Effect of enhanced nutrition services with community-based nutrition services on the diet quality of young children in Ethiopia

Poor diet quality related to inadequate complementary feeding is a major public health problem in low and middle-income countries including Ethiopia. Low dietary diversity has been linked to negative health outcomes in children. To provide a package of interventions to close nutritional gaps through agriculture, the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme was set up as a multi-sectoral initiative and the results of combined effects of community-based and enhanced nutrition services, compared to community-based alone, on diet diversity and diet quality of complementary feeding of young children are presented. The study used pre- and post-intervention design. Baseline (n = 4980) data were collected from May to July 2016, and follow-up (n = 2419) data from December 2020 to January 2021. From 51 intervention districts having the SURE programme, 36 intervention districts were randomly selected for baseline and 31 for the follow-up survey. The primary outcome was diet quality: minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD). Comparing endline to baseline over the 4.5-year intervention, the use of standard community-based nutrition services of growth monitoring and promotion increased (16%–46%), as did enhanced nutrition services of infant and young child feeding counselling, and agricultural advising (62%–77%). Women involved in home gardening significantly increased (73%–93%); however, household production of food decreased yet consumption of most own-grown foods increased. Importantly, MAD and MDD increased four-fold. The SURE intervention programme was associated with improvements in complementary feeding and diet quality through enhanced nutrition services. This suggests programmes targeted at nutrition-sensitive practices can improve child feeding in young children.     

Nutrition behaviour change communication causes sustained effects on IYCN knowledge in two cluster‐randomised trials in Bangladesh

Behaviour change communication (BCC) can improve infant and young child nutrition (IYCN) knowledge, practices, and health outcomes. However, few studies have examined whether the improved knowledge persists after BCC activities end. This paper assesses the effect of nutrition sensitive social protection interventions on IYCN knowledge in rural Bangladesh, both during and after intervention activities. We use data from two, 2‐year, cluster randomised control trials that included nutrition BCC in some treatment arms. These data were collected at intervention baseline, midline, and endline, and 6–10 months after the intervention ended. We analyse data on IYCN knowledge from the same 2,341 women over these 4 survey rounds. We construct a number correct score on 18 IYCN knowledge questions and assess whether the impact of the BCC changes over time for the different treatment groups. Effects are estimated using ordinary least squares accounting for the clustered design of the study. There are 3 main findings: First, the BCC improves IYCN knowledge substantially in the 1st year of the intervention; participants correctly answer 3.0–3.2 more questions (36% more) compared to the non‐BCC groups. Second, the increase in knowledge between the 1st and 2nd year was smaller, an additional 0.7–0.9 correct answers. Third, knowledge persists; there are no significant decreases in IYCN knowledge 6–10 months after nutrition BCC activities ended.     

Effects of an integrated poultry value chain,nutrition, gender and WASH intervention (SELEVER) on hygiene and child morbidity and anthropometry in Burkina Faso: A secondary outcome analysis of a cluster randomised trial

Nutrition-sensitive agriculture programmes have the potential to improve child nutrition outcomes, but livestock intensification may pose risks related to water, sanitation and hygiene (WASH) conditions. We assessed the impact of SELEVER, a nutrition- and gender-sensitive poultry intervention, with and without added WASH focus, on hygiene practices, morbidity and anthropometric indices of nutrition in children aged 2−4 years in Burkina Faso. A 3-year cluster randomised controlled trial was implemented in 120 villages in 60 communes (districts) supported by the SELEVER project. Communes were randomly assigned using restricted randomisation to one of three groups: (1) SELEVER intervention (n = 446 households); (2) SELEVER plus WASH intervention (n = 432 households); and (3) control without intervention (n = 899 households). The study population included women aged 15−49 years with an index child aged 2−4 years. We assessed the effects 1.5-years (WASH substudy) and 3-years (endline) post-intervention on child morbidity and child anthropometry secondary trial outcomes using mixed effects regression models. Participation in intervention activities was low in the SELEVER groups, ranging from 25% at 1.5 years and 10% at endline. At endline, households in the SELEVER groups had higher caregiver knowledge of WASH-livestock risks (∆ = 0.10, 95% confidence interval [CI] [0.04−0.16]) and were more likely to keep children separated from poultry (∆ = 0.09, 95% CI [0.03−0.15]) than in the control group. No differences were found for other hygiene practices, child morbidity symptoms or anthropometry indicators. Integrating livestock WASH interventions alongside poultry and nutrition interventions can increase knowledge of livestock-related risks and improve livestock-hygiene-related practices, yet may not be sufficient to improve the morbidity and nutritional status of young children.     

