evidence-based blog of Filippo Dibari

Posts Tagged ‘RUCF’

Lipid-Based Nutrient Supplements Do Not Affect the Risk of Malaria or Respiratory Morbidity in 6- to 18-Month-Old Malawian Children in a Randomized Controlled Trial

In Under-nutrition on September 28, 2014 at 7:03 am

by Charles Mangani, Per Ashorn, Kenneth Maleta, John Phuka,Chrissie Thakwalakwa,Kathryn Dewey, Mark Manary, Taneli Puumalainen, and Yin Bun Cheung

from J. Nutr. November 1, 2014

(download)

Abstract

Background: There is evidence to support the use of lipid-based nutrient supplements (LNSs) to promote child growth and development in low-income countries, but there is also a concern regarding the safety of using iron-fortified products in malaria-endemic areas.

Objective: The objective of this study was to test the hypothesis that 6- to 18-mo-old rural Malawian children receiving iron-containing (6 mg/d) LNSs would not have excess morbidity compared with infants receiving no supplementation.

Methods: A randomized controlled trial allocated 840 children to receive daily supplementation with 54 g/d LNS with milk protein base (milk-LNS), 54 g/d LNS with soy protein base (soy-LNS), 71 g/d corn-soy blend (CSB), or no supplementation from 6 to 18 mo of age. Morbidity was compared using a non-inferiority margin set at 20% excess morbidity in supplemented groups compared with the nonsupplemented group.

Results: Baseline characteristics were similar across groups. The proportion of days with febrile illness between 6 and 18 mo was 4.9%, and there were no differences between the groups: 4.9% (95% CI: 4.3, 5.5%), 4.5% (95% CI: 3.9, 5.1%), 4.7% (95% CI: 4.1, 5.3%), and 5.5% (95% CI: 4.7–6.3%) in the milk-LNS, soy-LNS, CSB, and control groups, respectively. The proportion of days with respiratory problems and diarrhea between 6 and 18 mo also did not differ between groups. Compared with controls, the incident rate ratio (95% CI) for clinical malaria was 0.80 (0.59, 1.09), 0.77 (0.56, 1.06), and 0.79 (0.58, 1.08) in milk-LNS, soy-LNS, and CSB, respectively, with 95% CIs confirming non-inferiority. The incidence of febrile episodes, diarrhea, respiratory problems or admission to hospital, prevalence of malaria parasitemia throughout the follow-up, and mean change in hemoglobin concentration from baseline were also similar between the groups.

Conclusions: Daily supplementation with 54 g of milk-based or soy protein–based LNS or 71 g of CSB did not result in increases in malaria or respiratory morbidity in children in a malaria-endemic setting. However, we could not conclude whether LNSs did or did not increase diarrheal morbidity. This trial was registered at clinicaltrials.gov as NCT00524446.

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Effect of Supplementation with a Lipid-Based Nutrient Supplement on the Micronutrient Status of Children Aged 6-18 Months Living in the Rural Region of Intibucá, Honduras.

In Under-nutrition on March 26, 2014 at 4:35 pm

Siega-Riz AM1, Estrada Del Campo Y, Kinlaw A, Reinhart GA, Allen LH, Shahab-Ferdows S, Heck J, Suchindran CM, Bentley ME.

Paediatr Perinat Epidemiol. 2014 Mar 13

 

Abstract

 

BACKGROUND:

Lipid-based nutrient supplements (LNS) have been effective in the treatment of acute malnutrition among children. We evaluated the use of LNS supplementation for improving the micronutrient status of young children.

