evidence-based blog of Filippo Dibari

Posts Tagged ‘nutrition interventions’

Maternal and Child Nutrition: Promoting Healthy Growth and Preventing Childhood Stunting

In Under-nutrition on September 14, 2014 at 6:06 am

Maternal and Child Nutrition Journal – Special Issue: Promoting Healthy Growth and Preventing Childhood Stunting

September 2013 – Volume 9, Issue Supplement S2 Pages 1–149

  • Editorial

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Promoting healthy growth and preventing childhood stunting: a global challenge (pages 1–5)

Adelheid W. Onyango

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12092

  • Original Article

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The World Health Organization’s global target for reducing childhood stunting by 2025: rationale and proposed actions (pages 6–26)

Mercedes de Onis, Kathryn G. Dewey, Elaine Borghi, Adelheid W. Onyango, Monika Blössner, Bernadette Daelmans, Ellen Piwoz and Francesco Branca

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12075

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Contextualising complementary feeding in a broader framework for stunting prevention (pages 27–45)

Christine P. Stewart, Lora Iannotti, Kathryn G. Dewey, Kim F. Michaelsen and Adelheid W. Onyango

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12088

  • Review Article

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Multi-sectoral interventions for healthy growth (pages 46–57)

Ma del Carmen Casanovas, Chessa K. Lutter, Nune Mangasaryan, Robert Mwadime, Nemat Hajeebhoy, Ana Maria Aguilar, Ciro Kopp, Luis Rico, Gonzalo Ibiett, Doris Andia and Adelheid W. Onyango

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12082

  • Original Articles

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Parental height and child growth from birth to 2 years in the WHO Multicentre Growth Reference Study (pages 58–68)

Cutberto Garza, Elaine Borghi, Adelheid W. Onyango, Mercedes de Onis and WHO Multicentre Growth Reference Study Group

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12085

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The economic rationale for investing in stunting reduction (pages 69–82)

John Hoddinott, Harold Alderman, Jere R. Behrman, Lawrence Haddad and Susan Horton

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12080

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The principles and practices of nutrition advocacy: evidence, experience and the way forward for stunting reduction (pages 83–100)

David Pelletier, Rukhsana Haider, Nemat Hajeebhoy, Nune Mangasaryan, Robert Mwadime and Satyajit Sarkar

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12081

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Key principles to improve programmes and interventions in complementary feeding (pages 101–115)

Chessa K Lutter, Lora Iannotti, Hilary Creed-Kanashiro, Agnes Guyon, Bernadette Daelmans, Rebecca Robert and Rukhsana Haider

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12087

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Designing appropriate complementary feeding recommendations: tools for programmatic action (pages 116–130)

Bernadette Daelmans, Elaine Ferguson, Chessa K. Lutter, Neha Singh, Helena Pachón, Hilary Creed-Kanashiro, Monica Woldt, Nuné Mangasaryan, Edith Cheung, Roger Mir, Rossina Pareja and André Briend

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12083

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Introducing infant and young child feeding indicators into national nutrition surveillance systems: lessons from Vietnam (pages 131–149)

Nemat Hajeebhoy, Phuong Hong Nguyen, Do Thanh Tran and Mercedes de Onis

Article first published online: 18 SEP 2013 | DOI: 10.1111/mcn.12086

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FAO (2013): The economics and nutritional impacts of food assistance policies and programs

In Under-nutrition on June 5, 2014 at 10:55 am

by Erin C. Lentz and Christopher B. Barrett

ESA Working Paper No . 13-04 – August 2013

Agricultural Development Economics Division – FAO

(download the doc)



Recent evidence on malnutrition and poverty raise important questions on the role of food assistance policies and programs. In this review article, we examine evidence on the economic and nutritional impacts of international food assistance programs (FAPs) and policies.
The returns on investments in FAPs are, on average, high but depend considerably on the targeting and cost structures as well as on food quality and role of complementary activities. We disaggregate findings into four classes of recipients. Returns to FAPs are highest for children under two. But, FAPs oriented towards early childhood interventions are less well funded than are interventions aimed at school-age children or at the broader, largely adult population even though available evidence indicates that these latter classes of interventions offer considerably lower average returns in economic, health, and nutrition terms.
Nonetheless, FAP effectiveness in achieving any of several objectives varies with a range of key factors, including targeting, additionality, seasonality, timeliness, incentive effects, social acceptability and political economy considerations.




World Bank book: What Can We Learn from Nutrition Impact Evaluations?

In Under-nutrition on September 22, 2013 at 8:28 pm

Author: World Bank. Year: 2010.

(from the World Bank web site)


High levels of child malnutrition in developing countries contribute to mortality and have long-term consequences for children’s cognitive development and earnings as adults. Recent impact evaluations show that many different interventions have had an impact on children’s anthropometric outcomes (height, weight, and birth weight), but there is no simple answer to the question “What works?” to address the problem. Similar interventions have widely different results in different settings, owing to differences in local context, the causes and severity of malnutrition, and the capacity for program implementation.

