evidence-based blog of Filippo Dibari

Posts Tagged ‘stunting’

Food systems and diets: facing the challenges of the 21st century

In Over-nutrition, Under-nutrition on September 27, 2016 at 7:26 am

from the webpage of the Global Panel on Agriculture and Food Systems for Nutrition

(download the report here)

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The Global Panel on Agriculture and Food Systems for Nutrition published its new Report, Food systems and diets: Facing the challenges of the 21st century on the 23rd September 2016.

This evidence-based Report is designed to help policymakers make their food systems more supportive of high quality diets.

The need for action on malnutrition

Poor diet is the number one risk factor driving the world’s disease burden.

Three billion people from 193 countries now have low quality diets and nearly half of all countries are experiencing the simultaneous problem of serious levels of undernutrition, overweight and obesity. Yet our global understanding about the quality of our diets is limited.

The Report

Using modelling and trend analysis, the Report generates a new understanding of diets and food systems, and how they could change by 2030.

The analysis shows that if current trends continue, by 2030 nearly half of the world’s adult population will be overweight or obese, up from one third today. The poorest countries are not immune to these trends.

It also shows how these trends have enormous economic impacts at the macro and micro levels, as well major consequences for mortality and morbidity. For example, at the macro level, cost are estimated to represent an annual loss of 10% global GDP, equivalent to a global financial crisis every year.

Drawing on over 250 data sources and peer-reviewed articles, the Report lists a series of recommendations for policymakers in low and middle income countries through a ‘Call to Action’.

The Report presents evidence showing that the risk that poor diets pose to mortality and morbidity is now greater than the combined risks of unsafe sex, alcohol, drug and tobacco use.

But, as the Report shows that there are many opportunities for action within the food system.

A Call to Action

This Report identifies decisions that policymakers need to take in the coming decade, particularly for women and children, to invest in effective policies to reduce all forms of malnutrition, repositioning food systems from feeding people to nourishing people.

Actions which go beyond agriculture to encompass trade, the environment and health, harnessing the power of the private sector and empowering consumers to demand better diets.

Enhancing the ability of food systems to deliver high quality diets is a choice that is well within the grasp of policymakers.  It is a choice that will help achieve the SDG goal of ending malnutrition in all its forms by 2030. It is a choice that will reap benefits for decades to come, for all people, in all countries.

Only a response on the scale and commitment used to tackle HIV/AIDS and malaria will be sufficient to meet the challenge, particularly in low- and middle-income countries.

“This Report makes clear the enormous challenge posed by malnutrition and poor diets generally to the detriment of many millions of individuals and indeed whole economies.”

Sir John Beddington, Co-Chair of the Global Panel, and former UK Chief Scientific Advisor

Associations of Suboptimal Growth with All-Cause and Cause-Specific Mortality in Children under Five Years: A Pooled Analysis of Ten Prospective Studies

In Under-nutrition on June 3, 2016 at 3:38 pm

Olofin I, McDonald CM, Ezzati M, Flaxman S, Black RE, et al. (2013) Associations of Suboptimal Growth with All-Cause and Cause-Specific Mortality in Children under Five Years: A Pooled Analysis of Ten Prospective Studies. PLoS ONE 8(5): e64636.

(download)

Abstract

 

Background

Child undernutrition affects millions of children globally. We investigated associations between suboptimal growth and mortality by pooling large studies.

Methods

Pooled analysis involving children 1 week to 59 months old in 10 prospective studies in Africa, Asia and South America. Utilizing most recent measurements, we calculated weight-for-age, height/length-for-age and weight-for-height/length Z scores, applying 2006 WHO Standards and the 1977 NCHS/WHO Reference. We estimated all-cause and cause-specific mortality hazard ratios (HR) using proportional hazards models comparing children with mild (−2≤Z<−1), moderate (−3≤Z<−2), or severe (Z<−3) anthropometric deficits with the reference category (Z≥−1).

