Spirulina Project – Efficacy Study on Child Malnutrition
Final Report
Kanakantapa, Chongwe District

June 2013
Preparedby:Programme Against Malnutrition
and Alliance Forum FoundationACKNOWLEDGEMENTS
The Spirulina pilot research was conducted in Kanakantapa, Chongwe district by the
Programme Against Malnutrition and Alliance Forum Foundation. The spirulina study
was co-funded by Alliance Forum Foundation and Programme Against Malnutrition and
was authorized by the University of Zambia Biomedical Research Ethics Committee(UNZAREC).
Sincere thanks go to Dr. Charles Msiska and Agness Aongola, Ministry of Health;
Dorothy Sikazwe, Ministry Community Development, Mother and Child Health;Charles Simulunda and Nancy Sakala, Ministry of Agriculture and Livestock and,
Albertina Kapeshi, National Food and Nutrition Commission for their technical support
and guidance during the study period.
Many thanks go to Dr. Takashi Hanada and Dr. Toru Rikimaru (JICA), Dr. Masato Yasui
and Dr. Toru Takebayashi (Keio University), Dr. Satoshi Morita (Yokohama City
University), and Dr. Shonchoy Abu (IDE-JETRO) for their comments and general
support during the design and implementation of the research.
The Ministry of Health, Ministry of Agriculture and Livestock, Ministry of Community
Development, Mother and Child Health, National Food & Nutrition Commission(NFNC), Chongwe District Health Management Team and District Agriculture Officeand University of Zambia Biomedical Research Ethics Committee (UNZAREC) are
acknowledged for the support and supervision provided during the study.
More notably many thanks go to the parents who willingly allowed their children toparticipant in the study; Kanakantapa Cassava Women Processors for having mixed anddistributed the porridge blends and the Child Growth Promoters who ensured that therequired children’s data was regularly recorded.

Table of Contents

Executive Summary ......................................................................................................... 1
1

Introduction ............................................................................................................. 2

1.1 Malnutrition in Zambia ................................................................................... 3
1.2 Food and Nutrition in Zambia ..................................................................... 3
2 Project Overview ..................................................................................................... 4
2.1 Project Objective .............................................................................................. 4
2.2 Efficacy of Spirulina ......................................................................................... 4
3 Survey Design........................................................................................................... 6
3.1 Materials and Methods .................................................................................... 6
3.2 Distribution of Porridge Blends ...................................................................... 6
3.3 Project Area ....................................................................................................... 7
3.4 Project Organization ........................................................................................ 8
3.5 Ethical Issues ................................................................................................... 10
3.6 Malnutrition Indicators (HAZ / WAZ / MUACZ) ....................................... 10
4 Analysis ................................................................................................................... 12
4.1 Descriptive Statistics ...................................................................................... 12
4.1.1
Balance Check at Baseline ...................................................................... 12
4.1.2
Descriptive Analysis on May and February Data ................................. 13
4.1.3
Proportion of Infected Children ............................................................. 14
4.2 Regression Analysis ........................................................................................ 14
4.2.1
Quantitative Strategy .............................................................................. 14
6 Discussion ............................................................................................................... 20
6.1 Weight for Age Z-score and Mid Upper Arm Circumference Z-score ...... 20
6.2 Limitations of the Study ................................................................................. 20
6.3 Comparing Results with Previous Studies ................................................... 21
6.4 Other Effects ................................................................................................... 22
7 Conclusion .............................................................................................................. 23
Appendix 1 .................................................................................................................... 24
Reference ....................................................................................................................... 26

Tables
Table 1: Sample size（counts on post-replacement children） ....................................... 7
Table 2: Average values for the three indicators - Kanakantapa ...................................... 8
Table 3: Explanation of Three Indicators ....................................................................... 10
Table 4: HAZ, WAZ and MUACZ Balanced-Check result in Base line data ................ 12
Table 5: Differences between February 2013 and April 2012 ........................................ 13
Table 6: Headcount Ratio of Malnourished Children ..................................................... 13
Table 7: Number of Sick Children by Disease ............................................................... 14
Table 8 : Impact of Spirulina on Child Growth .............................................................. 16

Figures
Figure 1: Under Five Rate of Malnutrition by Region (1990-2010) ................................ 2
Figure 2: Distribution of stunted under 5 Children in Africa ........................................... 3
Figure 3: Map of Kanakantapa Resettlement Scheme...................................................... 8
Figure 4: Operational Structure ........................................................................................ 9
Figure 5: Growth Curves in Kanakantapa .......................................................................11
Figure 6：Basic Concept of DID Model........................................................................ 15
Figure 7: The proportion of households eating sweet potato/nshima during the project
period ................................................................................................................. 17
Figure 8: Proportion of Households Consuming Food by Category .............................. 18
Figure 9: Households that did not Consume Protein Rich Foods per Month ................. 18

Acronyms
AFF
CGP

Alliance Forum Foundation
Child Growth Promoter

DALYs

Disability-Adjusted Life Years

DHMT

District Health Management Team

ZDHS

Zambia Demographic and Health Survey

DID

Difference in Differences

FAO

Food and Agriculture Organization

IISAM
JETRO

Intergovernmental Institution for the use of Micro-algae
Spirulina Against Malnutrition
Japan External Trade Organization

