Infant and young child feeding practices and associations between micronutrient adequacy, environmental enteric dysfunction and growth among 9-24 months old children in Nepal

Background: Stunting in low- and middle-income countries has severe intergenerational consequences for health and human capital. Immediate causes of stunting are inadequate dietary intake due to poor feeding practices and disease. Environmental enteric dysfunction (EED), a subclinical infection of the intestine, influences associations between nutrient intake and linear growth, but the manner and extent of this influence is largely unknown. Objective: This PhD thesis aims to assess tracking of WHO Infant and young child feeding (IYCF) practices, nutrient adequacy and associations between nutrient intake, EED and linear growth. Methods: Data from 231 children 9-24 months in the MAL-ED Nepal cohort was included. IYCF practices and nutrient adequacy was assessed by monthly 24-hour recalls. Anthropometry was measured monthly. Fecal markers for environmental enteric dysfunction (alpha-1-antitrypsin (AAT), myeloperoxidase (MPO) and neopterin (NEO)) were measured in stool samples collected quarterly, while lactulose:mannitol (L:M) ratio was assessed in urine collected at 15 months. Tracking of IYCF practices was assessed by Cohen’s weighted kappa and Generalized estimating equations (GEE) models. Associations between fecal markers and linear growth were assessed by linear regression and GEE models, while associations between nutrient intake and fecal markers and L:M ratio were assessed by GEE models. Results: Consumption of iron- or vitamin A-rich foods was reported in 1/3 of recalls. Tracking was moderate for dietary diversity score (DDS) and meal frequency and low for intake of iron- and vitamin A-rich foods. Micronutrient adequacy was extremely low and main problem nutrients identified were iron, zinc, calcium, vitamin A and niacin. Associations between fecal markers and 3-month length velocity were overall weak with few significant findings, apart from for MPO and EE-score (based on all three fecal markers). Similarly, negative but weak associations were found between nutrient intake and fecal markers for EED and L:M ratio. Significant associations between intake of potassium, magnesium, phosphorous, folate, vitamin C and MPO and between zinc, calcium, potassium, magnesium, phosphorous and %lactulose, were found. Conclusion: The low tracking for key IYCF practices and low nutrient adequacy found implies that urgent interventions to improve complementary feeding practices are needed. The usefulness of fecal markers to assess associations between EED and growth and the effect of improved nutrient intakes on EED require further research