (IQR; -4.8, -3.7)
compared with -3.0 (IQR -3.7, -2.4) among the non-WaSt children. All the four anthropomet-
ric deficits; wasted, stunted, underweight and low MUAC overlapped in WaSt children. We
observed that low MUAC and underweight overlapped in the majority (92.6%) of the study
sample. This was consistent with other reports which showed that children with WaSt tend to
have worse wasting and stunting Z-scores and are all underweight (WAZ < -2.0) [8, 14]. We
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Fig 4. Comparison of Kaplan Meier survival curves of WaSt vs. non-WaSt children among children who recovered from SAM in OTC,
Karamoja.
https://doi.org/10.1371/journal.pone.0230480.g004
found a range of WAZ in WaSt from a minimum of -6.83 to a maximum of -2.8. A previous
report showed a maximum WAZ of -2.36 in WaSt suggesting the low WAZ in WaSt could be
attributed to the joint effect of wasting and stunting [8]. This highlights the potential utility of
MUAC along with WAZ for screening and detecting WaSt in children at the community and
health facility levels [8]. Future research on the utility of MUAC and WAZ to detect WaSt chil-
dren using population-based data is recommended. Further research on how to integrate com-
munity case finding and referral protocol for WaSt into the existing therapeutic feeding
programmes would be needed.
Treatment outcomes and response
In the present analysis, the rate of recovery from SAM to MAM was lower than the SPHERE
humanitarian standard of > 75% in WaSt (58.0%) and non-WaSt (65.4%) groups [27]. The
number of deaths among WaSt and non-WaSt children were not large enough to make mean-
ingful comparison of treatment outcomes. Although children with WaSt seemed to have
gained weight at a higher velocity than those without WaSt, weight velocity was below the
SPHERE humanitarian standard of� 4.0 g/kg/day [27]. The prevailing harsh environmental
conditions and the highly infectious disease burden in Karamoja might have slowed the weight
gain velocity in children in our study. More children with WaSt were discharged as non-
response to treatment than those without WaSt. The default rate of 19.8% and 23.3% among
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Table 7. Multivariable analysis on factors associated with time to recovery among children admitted to OTC, Karamoja.
Attribute Bivariate Multivariate
cHR (95% CI) p-value aHR (95% CI) p-value
Sex
Male 1 1
Female 1.08 (0.91–1.29) 0.383 1.10 (0.92–1.32) 0.296
Age
6–23 1 1
24–59 1.23 (1.02–1.48) 0.027 1.30 (1.07–1.57) 0.007
WaSt
Yes 1 1
No 1.15 (0.96–1.37) 0.121 1.20 (0.98–1.43) 0.081
MUAC
< 10.5 cm 1 1
10.5–11.4 cm 1.86 (1.43–2.42) <0.001 2.03 (1.55–2.66) <0.001
� 11.5 cm 2.47 (1.65–3.69) <0.001 3.31 (2.18–5.02) <0.001
Geographical location
Kaabong district 1
Moroto district 2.70 (2.12–3.42) <0.001 3.34 (2.60–4.30) <0.001
Nakapiripirit district 1.63 (1.26–2.12) <0.001 1.95 (1.51–2.53) <0.001
cHR and aHR stands for crude and adjusted Hazard Ratios.
https://doi.org/10.1371/journal.pone.0230480.t007
children with WaSt and non-WaSt children respectively in our analysis were above the accept-
able limit of< 15% by the SPHERE humanitarian standard [27]. In contrast to the sub-optimal
treatment outcomes seen in our analysis, some previous studies reported high performance
treatment outcomes in Ethiopia [5] and Nigeria [6]. The treatment outcomes reported in our
study raise programme effectiveness concerns; which could partly be due to health system
weaknesses or poor child care practices at the community level or both. Given the precarious
food security situation in Karamoja; the high rate of non-response in WaSt children, treatment
defaults, discharged as cured without nutritional recovery, long treatment periods coupled
with low recovery rate warrant further investigations. There is a need for further research to
uncover the factors influencing the sub-optimal treatment outcomes. Consideration should be
given to efforts to improve OTC programme effectiveness in Karamoja.
