Intro animation:

Session recording:

Speakers and presentations:

• Session chair: Swetha Manohar, Johns Hopkins University
  @JohnsHopkins

• Philip James, London School of Hygiene & Tropical Medicine (LSHTM)
  @LSHTM 
  Effect of nutrition-sensitive agricultural interventions with participatory videos and women’s group meetings on maternal and child nutritional outcomes (UPAVAN trial): A four-arm cluster-randomised controlled trial in rural Odisha, India
  Presentation | Slides

• Emily Faerber, Emory University
  @emoryghi

  A nutrition-sensitive, orange-fleshed sweet potato project in Southern Ethiopia improves complementary feeding practices: An examination of impact pathways

  Presentation | Slides

• Pepijn Schreinemachers, World Vegetable Centre
  @go_vegetables
  Promoting healthier food choices among children: an innovative strategy combining school and home gardens
  Presentation | Slides

• Srujana Medithi, ICMR -National Institute of Nutrition
  @ICMRNIN
  Impact evaluation of micro-nutrients supplementation on nutritional status and oxidative stress of rural farm children in Telangana state, India
  Presentation | Slides

• Tracy Morse, University of Strathclyde
  @nyanitm @UniStrathclyde
  A combined complementary food hygiene and WASH intervention to reduce diarrhoeal disease in rural Malaw
  Presentation | Slides

Abstracts:

Effect of nutrition-sensitive agricultural interventions with participatory videos and women’s group meetings on maternal and child nutritional outcomes (UPAVAN trial): A four-arm cluster-randomised controlled trial in rural Odisha, India 

Philip James¹ Suneetha Kadiyala¹, Helen Harris Fry¹, Emma Beaumont¹, Heather Danton², Diana Elbourne¹, Emily Fivian¹, Hassan Haghparast-Bidgoli³, Peggy Koniz-Booher², Sneha Krishnan¹, Abhinav Kumar⁴, Naba Kishore Mishra⁵, Satyanarayan Mohanty^6, Nirmala Nair⁷, Meghan O'Hearn⁴, Manoj Parida⁶, Ronali Pradhan⁴, Shibnath Pradhan⁵, Suchitra Rath⁷, Shibanand Rath⁷, Jolene Skordis-Worrall³, Joanna Sturgess¹, Prasanta Tripathy⁷, Avinash Upadhay⁴, Audrey Prost³ and Elizabeth Allen¹

¹ London School of Hygiene & Tropical Medicine, London, UK

² JSI Research & Training Institute, Inc. Arlington, USA

³ University College London, Institute for Global Health, UK

⁴ Digital Green, New Delhi, India

⁵ Voluntary Association for Rural Reconstruction and Appropriate Technology, Keonjhar, India

⁶ Development Corner Consulting Pvt. Ltd. Bhubaneshwar, India

⁷ Ekjut, Jharkhand, India

Introduction

Almost a quarter of the world’s undernourished people live in India, and half of India depends on subsistence farming. We tested impacts of three nutrition-sensitive agricultural (NSA) interventions on maternal and child nutrition.

Methods

We conducted a parallel four-arm cluster-randomised trial in Odisha, India. 148 village clusters were allocated in the ratio 1:1:1:1 to a control arm or one of three interventions of fortnightly women’s groups meetings, with household visits, using 1) NSA videos (AGRI); 2) NSA and nutrition-specific videos (AGRI-NUT); 3) NSA videos and a nutrition-specific Participatory Learning and Action approach (AGRI-NUT+PLA). Allocation was stratified by distance to town and proportion of Scheduled Tribe or Scheduled Caste households. Impacts were assessed in children aged 0-23 months and female caregivers through cross-sectional surveys at baseline (November 2016-January 2017) and endline (November 2019-January 2020). Primary outcomes were proportion of children aged 6-23 months consuming ≥4/7 food groups in the previous 24 hours and mean maternal Body Mass Index (BMI). Secondary outcomes were proportion of mothers consuming ≥5/10 food groups in the previous 24 hours and proportion of children wasted (<-2 SD weight-for-length z-scores). Analyses were by intention-to-treat. Participants and intervention facilitators were not blind to allocation, but the research team were. The trial is registered with ISRCTN (65922679).  

