Effectiveness of Nutritional Support on Anthropometric Outcomes in Malnourished Children Under 5 Years

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In Iran, the participatory-supportive child nutrition improvement program has been scaled nationally since 2005. This study evaluated the effectiveness of this program in improving key nutritional indicators among malnourished children. Methods We conducted a community-based quasi-experimental trial with individual randomization and frequency-matched controls in urban city area of Mashhad, Iran. Malnourished children aged 6–60 months (n = 264) were enrolled from September 2024, with 264 completing 9-month follow-up (intervention = 131, control = 98). The intervention provided monthly food credits (6–11 million rials), customized baskets meeting caloric and macronutrient needs across four age strata, nutritional counseling, and bimonthly growth monitoring. Controls received routine care. Outcomes included changes in weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) z-scores. Results At baseline, controls were older and had significantly higher weight, height, and z-scores (all P < 0.001) and economic decile (p < 0.05) compared to the intervention group due to matching constraints. Over 9 months, the intervention group exhibited significant within-group gains in height (P < 0.001), HAZ (P = 0.02), and WHZ (P < 0.001). Improvements in stunting (42.1% vs. 31.1%) and wasting (26.5% versus 22.1%) were higher, and worsening of underweight was lower (11.3% versus 18.5%) in the intervention compared to the control group. However, the differences between groups were not statistically significant after adjusting for confounders. Conclusion This intervention program accelerated linear growth and acute nutritional improvement trajectories in an urban group with high financial burden. Children Anthropometric Indices Malnutrition Nutritional Support Program Effectiveness Iran Figures Figure 1 Figure 2 Figure 3 1. Introduction Malnutrition represents a major global health challenge, particularly in children, and is defined as an imbalance between nutrient intake and requirements for optimal growth, health, and function [ 1 ]. Malnutrition encompasses undernutrition (underweight, stunting, and wasting) and overnutrition [ 2 ]. This nutrient imbalance has profound consequences on physical health, cognitive development, and economic productivity, especially during the fetal life cycle and early years of life [ 3 ]. Chronic malnutrition in early life can lead to reduced brain capacity, impaired neurodevelopment, and increased risk of mental and cognitive disorders such as anxiety and depression in later life stages as well as obesity, metabolic syndrome, hypertension, type 2 diabetes, and cardiovascular diseases [ 4 – 6 ]. Globally, stunting has declined from 204.2 million in 2000 to 150.2 million (22.3%) in 2024; however, progress towards the Sustainable Development Goal )SDG 2.2( remains off-track, with approximately 125 million children projected to be stunted by 2030 without accelerated efforts. Also, in 2024, 42.8 million children (6.6%) were wasted, and 62.4 million children (9.6%) were underweight [ 7 , 8 ]. In Iran, A comprehensive study between 1998 and 2017 showed that the prevalence of underweight decreased from 10.9% to 4.3%, stunting from 15.4% to 4.8%, and wasting from 4.9% to 4.3% [ 9 ]. However, malnutrition's unequal distribution persists across regions within the country. The most important causes of malnutrition include infectious diseases, digestive diseases, low birth weight, limited access to adequate and nutritious food, poverty, household economic status, education, especially maternal education, social inequalities, regional conflicts, climate change, weak agricultural infrastructure and food distribution, and hygiene infrastructure [ 10 , 11 ].The relationship between social and economic factors and malnutrition is bidirectional, especially in childhood. While these factors can lead to malnutrition, the resultant malnutrition in children can reduce economic productivity and poverty in adulthood [ 12 ]. Figure 1 . illustrates the conceptual framework of the multilevel determinants of child malnutrition, including direct nutrition interventions, indirect health interventions, and other sectoral strategies directly or indirectly affecting nutrition (adapted from UNICEF framework). This figure underscores the multifaceted causes addressed by multisectoral programs such as Iran's participatory-supportive initiative. The economic burden of undernutrition is substantial, with a 2024 analysis estimating global annual costs of at least US $ 761 billion, equivalent to 0.7% of global gross national income. Furthermore, childhood stunting imposes significant private-sector losses in low- and middle-income countries, totaling at least US $ 135.4 billion in annual sales. Thus, malnutrition sustains a vicious cycle of poverty, disability, and deprivation [ 2 , 3 , 13 , 14 ]. Addressing this cycle requires targeted nutritional interventions and multisectoral policies aligned with global frameworks. The conceptual framework by the United Nations Children's Fund (UNICEF) delineates malnutrition's causes across three levels: immediate (inadequate dietary intake and infectious diseases), underlying (poverty, food insecurity, gender inequality, and limited access to health, education, and safe water), and basic (socioeconomic inequalities and inadequate infrastructure) [ 15 , 16 ]. Consistent with this model and contributing to international efforts to achieve SDG 2, Iran's participatory-supportive child nutrition improvement program began in the second half of 2005 in 86 cities and at least one city in each of the 30 provinces of Iran and gradually expanded throughout the country. This program was designed in collaboration with the Ministry of Health, the Imam Khomeini Relief Foundation, and the Program and Budget Organization and is recognized as a successful model of intersectoral cooperation. The program has three main axes. The first axis includes the distribution of food baskets containing essential items (rice, legumes, fortified oils, dairy products, and protein sources like meat or eggs) to low-income households to meet the nutritional needs of children. The second axis includes nutritional education and counseling (training sessions for mothers and caregivers to increase awareness regarding exclusive breastfeeding in the first 6 months, the introduction of nutritious complementary foods from 6 months of age, and the preparation of balanced meals with local resources) provided by community health workers and nutrition experts at comprehensive health centers. The third axis includes financial support (cash assistance or food vouchers) provided to needy families to improve their access to food items [ 17 – 20 ]. Despite successful implementation of this program in combating malnutrition in Iran, a comprehensive evaluation of its effectiveness has not been fully conducted. Program evaluation not only helps identify the strengths and weaknesses of interventions but also allows policymakers to allocate resources effectively and ensure the sustainability of programs [ 21 , 22 ]. This study aimed to investigate the effectiveness of the participatory-supportive child nutrition improvement program on improving the nutritional status of malnourished children under 5 years of age in Mashhad, Iran. 2. Materials and Methods 2 − 1. Study Design This study was a community-based quasi-experimental intervention trial with a control group. This study aimed to investigate the effectiveness of a nutritional support program on improving the nutritional status of malnourished children aged 6 to 60 months in Mashhad, Khorasan Razavi. The study was conducted across five health districts under Mashhad University of Medical Sciences, from September 2024 to June 2025 (9-month follow-up). 2–2. Study population Children were selected through data registered in the Department of Health and Provincial Health Center of the Mashhad University of Medical Sciences. Inclusion criteria were: (1) documented malnutrition; (2) receipt of nutritional support for ≥ 6 months (intervention group) or eligibility without enrollment (control group); (3) parental/caregiver informed consent; and (4) no evidence of underlying diseases. Exclusion criteria were: (1) parental/caregiver withdrawal; (2) post-enrollment diagnosis of severe diseases; (3) migration or loss to follow-up; and (4) non-adherence to protocol (e.g., non-use of food support or missed monitoring). 2–3. Sample size and Sampling Sample size was determined considering the mean weight-for-age Z-score difference of 0.03 (SD 0.62 and 0.68) based on findings of the study by Ghodsi et al., with α = 0.05, power = 80%, and intraclass correlation = 0.5, yielding 110 children per group. Accounting for 20% attrition, 132 per group were targeted (total n = 264). Sampling was done randomly. First, an Excel file of eligible children regardless of being a candidate for receiving the nutritional support program was obtained from the Department of Health and Provincial Health Center of Mashhad University of Medical Sciences. The five headquarters of the Health Deputy of Mashhad were divided into percentages based on the ratio of the population of children in each region to the total population of children in the city. Then, considering the required sample size (132 children per group) in each region was calculated. To reduce bias, the groups were matched based on age, gender, malnutrition status, and income decile using the frequency-based matching method. 2–4. Intervention The program, a multisectoral collaboration involving the Ministry of Health and Medical Education, Imam Khomeini Relief Foundation, and Program and Budget Organization, targeted low-income households (deciles 1–7) with malnourished children identified per WHO growth standards (e.g., inadequate weight gain, growth curve flattening, or Z-score <-3 SD). Main components included: Monthly food vouchers (6–11 million rials, depending on severity) credited via the SHOMA [ 23 ] application for purchasing dry goods (rice, legumes, oil) from designated stores, non-cashable to ensure food use. Age-specific food baskets (6–12, 12–24, 24–36, 36–60 months) tailored to caloric needs, serving sizes, and local preferences (Tables 1 ). Regular growth monitoring every 30–40 days at health centers per MANA protocols, with phase progression or graduation upon recovery. Table 1 Supplementary food basket for malnourished children Weight Food a Rice Pasta Legumes/Nuts Potato Vegetables Fruits Red meat White meat Egg Dairy products Total Energy # Boys/ Girls 6–12 months 600 450 600 600 900 900 600 600 600 3600 423 12–24 months 1200 1200 600 900 3000 3000 600 600 1200 12000 875 2–3 years 1500 1200 600 900 4500 4500 600 600 1200 12000 950 3-5 years 1650 1200 600 1200 4500 6000 600 1200 1350 12000 1081 a Weight (gr/person/month) # Total Energy (calorie/person/day) The control group received standard care: routine growth monitoring, examinations, and general nutrition counseling at equivalent intervals. Measurements occurred at baseline (September 2024) and follow-ups (December 2024, March 2025, June 2025). Children's enrollment flowchart is shown in Fig. 2 . 2–5. Data Collection and Variables Anthropometric outcomes (primary) were weight (Seca digital scale, ± 0.1 kg), height (Seca stadiometer, ± 0.1 cm), and Z-scores (weight-for-age [WAZ], height-for-age [HAZ], weight-for-height [WHZ]) calculated using WHO Anthro software. Other data was obtained via parental/caregiver questionnaire, which included age, gender, gestational age (preterm < 37 weeks; term 37–42 weeks), birth weight (4000 g), breastfeeding duration (≤ 6 months; 6–24 months; >24 months), formula duration (same categories), multivitamin use (yes/no), complementary food initiation (< 6 months; ≥6 months), and parental occupation. Household economic decile was sourced from Ministry of Health records. 2–6. Ethics Approval The study protocol was approved by the Ethics Committee of the Faculty of Medicine, Mashhad University of Medical Sciences and Health Services, Mashhad, Iran (ethics code: IR.MUMS.MEDICAL.REC.1403.223; research project code: 4022710). 