Results

53 809 children were eligible for this re-analysis and contributed a total of 55 359 person-years, during which 1315 deaths were observed. All degrees of underweight, stunting and wasting were associated with significantly higher mortality. The strength of association increased monotonically as Z scores decreased. Pooled mortality HR was 1.52 (95% Confidence Interval 1.28, 1.81) for mild underweight; 2.63 (2.20, 3.14) for moderate underweight; and 9.40 (8.02, 11.03) for severe underweight. Wasting was a stronger determinant of mortality than stunting or underweight. Mortality HR for severe wasting was 11.63 (9.84, 13.76) compared with 5.48 (4.62, 6.50) for severe stunting. Using older NCHS standards resulted in larger HRs compared with WHO standards. In cause-specific analyses, all degrees of anthropometric deficits increased the hazards of dying from respiratory tract infections and diarrheal diseases. The study had insufficient power to precisely estimate effects of undernutrition on malaria mortality.

Conclusions

All degrees of anthropometric deficits are associated with increased risk of under-five mortality using the 2006 WHO Standards. Even mild deficits substantially increase mortality, especially from infectious diseases.

What are the implications for humanitarian programming of responding to stunting in protracted emergency contexts, and what should we be doing about it?

In Under-nutrition on June 3, 2016 at 7:43 am

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from ENN

A number of recent reviews of crises, including Syria (ENN 2014), Lebanon and the Ukraine (GNC-ENN 2015) have raised questions about the humanitarian nutrition response in contexts where levels of wasting are not elevated or high in terms of emergency thresholds, but where stunting is prevalent.

ENN decided to investigate the implications of operating in situations of protracted crisis where levels of stunting may be high and of concern. This brief investigation included a review of documents and informal discussions with a number of nutrition focal points in some of the donors and agencies. The purpose is to begin to explore the issues and pose questions and in so doing get the issue of stunting in protracted contexts higher up the nutrition agenda

Download: Stunting-Brief-2015_WEB_01022016.pdf (PDF, 1.3mb)

Stunting: latest evidence (open source)

In Under-nutrition on May 19, 2016 at 8:42 pm

Stop stunting: improving child feeding, women’s nutrition and household sanitation in South Asia.

Víctor M. Aguayo and Purnima Menon

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12283/epdf

 

Childhood stunting: a global perspective.

Mercedes de Onis and Francesco Branca

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12231/epdf

 

Reducing stunting by improving maternal, infant and young child nutrition in regions such as South Asia: evidence, challenges and opportunities.

Kathryn G. Dewey

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12282/epdf

 

Feeding practices for infants and young children during and after common illness. Evidence from South Asia.

Kajali Paintal and Víctor M. Aguayo

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12222/epdf

 

Improving women’s nutrition imperative for rapid reduction of childhood stunting in South Asia: coupling of nutrition specific interventions with nutrition sensitive measures essential.

Sheila C. Vir

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12255/epdf

 

Can water, sanitation and hygiene help eliminate stunting? Current evidence and policy implications.

Oliver Cumming and Sandy Cairncross

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12258/epdf

 

Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries.

Mduduzi N. N. Mbuya and Jean H. Humphrey

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12220/epdf

 

Determinants of stunting and poor linear growth in children under 2 years of age in India: an in-depth analysis of Maharashtra’s comprehensive nutrition survey.

Víctor M. Aguayo, Rajilakshmi Nair, Nina Badgaiyan and Vandana Krishna

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12259/epdf

 

Achieving behaviour change at scale: Alive & Thrive’s infant and young child feeding programme in Bangladesh.

Tina Sanghvi, Raisul Haque, Sumitro Roy, Kaosar Afsana, Renata Seidel, Sanjeeda Islam, Ann Jimerson and Jean Baker

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12277/epdf

 

Evidence-based evolution of an integrated nutrition-focused agriculture approach to address the underlying determinants of stunting.