Findings

4478/5427 mother-child dyads responded at baseline, and 4291/4792 at endline. AGRI-NUT and AGRI-NUT+PLA, but not AGRI, increased the proportion of children consuming ≥4 food groups (adjusted relative risk (95% CI) AGRI: 1·06 (0·91, 1·23), p=0·44; AGRI-NUT: 1·19 (1·03, 1·37), p=0·02; AGRI-NUT+PLA: 1·27 (1·11, 1·46), p=0·001). We found no effect of any of the interventions on mean maternal BMI (adjusted mean differences AGRI: -0·05 (-0·34, 0·24), p=0·73; AGRI-NUT: 0·04 (-0·26, 0·33), p=0·80; AGRI-NUT + PLA: -0·03 (-0·3, 0·23), p=0·81). 

AGRI and AGRI-NUT+PLA both increased the proportion of mothers consuming ≥5/10 food groups, with AGRI-NUT having a marginal effect (adjusted relative risk AGRI: 1·21 (1·01, 1·45), p=0·043; AGRI-NUT: 1·16 (0·98, 1·38), p=0·077; AGRI-NUT+PLA: 1·30 (1·10, 1·53), p=0·002). We found no effect of any of the interventions on child wasting (adjusted relative risk AGRI: 0·95 (0·73, 1·24), p=0·69; AGRI-NUT: 0·96 (0·72, 1·29), p=0·78; AGRI-NUT+PLA: 0·96 (0·73, 1·26), p=0·76).

Conclusion

Our trial shows large improvements in achieving minimum child dietary diversity and, to our knowledge, is the first NSA trial to show an impact on maternal minimum dietary diversity. The largest effect sizes were found in AGRI-NUT+PLA, suggesting that enhanced participatory components could accelerate NSA intervention improvements in diet quality. Women’s groups using videos on NSA with nutrition-specific PLA presents a promising intervention to improve dietary quality. These components have been independently scaled up in many low-income contexts; their impacts could increase by improving converging efforts. Additional investments are required to improve anthropometric outcomes.

Funding: Bill and Melinda Gates Foundation, UK Department for International Development, USAID

A Nutrition-Sensitive, Orange-Fleshed Sweetpotato Project in Southern Ethiopia Improves Complementary Feeding Practices: An Examination of Impact Pathways

Emily C. Faerber¹

Roland Brouwer²

Jan Low³

Amy Webb Girard^1
1Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA
²International Potato Center, Hawassa, Ethiopia
³International Potato Center, Nairobi, Kenya

Introduction

Quality Diets for Better Health (QDBH) is a nutrition-sensitive agricultural project that promotes adoption of vitamin A-rich orange-fleshed sweetpotato (OFSP) and community nutrition education in southern Ethiopia. The objective of this study was to explore the extent to which nutrition knowledge and food security mediate the effect of the intervention, including any added benefit of an innovative feeding toolkit, on complementary feeding practices.

Methods

To evaluate the effectiveness of the intervention, we used a three-arm, cluster-randomized controlled trial with a control group; a partial intervention group that received OFSP planting material and community-based nutrition education lasting 8 months; and a full intervention group that received OFSP planting material, community-based nutrition education lasting 8 months, and the feeding toolkit. Households with infants <6 months completed a baseline survey in January 2018 just prior to the start of the nutrition training program; midline and endline surveys were conducted approximately 6 and 12 months later. To assess complementary feeding at midline and endline, we used novel indicators of portion size and complementary food consistency, as well as World Health Organization indicators for dietary diversity and feeding frequency. Individual indicators were summarized in a complementary feeding index (CFI; range 0-8). While controlling for covariates, we conducted mediation analysis to test whether food security (measured via the Food Insecurity Experience Score) and nutrition knowledge mediate changes in these outcomes at each follow-up. Mediation analyses were done in Mplus 7.4; standard errors were estimated using bootstrapping, and we present Bonferroni-adjusted 97.5% confidence intervals.