Egg intervention effect on linear growth no longer present after two years

The Lulun Project, a randomized controlled trial conducted in 2015, found that one egg per day for 6 months during early complementary feeding reduced stunting by 47% and increased linear growth by 0.63 length‐for‐age Z (LAZ). This follow‐up cohort study (Lulun Project II) aimed to test whether the growth effect remained in the egg intervention group compared with the control group after approximately 2 years. Mothers or caregivers from the Lulun Project were recontacted and recruited for this study. Enumerators collected data on socio‐economic and demographic factors, 24‐hr frequency of dietary intakes, morbidities, and anthropometric measures of height, weight, and head circumference using World Health Organization protocols. Statistical analyses followed the same analytical plan as Lulun Project, applying generalized linear models and regression modelling to test group differences in height‐for‐age z (HAZ) from LAZ at Lulun Project endline, and structural equation modelling for mediation. One hundred thirty‐five mother–child dyads were included in Lulun II, with 11% losses to follow‐up from endline Lulun Project. Growth faltering across all children was evident with HAZ ?2.07 ± 0.91 and a stunting prevelance of 50%. Regression modelling showed no difference between egg and control groups for the HAZ outcome and other anthropometric outcomes, and significant declines in HAZ from endline Lulun Project in the egg intervention are compared with control groups. Current dietary egg intake, however, was associated with reduced growth faltering in HAZ from Lulun Project endline to Lulun Project II, independent of group assignment and through mediation, explaining 8.8% of the total effect. Findings suggest the need for a longer intervention period and ongoing nutrition support to young children during early childhood.     

“Then you raise them with Shirchoy or cookies”: Understanding influences on delayed dietary diversity among children in Tajikistan

Dietary diversity is a key component of infant and young child feeding (IYCF) as well as adult health. In Tajikistan, a predominantly rural, former Soviet country in Central Asia, we conducted formative research to identify barriers to dietary diversity and strategies for nutrition behaviour change. In Spring, 2016, mixed‐methods data collection took place across 13 villages in all five regions, collecting collaborative mapping; structured assessments of stores and markets; home visits for dietary recalls; food storage, preparation, and meal observations; focus groups with pregnant women, mothers of young children, fathers, and mothers‐in‐law; and in‐depth expert interviews with local nutrition and health influentials. Overall, maternal diet was adequate in terms of diversity (only 13% reported <5/10 food groups in the past 24 hr); however, only 42% of index children 6–24 months met WHO guidelines for diversity, and only 34% met minimum acceptable diet criteria. In addition to issues of poverty and food scarcity, qualitative data reveal many behavioural barriers to timely introduction of diverse complementary foods. Women's strategies focused on gradual introduction of household diet components, without regard for diversity or nutrition. Foods such as meat were seen as costly and thus inappropriate for IYCF, and food taboos (i.e., fresh vegetables) further reduced diversity. Infant food preparation methods such as grinding were seen as impractical, and many foods were withheld until children develop teeth. Possible nutrition education strategies include point‐of‐purchase campaigns to improve availability and appeal of IYCF‐friendly foods, as well as influencing other key household members through mosques, schools, and health care providers.     