Nancy J. Haselow, Ame Stormer and Alissa Pries

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12260/epdf

 

Estimating the cost of delivering direct nutrition interventions at scale: national and subnational level insights from India.

Purnima Menon, Christine M. McDonald and Suman Chakrabarti

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12257/epdf

 

The costs of stunting in South Asia and the benefits of public investments in nutrition.

Meera Shekar, Julia Dayton Eberwein and Jakub Kakietek

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12281/epdf

 

Understanding the null-to-small association between increased macroeconomic growth and reducing child undernutrition in India: role of development expenditures and poverty alleviation.

William Joe, Ramaprasad Rajaram and S. V. Subramanian

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12256/epdf

 

Drivers of nutritional change in four South Asian countries: a dynamic observational analysis.

Derek Headey, John Hoddinott and Seollee Park

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12274/epdf

 

Rethinking policy perspectives on childhood stunting: time to formulate a structural and multifactorial strategy.

S V Subramanian, Iván Mejía-Guevara and Aditi Krishna

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12254/epdf

ENN: The relationship between wasting and stunting: policy, programming and research implications (2014)

In Under-nutrition on April 24, 2015 at 6:16 am

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by Tanya Khara and Carmel Dolan – from ENN website

Download – (4.2mb)

This paper is a narrative review of the available literature on the relationship between wasting andstunting. It was born out of previous work carried out by the ENN which illustrated the divide at programme, policy and financing level between wasting and stunting.

This divide ultimately has profound implications for how children worldwide receive nutrition interventions and services and, may well contribute to the lack of nutritional impact seen in programmes only addressing one part of the undernutrition problem.

Gaining a clearer and common understanding of the relationship between wasting and stunting has the potential to help governments and supporting organisations to better justify, design and evaluate programmes to improve childhood nutrition.

This paper aims to contribute to that clearer and common understanding.

Reaching the missing middle: Overcoming hunger and malnutrition in middle income countries

In Over-nutrition, Under-nutrition on April 23, 2015 at 7:00 am

by Shenggen Fan and Ertharin Cousin

wfp logo

from WFP web site

(download entire document)

Hunger and malnutrition are not problems exclusive to low income countries.

That is why the international community cannot realise its ambitious international agenda of achieving zero hunger and malnutrition without a renewed focus on countries in economic transition where hunger and malnutrition remain.

The majority of the world’s hungry and malnourished population now live in Middle Income Countries (MICs).

For these countries to best fulfil their vital role in supporting zero hunger and malnutrition, they must promote effective country-led strategies that will reduce hunger and malnutrition at home.

GAIN – x2 new working papers detailing lessons learned from six year Infant and Young Child Nutrition (IYCN) program

In Under-nutrition on April 15, 2015 at 12:44 pm

from GAIN website.

 

GAIN has recently published two new working papers detailing lessons learned from six year Infant and Young Child Nutrition (IYCN) program.

The papers were launched at our one day #Nutrition Now: 1,000 Days Symposium in London.

The two papers outline in detail challenges met and strategies used across 23 projects in 17 countries in Asia, Africa and Latin America. The projects are an innovative mix of public and private models and combine proven infant interventions, such as the promotion of breast feeding, with novel market-based strategies.

The papers each focus on a different element of GAINs approach:
Paper 1 examines lessons learned regarding effective public and private sector business models for production and delivery of complementary feeding products and fortified foods
Paper 2 analyses what we’ve learned about driving consumer awareness and behaviour change to ensure good feeding practices and uptake of complementary feeding products

Download the full reports:

Working Paper 1: Improving complementary feeding: Assessing public and private sector business models_

Working Paper 2: Promoting optimal infant feeding practices and effective use of complementary food for infants: Delivery lessons

Watch our videos:

GAIN in Indonesia: Improving nutrition and changing behaviours in the first 1,000 days  