JICA

Japan International Cooperation Agency

LIC

Low Income Countries

MDGs

Millennium Developing Goals

MUAC

Mid-Upper Arm Circumference

MUACZ

Mid-Upper Arm Circumference Z score

NFNC

National Food and Nutrition Commission

PAM

Programme Against Malnutrition

SADC

Southern African Development Community

UNICEF

United Nations Children’s FundUNZAREC

University of Zambia Biomedical Research Ethics Committee

USAID

United States Agency for International Development

WHO

World Health Organization

Executive Summary
This study tested the efficacy of spirulina on malnourished children in Zambia. Zambia
is situated in sub Saharan Africa where the rate of malnutrition especially stunting isvery high among under five children. Spirulina is a blue green micro algae thatcomprise abundant nutrients such as protein, minerals and vitamins.
The study was conducted from April 2012 to February 2013. The sample size comprised
sixty (60) children who were divided into two groups: spirulina treatment group and thecontrol group. The outcome of taking spirulina regularly was compared by collecting
anthropometric data every month from June 2012 to February 2013.
The results show improvement for all indicators to be higher in the treatment groupcompared to the control group. Furthermore, the regression result shows that spirulina
intake leads to 0.231 points more improvement in Height for Age Z-score (HAZ) (CI:-0.055 – 0.516). As for Weight for Age Z-score (WAZ) and Mid-Upper Arm
Circumference Z-score (MUACZ), spirulina intake had higher effect by 0.086 point and
0.377 point respectively, though not statistically significant.
This may be attributed to the relatively high average values of WAZ and MUACZ
before the treatment (WAZ: -0.7, MUACZ: -0.11). Both groups had relatively mild
malnutrition in reference to the two indicators in contrast to the seriously low value of
HAZ - Score, which was below -2 points. WAZ is a measure of both long and short term
nutritional adequacy while MUACZ reflects a recent and severe process that leads tosubstantial weight loss.
WAZ and MUACZ show insignificant effect because they are sensitive to short termchanges and may fluctuate from month to month. This may explain why spirulina intake
did not cause any statistically significant difference to WAZ and MUACZ. On the other
hand, a relatively high effect was observed in HAZ – score, a chronic malnutritionindicator. The results imply that spirulina consumption is effective in Zambia where
severe “stunting” is high in the country.

11

Introduction

Infant and child malnutrition is one of the most serious health problems in developing
countries and Zambia is no exception. Malnutrition impairs a child’s physical andmental development and can result in lower IQ and compromised immunity. Plletuer etal (1995) reported that 56% of children’s deaths in developing countries are caused bymalnutrition. According to the World Health Organization, underweight in low income
countries is a major health risk in infants and young children.
Improving the nutritional status of infants and young children is cardinal to theattainment of Millennium Development Goals (MDGs) which were set for countries toreduce poverty, foster people’s development and to improve their living conditions.
MDG No. 1 to halve, between 1990 and 2015, the proportion of people who suffer fromhunger and MDG No. 4 to reduce by two thirds, between 1990 and 2005, under-five
mortality rate are particularly important.
Although the nutritional status of under-five children is improving worldwide, African
children still suffer from high rates of malnutrition. Figure 1 below shows that the rateof underweight children in Africa between 1990 and 2010 has not changed much, whilethat of Asia and Latin America and Caribbean has significantly reduced.

Figure 1: Under Five Rate of Malnutrition by Region (1990-2010)

2

1.1

Malnutrition in Zambia

Sub-Saharan Africa has one of the most serious rates of chronic malnutrition in theworld. In Zambia, chronic malnutrition or stunting affects 45% of under five children
and remains the most common nutritional disorder, above the Sub-Saharan Africa
average of 42% (ZDHS, 2007) and is the eighth highest rate in the world (Figure 2).
Besides stunting, 5 % of the children are wasted while 15 % are under weight.
In addition, micronutrient deficiencies have enormous consequences to individuals andsociety through reduced productivity. 54% and 53 % of the children in Zambia sufferfrom vitamin A deficiency and iron deficiency respectively (CSO, 2009). Under fiveMortality Rate (U5MR) is at 119 per 1000 live births (ZDHS, 2007).

(Source: UNICEF, 2011)

Figure 2: Distribution of stunted under 5 Children in Africa

1.2

Food and Nutrition in Zambia

Maize and cassava are the main staple foods albeit maize is consumed by over 90% of
the population. Nshima prepared from maize or cassava is eaten with different types ofrelish such as vegetables, meat, fish, eggs and legumes. However, the Zambian nutrition
profile shows that 60% of households do not afford 3 meals per day (FAO, 2009) whichleads to inadequate nutrient intake and malnutrition.
The dietary energy supply was 1 905kcal per capita/day in 2000-2002. Households did
not meet the estimated energy requirement of 2056kcal per capita/day. Carbohydrates
such as cereals and starchy roots are the main source of energy which account for 80%
3

of the total energy intake. The level of intake suggests a general insufficient intake ofother essential nutrients as well such as protein and lipids.
2

Project Overview

The spirulina pilot study was conducted in Kanakantapa, Chongwe district. The study
covered households engaged in small scale farming and have similar dietary patterns
and lifestyle. The mothers and children who participated in the study continued with
their normal day to day activities during the pilot study undertaken from May 2012 toFebruary 2013.
2.1