Women's dietary diversity in rural Bangladesh: Pathways through women's empowerment

The relationship between women's empowerment and women's nutrition is understudied. We aimed to elucidate this relationship by quantifying possible pathways between empowerment and dietary diversity among women in rural Bangladesh. In 2015, we conducted a cross‐sectional survey of 2,599 married women ages 15–40 (median: 25) living in 96 settlements of Habiganj District, Bangladesh, as a baseline for the Food and Agricultural Approaches to Reducing Malnutrition trial. We collected data on women's empowerment (highest completed grade of schooling and agency), dietary diversity, and demographic factors, including household wealth. We used exploratory factor analysis and confirmatory factor analysis on random split‐half samples, followed by structural equation modelling, to test pathways from schooling, through domains of women's agency, to dietary diversity. Factor analysis revealed 3 latent domains of women's agency: social solidarity, decision‐making, and voice with husband. In the adjusted mediation model, having any postprimary schooling was positively associated with voice with husband (β₄₁ = .051, p = .010), which was positively associated with dietary diversity (β₅₄ = .39, p = .002). Schooling also had a direct positive association with women's dietary diversity (β₅₁ = .22, p < .001). Neither women's social solidarity nor decision‐making mediated the relationship between schooling and dietary diversity. The link between schooling and dietary diversity was direct and indirect, through women's voice with husband but not through women's social solidarity or decision‐making. In this population, women with postprimary schooling seem to be better able to negotiate improved diets for themselves.     

An integrated infant and young child feeding and small‐quantity lipid‐based nutrient supplementation programme in the Democratic Republic of Congo is associated with improvements in breastfeeding and handwashing behaviours but not dietary diversity

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ‐LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ‐LNS to improve IYCF practices, and ultimately children's nutritional status.     

Changes in growth,anaemia, and iron deficiency among children aged 6–23 months in two districts in Nepal that were part of the post‐pilot scale‐up of an integrated infant and young child feeding and micronutrient powder intervention

There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross‐sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6–23 months in two districts in Nepal that were part of a post‐pilot scale‐up of a IYCF–MNP programme. Multivariable log‐binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length‐for‐age z‐score <?2), wasting (weight‐for‐length z‐score <?2), underweight (weight‐for‐age z‐score <?2), anaemia (altitude‐adjusted haemoglobin <110 μg/L), moderate or severe anaemia (altitude‐adjusted haemoglobin <100 g/L), iron deficiency (inflammation‐adjusted ferritin <12 μg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12–23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable‐adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal–FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF–MNP programmes to improve children's nutritional status.     

Impacts of an egg intervention on nutrient adequacy among young Malawian children

Eggs are a rich source of multiple nutrients that support child growth and development. Provision of eggs as a complementary food may improve dietary adequacy among young children at risk for undernutrition. Our objective was to test the impact of an egg intervention on the adequacy of total nutrient intakes and micronutrient density among 6‐ to 15‐month‐old Malawian children. Children 6 to 9 months old, living in Mangochi District, Malawi, were randomly assigned to the intervention group (n = 331) receiving an egg per day or a control group (n = 329) consuming their usual diet. Dietary intakes of macronutrients, vitamins and minerals were assessed using 24‐h recalls at baseline, 3‐month midline and 6‐month endline, with repeat recalls in a subsample. Usual nutrient intake and micronutrient density distributions were modelled to estimate group means and prevalence of inadequacy. Group differences at midline and endline were tested using unequal variance t tests with bootstrapped standard errors. The egg intervention resulted in higher intakes of fat and protein and lower intakes of carbohydrates. The egg group had lower prevalence of inadequacy for selenium, vitamin A, riboflavin, vitamin B₅, vitamin B₁₂ and choline. Micronutrient density inadequacy was lower in the egg group for vitamin A and choline at midline and endline, riboflavin at midline and vitamin B₅ at endline. Inadequacy of nutrient intakes or density remained highly prevalent in both groups for multiple micronutrients. Though the egg intervention increased intakes of protein and several micronutrients, total intakes and micronutrient density of multiple micronutrients remained far below recommendations.     