2–7. Statistical analysis To assess the changes in the anthropometric status of children after 9 months, their nutritional status was divided into three categories; “worse”, when the child's nutritional status changed from normal to mild, moderate, or severe malnutrition; “better”, when the child's nutritional status improved from severe or moderate to mild malnutrition or normal; and “unchanged”, when no change in the child's nutritional status classification was observed during the study. Data normality was assessed using Shapiro-Wilk test. Baseline comparisons employed t-tests and χ² tests. Within-group changes over time were analyzed using repeated-measures ANOVA. Between-group differences in Z-score changes were compared via independent t-tests or mixed-effects models as appropriate. Longitudinal changes in anthropometric Z-scores were primarily evaluated using linear mixed-effects models, which included fixed effects for intervention group, time, and their interaction, while adjusting for gender, age, household economic decile, birthweight, breastfeeding duration, gestational age, age at introduction of complementary feeding, and multivitamin supplementation, with random intercepts for clustering variables to account for repeated measures and potential clustering effects. Analyses used Stata v17 and SPSS v26. 3. Result Table 2 shows the demographic and background characteristics of 229 malnourished children under 5 years of age (131 in the intervention and 98 in the control groups). There was no significant difference between the two groups in the distribution pattern of gender (P = 0.389), birth weight (P = 0.473), gestational age at birth (P = 0.418), duration of breastfeeding (P = 0.335), duration of formula feeding (P = 0.504), time to start complementary foods (P = 0.136), and multivitamin use (P = 0.247) categories. However, significant differences were observed in age (P < 0.001), paternal occupation (P = 0.043), maternal occupation (P = 0.022), and economic status percentile (P < 0.001) between the two groups. Table 2 Comparison of the demographic and background characteristics between the intervention and control groups at baseline Variable a Intervention group (n = 131) Control group (n = 98) Total P-Value* Sex Girl 65(60.18) 43(39.81) 108 0.389 Boy 66(54.54) 55(45.45) 121 Age (months) 6–12 months 0 10(100) 10 *0.001> 12–24 months 19(37.25) 32(62.74) 51 24–36 months 46(63.01) 27(36.98) 73 36–60 months 66(69.47) 29(30.52) 95 Birth weight (grams) Less than 1500 (very low) 4(44.44) 5(55.55) 9 0.473 1500–2500 (low) 19(50) 19(50) 38 2500–4000 (normal) 88(57.14) 66(42.85) 154 More than 4000 (macrosomia) 1(25) 3(75) 4 Gestational age at birth (weeks) Less than 37 (premature) 16(50) 16(50) 32 0.418 37–42 W 77(42.3) 105(57.69) 182 Duration of breast feeding (months) Less than 6 months 8(44.44) 10(55.55) 18 0.335 Between 6–24 months 57(55.88) 45(44.11) 102 More than 24 months 53(62.35) 32(37.64) 85 Duration of formula feeding (months) Less than 6 months 0 1(100) 1 0.504 Between 6–24 months 27(57.44) 20(42.55) 47 More than 24 months 2(50) 2(50) 4 Start of complementary foods (months) Under 6 months 119 (55.86) 94 (44.13) 213 0.136 Above 6 months 12 (75) 4 (25) 16 Consumption of multivitamins Yes 45(52.32) 41(47.67) 86 0.247 No 86(60.13) 57(39.86) 143 Paternal occupation Laborer 38(59.37) 26(40.62) 64 0.043* Driver 17(73.91) 6(26.08) 23 Employee 36(44.44) 45(55.55) 81 Unemployed 9(69.23) 4(30.76) 13 Other 29(64.44) 16 (35.55) 45 Maternal Occupation Housewife 120(57.97) 87(42.02) 207 0.372 Other 9(47.36) 10(52.63) 19 Economic decile 1–5 41(25.47) 120(74.53 161 < 0.001* 6–10 57(83.82) 11(16.18) 68 chi-square test was used for the comparison. * Significant difference at α < 0.05 a Value is presented a sn(%). Table 3 shows the mean and standard deviation of demographic and nutritional indicators of the participants at different stages of the study (baseline, third month, sixth month, and ninth month). At baseline, here was a significant difference in age (P < 0.001), weight (P < 0.001), and height (P < 0.001) at baseline, as well as WAZ (P < 0.001), HAZ (P < 0.001), and WHZ (P < 0.001). At 3rd month, there was a significant difference in height (P = 0.02), HAZ (P < 0.001) and WHZ (P < 0.001) between groups. At 6th month there was a significant difference in height (P = 0.03) and WHZ (P = 0.01) between the two groups. At 9th month, there was a significant difference in height (P = 0.03), HAZ (P < 0.001), and WHZ (P = 0.01) between groups. Table 3 Comparison of mean demographic and nutritional indicators between the intervention and control groups during the study Variable Intervention group (Mean ± standard deviation) Control group (Mean ± standard deviation) Mean difference P t Start of study Weight (kg) 11.56 ± 1.86 10.51 ± 1.64 -1.04 < 0.001* -3.62 Height (cm) 91.88 ± 8.12 85.02 ± 7.99 -6.86 < 0.001* -5.26 Z-Score W/A -1.59 ± 0.82 -1.17 ± 1.16 0.41 < 0.001* 2.72 Z-Score H/A -0.8 ± 1.23 -0.59 ± 1.97 0.21 0.39 0.85 Z-Score W/H 1.7 ± 0.97 -1.15 ± 1.02 0.54 < 0.001* 3.41 Third month Weight (kg) 12.38 ± 1.86 12.26 ± 2.04 -0.12 0.71 -0.36 Height (cm) 94.99 ± 7.61 91.73 ± 8.73 -3.26 0.02* -2.33 Z-Score W/A -1.45 ± 0.73 -0.92 ± 0.99 0.53 < 0.001* 3.75 Z-Score H/A -0.76 ± 1.12 -0.94 ± 3.86 -0.17 0.66 -0.43 Z-Score W/H 1.51 ± 0.93 -0.99 ± 0.98 0.52 < 0.001* 3.11 Sixth month Weight (kg) 12.43 ± 1.85 12.19 ± 1.68 -0.23 0.48 -0.69 Height (cm) 94.4 ± 7.61 91.33 ± 7.35 -3.06 0.03* -2.11 Z-Score W/A -1.38 ± 0.76 -1.15 ± 1.13 0.22 0.19 1.3 Z-Score H/A -0.81 ± 1.17 -0.99 ± 1.44 -0.17 0.46 -0.73 Z-Score W/H -1.34 ± 0.9 -0.9 ± 1.02 0.43 0.01* 2.38 Ninth month Weight (kg) 12.83 ± 1.92 12.67 ± 1.88 -0.15 0.58 -0.55 Height (cm) 97.15 ± 7.72 94.64 ± 8.02 -2.5 0.03* -2.12 Z-Score W/A -1.45 ± 0.83 -1.08 ± 1.06 0.37 < 0.001* 2.66 Z-Score H/A -0.68 ± 1.18 -0.48 ± 1.34 0.2 0.28 1.07 Z-Score W/H -1.58 ± 1 -1.19 ± 1.07 0.39 0.01* 2.5 Independent t-test was used for the comparison. WAZ=weight-for‐age Zscore;HAZ=height‐for‐age Zscore;WHZ=weight‐to‐height Zscore. * Significant difference at α < 0.05 Table 4 shows the trends in nutritional indicators among the study participants over time. There was a significant trend for changes in height (P < 0.001), HAZ (P = 0.02), and WHZ (p < 0.001). Table 4 Trend comparison between the intervention and control groups in nutritional indicators of the study participants over time Variable F P-Value* Weight 1.54 0.21 Height 10.41 < 0.001* Z-Score W/A 5.01 0.02* Z-Score H/A 0.14 0.7 Z-Score W/H 8.75 < 0.001* Repeated measures analysis of variance (ANOVA) was used for the comparison. * Significant difference at α < 0.05 Changes in nutritional status were evaluated for underweight, stunting, and wasting among intervention and control groups. For underweight status (intervention n = 115, control n = 65), 66.95% in the intervention group showed no change compared to 61.53% in the control, with 21.73% improving versus 20%, and 11.3% worsening versus 18.46%. In stunting (intervention n = 57, control n = 45), improvements were noted in 42.1% of the intervention group against 31.11% in the control, while no change occurred in 47.36% and 53.33%, respectively. For wasting (intervention n = 113, control n = 68), 26.54% improved in the intervention group compared to 22.05% in the control (Table 5 ). Table 5 Changes in Nutritional Status Between Baseline and Endline by Study Group Variable a Category Intervention Group (n) Control Group (n) P-Value Underweight status n = 115 n = 65 No change 77(66.95) 40(61.53) 0.411 Worse 13(11.3) 12(18.46) Better 25(21.73) 13(20) Stunting status n = 57 n = 45 No change 27(47.36) 24(53.33) 0.474 Worse 6(10.52) 7(15.55) Better 24(42.1) 14(31.11) Wasting status n = 113 n = 68 No change 59(52.21) 35(51.47) 0.654 Worse 24(21.23) 18(26.47) Better 30(26.54) 15(22.05) WAZ=weight-for‐ageZscore;HAZ=height‐for‐ageZscore;WHZ=weight‐to‐heightZscore. Value is presented a sn(%). Table 6 shows the mixed-effects linear regression analyses, adjusted for potential confounders including child gender, age, household economic decile, birthweight, breastfeeding duration, gestational age, age at introduction of complementary feeding, and multivitamin supplementation revealed that the intervention had a statistically significant positive effect on weight-for-age Z-scores (p < 0.001) and weight-for-height Z-scores (p < 0.001), indicating improved weight status and reduced wasting among intervention children compared to controls, with mean differences ranging from 0.270 to 0.284 units in baseline estimates. However, no significant effect was observed on height-for-age Z-scores (p = 0.5), consistent with the slower response of linear growth to short-term interventions. Although the intervention × time interaction term was nonsignificant across all three anthropometric outcomes (p > 0.80), indicating no overall differential trajectory between groups over the follow-up period, post-hoc pairwise comparisons of estimated marginal means revealed month-specific significant benefits favoring the intervention group. For weight-for-age Z-score, significant advantages were observed in month 9 (mean difference = 0.442, p = 0.008) and month 13 (mean difference = 0.602, p = 0.046), with near-significant trends in month 8 (p = 0.073) and month 14 (p = 0.065). For height-for-age Z-score, no significant differences emerged in any month (all p ≥ 0.199), consistent with the absence of an overall intervention effect on linear growth. In contrast, weight-for-height Z-score demonstrated the most pronounced month-specific effects, with statistically significant higher values in the intervention group in month 6 (mean difference = 0.411, p = 0.016), month 7 (mean difference = 0.837, p = 0.012), month 8 (mean difference = 0.734, p = 0.019), and month 9 (mean difference = 0.366, p = 0.042), alongside borderline trends in month 12 (p = 0.083). Table 6 Time-by-intervention results for anthropometric Z-scores Variables Intervention Time Intervention* Time Z-Score W/A < 0.001* 0.6 0.93 Z-Score H/A 0.5 0.96 0.91 Z-Score W/H < 0.001* 0.27 0.83 Table shows p-values from Type III tests of fixed effects in mixed-effects linear models, adjusted for child gender, age, household economic decile, birthweight, breastfeeding, and gestational age category. * Significant difference at α < 0.05. W/A: weight-for-age Z-score; H/A: height-for-age Z-score; W/H: weight-for-height Z-score. The figures (Fig. 3.1 , Fig. 3.2 , and Fig. 3.3 ) of changes in nutritional indicators show that the intervention and control groups had fluctuations in the indicators at different stages, and in the intervention group, WHZ and WAZ (Fig. 3.1 , Fig. 3.3 ) showed relative improvement in the middle stages and the HAZ index in the final stages, while the control group showed fluctuations (Fig. 3.2 ). 4. Discussion This study evaluated the impact of a shopping credit-based nutritional intervention on anthropometric outcomes among 229 malnourished children under 5 years of age in Mashhad, Iran, compared to a control group over a 9-month period. The intervention, targeted at low-income households, demonstrated statistically significant positive effects on weight-for-age Z-scores ( p < 0.001) and weight-for-height Z-scores (p < 0.001) in mixed-effects models. These improvements indicate enhanced weight status and reduced wasting among intervention children compared to controls. However, no significant effect was observed on height-for-age Z-scores (p = 0.5), aligning with the known slower response of linear growth to short-term nutritional support Categorically, the intervention group showed modestly higher rates of improvement in underweight (21.73% vs. 20%), stunting (42.1% vs. 31.11%), and wasting (26.54% vs. 22.05%) statuses compared to controls, underscoring targeted gains in acute malnutrition indicators. In our study, the longitudinal trends revealed differential patterns in nutritional indices, with HAZ exhibiting a steady increase over time (p = 0.02), while WAZ and WHZ showed initial improvements in the first three follow-ups followed by a plateau or slight decline by the ninth month. Overall temporal changes were significant for height (p < 0.001), HAZ (p = 0.02), and WHZ (p < 0.001), but not weight or WAZ, potentially attributable to seasonal factors such as winter infectious illnesses (e.g., colds and flu) that transiently affected weight gain without impacting linear growth. Additional barriers, including irregular credit deposits, challenges with the SHOMA application for registration, limited access to diverse food items (e.g., fruits, vegetables, and micronutrients), and household-level sharing of provisions, may have diluted sustained effects on chronic indices like HAZ, which reflect long-term malnutrition [ 8 , 24 ]. Socioeconomic status further moderated outcomes, as baseline differences in economic deciles (p < 0.001) and parental occupations (p = 0.022–0.043) highlight how entrenched poverty exacerbates