Potential For Dietary Calcium to Prevent Fluoride Uptake in Children in Halaba Special District, Southern Ethiopia: Knowledge, Attitudes, and Practices of Mothers
Tamirat Getachew Bantero1, Demmelash Mulualem1, Derese Tamiru Desta1, Getahun Wansisa Worancha2, Bergene Boshe Boricha1* and Susan J Whiting3
1School of Nutrition, Food Science and Technology, Academic Center of Excellence for Human Nutrition, Hawassa University, Ethiopia
2Faculty of Biosystems and water resources engineering, Institute of Technology, Hawassa University, Ethiopia
3College of Pharmacy and Nutrition, University of Saskatchewan, Canada
Submission: May 24 ,2022; Published: June 07, 2022
*Corresponding author: Bergene Boshe Boricha, School of Nutrition, Food Science and Technology, Academic Center of Excellence for Human Nutrition, Hawassa University, Hawassa, Ethiopia
How to cite this article:Tamirat G, Mulualem D, Derese T, Getahun W, Boshe B, Whiting SJ. Potential For Dietary Calcium to Prevent Fluoride Uptake in Children in Halaba Special District, Southern Ethiopia: Knowledge, Attitudes, and Practices of Mothers. JOJ Pub Health. 2022; 6(5): 555700. DOI: 10.19080/JOJPH.2022.06.555700
Abstract
Fluorosis is a public health problem in Ethiopia. Fluoride (F) absorption can be decreased by dietary calcium (Ca) which forms insoluble complexes with the fluoride ion F-. The aim of this study was to assess maternal knowledge, attitudes, and practice (KAP) towards calcium in an area with high water F (9.7± 0.27mg/L) in Halaba, Southern Ethiopia. A cross-sectional study was conducted in 254 child-mother pairs randomly chosen from two kebeles of the district, and a questionnaire was used to obtain KAP. Teff, maize, millet were the major cereals in the study area and milk followed from the animal source food. The majority (96.5%) of respondents had never heard about fluoride. More than two-thirds reported that they did not know about the causes of teeth decay and skeletal fluorosis, and just 2% were aware that calcium could mitigate fluorosis symptoms. As a follow-up, nutrition education was provided that included sources of calcium stressing locally available foods. This study suggests that future research should focus on behavior communication for enhancing the community’s knowledge, attitude, and practices towards fluorosis including improving calcium intake.
Keywords: Calcium; Fluoride; Fluorosis; Knowledge; Attitude; Practices; Intake; Ethiopia
Abbreviations: KAP: knowledge, attitudes, and practice; F: Fluoride; Ca: Calcium
Introduction
A recent systemic review [1] reported that in Ethiopia the mean fluoride (F) level in drinking water is greater than the WHO standard value of 1.5 mg/L and that in the Ethiopian rift valley, groundwater F varies from 0.1 to 75 mg/L. In SNNPR, the prevalence in drinking water sources of F concentration exceeding the WHO level of 1.5 mg/L was 57.1%, 25.9 %, and 50 % for well, spring, and tap water sources [2]. Thus, F is a major health concern throughout Ethiopia but particularly in the southern areas where groundwater fluoride is prevalent. Fluorosis can be categorized as dental, skeletal, and non-skeletal. All of these arise from high, continuous exposure to F in foods and water throughout the lifespan. The risk of dental fluorosis is of greatest concern for children below 8 years of age because enamel can no longer be repaired once pre-eruptive maturation has occurred [3,4]. In Halaba Kobochobare kebele of Ethiopia, previous research showed that drinking water sources contain fluoride above the WHO guideline value (1.5mg/L), and the fluoride content of most of the prepared foods was 1.3-3.2 mg/kg [5]. The prevalence of severe and moderate dental fluorosis was 20% in children. Skeletal fluorosis symptoms were found in 12-14% of children, and some nonskeletal fluorosis signs such as gastrointestinal symptoms were seen in 1-3 % of children [5].