Evaluation of a social network intervention on child feeding practices and caregiver knowledge

Food insecurity and poor infant and young child feeding (IYCF) practices contribute to undernutrition. The Kanyakla Nutrition Program was developed in rural Kenya to provide knowledge alongside social support for recommended IYCF practices. Utilizing a social network approach, the Kanyakla Nutrition Program trained community health workers (CHWs) to engage mothers, fathers, and grandparents in nutrition education and discussions about strategies to provide instrumental, emotional, and information support within their community. The 12‐week programme included six sessions and was implemented on Mfangano Island, Kenya, in 2014–2015. We analysed intervention effects on (a) nutrition knowledge among community members or CHWs and (2) IYCF practices among children 1–3 years. Nutrition knowledge was assessed using a postintervention comparison among intervention (community, n = 43; CHW, n = 22) and comparison groups (community, n = 149; CHW, n = 64). We used a quasi‐experimental design and difference‐in‐difference to assess IYCF indicators using dietary recall data from an ongoing cohort study among intervention participants (n = 48) with individuals living on Mfangano Island where the intervention was not implemented (n = 178) before the intervention, within 1 month postintervention, and 6 months postintervention. Findings showed no effect of the intervention on IYCF indicators (e.g., dietary diversity and meal frequency), and less than 15% of children met minimum acceptable diet criteria at any time point. However, knowledge and confidence among community members and CHWs were significantly higher 2 years postintervention. Thus, a social network approach had an enduring effect on nutrition knowledge, but no effects on improved IYCF practices.     

Importance of coverage and quality for impact of nutrition interventions delivered through an existing health programme in Bangladesh

Understanding implementation of interventions is critical to illuminate if, how, and why the interventions achieve impact. Alive & Thrive integrated a nutrition intervention into an existing maternal, neonatal, and child health (MNCH) programme in Bangladesh, documenting improvements in women's micronutrient supplement intake and dietary diversity. Here, we examined how well the nutrition intervention was implemented and which elements of implementation explained intervention impact. Survey data were collected in 2015 and 2016 from frontline health workers (FLW) and households in areas randomized to nutrition‐focused MNCH (intensified interpersonal counselling, community mobilization, distribution of free micronutrient supplements, and weight‐gain monitoring) or standard MNCH (antenatal care with standard nutrition counselling). Seven intervention elements were measured: time commitment, training quality, knowledge, coverage, counselling quality, supervision, and incentives. Multiple regression was used to derive difference‐in‐differences (DID) estimates. Using village‐level endline data, path analysis was used to determine which elements most explained intervention impacts. FLWs in both areas were highly committed and well supervised. Coverage was high (>90%) for counselling, supplement provision, and weight‐gain monitoring. Improvements were significantly greater for nutrition‐focused MNCH, versus standard MNCH, for training quality (DID: 2.42 points of 10), knowledge (DID: 1.20 points), delivery coverage (DID: 4.16 points), and counselling quality (DID: 1.60 points). Impact was substantially explained by coverage and delivery quality. In conclusion, integration nutrition intervention into the MNCH programme was feasible and well‐implemented. Although differences in coverage and counselling quality most explained impacts, all intervention elements—particularly FLW training and performance—were likely important to achieving impact.     

Cash and voucher assistance and children's nutrition status in Somalia

To address ongoing food insecurity and acute malnutrition in Somalia, a broad range of assistance modalities are used, including in‐kind food, food vouchers, and cash transfers. Evidence of the impact of cash and voucher assistance (CVA) on prevention of acute malnutrition is limited in humanitarian and development settings. This study examined the impact of CVA on prevention of child acute malnutrition in 2017/2018 in the context of the Somalia food crisis. Changes in diet and acute malnutrition were measured over a 4‐month period among children age 6–59 months from households receiving household transfers of approximately US$450 delivered either as food vouchers or a mix of in‐kind food, vouchers, and cash. Baseline to endline change in children's dietary diversity, meal frequency, minimum acceptable diet (MAD), mid‐upper arm circumference (MUAC), and acute malnutrition (MUAC < 12.5 cm) were compared using difference‐in‐difference analysis with inverse probability weighting. There were no statistically significant changes in dietary diversity, meal frequency, or the proportion of children with MAD for either intervention group. Adjusted change in mean MUAC showed increases of 0.5 cm (confidence interval [CI; 0.0, 0.7 cm]) in the food voucher group and 0.1 cm (CI [?0.1, 0.4]) in the mixed transfer group. In adjusted analysis, prevalence of acute malnutrition among children under 5 years increased by 0.7% (CI [?13.4, 14.4%]) among food voucher recipients and decreased by 4.8% (CI [?9.9, 8.1%]) in mixed transfer recipients. The change over time in both mean MUAC and acute malnutrition prevalence was similar for both interventions, suggesting that cash and vouchers had similar effects on child nutrition status.     

