evidence-based blog of Filippo Dibari

Posts Tagged ‘nutrition intervention’

Mobile phone technologies to improve the prevention and treatment of malnutrition?

In Under-nutrition on August 23, 2012 at 8:56 am

Source: Rapid SMS – http://www.rapidsms.org/

In 2011, WHO reports:

The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe.

A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks.” (download the entire doc)

(To learn more about m-Health, read this paper from the WHO Bulletin: Point of care in your pocket: a research agenda for the field of m-health)

The same WHO document mentions a wide range of  applications, but regretfully does not include the treatment or the prevention of malnutrition, although the potential is there. These are few examples:

  • In Kenya, in 2009, the Millennium Villages Project and the Columbia University looked into the use of SMS to support the community-based management of acute malnutrition in children under five. The pilot study concludes that “an
, which 

help in 
 (see the entire doc)
  • In Malawi, more recently, “UNICEF deployed SMS to address serious constraints within the national Integrated Nutrition and Food Security Surveillance (INFSS) System, which was facing slow data transmission, incomplete and poor quality data sets, high operational costs and low levels of stakeholder ownership.  Health workers now enter a child’s data, and through an innovative feedback loop system, Rapid SMS instantly alerts field monitors of their patients’ nutritional status. Automated basic diagnostic tests are now identifying more children with moderate malnutrition who were previously falling through the cracks.  This system also increased local ownership of the larger surveillance program through two-way information exchange.  Operational costs for the Rapid SMS system are significantly less than the current data collection system. The Government of Malawi is considering a national scale-up later this year” (read more here)
  • In the last 2 years, the same organization (Rapid SMS) has successfully piloted in Ethiopia a RUTF stock reporting and request system. This has the potential for improving the communications of stock levels and requests up the supply chain and consequently for avoiding supply breaks (more info here at page 42, and here)
  • WFP focuses on the prevention and treatment of moderate acute malnutrition and has also been involved with innovations using cash/vouchers and SMS for monitoring the implementation of programmes and for monitoring cases of malnutrition (read more at page 24 of this document)
  •  In 2011, UNICEF and Valid International undertook a “Global Mapping Review of Community-based Management of Acute Malnutrition” (with a focus on Severe Acute Malnutrition). In countries of interest, the same document suggests a review of innovative technologies to improve information flow to national level. Those include the use of Rapid SMS to improve timeliness and quality of reporting.  “Many countries have started or are recommending use of Rapid SMS“, because “the large number of centres makes compilation & transmission difficult”. For this reason, moving “towards Rapid SMS to improve transmission” is crucial.

Some of the organizations with promising capacities to design SMS platforms, and helping in fighting malnutrition, are listed here:

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Note that:

the Forum on Community-based Management of Acute Malnutrition will be preparing a more detailed Technical Brief on the subject of M-health and E-health in the coming months.

Feel free to contact the Forum, if you are interested in m-health & nutrition, or in any other aspect related to Community-management of Acute Malnutrition.

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Question: you know any other experience in this area of nutrition and m-health? Worth reporting on this blog? Please, share that: leave a comment (down here), or contact me.

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Save the Children (NGO) about treatment of Acute Malnutrition: Minimum Reporting Package User Guidelines

In Under-nutrition on August 21, 2012 at 10:46 am

(download the entire doc)

“These minimum Reporting Package (MRP) User Guidelines are intended to outline the definitions, reporting categories and performance indicators for monitoring and reporting on three feeding programmes using the MRP software.

“The programmes are: targeted Supplementary Feeding Programmes (SFPs), Outpatient Therapeutic Programmes (OTPs) and Stabilisation Centres (SCs).

“There is also guidance on interpreting and taking action on programme performance indicators.

“The audience for the guidelines are nutrition programme coordinators and M&E staff of NGOs involved in the monitoring and reporting process.”

On this blog you can find more information about management of acute malnutrition, and ready to use foods for undernutrition treatment.
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In Under-nutrition on August 19, 2012 at 10:15 am

The organization Action Against Hunger has released a brave, land marking “detailed analysis of current spending on nutrition and of the adequacy of current aid reporting systems“.