METHODS:

A 12-month randomised controlled trial was conducted among children aged 6-18 months living in Intibucá, Honduras. Communities (n = 18) were randomised into clusters matched by poverty indicators (9 intervention, n = 160 and 9 controls, n = 140). Intervention participants received LNS. All children received food vouchers and nutrition education. Primary outcomes included measures of micronutrient status: at baseline, 6 and 12 months’ blood were collected for assessment of folate, iron, zinc, riboflavin, and vitamin B12 status; haemoglobin was measured every 3 months; and dietary and anthropometry collected monthly. Longitudinal analyses were based on intent to treat and LNS adherence. Generalised estimating equations were used in the estimation of generalised linear regression models specified for the data.

RESULTS:

At 6-month follow-up, children in the intervention group had a lower proportion classified as deficient for B12 (43.6%) compared with the control (67.7%; P = 0.03). The intervention group had a higher mean concentration for folate at 6 months (P = 0.06), and improvements continued through 12 months for folate (P = 0.002) and vitamin A deficiency (P = 0.03). This pattern of results, with improved significance, remained in subanalysis based on LNS adherence.

CONCLUSION:

These data demonstrate that LNS improved select micronutrient status in young non-malnourished Honduran children.

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Systematic Review of Complementary Feeding Strategies amongst Children Less than Two Years of Age

In Under-nutrition on March 26, 2014 at 3:24 pm

by Zohra S. Lassi, Guleshehwar Zahid, Jai K. Das, Zulfiqar A. Bhutta

UKAID – 2013 (download)

Extract from Executive Summary

The prevalence of malnutrition in low- and middle-income countries (LMICs) is considerably high. Malnutrition leads to susceptibility to preventable infectious diseases and has an indirect association with the leading causes of death in children. According to an estimate, 19.4% of children less than five years of age in these countries wereunderweight (weight-for-age [WAZ] Z score <-2) and about 29.9% werestunted in the year 2011 (height-for-age [HAZ] Z score <-2). Malnutrition is preventable through effective complementary feeding practices. Several strategies have been employed to improve complementary feeding practices. These include nutritional education to mothers designed to promote healthy feeding practices; provision of complementary food offering extra energy (with or without micronutrient fortification); and increasing energy density of complementary foods through simple technology.

In this review, we have included randomised controlled trials (RCTs)and non-RCTsthat assessed the impact of complementary feedingand education on complementary feeding on linear growth, weight gain, iron status, and morbidity. Broadly, interventions were classified as education on complementary feedingand complementary feedingwith or without nutrition education. We have also mentioned the costs of the interventions given in the included studies and other complementary foods available globally.

All available papers/reports on the effect of complementary feeding(fortified or unfortified, but not micronutrients alone) and education on complementary feeding on children less than twoyears of age in Low and middle income countries (LMIC) were included. Studies that delivered intervention and assessed outcome for at least sixmonths were included. We excluded all those studies in which intervention was given for supplementary and therapeutic purposes and those that assessed the impact of micronutrients alone.

We included 11 randomised controlled trials (RCTs) and 7 non-RCTs. We conducted meta-analysis on RCTs. Amongst all RCTs, eight were on nutritionaleducation only.We found significant impact of nutritional education on linear growth (height-for-age Z scores: SMD 0.22; 95% Confidence Interval [CI]: 0.08, 0.37, n=1,486, 4 studies; stunting: risk ratio (RR) 0.72; 95% CI: 0.57, 0.93, n=1445, 2 studies)and weight (weight-for-age [WAZ]Z scores: SMD 0.20; 95%CI: 0.07, 0.33, n=1673, 4 studies). On the other hand, we found fourtrials in which children were provided with complementary feeding with orwithout nutrition education. We found that complementary feeding with or without education had a non-significant impact on HAZ scores (SMD 0.46; 95% CI: -0.24, 1.17, 4 studies, n=500), and WAZ(SMD 0.15; 95% CI: -0.09, 0.40, 2 studies, n=262).We also performed a meta-analysis based on the type of food, but we are unable to conclude which types of foods are the most effective in preventing undernutrition because the numbers of studies in each subtype were few.

