Objectives:
A community-based, randomized trial was designed to compare the
effect of nutrition education and/or iron supplementation
(weekly) on iron status of children in an urban slum in Delhi. Methods:
Four hundred and fifty one children, 9-36 months of age and
their caretakers (mothers), assigned to one of the following
groups were included in the cohort. Group 1, nutrition
education. Group 2, supplementation (with 20 mg elemental iron).
Group 3, nutrition education with supplementation (with 20 mg
elemental iron) and Group 4, control given placebo. The
intervention program was of four months duration, with a
treatment phase of 8 wk followed by 8 wk of no treatment. Results:
Post intervention, at 8 wk and at 16 wk, the hemoglobin change
in the nutrition education, supplementation, nutrition education
with supplementation and control groups was 2.9, 1.9, 3.8 and
–5.9%, respectively and 2.1, –1.9, 0 and –9.3%,
respectively (as compared to initial values). There was no
significant effect of any of the intervention at 8 weeks. At 16
wk, there was significant positive effect of nutrition education
group (p <0.05). The percent change in serum ferritin value
at 16 wk in the nutrition education, supplementation, nutrition
education with supplementation and control groups was 5.7, –2.3,
-3.4 and –40%, respectively. Serum ferritin values were
significantly higher for the nutrition education group
(p<0.001) as compared to the control. At 16 wk, the nutrition
education group mothers showed significantly higher nutrition
knowledge and the dietary iron intake of children was
significantly higher than their control group counterparts (p
<0.0001). Conclusions: The study suggests that
nutrition education did have a positive effect on the iron
status possibly by improving the dietary iron intake.
Key words: Dietary
iron, Iron deficiency anemia, Nutrition education,
Supplementation.
Iron deficiency
anemia is the most common form of malnutrition in the world, being
most prevalent and severe in young children (6-24 months) and women
of reproductive age(1). Evidences(2,3) suggest high prevalence of
iron deficiency anemia among children, less than three years of age
in India. Iron deficiency anemia is associated with developmental
delays, behavioral disorders and poor scholastic performance in
children(4). In animal model intrauterine and early life latent iron
deficiency induced irreversible neurotransmitter alterations(5)
which are related to developmental behavioral changes.
Several studies(6,7)
have suggested that supplementation with iron may increase
hematological indicators of iron status. Some researchers(8) have
documented a significant relationship between nutrition knowledge
and nutrition behavior, specific to iron. It is presumed that
detailed guidance on such topics as food purchasing, food
preparation and serving sizes(9), nutrient value of foods and
balanced diets(10) will provide individuals with enough information
and motivation to make wise decision about selections for good
health. However, there is lack of studies on evaluation of the true
impact of nutrition education intervention on dietary intake,
specially the intake of iron and on the iron status.
In this context, the
present study is an effort in designing and implementing a nutrition
intervention program aimed at both increasing knowledge about and
promoting positive attitudes and behavior change towards child
feeding practices, specific to iron intake. The paper reports on a
community-based nutrition education inter-vention trial to improve
the iron status and dietary iron intake of children 9-36 months of
age. The intervention was conducted through the Integrated Child
Development Services (ICDS) program involving the anganwadi workers.
Materials and
Methodology
A community-based
nutrition education intervention trial was designed based on the
hypotheses that focused nutrition education may reduce the risk of
iron deficiency anemia in young children. The study was designed as
an intervention program of nutrition education based on a
multi-media approach using print/audio-visual media, discussions
etc. targeted at mothers. At the same time and at the same site, an
intervention to improve iron status through supplementation alone
and nutrition education and supplementation together was also
implemented.
A complete record of
all children (9-36 months of age) - beneficiaries of the 41
anganwadis (AWs) from the Nand Nagri ICDS project in North-East
Delhi - was obtained from the respective anganwadi workers. A total
of 2629 children qualified to be registered in these 41 AWs. Based
on these data, using the random number Tables, 545 children aged
9-36 months of age and their caretakers (mothers) were invited to
participate in the study. Sample size was calculated according to
the statistical formula (11) as indicated:
(u + v)2 (ó12 + ó22)
n >
—–———————
(µ1 – µ2)2
where u = 1.28
(90% power), v = 1.96 (2 sided significance level at 5%), s1,
s2 (standard deviation) = 1.9 (based on a pilot study), µ1
– µ2 = 1 (difference between the mean hemoglobin).