Findings

Of 605 households enrolled at baseline, 548 (90.6%) and 523 (86.4%) completed midline and endline surveys. At midline, a food insecure season, food security and nutrition knowledge were higher in partial and full intervention households. At midline, CFI was only significantly higher in the full intervention group (βfull=0.73, 97.5% CI 0.41, 1.02). In both partial and full intervention groups, there were significant indirect effects of nutrition knowledge on CFI (βpartial=0.13, 97.5% CI 0.06, 0.25, βfull =0.16, 97.5% CI 0.08, 0.28). Also at midline, we observed a strong effect of the full intervention on CFI (βfull=0.54, 97.5% CI 0.21, 0.86) that was not explained by either mediator. At endline, a food secure season, there was no significant effect of the intervention on food security, but nutrition knowledge scores remained significantly higher in both the partial and full intervention groups. CFI was not significantly higher in either intervention group at endline, however there were significant indirect effects of nutrition knowledge on CFI in both groups (βpartial=0.05, 97.5% CI 0.01, 0.12; βfull=0.08, 97.5% CI 0.02, 0.16).

Conclusion

Modest improvements in complementary feeding are mediated by nutrition knowledge, though the strongest impact on complementary feeding was not mediated by either nutrition knowledge or food security and was only observed in the group receiving the feeding toolkit. The feeding toolkit may act as an effective cue to action for complementary feeding practices, though in our sample this effect was not sustained at endline during the food secure season.

References

WHO, Indicators for assessing infant and young child feeding practices, Part I Definitions. 2008, Geneva: World Health Organization.

Ballard, T.J., A.W. Kepple, and C. Cafiera, The food insecurity experience scale: developing a global standard for monitoring hunger worldwide. 2013, FAO: Rome.

Promoting healthier food choices among children: an innovative strategy combining school and home gardens

Pepijn Schreinemachers¹

Rachana Manandhar Shrestha¹

Ghassan Baliki²

Dhruba Raj Bhattarai³

Ishwori P. Gautam³

Puspa Lal Ghimire⁴

Bhishma P. Subedi⁴

Tilman Brück²

¹World Vegetable Center, Thailand

²Leibniz Institute of Vegetable and Ornamental Crops, Germany

³Nepal Agricultural Research Council

⁴Asia Network for Sustainable Agriculture and Bioresources, Nepal

Introduction

School garden programs have gained significant traction in the health, agriculture and education spheres because healthy food preferences and habits established in childhood could potentially lead to lifetime improvements to nutrition and health. However, evidence shows that school garden programs are more effective at influencing knowledge and preferences than at changing actual behavior [1-5]. This may be because school gardens insufficiently influence parents’ food behavior and do not increase the availability of healthy food in children’s homes. Using data from Nepal, this study tests whether school garden programs can be more effective when they explicitly aim to relieve these constraints.        

Methods

The study was implemented in Sindhupalchok District, Nepal. The cluster randomized controlled trial design included 15 treatment and 15 control schools randomly selected from a list of 52 eligible schools. The intervention targeted children in grades 4-5 and their primary caregivers. Treatment schools received teacher training in gardening, vegetable seeds, cash funds to purchase garden supplies, and technical support. Teaching followed a 23-week curriculum including nutrition and hands-on gardening. Caregivers received training in home gardening and nutrition and the same kind of vegetable seeds. Outcome variables included food knowledge, preferences and food choices measured as the number of meals that included vegetables. Data were collected from children and parents at the start of the school year in June 2018 and one year later. The data include observations for 779 schoolchildren and their parents. Children’s food choices were recorded every month using a food logbook. The sample is balanced at baseline and a double-difference estimator was used to quantify the average treatment effect. Furthermore, qualitative data were collected in five treatment schools that varied in their success implementing the program. Data were collected using focus group discussions with children and parents and in-depth interviews with teachers and analyzed thematically.

