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Black MM, Fernandez-Rao S, Nair KM, Balakrishna N, Tilton N, Radhakrishna KV, Ravinder P, Harding KB, Reinhart G, Yimgang DP, Hurley KM. A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency. J Nutr 2021; 151:2029-2042. [PMID: 33880548 PMCID: PMC8245888 DOI: 10.1093/jn/nxab066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/01/2020] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools. OBJECTIVES This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity. METHODS We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools. RESULTS At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity. CONCLUSIONS Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.
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Affiliation(s)
- Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
- RTI International, Research Triangle Park, NC, USA
| | - Sylvia Fernandez-Rao
- Department of Behavioral Science, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Krishnapillai Madhavan Nair
- Department of Micronutrient Research, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Nagalla Balakrishna
- Department of Biostatistics, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | - Nicholas Tilton
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Punjal Ravinder
- Department of Micronutrient Research, National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, India
| | | | - Gregory Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH, USA
| | - Doris P Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristen M Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Black MM, Yimgang DP, Hurley KM, Harding KB, Fernandez-Rao S, Balakrishna N, Radhakrishna KV, Reinhart GA, Nair KM. Mechanisms linking height to early child development among infants and preschoolers in rural India. Dev Sci 2019; 22:e12806. [PMID: 30715779 PMCID: PMC7428854 DOI: 10.1111/desc.12806] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 10/19/2018] [Accepted: 11/30/2018] [Indexed: 01/16/2023]
Abstract
Stunting has been negatively associated with children's development. We examined the range of height by testing hypotheses: (a) height is positively associated with children's development, with associations moderated by inflammation and (b) home environments characterized by nurturance and early learning opportunities is positively associated with children's development over time and attenuate associations with height. Data included 513 infants (mean age 8.6 months) and 316 preschoolers (mean age 36.6 months) in rural India from a randomized controlled trial of multiple micronutrient powders (MNPs). Measures included height (height-for-age z-scores based on WHO standards), inflammation (C-reactive protein concentration >5 mg/L), nurturance (HOME Inventory), child development (Mullens Scales of Early Learning), and inhibitory control (preschoolers). Linear mixed effects models accounting for repeated measures, clustering, and confounders were used to assess associations between height and child development over time (infants: enrollment, 6 and 12 months; preschoolers: enrollment and 8 months). Moderating effects of inflammation and nurturance were tested with interaction terms. Among infants and preschoolers, height and nurturance were positively associated with all domains of child development over time, with the exception of inhibitory control. Among preschoolers, in the presence of inflammation, height was not associated with child development. Among infants, but not preschoolers, a nurturant home environment attenuated significant associations between height with fine motor and receptive language development. The mechanisms associated with children's development over time are multifactorial and include direct and indirect associations among nutrition, health, and the home environment, as supported by the Nurturing Care Framework.
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Affiliation(s)
- Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD
- RTI International, Research Triangle Park, NC
| | - Doris P Yimgang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Kristen M Hurley
- Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Hurley K, Fernandez-Rao S, Nair KM, Balakrishna N, Radhakrishna K, Ravinder P, Tilton N, Reinhart G, Harding K, Black M. Grow Smart: An Integrated Nutrition and Early Child Development Intervention Among Infants Improves Expressive Language and Reduces Anemia and Iron Deficiency in Rural India (FS08-03-19). Curr Dev Nutr 2019. [DOI: 10.1093/cdn/nzz044.fs08-03-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Objectives
Nutritional deficiency and lack of early learning opportunities contribute to the loss of developmental potential. The objective is to evaluate the effects of an integrated nutrition and early learning intervention (ELI) on micronutrient status and the development of infants in rural India.
