The Child Nutrition and Development Study (CHNUDEV)

Focusing on growth of small children through diet diversification, better dietary intakes and improved hygiene

The main aim of the study is to investigate how a nutrition/stimulation education based on local needs and context can reduce stunting levels and improve development among children in the districts of Kabale and Kisoro, in South-Western Uganda.

We randomly allocated mothers of 6-8 months old children to intervention and control groups. In the intervention group, we provided nutrition education (delivered by nutritionists-Bachelor graduates). It includes the ten guiding principles of complementary feeding of a breastfed infants and cookery demonstrations as well as advice on oral hygiene. We encouraged every mother to establish a backyard garden and to keep small domestic animals which can provide the family with cheap animal sources of food. Hygiene in food preparation and service were an important part of the nutrition education.

We have taken outcome measures, at baseline when the children were aged 6 - 8 months, then when they were 20-24 and when they were 36 months. We could not detect any differences between the two study groups in any of the anthropometric measures of growth except that children in the intervention group had less growth faltering and better oral health at 36 months. Next, we repeated the measurements when the children were about to start school, i.e. at the age of 6-7 years. We could not find any any differences between the two study groups in any of the anthropometric measures of growth or in their body composition status. However, the intervention may have reduced concurrent stunting and being overweight over time (i.e. from child age 6-8 months to 60-72 months). Notably, at this time point the intervention children also had better oral status and less caries than the controls.

Developmental outcomes

In this study we also investigated the effects of the intervention on development outcomes (cognitive, language, motor). We assessed development using of Bayley Scales of Infant and toddler Development 3rd ed. and the Ages and Stages Questionnaire at baseline and when the children were aged 20-24 and 36 months. In addition we used the Mullen Scales of Early Learning scale at 36 months. A consistent finding was that all development outcomes were better among children belonging to the intervention group compared with the controls; at all time points and when assessed with the three research tools. The intervention also led to fewer mothers self-reporting depressive symptoms. At the child age of 7-8 years we found that children from the intervention group consistently scored better on two psychometric tools (Kaufman Assessment Battery for Children Second Edition and the Test of Variables of Attention). 

Current collaborators

• Per Ole Iversen, Professor, Department of Nutrition, University of Oslo, Norway, Principal Investigator
• Grace Muhoozi, Senior Lecturer, Department of Family life and Consumer Studies (Home Economics), Kyambogo University, Kampala, Uganda
• Prudence Atukunda, Associate Professor, Center for Crisis Psychology, University of Bergen, Norway
• Paul Kakwangire, PhD student, Department of Nutrition, University of Oslo, Norway
• Ane Westerberg, Associate Professor, Norwegian School of Health Sciences, Kristiania University College, Oslo, Norway
• Moses Ngari, PhD, The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya

• Ingvild Johnsen Brusevold, Associate Professor, Institute of Clinical Dentistry, University of Oslo, Norway

• Jens-Petter Berg, Professor, Department of Medical Biochemistry, Oslo University Hospital, Norway

• Archileo Kaaya, Professor, Department of Food Technology and Human Nutrition, Makerere University, Kampala, Uganda

Related publications

• Muhoozi, G.K.M., Atukunda, P., Mwadime, R., Iversen, P.O. & Westerberg, A.C. Nutritional and developmental status among 6 to 8 months old children in South-Western Uganda – a cross sectional study. Food Nutr Res 60: 30270, 2016.

• Muhoozi, G.K.M.,  Atukunda, P., Diep, L.M., Mwadime, R., Kaaya, A.N., Skaare, A.B., Willumsen, T., Westerberg, A.C. & Iversen, P.O. Nutrition, hygiene and stimulation education to improve growth, cognitive, language and motor development among infants in Uganda: a cluster-randomized trial. Matern Child Nutr 14:e12527, 2018.

