A multi-sectoral community development intervention has a positive impact on diet quality and growth in school-age children in rural Nepal.

Poor diet quality (diet diversity and animal-source food [ASF] consumption) during childhood negatively affects growth, development, behaviour and physiologic function in later life. Relatively less is known about the impact of poor diet on the growth of school-age children compared to children <5 years of age, especially in low/middle-income countries. A better understanding of delivery strategies for effective interventions to improve diet and hence growth in school-age children is needed. A 36-month longitudinal controlled impact evaluation in rural Nepal assessed the nutrition and growth of children <5 years of age in families assigned via community clusters to full package intervention (community development, training in nutrition [during pregnancy and for children <5 years] and livestock husbandry), partial package (training only) or control (no inputs). Concurrent data were collected prospectively (baseline plus additional four rounds) on school-age children (5-8 years at baseline) in these households; the present study analysed findings in the cohort of school-age children seen at all five study visits (n = 341). Diet quality improved more in the full package school-age children compared to those in partial package or control households. full package children consumed more ASF (ß +0.40 [CI 0.07,0.73], p < 0.05), more diverse diets (ß +0.93 [CI 0.55,1.31], p < 0.001) and had better head circumference z-scores (ß +0.21 [CI 0.07,0.35], p < 0.01) than control children. In conclusion, a multi-sectoral community development intervention was associated with improvements in diet and growth of school-age children in rural Nepal even though the intervention focused on the diet of children <5 years of age. The diet and growth of school-age children can be favourably influenced by community-level interventions, even indirectly.

Trajectories of child growth, child development, and home child-rearing quality during the Covid pandemic in rural Nepal.

BACKGROUND: Children, especially disadvantaged children in poor countries, were expected to be among the "biggest victims" of the Covid pandemic. Economic burdens, decreased nutritious foods, reduced medical care, school closures, and ill-health or death of family members were predicted to increase child undernutrition and developmental delays, and diminish home child-rearing quality. METHODS: A planned nutrition intervention could not be implemented due to Covid restrictions. However, three surveys (pre-Covid [December 2019], July 2021, and September 2021) in 280 Nepali households (309 parent-dyads, 368 children, 6-66 months old) collected demographics, child anthropometry and development (Ages and Stages Questionnaire-3 [ASQ-3]), and home child-rearing quality (caregiver engagement, learning resources, adult supervision [UNICEF's Multiple Indicator Cluster Survey]). Mixed-effect regression models adjusted for household (wealth, maternal education) and child factors (age, gender) and survey round. RESULTS: Height, mid-upper-arm circumference, and head circumference measurements improved over time. The total ASQ-3 score did not change: Communication scores increased while fine motor and personal-social scores declined. Girls' growth and development worsened more than boys. Caregiver engagement (especially mothers') generally declined, but learning resource availability increased. More children were left unsupervised at Round 2 than Round 1 or 3. CONCLUSIONS: In this sample, some aspects of child growth, development, and home child-rearing quality improved while others declined. Better understanding of these changes in child well-being and the family environment during the pandemic could provide insight on how to protect children during future crises.

Dairy Animal Ownership and Household Milk Production Associated with Better Child and Family Diet in Rural Nepal during the COVID-19 Pandemic.

The economic and health crises related to the COVID-19 pandemic raised considerable concern about child and family diet, especially among small-holder farming households in low- and middle-income countries (LMIC). In rural Nepal, 309 families (including 368 children aged 6−66 months) were enrolled pre-COVID-19 in a prospective study of a nutrition education intervention and family milk consumption. The intervention could not be implemented due to COVID-19; however, child and family diet was assessed in three household surveys (one before and two during the pandemic). Over time, after adjusting for child and household factors, child and family diet quality declined (reduced diet diversity, consumption of milk and animal-source-foods (ASF)). However, in dairy-animal-owning (vs. non-dairy-animal-owning) households, both children and family were more likely to consume milk (aOR respectively 2.88× (p < 0.05), 5.81× (p < 0.001)). Similarly, in households producing >3.5 L/d milk (vs. ≤3.5 L/d), children and family members were more likely to consume milk (respectively 7.45× and 11.88× (both p < 0.001)). Thus, the overall decline in child and family diet quality, especially related to milk consumption, was buffered independently by household ownership of ≥1 dairy animals (cow or buffalo) and by milk production >3.5 L/day. A better understanding of these protective factors might facilitate the development of interventions to promote resilience in future crises.