Therefore, a sample size of 75 children in each group with a total
sample size of 300 was calculated. A 50-60% safety margin was added
to allow for a maximum estimated non-response, giving a sample size n
ł 500 subjects.
Ethical approval for
the study was obtained from the institutional ethics committee and
the ICDS authorities. Following their advice, informed consent was
obtained from the parents participating in the study.
The 545 children
along with their mothers were allotted to one of the following four
study groups: (a) Nutrition education group, wherein,
education was imparted at informal meetings with mothers (once a
week for 8 wk). (b) The supplementation group, provided a
weekly oral dose of 20 mg of elemental iron (Ferium, M/S Emcure
Pharm. Ltd, Poona, India; VIFOR International Inc, Switzerland). (c)
The nutrition education with supple-mentation group (mothers
provided nutrition education and children oral supplementation i.e.,
20 mg of elemental iron/wk). (d) The control group, given
sugar syrup, administered weekly.
Of the 545 children
enrolled in different groups, parents of 451 children – nutrition
education (98), supplementation (129), nutrition education with
supplementation (105) and control (119) – consented to have their
children’s blood samples taken and were thus included in the
cohort.
The intervention
program was of four months (16 wk) duration, with a treatment (i.e.,
nutrition education and/or supplemen-tation) phase of 8 wk followed
by 8 wk of no treatment. The anganwadi workers administered the
intervention continuously for 8 wk, once a week. Prior to the
intervention, the anganwadi workers were oriented and trained to use
the education package prepared for the purpose and/or to administer
the iron syrup. At the end of the intervention (16 wk), all the
children were given necessary treatment, if required for anemia.
At entry, the
hemoglobin (Hb) and growth and dietary measures were carried out in
all children. Every fifth child had serum ferritin (SF) measured.
The mother’s nutrition knowledge, attitude towards improving child
feeding practices was assessed. After 8 wk of intervention
(treatment), hemoglobin levels were reassessed for all children in
the four groups. Subsequently, there was eight wk interval (when no
treatment was given) and at the end of the intervention (i.e.,
16 wk stage) all children were reassessed for Hb, SF, growth and
their diet intake. Mothers were re-surveyed regarding their attitude
and nutrition knowledge.
Hematological analysis
Twenty µl
blood by finger prick in 5ml Drabkin’s solution was transported
(protected from light) within 2 hours to the laboratory where
hemoglobin measurements were undertaken immediately. Hemoglobin
levels were assessed using the cyanmethemoglobin method(12). The
blood for serum ferritin was taken by venipuncture (from every fifth
child). Ferritin levels were determined by a commer-cially available
immunoassay (Spectro Ferritin kit, Ramco Lab, Inc, Houston, TX). For
all the subjects included for the serum ferritin estimation, the
detection of C-Reactive Protein (CRP) was undertaken using AVITEX-CRP
Latex Test (Omega Diagnostic Limited, Scotland, UK).
Diagnostic Criteria
Anemia was classified
based on the WHO recommended cut-off value of <11.0g/dL for
children 5 months to 5 years of age(13). Hb concentrations less than
7.0g/dL were considered severe anemia, 7.0 to 9.9g/dL as moderate
anemia and 10.0 to 10.9g/dL as mild anemia. A cut-off value of 10
µg/L for serum ferritin was chosen based on the recommen-dations of
WHO for diagnosis of iron deficiency(13).
Growth parameters
Height, weight and
mid upper arm circumference (MUAC) were measured using standard
techniques and those <90% of height and weight as compared to
50th centile of Indian children(14) were taken as stunted and
undernourished, respectively.
Nutrition Education
Package
A series of studies
were conducted which aimed to survey the nutrient intake, food
selection, nutrition knowledge and attitudes of mother’s regarding
child feeding and iron nutrition. These studies, a part of the
formative research, formed the bases for the development of the
nutrition education package which included: A Flip Chart: A
simple, well illustrated set of cards (chart) presenting 8-9
concepts related to healthy child feeding practices; An
Information Leaflet: A visually (pictorial/graphic) enriched
leaflet providing specific advice for improving iron status and
information regarding feeding schedule for children; A Calendar:
A useful reference and hand-out material highlighting the
consequences of anemia and presenting simple messages related to
improving iron status by consuming iron-rich foods and iron
enhancers; A Video Program specific to preventing iron
deficiency anemia.