• Muhoozi, G.K.M., Atukunda, P.,  Skaare, A.B., Willumsen, T., Diep, L.M., Westerberg, A.C. & Iversen, P.O. Effects of nutrition and hygiene education on oral health and growth among toddlers in rural Uganda: follow-up of a cluster-randomized controlled trial. Trop Med Int Health 23: 391-303, 2018.

• Atukunda, P., Muhoozi, G.K.M, van den Broek, T.J., Kort, R., Diep, L.M., Kaaya, A.N., Iversen, P.O. & Westerberg, A.C. Child development, growth and microbiota: follow-up of a randomized education trial in Uganda. J Glob Health 9(1):010431, 2019.

• Atukunda P, Muhoozi GKM, Westerberg AC, Iversen PO. Nutrition, hygiene and stimulation education for impoverished mothers in rural Uganda: Effect on maternal depression symptoms and their associations to child development outcomes. Nutrients. 11;11(7), 2019.

• Wacoo, A.P., Atukunda, P., Muhoozi, G., Braster, M., Wagner, M., van den Broek, T., Sybesma, W., Westerberg, A., Iversen, P.O. & Kort, R. Aflatoxins: Occurrence, exposure, and binding to lactobacillus species from the gut microbiota of rural Ugandan children. Microorganisms 8: 347, 2020.

• Iversen, P.O., Atukunda, P., Kort, R., Ueland, P.M., Westerberg, A.C. & Muhoozi, G.K.M. No associations between microbiota signalling substances and cognitive, language and motor development among three-year-old rural Ugandan children. Acta Paediatr 109:2339-2341, 2020.

• Atukunda, P., Muhoozi, G.K., Diep, L.M., Berg, J.P., Westerberg, A.C. & Iversen, P.O. The association of urine markers of iodine intake with development and growth among children in rural Uganda: a secondary analysis of a randomised education trial. Public Health Nutr 24:3730-3739 2020.

• Kakwangire, P., Moss, C., Matovu, N., Atukunda, P., Westerberg, A.C., Iversen, P.O. & Muhoozi, G. The association between dietary diversity and development among children under 24 months in rural Uganda: Analysis of a cluster-randomized maternal education trial. Publ Health Nutr 24:4286-4296, 2021.

• Iversen, P.O., Ngari, M., Westerberg, A.C., Muhoozi, G. & Atukunda, P. Child stunting concurrent with wasting or overweight: A 6-year follow-up of a randomized maternal education trial in Uganda. Nutrition 89:111281, 2021.

• Kort, R., Schlösser, J., Vazquez, A.R., Atukunda, P., Muhoozi, G., Wacoo, A.P., Sybesma, W., Westerberg, A.C., Iversen, P.O. & Schoen, E. Model selection reveals the butyrate-producing gut bacterium Coprococcus eutactus as predictor for language development in three-year-old rural Ugandan children. Front Microbiol 12:681485, 2021.

• Atukunda, P., Ngari, M., Chen, X., Westerberg, A.C., Iversen, P.O. & Muhoozi, G.Longitudinal assessments of child growth: A six-year follow-up of a cluster-randomized maternal education trial. Clin Nutr 40: 5106-5113, 2021.

• Atukunda, P., Eide, W.B., Kardel, K.R., Iversen, P.O. & Westerberg, A.C. Unlocking the potential for achievement of the UN Sustainable Development Goal 2 – “Zero Hunger” - in Africa: Targets, strategies, synergies and challenges. Food Nutr Res 65: 7686, 2021.

• Quamme, S.H. & Iversen, P.O. Prevalence of child stunting in Sub-Saharan Africa and its risk factors. Clin Nutr Open Sci 42: 49-61, 2022.

• Muhoozi, G., Li, K., Atukunda, P., Skaare, A.B., Willumsen, T., Enersen, M., Westerberg, A.C., Morris, A., Vieira, A.R., Iversen, P.O., Methé, B.A. Child saliva microbiota and caries - a randomized controlled maternal education trial in rural Uganda. Sci Rep 12: 7857, 2022.