nutritional inequities; global evidence links low SES to 2.2–3.8-fold higher stunting odds in low- and middle-income countries (LMICs), with population-level SES improvements driving height gains of 7–10 cm over decades in countries like Japan and South Korea [ 25 – 27 ]. These secular trends demonstrate that sustained economic development, when coupled with equitable food systems and public health interventions, can reverse chronic malnutrition and enhance linear growth across generations [ 28 – 30 ]. Compared to other interventions, our shopping credit program aligns with but extends beyond traditional food basket distributions or supplementary feeding in Iran and the Middle East, achieving notable WHZ and WAZ gains despite a short duration. For instance, Ghodsi et al.'s 2021 quasi-experimental evaluation of Iran's National Food Distribution Program reported no significant inter-group differences in Z-scores after 6 months, attributing limited efficacy to economic constraints, food sharing, and nutrient inadequacies [ 20 ]; Similarly, our study faced analogous challenges, yet the credit mechanism yielded superior month-specific WHZ improvements, likely due to enhanced household agency in food selection. Derakhshandeh et al. evaluated nutritional support packages of 600 kcal/day among 3,667 malnourished children under 5 years of age for 9 months in Fars province, Iran. The study showed non-significant reductions in the prevalence of moderate (3.7%) and severe (2.5%) underweight, moderate (0.5%) and severe (1%) stunting, and moderate (5.9%) and severe (2.5%) wasting (P > 0.05), indicating a higher relative improvement in WHZ in girls and a higher risk of malnutrition in boys. The reported limitations of the study were the short duration of the study (9 months), irregular distribution, and sharing of food within the family [ 31 ]. A 2024 community-based trial by Shenavar et al. combining complementary feeding with education achieved significant Z-score gains after 10 months suggested that integrating credit donation with nutrition counseling could amplify effects [ 19 ]. Similarly, a recent Eastern Mediterranean Region (EMR) meta-analysis confirming community interventions' stronger impact on WHZ when linked to health services like growth monitoring [ 24 ]. Globally, analogous cash or voucher transfer programs have shown consistent benefits in LMICs, increasing household expenditure on nutrient-rich foods by 10–20% and dietary diversity scores by approximately 0.7 points while reducing childhood wasting by 1.2 percentage points [ 32 , 33 ]. These impacts are partly mediated by improved micronutrient intake, which strengthens immune response and reduces infection-related catabolic stress [ 34 ]. From a mechanistic perspective, shopping credits exert direct effects primarily through bridging food affordability gaps in resource‑limited households, thereby enabling access to energy‑dense and protein‑rich diets. This facilitates short‑term anabolic responses, including enhanced protein synthesis, insulin‑like growth factor‑1 (IGF‑1) signaling, and improved muscle and fat accretion—all contributing to rapid gains in WAZ and WHZ [ 35 ]. Recent studies corroborate these findings, showing that cash‑based nutritional interventions can upregulate anabolic hormone activity and reduce pro‑inflammatory cytokine levels within months of implementation [ 36 , 37 ]. The indirect effects operate through psychosocial and environmental pathways. Reduced financial stress may attenuate chronic cortisol elevation that otherwise promotes protein catabolism, while increased income fosters improved caregiving behaviors, feeding frequency, and hygiene practices. [ 38 , 39 ]. Moreover, households experiencing decreased economic strain can reallocate funds toward healthcare, preventive measures, and sanitation—further lowering infection risk and supporting micronutrient intake [ 35 , 40 , 41 ]. However, Chronic deprivation perpetuates recurrent infections and systemic inflammation, disrupting growth plate cartilage activity and impairing endocrine regulation over prolonged periods. These mechanisms collectively emphasize that while acute malnutrition responds to targeted nutritional input, eradicating stunting necessitates multisectoral strategies addressing poverty, infection, and environmental health determinants [ 1 , 40 , 42 , 43 ]. 5. Strengths and Limitations The strengths of this study include conducting a large community-based quasi-experimental evaluation of the Iranian National Electronic Nutrition Voucher Program (SHOMA) in a real-world setting. The study employed proportional sampling across all five geographical regions of Mashhad, individual-level random assignment within each region, and frequency matching on key variables (age, sex, degree of malnutrition, and household income decile) to enhance comparability between intervention and control groups. Additionally, the study incorporated a 9-month follow-up period with four repeated measurements, which provided robust longitudinal data. Nevertheless, several limitations should be acknowledged. First, the quasi-experimental design—where final enrollment in the support program was ultimately determined by the Ministry of Cooperatives, Labour and Social Welfare—prevented full randomization. Second, the absence of any nutritional support in the control group led to reduced adherence and a substantially higher attrition rate in this arm (25.8%), raising the possibility of attrition bias. Third, the lack of structured nutrition education for caregivers and the relatively short intervention duration of 9 months may have constrained the program’s impact on chronic nutritional indicators, particularly linear growth )HAZ), and limited our ability to evaluate long-term sustainability. Fourth, the study did not collect detailed data on certain key socioeconomic and caregiving variables, including precise household income levels (beyond decile categorization), parental or caregiver education attainment, maternal nutritional status during pregnancy, household food security scores and frequency or severity of child illnesses; the inclusion of these variables could have allowed for more comprehensive adjustment for residual confounding and deeper exploration of mediators influencing nutritional outcomes. Future studies should consider extending the follow-up duration and integrating systematic, theory-based nutrition education for children’s families and caregivers through primary health centers. Such enhancements are likely to maximize intervention effectiveness, improve participant adherence, and yield more definitive evidence regarding long-term outcomes. 6. Conclusion The findings of our study suggested that the national intervention to improve access to the required food items for malnourished children under 5 year of age could prevent malnutrition from worsening and produced modest improvements in malnourished indices of these children. However, implementation barriers, including economic hardship, irregular delivery, and household food sharing often limited the effectiveness of the program. Therefore, complete elimination of malnutrition requires the concordance of other comprehensive strategies besides improving the current program in terms of malnourished children identification and facilitating credit allocation through removing administrative barriers. Declarations Ethics approval and consent to participate: This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. The research protocol was reviewed and approved by the Regional Ethics Committee in Medical Science Research at Mashhad University of Medical Sciences (approval ID: IR.MUMS.MEDICAL.REC.1403.223). All participants were children under 5 years of age. Written informed consent was obtained from parents or legal guardians of all child participants prior to enrollment. Conflict of interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Financial Support This research received funding from Mashhad University of Medical Sciences (grant number: 4022710). No additional external funding was received. Consent for publication: Not applicable. Author Contribution Study concept and design: SRS, MNDrafting of the manuscript: RR, AJEStudy implementation: RR, FE, OEData validation: RR, OEStatistical analysis and interpretation of data: RR, MV, AJEAll authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work. MN and SRS also accept the correspondence of the manuscript on behalf of all the authors. Acknowledgement We thank the staff of the Department of Health and Provincial Health Center of Mashhad University of Medical Sciences for their assistance in data provision and participant recruitment. We also acknowledge the contributions of the collaborating organizations: Ministry of Health and Medical Education, Imam Khomeini Relief Foundation, and Program and Budget Organization. Data Availability The datasets generated and analyzed during the current study are available from the Department of Health and Provincial Health Center of Mashhad University of Medical Sciences upon official written request. The authors do not have the authority or access to share any data without prior permission from the relevant organization. References UNICEF. The state of food security and nutrition in the world 2024: Financing to end hunger, food insecurity and malnutrition in all its forms. 2024. Keats EC, Das JK, Salam RA, Lassi ZS, Imdad A, Black RE, Bhutta ZA. Effective interventions to address maternal and child malnutrition: an update of the evidence. Lancet Child Adolesc Health. 2021;5(5):367–84. Victora CG, Hartwig FP, Vidaletti LP, Martorell R, Osmond C, Richter LM, Stein AD, Barros AJ, Adair LS, Barros FC. Effects of early-life poverty on health and human capital in children and adolescents: analyses of national surveys and birth cohort studies in LMICs. Lancet. 2022;399(10336):1741–52. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. lancet. 2007;369(9555):60–70. Kirolos A, Harawa PP, Chimowa T, Divala O, Freyne B, Jones AG, Lelijveld N, Lissauer S, Maleta K, Gladstone MJ. Long-term outcomes after severe childhood malnutrition in adolescents in Malawi (LOSCM): a prospective observational cohort study. Lancet Child Adolesc Health. 2024;8(4):280–9. Saklayen MG. The global epidemic of the metabolic syndrome. Curr Hypertens Rep. 2018;20(2):1–8. Organization WH. World health statistics 2025: monitoring health for the SDGs. Sustainable Development Goals: World Health Organization; 2025. Organization WH, Fund, UNCs. The UNICEF-WHO-World Bank Joint Child Malnutrition Estimates (JME) standard methodology: tracking progress on SDG Indicators 2.2. 1 on stunting, 2.2. 2 (1) on overweight and 2.2. 2 (2) on wasting: World Health Organization; 2024. Ghodsi D, Rasekhi H, Yari Z, Roustaee R, Nikooyeh B, Faramarzi A, Eini-Zinab H, Neyestani TR. Prediction and analysis of trends in the nutritional status of children under 5 years in Iran: reanalysis of the results of national surveys conducted between 1998 and 2020. Front Nutr. 2023;10:1083318. UNICEF. The state of food security and nutrition in the world 2023. 2023. Akparibo R, Aryeetey RNO, Asamane EA, Osei-Kwasi HA, Ioannou E, Infield Solar G, Cormie V, Pereko KK, Amagloh FK, Caton SJ. Food security in Ghanaian urban cities: A scoping review of the literature. Nutrients. 2021;13(10):3615. Kirolos A. Medium-and long-term outcomes after exposure to severe childhood malnutrition. The University of Liverpool (United Kingdom); 2023. Jain S, Ahsan S, Robb Z, Crowley B, Walters D. The cost of inaction: a global tool to inform nutrition policy and investment decisions on global nutrition targets. Health Policy Plann. 2024;39(8):819–30. Akseer N, Tasic H, Onah MN, Wigle J, Rajakumar R, Sanchez-Hernandez D, Akuoku J, Black RE, Horta BL, Nwuneli N. Economic costs of childhood stunting to the private sector in low-and middle-income countries. EClinicalMedicine 2022, 45. Black MM, Lutter CK, Trude AC. All children surviving and thriving: re-envisioning UNICEF's conceptual framework of malnutrition. Lancet Global Health. 