Childhood stunting remains a public health burden worldwide. Although many studies have examined early life and in‐utero risk factors; most have been observational and have used analytic techniques that make inferences limited to population means, thereby obscuring important within‐group variations. This study addressed that important gap. Using data from a birth cohort of Ugandan infants (n = 4528), we applied group‐based trajectory modelling to assess diverse patterns of growth among children from birth to 1‐year old. A multinomial regression model was conducted to understand the relationship between risk factors and observed patterns across groups. We found that the onset of stunting occurred before birth and followed four distinct growth patterns: chronically stunted (Group 1), recovery (Group 2), borderline stunted (Group 3) and normal (Group 4). The average length‐for‐age z‐score (LAZ) at birth was −2.6, −3.9, −0.6 and 0.5 for Groups 1–4, respectively. Although both Groups 1 and 2 were stunted at birth, stunting persisted in Group 1 while children in Group 2 recovered by the fourth month. Group 3 exhibited mild stunting while Group 4 was normal. Wasting and underweight were observed in all groups, with the highest prevalence of underweight in Group 1. Wasting gradually increased among children born already stunted (Groups 1 and 2). This showed the importance of distinguishing children by their growth patterns rather than aggregating them and only comparing population averages against global growth standards. The design of nutrition interventions should consider the differential factors and potential for growth gains relative to different risks within each group.
Background: The Nutrition Governance Index (NGI) defines a first standardized approach to quantifying the ‘quality of governance’ in relation to national plans of action to accelerate improvements in nutrition. It was created in response to growing demand for evidence-based measures that reveal opportunities and challenges as nutrition-related policies on paper are translated into outcomes on the ground. Numerous past efforts to measure ‘governance,’ most notably World Health Organization’s (WHO’s) NGI and the separate Hunger and Nutrition Commitment Index (HANCI), both of which lack granularity below the national level and each of which fails to capture pinch points related to necessary cross-sectoral actions. This paper addresses such caveats by introducing an innovative metric to assess self-reported practices of, and perceptions held by, administration officials tasked with implementing government policy at the sub-national level. The paper discusses the development of this metric, its methodology, and explores its application in the context of Nepal. Methods: Conducted as part of a nationally representative longitudinal survey across 21 of Nepal’s 75 districts, the substudy on which this paper is based used data from 520 government and non-government officials at different geographic and administrative tiers of authority. Using robust statistical techniques, structured questionnaire data were condensed into a score using a scale from 0 to 100. Results: Six domains were identified through the analysis: Understanding Nutrition and related responsibilities; Collaboration; Financial Resources; Nutrition Leadership, Capacity, and Support. About half of all health sector representatives achieved a high score (>3 on 5-point scale) compared to representatives in other sectors of government activity (such as agriculture or education) (χ2=12.99, P<.003). The health sector also showed the most improvement in mean NGI score over a two-year follow-up period. Conclusion: This paper shows that self-reported perceptions and behaviors of those responsible for policy implementation can be usefully quantified. The NGI can be used to assess countries’ readiness for the application of nutrition policies.
Background The public health burden of undernutrition remains heavy and widespread, especially in low-income countries like Nepal. While predictors of undernutrition are well documented, few studies have examined the effects of political will and quality of policy or program implementation on child growth. Methods Data were collected from two nationwide studies in Nepal to determine the relationship between a metric of nutrition ‘governance’ (the Nutrition Governance Index), derived from interviews with 520 government and non-government officials responsible for policy implementation and anthropometry measured for 6815 children in 5556 households. We employed Generalized Estimating Equation (GEE) and multilevel regression models. Results A higher NGI (more effective nutrition governance) is positively associated with height-for-age as well as weight-for-height in children over 2 years of age compared to younger children (HAZ; β = 0.02, p < 0.004, WHZ; β = 0.01, p < 0.37). Results from the hierarchical model show that a one-point increase in the NGI is significantly associated with a 12% increase in HAZ and a 4% increase in WHZ in older children (> 24 months old). Mothers’ education, child’s age, BMI and no fever in the past 30 days were also protective of stunting and wasting. Seven percent and 17% of the overall variance in HAZ and WHZ, respectively, are accounted for by variations across the 21 district locations in which sampled households were located. Mean HAZ differs considerably across districts (intercept = 0.116, p < 0.001). Conclusions These results highlight the importance of effective management of policy-based programming and resource use to bring about nutrition gains on the ground. The NGI explained a non-negligible amount of variation in HAZ and WHZ, which underscores the fundamental role that good governance plays in promoting child nutrition and growth, and the value of seeking to measure it to assist governments in moving policies from paper to practice.
Introduction Women and infants are among the most vulnerable groups for micronutrient deficiencies. Pregnancy micronutrient status can affect birth outcomes and subsequent infants’ growth. Methods We determined the relationship between maternal iron and vitamin A status at delivery using several biomarkers (ferritin, soluble transferrin receptor [sTFR], body iron stores [BIS], hemoglobin and retinol binding protein [RBP]) and birth outcomes (body weight, Z-scores, head circumference, small-for-gestational-age and preterm birth) in rural Uganda. We investigated women who had serum results at the point of delivery and paired them to their infants at birth (n = 1244). We employed multivariable linear and logistic regression, adjusting for clustering at the subcounty level to determine the relationship between maternal micronutrients and birth outcomes. Results After adjusting for relevant factors, we found that maternal iron status (ferritin and BIS) and anemia (hemoglobin) were not significantly associated with the assessed birth outcomes. However, there was a significant association between serum sTFR and preterm births (AOR: 0.67; 95% CI 0.48–0.94). For Vitamin A, we observed a significant positive association between RBP and length-for-age (LAZ) at birth (β = 0.12, p < 0.030). Discussion These findings indicate that the relationship between maternal iron status and birth outcomes needs to be further investigated, because depending on the biomarker used the associations were either in favor of an adverse birth outcome or not significant. Additionally, they confirm that higher maternal RBP levels could be beneficial for birth outcomes. Clinicaltrials.gov as NCT04233944.
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