The areas/messages
identified for inter-vention/reinforcement included.
Under Child feeding
practices: Exclusive breast
feeding for 6 months; introducing complementary foods by 6 months;
providing appropriate foods (in term of consistency, quality and
quantity) during the infancy and early childhood period; encouraging
small, but frequent feedings; initiating the child to the family
food by one year of age; emphasizing the importance of solid food
rather than milk-based diet for children; reinforcing the importance
of hygiene and cleanliness with respect to child feeding.
Under improving iron
status:Iron deficiency anemia
– causes, symptoms and prevention; ensuring adequate inclusion of
iron-rich foods; encouraging the consumption of vitamin C-rich foods
along with the meals; cooking food in iron vessels; avoiding iron
absorption inhibitors such as tea; preventing worm infestations by
maintaining good personal and environmental hygiene practices(15).
Food and Nutrient Intake
The food and nutrient
intake of children was assessed using a 10-item food frequency and
amount questionnaire (FAQ). The FAQ was designed with the intention
to estimate the usual frequency and/or amount of consumption of
specific items of food and drinks, including dietary supplements
such as minerals, vitamin drops etc. by children. The
questionnaire consisted of two components - a food list and a
frequency response section for subjects to report how often each
food was eaten.
Food models and
series of photographs were used to help mother’s quantify the
amount of food consumed. The weight of the food portions consumed
was derived from the known weights of the portions portrayed in the
photographs and/or from weighing duplicate portions of the items
consumed.
The reliability of
the dietary intake data was assessed by correlating the mean intake
of the major nutrients derived from the FAQ record with the mean
nutrient intake derived from the 3 day diet record method for
approximately one-fifth of the total sample. There was a significant
positive association between the two methods for all nutrients,
except vitamin C. The difference between mean nutrient intakes of
paired samples was calculated and assessed using t-test. Overall,
the results for the 2-3 day dietary record method appeared to be
marginally lower than the food frequency and amount method although
the difference was only significant for vitamin C (p < 0.001).
Validity of the
dietary intake data was assessed by correlating dietary iron intake
of 30 subjects with an independent measure of hemoglobin(16). The
correlation (r = 0.494, p = 0.006) was significant (p < 0.001).
The mean food intake
was assessed for adequacy by comparing with the balanced diet for
children as per the Dietary Guidelines for Indians(17). The nutrient
intake of children was computed as per the Indian Council of Medical
Research’s (ICMR) "Food Composition Tables". For few
specific local foods/items e.g., Rusk, ‘phan’ (puffed
patty) (for which data were not available in the Food Composition
Table) nutritive value estimation was undertaken in the Food
Analysis and Research Center (FARC), New Delhi, India. For breast
fed infants, the quantity of breast milk consumed was estimated
based on data specific to Indian children(18).
Maternal Nutrition Knowledge
The maternal
nutrition knowledge score was assessed using an 18-item
multiple-choice visual format questionnaire, specially designed for
use with illiterate subjects. The questionnaire focused on assessing
the know-ledge of mother regarding the following aspects, specific
to child feeding and iron deficiency anemia.
• Familiarity
with nutrition terms and disease sign/symptoms
• Knowledge about
present recommenda-tions for child feeding practices
• Understanding
practical applications of the recommendations, in terms of food
and eating
Four questions
assessed knowledge about nutrient term, symptoms and disease
condi-tion. Seven items assessed the knowledge about present
recommendations for child feeding. Seven questions assessed the
practical application of nutrition principles. These questions were
defined as those items relating to specific foods. The final
questionnaire was developed following a series of pilot studies. A
logical analysis survey was undertaken, involving 3 experts, to rate
possible topics for inclusion in the questionnaire. Wording and
comprehen-sion were assessed using visual analogue scale with
experts and 20 subjects. The discrimi-nating power was calculated by
administering the questionnaire to 20 graduate nutrition students.