We found that these interventions had a significant impact on reducing the prevalence of respiratory illness (RR 0.68; 95% CI: 0.48, 0.97, 2 studies, n=629). However, there was no difference in fever and diarrhoea episodes.

We also attempted to gather data on cost of the interventions, food products, and complementary feeding strategies used in the included studies. Most papers did not mention estimates of cost and thus, we contacted the authors with the request to provide us with cost data. We have also included cost estimates of various complementary foods that were not used in any of the interventions included in this review but can potentially have an impact in reducing undernutrition. The cost of different baby food products, including cereals, porridge, and biscuits produced by different manufacturers were identified via web search.

The scarcity of available studies and their heterogeneity as well as the variety in complementary feeding interventions make it difficult to determineone particular type of complementary feeding intervention as the most effective. Nonetheless, the results of this review indicate that effectively implemented provision of complementary feedingand education on complementary feedinghave a potential to prevent undernutrition in children. Our review also found that nutritional education and complementary feeding (either individually or combined) both have the potential to reduce morbidity from respiratory infections. However, further high-quality studies need to be conducted which report consistent outcome measures and similar interventions in order to accurately map out which interventions, if scaled up, can be effective.Moreover, these trials should consider using standardised types of food inthe intervention so that evidence can be formulated on which type of food is most effective. It is ideal to keep the duration of intervention for at least six months since anthropometric improvements are gradual. Trials should report consistent outcomes and also include morbidity outcomes. Despite clear evidence of the disastrous consequences of childhood nutritional deprivation in the short and long terms, nutritional health remains a low priority. Therefore, enhanced and rigorous actions are needed to deliver and scale up nutritional education and complementary feeding interventions.

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Iron bioavailability from a lipid-based complementary food fortificant mixed with millet porridge can be optimized by adding phytase and ascorbic acid but not by using a mixture of ferrous sulfate and sodium iron EDTA

In Under-nutrition on March 22, 2014 at 9:14 am

by Cercamondi CI, Egli IM, Mitchikpe E, Tossou F, Hessou J, Zeder C, Hounhouigan JD, Hurrell RF

J Nutr. 2013 Aug;143(8):1233-9

Abstract

Home fortification with lipid-based nutrient supplements (LNSs) is a promising approach to improve bioavailable iron and energy intake of young children in developing countries.

To optimize iron bioavailability from an LNS named complementary food fortificant (CFF), 3 stable isotope studies were conducted in 52 young Beninese children. Test meals consisted of millet porridge mixed with CFF and ascorbic acid (AA).

Study 1 compared iron absorption from FeSO4-fortifed meals with meals fortified with a mixture of FeSO4 and NaFeEDTA. Study 2 compared iron absorption from FeSO4-fortifed meals without or with extra AA. Study 3 compared iron absorption from FeSO4-fortified meals with meals containing phytase added prior to consumption, once without or once with extra AA. Iron absorption was measured as erythrocyte incorporation of stable isotopes.

In study 1, iron absorption from FeSO4 (8.4%) was higher than that from the mixture of NaFeEDTA and FeSO4 (5.9%; P < 0.05). In study 2, the extra AA increased absorption (11.6%) compared with the standard AA concentration (7.3%; P < 0.001). In study 3, absorption from meals containing phytase without or with extra AA (15.8 and 19.9%, respectively) increased compared with meals without phytase (8.0%; P < 0.001). The addition of extra AA to meals containing phytase increased absorption compared with the test meals containing phytase without extra AA (P < 0.05).

These findings suggest that phytase and AA, and especially a combination of the two, but not a mixture of FeSO4 and NaFeEDTA would be useful strategies to increase iron bioavailability from a CFF mixed with cereal porridge.