• Engh, M.S., Muhoozi, G.K.M., Ngari, M., Skaare, A.B., Westerberg, A.C., Iversen, P.O., Brusevold, I.J. & Atukunda, P. Long-term effects of a randomized maternal education trial in rural Uganda: Implications for child oral health. Am J Trop Med Hyg 107: 939-947, 2022.

• Ahmed, M., Muhoozi, G.K.M., Atukunda, P., Westerberg, A.C., Iversen, P.O. & Wangen, K.R. Cognitive development among children in a low-income setting: cost-effectiveness analysis of a maternal nutrition education intervention in rural Uganda. PLoS One 18: e0290379, 2023.

• Kakwangire, P., Muhoozi, G., Ngari, M., Matovu, N., Westerberg, A.C., Iversen, P.O. & Atukunda, P. 8-year follow-up of a maternal education trial in a low-resource setting. Pediatrics (in press).

• Kakwangire, P., Atukunda, P., Ngari, M., Westerberg, A.C., Iversen, P.O. & Muhoozi, G. Long-term effects on depressive symptoms among Ugandan mothers – Findings from a follow-up of a cluster-randomized education trial in a rural low-resource setting. J Affect Dis 351:598-606, 2024.

Related Theses

Master theses

• The association between dietary diversity and early childhood development among children under 24 months in South-Western Uganda: An exploratory secondary analysis of a cluster randomised maternal education trial; by Paul Kakwangire, London School of Hygiene and Tropical Medicine, 2018.
• Nutrition-related education intervention to improve cognitive development among impoverished small children in rural Uganda: A cost-effectiveness analysis; by Montasir Ahmed, University of Oslo, 2020.
• Cultivation of the anaerobic gut bacterium Coprococcus eutactus and its potential  role in the gut-brain axis; by Job Schlösser, University of Amsterdam, 2020.
• Long-term effects of a randomized maternal education trial in rural Uganda: Implications for child oral health (assignment for specialization in dentistry - equivalent to a master thesis); by Marit Stokke Eng, University of Oslo, 2022.
• Maternal depression and nutrition status of children 5-7 years old in selected districts of South-Western Uganda; by Ruth Ninsiima, Kyambogo University, 2023.

PhD theses

• Maternal education to improve growth, development and oral health among small children in rural Uganda; by Grace Muhoozi, University of Oslo, 2018.
• Improved child development outcomes in rural Uganda: long-term follow-up of a randomized maternal education trial; by Prudence Atukunda, University of Oslo, 2020.
• Detection and reduction of aflatoxin in the food chain; by Paul Alex Wacoo, University of Amsterdam, 2020.

Participation at conferences, meetings etc.:

• Global Health Conference, Norwegian Global Health Networks with Impact, Bergen, Norway, 2016 
• Nordic Nutrition Conference, Gothenburg, Sweden, 2016 
• 4th International Conference on Nutrition and Growth, Amsterdam, The Netherlands, 2017 
• First East African Research in Progress Meeting, Moshi, Tanzania, 2017 
• 7th MUHAS Conference, Dar-es-Salaam, Tanzania, 2019
• 16th Congress of the European Academy of Paediatric Dentistry, Lisbon, Portugal, 2022
• 10th International Conference on Nutrition and Growth, London, UK, 2023 
• 2nd Conference on the Right to Adequate Food in Uganda, Kampala, Uganda, 2023
• 9th East African Health & Scientific Conference, Kigali, Rwanda, 2023

Awards

• Best annual poster-prize, Department of Nutrition, University of Oslo,Norway, 2019
• Best poster-prize, 9th East African Health & Scientific Conference, Kigali, Rwanda, 2023

Funding

• The University of Oslo

• The Throne Holst Foundation

• RELIGHT (Center for Global Health, University of Oslo)