The multiple-choice
questionnaire was presented to each subject and each question was
read in full, the visuals shown in a one-to-one interview. The
interviewer on a precoded answer sheet recorded responses. During
analysis, items were scored as 1 for a correct response and 0 for an
incorrect response. The possible score range was from 0-18. Results
were expressed as a total score out of 18 and as percentage correct
answer out of a possible 18 (100%).
Attitude Questionnaire
The attitude
questionnaire was developed based on the Expectancy Value Model
described by Fishbein and Ajzen(19). The questions comprised 22
statements, which covered the four components of the Expectancy
Value Model, which are attitude (behavior belief × outcome
evaluation) and subjective norm (normative belief × motivation to
comply). To measure these components, questions (and responses) were
designed as follows:
Attitude -
This was assessed by constructing eight pairs (one each for behavior
belief and outcome evaluation) of statements on the relationship
between ‘improving child feeding practices’ and exclusive breast
feeding for 4-6 months, frequency of meals, reducing the milk intake
and increasing the solid food intake, putting the child on family
food by one year of age, introducing variety in meals, control of
mother over child eating habits and maintaining iron status and
reducing the risk of iron deficiency anemia. The belief statements
were assessed on the scale ‘strongly agree’ to ‘strongly
disagree’ and corresponding evaluation statement on the scale ‘very
desirable’ to ‘very undesirable’. The belief statements were
identified from the beliefs assessed during the group discussion
sessions with mothers.
Subjective Norm –
This was assessed by three pairs of statements (one each for
normative belief and motivation to comply) which queried whether the
respondent thought her mother-in-law/mother, husband, doctor/anganwadi
worker would like her to improve the child feeding habit and the
respondents motivation to comply with these referents. The
statements on normative belief were assessed on the scale ‘strongly
agree’ to ‘strongly disagree’ and corresponding motivation to
comply items on the scale ‘wishing to do’ or ‘not to do’
what referents thought they ought to. The normative belief items
were identified from group discussion work.
The questionnaire
contained 22 questions in the form of statements with seven category
Likert response scales(20) labeled only at extreme ends. For all
questions the center of the response scale was taken as zero, and
hence responses were rated as -3 to +3 other than the motivation to
comply questions, which were rated 0 to 6(21).
Statistical Analysis
The impact of
intervention, on the hematological indices, was determined by using
the factorial design analysis. Analysis of Variance (ANOVA) was used
to determine group differences in dietary intake data, anthropometry,
and maternal nutrition knowledge and attitude scores. All the
observations on serum ferritin were taken on natural log scales and
then compared. Geometric mean was computed using the log transformed
(natural logarithm) serum ferritin observations. Significant
difference was defined as p <0.05
Results
Three hundred and
sixty four of the 451 children included in the cohort (at baseline)
completed the study protocol for a follow up rate of 81% (nutrition
education 74.4%, supplementation 84.5%, nutrition education plus
supplementation group 81.9%, control 79.8%) at 16 wk. Complete
serial data at the three point of time, initial, 8 and 16 wk, were
obtained from 232 subjects for hemoglobin. The reason for the
moderately high dropout rate over the study period could be
attributed to population mobility and/or families not cooperating
for repeated hematological measurements, after initial recruitment. Table
I shows the characteristics of the children and families (232
subjects).