Project Objective

The aim of the spirulina pilot project was to explore the effectiveness of spirulina on
malnourished under five children. Three numeric indicators, Height for Age Z-score(HAZ), Weight for Age Z-score (WAZ), and Mid Upper Arm Circumference Z-score(MUACZ) were used to evaluate the effectiveness of spirulina.
2.2
Efficacy of Spirulina
Spirulina is a blue green micro algae indigenous to Africa. Spirulina can sustainably
contribute to alleviating malnutrition in Zambia because it is rich in various nutrients, iseasy to produce, and can be added to many traditional foods.
Spirulina contains various nutrients such as protein, beta-carotene, iron, and vitamin B
which are usually deficient in undernourished populations. Kwashiorkor (caused byprotein deficiency), vitamin A deficiency, and anaemia (caused by iron deficiency) arecommon public health nutrition problems in Zambia and increased intake of spirulina
can help control these deficiencies.
The United Nations and other international bodies recognize the importance of spirulina
in combating malnutrition. The United Nations Economic and Social Council
established the Intergovernmental Institution for the use of Micro-algae Spirulina
Against Malnutrition (IISAM). The organization works to promote the use of spirulina
in tackling malnutrition.
The ease with which spirulina can be cultivated is attractive. Spirulina needs less waterand energy compared with other protein rich foods such as soybeans and meat and is
cost effective as it takes only takes two weeks to grow. The abundant rivers and sunlightin Zambia provide a suitable environment for growing spirulina.
From a nutrition point of view, spirulina’s blue and green colours are useful. The
colours help to raise awareness on the rich nutrient content of spirulina.
4

2.3

Significance of Spirulina Project

Health promotions targeting knowledge enhancement on maternal and child nutritionand direct nutrient supplementation are often utilized as nutrition intervention
programmes in developing countries. The Lancet in 2008, published a series of papers
on maternal and child under nutrition in which the need to focus on the crucial period
from conception to a child’s second birthday was identified.
Various intervention programmes were evaluated based on their cost-effectiveness and it
was concluded that breastfeeding promotion and support, vitamin A supplementation,and zinc supplementation have the largest effect on child under nutrition. As describedabove, spirulina can contribute to increased supply of vitamin A and balanced protein.
There are few studies which document the effectiveness of spirulina. Simpore et al.
(2006) reported that spirulina was effective in undernourished children in Burkina Faso.
However, the study did not avoid the other factors which could have affected the results.
K. F. Michaelson et al. in 2009 pointed out that the evidence of spirulina efficacy wassparse and further investigations were required. In this respect, the spirulina pilot study
is the first in Zambia that examined the effectiveness of spirulina on malnourishedchildren and contributes to accumulation of sound evidence of spirulina’s efficacy.

5

3
3.1

Survey Design
Materials and Methods

A total of 60 malnourished under five children between the ages of 18 - 36 months wereselected from a sample of 295 children who were screened at Kanakantapa Rural HealthCentre, Chongwe district using the weight for age, height for age and MUAC indicators.
The 60 chronically least-nourished children were evaluated on an index generated from
simple summation of HAZ and WAZ. The division into treatment and control groups
was undertaken by putting the 60 samples in ascending order from mild to the severely
malnourished and evaluated by simple summation of WHZ and MUACZ, whichindicate acute-malnutrition.
Thereafter, the sample children were alternatively divided into treatment and control
groups from the top of the list. The two groups were further adjusted to ensure children
were balanced in relation to sex, geographical area and the rate of malnutrition to avoid
generating any bias in the initial level of malnutrition. This sampling method was not
pure-random sampling. The t-test results in Table 4 for both treatment and control
groups prove that there was no difference at 10% significance level.1 The selectedmalnourished children comprised:a) Treatment Group, 30 children provided with spirulina andb) Control Group, 30 children without spirulina.
3.2

Distribution of Porridge Blends

Five (5) kg of roller meal2 mixed with 300g of spirulina, 0.8 kg sugar and 0.1 kg salt
was distributed monthly to the target group to ensure compliance. The control group
was provided with the same blend but without spirulina. Each child in both the control
and target groups was fed porridge twice a day in the morning and afternoon.
The porridge blends were provided for nine (9) months i.e. June 2012 – February 2013.
Physical measurements of weight, height and MUAC for both groups were recorded
every month by trained Child Growth Promoters (CGPs) at each Health Post.
Participating children whose mothers or caregivers did not attend growth monitoring
sessions were followed up by CGPs unless they had gone out of the village for a while
1
A few children dropped out from the project during the study due to father’s opposition or moving out of thevillage. In the first month of the project, the children were replaced. The number of replaced children was 7 (6treatment group, 1 control group). The balanced-check result which proves HAZ and WAZ are almost balanced isgiven below. Treatment group had moderate to severe initial value of HAZ and MUACZ compared to the control
group which could have been due to the selection and replacement of children who dropped.
2
Roller meal is made from maize and has an extraction rate of about 90%.

6

due to economic factors or family issues.
In case of missing values, the child was omitted from the analysis. However, children
who could not continue participating in the project for various reasons after the first twomonths were replaced. Thereafter, no replacement was made and Table 1 shows thenumber of samples in each month.