Maternal depression is associated with less dietary diversity among rural Nepali children.

Maternal depression has been associated with adverse child growth and development; less is known about its relation to children's diet. In a cross-sectional study embedded at endline of a longitudinal community development intervention, mothers of 629 children (age 23-66 months) in rural Nepal responded to household and children's diet questionnaires and were screened for depression. Child anthropometry and development (Ages and Stages Questionnaire) were assessed. Regression models examined children's diet, growth and development, adjusting for household, child and maternal characteristics. The prevalence of maternal depression was 21%. Maternal depression was associated with 11% lower likelihood that the child consumed one additional food group [Poisson regression, adjusted relative risk (aRR) 0.89, 95% confidence intervals (95% CI 0.81, 0.99), p = 0.024] and 13% lower likelihood that the child consumed one additional animal source food (ASF) [aRR 0.87, (95% CI 0.76, 1.01), p = 0.061] compared with children of nondepressed mothers. However, maternal depression was not associated with either child anthropometry or development: these outcomes were strongly associated with better home child-rearing quality. Stunting also related to child age and intervention group; child development related to mother's education and household wealth. This study suggests a correlation between maternal depression and child dietary diversity. This association could be due to unmeasured confounders, and therefore, further research is warranted. Understanding the relationship of depression to child outcomes-and the role of other potentially compensatory household factors-could help address some of the earliest, modifiable influences in a child's life and contribute to innovative approaches to improve child well-being.

Child Diet and Household Characteristics Relate Differently to Child Development at the Beginning and the End of the Second "1000 Days" in Rural Nepal.

The "second 1000 days" is a period of rapid brain growth which consolidates developmental foundations and establishes school readiness. Understanding the relation between household characteristics, child diet, and child development remains incomplete, especially in resource-poor settings where >250 million children risk not achieving their full developmental potential. Child developmental performance was assessed (Ages & Stages Questionnaire [ASQ]) at ages 2 and 5 years in a cohort of Nepali children (n = 207) whose families participated in a nutrition/livestock management+community development intervention trial. Relationships between child developmental performance and mother's education, family wealth, child diet (animal source food [ASF] consumption, dietary diversity score [DDS]), school attendance, and intervention group were examined by adjusted linear regressions. These relationships varied at the 2 ages. At age 2 years, ASQ scores related positively to "Full Package Intervention" and negatively to "Partial Package Intervention" membership. At age 5 years, intervention group did not relate to ASQ scores. Mother's education did not relate to developmental findings for 2-year-olds. Mother's education, wealth, and school attendance positively predicted ASQ scores for these same children as 5-year-olds. Animal source food consumption was related to child development more strongly at age 5 than at 2 years. DDS had a less pronounced relationship to development than ASF consumption at both ages. Over this time span bracketing the second 1000 days, household characteristics and child diet related differentially to developmental performance depending on child age. Better understanding of the timing and mechanisms of these relationships is needed to effectively design interventions targeting improved child development in resource-poor settings.

MILK Symposium review: Milk consumption is associated with better height and weight in rural Nepali children over 60 months of age and better head circumference in children 24 to 60 months of age.