The adverse effects of fluoride have been linked to poor calcium intake. With a low calcium diet, the ability of calcium to bind fluoride and prevent its absorption does not occur and fluorosis proceeds more quickly [6]. Fluoride, when ingested as sodium fluoride on an empty stomach, has a bioavailability of almost 100% but when taken concomitantly with a glass of milk or with a calcium-rich breakfast its bioavailability decreases to 70% and 60%, respectively [7,8]. Thus, it has been postulated by researchers studying fluorosis in Ethiopia that an increased of dietary calcium may reduce fluorosis progression [5,9]. Recently we tested this hypothesis by conducting an intervention with calcium in women living in a high fluoride area of Ethiopia, using eggshell powder as a supplemental source of calcium, and this provided support for calcium mitigating fluorosis signs and symptoms [10]. Further, our recent epidemiological studies show an association between calcium intake from foods and fluorosis signs and symptoms in adults [10] and in school-age children Tefera et al. [11]. However, knowledge of fluorosis and of the role calcium might play remains sparse in Ethiopia despite efforts to improve knowledge, attitudes, and practice (KAP) (Kebede – AJFAND). Hence, more information is needed on preventing fluorosis as young children are still growing and have erupting teeth. We, therefore, report our study of maternal KAP towards fluoride and calcium in an area where signs and symptoms of fluorosis are prevalent in children, with the aim to assess gaps in KAP. A secondary aim was to gather information on fluoride and calcium-containing foods in order to design appropriate nutrition education materials.
Materials and Methods
Study area
Halaba district is located 315 km south of Addis Ababa and is geographically located at 7017’ N latitude and 38006’ E longitude. It is a special district where the administration directly reports to the regional state. The altitude of the district ranges from 1554 to 2149 m but most of the areas in the district are found at about 1800 m. Rainfall has been a major limiting factor in agricultural production in the area, and as a result, it is one of the districts in SNNPR where drought is observed [12]. Two kebeles were selected purposively. A list of households with children 3-8 years were identified. 127 study participants were selected by the simple random method from each kebele.
Study participants
This cross-sectional survey, study participants were randomly selected mothers who have children from the age of 3-8 years. The sample size was determined by G*power version 3.0.10. For a two-tailed t-test with an effect size of 0.5, based on Cohen’s d effect size calculation ranges from 0.2 to 0.5 [13], for α equal to 0.05, and for a power 80. The total sample size for the cross-sectional study was 254 with equal numbers from two kebeles. 127 mother-child pairs per kebele were selected by the simple random method. Water and staple foods were selected purposively from each area determine the fluoride levels.
Measurement and data collection procedures
The method of data collection was by using an interviewer administrated questionnaire containing the demographic and socioeconomic characteristics, KAP questions, and a multiple-choice checklist on calcium intake. All interviewers also completed a 24-hour dietary recall with mothers of each child’s intake, using photographs, food models, household measurements (spoons, cups) and food weighing scale to help subjects accurately estimate amounts of food consumed. Liquids were recorded quantities as volumes, preferably using the respondents’ own household utensils calibrated with graduated cylinders plastic. A 24-hour recall, KAP questionnaire, drinking water sample, staple food sample, in households where there is more than one child, the index child was selected by tossing a random number.
Calcium and Fluoride Intakes
The amount of calcium and fluoride were calculated manually using two stages [14]. In the first stage, the nutrient intake data were recorded separately for each respondent. Portion sizes and quantities were converted into weight equivalents. In the second stage, for each respondent, the weight equivalent was computed manually using the Ethiopian Food Composition tables Part III and Part IV (EPHI, 1998) for calcium and laboratory analysis results for fluoride.
Follow-up Nutrition Education
Sessions of nutrition education were delivered on sources of fluoride, calcium-rich food, and its benefit to minimize fluoride toxicity. For nutrition education, copies of a poster showing the key messages about food groups, sources of fluoride and calciumrich food, and their role to mitigate fluorosis was made and shared with the community. Images of children fetching water, how fluoride affects teeth, as well as locally available foods with an emphasis on those making a calcium-rich diet were included. Nutrition education sessions were delivered by the investigator and two research assistants in both kebeles.
Data management and analysis
All data were entered, cleaned, and analyzed using statistical software SPSS version [15]. All continuous data were checked for normality using the Kolmogorov Smirnov test. Fluoride and calcium contents were calculated for mean intake, percent of recommended daily allowance, and upper tolerable intake, and descriptive statistics (mean ±SD), frequency and percentage) were used to display the study findings.
Ethical considerations
The study approval was obtained from the Institutional Review Board of the College of medicine and health science at Hawassa University. Informed written consent was taken from the study participant mothers.