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Food allowance optmization model

In Under-nutrition on February 5, 2014 at 12:11 pm

by Viesturs Rozenbergs, Imants Skrupskis, Dace Skrupska, Ērika Rozenberga

RURAL ENVIRONMENT. EDUCATION. PERSONALITY. Jelgava, 20 – 21.03.2013

(download)

Abstract

Possibility of food allowance optimization by using MS Solver tool is analysed in the research. The model is developed by balancing 22 food products and 30 constraints – 8 nutrients and 22 minimum amounts of food products. The new method differs from the applications of linear programming described in the special literature on nutrition science not only with increased nutritional constraints, but also the minimum amount of every product is introduced as constraints, which does not essentially change costs, but provide quality, for example, for tea or coffee it is recommended to define not x≥0, but x≥3. By modifying minimum amounts of tea, coffee, sugar, spices, it is possible to obtain up to 70% economy from the initial rate. Application of the model is approbated in the computer class during practical classes for students of nutrition science.

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The use of linear programming to determine whether a formulated complementary food product can ensure adequate nutrients for 6- to 11-month-old Cambodian infants

In Under-nutrition on February 5, 2014 at 11:46 am

Jutta KH Skau, Touch Bunthang, Chhoun Chamnan, Frank T Wieringa, Marjoleine A Dijkhuizen, Nanna Roos, and Elaine L Ferguson

Am J Clin Nutr January 2014 vol. 99 no. 1 130-138

Abstract

Background: A new software tool, Optifood, developed by the WHO and based on linear programming (LP) analysis, has been developed to formulate food-based recommendations.

Objective: This study discusses the use of Optifood for predicting whether formulated complementary food (CF) products can ensure dietary adequacy for target populations in Cambodia.

Design: Dietary data were collected by 24-h recall in a cross-sectional survey of 6- to 11-mo-old infants (n = 78). LP model parameters were derived from these data, including a list of foods, median serving sizes, and dietary patterns. Five series of LP analyses were carried out to model the target population’s baseline diet and 4 formulated CF products [WinFood (WF), WinFood-Lite (WF-L), Corn-Soy-Blend Plus (CSB+), and Corn-Soy-Blend Plus Plus (CSB++)], which were added to the diet in portions of 33 g/d dry weight (DW) for infants aged 6–8 mo and 40 g/d DW for infants aged 9–11 mo. In each series of analyses, the nutritionally optimal diet and theoretical range, in diet nutrient contents, were determined.

Results: The LP analysis showed that baseline diets could not achieve the Recommended Nutrient Intake (RNI) for thiamin, riboflavin, niacin, folate, vitamin B-12, calcium, iron, and zinc (range: 14–91% of RNI in the optimal diets) and that none of the formulated CF products could cover the nutrient gaps for thiamin, niacin, iron, and folate (range: 22–86% of the RNI). Iron was the key limiting nutrient, for all modeled diets, achieving a maximum of only 48% of the RNI when CSB++ was included in the diet. Only WF and WF-L filled the nutrient gap for calcium. WF-L, CSB+, and CSB++ filled the nutrient gap for zinc (9- to 11-mo-olds).

Conclusions: The formulated CF products improved the nutrient adequacy of complementary feeding diets but could not entirely cover the nutrient gaps. These results emphasize the value of using LP to evaluate special CF products during the intervention planning phase.

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Hybrid public/private delivery of preventative Lipid-based Nutrient Supplement products

In Under-nutrition on November 14, 2013 at 11:31 am

If you are interested in the implications of the delivery mechanisms of the LNS products, do not miss this paper published on the SCN News Bullettin, by Travis J.Lybbert, UCDAVIS.