Incidence rate of recovery
Non-WaSt children had a slightly higher incidence rate of recovery compared to children with
WaSt. Nonetheless, the median time to recovery in WaSt and non-WaSt children was not sta-
tistically different. Children with MUAC< 10.5 cm at admission had the lowest incidence of
recovery which is explained by the long median time to recovery compared to those with
MUAC 10.5–11.4 cm and MUAC� 11.5 cm. A previous study indicates wasted children are
likely to experience lower incidence rates of recovery than those with edematous malnutrition
[28]. The possible explanation for the low incidence rate of recovery seen in this analysis could
be because children in this cohort had SAM. Children in Kaabong district had a longer treat-
ment duration than those in Moroto and Nakapiripirit districts. The recommended length of
stay in treatment is< 60 days as per the SPHERE Humanitarian standard and the national
IMAM guidelines [22, 27]. The variation in treatment outcomes in the districts might be due
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
to differences in the quality of services and childcare practices. Efforts to investigate and
address the difference in treatment outcomes in Karamoja are recommended.
Factors associated with time to recovery
In the present study, age, low MUAC at admission and geographical location were associated
with time to recovery. The probability of recovery was significantly higher in children aged
24–59 months (1.30 times), children with MUAC 10.5–11.4 cm (2.03 times); and
MUAC� 11.5cm (3.31 times) at admission, and in those living in Moroto (3.34 times) and
Nakapiripirit (1.95 times) districts. Sex was not significantly associated with time to recovery
at bivariate and multivariate analyses. However, it was retained in the model given the marked
sex difference of WaSt patterns in the analysis. In the model, children without WaSt had 1.20
times higher probability of recovery compared to children with WaSt though not statistically
significant. Our findings were consistent with a previous study that found children aged> 24
months had 1.25 times higher probability of recovery from SAM compared to children
aged< 24 months [29]. In contrast, older children aged> 3 years were less likely to recover
from SAM compared with younger children aged < 3 years in previous studies [28, 30]. Chil-
dren aged< 24 months in our study probably had worse severity of acute malnutrition leading
to poor treatment outcomes. From our analysis, children with very low MUAC <10.5cm,
being < 24 months old and living in Kaabong district were less likely to recover from SAM.
The low values of MUAC at admission seen in this study could be a consequence of poor
health-seeking behaviors and child care practices. Particular attention should be given to early
community case finding, referral, and treatment of SAM and WaSt to avoid poor outcomes
especially among children aged less than 24 months in Karamoja. Barriers to the uptake of
OTC services and remaining in treatment till recovery from SAM need to be investigated and
addressed.
Limitations
The use of secondary datasets taken from routine programmes in health facilities has inherent
limitations. Random error is often associated with a fixed sample size used in retrospective
studies. We obtained a ±1.68% tolerable error from our sample size of 788 using the modified
Kish Leslie formula [31]. We considered 95% level of confidence, a 3% pooled prevalence of
WaSt [9], and a design effect of 2. We concluded that between 47.02% to 50.38% of the chil-
dren in our sample had WaSt.
The exclusion of children with incomplete data, cleaning of missing data and anthropomet-
ric measurement outliers may be potential sources of selection bias. However, we censored out
of range and implausible anthropometric data. We could not censor Z-scores outliers based on
the WHO flagging criteria because the dataset was a cohort of children with SAM [24]. This
approach may have introduced selection bias in our analysis. Our analysis included only chil-
dren who had complete data on all four anthropometric deficits; MUAC, WAZ, WHZ, and
HAZ in the dataset. Selection bias may have been minimal because median age and sex distri-
bution between children in our sample and those excluded from this analysis did not differ.
