Effectiveness of unconditional cash transfers combined with lipid-based nutrient supplement and/or behavior change communication to prevent stunting among children in Pakistan: a cluster randomized controlled trial

Community-Based Child Food Interventions/Supplements for the Prevention of Wasting in Children Up to 5 Years at Risk of Wasting and Nutritional Oedema: A Systematic Review and Meta-Analysis

CONTEXT

Malnutrition poses a significant threat to child health, with millions of children worldwide affected by wasting, which increases the risk of morbidity and mortality.

OBJECTIVE

In this study we sought to evaluate the effectiveness of community-based infant/child food interventions and supplements for preventing wasting among children up to 5 years at risk of wasting and nutritional oedema. The World Health Organization commissioned this review to update their guidelines on wasting due to malnutrition in children.

DATA SOURCES

Nine databases were searched from inception until July 2021 and an updated search was carried out on MEDLINE and Ovid MEDLINE until April 13, 2023, and included 24 studies (98 articles) evaluating the impact of community-based infant/child food interventions/supplements for the prevention of wasting among children up to 5 years.

DATA EXTRACTION

Two review authors independently extracted data and assessed the quality of included studies using the Cochrane Risk of Bias Tool 2.0. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria were used to assess the quality of evidence.

DATA ANALYSIS

This review included 19 cluster-randomized controlled trials (cRCTs) and 5 RCTs evaluating the impact of community-based infant/child food interventions/supplements including fortified blended foods (FBFs), small-quantity (SQ), medium-quantity (MQ), or large-quantity (LQ) lipid-based nutrient supplements (LNS), and multiple micronutrient powder (MNP) for the prevention of wasting among children up to 5 years of age. The analysis showed that infants/children given supplementation with LNS (either SQ, MQ, or LQ) had significantly reduced wasting and significant improvements in weight-for-age z-score, mid-upper-arm circumference (MUAC), and underweight prevalence, along with significant reductions in mortality. The MNP supplementation had little or no impact on wasting but was associated with increased incidences of rapid breathing/chest indrawing and diarrhea morbidity. Overall, the studies were judged to have raised some concerns for the outcomes of wasting and adverse anthropometric indices. However, the GRADE analysis suggested low-to-moderate certainty of outcomes.

CONCLUSIONS

The findings of this review highlight the effectiveness of SQ-LNS and MQ/LQ-LNS supplementation in decreasing rates of wasting, underweight, and mortality and increasing MUAC and weight-for-age z-scores. Methodological limitations in most studies emphasize the need for future trials with direct comparisons of various dietary supplementation strategies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021277429.

Evidence on Strategies for Integrating Nutrition Interventions with Health and Immunization Systems in Conflict-affected Areas of Low- and Lower-middle-income Settings-A Systematic Review

CONTEXT

Pervasive conflict and war adversely affect a nation's sustainable development. Health and health systems deteriorate, causing long-lasting impacts on diets and nutrition. For the most vulnerable, integrated models of delivery of essential nutrition interventions are critical for the efficiency and sustainability of programs in these settings.

OBJECTIVE

The objective of this systematic review was to provide evidence on coverage, utilization, and impact of integrated programs in conflict-affected, low- and middle-income countries (LMICs).

DATA SOURCES

A database search was conducted in MEDLINE, Embase, CINAHL, and CENTRAL from January 1, 2000 to February 14, 2024. Gray literature was also reviewed.

DATA EXTRACTION

Quantitative and qualitative studies, including observational or intervention designs, and reviews and program evaluations conducted in LMICs, focusing on women (≥19 years) and children (0-19 years) were included. Data extraction and risk-of-bias assessment were conducted independently by 2 investigators using a standardized tool.

DATA ANALYSIS

In total, 93 studies (103 reports) were included from 25 countries, including 32 unique gray literature records. The conflict-affected regions included South-East Asia (n = 27), Eastern-Mediterranean (n = 8), Africa (n = 58), and the Americas (n = 1). The review distinguished programs based on nutrition-specific, nutrition-sensitive, and health components. Although the coverage and utilization of integrated nutrition and health programs has been substantial, the impact of the strategies on health and nutrition has been limited. The meta-analysis found no significant differences in rates of wasting among children under 5 years; however, it showed that children who received an integrated strategy experienced a 28% lower risk of underweight (P = .007) and a 12% reduced risk of stunting (P = .05) compared with those who did not.