Despite the issues related to data collection, the results are striking:

  • “Investment in nutrition is inadequate. Current investments in proven nutrition interventions account for approximately 1% of the estimated US$11.8 billion required to tackle undernutrition
  • “44% of investments in direct nutrition interventions were allocated to projects to reduce micronutrient deficiencies, 40% to treat malnourished children with special foods and 14% to promote good nutritional practices
  • “Comprehensive programmes which deliver the full package of direct nutrition interventions were inadequate (only 2% of funding)
  • “Nutrition programmes were mainly delivered through the health sector or in response to humanitarian crises. Few are delivered through development programmes indicating the reactive, short-term and unpredictable nature of aid for nutrition
  • The “data indicates that aid is not necessarily directed to the countries with the highest burden (in terms of caseload) of undernutrition, particularly in the Africa region
  • “Fulfilment of individual donor commitments varied widely. Collectively, there was a negative trend indicating that donors failed to deliver 11% of their commitments”

The same document reports also important recommendations for the future.

Download the entire paper, here

Video – The Republic Of Hunger: every third malnourished child in the world is from India

In Under-nutrition on August 16, 2012 at 6:53 am

From AlJazeera web site:

“More than 40 per cent of India’s 61 million children are malnourished, prompting the prime minister to declare the problem a “national shame”.

“A recent report reveals that levels are twice that of sub-Saharan Africa, making every third malnourished child in the world an Indian.

“India has one of the fastest-growing economies in the world and runs one of the largest child feeding programmes.

“But critics say only a fraction of aid reaches the needy.”


Find more posts about India and malnutrition on this blog.

The effect of an integrated multisector model for achieving the Millennium Development Goals and improving child survival in rural sub-Saharan Africa: a non-randomised controlled assessment

In Under-nutrition on August 13, 2012 at 1:15 pm

Pronyk PM, Muniz M, Nemser B et al. – The Lancet 379: 2179-88; 2012

In the year 2000, world leaders committed their nations to achieving the Millennium Development Goals (MDGs), by establishing a new global partnership to reduce extreme poverty and address a series of related health and development issues. One of the MDGs is to reduce child mortality by two-thirds between 1990 and 2015. The Millennium Villages Project (MVP) was designed as a 10-year initiative to support the integrated delivery of a package of scientifically proven interventions.  The primary aim of the MVP is to accomplish MDGs across a diverse set of rural, sub-Saharan African sites. Local partnerships were forged among the MVP staff members, representatives of local communities, and government personnel to coordinate activities across multiple sectors, including health, agriculture, the environment, education, business and infrastructure development. The aim of the paper reviewed in this month’s edition of NNA was to assess the effects of the project on MDG-related outcomes, including child mortality, 3 years after its implementation.

The Millennium Village sites were chosen to represent a broad range of agro-ecological conditions in nine sub-Saharan African countries. The average population size of the rural intervention villages was ~35,000 residents, who were characterized by high levels of poverty and undernutrition. Starting in 2006, simultaneous investments were made in the aforementioned sectors at a planned total annual cost of 120 USD per person. In agriculture, interventions were designed to increase crop yields and enhance food security by promoting subsidized fertilizers and improved seeds for major staple crops. Additional efforts to improve nutrition via agriculture included support for cultivation of nutritious crops in home gardens, fish farming, and livestock and small animal rearing (1). Direct nutrition interventions included child-growth monitoring, vitamin A supplementation and treatment of acute malnutrition. Community-health workers were also trained to promote exclusive breastfeeding for the first 6 months of life and encourage locally appropriate complementary foods and continued breast feeding thereafter (1). Nutrition-related efforts also focused on improving maternal access to prenatal care, including iron and folic acid supplementation. All interventions were adapted and flexibly implemented in response to local conditions after consultations with government leaders and local community representatives (2).

The current MVP assessment included measurement of selected MDG-related outcomes before and 3 years after the intervention was initiated. Both sets of assessments were conducted during pre-harvest periods. Local comparison village sites were identified for the follow-up assessment to enhance the plausibility that any recorded changes in the intervention villages were due to exposure to the interventions. The comparison sites were randomly selected from up to three candidate villages matched on community-level parameters that were deemed to be possibly associated with the child mortality and other MDG outcomes. Efforts were made to ensure adequate distance between Millennium Village sites and comparison sites to minimize spillover effects (average distance 40 km). At each assessment round a household survey was completed to gather information on demographic characteristics, education, employment assets, land ownership, agricultural practices, food security, bednet usage, and access to basic services including water, sanitation, energy, transport, and communication. An additional questionnaire was administered to an adult aged 15-49 years to examine health-related MDGs, nutrition and common causes of child mortality. Blood smears were collected to assess malaria parasitemia, and anthropometric assessments were done for children younger than 5 years of age.