2020;8(6):e766–7. Schmall A: Applying a Global Nutrition Conceptual Framework to Analyze Potential Determinants of Influence on Child Nutrition Among Children Participating in Nutrition Assistance Programs: Insights From Burkina Faso, Sierra Leone, and the United States. Tufts University, Gerald J. and Dorothy R. Friedman School of Nutrition …. MALEK AH, SHEYKH AR, KIMIAGAR SM, Siasi F, Abdollahi Z, Jazayeri A, Keyghobadi K, Ghaffarpoor M, Noroozi F, Kalantari N. Multi-Disciplinary Interventional Model for Reducing Malnutrition among Children in Iran. 2003. Ghodsi D, Omidvar N, Rashidian A, Raghfar H, Eini-Zinab H, Ebrahimi M. Key informants’ perceptions on the implementation of a national program for improving nutritional status of children in Iran. FoodNutr Bull. 2017;38(1):78–91. Shenavar R, Sajjadi SF, Farmani A, Zarmehrparirouy M, Azadbakht L. Improvement in anthropometric measurements of malnourished children by means of complementary food and nutritional education in fars province, Iran: a community-based intervention. Front Nutr. 2022;9:813449. Ghodsi D, Omidvar N, Rashidian A, Eini-Zinab H, Raghfar H, Aghayan M. Effectiveness of the national food supplementary program on children growth and nutritional status in Iran. Matern Child Nutr. 2018;14(3):e12591. Citaristi I. United Nations Children's Fund—UNICEF. The Europa Directory of International Organizations 2022. edn.: Routledge; 2022. pp. 165–77. Panchal F, Parmar R, Shringarpure K, Damor J. A Cohort Study to Evaluate the Effect of Nutritional Intervention on Severe Acute Malnutrition Children Admitted to A Nutritional Rehabilitation Centre in A Tertiary Care Hospital in Central Gujarat, India. 2024. Refah Iranian Information Technology Services Company. Shoma: National Credit Network. n.d. Ghodsi D, Omidvar N, Nikooyeh B, Roustaee R, Shakibazadeh E, Al-Jawaldeh A. Effectiveness of community nutrition-specific interventions on improving malnutrition of children under 5 years of age in the eastern mediterranean region: A systematic review and meta-analysis. Int J Environ Res Public Health. 2021;18(15):7844. Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatrics Int child health. 2014;34(4):250–65. Perkins JM, Subramanian SV, Davey Smith G, Özaltin E. Adult height, nutrition, and population health. Nutr Rev. 2016;74(3):149–65. Vaivada T, Akseer N, Akseer S, Somaskandan A, Stefopulos M, Bhutta ZA. Stunting in childhood: an overview of global burden, trends, determinants, and drivers of decline. Am J Clin Nutr. 2020;112:S777–91. Hoddinott J, Behrman JR, Maluccio JA, Melgar P, Quisumbing AR, Ramirez-Zea M, Stein AD, Yount KM, Martorell R. Adult consequences of growth failure in early childhood123. Am J Clin Nutr. 2013;98(5):1170–8. Ruel MT, Alderman H. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? lancet. 2013;382(9891):536–51. Adair LS, Fall CH, Osmond C, Stein AD, Martorell R, Ramirez-Zea M, Sachdev HS, Dahly DL, Bas I, Norris SA. Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohort studies. Lancet. 2013;382(9891):525–34. Derakhshandeh-Rishehri S-M, Shenavar MSc R, Farmani BSA, Hemmati PhD A, Faghih PhD S. The effects of nutritional support baskets on growth parameters of under five years old children with malnutrition and low socio-economic status. Journal of Tropical Pediatrics 2021, 67(1):fmab007. Victora CG, Christian P, Vidaletti LP, Gatica-Domínguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397(10282):1388–99. Sibson VL. A mixed methods study on the influence of a seasonal cash transfer and male labour migration on child nutrition in Tahoua, Niger. UCL (University College London); 2020. Ruel MT, Quisumbing AR, Balagamwala M. Nutrition-sensitive agriculture: what have we learned so far? Global food Secur. 2018;17:128–53. Ngamasana EL, Moxie J. Cash transfer, maternal and child health outcomes: a scoping review in sub-Saharan Africa. Global health action. 2024;17(1):2309726. Emma-Nnopu A. The Impact of Micronutrient Intake on Inflammatory Cytokines: A Community-Based Diet Intervention. Texas Christian University; 2025. Hernandez Saavedra D. Molecular regulation of nutrient sensing and immunometabolism by calorie restriction. University of Illinois at Urbana-Champaign; 2018. Ahmed T, Mahfuz M, Ireen S, Ahmed AS, Rahman S, Islam MM, Alam N, Hossain MI, Rahman SM, Ali MM. Nutrition of children and women in Bangladesh: trends and directions for the future. J Health Popul Nutr. 2012;30(1):1. Hossain S, Chowdhury PB, Biswas RK, Hossain MA. Malnutrition status of children under 5 years in Bangladesh: A sociodemographic assessment. Child Youth Serv Rev. 2020;117:105291. UNICEF: Europe and Central Asia Regional Overview of Food Security and Nutrition. 2024: Managing water sustainably for improved food security and nutrition: Food & Agriculture Org.; 2025. Al Sharjabi SJ, Al Jawaldeh A, Hassan OEH, Dureab F. Understanding the food and nutrition insecurity drivers in some emergency-affected countries in the eastern Mediterranean region from 2020 to 2024. Nutrients. 2024;16(22):3853. Saavedra JM, Dattilo AM. Early nutrition and long-term health: mechanisms, consequences, and opportunities. Woodhead Publishing; 2022. Wonga SC, Phillipb M, Kotnikd P. The Physiology and Mechanisms of Growth. Endocr Rev. 2023;12(44):1–13. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 13 Apr, 2026 Reviewers agreed at journal 11 Apr, 2026 Reviewers agreed at journal 08 Apr, 2026 Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 13 Mar, 2026 Editor invited by journal 06 Mar, 2026 Submission checks completed at journal 05 Mar, 2026 First submitted to journal 25 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8882026","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":618312018,"identity":"60913be6-6ee1-415c-b493-f7cc37bee637","order_by":0,"name":"Raha Rivaz","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Raha","middleName":"","lastName":"Rivaz","suffix":""},{"id":618312019,"identity":"72f09520-25e9-4148-aea0-7ec748028250","order_by":1,"name":"Mehdi Varmaghani","email":"","orcid":"","institution":"Mashhad University of Medical 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18:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8882026/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8882026/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106381524,"identity":"e4024441-3442-4791-96cb-b9e61601f4c9","added_by":"auto","created_at":"2026-04-08 05:22:39","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57544,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFramework for Classifying Nutritional Interventions for Malnutrition\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8882026/v1/74562002dd221fdefebab864.jpg"},{"id":106381525,"identity":"9ca14b9f-3f4c-4aae-979f-cbd85f4b9ec2","added_by":"auto","created_at":"2026-04-08 05:22:39","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":36490,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of the study procedure\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8882026/v1/eb08efc455481481afc33b7e.jpg"},{"id":106381526,"identity":"99359da8-8d3b-4118-8aaa-60175269e7f6","added_by":"auto","created_at":"2026-04-08 05:22:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":164222,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrend of changes in nutritional indicators of children under 5 years of age suffering from malnutrition over time\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8882026/v1/0cc7af893be32e4d4f8c88cc.png"},{"id":106381536,"identity":"8a95a003-0ef8-488b-993c-d412e3ba37c2","added_by":"auto","created_at":"2026-04-08 05:22:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1575254,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8882026/v1/5fd0bd37-1cab-4b98-a7b4-b80343f5656a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffectiveness of Nutritional Support on Anthropometric Outcomes in Malnourished Children Under 5 Years \u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eMalnutrition represents a major global health challenge, particularly in children, and is defined as an imbalance between nutrient intake and requirements for optimal growth, health, and function [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Malnutrition encompasses undernutrition (underweight, stunting, and wasting) and overnutrition [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This nutrient imbalance has profound consequences on physical health, cognitive development, and economic productivity, especially during the fetal life cycle and early years of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Chronic malnutrition in early life can lead to reduced brain capacity, impaired neurodevelopment, and increased risk of mental and cognitive disorders such as anxiety and depression in later life stages as well as obesity, metabolic syndrome, hypertension, type 2 diabetes, and cardiovascular diseases [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGlobally, stunting has declined from 204.2\u0026nbsp;million in 2000 to 150.2\u0026nbsp;million (22.3%) in 2024; however, progress towards the Sustainable Development Goal )SDG 2.2( remains off-track, with approximately 125\u0026nbsp;million children projected to be stunted by 2030 without accelerated efforts. Also, in 2024, 42.8\u0026nbsp;million children (6.6%) were wasted, and 62.4\u0026nbsp;million children (9.6%) were underweight [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In Iran, A comprehensive study between 1998 and 2017 showed that the prevalence of underweight decreased from 10.9% to 4.3%, stunting from 15.4% to 4.8%, and wasting from 4.9% to 4.3% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, malnutrition's unequal distribution persists across regions within the country.\u003c/p\u003e \u003cp\u003eThe most important causes of malnutrition include infectious diseases, digestive diseases, low birth weight, limited access to adequate and nutritious food, poverty, household economic status, education, especially maternal education, social inequalities, regional conflicts, climate change, weak agricultural infrastructure and food distribution, and hygiene infrastructure [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].The relationship between social and economic factors and malnutrition is bidirectional, especially in childhood. While these factors can lead to malnutrition, the resultant malnutrition in children can reduce economic productivity and poverty in adulthood [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. illustrates the conceptual framework of the multilevel determinants of child malnutrition, including direct nutrition interventions, indirect health interventions, and other sectoral strategies directly or indirectly affecting nutrition (adapted from UNICEF framework). This figure underscores the multifaceted causes addressed by multisectoral programs such as Iran's participatory-supportive initiative. The economic burden of undernutrition is substantial, with a 2024 analysis estimating global annual costs of at least US\u003cspan\u003e$\u003c/span\u003e761\u0026nbsp;billion, equivalent to 0.7% of global gross national income. Furthermore, childhood stunting imposes significant private-sector losses in low- and middle-income countries, totaling at least US\u003cspan\u003e$\u003c/span\u003e135.4\u0026nbsp;billion in annual sales. Thus, malnutrition sustains a vicious cycle of poverty, disability, and deprivation [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAddressing this cycle requires targeted nutritional interventions and multisectoral policies aligned with global frameworks. The conceptual framework by the United Nations Children's Fund (UNICEF) delineates malnutrition's causes across three levels: immediate (inadequate dietary intake and infectious diseases), underlying (poverty, food insecurity, gender inequality, and limited access to health, education, and safe water), and basic (socioeconomic inequalities and inadequate infrastructure) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Consistent with this model and contributing to international efforts to achieve SDG 2, Iran's participatory-supportive child nutrition improvement program began in the second half of 2005 in 86 cities and at least one city in each of the 30 provinces of Iran and gradually expanded throughout the country. This program was designed in collaboration with the Ministry of Health, the Imam Khomeini Relief Foundation, and the Program and Budget Organization and is recognized as a successful model of intersectoral cooperation. The program has three main axes. The first axis includes the distribution of food baskets containing essential items (rice, legumes, fortified oils, dairy products, and protein sources like meat or eggs) to low-income households to meet the nutritional needs of children. The second axis includes nutritional education and counseling (training sessions for mothers and caregivers to increase awareness regarding exclusive breastfeeding in the first 6 months, the introduction of nutritious complementary foods from 6 months of age, and the preparation of balanced meals with local resources) provided by community health workers and nutrition experts at comprehensive health centers. The third axis includes financial support (cash assistance or food vouchers) provided to needy families to improve their access to food items [\u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite successful implementation of this program in combating malnutrition in Iran, a comprehensive evaluation of its effectiveness has not been fully conducted. Program evaluation not only helps identify the strengths and weaknesses of interventions but also allows policymakers to allocate resources effectively and ensure the sustainability of programs [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This study aimed to investigate the effectiveness of the participatory-supportive child nutrition improvement program on improving the nutritional status of malnourished children under 5 years of age in Mashhad, Iran.