Improving nutrition for infants and children

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Evidence of Effective Approaches to SBCC for Preventing and Reducing Stunting and Anemia

In Under-nutrition on October 27, 2014 at 3:28 pm

From Spring web page

(download the doc)

Evidence suggests that simply increasing knowledge and awareness of good nutrition practices rarely leads to sustained behavior change, nor is sustained change in nutrition behavior likely to be achieved through a single activity. Several specific behaviors or practices impact nutritional status during the critical first 1,000 days (pregnancy to age two), while complex, contextual determinants also influence individual decisions to consider, test, adopt and sustain a given behavior or practice. The field of Social and Behavior Change Communication (SBCC) is a collection of approaches and tools informed by behavioral theories and used to design public health interventions.

This review, part of a broader effort by SPRING to support governments and other stakeholders in their delivery of high impact nutrition practices, provides a summary of peer-reviewed evidence regarding the effectiveness of SBCC approaches to increase the uptake of three key nutrition behaviors: women’s dietary practices during pregnancy and lactation, breastfeeding practices, and complementary feeding practices. SBCC interventions have been broadly categorized into three areas: interpersonal communication; use of media; and community/social mobilization. This review also identifies gaps in the evidence and recommendations for further areas of study.

This review includes a total of 91 studies identified using the Ovid MEDLINE database. Recognizing the potential value of a broad array of study designs, results from five study types are included: reviews (including meta-analysis), randomized controlled trials, longitudinal studies, repeated cross-sectional studies, and cross-sectional studies. Excluded studies include those with data from high income countries, those published prior to 2000, those written in a language other than English, and those that focused exclusively on refinement of a research methodology. Other exclusions are noted in the text.

Each of the following sections contain interactive tables featuring the articles reviewed for this study.

Findings related to women’s dietary practices during pregnancy and lactation

Undernutrition during pregnancy and lactation is a critical determinant of maternal, neonatal, and child health outcomes. Improving dietary adequacy during pregnancy and lactation is important to help women accommodate their nutritional requirements as well as their children’s requirements during intrauterine development and while breastfeeding (Haileslassie, et al., 2013).

The body of literature on the effectiveness of SBCC to improve women’s dietary practices during pregnancy and lactation is still small (only 15 peer-reviewed studies met the inclusion criteria), but indicates that SBCC approaches can and do succeed in improving uptake of the behaviors promoted. The greatest gap in the literature was in evidence of effectiveness of SBCC in improving rest and workload during pregnancy. Given the importance of women’s dietary practices during pregnancy and lactation, the dearth of evidence is notable.

Browse this section’s interactive table of articles

Findings related to breastfeeding practices

Breastfeeding is widely recognized as one of the most costeffective investments to improve child survival (UNICEF, 2013), as well as cognitive and motor development and academic performance (Horta et al, 2013). Breastfeeding also imparts critical benefits to the woman, including natural postnatal infertility. Despite the promise of optimal breastfeeding practices, rates for WHO recommended breastfeeding practices remain low (UNICEF, 2013).

The body of literature on the effectiveness of SBCC approaches in improving breastfeeding practices is strong and broad (62 peer-reviewed studies met the inclusion criteria) and supports the claim that SBCC approaches can and do succeed in improving uptake of the behaviors promoted.

Evidence from several studies strongly suggests that increasing the number of contacts increases the positive effect of SBCC on breastfeeding practices. Greater consistency in how breastfeeding practices are measured – the definitions of indicators and the methods of data collection – exists for breastfeeding practices when compared to women’s dietary practices and complementary feeding practices, but even with globally-recognized indicators and measurement guidance, considerable variation remains.

Browse this section’s interactive table of articles

Findings related to complementary feeding practices

Timely appropriate complementary feeding are critical to a child’s growth and development and could avert millions of disability-adjusted life years, but global coverage of optimal complementary feeding practices remains low.