Results and conclusions
Spending levels on MDG-related activities by governments, non-governmental organizations, and the communities were estimated to be 27 USD per person at baseline.  Average annual spending in the third year of the project increased to about 116 USD per person, of which 25 USD was spent on health. After 3 years of intervention, reductions were reported in poverty, food insecurity, stunting prevalence and malaria parasitemia across the nine Millennium Village sites.  No changes were reported in access to antenatal care or prevalence of wasting and underweight in children younger than 2 years of age. Mortality rates in children younger than 5 years of age decreased by 22% in Millennium Village sites relative to baseline (absolute decrease 25 deaths per 1000 live births, p=0.015) and 32% relative to the matched comparison sites (30 deaths per 1000 live births, p=0.033). Regrettably, no information was reported on exclusive breastfeeding rates or timely introduction of complementary feeding. The authors concluded that the integrated, multi-sectoral approach produced a rapid decline in child mortality in the study communities.

Program and Policy Implications
These results provide encouraging evidence that accelerated progress in achieving the MDGs, including reductions in child mortality, is possible in rural areas of sub-Saharan Africa. The authors suggest that integrated approaches that deliver health-sector inputs alongside broader investments in agriculture, nutrition, environment, and basic infrastructure hold great potential. Major challenges for the health-related interventions were related to commodity procurement and supply chain management, improving health-worker performance at clinical facilities and building the capacity of community-based, front-line health-workers. The authors hypothesized that these systemic weaknesses prevented major shifts in health-sector outcomes, which require a continuum of skilled health care personnel who are capable of providing diarrhea and pneumonia case management, antenatal care and postnatal examinations. Because no information was reported from in-depth nutritional assessments, little is known about the impact of the interventions on breastfeeding behaviors, age-appropriate complementary feeding practices, and specific aspects of young children’s nutritional status.

NNA Editors’ comments*
Integrating nutrition interventions into a multi-sectoral development program, such as that applied in the Millennium Village Project, is promising; and nutritionists should seek opportunities for promoting the nutrition agenda within this type of broad-based development projects. More information is needed on the impact and effectiveness of these integrated programs on nutritional outcomes.  Ideally, the impact assessment of any new program should be planned prior to the implementation of the intervention, so that the evaluation can be designed to strengthen the study conclusions. In the present study, no comparison villages were included initially because of ethical concerns regarding the inclusion of these communities without offering any additional programmatic inputs.  However, because the intervention and comparison villages were not randomly assigned initially, a true baseline comparison was not possible, which leaves the current findings open to criticism (3).  It is possible that the reported effects may not be specifically or entirely related to the intervention.

Because all interventions of the MVP were implemented at about the same time in all nine sites, it is not possible to evaluate which of the multiple interventions were most effective and whether any specific interventions might need further improvement. Considering the high investment costs and concerns raised about their sustainability (3), better understanding of the cost-effectiveness of the different program components would be useful. As new programs are being considered, program managers, public health experts and scientists should work closely with each other to optimize the program implementation and ensure suitable evaluations are planned to guide ongoing and future programs.

1.       Remans R, Pronyk PM, Fanzo JC, et al. Multisector intervention to accelerate reductions in child stunting: an observational study from 9 sub-Saharan African countries. Am J Clin Nutr 94: 1632-42; 2011. http://www.ajcn.org/content/94/6/1632.abstract
2.       Sanchez P, Palm C, Sachs J, et al. The African Millennium Villages. Proc Natl Acad Sci USA 204 : 16775-80 : 2007. http://www.pnas.org/content/104/43/16775.full.pdf+html
3.       Malenga G, Molyneux M. The Millennium Villages project. The Lancet DOI:10.1016/S0140-6736(12)60369-9. http://press.thelancet.com/mv.pdf
*These comments have been added by the editorial team and are not part of the cited publication.

Context-specific choice of food aid items (USAID)

In Under-nutrition on August 12, 2012 at 10:22 am

(click directly on the flowchart for an enlarged view)

In a recent document (2011), USAID, in collaboration with the UN Global Nutrition Cluster, UNHCR WFP and other organizations, suggest which type of programme and food commodities are more adequate.

However, it was concluded that there is no one food product that can meet every kind of programming goal, and no one programming approach that fits all needs.

The same panel  developed decision trees and few flow charts to help policy makers and donors in taking more informed decisions about programmes and choice of food-products.

The original program guidance is available here, whereas another version of the same, visible above, was adjusted in one chapter of my PhD thesis.

Open Source: a spread sheet application for planning, calculating and monitoring the Nutritional Value of food

In Under-nutrition on August 11, 2012 at 11:49 am

The planning, calculation, and monitoring application for food assistance programmes, NutVal 3.0 has an expanded database of commodities and products, and new population sub-groups to use for asssessing the adequacy of food assistance. NutVal is designed to run on Excel 2003 and later versions.