3.3

Table 1:

Sample size（counts on post-replacement children）

2012

2013

Health
Post

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

F
H
K

30
12
18

16
12
17

28
12
18

26
11
15

28
10
16

20
10
17

26
11
11

27
10
17

28
10
15

26
10
16

Total

60

45

58

52

54

47

48

54

53

52

Project Area

Kanakantapa Resettlement Scheme in Chongwe district, Lusaka province was selected
for implementing the pilot project. Kanakantapa is located approximately 60 km from
Lusaka city and the project covered Health Posts F, H and K as shown in Figure 3
below.
Kanakantapa was selected because neither government nor NGOs were distributing
food supplements such as Plumpy’nut3, thus there was no influence from other projects.
In addition, the involvement of the Programme Against Malnutrition (PAM) in
conducting the study made it easier for the community to gain confidence and to bewilling to participate in the study.
The proportion of undernourished children in Lusaka province is the lowest in the
country, however 37.2% of children are stunted and 9.7% are wasted (ZDHS, 2007).
When the children were screened in this study area in May 2012, 36.5% of population
was stunted and 5.1% were wasted. The results of the screening undertaken in the study
area correlated with the provincial averages.

3

A peanut-based paste distributed in small sachets7

Figure 3: Map of Kanakantapa Resettlement Scheme
Table 2: Average values for the three indicators - Kanakantapa
Obs
Health Post H
Health Post F
Health Post K
Total

80
116
99
295

Average
HAZ

WAZ

MUACZ

-1.316-1.366-1.306-1.332-0.289-0.355-0.151-0.2690.083-0.474-0.065-0.186

In addition, Kanakantapa has limited access to medical facilities. Chatt and Robert(2010) revealed that about 1/3 of the population did not go to a clinic even if theyneeded medical assistance because of the difficulty in accessing a clinic compounded byinadequate medical supplies. Poor health facilities are acknowledged as a common
feature in the country (MoH, 2005).
3.4

Project Organization

The project was approved by University of Zambia Biomedical Research Ethics
Committee (UNZAREC), Ministry of Health, the National Food and Nutrition
Commission (NFNC) and, District Health Management Team (DHMT). Meetings to
discuss the purpose of the study were held with community leaders and local politicians.
A steering committee comprising the Ministries of Health, Agriculture and Livestock,
Community Development, Mother and Child Health; National Food and Nutrition
Commission, Programme Against Malnutrition and Alliance Forum Foundation was
8constituted to monitor and supervise the project.
Quarterly progress reports were submitted to the Ethics Committee and government
after 3 months and 6 months of project implementation.
Mixing, packaging and distribution of porridge blends was undertaken by the
Kanakantapa Cassava Women Processors. The women processors were engaged
because they own the Cassava-Processing Centre which has good facilities; because of
their processing skills and to encourage ownership of the project in the study area. The
blends were distributed to each Health Post once a month, see Figure 4 below.
Anthropometric measurements were conducted by experienced CGPs who were further
trained by the National Food and Nutrition Commission. CGPs in addition monitoredcompliance by regularly visiting participants’ households. In addition, CGPs
administered the 24 Hour Recall once a month for each child. Disease incidence over a
period of one month and comments from mothers or caregivers were also recorded.
The data was collected and submitted to PAM and AFF. AFF Tokyo office conductedstatistical analysis and consulted with PAM after which reports were developed andsubmitted to relevant authorities.

Figure 4: Operational Structure

9

3.5

Ethical Issues

The research project was approved by UNZAREC in February 2012. The study ensured
voluntary participation, informed consent, and confidentiality of mothers throughout the
research period. Careful attention was given to children as much as possible to avoid
any risk of harm during the study. Stakeholders’ participation was also acknowledged
and supported throughout the study period.
3.6

Malnutrition Indicators (HAZ / WAZ / MUACZ)

Three indicators were used to assess the nutritional status of under five children: height
for age Z-score - HAZ, weight for age Z-score - WAZ and mid – upper arm
circumference Z-score - MUACZ. HAZ is an indicator of chronic malnutrition, while
WAZ and MUACZ are indicators of chronic and current malnutrition and, acutemalnutrition respectively.
WHO Multicentre Growth Standards (WHO, 2006) were used as reference for thenutritional status in the study. WHO and UNICEF define stunting as children whose
height – for – age Z-score is below minus two standard deviation (HAZ <-2) andunderweight as children whose weight – for – age Z-score is below minus two standard
deviation (WAZ <-2). If these indicators are minus three (-3) standard deviation andbelow, the child’s nutritional status is said to be “severe”.
Table 3: Explanation of Three Indicators

Figure 5 below shows the height and weight growth curves for 295 children in
Kanakantapa as plotted during the baseline study in May 2012. The standard growth
curve (HAZ / WAZ =0) is the third line from the top (blue line), and the bottom line
shows -2SD (red line). Many children screened fell below the blue line. Few children
were underweight (WA Z-score <-2) but many children were stunted (HA Z –score <-2).
Figure 7 and 8 below showed that the main staple food in the study area is maize(carbohydrate), and households had inadequate foods rich in protein and micronutrients.
This may be one possible explanation for the high rate of stunting in Kanakantapa.

10

(cm)

Height for Age (Female) (n=161）(cm)

Height for Age (Male) (n=134)

(kg)

(kg)

Weight for Age (Female)(n=161)

Weight for Age (Male) (n=134)

Figure 5: Growth Curves in Kanakantapa
The Anthropo4 software, designed by WHO, was utilized to calculate growth indicators
using the height, weight, and MUAC data. Length for age for children under 2 years old,and height for age for children aged 2 and above were measured according to WHO
guidelines.