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cp\u003e \u003cb\u003e2\u0026thinsp;\u0026minus;\u0026thinsp;1. Study Design\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study was a community-based quasi-experimental intervention trial with a control group. This study aimed to investigate the effectiveness of a nutritional support program on improving the nutritional status of malnourished children aged 6 to 60 months in Mashhad, Khorasan Razavi. The study was conducted across five health districts under Mashhad University of Medical Sciences, from September 2024 to June 2025 (9-month follow-up).\u003c/p\u003e\n\u003ch3\u003e2–2. Study population\u003c/h3\u003e\n\u003cp\u003eChildren were selected through data registered in the Department of Health and Provincial Health Center of the Mashhad University of Medical Sciences. Inclusion criteria were: (1) documented malnutrition; (2) receipt of nutritional support for \u0026ge;\u0026thinsp;6 months (intervention group) or eligibility without enrollment (control group); (3) parental/caregiver informed consent; and (4) no evidence of underlying diseases.\u003c/p\u003e \u003cp\u003eExclusion criteria were: (1) parental/caregiver withdrawal; (2) post-enrollment diagnosis of severe diseases; (3) migration or loss to follow-up; and (4) non-adherence to protocol (e.g., non-use of food support or missed monitoring).\u003c/p\u003e\n\u003ch3\u003e2–3. Sample size and Sampling\u003c/h3\u003e\n\u003cp\u003eSample size was determined considering the mean weight-for-age Z-score difference of 0.03 (SD 0.62 and 0.68) based on findings of the study by Ghodsi et al., with α\u0026thinsp;=\u0026thinsp;0.05, power\u0026thinsp;=\u0026thinsp;80%, and intraclass correlation\u0026thinsp;=\u0026thinsp;0.5, yielding 110 children per group. Accounting for 20% attrition, 132 per group were targeted (total n\u0026thinsp;=\u0026thinsp;264).\u003c/p\u003e \u003cp\u003eSampling was done randomly. First, an Excel file of eligible children regardless of being a candidate for receiving the nutritional support program was obtained from the Department of Health and Provincial Health Center of Mashhad University of Medical Sciences. The five headquarters of the Health Deputy of Mashhad were divided into percentages based on the ratio of the population of children in each region to the total population of children in the city. Then, considering the required sample size (132 children per group) in each region was calculated. To reduce bias, the groups were matched based on age, gender, malnutrition status, and income decile using the frequency-based matching method.\u003c/p\u003e\n\u003ch3\u003e2–4. Intervention\u003c/h3\u003e\n\u003cp\u003eThe program, a multisectoral collaboration involving the Ministry of Health and Medical Education, Imam Khomeini Relief Foundation, and Program and Budget Organization, targeted low-income households (deciles 1\u0026ndash;7) with malnourished children identified per WHO growth standards (e.g., inadequate weight gain, growth curve flattening, or Z-score \u0026lt;-3 SD).\u003c/p\u003e \u003cp\u003eMain components included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eMonthly food vouchers (6\u0026ndash;11\u0026nbsp;million rials, depending on severity) credited via the SHOMA [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] application for purchasing dry goods (rice, legumes, oil) from designated stores, non-cashable to ensure food use.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAge-specific food baskets (6\u0026ndash;12, 12\u0026ndash;24, 24\u0026ndash;36, 36\u0026ndash;60 months) tailored to caloric needs, serving sizes, and local preferences (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRegular growth monitoring every 30\u0026ndash;40 days at health centers per MANA protocols, with phase progression or graduation upon recovery.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eSupplementary food basket for malnourished children\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight Food\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePasta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eLegumes/Nuts\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePotato\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVegetables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFruits\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRed meat\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWhite meat\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEgg\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDairy products\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003eEnergy\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBoys/\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eGirls\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6\u0026ndash;12 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e12\u0026ndash;24 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e875\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2\u0026ndash;3 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e950\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3-5 \u003cb\u003eyears\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e12000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e1081\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003e\u003csup\u003ea\u003c/sup\u003e Weight (gr/person/month) \u003csup\u003e#\u003c/sup\u003eTotal Energy (calorie/person/day)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe control group received standard care: routine growth monitoring, examinations, and general nutrition counseling at equivalent intervals. Measurements occurred at baseline (September 2024) and follow-ups (December 2024, March 2025, June 2025). Children's enrollment flowchart is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003e2–5. Data Collection and Variables\u003c/h3\u003e\n\u003cp\u003eAnthropometric outcomes (primary) were weight (Seca digital scale, \u0026plusmn;\u0026thinsp;0.1 kg), height (Seca stadiometer, \u0026plusmn;\u0026thinsp;0.1 cm), and Z-scores (weight-for-age [WAZ], height-for-age [HAZ], weight-for-height [WHZ]) calculated using WHO Anthro software.\u003c/p\u003e \u003cp\u003eOther data was obtained via parental/caregiver questionnaire, which included age, gender, gestational age (preterm\u0026thinsp;\u0026lt;\u0026thinsp;37 weeks; term 37\u0026ndash;42 weeks), birth weight (\u0026lt;\u0026thinsp;1500 g; 1500\u0026ndash;2500 g; 2500\u0026ndash;4000 g; \u0026gt;4000 g), breastfeeding duration (\u0026le;\u0026thinsp;6 months; 6\u0026ndash;24 months; \u0026gt;24 months), formula duration (same categories), multivitamin use (yes/no), complementary food initiation (\u0026lt;\u0026thinsp;6 months; \u0026ge;6 months), and parental occupation. Household economic decile was sourced from Ministry of Health records.\u003c/p\u003e\n\u003ch3\u003e2–6. Ethics Approval\u003c/h3\u003e\n\u003cp\u003e The study protocol was approved by the Ethics Committee of the Faculty of Medicine, Mashhad University of Medical Sciences and Health Services, Mashhad, Iran (ethics code: IR.MUMS.MEDICAL.REC.1403.223; research project code: 4022710).\u003c/p\u003e\n\u003ch3\u003e2–7. Statistical analysis\u003c/h3\u003e\n\u003cp\u003eTo assess the changes in the anthropometric status of children after 9 months, their nutritional status was divided into three categories; \u0026ldquo;worse\u0026rdquo;, when the child's nutritional status changed from normal to mild, moderate, or severe malnutrition; \u0026ldquo;better\u0026rdquo;, when the child's nutritional status improved from severe or moderate to mild malnutrition or normal; and \u0026ldquo;unchanged\u0026rdquo;, when no change in the child's nutritional status classification was observed during the study.\u003c/p\u003e \u003cp\u003eData normality was assessed using Shapiro-Wilk test. Baseline comparisons employed t-tests and χ\u0026sup2; tests. Within-group changes over time were analyzed using repeated-measures ANOVA. Between-group differences in Z-score changes were compared via independent t-tests or mixed-effects models as appropriate. Longitudinal changes in anthropometric Z-scores were primarily evaluated using linear mixed-effects models, which included fixed effects for intervention group, time, and their interaction, while adjusting for gender, age, household economic decile, birthweight, breastfeeding duration, gestational age, age at introduction of complementary feeding, and multivitamin supplementation, with random intercepts for clustering variables to account for repeated measures and potential clustering effects. Analyses used Stata v17 and SPSS v26.\u003c/p\u003e"},{"header":"3. Result","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the demographic and background characteristics of 229 malnourished children under 5 years of age (131 in the intervention and 98 in the control groups). There was no significant difference between the two groups in the distribution pattern of gender (P\u0026thinsp;=\u0026thinsp;0.389), birth weight (P\u0026thinsp;=\u0026thinsp;0.473), gestational age at birth (P\u0026thinsp;=\u0026thinsp;0.418), duration of breastfeeding (P\u0026thinsp;=\u0026thinsp;0.335), duration of formula feeding (P\u0026thinsp;=\u0026thinsp;0.504), time to start complementary foods (P\u0026thinsp;=\u0026thinsp;0.136), and multivitamin use (P\u0026thinsp;=\u0026thinsp;0.247) categories. However, significant differences were observed in age (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), paternal occupation (P\u0026thinsp;=\u0026thinsp;0.043), maternal occupation (P\u0026thinsp;=\u0026thinsp;0.022), and economic status percentile (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between the two groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eComparison of the demographic and background characteristics between the intervention and control groups at baseline\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;131)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGirl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65(60.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(39.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(54.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55(45.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e*0.001\u0026gt;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u0026ndash;24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(37.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(62.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24\u0026ndash;36 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46(63.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(36.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;60 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66(69.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(30.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirth weight (grams)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 1500 (very low)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4(44.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(55.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1500\u0026ndash;2500 (low)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2500\u0026ndash;4000 (normal)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88(57.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66(42.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 4000 (macrosomia)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1(25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3(75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational age at birth (weeks)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 37 (premature)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e37\u0026ndash;42 W\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77(42.