Child undernutrition afflicts >150 million children worldwide, contributing to poor child growth, increased risk of infections, and loss of developmental potential. Animal-source foods (ASF) can ameliorate these problems by providing high-quality, high-density, and bioavailable protein and micronutrients. However, many children in developing countries lack ASF in their diet, although generally milk is the ASF most often consumed. Nevertheless, the relation of ASF-and that of specific ASF-to child growth in these contexts has been difficult to define, as has the association between diet and child and household factors in influencing growth outcomes. To better understand these relationships, we evaluated child growth by age groups (6-23 mo, 24-60 mo, and >60 mo) in relation to ASF consumption in rural Nepal. We used an observational study design that leveraged a data set generated through a 3-yr longitudinal controlled impact evaluation of a community-development intervention. Child anthropometry and 24-h diet recall were obtained at 5 household visits. At baseline, children were generally undernourished: 47% were stunted, 46% underweight, 17% wasted, and 24% microcephalic. Patterns of undernutrition varied with age but improved somewhat over time. Over the 3-yr period of study (9,283 observations), ASF were consumed infrequently: milk in 28% of assessments, meat in 27%, and eggs in 15%. Consumption patterns differed by age group, with younger children (6-23 mo) consuming more milk and less meat than children 24 to 60 or >60 mo. Consumption of even a single ASF at any of the 5 surveys was associated with greater growth in bivariate analysis. After adjustment for household (group assignment, survey round and its interaction, wealth, income, livestock and land ownership, maternal education) and child factors (age, sex, baseline anthropometry), mixed-effect linear regression analysis showed that milk consumption related to higher height for age and weight for age z-scores for children >60 mo of age and to higher head circumference z-score for children age 24 to 60 mo. For children >60 mo, egg consumption also related to higher weight z-scores. Household and child factors also influenced these outcomes. Of the ASF, milk had the strongest and most consistent relationship to child growth. Better measures of diet intake could reveal stronger associations between diet consumption patterns and child growth. Regardless, milk may be a key ASF to target for growth promotion among undernourished rural Nepali children.

Diet quality over time is associated with better development in rural Nepali children.

Developmental delays affect between 150 and 200 million children <5 years of age worldwide. Outside of diet supplement studies, relatively little is known about the relationships between diet quality and developmental status in resource-poor settings. We examined associations between different aspects of dietary quality (dietary diversity score [DDS] and animal-source food [ASF] consumption) and child development (assessed using the Ages and Stages Questionnaire-3 [ASQ-3]) among children whose families were enrolled in a community development intervention trial (implemented by Heifer Nepal) in western Nepal. Two sets of analyses were performed: (a) cross-sectional Sample (N = 629) seen at the endline survey and (b) longitudinal sample (N = 269) with complete dietary records (six surveys over 48 months). In both samples, child development was significantly related to household wealth, maternal education, and especially home environmental quality. In the cross-sectional sample, greater consumption of eggs (adjusted odds ratio [aOR] 0.80, p = .04) or dairy products (aOR 0.95, p = .05) over the previous 7 days significantly reduced odds of low total ASQ score, by logistic regression analysis. In the longitudinal sample, only egg consumption and cumulative DDS and ASF scores were associated with significantly reduced odds of low total ASQ score (aORs 0.59-0.89). In adjusted linear regression analysis, both cumulative DDS (ß [CI]: 1.92 [0.4, 3.5]) and ASF scores (2.46 [0.3, 4.7]) were significantly associated with greater continuous total child development. Programmes targeting child development must address home environmental quality as well as long-term diet quality.

Multisectoral community development in Nepal has greater effects on child growth and diet than nutrition education alone.

OBJECTIVE: To compare the impact on child diet and growth of a multisectoral community intervention v. nutrition education and livestock management training alone. DESIGN: Longitudinal community-based randomized trial involving three groups of villages assigned to receive: (i) Full Package community development activities, delivered via women's groups; (ii) livestock training and nutrition education alone (Partial Package); or (iii) no intervention (Control). Household surveys, child growth monitoring, child and household diet quality measures (diet diversity (DD), animal-source food (ASF) consumption) were collected at five visits over 36 months. Mixed-effect linear regression and Poisson models used survey round, treatment group and group-by-round interaction to predict outcomes of interest, adjusted for household- and child-specific characteristics. SETTING: Banke, Nepal. PARTICIPANTS: Households (n 974) with children aged 1-60 months (n 1333). RESULTS: Children in Full Package households had better endline anthropometry (weight-for-age, weight-for-height, mid-upper-arm-circumference Z-scores), DD, and more consumption of ASF, after adjusting for household- and child-specific characteristics. By endline, compared with Partial Package or Control groups, Full Package households demonstrated preferential child feeding practices and had significantly more improvement in household wealth and hygiene habits. CONCLUSIONS: In this longitudinal study, a comprehensive multisectoral intervention was more successful in improving key growth indicators as well as diet quality in young children. Provision of training in livestock management and nutrition education alone had limited effect on these outcomes. Although more time-consuming and costly to administer, incorporating nutrition training with community social capital development was associated with better child growth and nutrition outcomes than isolated training programmes alone.