4

http://www.who.int/childgrowth/software/en/11

4

Analysis

4.1

Descriptive Statistics

Data analysis involved comparison of averages between target and control groups oncollected indices; HAZ, WAZ and MUACZ. Chapter 4 is firstly a check of the balanceof three indices using the baseline data collected in May; Chapter 4.2.2. Chapter 4.2.3,
the difference between February 2013 and April 2012 is analyzed to determine howmuch of the level of improvement in the nutritional status of children was due tospirulina.
4.1.1

Balance Check at Baseline

To assess the effectiveness of spirulina, the most desirable condition is to ideally havechildren at the same level of development between treatment and control groups. Above
all, the initial nutritional status must be the same. The larger the difference in the initial
data, the more serious is the bias in the results.
A t-test to check whether any bias existed in the explained valuables (HAZ, WAZ,
MUACZ) between the two groups was conducted. The result did not show any
statistically significant difference, see Table 4 below. However, it is important to notethat the difference in MUACZ (0.23) is not small compared to the other two indices,thus the need for paying closer attention to MUAC in the subsequent analysis.
Table 4: HAZ, WAZ and MUACZ Balanced-Check result in Base line data
(1)

HAZ

(2)

WAZ

(3)

MUACZ

Treatment

Control

Treatment

Control

Treatment

Control

Mean-2.252

-2.26

-0.71

-0.67

0.01

-0.22

Variance

0.667

0.831

0.39

0.9

1.2

0.91

Observation

30

30

30

30

30

29

Degree offreedomt-valueP-value(one-side)
One-side test
P-value(two-side)
Two-side test

57

50

56

0.033

-0.21

0.84

0.487

0.42

0.2

1.672

1.68

1.67

0.974

0.83

0.41

2.002

2.01

2

12

4.1.2

Descriptive Analysis on May and February Data

To measure the average improvement of children's nutritional indicators, the difference
between February 2013 and May 2012 was calculated, which is summarized in Table 5.
Each index is standardized into z-score value. If the difference of the two periods is
positive, the implication is that the child grew as expected when evaluated against thestandard children’s growth chart.
On average, the growth of children in the treatment group was higher than the control
group for all the three indicators. Of the three indicators, WAZ had the least average
improvement compared to the considerable improvement in HAZ (0.47: treatment, 0.34:
control).
Table 6 illustrates the number of undernourished children who became healthier. Table 6
shows the headcount ratio of 60 undernourished sample children, defined by two
standard lines: that is z<-2 and z<-1.5. In total, 58% of children were “stunted”(HAZ<-2) in April. The proportion of stunted children decreased to 34.6% in February
2013. In the same way, 8% of children were “underweight” (WAZ<-2) in April, but
decreased to 3.8% in February.
Table 5: Differences between February 2013 and April 2012
Baseline
Change

WAZ

HAZ

MUAC

Treatment-0.71-2.2520.01

Control

-0.67

-2.26

-0.22

Treatment

0.12

0.47

0.35

Control

0.02

0.34

-0.03

May and Feb

Table 6: Headcount Ratio of Malnourished Children
HAZ
Treatment
Control
ALL

WAZ

MUACZ

April

Feb

April

Feb

April

Feb

<-1.5

73.3%

51.9%

20.0%

14.8%

3.3%

3.7%

<-2

56.7%

37.0%

13.3%

7.4%

3.3%

0.0%

<-1.5

76.7%

68.0%

16.7%

20.0%

10.0%

4.0%

<-2

60.0%

32.0%

3.3%

0.0%

6.7%

0.0%

<-1.5

75.0%

59.6%

18.3%

17.3%

6.7%

3.8%

<-2

58.3%

34.6%

8.3%

3.8%

5.0%

0.0%

13

4.1.3

Proportion of Infected Children

Mothers or caregivers were asked whether the children had malaria, a cough, fever anddiarrhoea in the months preceding the social economic survey that was conducted in
December 2013 according to the categories listed in Zambia Demographic and Health
Survey (ZDHS, 2007). The duration of recall is set at 6 months for malaria and 2 weeks
for other illnesses.
The number of sick children in each group was recorded and thereafter, a test was
conducted to determine whether there was a significant difference. The results presented
in Table 7 showed that the spirulina treatment group had fewer sick children due tomalaria than the control group. However, there was no significant difference for theother illnesses.
Table 7:

Number of Sick Children by Disease

Y=infected/N
Disease＝notinfected

Malaria
Fever
Coughing
Diarrhoea

4.2

Group

Treatment Control

total Chi-square Pvalue

Y

4

11

15

N

24

17

41

Y

8

10

18

N

20

17

37

Y

8

10

18

N

20

18

38

Y

8

6

14

N

20

22

42

4.462

0.03470.447

0.50360.327

0.5671

0.381

0.5371

Regression Analysis

According to descriptive statistics, the average point of improvement for eachnutritional index is larger in the treatment group than the control group. However, it isunclear whether the average difference was purely caused by spirulina because a child’sdevelopment status can be correlated to many other factors. To account for such factors,
regression analysis was conducted. Given below is an explanation of the model used toestimate the pure impact of spirulina on child growth followed by the results.
4.2.1

Quantitative Strategy

To determine the impact of spirulina, the Difference in Difference (DID) model was
14

used. The following formula shows how the variable was calculated.
reatmentTim: Output variables (HAZ, WAZ, MUACZ): Takes 1 if child is in treatment group, 0 otherwise
Tim : Time specific effect: group specific effect
The DID analysis is a popular method widely used in project evaluation analysis. The
basic concept of the model is to compare average point “before” and “after” theprogramme between the treatment group and the control group. The objective of thismodel is to estimate the pure project effect excluding both time-specific effect andgroup specific-effect. Coefficient
represents the pure project impact in the equation
above. This concept is summarized in Figure 6 below.