Results
(Table 1) A total of 254 children aged 3-6 years were included in the study. The median age of the study subjects was 4 (IQR: 3-6) years. The male to female ratio of participant children was 1.2 and all respondents were from Halaba ethnic group and Muslim by religion.
Subject Characteristics
Table 1 shows the characteristics of the families in which the target children were selected. Details are found in the table, but the additional discussion was given for the source of drinking water. As the finding of this study as participant mothers responded 146(57.48%) of them use pond water. In comparison to spring water, dams and open pans, and stream water; pond water contains high mean concentration of fluoride [16].
Children’s Calcium and fluoride Intakes
Table 2 shows the concentration of Calcium and fluoride in collected food samples from the study households. Mean (±SD) of Calcium of 1-3 years children were 277.4±189.1 and 87% of them below recommended daily allowance (500). For age 4 and above years, mean (±SD) of calcium concentration was 362.9±234.3 and 75.1% of the participants’ calcium level below the recommended daily allowance which is 800.
Mothers’ knowledge and practices about fluoride and fluorosis
Almost no one knew the link between fluoride intake and fluorosis, as shown in Table 3. Few were familiar with calcium and its connection to fluorosis. More know about tooth decay. As, a study conducted among 4852 Ethiopian rift valley residences, the prevalence of dental fluorosis was estimated to be 28% ranging from 24 to 32% and Studies reported a high prevalence of dental fluorosis in the Rift Valley region of Ethiopia where the level of fluoride, especially in groundwater is significantly high [17-19].
Mothers’ Attitudes about calcium and fluoride intake
The respondents were interviewed to grasp their attitude about calcium and fluoride with the lens of reducing fluoride toxicity. Behavior-related attitudes were categorized as the risk of excessive fluoride consumption, negative consequences of excess fluoride intake, social norms for who approves calcium consumption, self-efficacy of the mother to add calcium-rich foods for their children, costs, and health beliefs of calcium consumption. Only small segments of respondents (5.9%) strongly agree that excessive fluoride intake would be a risk of fluorosis. Almost one-third (33.46%) perceive that excessive fluoride intake and a low level of calcium intake would not be advantageous. More than half (56.7%) disagree that the costs of calcium-rich food including finger millet require too much money. A Poster showing calcium-containing foods in the community and how these might be used to reduce fluorosis was prepared and presented to the community (Table 4) (Figure 1). Maternal awareness of calcium-rich food and fluorosis reduction was improved due to education by showing of the poster.
1Fluoride values were measured.
2Calcium values were calculated from food composition data.
Discussion
The findings of this study show that maternal knowledge, attitudes, and practices towards exposure to fluoride by their children is low in Halaba special district, Southern Ethiopia, which is a concern in an area of Ethiopia where fluorosis is prevalent. There is growing evidence that calcium intake can mitigate fluorosis symptoms [6,9,10] yet mothers in this area were not aware, and calcium intakes of children are low. The main finding of this study shows very few mothers were aware of fluoride and the consequences of excess intake, yet dental and skeletal fluorosis are visibility prevalent in the Rift Valley [5,20-22]. In the current study, only 5.9% of respondents strongly agreed that excessive fluoride intake would be a risk for fluorosis. Surprisingly, respondents did not perceive excessive fluoride consumption as a risk for fluorosis. An earlier study of KAP done on fluorosis and its mitigation in three endemic areas of Ethiopia also showed there is a knowledge gap about fluoride and its health consequences [6]. Thus, in the intervening time there remains a knowledge gap about the consequences of fluoride.
Studies show fluorosis mitigation is mainly addressed through defluoridation of water in most cases. There are suggestions that nutritional supplements can also be used as a part of curative measures, such as focusing on adequate intake of foods rich in calcium, vitamins C and E, and antioxidants, along with consuming safe drinking water [23]. Others have focused many on calcium which as a divalent cation can bind the fluoride ion and prevent its absorption [10]. Hence, diets poor in calcium facilitate an increase in the body’s retention of fluoride leading to excessive accumulation of fluoride in the body that can interfere with the normal growth and development of bones during childhood.