Download the most recent version of NutVal

NutVal was developed UNHCR, WFP, IGH/UCL and Global Nutrition Cluster.

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This blog hosts other posts related to the use of nutritional software.

Randomized, Double-Blind, Placebo-Controlled Trial Evaluating the Need for Routine Antibiotics as Part of the Outpatient Management of Severe Acute Malnutrition

In Under-nutrition on August 11, 2012 at 11:23 am

by Mark J. Manary, Kenneth Maleta, Indi Trehan
Food and Nutrition Technical Assistance II Project (FANTA-2) Bridge, FHI
360, March 2012

(download the entire document)

The Food and Nutrition Technical Assistance (FANTA) Project undertook a clinical trial comparing nutritional recovery and mortality outcomes in children with severe acute malnutrition (SAM) receiving 1 week of amoxicillin, cefdinir, or placebo, in addition to usual peanut-based ready-to-use therapeutic food (RUTF) therapy. This report documents the outcomes of the trial, which clearly showed the benefit of using antibiotics in the outpatient treatment of SAM without medical complications in a setting with high levels of kwashiorkor and HIV infection.

How to design, pre-test and trial low cost, local RUTF products to rehabilitate severely malnourished children and adults

In Under-nutrition on August 9, 2012 at 3:55 pm

The latest number of Field Exchange, a journal published by ENN, contains a summary of a recent research paper describing how to use “Linear programming to design low cost, local RUTF” with the aid of Microsoft Excel software.

Whereas the original paper abstract can be found on The Journal of Nutrition web site, in the Field Exchange journal (issue 43, part 1), the article summary is available (for free) at page 36, including an “adapted” flow chart with the step sequence proposed for the design (see beneath), the pre-testing and the trialling of these products, currently in high demand in feeding programmes around the world.

The authors of the original paper are Filippo Dibari (author also of this blog), El Hadji I. Diop, Steven Collins, and Andrew Seal from Valid International and the University College of London.

More information about the Linear Programming, applied to the field of nutrition, is also available from another post in this same blog.

Effects of psychosocial stimulation on improving home environment and child-rearing practices: results from a community-based trial among severely malnourished children in Bangladesh

In Under-nutrition on August 9, 2012 at 12:45 pm

Nahar BHossain MIHamadani JDAhmed TGrantham-McGregor SPersson LA.

BMC Public Health. 2012 Aug 7;12(1):622. [Epub ahead of print]




Parenting programmes are effective in enhancing parenting practices and child development. This study evaluated the effects of a intervention with psychosocial stimulation (PS) on the quality of the home environment and mothers’ child-rearing practices in a community-based trial with severely malnourished Bangladeshi children.


Severely underweight children (n = 507), 6-24 months of age, were randomly assigned to five groups: PS; food supplementation (FS); PS + FS; clinic-control (CC); and, hospital-control (CH). PS included fortnightly follow-up visits for six months at community clinics where a play leader demonstrated play activities and gave education on child development and child rearing practices. FS comprised cereal-based supplements (150-300 kcal/day) for three months. All groups received medical care, micronutrient supplements and growth monitoring. Mothers were given the Home Observation for Measurement of the Environment (HOME) inventory and a questionnaire on parenting at baseline and after six months to assess the outcome.


322 children completed the study. After six months of intervention the PS + FS and PS groups benefitted in the total HOME score (depending on the comparison group, effect sizes varied from 0.66 to 0.33 SD) The PS + FS and PS groups also benefitted in two HOME subscales: maternal involvement (effect sizes: 0.8 to 0.55 SD) and play materials, (effect sizes: 0.46 to 0.6 SD), and child-rearing practices scores (effect size: 1.5 to 1.1 SD). The PS + FS group benefitted 4.0 points in total HOME score compared with CH, 4.8 points compared with CC and 4.5 points compared with FS (p < 0.001 for all). The PS group benefitted 2.4 points compared with CH (p = 0.035), 3.3 points compared with CC (p = 0.004), and 2.9 points compared with FS (p = 0.006). Child-rearing practice scores of the PS + FS group improved 7.7, 6.4 and 6.6 points and the PS group improved 8.5, 7.2 and 7.4 points more than CH, CC and FS, respectively (p < 0.001 for all).


Child-rearing practices of mothers of severely malnourished children and the quality of their home environment can be improved through community-based psychosocial stimulation with or without food supplementation. This may be of importance to promote child development.

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