(download)

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Formative assessment to design the packaging of a lipid-based nutrient supplement for a home fortification program to improve the nutritional status of young children in the Democratic Republic of Congo

In Under-nutrition on September 7, 2013 at 1:35 pm

 

From the  Home Fortification Technical Advisory Group (HF-TAG)

(download)

EXECUTIVE SUMMARY

The Democratic Republic of Congo (DRC) is a vast country with more than 66 million inhabitants. Despite being one of largest reserves of natural resources in the world, child survival remains of concern in DRC. Based upon the preliminary results of the 2010 MICS Survey (Multiple Indicators Cluster Survey), National rates of malnutrition are high: wasting (9%), stunting (43%) and underweight (24%). In an effort to combat malnutrition UNICEF has implemented a 3- year Infant and Young Child Feeding IYCF strategy that integrates IYCF counseling (based on the WHO Ten Guiding Principles) in the Minimum Health Package. An important component of the DRC UNICEF 3-year IYCF strategy is a pilot program that will provide counseling to pregnant women, IYCF counseling, community messages, and a small quantity (20g per day) lipid based nutrient supplement (LNS) for infants (daily for children 6-12 months of age), using the existing health care infrastructure. The pilot program will be implemented in Kasenga health zone (HZ) and pending the results of the pilot program, the enhanced IYCF program will be scaled up to other HZ’s in DRC.

The goal of the program is to improve the nutritional status of children aged 0-12 months of age in Kasenga Health zone by reducing the prevalence of anemia, vitamin A deficiency and improving infant and young child feeding practices through the delivery of key messages and the distribution of lipid based nutritional supplements (LNS) (for children 6-12 months of age). The purpose of this present document is to describe the process to design the packaging of the LNS product that will be distributed as part of the pilot project.

In October 2010 an initial formative assessment was conducted to guide the design of the proposed packaging of an LNS product, to be used in in the pilot program. A second formative assessment, conducted in June 2011, re-tested the design elements of the packaging and tested the concept of providing the LNS in a multi sachet strip. The results of this second formative study were used to finalize the package and branding of the LNS. This report presents the results of the second formative study.

The specific aim of the second formative assessment was to determine which name, color, general style, and images communicate important product-related messages and would maximize the appropriate use of the product in an area with low literacy levels.

A study protocol was developed by CDC and Nutriset describing the methodology and tools that would be used in the formative assessment. Focus group discussions (FGD) and key interviews (KI) were the primary methods chosen to collect the data.

Data was collected in two locations of Lubumbashi, Katanga region: Mabaya, a rural village and Kipushi, a peri-urban area.

Results show that the majority of the study participants read the different images on the multi sachet strip as a story line. The images were interpreted as a series of events that must happen in a child’s life to ensure that the child stays healthy and develops well. The messages of washing the child’s hands, feeding the child with breastmilk and enriching complementary foods are seen as necessary elements in order to have a playful and active child. Participants retained

the main messages that the strip should convey: child care, product use, target group, as well as potential product benefits.

All participants recognized the mother and the children in the images as “Congolese” and “African”. Green and brown were identified as suitable colors for the LNS packaging and were associated with qualities such as health, growth, and development of the child. White could add a positive association by making a link to the milk content of the product.

The participants preferred the names Kulazuri (eating well) and Afiabora (good health) for the LNS. After further discussion of the name options with the field team and UNICEF staff a combination of the first two name proposals was found “Kulabora” (eating better).

The results from this formative study were used to finalize the design of the LNS product, which is currently being distributed in Kasenga health zone.

– See more at: http://hftag.gainhealth.org/resources/formative-assessment-design-packaging-lipid-based-nutrient-supplement-home-fortification-p#sthash.MvLVxabW.dpuf

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Corporations and the fight against hunger: why CSR won’t do

In Under-nutrition on August 12, 2013 at 6:01 am

by Steve Collins and Paul Murphy – on The Guardian Professional, Thursday 18 July 2013 10.51 BST

In addition to the many millions still suffering from acute malnutrition, over one-third of all children in developing countries globally experience chronic malnutrition – often referred to as “hidden hunger” (pdf). Aside from the inherent suffering, the devastating longer-term consequences (both for the child and ultimately for their country) are often not understood.