Findings

The quantitative data show the following impact of the intervention: (a) Food and nutritional knowledge increased by 26.4% over mean baseline levels for parents (p<0.01), but the effect for children was not significant. (b) Children’s liking for vegetables increased by 6.3% (p<0.01) and their parents liking for vegetables increased by 10.2% (p<0.10). (c) The proportion of children’s meals that included vegetables increased by 15.1-25.9%, depending on the period of the year. The qualitative research confirms an increase in children’s vegetable consumption and improved attitudes toward healthy eating. We posit that these significant effects were created because the intervention targeted both children and parents and enhanced the availability of vegetables within the household. The study design does not allow disentangling the effects of the home and school gardens; yet a previous study that implemented only school gardens showed no significant effect on vegetable intake [3], which suggests that the combination of the two interventions was necessary to influence children toward healthier food choices.

Conclusion

The results of this study point at the importance of comprehensive intervention designs—as opposed to school gardens as a standalone intervention—that aim to promote healthier food choices not just at the individual level, but at a household or community level. Hence, school gardens in low-income countries must not only try to influence children’s food preferences and food behavior, but also make healthy food more available in children’s homes while also nudging parents toward healthier food choices.

References

Ohly, H., Gentry, S., Wigglesworth, R., Bethel, A., Lovell, R., Garside, R., 2016. A systematic review of the health and well-being impacts of school gardening: synthesis of quantitative and qualitative evidence. BMC Public Health 16(1), 286.

Blair, D., 2009. The Child in the Garden: An Evaluative Review of the Benefits of School Gardening. The Journal of Environmental Education 40(2), 15-38.

Schreinemachers, P., Bhattarai, D.R., Subedi, G.D., Acharya, T.P., Chen, H.-p., Yang, R.-y., Kashichhawa, N.K., Dhungana, U., Luther, G.C., Mecozzi, M., 2017. Impact of school gardens in Nepal: a cluster randomised controlled trial. Journal of Development Effectiveness 9(3), 329-343.

Schreinemachers, P., Ouedraogo, M.S., Diagbouga, S., Thiombiano, A., Kouamé, S.R., Sobgui, C.M., Chen, H.-P., Yang, R.-Y., 2019. Impact of school gardens and complementary nutrition education in Burkina Faso. Journal of Development Effectiveness 11(2), 132-145.

Schreinemachers, P., Rai, B.B., Dorji, D., Chen, H.-p., Dukpa, T., Thinley, N., Sherpa, P.L., Yang, R.-Y., 2017. School gardening in Bhutan: Evaluating outcomes and impact. Food Security 9(3), 635-648.

Impact evaluation of micro-nutrients supplementation on nutritional status and oxidative stress of rural farm children in Telangana state, India

Srujana Medithi¹

¹ICMR - National Institute of Nutrition, Hyderabad, Telangana, India

Introduction

Farming community is at higher risk to pesticides during agricultural activities. Nutritional status plays a significant role by modifying the possible susceptibility to pesticide exposure (Kordas et al., 2007). Susceptibility also relies on physiological factors (age and gender), Since children are heavily exposed to pesticides in proportion to body-weight and physiology, they are more vulnerable than adults to conceivable antagonistic impacts. Nutrient deficiency can be addressed with micro-nutrient supplementation which may improve nutritional status and increase susceptibility. Hence, present study aimed to evaluate possible protective effects of micro-nutrients among children who are exposed to pesticides (helping their parents in farms).       