Figure 6：Basic Concept of DID Model
Time specific-effect captures seasonally specific factors common to both treatment andcontrol groups. For example, variation in feeding caused by seasonality between April
and February, see Figures 7-9 below or the effect of blended mealie meal given to thecontrol group has a time-specific effect. Mealie meal distribution is one of thetime-specific effects, because occurrence of the intervention differs depending on the
periods. No distribution was conducted in April 2012, the baseline month. Distributionof mealie meal was undertaken from June 2012 to February 2013.
Group specific effect captures and controls individual trends correlated with childnutrition such as age and diseases. In this sampling method, unobservable variables may
be unevenly distributed among the two groups. Therefore, a method to control their15

influences was applied. These group-specific factors are able to capture the effect oftime-invariant factors. The DID model is robust against both time-specific and groupspecific factors.
4.2.2

Regression Results

Table 8 shows the results of the regression. It is evident that the time-treatment crosscoefficient (β) is the pure project effect. Regression analysis on HAZ indicates that thetreatment group improved by 0.231 points more than the control group on average. Thisis statistically significant at 10% level. In addition although insignificant, the regression
analysis shows that the coefficient β is positive by 0.086 point on WAZ and 0.377
points on MUACZ.
Table 8 :Impact of Spirulina on Child Growth
HAZ

Mean

value

baseline

WAZ

MUACZ

at

Note

** p<0.01,
-2.26

-0.69

-0.10

** p<0.05,* p<0.1

0.22

0.0117-0.0732

Coefficient(0.17)(0.26)(0.21)

P-value(0.33)(0.97)(0.76)

SE[-0.518 , 0.959][-1.126 , 1.149][-0.971 , 0.825]

0.231*

0.08610.377(0.07)(0.16)(0.28)

P-value(0.07)(0.64)(0.31)

SE[-0.598 , 0.770][-0.824 , 1.578]

Time (α)

Treatment Time(β)[-0.0547 ,
0.516]

Sample size

108

111

111

Number of children

58

60

60

Housman p-value

0.77210.99930.4064

5.0

95% CI
Coefficient

95% CI

Dietary Patterns

Food diversity was investigated in Kanakantapa using the 24 hour recall method.
Project participants were asked what the children ate in the 24 hours preceding the dateof data collection. The findings are shown in Figures 7 – 9 below.
16

In Kanakantapa, Chongwe district,nshima made from maize and sweet
potatoes are often consumed as staples.
Figure 7 shows the proportion ofhouseholds that consumed those twostaples during the study period.
Nshima was consumed by more than
90% of the households throughout the
project period. On the other hand,sweet potato was consumed by morethan 50% of the households from
June to July, while only few ofhouseholds consumed sweet potatoes

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
6月 7月 8月 9月 10月 11月 12月 1月 2月
sweet potato

nshimaFigure 7: The proportion of households eating
sweet potato/nshima during the project period

after October.
In Kanakantapa, maize nshima is the staple food. However, maize protein is deficient in
tryptophan, one of the essential amino acids. The low quality protein in maize can leadto serious health problems if dietary diversity is limited. One such health problem iskwashiorkor, due to protein deficiency in children who consume enough calories, but
are still malnourished because they do not get enough protein.
Another health problem sometimes related to maize consumption is pellagra, a vitamin
deficiency that occurs when one does not get enough niacin or tryptophan. In 2002, anoutbreak of pellagra was reported in the southern part of the country (Reliefweb, 2002)
signifying the importance of consuming foods that contain enough tryptophan toprevent malnutrition.
Other foods such as meat, fish, and vegetables are also consumed as side dishes. Figure
8 below shows the percentage of studied households confirming the consumption ofeach food category: meat/egg/dairy products; fish, vegetables, and pulses. Vegetables,
which are a source of vitamins and minerals are consumed by almost 80% ofhouseholds. Of the other foods (meat/egg/dairy products, fish, and pulses), fish is
consumed by 30-50% of households.

17

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%

meat/egg/dairy
productsfish
vegetables
pulsesFigure 8: Proportion of Households Consuming Food by Category

In comparison, meat/egg/dairy products and pulses are consumed by fewer households,
10-40% and 5-40% respectively. There were variations through the project period. The
results indicate that protein intake of the population is affected by seasonality or otherfactors and thus varies from month to month.
To understand how such factors may affect household diets, an evaluation of thepercentage of households that did not eat protein-rich foods (meat/egg/dairy products,
fish, and pulses) was conducted. The proportion in each month is shown in Figure 9
below. The percentage varied from month to month although generally the proportion ofhouseholds increased from October 2012 to February 2013.
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%

Figure 9: Households that did not Consume Protein Rich Foods per Month18

Although human growth is affected by both hereditary and environmental factors,
children in this age group are more strongly affected by environmental rather thanhereditary factors. The study findings revealed chronic inadequate consumption ofprotein as shown in Figure 8, inadequate of staples and side dishes in the dry season
especially between October and January (Figure 7 and 8).
The results show that one of the obstacles for improving child development in this study
area is not being able to access and feed children with sufficient amounts of nutritious
foods. Spirulina can thus be expected to contribute remarkably to improve growth ofunder five children.