TABLE I
Characteristics of Children and Their Families in the Four Study Groups
| Characteristics |
Control
(n= 58)
|
Supplementation
(n=58)
|
Nutrition
Education
(n=58) |
Nut
Education +
Supplementation
(n = 58) |
Significance
p value
|
| |
Child-related age1 (mo)
|
20.6
|
21.1
|
20.0
|
21.1
|
0.878
|
|
(8.9)
|
(8.0)
|
(7.6)
|
(8.5) |
|
Sex2 M
|
56.9
|
44.8
|
43.1
|
41.4
|
0.325
|
F
|
43.1
|
55.2
|
56.9
|
58.6
|
|
Height1 (cm)
|
73.0
|
75.0
|
73.7
|
74.5
|
0.243
|
|
(6.8)
|
(4.6)
|
(5.6)
|
(5.5) |
|
Weight1 (kg)
|
8.6
|
8.3
|
8.1
|
8.3
|
0.267
|
|
(1.9)
|
(1.2)
|
(1.4)
|
(1.4) |
|
MUAC1 (cm)
|
12.6
|
12.7
|
12.7
|
12.7
|
0.967
|
|
(1.1)
|
(0.9)
|
(0.9)
|
(0.9) |
|
| Mother’s
Education2 |
• Illiterate
|
62.1
|
58.2
|
52.6
|
41.1
|
0.08
|
• Primary
|
24.1
|
14.5
|
17.5
|
22.4 |
|
• Secondary
|
13.8
|
24.6
|
24.6
|
36.2 |
|
• Others
|
—
|
3.4
|
5.2
|
— |
|
| Mother’s
Occupation2 |
• Housewife
|
96.5
|
90.1
|
82.8
|
89.5
|
0.26
|
• Unskilled
|
—
|
1.8
|
—
|
— |
|
• Skilled
|
1.7
|
7.3
|
15.5
|
8.8 |
|
• Others
|
1.7
|
—
|
1.7
|
1.8 |
|
| Family
Income in Rupees2 (annual) |
No Income
|
—
|
1.8
|
3.4
|
3.4
|
0.295
|
0 - 20,000
|
62.5
|
70.9
|
55.2
|
65.5 |
|
20,001 - 40,000
|
37.5
|
21.8
|
39.7
|
29.3 |
|
40,001 - 60,000
|
—
|
5.2
|
1.7
|
1.7 |
|
| Birth
interval2 |
• One year
|
6.5
|
7.9
|
11.6
|
11.9 |
|
• Two years
|
47.8
|
28.9
|
23.3
|
21.4
|
0.405
|
• Three years
|
28.3
|
28.9
|
34.9
|
33.3 |
|
• Four years
|
8.7
|
15.8
|
18.6
|
9.5 |
|
• Five years
|
4.3
|
7.9
|
2.3
|
9.5 |
|
• > Five years
|
4.3
|
10.5
|
9.3
|
14.3 |
|
M = male; F = female; 1. Values are mean, values in parentheses are SD; 2. Values are percentages.
No significant
differences were found in the baseline data between groups. In all
the four groups, large number of families were disadvantaged by
maternal education and family income. Mothers were predominantly
housewives and majority of them had 2-3 children.
The compliance with
the attendance at the nutrition education sessions and/or treatment
with iron by mouth were high (more than 75% of the subjects
completed the 8 wk course) as noted from the attendance sheet
maintained by the anganwadi workers. Children receiving iron
supplementation were given a total of 8 doses. The preparation was
found to be palatable and no untoward side effect was noted.
Response of Hemoglobin and serum
ferritin
The baseline
prevalence of anemia was 57.3%. Mean Hb was 105 ± 16.0 g/L for the
total study group. There was no significant difference in the mean
Hb values between the control and intervention group children at
baseline. The change in hemoglobin at 8 wk was 2.9, 1.9, 3.8 and –5.9%
for the nutrition education, supplementation, nutrition education
with supplementation and control group, respectively. The
corresponding change at 16 wk was 1.9, –1.9, 0 and –9.3%,
respectively with a significant main effect of nutrition education
(p <0.05) and supplementation (p <0.05) (Table II).
