Full title:

The effect of microbial exposure and environmental enteric dysfunction on child growth – evaluation of a combined nutrition and food hygiene intervention in Bangladesh

An estimated 151 million children under 5 years worldwide suffer from chronic undernutrition. Key causes of undernutrition in children are an insufficient intake of nutritious food as well as poor sanitation and hygiene practices, leading to repeated enteric infection and illness.
Complementary food in low-income settings often has a high burden of microbes, due to unhygienic preparation, storage, or feeding practices. Feeding of contaminated foods puts the child at risk of ingesting pathogenic bacteria and to develop repeated intestinal infection and diarrheal disease, or a subclinical inflammatory condition termed environmental enteric dysfunction (EED).

Consistent adoption of handwashing and food hygiene practices can considerably reduce microbial food contamination and thereby incidence of intestinal infection. However, changing practice of these behaviours remains challenging and new strategies are needed to facilitate food hygiene behaviour in household and community settings.

The FHEED study tests the hypothesis that a combined food hygiene and nutrition intervention can reduce undernutrition in children through decreasing intestinal infections and development of EED and by improving intestinal microbiota composition and development.

The study is embedded in the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized trial, including 2700 women and their children under 3 years in 96 settlements in Habigonj District, Sylhet Division, Bangladesh from 2015 to 2020. From July 2017 to February 2018, a behaviour change intervention was added to the trial to strengthen the food hygiene component in FAARM. The food hygiene intervention used a behavior-centered design by employing emotional drivers (such as pride, disgust and nurture) as well as engaging group activities (including games and competitions) and repeated individual household visits to improve common food hygiene practices among study participants.

The FHEED study was added to the FAARM trial to evaluate the impact of the food hygiene intervention on maternal food hygiene practice, the contamination of complementary foods and the development of EED and diarrheal disease in children. The main outcomes of interest are biomarkers for EED status, enteropathogen burden, microbiota composition, diarrhea prevalence, complementary food contamination, and maternal food hygiene behaviour.