Effect of tailored dietary guidance for pregnant women on nutritional status: A double‐cohort study

This double cohort study aimed to evaluate the effect of tailored dietary guidance for pregnant women on dietary intake, nutritional status, and infant birth weight. Healthy pregnant women were recruited at an antenatal clinic during two phases over 2 years. The historical controls were analyzed a year prior to the intervention group. In both groups, data were collected at 19–26 gestational weeks (baseline) and at 34–37 gestational weeks (outcome measurement). The intervention included the following: (a) assessments of maternal dietary nutritional intake using the brief self‐administered diet history questionnaire, (b) individual feedback based on the assessments of maternal nutritional status, (c) tailored guidance for a healthy diet, (d) original cooking recipes, and (e) goal sharing. Mann–Whitney U test was used to compare the outcome data between the groups. Of the 378 eligible women, 309 women had follow‐up questionnaire data. Blood samples were obtained from 202 women. Despite a lack of improvement in reported dietary intake, plasma eicosapentaenoic acid (p = .002), docosahexaenoic acid (p < .001), arachidonic acid (p < .001), and dihomo‐gamma‐linolenic acid (p < .001) concentrations as well as maternal weight gain (p = .019) were significantly higher in the intervention group. However, serum folate (p = .031) concentration was significantly lower in the intervention group, and there were no significant differences between the groups in 25‐hydroxy vitamin D levels, blood count, average birth weight, and rate of low birth weight infants. Assessment‐based tailored guidance individualized to maternal dietary intake might partially contribute to improved nutrition in pregnant women.     

A behaviour change intervention with lipid‐based nutrient supplements had little impact on young child feeding indicators in rural Kenya

Poor infant and young child feeding (IYCF) practices are associated with linear growth faltering. Our objective was to evaluate the impact of a nutrition and water and sanitation for health intervention on three IYCF indicators—minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD) in Kenyan children. Households were randomized into one of eight groups: (a) active control; (b) passive control; (c) water quality (W); (d) sanitation (S); (e) handwashing (H); (f) combined Water, Sanitation, and Handwashing; (g) nutrition (N); and (h) combined WSH + N. In the N and WSH + N arms, community‐based promoters counselled households on optimal IYCF practices, and small‐quantity lipid‐based nutrient supplements (SQ‐LNS) were provided to children 6–24 months of age. Twelve months (Year 1) and 24 months (Year 2) after interventions began, enumerators surveyed mothers to ascertain IYCF practices. We made pairwise comparisons of each intervention arm versus the active control arm using log binomial models. In total, 3,652 caretakers were surveyed at Year 1 and 4,987 caretakers at Year 2. Compared with the active control, there were no differences in any of the arms in MDD, MMF, or MAD, aside from an increase in MDD at Year 1 in the nutrition only arm but not in the combined WSH + N arm (N: 68%; WSH + N: 61%; C: 61%; N arm prevalence ratio: 1.13 95% CI [1.01, 1.25]). In this setting, a nutrition behaviour change communication intervention had little impact on IYCF indicators. The provision of SQ‐LNS was not detrimental to current IYCF indicators in the community.     

M‐SAKHI—Mobile health solutions to help community providers promote maternal and infant nutrition and health using a community‐based cluster randomized controlled trial in rural India: A study protocol

Reduction of childhood stunting is difficult to achieve by interventions that focus only on improving nutrition during infancy. Comprehensive interventions that extend through the continuum of care from pregnancy to infancy are needed. Mobile phones are now successfully being used for behaviour change communication to improve health. We present the methodology of an mHealth intervention “Mobile Solutions Aiding Knowledge for Health Improvement” (M‐SAKHI) to be delivered by rural community health workers or Accredited Social Health Activists (ASHAs) for rural women, below or up to 20 weeks of pregnancy through delivery until their infant is 12 months of age. This protocol paper describes the cluster randomized controlled trial to evaluate the effectiveness of M‐SAKHI. The primary objective of the trial is to reduce the prevalence of stunting (height‐for‐age < ?2 z‐score) in children at 18 months of age by 8% in the intervention as compared with control. The secondary objectives include evaluating the impact on maternal dietary diversity, birth weight, infant and young child feeding practices, infant development, and child morbidity, along with a range of intermediate outcomes for maternal, neonatal, and infant health. A total of 297 ASHAs, five trained counsellors, and 2,501 participants from 244 villages are participating in this study. The outcome data are being collected by 51 field research officers. This study will provide evidence regarding the efficacy of M‐SAKHI to reduce stunting in young children in rural India, and if effective, the cost‐effectiveness of M‐SAKHI.     