Dietary Diversity and Child Development in the Far West of Nepal: A Cohort Study.

Poverty adversely affects child development through multiple pathways in low- and middle-income countries. Relationships between diet and child development are poorly understood. In this study, we aimed to explore these associations in a longitudinal cohort of 305 children in rural Nepal (baseline mean age 14 months), evaluating dietary diversity and the consumption of specific food groups at three timepoints over 1.5 years. Child development was assessed using the Ages and Stages questionnaire-version 3 (ASQ-3). Associations between the number of days that children consumed minimum dietary diversity (MDD) (≥4/8 items) and specific food groups over time (range 0-3) and total and subscale ASQ scores at age 23-38 months were estimated using multiple linear and logistic regression, dichotomizing scores at the lowest quartile. After adjusting for confounders, each additional day of consuming MDD was associated with a 35% reduction in the odds of low total ASQ score [OR 0.65, 95% CI (0.46, 0.92)]. The consumption of animal source foods [OR 0.64, (0.46, 0.89)], and vegetables/fruits [OR 0.60, (0.41, 0.90), but not processed foods [OR 0.99, (0.62, 1.59)] was associated with lower odds of low total development. Vegetables, fruits and animal source foods may be important for child development in this setting.

Women's education level amplifies the effects of a livelihoods-based intervention on household wealth, child diet, and child growth in rural Nepal.

BACKGROUND: Many organizations seek to alleviate poverty in the developing world, often focusing their interventions on women. The role, status, and education of women are fundamentally important facets of development. Thus, understanding the interaction of women's educational level and the response to interventions is important. Therefore, we examined the impact of educational level of household adults on responses to a livestock-based community intervention. METHODS: Six pair-matched communities in 3 districts of Nepal (Chitwan/Nawalparasi/Nuwakot), were randomly assigned to receive community development activities via women's self-help groups at baseline or 1 year later. At 6 intervals over 48 months, a 125- item questionnaire addressing family demographics and child health/nutrition was completed in each household, plus child growth monitoring. Results were analyzed in relation to the highest education attained by any woman in the household, the child's mother, men, or any other adult in the household. RESULTS: Outcomes (wealth, water/toilet availability, child diet diversity and growth) all significantly related to adult education. However, notable differences were found comparing the impact of men's and women's education. Percent change in wealth score was significant only in households where women had primary or secondary education (respectively, p = .0009 and p < .0001). Increased soap use related only to women's education (p < .0001). When adjusted for group assignment, baseline income, wealth, and animal scores, higher women's education was significantly associated with increased household wealth (p < .0001), better child height-for-age z scores (HAZ, p = .005), and improved child diet diversity (p = .01). Higher mother's education predicted better child HAZ (primary, p = .01, secondary, p = .03) and diet diversity (primary, p = .05, secondary, p < .0001). Higher men's education was significantly associated with household wealth (p = .02) and child diet diversity (p = .04), but not HAZ; higher education of any household member was associated only with household wealth (p < .0001). Moreover, households where the mother's education was better than the best-educated man also were significantly more likely to have children with better HAZ and dietary diversity (p = .03, p < .0001). Thus, the educational level of women and mothers had the broadest impact on child outcome variables. CONCLUSIONS: Household characteristics vary among participants in most community development projects. Of these, adult education likely mediates response to the inputs provided by the intervention. Particularly in interventions directed towards women, better education may enhance the ability of households to put interventions into practice, thus improving wealth, hygiene, and child diet and growth indices.

Head growth of undernourished children in rural Nepal: association with demographics, health and diet.