CONCLUSION

This review has provided an in-depth insight into integrated nutrition and health strategies in conflict-affected settings, identifying key facilitators and barriers that can inform future policy and program design. Integrating nutrition programs into health systems and enhancing government and community ownership could enhance efficiency and sustainability, given challenging environments.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration No. CRD42022373993.

Genetic Perception Versus Nutritional Factors: Analyzing the Indigenous Baduy Community's Understanding of Stunting as a Health Issue

This study investigates the challenges and opportunities in addressing public health issues in the context of stunting in the Baduy community. Baduy is a remote indigenous group in Indonesia. The Indonesian government and NGOs such as SRI and Dompet Dhuafa have attempted to abolish stunting. However, factors such as cultural aspects, communication gaps, and logistic problems prevent the optimization of health interventions. Midwives and other health workers have yet to win the community's trust and provide quality services, but the lack of sustainable solutions further worsens their problem. This studyhighlights the urgency of culturally appropriate, long-term strategies that stay within the unique Baduy lifestyle and belief system, including integrating the tribal leaders into health campaigns. This study also seeks to explain the role of modern healthcare in the Baduy community, particularly the functional acceptance of modern medicine due to its effectiveness in treating severe health problems. However, controversies regarding access to healthcare for Indigenous peoples, especially regarding government resources for care in urban centers, reveal broader issues of healthcare equity in Indonesia. The study finds the need to advocate improved and culturally sensitive interventions, particularly in health communication and government support, to ensure sustainable improvements in public health for Indigenous peoples such as the Baduy.

The cost-effectiveness of a cash-based transfer, specialised nutritious food, and social and behaviour change communication intervention package to prevent undernutrition among children 6-23 months in Pakistan: A cluster randomised controlled trial

Background

There is mixed evidence on the cost-effectiveness of cash transfers, along with food supplements and behaviour change communication interventions in improving child nutrition outcomes. To add to existing literature, we examined the cost-effectiveness of medium-quantity lipid-based nutrient supplement (LNS) and social and behaviour change communication (SBCC) messaging, separately and combined, compared to an existing unconditional cash transfers (UCT) programme in children 6-23 months of age in the district Rahim Yar Khan, Pakistan.

Methods

This was a four-arm, community-based cluster randomised controlled trial. The UCT provided a quarterly sum of USD 32, the medium-quantity LNS contained a daily ration of 50 g of LNS, and the SBCC included monthly and quarterly messaging on nutrition, health, and hygiene to eligible households. Cost data were collected from a provider perspective through the review of procurement invoices and budgets, as well as interviews with stakeholders. We examined cost-effectiveness via statistically significant differences between the intervention and control arms, and estimated as cost per case of stunting, and disability-adjusted life years (DALYs) averted at six and 18 months of intervention.

Results

Costs were higher for SBCC intervention combinations (UCT + SBCC and UCT + LNS + SBCC) due to high training costs for lady health workers. UCT + LNS achieved a reduction in stunting at a per-case cost of USDS 278.74 at six months and USD 897.15 at 18 months. UCT + LNS + SBCC achieved a reduction in stunting at per case cost of USD 846.48 at six months and USD 2324.58 at 18 months. The cost per DALYs averted for preventing stunting was USD 234 to USD 557.42 at six months, and USD 787.73 to USD 1537 at 18 months without discounting and age-weights.

Conclusions

Although the affordability of such interventions is arguable, combining UCTs with LNS appears to be very cost-effective for reducing undernutrition and averting DALYs, while combining cash transfers with LNS and SBCC showed limited cost-effectiveness when targeting stunting.

Registration

Clinicaltrials.gov: NCT03299218.

Specialized nutritious foods and behavior change communication interventions during the first 1000 d of life to prevent stunting: a quasi-experimental study in Afghanistan

BACKGROUND

Considerable evidence supports the effectiveness of nutritional supplementation with or without nutrition education in preventing stunting in developing countries, but evidence from Afghanistan is scarce.