Methods
513 infants (6–12mo) were enrolled from 26 villages in rural India and randomized using a 2 × 2 design to receive multiple micronutrient powders (MNP containing iron, zinc, vitamins A, B2, B12, C and folic acid) vs. placebo (B2) and EL vs. control. The ELI was based on the UNICEF-developed Care for Child Development. Baseline (BL), post-intervention (6 mo) and follow-up (12 mo) evaluations included Mullens Scales of Early Learning, anthropometry, and 2 ml venous blood (BL & 12 mo). Data were analyzed using linear mixed effects regression models with random village/subject intercepts accounting for site of recruitment and repeated measures. For biomarker outcomes, main effects of MNP was assessed. P-values of <0.05 considered statistically significant. For child development outcomes, main effects of MNP and ELI were analyzed separately, and three-way interactions (MNP*ELI*midline or MNP*ELI*end line) were tested.
Results
At baseline, the mean age of mothers was 22.9y (SD = 2.9) and 99.6% were married. Most mothers (84.2%) had attended some schooling. Mean infant age was 8.6 mo (SD = 2.2); 53.0% were male. Anemia prevalence was 66.4%. No significant baseline differences were found. At end line, infants in the MNP group had significantly higher hemoglobin (11 g/dl vs.10 g/dl) and ferritin (18.2ug/l vs.11.5 ug/l) values compared to infants in the placebo groups, respectively. Infants in the MNP group (mean = 39.5; SE = 0.6) versus placebo group (mean = 37.7; SE = 0.6) also scored significantly higher in expressive language and marginally higher in visual reception (mean = 42.5; SE = 0.5; P = 0.06) and social-emotional behavior (mean = 24.1; SE = 0.2; P = 0.052), compared to the placebo (mean = 41.1; E = 0.6, mean = 23.5; SE = 0.2, respectively). Significant interactions in visual reception and expressive language performance showed that children who received either or both interventions had better scores than children who received neither.
Conclusions
Home MNP and EL interventions can improve infant MN status and development.
Funding Sources
Mathile Institute for the Advancement of Human Nutrition, Nutrition International, Sackler Institute for Nutrition Science of the New York Academy of Science.
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Affiliation(s)
| | | | | | | | | | | | - Nicholas Tilton
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
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Black MM, Fernandez-Rao S, Hurley KM, Tilton N, Balakrishna N, Harding KB, Reinhart G, Radhakrishna KV, Nair KM. Growth and development among infants and preschoolers in rural India. International Journal of Behavioral Development 2016. [DOI: 10.1177/0165025416644690] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Economic inequities are common in low and middle-income countries (LMIC), and are associated with poor growth and development among young children. The objectives are to examine whether maternal education and home environment quality: 1) protect children by attenuating the association between economic inequities and children’s growth and development, or 2) promote children’s growth and development, regardless of economic inequities. The sample includes 512 infants and 321 preschoolers in 26 villages in rural India (Project Grow Smart). Data for children: physical growth (weight and length/height measured) and development (Mullen Scales of Early Learning); for mothers/households: economic inequities measured by household assets, education, depressive symptoms, and home environment (HOME Inventory). Data are analyzed with linear mixed models (LMM) for infants and preschoolers separately, adjusted for village/preschool clustering, including asset-by-education/home interactions. Among infants, but not preschoolers, the education/home factor attenuates relations between assets and growth, eliminating differential relations in infant growth between high/low-asset families, suggesting protection. Among infants and preschoolers, the education/home factor is significantly or marginally associated with most child development scales, regardless of economic inequities, suggesting promotion. Strategies to enhance maternal education and home environment quality may protect infants in low-asset families from poor growth, promote development among infants and preschoolers, and prevent early disparities.