Progress has been made in the fight against malnutrition. The development of highly fortified nutritious pastes, ready-to-use therapeutic foods, together with community-based management has revolutionised our ability to treat severe malnutrition. These products are eaten directly from the pack, do not require mixing with water, are stable without refrigeration and are highly convenient and palatable. Combined with the innovative approach of empowering mothers by delivering nutritional care to people in their communities rather than in hospitals, these foods have resulted in dramatic improvements in treatment and prevention, with death rates cut fivefold. But the problem is too big to leave to the UN, NGOs and the public sector to resolve.

 Engaging private sector

There is an opportunity for the private sector to lead in tackling this problem but traditional models that approach the treatment and prevention of malnutrition from the perspective of corporate social responsibility or charity, are not only failing to address the problem, they are also missing major opportunities for revenue growth. Malnutrition can now be treated at real scale. However, in order to extend this approach to include prevention, we need more effective engagement with the corporate sector. The debate shouldn’t be about if, but rather about how, the private sector should engage.

We set up our company, Valid Nutrition, as a social enterprise with the specific mission of manufacturing these life saving foods exclusively in developing countries and making them more available, appealing and affordable to those who need them most. Fundamental to our vision and approach is the concept of regarding malnourished people as customers – and not just as passive beneficiaries of goodwill.

In our opinion, the reason engagement has moved so slowly is that it has been based too often on a flawed CSR viewpoint. Despite all the hyperbole, CSR tends to be peripheral in most organisations and is not woven into the fabric of the business. It’s not always transparent and there maybe strings attached. Sometimes it’s driven by a need to buy profile and even worse, CSR has been used as a type of moral counterbalance to practices that have had direct negative impacts on the poor. To make a lasting difference, we believe the prevention of malnutrition must be integrated into the core business of major food companies. Realistically, that requires shareholders to receive a tangible return. At some point, companies must be able to generate profit out of their engagement with the so-called “base of the pyramid” (the economically poorest 1 billion people on our planet). Controversial perhaps, but also rooted in realism.

So how can we align two such apparently conflicting aims – the prevention and treatment of malnutrition, and profit making?

Advantages of a business model

Ultimately, there should be no conflict. The World Bank has identifiedmalnutrition as the single greatest cause of poverty. There is strong evidence that children who receive adequate nutrition go on to have substantially increased earning power as adults [43% more according to a major study published in The Lancet, in 2008]. A lifetime of increased earning power from an initial investment of less than $100 (£66), is a massive return that has huge potential to boost consumer markets and economies. Given the vast numbers of people in this segment of the global population, investment in early child nutrition is highly economically attractive for both governments and industry alike.

Reaching those consumers however demands that we create viable business models that establish better mechanisms for engagement between public and private sectors. There are two distinct and complementary models that combine and maximise the comparative advantages of each sector; one designed to increase the efficiency, impact and reach of free or subsidised products, the second, designed to increase the availability, purchase and consumption of beneficial nutritional products by those who can afford them. Both require standards and metrics to guarantee efficacy and protect the food security and self-sufficiency of vulnerable groups. Ingredients must be procured in developing countries in a way that supports local agriculture and avoids the dumping of subsidised farm outputs on the developing world.

The first model requires public nutrition interventions targeting the very poor. The low or non-existent purchasing power of these groups means that such products must be free or heavily subsidised, funded by public bodies, manufactured by businesses willing to accept a low margin and targeted to public sector and civil society actors. Although many of the essential elements of this system are already in place, its efficacy and impact needs to be increased by better harnessing private sector capability. We need commercial engagement to expand production, reduce cost and enhance distribution of new appropriately formulated foods. We also need to link these initiatives to public sector nutritional assessment and diagnosis through the use of prescriptions or vouchers. The widespread use of mobile phones, even in the poorest communities, provides an exciting and powerful potential mechanism for related cash transfers to offset against purchase price.