Methods

A community-based cross-sectional study was conducted among the farm children (9-12 years, n = 66 and 13-15 years, n = 63) belonging to the Ranga Reddy district (Telangana state, India). The study was approved by the Institutional Ethical Committee, Indian Council of Medical Research - National Institute of Nutrition, Hyderabad. Before the commencement of the study, written consent was obtained from the children’s parents and blood sample (8 mL) was collected to estimate pesticide residues (Liquid Chromatography-Tandem Mass Spectrometry), micro-nutrient status [vitamins A, E (High-performance liquid chromatography) and D3 (ELISA) and minerals: calcium, copper, zinc, magnesium and manganese (Atomic Absorption Spectroscopy)], Acetylcholinesterase (AChE) levels (Semi-auto analyzer), oxidative stress parameters: superoxide-dismutase (ELISA), catalase, lipid-peroxidation (Spectrophotometer) and reduced glutathione (Spectrofluorometer). The children were provided with supplementation of micro-nutrient (multi-vitamin - multi-mineral) capsules (30 days) and the blood samples (9-12 years, n=54 and 13-15 years, n=56) were collected again for analysis of various biochemical parameters which are indicated above. Statistical analysis was performed using SPSS 21.0 version software. The percentage of samples detected with pesticide residues were calculated. Paired Student’s “t”- test was conducted to compare the difference between the pre and post-supplementation analysis. Significance was considered at p <0.05 and p <0.01.

Findings

Baseline data showed five organophosphorus pesticide residues: Chlorpyrifos, Diazinon, Malathion, Monocrotophos and Phosalone in children (both age groups). Post-supplementation results have shown two residues only (Chlorpyrifos and Diazinon). It appears that supplementation could have enhanced pesticide metabolism and subsequently escalated their elimination because of which their serum levels decreased, as similarly reported in earlier animal studies (Olsvik et al., 2015). Increased vitamins A, D3 and calcium, was observed upon supplementation but was not statistically significant. Significant increased vitamin E, copper, magnesium and zinc were observed upon supplementation in both age groups and manganese in 13-15 years children (p<0.01 and p<0.05). Further, there was an improvement in AChE activity and a decrease in lipid-peroxidation (both the age groups). Catalase levels significantly improved in 13- 15 years children (p<0.01). Though an increase was observed in superoxide-dismutase and reduced glutathione levels (both the age groups), the increase was not statistically significant. A similar study among sprayers reported significant alteration in serum lipid-peroxidation, superoxide-dismutase, catalase, zinc, and copper upon supplementation (15 days), concluding the crucial role of vitamin E in restoring antioxidant enzymes (Patil et al., 2012, 2014). Studies in human erythrocytes showed protective effects of vitamins C and E (Gultekin et al., 2001).

Conclusion

Overall, in the present study, supplementation appears to tune-up the metabolic rate in children, which may further help to maximize their health benefits. Further, significantly improved levels of vitamins and minerals, AChE activity and oxidative stress parameters were seen after supplementation, which indicates the potential protective effect of micro-nutrients to attain optimal nutritional status and improve their susceptibility. Though present study has demonstrated beneficial effects of supplementation in children, the study suggests the need for further intervention studies among various physiological age and gender-based groups for a comprehensive understanding of potential protective effects of the micro-nutrients and the underlying mechanism.

References

Kordas, K., Lonnerdal, B., Stoltzfus, R.J., 2007. Interactions between Nutrition and Environmental Exposures: Effects on Health Outcomes in Women and Children. The Journal of Nutrition, 137 2794–2797.

Olsvik, P.A., Berntssen, M.H.G., Softeland, L., 2015. Modifying Effects of Vitamin E on Chlorpyrifos Toxicity in Atlantic Salmon. Plos One, 10 (3) e0119250.

Patil, J.A., Patil, A.J., Sontakke, A.V., Govindwar, S.P., 2014. Alteration of biochemical parameters after supplementation of multivitamins and minerals of sprayers on grape gardens of Western Maharashtra (India). Al Ameen Journal of Medical Sciences, 7 (1) 45-51.