BACKGROUND: Brain development in early childhood is a key determinant of later cognition, social achievement and educational success. Head circumference (HC) measurements are a simple method to assess brain growth, yet reports of these measurements are uncommon in nutritional surveys of undernourished children. OBJECTIVE: To evaluate HC measurements in a population of rural Nepali children and relate these measurements to demographics, health and diet. METHODS: An observational study of head growth was nested within a longitudinal evaluation of a livestock-based agricultural intervention in rural Nepal. Between 538 and 689 children (aged 6 months to 8 years) were measured (height, weight, HC) at each of six survey visits. A total of 3652 HC measurements were obtained. Results were converted to Z-scores (WHO Anthro). RESULTS: Mean head circumference Z-scores (HCZ) diminished progressively over the first 4 years of life; a decline of 30% occurred between 3 and 4 years of age (-1.73 to -2.45, P < 0.0001). Overall, 56% of HCZ were <-2. Gender-adjusted HCZ (but not other measurements) were significantly lower for girls than boys [mean (SD) -2.31 (1.0) vs -1.99 (0.094), P < 0.0001]; girls more often had microcephaly (61% vs 50%, P < 0.0001). For children <3 years of age, HCZ were better in those who had eaten two or more animal-source foods (ASFs) within the previous 24 h [-1.69 (.05) vs -2.08 (0.10), P = 0.001] than in those who had eaten none or only one; HCZ correlated with the number of ASFs consumed (P < 0.001). Regression analyses demonstrated that the main determinants of HCZ were age, weight-for-age Z-scores (WAZ) and gender; 43% of the variance in HCZ in younger children was explained by WAZ and ASF consumption. CONCLUSION: HCs reflect brain size in young children; brain size is linked to cognitive function. Poor head growth represents another facet of the 'silent emergency' of child undernutrition. Routine HCZ assessments may contribute to better understanding of the links between poverty and cognitive development.

Community development and livestock promotion in rural Nepal: effects on child growth and health.

BACKGROUND: More than 50% of children in Nepal are malnourished. Economic growth and poverty reduction are not always sufficient to improve the health and nutritional status of children. Heifer Nepal uses livestock training as a tool for community development and poverty alleviation but does not directly address child health and nutrition. OBJECTIVE: To systematically assess the effects of Heifer activities on child health and nutrition. METHODS: The study was a 2-year, longitudinal, randomized, controlled trial in six communities in Nepal (both Terai and hills), pair-matched for specific characteristics, randomly assigned to receive Heifer community development activities at baseline (intervention) or 1 year (control). At 6-month intervals over a period of 2 years, child anthropometric and comprehensive household surveys were performed. RESULTS: Four hundred fifteen households were enrolled containing 607 children 6 months to 5 years of age. The intervention and control communities were equivalent for baseline socioeconomic status, household size, ownership of land and animals, and child nutrition and health. At 12 months (prior to animal donations), the Terai intervention group had improved child weight (p = .04), improved child height (p = .05), and reduced sick days (p = .03), as well as increased household income (p = .004), increased ownership of animals (p = .04) and land (p = .04), and improved sanitation practices (p < .01). In all districts, longer participation in Heifer activities corresponded to more improvement in child height-for-age z-scores. CONCLUSIONS: Heifer interventions resulted in improved socioeconomic status and household income per family member. Children under 60 months of age in the intervention group had greater incremental improvement in height-for-age and weight-for-age z-scores than children in the control group, and longer participation in Heifer activities was associated with better growth. Poverty alleviation programs, such as Heifer, may indirectly benefit child growth.

Preventing highly pathogenic avian influenza (HPAI) at the rural community level: a case study from Cambodia.

Poultry is an integral part of the rural livelihoods in Cambodia, with more than half of the households keeping poultry in their small-scale, traditional, and extensive backyards. More than 20 highly pathogenic avian influenza (HPAI) outbreaks have been reported since 2004 with deaths of over 21,000 birds. During the HPAI outbreaks, some of the flocks in the rural areas were culled without compensation and producers were not allowed to sell outside of the community. Heifer International worked with 2,000 rural families through local project partners in the target communities to develop an effective intervention mechanism to mitigate the impact of the HPAI crisis. Heifer International provided training, public education, and networking as well as promoting model farms based on improved scavenging poultry management. Each community selected one farm family to serve as a model farm. They were trained in Heifer's working approach and committed to practicing integrated farming systems based on scavenging poultry management. One Village Animal Health Worker (VAHW) in each community participated during the project implementation, playing a key role in the information exchange and the interaction between the communities and the avian influenza experts. Formal and informal trainings were conducted for all project partners and project recipients through experts and VAHWs, respectively. There have been no outbreaks reported in the communities in the project areas. Farmers have started using appropriate techniques to maintain biosecurity. They are passing on the knowledge and the skills to the surrounding communities. This participatory approach in educating rural farmers can serve as a model to mitigate HPAI in the developing countries around the world.