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105(57.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of breast feeding (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8(44.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(55.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween 6\u0026ndash;24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57(55.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(44.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53(62.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(37.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of formula feeding (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.504\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBetween 6\u0026ndash;24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27(57.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20(42.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than 24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2(50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStart of complementary foods (months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnder 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (55.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (44.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e213\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eConsumption of multivitamins\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45(52.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41(47.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.247\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86(60.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57(39.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePaternal occupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaborer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(59.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26(40.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.043*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDriver\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17(73.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(26.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36(44.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45(55.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(69.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4(30.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29(64.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (35.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaternal Occupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120(57.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87(42.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e207\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.372\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(47.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10(52.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEconomic decile\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41(25.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e120(74.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57(83.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(16.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003echi-square test was used for the comparison.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Significant difference at α\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Value is presented a sn(%).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the mean and standard deviation of demographic and nutritional indicators of the participants at different stages of the study (baseline, third month, sixth month, and ninth month). At baseline, here was a significant difference in age (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), weight (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and height (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) at baseline, as well as WAZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HAZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and WHZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). At 3rd month, there was a significant difference in height (P\u0026thinsp;=\u0026thinsp;0.02), HAZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and WHZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) between groups. At 6th month there was a significant difference in height (P\u0026thinsp;=\u0026thinsp;0.03) and WHZ (P\u0026thinsp;=\u0026thinsp;0.01) between the two groups. At 9th month, there was a significant difference in height (P\u0026thinsp;=\u0026thinsp;0.03), HAZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and WHZ (P\u0026thinsp;=\u0026thinsp;0.01) between groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of mean demographic and nutritional indicators between the intervention and control groups during the study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention group\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003cp\u003e(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean difference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eStart of study\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.56\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91.88\u0026thinsp;\u0026plusmn;\u0026thinsp;8.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.02\u0026thinsp;\u0026plusmn;\u0026thinsp;7.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-5.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score H/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.59\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eThird month\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.38\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.26\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.99\u0026thinsp;\u0026plusmn;\u0026thinsp;7.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.73\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.92\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score H/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.76\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.94\u0026thinsp;\u0026plusmn;\u0026thinsp;3.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eSixth month\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score H/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.99\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.34\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNinth month\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.67\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.15\u0026thinsp;\u0026plusmn;\u0026thinsp;7.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94.64\u0026thinsp;\u0026plusmn;\u0026thinsp;8.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.03*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.45\u0026thinsp;\u0026plusmn;\u0026thinsp;0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.08\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score H/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.68\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-1.19\u0026thinsp;\u0026plusmn;\u0026thinsp;1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eIndependent t-test was used for the comparison. WAZ=weight-for‐age Zscore;HAZ=height‐for‐age Zscore;WHZ=weight‐to‐height Zscore.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Significant difference at α\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e shows the trends in nutritional indicators among the study participants over time. There was a significant trend for changes in height (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HAZ (P\u0026thinsp;=\u0026thinsp;0.02), and WHZ (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTrend comparison between the intervention and control groups in nutritional indicators of the study participants over time\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-Value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZ-Score W/A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.02*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZ-Score H/A\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eZ-Score W/H\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eRepeated measures analysis of variance (ANOVA) was used for the comparison.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Significant difference at α\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eChanges in nutritional status were evaluated for underweight, stunting, and wasting among intervention and control groups. For underweight status (intervention n\u0026thinsp;=\u0026thinsp;115, control n\u0026thinsp;=\u0026thinsp;65), 66.95% in the intervention group showed no change compared to 61.53% in the control, with 21.73% improving versus 20%, and 11.3% worsening versus 18.46%. In stunting (intervention n\u0026thinsp;=\u0026thinsp;57, control n\u0026thinsp;=\u0026thinsp;45), improvements were noted in 42.1% of the intervention group against 31.11% in the control, while no change occurred in 47.36% and 53.33%, respectively. For wasting (intervention n\u0026thinsp;=\u0026thinsp;113, control n\u0026thinsp;=\u0026thinsp;68), 26.54% improved in the intervention group compared to 22.05% in the control (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges in Nutritional Status Between Baseline and Endline by Study Group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention Group (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl Group (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eUnderweight status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;115\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;65\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77(66.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40(61.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.411\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12(18.46)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBetter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25(21.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13(20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eStunting status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;57\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27(47.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24(53.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.474\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6(10.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7(15.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBetter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14(31.11)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eWasting status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;113\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en\u0026thinsp;=\u0026thinsp;68\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59(52.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35(51.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.654\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24(21.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18(26.47)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBetter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30(26.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15(22.05)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eWAZ=weight-for‐ageZscore;HAZ=height‐for‐ageZscore;WHZ=weight‐to‐heightZscore. Value is presented a sn(%).