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6Discussion
6.1 Weight for Age Z-score and Mid Upper Arm Circumference Z-score

There are three possible reasons for obtaining insignificant Treatment_Time ( β )coefficient when WAZ and MUACZ variables are analyzed.
A) Children had mild malnutrition as seen in the initial average value of -0.7 point for
WAZ and -0.11 for MUACZ in contrast to HAZ which was more than -2 points(HAZ: -2.25 point). The two indicators are sensitive to recent changes in dietaryintake and infection. Thus, the children’s growth was more likely to have fluctuatedduring the study period giving statistically insignificant difference.
a) Although spirulina is a nutritious food that contains a variety of important nutrientsfor child development such as zinc, protein and minerals, it does not contain muchenergy in 10g. An adequate diet particularly in energy is necessary for child growthand building of muscle and fat tissues.
b) Weight and MUAC largely fluctuated from one month to month because they areaffected by seasonal or individual factors such as seasonal food availability, disease
incidence and daily activity. Spirulina’s effect can be concealed by such factors.
Further, the study was only conducted for 9 months, a timeframe which is not enough toassess the long term impact of spirulina. A much longer study with a bigger sample size
could reveal significant results on the effect spirulina for the two indicators, WAZ andMUACZ.
6.2

Limitations of the Study

The following were the limitations of this study.
a) The study did not include a “double blind test” with a placebo. Mothers or
caregivers knew the children or households that were in the treatment group andthe control group. This might have led to creating biases in their reactions5.
b) Because it was entirely up to the study children to eat porridge or not, there wasstill a problem of “compliance”. The assumption was that the study children in
the control group ate the blended porridge as recommended. However, sharing
5

The direction of bias is not uniquely defined. For example, the result was upwardly biased if only control children
sold porridge because control children eat less amount of porridge. However, the mother could earn cash income.
Nutritional indices might have been improved by Income effect (such as other food intervention). It might haveinduced downward bias. Moreover, the mother might have increased other food intervention due to porridge
consumption decreasing. It causes the amount of other food intake is fewer in control group meaning the result wasbiased downwardly.

20

the porridge with other family members affected compliance. If this was the case,the amount of porridge consumed was no longer the same between treatment
and control groups.
The same can be said of the treatment group. If the treatment group children
disliked spirulina and refused to eat, the quantity of porridge consumed between
the treatment and control groups was not the same.
However, the study revealed high acceptance of spirulina among the treatmentgroup and perhaps the spillover effect was minimal based on the results obtained
for the three indicators.
c) The few drop-outs might have influenced the results. Because the original
sample size was small, the population was susceptible to any changes. When thereasons for dropping out are correlated with being in treatment or control group
and, are correlated with unobservable variable which affects health status, theresult could be biased.
For example, if a treatment child dropped out due to the father’s opposition
stemming from the father’s dislike of spirulina due to superstitious ethnic or
religious reasons such as “satanism”, the number of drop outs could concentratein specific ethnicity or religion in the Target group.
6.3

Comparing Results with Previous Studies

There are few studies that have tested the efficacy of spirulina on malnourished children.
Simpore et al (2005) created four groups by dividing treatment and control and HIV
positive and negative groups. Traditional mealie meal with spirulina was provided to thetreatment group, while the control group received just mealie meal.
Weight gain and hemoglobin improvement were reported in groups supplied withspirulina particularly for HIV negative children. Other studies that investigated similargroups found that a combination of spirulina and misola (millet, coja, peanut) was
superior to spirulina or misola alone for nutritional rehabilitation of severely andmoderately underweight children aged 6-60 months (Simpore et al, 2006).
The studies demonstrated that spirulina supplementation proved to be good treatment
for rehabilitating malnourished children evaluated on WAZ and WHZ. However, there
does not seem to be any study that shows evidence of spirulina efficacy for chronicchild malnutrition (stunting). This is the first semi-clinical study testing spirulina
efficacy not only in Zambia, but also in southern Africa. The evidence from this study
21

implies that a combination of spirulina and mealie meal is effective in improving thenutritional status of undernourished children.
6.4

Other Effects

In this study, quantitative analysis of three indicators: HAZ, WAZ, and MUACZ wasconducted. Apart from child growth, other studies showed that spirulina can have goodeffect on health. As discussed above, disease incidence data collected and analyzed
during the study period showed that there were fewer malaria cases in the treatmentgroup compared to the control group.
Both natural and acquired immunity are activated by malaria infection which
contributes to decreased susceptibility to clinical malaria (Osier, et al., 2008). For
example, malaria infection activates T-cells leading to macrophage activation,
phagocytosis of parasite red blood cells, and elaboration of cytokines and small
inflammatory molecules (Good, 2001). Some studies have confirmed that spirulina
helps to activate the immune system in vitro (Karkos, Leong, Karkos, Sivanji, &Assimakopoulos, 2011). Such immune system activation may enhance immunity tomalaria and reduces susceptibility to infection.
Furthermore, other effects on health were reported by mothers or caregivers andstakeholders which are important to qualitatively evaluate as given in Appendix 1.