TABLE II
Hematological Measurements and Impact of the Intervention at 8 and 16 wk in the Study Groups
Variable
|
Initial
|
8 weeks
|
16 weeks
|
Significance
|
p value
|
Hemoglobin (g/l)1
|
|
|
|
At 8 wk |
|
Nutrition Education
|
103
|
106
|
105
|
Main effect |
|
(n = 58)
|
(15)
|
(15)
|
(15)
|
Nutrition education
|
0.776
|
|
|
|
|
Supplementation
|
0.402
|
Supplementation
|
105
|
107
|
103 |
|
|
(n = 58)
|
(14)
|
(12)
|
(16)
|
Nutrition education* |
|
Nut. Education + Supplmentation
|
104
|
108
|
104
|
Supplementation
|
0.209
|
(n = 58)
|
(20)
|
(19)
|
(21)
|
At 16 wk |
|
|
|
|
|
Main effect |
|
Control
|
107
|
101
|
97
|
Nutrition education
|
0.042*
|
(n = 58)
|
(15)
|
(14)
|
(14)
|
Supplementation
|
0.013*
|
|
|
|
|
Nutrition education* |
|
|
|
|
|
Supplementation
|
0.853
|
Serum Ferritin (µg/L)2
|
Nutrition Education
|
5.3
|
—
|
5.6
|
Main effect |
|
(n = 15)
|
(4.0-6.99)
|
|
(4.77-6.64)
|
Nutrition education
|
<0.00*
|
Supplementation
|
4.3
|
—
|
3.3
|
Supplementation
|
0.493
|
(n = 15)
|
(3.34-5.58)
|
|
(2.51-4.41) |
|
|
Nutrition Education
|
5.8
|
—
|
5.6
|
Nutrition education* |
|
+ Supplementation (n = 15)
|
(5.22-6.49)
|
|
(4.42-6.48)
|
Suplementation
|
0.610
|
Control
|
5.7
|
|
3.4 |
|
|
(n = 15)
|
(4.79-6.88)
|
–
|
(2.21-3.35) |
|
|
* Significantly different; 1. Values are mean, values in parenthesis are SD; 2. Values are percentages.
One hundred and six
children were assessed for serum ferritin along with C-Reactive
Protein (CRP) at baseline. Geometric mean serum ferritin
concentration was 5.3 µg/1 (with 95% confidence interval of
4.00-6.99) for the total study group. Sub-clinical infection as
evident by positive CRP was found in 16 (15%) children. Ninety (85%)
were C-reactive negative. At 16 wk, 91 children (86%) could be
followed up. Ninety three per cent were C-reactive negative.
Sub-clinical infection as evident by positive CRP was found in 6
(6.6%) children. Complete serial data at two points of time, initial
and 16 wk, could however, be obtained from 60 subjects (15 subjects
in each of the study groups) for serum ferritin (Table II).
Data indicated a fall of 50%, 17% and 13% in the serum ferritin
value in the control, supplementation and nutrition education with
supplementation group, respectively. The main effect of nutrition
education was a rise in ferritin value by 14% (p <0.001).
Impact of Intervention on Maternal
Nutrition Knowledge
The mean baseline
nutrition knowledge score was 5.7 ± 2.15 (Total score 18, Median 6,
Range 1-12). In terms of percentage, the mean score was 31.6 ±
11.96%. The mean nutrition knowledge score of subjects in each of
the four study groups at 16 wk is presented in Table III.
Data suggest that at the end of the intervention mothers in the
nutrition education and the nutrition education cum supplementation
group scored significantly higher (p <0.001).
TABLE III
Nutrition Knowledge Score of Mothers at Baseline and at 16 Weeks*
Nutrition
knowledge
score
|
Baseline
|
|
Significance
|
|
|
Control
|
Supplementation
|
Nutrition
Education
|
Nutrition
Education +
Supplementation
|
|
Total score
|
5.7
|
5.5
|
5.4
|
11.6
|
11.4 |
|
|
(2.2)
|
(2.2)
|
(2.2)
|
(2.7)
|
(2.7)
|
<0.001
|
%Score
|
31.6
|
30.6
|
30.3
|
64.6
|
63.3 |
|
|
(12.0)
|
(12.4)
|
(12.4)
|
(15.1)
|
(14.9) |
|
*Values are mean, values in parentheses are SD.
Individual item
analysis data revealed lowest scores, in all the four groups, for
the component on practical applications i.e., questions
related to nutrient-rich food sources and food combinations.
Impact of Intervention on Maternal
Attitude Towards Improving Child Feeding Practices
Table IV
presents the total mean score for the attitude and subjective norm
component for each of the four groups. Nutrition education and
nutrition education plus supplementation group recorded
significantly higher values (p<0.001) for attitude component. As
for the subjective norm component, high values were recorded in all
four groups suggesting that overall this group of women felt a lot
of social pressure to improve child feeding practices.