The evidence of the effect of SBCC on complementary feeding practices is quite broad (30 studies met the inclusion criteria) and clearly indicates that SBCC interventions can improve a wide range of complementary feeding practices. However, measures of optimal complementary feeding are so varied that it is particularly challenging to draw conclusions regarding the effectiveness of particular SBCC approaches.

Browse this section’s interactive table of articles

Common findings

The SBCC approach most used, and the only one used without other communication interventions, was interpersonal communication. While media and community/ social mobilization were used, they were always used with at least one other communication approach.

Studies included in this review employed a wide range of implementation strategies with variations in the interactions or combinations with other interventions, target groups, content, messages, scale and coverage, length and intensity, as well as context. Very little has been done to compare the effect of differences in the delivery science, particularly when implemented at scale.

The majority of the studies were implemented on a small scale, typically with fewer than 500 people per group.

Additionally, there was considerable variation in how women’s dietary practices and complementary feeding practices were defined and measured.

Conclusions

Evidence suggests that using multiple SBCC approaches and channels to change behaviors is more effective than using one, that targeting multiple contacts has a greater effect than targeting only the woman herself, and that more visits or contacts results in greater change. However, such comparisons are not well-tested in the literature. Very few comparisons have been made between the effect of timing of communications and what little has been done presents contradictory evidence. Unfortunately, it can be challenging to conduct such studies that compare differences in delivery and/or disaggregate single approaches within a multiapproach intervention. SBCC practitioners and researchers must assess whether that line of research is useful.

Differences in local context (including social norms, culture, and environmental factors) as well as differences in the implementation and scale of implementation also affect the success of interventions. This underscores the importance of proper context assessments, formative research and/or ethnographic study prior to SBCC implementation.

Finally, if practices and indicators are not standardized, a project may improve behaviors but it will be difficult to attribute changes in outcomes. This underscores the importance of developing practices and indicators that are globally recognized, accepted, and used by the research and program communities. At the same time, many nutrition interventions are suited to iterative programming for incremental change toward the optimal, evidence-based behaviors. This means that more easily achieved indicators (components of standardized indicators or shorter time periods) may also be needed to measure progress toward the ultimate goal of changes in the standardized indicators of behaviors.

Other areas particularly important for future evaluations and operations research include:

  • the effect of targeting multiple audiences or influencers of the behaviors being promoted, rather than focusing on one target population;
  • the effect of the same SBCC intervention implemented in different contexts (social and environmental);
  • the effectiveness of different approaches (including intensity and targeting) for different behaviors;
  • the cost and cost effectiveness of various SBCC approaches (particularly as it relates to scalability); and
  • the effectiveness and sustainability of these approaches when implemented at scale.

School Feeding: Can stunting be reversed? Yes, and Peru is showing us how

In Under-nutrition on October 27, 2014 at 7:59 am

From the web site of Schools & Health.

 

Children affected by the 2008 food crisis in Peru show stunting can be reversed. Is it time to focus beyond the first 1,000 days?

In 2008 there was a terrible food crisis in Peru. The price o​f rice doubled in three months and millions of families were struggling to put food on the table. Six years on, thousands of Peruvian children who were babies and toddlers during the food crisis are much smaller than they should be. And for many, their cognitive skills development has been negatively affected too.

Children’s bodies and brains develop fastest when they’re in the womb and during the first two years of their lives: the first thousand days. And it’s during this crucial period that physical stunting and cognitive impairment can really set in if pregnant mothers and babies miss out on adequate nutrition.

Research has suggested that early stunting and its effects are irreversible. So will these Peruvian children’s futures be permanently blighted because they weren’t getting enough to eat when they were little?

At Young Lives we’ve been studying the progress of 12,000 children in Peru, Vietnam, Ethiopia, and India – measuring all aspects of their physical, cognitive, and social development since 2002. We’ve been following the development of children who were undernourished early in their lives and we’ve discovered that the effects of early undernutrition aren’t always irreversible. Some children in our studies were able to recover from early stunting and develop normally.