Patil, J.A., Patil, A.J., Sontakke, A.V., Sanjay, P., 2012. Effect of Vitamin E Supplementation on Biochemical Parameters in Pesticides Sprayers of Grape Gardens of Western Maharashtra (India). Govindwar. Indian Journal of Clinical Biochemistry, 27 (2) 134–140.

Gultekin, F., Delibas, N., Yasar, S., Kilinc, S., 2001. In vivo changes in antioxidant systems and protective role of melatonin and a combination of vit C & E on oxidative damage in erythrocytes induced by chlorpyrifos-ethyl in rats. Archives of Toxicology, 75 88–96.

A combined complementary food hygiene and WASH intervention to reduce diarrhoeal disease in rural Malawi

Tracy Morse^1,2

Elizabeth Tilley^2,3

Kondwani Chidziwisano²

Rossanie Daudi²

¹Dept of Civil and Environmental Engineering, University of Strathclyde

²WASHTED Centre, University of Malawi - Polytechnic, Blantyre, Malawi

³EAWAG, Zurich, Switzerland

Methods

Diarrhoeal disease continues to be the second leading cause of death in children under five, with approximately 700,000 deaths worldwide annually. It is estimated that 50% of these deaths occur in Africa, and 72% occur in the first two years of life, resulting in a higher mortality rate in children than HIV, tuberculosis and malaria combined. However, recent WASH intervention studies have reported minimal impact on diarrhoeal disease in children under five, and research is providing increasing evidence that poor food hygiene of complementary foods plays a significant role in diarrhoeal diseases transmission in low income environments.

Methods

We designed and implemented a theory-based complementary food hygiene and WASH intervention in rural Malawi and evaluated its impact on diarrhoeal disease in children under the age of five years. The Hygienic Family intervention was informed by formative research and grounded in the RANAS (Risk, Attitude, Norms, Ability and Self – regulation) Model, and aimed to ensure inclusion of all family members and support the concept of whole community improvements versus individualism. The intervention was compiled of four modules (hand washing with soap, food hygiene, faeces management and water management) implemented as a before and after trial with a control and two treatment arms to measure the relative impact of: (1) a food hygiene intervention (treatment group 1: n=400) relative to a WASH + food hygiene intervention (treatment group 2: n=400), and (2) each intervention relative to the control group (n=200). The intervention was delivered for 9 months through caregiver cluster meetings and household visits, with treatment group 1(T1) receiving only hand washing with soap and food hygiene interventions, and treatment group 2 (T2) receiving all four modules.

Findings

Diarrhoeal disease was measured as the primary outcome of interest. This was measured through self reporting (diarrhoeal disease in the two weeks prior) at baseline, midline and endline. Baseline reported an overall rate of 44% diarrhoea (T1=45%; T2=45%; C=43%) which was in line with national rates for children <12 months (41%). Midline measurements were taken at the completion of the handwashing with soap and food hygiene modules and saw a significant reduction in treatment groups (T1=14%; T2=16%) versus the control (C=27%) which was again in line with national rates for children <24 months (29%). This was repeated in end line results following completion of WASH modules in T2 (T1=6%; T2=5%; C=16%; national=14%). Additional analysis examined the impact of the covariates such as vaccination completion, gender, socio-economic status, breastfeeding, hygienic infrastructure, animal ownership, intervention compliance, and household demographics and found that none had a significant impact on diarrhoeal disease reduction. As such the only significant predictor of diarrhoeal disease reduction as being part of the intervention as a whole, indicating potential marginal gains from multiple barriers to disease transmission.

Conclusion

These preliminary results indicate that there has been a significant reduction in diarrhoeal disease in all targeted households, with no significant difference between the two treatment areas. As such, the reduction in diarrhoea appears primarily associated with improvements in hand washing with soap and food hygiene, although control of other sources of infection, e.g. animal contact, should not be discounted as important. Future nutrition and WASH programmes should ensure that hygiene of complementary foods is effectively integrated into programming and education for caregivers.

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