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the mixed-effects linear regression analyses, adjusted for potential confounders including child gender, age, household economic decile, birthweight, breastfeeding duration, gestational age, age at introduction of complementary feeding, and multivitamin supplementation revealed that the intervention had a statistically significant positive effect on weight-for-age Z-scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and weight-for-height Z-scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating improved weight status and reduced wasting among intervention children compared to controls, with mean differences ranging from 0.270 to 0.284 units in baseline estimates. However, no significant effect was observed on height-for-age Z-scores (p\u0026thinsp;=\u0026thinsp;0.5), consistent with the slower response of linear growth to short-term interventions. Although the intervention \u0026times; time interaction term was nonsignificant across all three anthropometric outcomes (p\u0026thinsp;\u0026gt;\u0026thinsp;0.80), indicating no overall differential trajectory between groups over the follow-up period, post-hoc pairwise comparisons of estimated marginal means revealed month-specific significant benefits favoring the intervention group. For weight-for-age Z-score, significant advantages were observed in month 9 (mean difference\u0026thinsp;=\u0026thinsp;0.442, p\u0026thinsp;=\u0026thinsp;0.008) and month 13 (mean difference\u0026thinsp;=\u0026thinsp;0.602, p\u0026thinsp;=\u0026thinsp;0.046), with near-significant trends in month 8 (p\u0026thinsp;=\u0026thinsp;0.073) and month 14 (p\u0026thinsp;=\u0026thinsp;0.065). For height-for-age Z-score, no significant differences emerged in any month (all p\u0026thinsp;\u0026ge;\u0026thinsp;0.199), consistent with the absence of an overall intervention effect on linear growth. In contrast, weight-for-height Z-score demonstrated the most pronounced month-specific effects, with statistically significant higher values in the intervention group in month 6 (mean difference\u0026thinsp;=\u0026thinsp;0.411, p\u0026thinsp;=\u0026thinsp;0.016), month 7 (mean difference\u0026thinsp;=\u0026thinsp;0.837, p\u0026thinsp;=\u0026thinsp;0.012), month 8 (mean difference\u0026thinsp;=\u0026thinsp;0.734, p\u0026thinsp;=\u0026thinsp;0.019), and month 9 (mean difference\u0026thinsp;=\u0026thinsp;0.366, p\u0026thinsp;=\u0026thinsp;0.042), alongside borderline trends in month 12 (p\u0026thinsp;=\u0026thinsp;0.083).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTime-by-intervention results for anthropometric Z-scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention* Time\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score H/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eZ-Score W/H\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eTable shows p-values from Type III tests of fixed effects in mixed-effects linear models, adjusted for child gender, age, household economic decile, birthweight, breastfeeding, and gestational age category. * Significant difference at α\u0026thinsp;\u0026lt;\u0026thinsp;0.05. W/A: weight-for-age Z-score; H/A: height-for-age Z-score; W/H: weight-for-height Z-score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe figures (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3.1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3.2\u003c/span\u003e, and Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3.3\u003c/span\u003e) of changes in nutritional indicators show that the intervention and control groups had fluctuations in the indicators at different stages, and in the intervention group, WHZ and WAZ (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3.1\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e3.3\u003c/span\u003e) showed relative improvement in the middle stages and the HAZ index in the final stages, while the control group showed fluctuations (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3.2\u003c/span\u003e).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study evaluated the impact of a shopping credit-based nutritional intervention on anthropometric outcomes among 229 malnourished children under 5 years of age in Mashhad, Iran, compared to a control group over a 9-month period. The intervention, targeted at low-income households, demonstrated statistically significant positive effects on weight-for-age Z-scores ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and weight-for-height Z-scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in mixed-effects models. These improvements indicate enhanced weight status and reduced wasting among intervention children compared to controls. However, no significant effect was observed on height-for-age Z-scores (p\u0026thinsp;=\u0026thinsp;0.5), aligning with the known slower response of linear growth to short-term nutritional support Categorically, the intervention group showed modestly higher rates of improvement in underweight (21.73% vs. 20%), stunting (42.1% vs. 31.11%), and wasting (26.54% vs. 22.05%) statuses compared to controls, underscoring targeted gains in acute malnutrition indicators.\u003c/p\u003e \u003cp\u003eIn our study, the longitudinal trends revealed differential patterns in nutritional indices, with HAZ exhibiting a steady increase over time (p\u0026thinsp;=\u0026thinsp;0.02), while WAZ and WHZ showed initial improvements in the first three follow-ups followed by a plateau or slight decline by the ninth month. Overall temporal changes were significant for height (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HAZ (p\u0026thinsp;=\u0026thinsp;0.02), and WHZ (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), but not weight or WAZ, potentially attributable to seasonal factors such as winter infectious illnesses (e.g., colds and flu) that transiently affected weight gain without impacting linear growth. Additional barriers, including irregular credit deposits, challenges with the SHOMA application for registration, limited access to diverse food items (e.g., fruits, vegetables, and micronutrients), and household-level sharing of provisions, may have diluted sustained effects on chronic indices like HAZ, which reflect long-term malnutrition [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Socioeconomic status further moderated outcomes, as baseline differences in economic deciles (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and parental occupations (p\u0026thinsp;=\u0026thinsp;0.022\u0026ndash;0.043) highlight how entrenched poverty exacerbates nutritional inequities; global evidence links low SES to 2.2\u0026ndash;3.8-fold higher stunting odds in low- and middle-income countries (LMICs), with population-level SES improvements driving height gains of 7\u0026ndash;10 cm over decades in countries like Japan and South Korea [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. These secular trends demonstrate that sustained economic development, when coupled with equitable food systems and public health interventions, can reverse chronic malnutrition and enhance linear growth across generations [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared to other interventions, our shopping credit program aligns with but extends beyond traditional food basket distributions or supplementary feeding in Iran and the Middle East, achieving notable WHZ and WAZ gains despite a short duration. For instance, Ghodsi et al.'s 2021 quasi-experimental evaluation of Iran's National Food Distribution Program reported no significant inter-group differences in Z-scores after 6 months, attributing limited efficacy to economic constraints, food sharing, and nutrient inadequacies [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]; Similarly, our study faced analogous challenges, yet the credit mechanism yielded superior month-specific WHZ improvements, likely due to enhanced household agency in food selection. Derakhshandeh et al. evaluated nutritional support packages of 600 kcal/day among 3,667 malnourished children under 5 years of age for 9 months in Fars province, Iran. The study showed non-significant reductions in the prevalence of moderate (3.7%) and severe (2.5%) underweight, moderate (0.5%) and severe (1%) stunting, and moderate (5.9%) and severe (2.5%) wasting (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating a higher relative improvement in WHZ in girls and a higher risk of malnutrition in boys. The reported limitations of the study were the short duration of the study (9 months), irregular distribution, and sharing of food within the family [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. A 2024 community-based trial by Shenavar et al. combining complementary feeding with education achieved significant Z-score gains after 10 months suggested that integrating credit donation with nutrition counseling could amplify effects [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Similarly, a recent Eastern Mediterranean Region (EMR) meta-analysis confirming community interventions' stronger impact on WHZ when linked to health services like growth monitoring [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Globally, analogous cash or voucher transfer programs have shown consistent benefits in LMICs, increasing household expenditure on nutrient-rich foods by 10\u0026ndash;20% and dietary diversity scores by approximately 0.7 points while reducing childhood wasting by 1.2 percentage points [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. These impacts are partly mediated by improved micronutrient intake, which strengthens immune response and reduces infection-related catabolic stress [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a mechanistic perspective, shopping credits exert direct effects primarily through bridging food affordability gaps in resource‑limited households, thereby enabling access to energy‑dense and protein‑rich diets. This facilitates short‑term anabolic responses, including enhanced protein synthesis, insulin‑like growth factor‑1 (IGF‑1) signaling, and improved muscle and fat accretion\u0026mdash;all contributing to rapid gains in WAZ and WHZ [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Recent studies corroborate these findings, showing that cash‑based nutritional interventions can upregulate anabolic hormone activity and reduce pro‑inflammatory cytokine levels within months of implementation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The indirect effects operate through psychosocial and environmental pathways. Reduced financial stress may attenuate chronic cortisol elevation that otherwise promotes protein catabolism, while increased income fosters improved caregiving behaviors, feeding frequency, and hygiene practices. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Moreover, households experiencing decreased economic strain can reallocate funds toward healthcare, preventive measures, and sanitation\u0026mdash;further lowering infection risk and supporting micronutrient intake [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. However, Chronic deprivation perpetuates recurrent infections and systemic inflammation, disrupting growth plate cartilage activity and impairing endocrine regulation over prolonged periods. These mechanisms collectively emphasize that while acute malnutrition responds to targeted nutritional input, eradicating stunting necessitates multisectoral strategies addressing poverty, infection, and environmental health determinants [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Strengths and Limitations","content":"\u003cp\u003eThe strengths of this study include conducting a large community-based quasi-experimental evaluation of the Iranian National Electronic Nutrition Voucher Program (SHOMA) in a real-world setting. The study employed proportional sampling across all five geographical regions of Mashhad, individual-level random assignment within each region, and frequency matching on key variables (age, sex, degree of malnutrition, and household income decile) to enhance comparability between intervention and control groups. Additionally, the study incorporated a 9-month follow-up period with four repeated measurements, which provided robust longitudinal data.\u003c/p\u003e \u003cp\u003eNevertheless, several limitations should be acknowledged. First, the quasi-experimental design\u0026mdash;where final enrollment in the support program was ultimately determined by the Ministry of Cooperatives, Labour and Social Welfare\u0026mdash;prevented full randomization. Second, the absence of any nutritional support in the control group led to reduced adherence and a substantially higher attrition rate in this arm (25.8%), raising the possibility of attrition bias. Third, the lack of structured nutrition education for caregivers and the relatively short intervention duration of 9 months may have constrained the program\u0026rsquo;s impact on chronic nutritional indicators, particularly linear growth )HAZ), and limited our ability to evaluate long-term sustainability. Fourth, the study did not collect detailed data on certain key socioeconomic and caregiving variables, including precise household income levels (beyond decile categorization), parental or caregiver education attainment, maternal nutritional status during pregnancy, household food security scores and frequency or severity of child illnesses; the inclusion of these variables could have allowed for more comprehensive adjustment for residual confounding and deeper exploration of mediators influencing nutritional outcomes.