The consequences of malnutrition, and effects of multiple micronutrient powders, on young child development in India Open Access

Larson, Leila (Fall 2017)

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Nutrition plays an important role in the growth and development of a child, particularly in low- and middle- income countries where malnutrition is often widespread. Nutrition programs, especially in children under two years of age, have the potential to improve the mental developmental of at-risk populations. This dissertation uses data from a two-arm randomized cluster effectiveness trial of home fortification with multiple micronutrient powders (MNPs) in children 6-18 months of age living in rural Bihar, India. Objectives were to examine 1) the nutritional, psychosocial, environmental, and household correlates of child development, and identify mediators between dietary diversity and mental development, 2) the impact of home fortification with MNPs on motor and mental development, memory, and executive function, and 3) a path analysis of the relations between diet, hemoglobin, nutritional status, motor development, stimulation and various cognitive domains. Results identified length-for-age z-scores (LAZ), dietary diversity, and psychosocial stimulation as significant predictors of motor and mental development. Further, stimulation, gross motor development, and fine motor development were significant mediators in the relation between dietary diversity and mental development.  Results of the impact evaluation indicate that children who received MNPs and whose caregivers received nutrition counseling performed better on tests of motor and mental development than children whose caregivers received nutrition counseling only. We also found greater impacts of MNPs on motor and mental development in children from households with higher stimulation scores at baseline compared to those from households with lower stimulation scores at baseline. Lastly, the path analysis indicated significant direct and indirect associations between LAZ, motor development and personal social skills, language development, memory, and executive function. Stimulation was significantly associated with language abilities, and hemoglobin concentrations with memory. The findings from this dissertation suggest that nutrition indicators, such as dietary diversity and LAZ, are important predictors of early child development, and could influence cognitive abilities through motor development and psychosocial stimulation. Programs addressing both stimulation and nutrition could have important impacts on child development. In this context, despite low coverage and overworked frontline health workers, home fortification with MNPs was found to have modest effects on early child development.

Table of Contents

Chapter 1: Introduction

1.1 Aims. 4

Chapter 2: Literature review.. 5

2.1 Micronutrients and how they affect child development 6

2.2 Effect of nutrition on child development: evidence from randomized trials in humans. 12

2.3 Conceptual framework for how nutrition improves child development 15

2.4 Mediating pathways between nutrition and child development 16

2.5 Nutrition in the context of India. 19

2.7 Chapters 1 and 2 references. 21

Chapter 3: A Meta-analysis of Nutrition Interventions on Mental Development of Children Under-Two in Low- and Middle-Income Countries. 30

3.1 Abstract 31

3.2 Introduction. 32

3.3 Methods. 35

3.4 Results. 38

3.5 Discussion. 42

3.6 Acknowledgements. 46

3.7 Chapter 3 references. 47

3.8 Bridge statement 1. 71

Chapter 4: A cross-sectional survey in rural Bihar, India indicates that nutritional status, diet and stimulation are associated with motor and mental development in young children. 73

4.1 Abstract 74

4.2 Introduction. 75

4.3 Participants and Methods. 76

4.4 Results. 80

4.5 Discussion. 83

4.6 Acknowledgements. 87

4.7 Chapter 4 references. 88

4.8 Bridge statement 2. 100

Chapter 5: Effectiveness of a home fortification program with multiple micronutrients on infant and young child development: a cluster randomized trial in rural Bihar, India. 101

5.1 Abstract 102

5.2 Introduction. 104

5.3 Methods. 105

5.4 Results. 117

5.5 Discussion. 119

5.6 Acknowledgements. 122

5.7 Chapter 5 references. 124

5.8 Bridge statement 3. 141

Chapter 6: A path analysis of nutrition, stimulation, and child development among young children in Bihar, India. 142

6.1 Abstract 143

6.2 Introduction. 144

6.3 Methods. 148

6.4 Results. 153

6.5 Discussion. 155

6.6 Acknowledgements. 159

6.7 Chapter 6 references. 161

Chapter 7: Discussion. 185

7.1 Generalizability of findings from the Bihar trial 187

7.2 Home fortification with multiple micronutrients in the context of other food fortification strategies 189

7.3 The small effects of nutrition interventions on child development 193

7.4 What evidence means for decision making. 195

7.5 Implications for future research. 197

7.6 Limitations. 204

7.7 Strengths. 207

Chapter 8: Conclusions. 208

Chapters 7 and 8 references 210

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