Impact evaluations of programs supported by the Bank, which are generally large-scale, complex interventions in low-capacity settings, show equally variable results. The findings confirm that it should not be assumed that an intervention found effective in a randomized medical setting will have the same effects when implemented under field conditions. There are many robust experimental and quasi-experimental methods for assessing impact under difficult circumstances often found in field settings.

The relevance and impact of nutrition impact evaluations could be enhanced by collecting data on service delivery, demand-side behavioral outcomes, and implementation processes to better understand the causal chain and what part of the chain is weak, in parallel with impact evaluations. It is also important to understand better the distribution of impacts, particularly among the poor, and to document better the costs and effectiveness of interventions.

High levels of child malnutrition in developing countries are contributing to mortality and present long-term consequences for the survivors. An estimated 178 million children under age 5 in developing countries are stunted (low height for age) and 55 million are wasted (low weight for height). Malnutrition makes children more susceptible to illness and strongly affects child mortality. Beyond the mortality risk in the short run, the developmental delays caused by undernutrition affect children’s cognitive outcomes and productive potential as adults. Micronutrient deficiencies—vitamin A, iron, zinc, iodine, for example—are also common and have significant consequences. Progress in reducing malnutrition has been slow: More than half of countries are not on track to achieve the Millennium Development Goal of halving the share of children who are malnou-rished (low weight for age) by 2015. The food price and financial crises are making achievement of this goal even more elusive. The World Bank has recently taken steps to ex-pand its support for nutrition in response to the underlying need and the increased urgency due to the crises.

WHAT DO WE KNOW ABOUT REDUCING MALNUTRITION? The increased interest and resources focused on the problem of high and potentially increasing rates of undernutrition raises the question, what do we know about the causes of malnutrition and the in-terventions most likely to reduce it? The medical literature points to the need to intervene during gestation and the first two years of life to prevent child malnutrition and its consequences. It suggests that investments in interventions during this window of opportunity among children under 2 are likely to have the greatest benefits. Recently published meta-analyses of the impact evaluation literature point to several interventions found effective for reducing undernutrition in specific settings. However, there are limitations to the generalizability of those reviews’ findings, particularly in the context of large-scale government programs most likely to be supported by the World Bank. The reviews tend to disproportionately draw on the findings of smaller, controlled experiments; there are few examples of evaluations of large-scale programs, over which there is less control in implementation. In reviewing a large number of studies, interventions, and outcomes, they tend to focus on average impacts. They generally do not explain the magnitude or variability of impacts across or within studies. Very few address the programmatic reasons why some interventions work or don’t work, nor do they assess the cost-effectiveness of interventions.

Objectives of the Review This paper reviews recent impact evaluations of interventions and programs to improve child anthropometric outcomes—height, weight, and birth weight—with an emphasis on both the findings and limitations of the literature and on understanding what might happen in a non-research setting. It further reviews in greater detail the experience and lessons from evaluations of the impact of World Bank-supported programs on nutrition outcomes. Specifically, the review addresses four questions. First, what can be said about the impact of different interventions on children’s anthropometric outcomes? Second, how do these findings vary across settings and within target groups, and what accounts for this variability? Third, what is the evidence of the cost-effectiveness of these interventions? Finally, what have been the lessons from implementing impact evaluations of Bank-supported programs with anthropometric impacts? While there are different dimensions of child nutrition that could be explored, the report focuses on child anthropometric outcomes — weight, height, and birth weight. These are the most common nutrition outcome indicators in the literature and the most frequently monitored by national nutrition programs supported by the World Bank. Low weight for age (underweight) is also the indicator for one of the MDGs. Methodology and Scope Forty-six nutrition impact evaluations published since 2000 were systematically reviewed. These evaluations assessed the impact of diverse interventions—community nutrition programs, conditional and unconditional cash transfers, early child development programs, food aid, integrated health and nutrition services, and deworming. All of the evaluations used research designs that compared the outcomes among those affected by the project to the counterfactual—that is, what would have happened to a similar group of people in the absence of the intervention. About half used randomized assignment to create treatment and control groups, while the remainder used matching and various econometric techniques to construct a counterfactual. Among the 46 evaluations, twelve assessed the impact of World Bank-supported programs on nutrition outcomes in eight countries. While the broader review relies on the analysis of the published impact evaluations as the main source of data, for these twelve evaluations project documents and research outputs were reviewed and World Bank staff, country officials and the evaluators and re-searchers who conducted the studies were interviewed.