In the current study, very few participants (2.4%) indicated calcium ingestion had benefits for mitigating excess fluoride intake, and no one used calcium foods for this reason. Calcium intakes are low in many areas of Ethiopia [34] but data on calcium intakes are sparse, especially for children. In our study, children aged 1 to 3 years had intakes of 277 [38].4 ±189.1 mg per day. This is lower than that reported in Dale district where [37] showed for children 1-2 years old, calcium intake was 426 ± 238 mg/day. This is an area where enset, a high calcium food, was often part of the diet). In our study children 4-8 years of age had calcium intakes of 362.9±234.3 mg per day which is lower than that of children aged 6-8 years measured in a different area of Halaba, 544 ± 203 [24]. In the latter study, children were older and so may have had a high overall food intake. The majority of the respondents believe that they will try to increase child’s diet rich in calcium if the health approves it. Interestingly, more than half (56.7%) disagree that the costs of calcium-rich food including finger millet and milk require too much money. This shows that the costs for calcium-rich foods might not be a matter.
In the current study, and that of Tefera et al. [11], estimated fluoride intakes of children using actual fluoride levels of local foods. We found fluoride intakes to be approximately 3 mg per day from foods alone while Tefera et al. [11] reported over 10 mg per day and Kebede et al. [5] found 7.9 mg. Differences may be due to different food patterns. Foods grown in parts of the country not afflicted with high F would be lower than foods grown locally. Urine F excretion is a rough reflection of F intake as there is a high percentage of ingested F that is absorption, especially in growing children. Urinary F reflects dietary intake and Kebede et al. [5] reported F excretion of 3.3 ± 2.2 mg/L for children in Halaba while it was close to 9 mg/L in other parts of Ethiopia.
Knowledge and awareness of dental fluorosis are important factors to self-prevention and control of dental fluorosis. Increasing knowledge of fluorosis and mitigating thought calcium reach food and antioxidants among parents and the general population could be one of the approaches to help reduce the fluorosis prevalence in this community [25]. The simple interventions to reduce fluorosis include the provision of surface water, rainwater, and consumption of Low-fluoride groundwater and other interventions are defluoridation of water through flocculation and adsorption [26]. Similarly, health education and better nutrition are some of the cost-effective intervention measures [27]. The education delivered should incorporate information about the overall health consequences of excessive fluoride intake and sources of fluoride, along with preventive methods that need to be taken [28].
Two major interventions are suggested to prevent fluorosis: a) withdrawal of fluoride sources by which the progression of the disease would be arrested and b) promotion of a nutritive diet with adequate intake of calcium, iron, folic acid, vitamins C and E, and other antioxidants through dairy products, vegetables, and fruits. Nutritional intervention requires counseling of fluorosis and education of the female members of the households who are responsible for cooking and serving food for the family. They are educated about the locally grown/available food, or agricultural crops that are high in calcium, vitamin C, and other antioxidants, and that need to be consumed on a daily basis through breakfast, lunch, and dinner [29]. Creating awareness about the sources of fluoride can help make informed choices regarding water and other items of consumption, enabling potential victims to be engaged in need-based preventive measures in the affected areas [30]. Health and nutrition education will help to reduce the effect of ingested fluoride until either defluoridation techniques are employed or the water source is changed [6]. In addition, fluoride-reducing treatments may be key to addressing widespread dental health problems faced by millions of rural residents in Ethiopia’s remote, poverty-stricken Main Rift Valley [31-37].
Conclusion
The evidence from this study reveals that the majority of respondents in a high fluorosis area had never heard about fluoride at the time of the study. Only a small number of the respondents knew the sources of fluoride and the consequences of excessive fluoride ingestion. Similarly, very few respondents indicated calcium ingestion benefits to mitigate excess fluoride intake. Treating for fluoride removal/ fluorosis mitigation was not being practiced by many respondents. The majority of respondents did not perceive as fluorosis as risky. Children’s dietary calcium intakes were very low. With nutrition education, the majority of the respondents would consider trying to make their child’s diet higher in calcium if this would improve their child’s health.
Acknowledgments
The authors appreciate and acknowledge Hawassa University and University of Saskatchewan for being the source of funds for this project.
Conflict of interests
The authors declare no conflicts of interest. The sponsors had no role in the design, execution, interpretation, or writing of the study.
References
- Demelash H, Beyene A, Abebe Z, Melese (2019) A Fluoride Concentration in Ground Water and Prevalence of Dental Fluorosis in Ethiopian Rift Valley: Systematic Review and Meta-Analysis. BMC Public Health 19(1): 1298.