TABLE IV
Scoring for the Components of the Attitude model in the Four Study Groups*
Component
|
Control
|
Supplementation
|
Nutrition
Education
|
Nutrition
Education plus
Supplementation
|
Possible
Score
|
p value
|
Attitude
|
–2.1
|
–13.3
|
34.8
|
10.1
|
–72 to +72
|
<0.0001
|
|
(1.2)
|
(3.0)
|
(17.3)
|
(25.4) |
|
Subjective norms
|
46.8
|
41.5
|
53.7
|
51.1
|
–54 to 54
|
<0.0001
|
|
(13.7)
|
(21.5)
|
(2.4)
|
(1.7) |
|
|
*Values are mean, values in parenthesis are SD;
The scoring for
individual questions in the attitude component indicated that the
questions relating to improving feeding practices to reducing the
risk of anemia scored much higher than the other belief items. No
significant difference for this variable was recorded among the
study groups. Overall significant positive feelings related to
exclusive breast feeding for 4-6 months (p < 0.001), feeding
children 4-5 times a day (p < 0.001), providing variety of foods
in the child’s diet (p <0.001), putting the child on to the
family food by one year (p <0.001) and reducing the milk intake
and giving more solid food (p <0.001) was recorded in the
nutrition education group. Mother’s attitude towards control over
child’s feeding habits did not seem to improve as a result of
intervention as negative feelings were recorded in each of the four
study groups (for this component), with the difference not being
significant.
Impact of Intervention on Nutrient
Intake and Dietary Adequacy
The mean daily
nutrient intake for children was derived from the food frequency
questionnaire (FAQ) and the data are presented in Table V.
Baseline data suggest that nutrient intake of children ranged from
45% (iron) to 233% (protein) of RDA, with energy and iron falling
much below the current requirements for this population. Inter-group
comparison of the mean daily dietary intake (for energy, protein,
iron and vitamin C) in the four study groups at 16 wk and in
relation to the baseline nutrient intake, revealed that children in
the nutrition education group had significantly higher intakes of
energy, protein and iron (p < 0.001). No significant difference
in the vitamin C intake was recorded within the groups. The
energy/iron adequacy of the diet (at 16 wk) did not change much as
compared to the adequacy at the initial stage in control children,
but it increased significantly in the nutrition education group (p
<0.05). Nutrient intake at the end of the intervention ranged
from 47% (iron) to 295 % (protein) of RDA’s, with energy (deficit
ranging from 34% to 44%) and iron (deficit ranging from 38% for
nutrition education group to 53% for supplementation group) still
falling below the current RDA’s for this population(17).
TABLE V
Daily Nutrient Intake and Percent Adequacy of the Diet as Compared to the
Recommended Dietary Allowance at Baseline and at 16 Weeks(1–3).
| |
|
At
16 weeks |
Significance |
Nutrition
|
Baseline
|
Control
|
Supplementation
|
Nutrition
Education
|
Nutrition
Education +
Supplementation |
|
Energy Kcal
|
694
|
692
|
704
|
821
|
719
|
<0.0001
|
|
|
(56)
|
(56)
|
(57)
|
(66)
|
(58) |
|
Protein g
|
49
|
36
|
39
|
66
|
39
|
<0.0001
|
|
|
(223)
|
(165)
|
(177)
|
(295)
|
(186) |
|
Iron mg
|
5.4
|
5.9
|
5.6
|
7.4
|
6.1
|
<0.0001
|
|
|
(45)
|
(48)
|
(47)
|
(62)
|
(51) |
|
Vitamin C mg
|
57
|
50
|
57
|
70
|
65
|
0.1135
|
|
|
(143)
|
(125)
|
(143)
|
(175)
|
(163) |
|
1. Values are mean, n = 277 (nutrition education 81, supplementation 63, nutrition education with
supplementation 69, control 64).
2.Values in parenthesis are percentage adequacy of the diet as compared to the Indian
recommended dietary allowances (ICMR 1998).
3.The Indian recommended dietary allowances (RDA) is 1240 KCal for energy, 22 g for protein,
12 mg for iron and 40 mg for vitamin C for children aged 1-3 years.
Growth Data
Baseline data
indicated that underweight (90.4%) and stunting (44.8%) was widely
prevalent among the children. There was no difference in mean
weight, height or mid; upper arm circumference at 16 wk between the
control and intervention groups.
Discussion
In this population
group, wherein, the iron and nutritional status was highly
compromised, evidence suggests that nutrition education intervention
was effective, as it improved the dietary iron intake and prevented
the children from suffering the sharp decline in iron status, noted
in the control.
