The Sokoto Syndemic: A call for a paradigm shift in tackling childhood malnutrition in Nigeria

Childhood malnutrition and infection are known to interact synergistically, yet the biochemical evidence for this bidirectional relationship in high-burden settings remains inadequately characterized. To examine the association between protein-energy malnutrition, micronutrient deficiencies, and systemic inflammation (C-reactive protein, CRP) among under-five children in Sokoto State, Nigeria, and to characterize the malnutrition-inflammation syndemic. A community-based cross-sectional study was conducted among 150 children aged 6–59 months attending primary health centers in Sokoto State. Anthropometric measurements (weight, height, MUAC) were collected, and venous blood samples were analyzed for prealbumin, CRP, serum retinol (vitamin A), hemoglobin, albumin, and zinc. Children were classified by nutritional status using WHO growth standards and MUAC cut-offs. Statistical analyses included independent t-tests, Pearson correlation, chi-square tests for trend, and logistic regression. The prevalence of elevated CRP (>3 mg/L) was 78.0% (n=117), with 10.0% (n=15) exhibiting severe inflammation (>10 mg/L). Malnourished children (MUAC <12.5 cm) had significantly higher CRP levels than well-nourished children (6.7 ± 2.4 vs. 4.3 ± 1.9 mg/L, p < 0.001). A strong dose-response relationship was observed: CRP elevation increased from 51.1% in normal children to 78.7% in MAM and 92.9% in SAM (p < 0.001). CRP showed significant negative correlations with all anthropometric indices (r = -0.41 to -0.53, p < 0.01) and with prealbumin (r = -0.58, p < 0.001). Among children with SAM, 92.9% had elevated CRP and 100% had concurrent protein-energy and micronutrient deficiencies. Logistic regression revealed that children with SAM had 12.2 times higher odds of elevated CRP compared to normal children (AOR = 12.19, 95% CI: 3.38–43.95, p < 0.001). The malnutrition-inflammation syndemic is highly prevalent among under-five children in Sokoto State, with nearly all severely malnourished children exhibiting systemic inflammation. The bidirectional relationship between malnutrition and inflammation creates a self-perpetuating cycle that exacerbates morbidity and mortality. These findings mandate integrated interventions that simultaneously address nutritional rehabilitation and infection control.