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Affiliation(s)
- Maureen M. Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sylvia Fernandez-Rao
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | - Kristen M. Hurley
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Nicholas Tilton
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nagalla Balakrishna
- National Institute of Nutrition, Indian Council of Medical Research, Hyderabad, Telangana, India
| | | | - Greg Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, OH, USA
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Bentley ME, Johnson SL, Wasser H, Creed-Kanashiro H, Shroff M, Fernandez-Rao S, Cunningham M. Formative research methods for designing culturally appropriate, integrated child nutrition and development interventions: an overview. Ann N Y Acad Sci 2014; 1308:54-67. [PMID: 24673167 PMCID: PMC4269231 DOI: 10.1111/nyas.12290] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Nutritional and developmental insults in the first few years of life have profound public health implications, including substantial contributions to neonatal, infant, and early childhood morbidity and mortality, as well as longer term effects on cognitive development, school achievement, and worker productivity. Optimal development that can lead to the attainment of an individual's fullest potential, therefore, requires a combination of genetic capacity, adequate nutrition, psychosocial stimulation, and safe, clean physical environments. Researchers and policymakers have called for integrated child nutrition and development interventions for more than 20 years, yet there are only a handful of efficacy trials and even fewer examples of integrated interventions that have been taken to scale. While a critical component in the design of such interventions is formative research, there is a dearth of information in both the literature and policy arenas to guide this phase of the process. To move the field forward, this paper first provides an overview of formative research methods with a focus on qualitative inquiry, a description of the critical domains to be assessed (infant and young child feeding, responsive feeding, and child development), and currently available resources. Application of these methods is provided through a real-world case study--the design of an integrated nutrition and child development efficacy trial in Andhra Pradesh, India. Recommendations for next steps are discussed, the most important of which is the need for a comprehensive set of formative guidelines for designing locally tailored, culturally appropriate, integrated interventions.
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Affiliation(s)
- Margaret E. Bentley
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC,Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Susan L. Johnson
- Children's Eating Laboratory, Department of Pediatrics, Section of Nutrition, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Heather Wasser
- Center for Women's Health Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Monal Shroff
- Michigan Public Health Institute, Okemos, Michigan
| | | | - Melissa Cunningham
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Fernandez-Rao S, Hurley KM, Nair KM, Balakrishna N, Radhakrishna KV, Ravinder P, Tilton N, Harding KB, Reinhart GA, Black MM. Integrating nutrition and early child-development interventions among infants and preschoolers in rural India. Ann N Y Acad Sci 2014; 1308:218-231. [PMID: 24673168 DOI: 10.1111/nyas.12278] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article describes the development, design, and implementation of an integrated randomized double-masked placebo-controlled trial (Project Grow Smart) that examines how home/preschool fortification with multiple micronutrient powder (MNP) combined with an early child-development intervention affects child development, growth, and micronutrient status among infants and preschoolers in rural India. The 1-year trial has an infant phase (enrollment age: 6-12 months) and a preschool phase (enrollment age: 36-48 months). Infants are individually randomized into one of four groups: placebo, placebo plus early learning, MNP alone, and MNP plus early learning (integrated intervention), conducted through home visits. The preschool phase is a cluster-randomized trial conducted in Anganwadi centers (AWCs), government-run preschools sponsored by the Integrated Child Development System of India. AWCs are randomized into MNP or placebo, with the MNP or placebo mixed into the children's food. The evaluation examines whether the effects of the MNP intervention vary by the quality of the early learning opportunities and communication within the AWCs. Study outcomes include child development, growth, and micronutrient status. Lessons learned during the development, design, and implementation of the integrated trial can be used to guide large-scale policy and programs designed to promote the developmental, educational, and economic potential of children in developing countries.
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Affiliation(s)
- Sylvia Fernandez-Rao
- Department of Behavioural Sciences, National Institute of Nutrition, Hyderabad, India
| | - Kristen M Hurley
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland.,Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Nagalla Balakrishna
- Department of Biostatistics, National Institute of Nutrition, Hyderabad, India
| | | | - Punjal Ravinder
- Department of Micronutrient Research, National Institute of Nutrition, Hyderabad, India
| | - Nicholas Tilton
- Department of Micronutrient Research, National Institute of Nutrition, Hyderabad, India
| | | | - Greg A Reinhart
- The Mathile Institute for the Advancement of Human Nutrition, Dayton, Ohio
| | - Maureen M Black
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
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Johnson W, Vazir S, Fernandez-Rao S, Kankipati VR, Balakrishna N, Griffiths PL. Using the WHO 2006 child growth standard to assess the growth and nutritional status of rural south Indian infants. Ann Hum Biol 2012; 39:91-101. [DOI: 10.3109/03014460.2012.657680] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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