\u003c/p\u003e \u003cp\u003eFuture studies should consider extending the follow-up duration and integrating systematic, theory-based nutrition education for children\u0026rsquo;s families and caregivers through primary health centers. Such enhancements are likely to maximize intervention effectiveness, improve participant adherence, and yield more definitive evidence regarding long-term outcomes.\u003c/p\u003e"},{"header":"6. Conclusion","content":"\u003cp\u003eThe findings of our study suggested that the national intervention to improve access to the required food items for malnourished children under 5 year of age could prevent malnutrition from worsening and produced modest improvements in malnourished indices of these children. However, implementation barriers, including economic hardship, irregular delivery, and household food sharing often limited the effectiveness of the program. Therefore, complete elimination of malnutrition requires the concordance of other comprehensive strategies besides improving the current program in terms of malnourished children identification and facilitating credit allocation through removing administrative barriers.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. The research protocol was reviewed and approved by the Regional Ethics Committee in Medical Science Research at Mashhad University of Medical Sciences (approval ID: IR.MUMS.MEDICAL.REC.1403.223). All participants were children under 5 years of age. Written informed consent was obtained from parents or legal guardians of all child participants prior to enrollment.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of interest\u003c/h2\u003e \u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eFinancial Support\u003c/h2\u003e \u003cp\u003eThis research received funding from Mashhad University of Medical Sciences (grant number: 4022710). No additional external funding was received.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy concept and design: SRS, MNDrafting of the manuscript: RR, AJEStudy implementation: RR, FE, OEData validation: RR, OEStatistical analysis and interpretation of data: RR, MV, AJEAll authors gave final approval of the version to be published and agreed to be accountable for all aspects of the work. MN and SRS also accept the correspondence of the manuscript on behalf of all the authors.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We thank the staff of the Department of Health and Provincial Health Center of Mashhad University of Medical Sciences for their assistance in data provision and participant recruitment. We also acknowledge the contributions of the collaborating organizations: Ministry of Health and Medical Education, Imam Khomeini Relief Foundation, and Program and Budget Organization.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the Department of Health and Provincial Health Center of Mashhad University of Medical Sciences upon official written request. The authors do not have the authority or access to share any data without prior permission from the relevant organization.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF. The state of food security and nutrition in the world 2024: Financing to end hunger, food insecurity and malnutrition in all its forms. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeats EC, Das JK, Salam RA, Lassi ZS, Imdad A, Black RE, Bhutta ZA. 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Key informants\u0026rsquo; perceptions on the implementation of a national program for improving nutritional status of children in Iran. FoodNutr Bull. 2017;38(1):78\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShenavar R, Sajjadi SF, Farmani A, Zarmehrparirouy M, Azadbakht L. Improvement in anthropometric measurements of malnourished children by means of complementary food and nutritional education in fars province, Iran: a community-based intervention. Front Nutr. 2022;9:813449.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhodsi D, Omidvar N, Rashidian A, Eini-Zinab H, Raghfar H, Aghayan M. Effectiveness of the national food supplementary program on children growth and nutritional status in Iran. Matern Child Nutr. 2018;14(3):e12591.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCitaristi I. United Nations Children's Fund\u0026mdash;UNICEF. The Europa Directory of International Organizations 2022. edn.: Routledge; 2022. pp. 165\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePanchal F, Parmar R, Shringarpure K, Damor J. A Cohort Study to Evaluate the Effect of Nutritional Intervention on Severe Acute Malnutrition Children Admitted to A Nutritional Rehabilitation Centre in A Tertiary Care Hospital in Central Gujarat, India. 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRefah Iranian Information Technology Services Company. Shoma: National Credit Network. n.d.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGhodsi D, Omidvar N, Nikooyeh B, Roustaee R, Shakibazadeh E, Al-Jawaldeh A. Effectiveness of community nutrition-specific interventions on improving malnutrition of children under 5 years of age in the eastern mediterranean region: A systematic review and meta-analysis. 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Am J Clin Nutr. 2013;98(5):1170\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuel MT, Alderman H. Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? lancet. 2013;382(9891):536\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdair LS, Fall CH, Osmond C, Stein AD, Martorell R, Ramirez-Zea M, Sachdev HS, Dahly DL, Bas I, Norris SA. Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohort studies. Lancet. 2013;382(9891):525\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDerakhshandeh-Rishehri S-M, Shenavar MSc R, Farmani BSA, Hemmati PhD A, Faghih PhD S. The effects of nutritional support baskets on growth parameters of under five years old children with malnutrition and low socio-economic status. \u003cem\u003eJournal of Tropical Pediatrics\u003c/em\u003e 2021, 67(1):fmab007.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVictora CG, Christian P, Vidaletti LP, Gatica-Dom\u0026iacute;nguez G, Menon P, Black RE. Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda. Lancet. 2021;397(10282):1388\u0026ndash;99.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSibson VL. A mixed methods study on the influence of a seasonal cash transfer and male labour migration on child nutrition in Tahoua, Niger. UCL (University College London); 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuel MT, Quisumbing AR, Balagamwala M. Nutrition-sensitive agriculture: what have we learned so far? Global food Secur. 2018;17:128\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNgamasana EL, Moxie J. Cash transfer, maternal and child health outcomes: a scoping review in sub-Saharan Africa. Global health action. 2024;17(1):2309726.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmma-Nnopu A. The Impact of Micronutrient Intake on Inflammatory Cytokines: A Community-Based Diet Intervention. Texas Christian University; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHernandez Saavedra D. Molecular regulation of nutrient sensing and immunometabolism by calorie restriction. University of Illinois at Urbana-Champaign; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmed T, Mahfuz M, Ireen S, Ahmed AS, Rahman S, Islam MM, Alam N, Hossain MI, Rahman SM, Ali MM. Nutrition of children and women in Bangladesh: trends and directions for the future. J Health Popul Nutr. 2012;30(1):1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHossain S, Chowdhury PB, Biswas RK, Hossain MA. Malnutrition status of children under 5 years in Bangladesh: A sociodemographic assessment. Child Youth Serv Rev. 2020;117:105291.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF: Europe and Central Asia Regional Overview of Food Security and Nutrition. 2024: Managing water sustainably for improved food security and nutrition: Food \u0026amp; Agriculture Org.; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl Sharjabi SJ, Al Jawaldeh A, Hassan OEH, Dureab F. Understanding the food and nutrition insecurity drivers in some emergency-affected countries in the eastern Mediterranean region from 2020 to 2024. Nutrients. 2024;16(22):3853.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaavedra JM, Dattilo AM. Early nutrition and long-term health: mechanisms, consequences, and opportunities. Woodhead Publishing; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWonga SC, Phillipb M, Kotnikd P. The Physiology and Mechanisms of Growth. Endocr Rev. 2023;12(44):1\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Children, Anthropometric Indices, Malnutrition, Nutritional Support Program, Effectiveness, Iran","lastPublishedDoi":"10.21203/rs.3.rs-8882026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8882026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMalnutrition remains a major public health issue among children under 5 years in resource-limited settings, impairing growth, cognitive development, and long-term health outcomes. In Iran, the participatory-supportive child nutrition improvement program has been scaled nationally since 2005. This study evaluated the effectiveness of this program in improving key nutritional indicators among malnourished children.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a community-based quasi-experimental trial with individual randomization and frequency-matched controls in urban city area of Mashhad, Iran. Malnourished children aged 6\u0026ndash;60 months (n\u0026thinsp;=\u0026thinsp;264) were enrolled from September 2024, with 264 completing 9-month follow-up (intervention\u0026thinsp;=\u0026thinsp;131, control\u0026thinsp;=\u0026thinsp;98). The intervention provided monthly food credits (6\u0026ndash;11\u0026nbsp;million rials), customized baskets meeting caloric and macronutrient needs across four age strata, nutritional counseling, and bimonthly growth monitoring. Controls received routine care. Outcomes included changes in weight-for-age (WAZ), height-for-age (HAZ), and weight-for-height (WHZ) z-scores.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAt baseline, controls were older and had significantly higher weight, height, and z-scores (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and economic decile (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared to the intervention group due to matching constraints. Over 9 months, the intervention group exhibited significant within-group gains in height (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), HAZ (P\u0026thinsp;=\u0026thinsp;0.02), and WHZ (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Improvements in stunting (42.1% vs. 31.1%) and wasting (26.5% versus 22.1%) were higher, and worsening of underweight was lower (11.3% versus 18.5%) in the intervention compared to the control group. However, the differences between groups were not statistically significant after adjusting for confounders.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis intervention program accelerated linear growth and acute nutritional improvement trajectories in an urban group with high financial burden.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Nutritional Support on Anthropometric Outcomes in Malnourished Children Under 5 Years","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-08 05:22:36","doi":"10.21203/rs.3.rs-8882026/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-14T00:18:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"282170321750790547537456838244517104249","date":"2026-04-12T03:10:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2196129375910811388864514304487880977","date":"2026-04-08T21:27:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-01T14:21:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-13T10:13:10+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-06T12:48:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-05T15:09:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-02-25T16:24:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"062ded1e-c28e-436f-825c-49f01ace57f4","owner":[],"postedDate":"April 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-08T05:22:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-08 05:22:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8882026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8882026","identity":"rs-8882026","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}