- Alemu ZA, Mengesha SD, Alemayehu TA, Serte MG, Kidane AW, et al. (2015) Retrospective Study of Fluoride Distribution in Ethiopian Drinking Water Sources. Asian Journal of Applied Science and Engineering 4(2): 127-136.
- Jackson RD, Kelly SA, Katz B, Brizendine E, Stookey GK (1999) Dental Fluorosis in Children Residing in Communities with Different Water Fluoride Levels: 33 Month Follow Up. Pediatr Dent (21): 248-254.
- Liang H, Steven ML, John JW, Barbara B, Joseph C (2006) Fluoride Intake Levels in Relation to Fluorosis. Caries Resistance 40(6): 494-500.
- Kebede A, Retta N, Abuye C, Whiting SJ, Kassaw M, et al. (2016) Dietary Fluoride Intake and Associated Skeletal and Dental Fluorosis in School Age Children in Rural Ethiopian Rift Valley. Int J Environ Res Public Health 13(8): 756.
- Kebede A, Retta N, Abuye C, Malde MK (2016) Community Knowledge, Attitude and Practices (KAP) on Fluorosis and its Mitigation in Endemic Areas of Ethiopia. African Journal of Food, Agriculture, Nutrition and Development 16(1): 10711-10722.
- World Health Organization (2002) Environmental Health Criteria 227. Fluorides. Geneva: World Health Organization.
- Fawell J, Balley K, Chilton J, Dahi E, Fewtrell L, et al. (2006) WHO, Fluoride in Drinking-Water. IWA Publishing London, UK.
- Malde MK, Zerihun L, Julshamn K, Bjorvatn K (2004) Fluoride, Calcium and Magnesium Intake in Children Living in a High-Fluoride Area in Ethiopia. Intake Through Food. Int J Paediat Dent 14(3): 167-174.
- Mulualem D, Hailu D, Tessema M, Whiting SJ (2021) Efficacy of Calcium-Containing Eggshell Powder Supplementation on Urinary Fluoride and Fluorosis Symptoms of Women in Ethiopian Rift Valley. Nutrients 13(4): 1052.
- Tefera N, Mulualem D, Baye K, Tessema M, Woldeyohannes M, et al. (2022) Association between Dietary Fluoride and Calcium Intake of School-Age Children with Symptoms of Dental and Skeletal Fluorosis in Halaba, Southern Ethiopia. Frontiers in Oral Health 4(3): 853719.
- Alaba Woreda Water Resource Development Office (AW-WRDO) (2007) Alaba Special Woreda Water Resources Development Office Schemes. Environmental Development Program AW-WRDO, Hawasa.
- Cohen L, Manion L, Morrison K (2007) Research methods in education. Routledge, New York.
- Rosalind S, Gibson, Ferguson EL (2008) An Interactive 24-hour Recall for Assessing the Adequacy of Iron and Zinc Intakes in Developing Countries.
- Melaku Z, Assefa G, Enqusilassie F, Bjorvatn K, Tekle-Haimanot R (2012) Epidemiology of skeletal fluorosis in Wonji Shoa Sugar Estate, Wonji, Ethiopia: a Community-Based Survey. Ethiop Med J 50(4): 307-313.
- Wambu EW, Agong SG, Anyango B, Akuno W, Akenga T (2014) High Fluoride Water in Bondo-Rarieda Area of Siaya County, Kenya: A Hydro-Geological Implication on Public Health in the Lake Victoria Basin. BMC Public Health 14(1): 462.
- Wondwossen F, Åstrøm AN, Bjorvatn K, Bårdsen A (2004) The Relationship between Dental Caries and Dental Fluorosis in Areas with Moderate-and High-Fluoride Drinking Water in Ethiopia. Community Dent Oral Epidemiol 32(5):337-344.
- Tekle-Haimanot R, Fekadu A, Bushera B, Mekonnen Y (1995) Fluoride levels in water and endemic fluorosis in Ethiopian Rift Valley. International Workshop on Fluorosis and Defluoridation of Water.
- Tekle-Haimanot R, Melaku Z, Kloos H, Reimann C, Fantaye W, et al (2005) The Geographic Distribution of Fluoride in Surface and Groundwater in Ethiopia with an Emphasis on the Rift Valley. Sci Total Environ 367(1):182-190.