In particular, our results show that around 50% of children in Peru who were stunted in 2002, when they were around a year old, were not stunted in 2009. The same figure was around 45% for India.

So while the first thousand days are very important, the rest of a child’s life is too. It now seems clear that children can recover from stunting after their first thousand days.

Our findings indicate that factors like household income, maternal education and health, local water, sanitation and health infrastructure, which are key to stunting prevention, are also important for recovery from stunting.

Recovery from stunting after the first thousand days may also lead to the reversal of developmental setbacks such as cognitive impairment. Our findings suggest that children who recovered from early stunting performed better in vocabulary and mathematics tests than children who remained stunted.

School meals, cash transfer and health programmes can help

This and other evidence suggests that school feeding programmes may help undernourished children to recover from stunting. Young Lives fin​dings show that India’s national school feeding programme helped children to recover from a decline in growth due to a severe drought when they were one-year-old. In Peru, national feeding programmes, such as Qali Warma and Vaso de Leche may have helped children who became stunted as a result of the food crisis to recover.

Conditional cash transfer programmes that provide financial incentives to poor households to invest in children’s health may also be a powerful instrument in the fight against child undernutrition​. An example of such a programme in Peru is Juntos, which requires that children below the age of five in families that receive the support, must attend health facilities for comprehensive healthcare and nutrition.

To prevent stunting, there are potential benefits to extending the coverage of early child development programmes to older children. For example, Cuna Mas in Peru, which aims to improve development for children living in poverty, could be extended from children younger than three to children younger than six-years-old.

There’s no doubt about the importance of the first thousand days for a child’s growth and development, so nutrition intervention needs to start early. But intervention shouldn’t always end when the child reaches two. It needs to be sustained throughout childhood and target the most stunted and undernourished children so they have a decent chance to recover.​

The Making of a Messenger: Engaging Extension and Advisory Service Providers in Nutrition-Sensitive Agriculture | SPRING

In Under-nutrition on October 19, 2014 at 6:54 am

Date(s):  October 29, 2014 – from USAID web site

Agriculture extension agents are a valuable source of information and expertise for many small scale farmers across the globe. As global understanding builds around the linkages between agriculture and nutrition, efforts are currently underway to integrate activities promoting nutrition into agriculture extension programming in several Feed the Future countries. Join SPRING and the Modernizing Extension and Advisory Services (MEAS) project in a two-part webinar series exploring these efforts in Malawi and Ethiopia.

The first event, scheduled for October 29th at 9:00 a.m. EST, will focus on MEAS’s assessment of agricultural extension, nutrition education, and integrated agriculture-nutrition programs and systems in Malawi. The assessment aims to inform the design of an activity that will strengthen delivery of coordinated and integrated extension and nutrition outreach services in Malawi’s Feed the Future focus districts. Vickie Sigman, Independent Senior Agriculture Extension Specialist, will discuss the various programs and systems in place in Malawi to deliver integrated extension and nutrition outreach services. Service delivery constraints and possibilities for addressing existing constraints will aslo be highlighted. Paul McNamara, Director, Modernizing Extension and Advisory Services Project and Valerie Rhoe, Senior Technical Advisor at Catholic Relief Services, will serve as respondents as part of the presentation.

The second event is scheduled for November 13th at 9:00 a.m. EST and will examine SPRING’s recent work in Ethiopia. SPRING collaborated with the USAID Mission and several Feed the Future implementing partners  to document the experiences and coordination among Feed the Future partners utilizing public extension agriculture Development Agents (DAs) to deliver nutrition messages and interventions at the community-level. SPRING’s Social and Behavior Change Advisor, Ashley Aakesson, will discuss the processes, challenges, successes, and lessons learned from project staff, government staff including DAs, and community members, and ways current programming and coordination could be adjusted to improve nutrition outcomes.

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