The Triple Burden: How Dietary Diversity, Maternal Education, and Poverty Drive the Malnutrition Syndemic in Sokoto State, Nigeria

Abstract

Childhood malnutrition in Northern Nigeria remains persistently high. However, the integrated relationship between visible anthropometric failure, underlying biochemical derangements, and socio-demographic determinants has been inadequately characterized. This study aimed to identify independent predictors of malnutrition and quantify the burden of “hidden hunger” among children under five years in Sokoto State, Nigeria. A community-based cross-sectional study was conducted among 150 mother-child pairs attending primary health centers across twelve Local Government Areas in Sokoto State between September 2024 and September 2025. Anthropometric measurements (weight, height, mid-upper arm circumference) and venous blood samples for biomarker analysis (prealbumin, C-reactive protein, serum retinol, hemoglobin, albumin, zinc) were collected. Multivariable binary logistic regression identified independent predictors of underweight (weight-for-age Z-score < -2 standard deviations), with results reported as adjusted odds ratios (AOR) and 95% confidence intervals (CI). The prevalence of underweight was 83.3% (95% CI: 76.5–88.6), with 20.0% severely underweight. Vitamin A deficiency affected 91.3% (95% CI: 86.7–95.9), zinc deficiency 73.3% (95% CI: 66.2–80.4), and anemia 78.7% (95% CI: 72.1–85.3). Critically, 72.3% of children classified as “normal” by mid-upper arm circumference (>12.5 cm) had vitamin A deficiency, and 38.3% had three or more concurrent deficiencies. Multivariable analysis identified three independent predictors: low household dietary diversity (≤4 food groups) was the strongest predictor (AOR = 4.2, 95% CI: 1.8–9.8, p = 0.001); low maternal education (none/Qur’anic only) (AOR = 3.1, 95% CI: 1.3–7.4, p = 0.011); and extreme household poverty (<₦20,000/month) (AOR = 2.8, 95% CI: 1.2–6.5, p = 0.018). Systemic inflammation (elevated C-reactive protein >3 mg/L) affected 78.0% of children, with a dose-response relationship from normal (51.1%) to moderate acute malnutrition (78.7%) to severe acute malnutrition (92.9%) (p < 0.001). The malnutrition crisis in Sokoto State represents “a syndemic” driven by the synergistic interaction of dietary inadequacy, maternal educational deprivation, and extreme poverty. The high prevalence of hidden hunger among anthropometrically normal children reveals that sole reliance on anthropometry misses the majority of micronutrient deficiencies. These findings mandate integrated, multi-sectoral interventions addressing dietary diversity, women’s education, poverty alleviation, and infection control simultaneously.