- Assefa G, Shifera G, Melaku Z, Haimanot RT (2004) Clinical and Radiological Prevalence of Skeletal Fluorosis among Retired Employees of Wonji-Shoa Sugar Estate in Ethiopia. East Afr Med J 81(12): 638-640.
- Kravchenko J, Rango T, Akushevich I, Atlaw B, Mc Cornick PG, et al. (2014) The Effect of Non-Fluoride Factors on Risk of Dental Fluorosis: Evidence from Rural Populations of the Main Ethiopian Rift. Sci Total Environ. Vol (488-489): 595-606.
- Khairnar MR, Dodamani AS, Jadhav HC, Naik RG, Deshmukh MA (2015) Mitigation of Fluorosis - A Review. J Clin Diagn Res 9(6): 5-9.
- Sami E, Vichayanrat T, Satitvipawee P (2015) Dental Fluorosis and its Relation to Socioeconomic Status, Parents’ Knowledge and Awareness Among 12-Year-Old School Children in Quetta, Pakistan. The Southeast Asian journal of tropical medicine and public health 46(2): 360-368.
- Almebo A, Mangasha HB, Ashuro Z, Soboksa NE, Kanno GG, et al. (2021) Utilization of Community-Level Fluoride-Filtered Water and its Associated Factors in Dugda Woreda of East Shewa Zone, Oromia Region, Ethiopia. Environ Health Insights (15).
- Arlappa N, Atif Qureshi I, Srinivas R (2013) Fluorosis in India: an overview. Int J Res Dev Health 1(2): 97-102.
- Abebe W (2010) Health hazards of fluoride as related to Ethiopia: a review of some relevant issues for preventive approaches. Health Issue 2(1): 59-84.
- Susheela AK, Bhatnagar M (2002) Reversal of Fluoride Induced Cell Injury through Elimination of Fluoride and Consumption of Diet Rich in Essential Nutrients and Antioxidants. Molecular and Cellular Biochemistry (234-235): 335-340.
- Kloos H, Haimanot RT (1999) Distribution of Fluoride and Fluorosis in Ethiopia and Prospects for Control. Trop Med Int Health 4(5): 355-364.
- Rango T, Kravchenko J, Atlaw B, McCornick PG, Jeuland M, et al. (2012) Groundwater Quality and its Health Impact: An Assessment of Dental Fluorosis in Rural Inhabitants of the Main Ethiopian Rift. Environ Int 43: 37-47.
- EFSA (European Food Safety Authority) (2005) Opinion of the Scientific Panel on Dietetic Products, Nutrition and allergies (NDA) on the tolerable upper intake level of fluoride. EFSA J 3(3): 192.
- Lu Y, Sun ZR, Wu LN, Wang X, Lu W, et al. (2000) Effect of High-Fluoride Water on Intelligence in Children. Fluoride 33(2): 74-78.
- Mobley C, Marshall TA, Milgrom P, Coldwell SE (2009) The Contribution of Dietary Factors to Dental Caries and Disparities in Caries. In Academic Pediatrics 9(6): 410-114.
- Nagarajappa R, Pujara P, Sharda AJ, Asawa K, Tak M et al. (2013) Comparative Assessment of Intelligence Quotient among Children Living in High and Low Fluoride Areas of Kutch, India-a Pilot Study. Iran J Public Health 42(8): 813-818.
- Tesfaye B, Sinclair K, Wuehler SE, Moges T, De-Regil LM, et al. (2018) Applying International Guidelines for Calcium Supplementation to Prevent Pre-Eclampsia: Simulation of Recommended Dosages Suggests Risk of Excess Intake in Ethiopia. Public Health Nutr 15: 1-11.
- US Public Health Service (1962) Drinking Water Standards. US Government, Washington DC, USA.
- Mulualem D, Hailu D, Tessema M, Whiting SJ (2022) Association of Dietary Calcium Intake with Dental, Skeletal and Non-Skeletal Fluorosis Among Women in the Ethiopian Rift Valley. Int J Environ Res Publ Health 19(4): 2119.
- Tezera F, Whiting SJ, S Gebremedhin (2017) Dietary Calcium Intake and Sunlight Exposure among Children Aged 6-23 Months in Dale Woreda, Southern Ethiopia. Afr.J.Food Agri.Nutr.Dev 17(3): 12427- 12440.