Nutrition education improves dietary diversity of children 6-23 months at community-level: Results from a cluster randomized controlled trial in Malawi

<div><p>Background: Low dietary quality and quantity and inappropriate feeding practices can cause undernutrition. Poor nutritional status in early childhood is associated with growth faltering. The objective of the study was to assess the potential of community-based nutrition education to improve height-for-age z-scores in children 6–23 months of age.</p><p>Methods and Findings: We carried out a cluster-randomized-controlled trial to assess the effectiveness of nutrition education. A total of 24 Extension Planning Area Sections served as clusters. The selection criteria were: the position of the extension officer was staffed and the sections had been selected by the project for activities in its first project year. The sections were randomized into intervention and control restricted on mean height for age Z-score using baseline information. In the intervention area, food security activities and community-based nutrition education was implemented. The control area received food security activities only. At baseline (2011) and endline (2014), caregivers with a child below two years of age were enrolled. Data assessment included anthropometric measurements, interviews on socio-economic status, dietary intake and feeding practices. A difference-in-differences estimator was used to calculate intervention effects. A positive impact on child dietary diversity was observed (B (SE) = 0.39 (0.15), p = 0.01; 95%CI 0.09–0.68). There was a non-significant positive intervention effect on mean height-for-age z-scores (B (SE) = 0.17 (0.12), p = 0.15; 95%CI -0.06–0.41). Limitations: The 24h dietary recalls used to measure dietary diversity did not consider quantities of consumed foods. Unrecorded poor quality of consumed foods might have masked a potential benefit of increased child dietary diversity on growth.</p><p>Conclusions: Participatory community-based nutrition education for caregivers improved child dietary diversity even in a food insecure area. Nutrition education should be part of programs in food insecure settings aiming at ameliorating food insecurity among communities.</p></div

Content of nutrition education (FAO 2014).

<p>Content of nutrition education (FAO 2014).</p

Flow-diagram of trial design.

<p>After a cross-sectional baseline survey in August/September 2011, the project area was divided in control and intervention area based on mean HAZ. From September 2011 –December 2014 the control area received agricultural activities only, while the intervention area received agricultural activities as well as two rounds of NE in the same time period. A cross-sectional endline survey was conducted in August/September 2014.</p

Indirect effects of nutrition education on HAZ.

<p>Pathway A: NE (the independent variable) impact on CDD (the mediator) controlled for age and sex of the child, wealth status of the household and educational status of the mother. Pathway B: HAZ (the dependent variable) influenced by CDD (the mediator) controlled for age and sex of the child, wealth status of the household, educational status and height of the mother. Pathway C: the model does not consider a direct effect of NE on HAZ.</p

Prevalence of food consumption and IYCF indicators at baseline and endline.

<p>Prevalence of food consumption and IYCF indicators at baseline and endline.</p

Characteristics of primary caregivers and children at baseline and endline.

<p>Characteristics of primary caregivers and children at baseline and endline.</p

CONSORT flow diagram for (A) Baseline survey 2011 and (B) Endline survey 2014.

<p>CONSORT flow diagram for (A) Baseline survey 2011 and (B) Endline survey 2014.</p

Household characteristics at baseline and endline.

<p>Household characteristics at baseline and endline.</p

Mean child hemoglobin concentrations (±SD) by age groups in months with respective maternal hemoglobin concentrations.

<p>3<4 mo: N = 38, 4<5 mo: N = 45, 5<6 mo: N = 39, 6<7 mo: N = 52, 7<8 mo: N = 55, 8<9 mo: N = 55, 9<10 mo: N = 56, 10<11 mo: N = 57, 11<12 mo: N = 55, 12<13 mo: N = 60, 13<14 mo: N = 53, 14<15 mo: N = 44, 15<16 mo: N = 28, 16<17 mo: N = 46, 17<18 mo: N = 32, 18<19 mo: N = 29, 19<20 mo: N = 25, 20<21 mo: N = 37, 21<22 mo: N = 42, 22<23 mo: N = 40, 23<24 mo: N = 33. mo = months.</p

Mean RBP concentrations by age groups in months for children without any signs of inflammation only.

<p>3 mo: N = 38, 4mo: N = 45, 5mo: N = 39, 6mo: N = 52, 7mo: N = 55, 8mo: N = 55, 9mo: N = 57, 10mo: N = 57, 11mo: N = 55, 12mo: N = 60, 13mo: N = 53, 14mo: N = 44, 15mo: N = 28, 16mo: N = 46, 17mo: N = 32, 18mo: N = 29, 19mo: N = 26, 20mo: N = 37, 21mo: N = 42, 22mo: N = 40, 23mo: N = 33; mo = months.</p