Evaluation of the
impact of intervention on maternal nutrition knowledge indicated an
overall improvement in the nutrition score. The attitude data showed
that the education intervention was associated with higher scores,
implying a change in beliefs.
The nutrition
education intervention, focusing on food-based strategies promoting
consumption of iron-rich foods and foods that increase absorption of
iron (vitamin C rich foods) brought about significant changes in
intake (improved energy, protein, iron (by 37%) and vitamin C
intake). The adequacy of cereals, pulses, other vegetables, fruits,
oil/fats intake was high in groups where nutrition education was a
component as compared to control and supplementation group. Although
the intake of green leafy vegetables was low among children in all
the four groups, perhaps cereals and pulses may have been the main
contributory food for iron, the intake of which was certainly higher
in groups where nutrition education was a component. Further, the
high vitamin C intake attributed to the high intakes of fruits and
other vegetables recorded in the food intake data specific to
nutrition education group may have also contributed in terms of
better absorption of iron from the diet.
However, inspite of
the improved nutrient intake, the overall adequacy of the diet (in
terms of energy and iron) as compared to the Indian Recommended
Allowances for Children remained low in all the groups. A deficit of
34% for energy and 38% for iron was recorded for the nutrition
education group (as compared to 44% deficit for energy and 52%
deficit for iron in the control). Latest WHO recommendations(22) on
dietary requirements in young children are considerably lower than
early ones. It is being recommended that dietary energy intakes
should remain at 100 kcal/kg after three months of age and through
out infancy, with the estimate energy requirement for boys and girls
aged 12-35 months ranging from 844-1184 kcal/d and 768-1139 kcal/d,
respectively. From these data, it may seem reasonable to suggest
that perhaps the present ICMR recommended energy intakes for young
children (1240 kcal/d for children 1-3 years of age) may require
reconsideration.
Further, the limited
effect of nutrition education intervention on improving the overall
diet adequacy may possibly be due to the fact that moderate to
severe malnutrition was prevalent in the study group. Only 9.6%
children were well nourished. Under such circumstances, wherein, the
children’s diet (before the intervention) was highly compromised,
perhaps a long term systematically sequenced communication effort,
providing repeated exposure to the messages (much beyond the 8 wk
period), advocating good weaning practices of initiating
supplementary food by six months, giving small but frequent feeds to
children etc. may have been more beneficial. Moreover, we recognize
that many other factors influence the food intake of children. The
high scoring for the items in the attitude scale relating to
referents influence(23) speculate that it might be more successful
to focus on "group" nutrition health education using
community groups and more involvement from families (particularly
mothers-in-law, husbands etc.) themselves.
It is strongly being
proposed(24) and few studies(25) have indicated that in controlled
situations, intermittent iron supplementation can effectively reduce
the prevalence of iron deficiency in several groups, particularly
young children. In the present study, a weekly supplement of 20 mg
Fe only marginally improved the iron status as compared to the
control. Weekly supplementation was not efficacious, perhaps due to
the facts that baseline anemia was high (57.3%), as well as the dose
and duration of supplementation may have been insufficient (26) for
this group of children with a highly compromised iron status.
The present study
suggests that nutrition education did have a positive effect on the
iron status possibly by improving the dietary iron intake. Long-term
community-based approaches involving dietary education emphasizing
optimum feeding schedules and adequate diets for children may
possibly reduce the risk of anemia and raise iron status. Short-term
low level (weekly) elemental iron administration did not have much
protective effect. These findings suggest that dietary
diversification through nutrition education as well as dietary iron
availability through fortification on long term basis will possibly
control prevalent moderate to severe degree of anemia in growing
children.
Acknowledgement
We thank Prof. M.M.A.
Faridi, Head, Department of Pediatrics for providing the facilities.
Mr. Rajeev Kumar, Biostatistics Unit, University College of Medical
Sciences, Delhi, guided the statistical analysis.
Contributors:
DK, KNA, SS planned the study. DK collected the data. KNA, SS guided
the data collection. DK drafted the manuscript and KNA, SS
critically reviewed the manuscript and finalized the draft. KNA will
act as guarantor for the paper.
Competing interest: None
stated.
Funding: Partly
UNICEF, New Delhi.