Effectiveness of a community‐based nutrition programme to improve child growth in rural Ethiopia: a cluster randomized trial

Few trials have shown that promoting complementary feeding among young children is effective in improving child linear growth in resource‐challenged settings. We designed a community‐based participatory nutrition promotion (CPNP) programme adapting a Positive Deviance/Hearth approach that engaged mothers in 2‐week nutrition sessions using the principles of ‘learning by doing’ around child feeding. We aimed to test the effectiveness of the CPNP for improving child growth in rural Ethiopia. A cluster randomized trial was implemented by adding the CPNP to the existing government nutrition programmes (six clusters) vs. government programmes only (six clusters). A total of 1790 children aged 6 to 12 months (876 in the intervention and 914 in the control areas) were enrolled and assessed on anthropometry every 3 months for a year. Multi‐level mixed‐effect regression analysis of longitudinal outcome data (n = 1475) examined the programme impact on growth, adjusting for clustering and enrollment characteristics. Compared with children 6 to 24 months of age in the control area, those in the intervention area had a greater increase in z scores for length‐for‐age [difference (diff): 0.021 z score/month, 95% CI: 0.008, 0.034] and weight‐for‐length (diff: 0.042 z score/month, 95% CI: 0.024, 0.059). At the end of the 12‐month follow‐up, children in the intervention area showed an 8.1% (P = 0.02) and 6.3% (P = 0.046) lower prevalence of stunting and underweight, respectively, after controlling for differences in the prevalence at enrollment, compared with the control group. A novel CPNP programme was effective in improving child growth and reducing undernutrition in this setting. © 2016 John Wiley & Sons Ltd     

Mother's dietary diversity and association with stunting among children <2 years old in a low socio‐economic environment: A case–control study in an urban care setting in Dhaka,Bangladesh

Mothers are often responsible for preparing nutritious foods in their households. However, the quality of mother's diets is often neglected, which may affect both mother's and child's nutrition. Because no single food contains all necessary nutrients, diversity in dietary sources is needed to ensure a quality diet. We aimed to study the association between mother's dietary diversity and stunting in children <2 years attending Dhaka Hospital of icddr,b, a diarrhoeal disease hospital in Dhaka, Bangladesh. A case–control study (n = 296) was conducted from November 2016 to February 2017. Data were collected from mothers of stunted children <2 years (length‐for‐age z score [LAZ] < ?2) as “cases” and nonstunted (LAZ ≥ ?1) children <2 years as “controls.” Mothers were asked to recall consumption of 10 defined food groups 24 hr prior to the interview as per Guidelines for Minimum Dietary Diversity for Women. Among the mothers of cases, 58% consumed <5 food groups during the last 24 hr, compared with 45% in control mothers (P = 0.03). Children whose mothers consumed <5 food groups were 1.7 times more likely to be stunted than children whose mothers consumed ≥5 food groups (P = 0.04). Intake of food groups such as pulses, dairy, eggs, and vitamin A rich fruit was higher in control mothers. Proportion of mother's illiteracy, short stature, monthly family income <BDT 11,480, absence of bank account, and poor sanitation was also found to be higher in stunted group. Further study particularly intervention or longitudinal study to see the causality of mother's dietary diversity with child stunting is recommended.     