The second model requires appropriately formulated consumer food products to be sold to the lower levels of the socio-economic pyramid at affordable prices. Each consumer persuaded to buy effective nutritional snacks, enhances the economic productivity of future generations and frees up vital public resources to focus on those who cannot afford even the simplest foods.

To achieve this requires innovation, courage and imagination. Although ultimately the market is attractive, private sector companies entering this space on their own, face high initial risk, especially having to accept diluted margins for a considerable period. Unfortunately, typical shareholder requirements (including from many so-called “impact investors”) preclude this sort of patience and vision.

Going beyond CSR

Many companies also fear criticism of their motives in attempting to operate commercially. Business requires encouragement to face challenges. We are convinced that we can demonstrate that suitable commercial models can align revenue generation with social impact.

We believe that to open up this market requires a new genre of businesses, free from the short-term demands of typical shareholders. Structured imaginatively to avoid dilution of corporate margins, such businesses could harness commercial sector capability through purchasing R&D and “route to market” expertise and develop suitable brands produced on a commercial basis that penetrate through the population pyramid.

Such social businesses, committed to addressing humanitarian need while also achieving a commercial return, are beginning to emerge. By combining an enterprising social vision with a disciplined business approach, many are now punching above their weight and can use their presence to leverage a much wider ethical engagement from other commercial actors.

The current model for nutritional development has failed the poor of so many developing nations. Much CSR contributes to this failure through its focus on disbursements that do nothing to harness business capability or add value to the money given. Socially orientated corporate engagement through commercial enterprises can however create a multiplier effect that both improves nutrition and ultimately fosters sustainable economic development. This in turn can stimulate agricultural activity, thereby helping to create a positive cycle that both treats and prevents undernutrition. Such an approach will increase both the social and economic returns of investment.

Enabling all children to reach their full potential depends largely on nutrition. By imaginatively broadening the scope of engagement with the private sector, we can make meaningful and sustainable progress and in so doing create a massive beneficial change for individuals, societies and economies.

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Dr Steve Collins, is a medical doctor, child nutrition expert and chairman of Valid Nutrition. Paul Murphy is Valid Nutrition’s chief executive. Prior to joining the social enterprise, he worked with Unilever in a variety of senior roles for over 27 years.

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An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia

In Under-nutrition on August 28, 2012 at 8:52 pm

by Bridget Fenn, Assaye T Bulti, Themba Nduna, Arabella Duffield and Fiona Watson

Public Health Nutrition / Volume 15 / Issue 09 / September 2012 , pp 1746-1754

Abstract

Objective To determine which interventions can reduce linear growth retardation (stunting) in children aged 6–36 months over a 5-year period in a food-insecure population in Ethiopia.

Design We used data collected through an operations research project run by Save the Children UK: the Child Caring Practices (CCP) project. Eleven neighbouring villages were purposefully selected to receive one of four interventions: (i) health; (iii) nutrition education; (iii) water, sanitation and hygiene (WASH); or (iv) integrated comprising all interventions. A comparison group of three villages did not receive any interventions. Cross-sectional surveys were conducted at baseline (2004) and for impact evaluation (2009) using the same quantitative and qualitative tools. The primary outcome was stunted growth in children aged 6–36 months measured as height (or length)-for-age Z-scores (mean and prevalence). Secondary outcomes were knowledge of health seeking, infant and young child feeding and preventive practices.

Setting Amhara, Ethiopia.

Subjects Children aged 6–36 months.

Results The WASH intervention group was the only group to show a significant increase in mean height-for-age Z-score (+0·33, P = 0·02), with a 12·1 % decrease in the prevalence of stunting, compared with the baseline group. This group also showed significant improvements in mothers’ knowledge of causes of diarrhoea and hygiene practices. The other intervention groups saw non-significant impacts for childhood stunting but improvements in knowledge relating to specific intervention education messages given.

Conclusions The study suggests that an improvement in hygiene practices had a significant impact on stunting levels. However, there may be alternative explanations for this and further evidence is required.

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