title: Prevalence of modifiable risk factors for acute malnutrition as well as validation of an assessment tool in six to twenty-four-month-old children in peripheries of Lahore, Pakistan
Creators: name: Khan, Amara
Publisher: name: University of Glasgow
Year: 2023

description: Undernutrition remains a global challenge for lower-middle-income countries (LMICs), including Pakistan. The recent COVID-19 pandemic-related economic crisis in the food and health system has threatened to deteriorate the indicators of undernutrition in LMICs. Nutrition interventions during the first two years of life are reported to have a significant impact on stunting prevention. The Lancet series on Maternal and Child Undernutrition in 2013, which included three new review papers building upon findings from the previous 2008 series, highlights the growing body of evidence supporting essential interventions in the fight against malnutrition. These review studies underscore the importance of interventions such as breastfeeding, complementary feeding, dietary supplementation for children, dietary diversity, feeding behaviours and stimulation, as well as the treatment of severe acute malnutrition, diarrhoea, and pneumonia. Ready to use Foods (RUF) are used by partners and governments in Pakistan to treat severe and moderate wasting in Pakistan. These RUFs are expensive, energy-dense, and sweet. Also, literature published in the country lacks evidence of its association with feeding and caring practices and malnutrition. Therefore, the research in this thesis aimed to: 1. Develop an assessment tool to assess and quantify the modifiable risk factors for malnutrition in this population. 2. Assess the prevalence of modifiable risk factors among both malnourished and healthy children. 3. Test the effect of supplementary foods on growth and eating behaviour. 4. Assess the feasibility of delivering a non-food-based targeted intervention. The first study was conducted in Glasgow to develop and validate a tool to describe eating avidity and aversion among Urdu and English-speaking mothers in relation to their children. Phrases were taken from previously used tools and refined based on a back-translation approach by native Urdu speakers. These were then tested again with English-speaking mothers, as well as with Urdu mothers. The eleven best-performing phrases describing different eating and feeding behaviours included, "likes food a lot, is interested in food, enjoys eating, enjoys a wide variety of foods, eats quickly, and finishes meals” for eating avidity and “turns head when offered food, pushes food away, cries and screams during meals, spits out food and meals last more than one hour” for food refusal. These phrases were incorporated in the International Complementary Feeding Assessment Tool (ICFET) to be used further. A total of 22 English-speaking and 16 Urdu-speaking participants were recruited for the study. Participants were shown four videos of children exhibiting different eating behaviours and were asked to complete the Likert scaling tool. Overall, participants from both language groups in UK showed high agreement for the avidity phrases, with the highest agreement, 97%, for the phrase related to interest in food and the lowest, 57%, for eating quickly. A set of identified phrases to describe infant eating avidity and avoidance were therefore validated and showed consistent intercorrelation among language groups. The validated tool was then used to assess the prevalence of risk factors among healthy and malnourished infants in the peripheries of Lahore, Pakistan. 108 mother-child pairs (42% healthy &amp; 58% malnourished 52% female infants) from four primary healthcare facilities in Lahore were recruited. In addition to maternal interviews, anthropometric measurements of children were recorded. This included 13% from 6 to 9 months age 22% were from 10–12 months, and the majority (64%) were from the age group of 13-24 months. The mean weight, height, and age of mothers at the time of recruitment were 60.1±10.7 kg, 160.4±10.3cm, and 28.5±5.2 years, respectively. While on average, there were three children born to every mother, and over half (65%) of the households had more than one under-five child. Both malnourished and healthy groups showed similar family characteristics. However, number of children who were still breastfeeding were higher among the healthy group (78.6%) compared to the malnourished ones (54.5%) (p=0.01). Complementary feeding started after the age of 7 months was more common among the malnourished group, but food frequency was similar. Avidity scores were higher among the malnourished group, though not significantly different. However, scores for food refusal, eating avidity, force-feeding, and maternal stress showed no significant association among both groups although "hold food in the mouth for too long and meals last more than 30 minutes" were more common among the healthy group, while "spits out food" was more common among the malnourished group. The findings from the first study in Pakistan reported that ICFET has successfully identified critical modifiable practices among both healthy and malnourished children. However, training of data collectors, use of anthropometric equipment, and data on developmental milestones reflected the need to improve further. Finally, a Cluster Randomized Control Trial (CRCT) was planned to assess the effect of RUF on childcare practices. For this study, 90 first-time identified moderately acute malnourished (MAM) children, along with their mothers (48 in Ready to Use Supplementary Food (RUSF) and 42 in Multi Micronutrient Sachets (MMS)), were recruited from eight primary healthcare facilities in Lahore, Pakistan. Due to the COVID outbreak, only one follow-up after four weeks could be completed for 43 Children (RUSF 32 &amp; MMS 11). Despite the consumption of one sachet of RUSF, which provided around 500 kcal, no significant improvement in weight, MUAC, WAZ, and HAZ was found. However, a significant improvement in food refusal was seen (median change = -0.43, P=0.001) and in maternal anxiety (median change = -0.28; P= 0.005) was seen at a one-month follow-up. Force-feeding and avidity remained the same from baseline to follow-up. Further analysis from combined datasets of study 1 conducted in Pakistan and CRTC showed no relationship between feed frequency, dietary diversity, and nutritional status. Although non-significant, maternal anxiety scores were higher among the malnourished group (healthy; 0.93 vs wasted 1.14, stunted 1.36). Scores for food refusal were higher among stunted only (2.97) if compared with wasted and healthy 0.08 and 1.17, respectively. As part of the CRCT, a qualitative study to assess the feasibility of delivering targeted nutrition advice through primary healthcare settings was also conducted to provide the basis for using ICFET by primary healthcare practitioners. The qualitative study highlighted significant gaps in delivering nutritional counselling to mothers attending to primary healthcare facilities in Pakistan, which included training, IEC material, and clear guidelines for both treatment and prevention of malnutrition. A strong opinion from participants was reported for a need to have a comprehensive tool to identify the exact cause of malnutrition and subsequent capacity development to deliver targeted nutrition counselling at primary healthcare facilities. It is suggested that additional evidence from local settings will be required to understand primary healthcare workers' capacity, time, and interest to engage in nutrition counselling, specifically targeted counselling, given the complex trends of under/over and the double burden of malnutrition. As the CRCT could not be completed due to the pandemic, an additional analysis of the anthropometric data collected was undertaken. A two-stage screening for acute malnutrition is suggested to minimise the chance of missing truly wasted and inclusion of not wasted children in nutrition programs. Overall, it can be concluded that modifiable risk factors, such as low meal frequency and dietary diversity among infants aged 6 to 24 months, are prevalent in Pakistan. RUSF did not significantly improve anthropometry in moderately malnourished children. While MUAC is a common screening tool in community settings, using it alone for MAM children can misidentify healthy children and miss actual wasted ones. Further research with larger sample size and longer follow-up is needed, along with an online tool for improved data quality.