Dietary patterns of 6–24‐month‐old children are associated with nutrient content and quality of the diet

We determined the associations of dietary patterns with energy/nutrient intakes and diet quality. Previously collected single 24‐hr dietary recalls for children aged 6–11 months (n = 1,585), 12–17 months (n = 1,131), and 18–24 months (n = 620) from four independent studies in low socio‐economic populations in South Africa were pooled. A maximum‐likelihood factor model, with the principal‐factor method, was used to derive dietary (food) patterns. Associations between dietary pattern scores and nutrient intakes were determined using Kendall's Rank Correlations, with Bonferroni‐adjusted significance levels. For both 6–11 months and 12–17 months, the formula milk/reverse breast milk pattern was positively associated with energy and protein intake and mean adequacy ratio (MAR). The family foods pattern (6–11 months) and rice and legume pattern (12–17 months) were positively associated with plant protein, fibre, and PU fat; both for total intake and nutrient density of the complementary diet. These two patterns were also associated with the dietary diversity score (DDS; r = 0.2636 and r = 0.2024, respectively). The rice pattern (18–24 months) showed inverse associations for nutrient intakes and nutrient densities, probably because of its inverse association with fortified maize meal. The more westernized pattern (18–24 months) was positively associated with unfavourable nutrients, for example, saturated fat and cholesterol. These results highlight that underlying dietary patterns varied in terms of energy/nutrient composition, nutrient adequacy, nutrient densities of the complementary diet, and dietary diversity.     

Men's nutrition knowledge is important for women's and children's nutrition in Ethiopia

In an effort to address undernutrition among women and children in rural areas of low‐income countries, nutrition‐sensitive agriculture (NSA) and behaviour change communication (BCC) projects heavily focus on women as an entry point to effect nutritional outcomes. There is limited evidence on the role of men's contribution in improving household diets. In this Agriculture to Nutrition trial (Clinicaltrials.gov identifier: NCT03152227), we explored associations between men's and women's nutritional knowledge on households', children's and women's dietary diversity. At the midline evaluation conducted in July 2017, FAO's nutrition knowledge questionnaire was administered to male and female partners in 1396 households. There was a high degree of agreement (88%) on knowledge about exclusive breastfeeding between parents; however, only 56–66% of the households had agreement when comparing knowledge of dietary sources of vitamin A or iron. Factor analysis of knowledge dimensions resulted in identifying two domains, namely, ‘dietary’ and ‘vitamin’ knowledge. Dietary knowledge had a larger effect on women's and children's dietary diversities than vitamin knowledge. Men's dietary knowledge had strong positive associations with households' dietary diversity scores (0.24, P value = 0.001), children's dietary diversity (0.19, P value = 0.008) and women's dietary diversity (0.18, P value < 0.001). Distance to markets and men's education levels modified the effects of nutrition knowledge on dietary diversity. While previous NSA and BCC interventions predominantly focused on uptake among women, there is a large gap and strong potential for men’s engagement in improving household nutrition. Interventions that expand the role of men in NSA may synergistically improve household nutrition outcomes.     

Water insecurity potentially undermines dietary diversity of children aged 6–23 months: Evidence from India

Dietary diversity is a crucial pathway to child nutrition; lack of diversity may deprive children of critical macro and micronutrients. Though water along with hygiene and sanitation is a known driver of child undernutrition, a more direct role of household water in shaping dietary diversity remains unexplored. Existing literature provides a sound theoretical basis to expect that water could affect dietary diversity among young children. Here, we test the proposition that suboptimal household access to water and low regional water availability associate with lower dietary diversity among young children. Using the nationally representative 2015–2016 India Demographic and Health Survey data, we conducted a probit analysis on the sample of 69,841 children aged 6–23 months to predict the probability that a child achieves minimum standards of dietary diversity (MDD). After controlling for relevant socioeconomic and gender‐related covariates, we found that children in household with suboptimal household water access were two percentage points less likely to achieve MDD, when compared with those from households with optimal water access. Children in high water availability regions had nine percentage points greater probability of achieving MDD compared with children from low water availability regions, accounting for household water access. As dietary diversity is central to nutrition, establishing the role of water access in shaping early childhood dietary diversity broadens the framework on how household material poverty shapes child malnutrition—independent of sanitation and hygiene pathways. This provides additional window for nutrition planning and intervention wherein water‐based strategies can be leveraged in multiple ways.