22

7Conclusion

The study was conducted to assess the nutrition impact of spirulina on 60
undernourished children in Zambia. To assess the impact of daily spirulina intake on thegrowth of malnourished children, the 60 children were divided into treatment andcontrol groups. The treatment group was fed with 10g of spirulina per day which was
mixed with roller meal.
Three numeric indicators to measure the effect of spirulina i.e. Height for Age Z-score(HAZ), Weight for Age Z-score (WAZ), and Mid Upper Arm Circumference Z-score(MUACZ) were employed. According to the results, the treatment group improved morethan the control group by 0.086 points for WAZ and 0.377 points for MUACZ. However,the differences in the results for both indices were not statistically significant.
On the other hand, there was a significant difference in HAZ at 10% significance level.
Through spirulina intake, the treatment group children improved on average by 0.231
points more than the control group. The statistical difference in HAZ implies thatspirulina consumption is an effective food intervention particularly in Zambia, where
severe “stunting” is wide-spread.

23

Appendix 1
The appendix highlights reactions from field officers and mothers of participating
children of their experience during the study period. Besides the quantitative results
discussed above, these qualitative results are useful findings of the study.
1. Voice from field officers in Kanakantapaa) “I am satisfied to see that not only did the child grew well but that the effect onchild health was better than expected throughout this project when children aged
18 to 36 months old were fed with spirulina porridge two times a day for 9
months (including the 3 months extension period.)”b) “I am so happy to hear mothers’ comments, such as “My baby became more
active and gained weight” and “Her skin is now in good condition.” Many
people have confidence on the effects of spirulina.”c) “I am also interested in the positive changes of their dietary habits, “My childovercame his poor food consumption habits. He can finally eat vegetables!” and“Feeding my baby regularly with porridge became a habit for me.”d) “This spirulina project provided local people not only with positive results but
also the positive changes in their dietary habits and the wonderful chance tothink about their basic food needs on a daily basis were encouraging.”
2. Voice from mothers participated in this project1)

I will not change my dietary style after starting the project. (C/T)

2)

Since my child started eating spirulina, the weight increased; so did the energy
level. (C/T)

3)

My child’s skin condition is much better now; I really hope the projectcontinues. (C/T)

4)

At the beginning of this project, my child could not eat spirulina porridge but
he is used to it now. (T)5)

After the project, my child asked “Aren’t you cooking the porridge, mom? “(T)6)

I was afraid that people think I am in “satanism” when the project started. (T/C)

7)

Cooking porridge on time; became part of our daily practice. So when I delayed,
my child said, “Mom, please cook the porridge! “(T/C)
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8)

The children’s appetite has improved (T/C)

9)

Before the project, my children did not eat vegetables. But they like vegetables
now. (T)10) My child can eat anything, no dislikes. (C/T)
11) I am spending much time to prepare porridge than before. (T/C)
12) There are improvements on the children’s health. (T/C)(Source: Minutes of the final meeting in Kanakantapa)

25

Reference[1] BhuttaZA et al. [2008] “Maternal and Child Undernutrition 3. What works?
Interventions for maternal and child undernutiriton and survival.” Lancet, vol.371(9610) p417-440[2] Chatt,C. and Robert, L. [2010] ”Access to, and the delivery of, free healthcare in
Kanakantapa, and rural Zambia” , African Journal of Health Science , vol.14(3-4), p15-25[3] Food and Agriculture Organization [2010] “Nutrition country profile the republic ofZambia”[4] Kim,F.M. et al. [2009] “Choice of foods and ingredients for moderately malnourishedchildren 6 months to 5 years of age” , Food and Nutrition Bullitain,S343-404[5] KarkosDP, et al. [2011] [2011]P, utrition Bullitain,S343-404nts for moderately malnourishedcEvidence-Based Complementary and Alternative Medicine.
[5] Ministry of Health Zambia [2005] “Fourth National Health Strategic Plan 2006 – 2010”,
p22-24[6] PelletierDL., Frongillo. E. A., Schroeder D.G., and Habicht J.P. [1995]] “The effect ofmalnutrition on child mortality in developing countries.” Bulletin World Health Organization,
vol.73(4) p443-448[7] OsierFH, et al. [2008] “2008] , et al. ealth OrganizationG., and Habicht J.P. [1995]] “Theeffect of malnutrition on child mortality in developing countries.” Infect Immun vol.76(5),2240-2248.
[8] Simpore,J et al [2005] “Nutrition Rahabilitation of the HIV-Infected and Negative
Undernourished Children Utlizion Spiruline, Pakistan Journal of Biological Science 8(4):p589-595[9] SimporeJ, et al. [2006] “Nutrition rehabilitation of undernourished children utilizing
Spirulina and Misola.” NutrJ. Vol5(3)[10] UNICEF [2013] “Improving child nutrition. The achievable imperative for global progress”[11] Woodridge, J. M. [2012] “Economic analysis of cross section and panel data 2nd edition”,
Cambridge, the MIT press, p146-150[12] World Health Organization Department of Nutrition [2011][13] Zambia Central Statistical Office [2007], Zambia Demographic and Health Survey 2007[14] “Pellagra breaks out in famine-hit Zambia” [2002],(http://reliefweb.int/report/zambia/pellagra-breaks-out-famine-hit-zambia)

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