Distribution of WaSt and non-WaSt had no statistical difference in the study districts. In the
study setting, acute malnutrition was screened using MUAC and pitting edema per the
national guidelines in the community.[22]. This may have introduced selection bias into our
study. Children with normal MUAC but low WHZ may have been missed in our study. There-
fore, our results should be interpreted in consideration with this limitation. Future studies
should consider using data from MUAC and WHZ–based community case search programme
settings.
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Analysis of data on patient treatment is prone to information bias due to erroneous mea-
surements by health workers and irregular patient attendance to OTC. Nevertheless, informa-
tion bias may have been minimal due to the use of standard of operation (SOP) manuals for
OTC and the technical assistance provided by CUAMM to health workers for OTC services in
Karamoja. We used the OTC programme admission criteria particularly for SAM to inform
eligibility of study participants [22] We also censored children who were discharged as cured
but had not achieved nutritional recovery in the Cox proportional hazard regression. This
might have minimized information bias due to differential misclassification of exposure given
knowledge of the treatment outcome.
Our study was cross-sectional which precluded control of all possible confounding factors
because of missing or inadequate measurement of variables. We were unable to control for
possible confounding factors such as comorbidity because they were unavailable in the dataset;
this would have explained the sub-optimal treatment outcomes and response seen in the analy-
sis. There was no interaction between variables at the multivariate analysis. A robust standard
error was used to minimize any noise in the data in the multivariate Cox proportional hazard
regression analysis. The findings of this analysis could be useful baseline information for future
studies and contribute evidence on the need to optimize the current OTC protocol to detect
and treat WaSt cases. Future research could consider the use of data from OTC programme
with WHZ� -2 or MUAC� 12.5 cm discharge criteria for recovery.
Conclusions
The high prevalence of children with WaSt in this analysis uncovers a public health priority
group that deserve particular attention by current therapeutic feeding programmes. The exist-
ing therapeutic feeding protocol could be used to detect and effectively treat children with
WaSt. However, further research work on community case finding and referral of WaSt in
therapeutic feeding programmes is recommended. Factors associated with the high rate of
non-response, long duration of treatment and low recovery rates in WaSt children need to be
identified and addressed for effective OTC programme in Karamoja.
Supporting information
S1 Study dataset.
(XLS)
Acknowledgments
We thank all staff of the district health directorate of Kaabong, Moroto, and Nakapiripirit, the
staff of UNICEF Uganda in Kampala and Moroto offices, and the staff of CUAMM, the local
government in Kaabong, Moroto and Nakapiripirit districts for supporting the fieldwork for
the OTC dataset used in this study.
Author Contributions
Conceptualization: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joanita Nangendo, Joan
N. Kalyango, André Briend, Charles A. S. Karamagi.
Data curation: Gloria A. Odei Obeng-Amoako.
Formal analysis: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joan N. Kalyango, André
Briend, Charles A. S. Karamagi.
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PLOS ONE Concurrently wasted and stunted children in outpatient therapeutic feeding programme in Karamoja, Uganda
Funding acquisition: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joan N. Kalyango,
Charles A. S. Karamagi.
Investigation: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joan N. Kalyango, André
Briend, Charles A. S. Karamagi.
Methodology: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joanita Nangendo, Joan N.
Kalyango, Mark Myatt, André Briend, Charles A. S. Karamagi.
Project administration: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joanita Nangendo,
Joan N. Kalyango, Charles A. S. Karamagi.
Resources: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joel Conkle.
Supervision: Henry Wamani, Ezekiel Mupere, Joan N. Kalyango, Mark Myatt, André Briend,
Charles A. S. Karamagi.
Visualization: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joel Conkle, Richmond
Aryeetey, Joan N. Kalyango, Mark Myatt, André Briend, Charles A. S. Karamagi.
Writing – original draft: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joan N. Kalyango,
Mark Myatt, André Briend, Charles A. S. Karamagi.
Writing – review & editing: Gloria A. Odei Obeng-Amoako, Henry Wamani, Joel Conkle,
Richmond Aryeetey, Joanita Nangendo, Ezekiel Mupere, Joan N. Kalyango, Mark Myatt,
André Briend, Charles A. S. Karamagi.
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