Findings A wide range of interventions had a positive impact on indicators related to height, weight, wasting, and low birth weight. There were a total of 10 different outcome indicators for the four main anthropometric outcomes. A little more than half of the evaluations addressing a height-related indicator found program impacts on at least one group of children, and this was true for about the same share of interventions aimed at improving weight-related and wasting (low weight for height)-related indicators. About three-quarters of the 11 evaluations of interventions that aimed at improving birth weight indicators registered an impact in at least one specification, including five out of seven micronutrient interventions. There was no clear pattern of impacts across interventions—in every intervention group there were examples of programs that did and did not have an impact on a given indicator, and with varying magnitude. Evaluations of the nutritional impact of programs supported by the World Bank, which are generally large-scale, complex, and implemented in low-capacity settings, show equally variable results. Even controlling for the specific outcome indicator, studies often targeted children of different age groups that might be more or less susceptible to the interventions. It is thus difficult to point to interventions that are systematically more effective than others in reducing malnutrition across diverse set-tings and age groups. Differences in local context, variation in the age of the children studied, the length of exposure to the intervention, and differing methodologies of the studies account for much of the variability in results. Context includes factors like the level and local determinants of malnutrition, differences in the characteristics of beneficiaries (including their age), the availability of service infrastructure, and the implementation capacity of government. Outside of a research setting in the context of a large government program there are many things that can go wrong in either service delivery or the demand response that can compromise impact. Beyond this, there are social factors like the status of women or the presence of civil unrest that can affect outcomes. These findings underscore the conclusion that it should not be assumed that an intervention found effective in a randomized controlled trial in a re-search setting will have the same effects when implemented under field conditions in a different set-ting. They also point to the need to understand the prevailing underlying causes of malnutrition in a given setting and the age groups most likely to benefit in selecting an intervention. Further, impact evaluations need to supplement data measuring impact with data on service delivery and demand-side behavioral outcomes to demonstrate the plausibility of the findings, to understand what part of a program works, and to address weak links in the results chain to improve performance. There is scant evidence on the distribution of nutrition impacts — who is benefiting and who is not – or on the cost-effectiveness of interventions Just because malnutrition is more common among the poor does not mean that they will disproportionately benefit from an intervention, particularly if acting on new knowledge or different incentives relies on access to education or quality services. Only a third of the 46 evaluations looked at the distribution of impacts by gender, mother’s education, poverty status, or availability of complementary health services. Only nine assessed the impacts on nutritional outcomes of the poor compared with the non-poor. Among the evaluations that did examine variation in results, several found that the children of more educated mothers or in better-off communities are benefiting the most. Bank-supported cash transfers, community nutrition, and early child development programs in six of eight countries had some impact on child anthropometric outcomes. Of the 12 impact evaluations of Bank support, all but one were of large-scale government programs with multiple interventions and a long results chain. Three-quarters found a positive impact on anthropometric outcomes of children in at least one age group, although the magnitude was in some cases not large or applied to a narrow age group. Most of the impact evaluations involved assessment of completely new programs and involved World Bank researchers. Most used quasi-experimental evaluation designs and two-thirds assessed impact after at most 3 years of program implementation. Only half of the evaluations documented the distribution of impacts and only a third presented information on the costs of the intervention (falling short of cost-effectiveness analysis). In two of the countries (Colombia and the Philippines) the evaluations likely had an impact on government policy or programs.

Lessons A number of lessons for development practitioners and evaluators arose from the review of impact evaluations of World Bank nutrition support. For task managers: – Impact evaluations of interventions that are clearly beyond the means of the government to sustain are of limited relevance. The complexity, costs, and fiscal sustainability of the intervention should figure into the decision as to whether an impact evaluation is warranted. – Impact evaluations are often launched for the purpose of evaluating completely new pro-grams, but they may be equally or even more useful in improving the effectiveness of ongoing programs. – There are methods for obtaining reliable impact evaluation results when randomized assignment of interventions is not possible for political, ethical, or practical reasons. For evaluators: – In light of the challenges of evaluating large-scale programs with a long results chain, it is well worth the effort to assess the risks to disruption of the impact evaluation ahead of time and identify mitigation measures. – The design and analysis of nutrition impact evaluations need to take into account the likely sensitivity of children of different ages to the intervention. – For the purposes of correctly gauging impact, it is important to know exactly when delivery of an intervention took place in the field (as opposed to the official start of the program). – Evaluations need to be designed to provide evidence for timely decision-making, but with sufficient elapsed time for a plausible impact to have occurred.

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Latest WHO release: “Essential Nutrition Actions: Improving maternal, newborn, infant and young child nutrition”

In Over-nutrition, Under-nutrition on June 12, 2013 at 4:51 pm

by WHO web page

Downloads:  Full document – pdf, 1.09Mb


Malnutrition in all its forms is closely linked, either directly or indirectly, to major causes of death and disability worldwide. The causes of malnutrition are directly related to inadequate dietary intake as well as disease, but indirectly to many factors, among others household food security, maternal and child care, health services and the environment. While most nutrition interventions are delivered through the health sector, non-health interventions can also be critical. Actions should target the different causes to reach sustainable change, which requires a multisectoral approach.

This document provides a compact of WHO guidance on nutrition interventions targeting the first 1,000 days of life. Focusing on this package of essential nutrition actions (ENA), policy-makers could reduce infant and child mortality, improve physical and mental growth and development, and improve productivity. Part I presents the interventions currently recommended by WHO, summarizes the rationale and the evidence, and describes the actions required to implement them. The document uses a life course approach, from pre-conception throughout the first 2 years of life. Part II provides an analysis of community-based interventions aimed at improving nutrition and indicates how effective interventions can be delivered in an integrated fashion. It shows how the ENAs described in the first part have been implemented in large-scale programmes in various settings, what the outcomes have been, and to examine the evidence for attribution of changes in nutritional outcomes to programme activities.

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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

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