OBJECTIVES

This project aimed to assess the effectiveness of specialized nutritious food (SNF), social and behavior change communication (SBCC) intervention to prevent stunting among children under 2 y during the first 1000 d of life in Badakhshan, Afghanistan.

METHODS

We used a community-based quasi-experimental pre-post study design with a control group. Pregnant and lactating women received a monthly ration of 7.5 kg of super cereal (250 g/d) during pregnancy and the first 6 mo of breastfeeding. Children aged 6-23 mo received 30 sachets of medium-quantity lipid-based nutrient supplement (50 g/sachet/d) monthly. We compared pre- and postintervention assessments of the intervention and control groups to isolate the effect of the intervention on key study outcomes at the endline by difference-in-differences (DID) estimates.

RESULTS

A total of 2928 and 3205 households were surveyed at baseline and endline. DID estimates adjusted for child, maternal, and household characteristics indicated a significant reduction in stunting (DID: -5% (95% confidence interval [CI]: -9.9, -0.2) and underweight (DID: -4.6% (95% CI: -8.6, -0.5) among children <2 y of age. However, DID estimates for wasting among children in the intervention and control groups were not significantly different (DID: -1.7 (95% CI: -5.1, 1.6). Furthermore, exposure to the SBCC messages was associated with improvements in the early initiation of breastfeeding (DID: 19.6% (95% CI: 15.6, 23.6), exclusive breastfeeding under 6 mo (DID: 11.0% (95% CI: 2.3, 19.7), minimum meal frequency (DID: 23% (95% CI: 17.7, 28.2), and minimum acceptable diet (DID: 13% (95% CI: 9.8, 16.3).

CONCLUSIONS

The provision of SNF in combination with SBCC during the first 1000 d of life was associated with reduction in stunting and underweight and improvements in infant and young child feeding practices among children under 2 y of age. This trial was registered at clinicaltrials.gov as NCT04581993.

The interlink between chrono-nutrition and stunting: current insights and future perspectives

Stunting is the one factor that is responsible for the irretrievable damage to children's mental and physical health. Stunting imitates chronic undernutrition throughout the most extreme critical stages of growth and development of a child in their early life, and due to that stunted child does not completely develop and are too short for their age. Stunting is mainly linked with brain underdevelopment, along with lifelong damaging consequences, comprising weakened mental and learning capacity, deprived performance in school during childhood, and enhanced risks of nutrition linked to chronic long-lasting ailments, such as diabetes, hypertension, diabesity, and obesity in the future. In this review, the authors mainly summarize the latest studies related to chronic nutrition and how it is related to stunting. Optimal nutrition, particularly during pregnancy and the first 24 months of a child's life, is crucial in preventing stunting. Circadian rhythms play a significant role in maternal and fetal health, affecting outcomes such as premature birth and stunting. Maintaining a balanced diet, avoiding late-night carbohydrate-heavy meals during pregnancy, and promoting breastfeeding align with the body's biological clock, which can benefit newborns in various ways. Providing dedicated spaces for breastfeeding in public places is important to support infant health.

Improving transportability of randomized controlled trial inference using robust prediction methods

Randomized trials have been the gold standard for assessing causal effects since their introduction by Fisher in the 1920s, since they can eliminate both observed and unobserved confounding. Estimates of causal effects at the population level from randomized controlled trials can still be biased if there are both effect modification and systematic differences between the trial sample and the ultimate population of inference with respect to these modifiers. Recent advances in the survey statistics literature to improve inference in nonprobability samples by using information from probability samples can provide an avenue for improving population causal inference in randomized controlled trials when relevant probability samples of the patient population are available. We review some recent work in "transporting" causal effect estimates from trials to populations, focusing on the setting where there is a "benchmark" or population-representative sample along with the RCT sample. We then propose estimators using either inverse probability weighting (IPWT) or prediction that can accommodate unequal probability of selection in the "benchmark" or population, and use Bayesian additive regression trees for both inverse probability of treatment weighting and prediction estimation that do not require specification of functional form or interaction. We also consider how the assumption of ignorability may be assessed from observed data and propose a sensitivity analysis under the failure of this assumption. We compare our proposed approach with existing methods in simulation and apply these alternative approaches to a study of pulmonary artery catheterization in critically ill patients. We also suggest next steps for future work.

Lipid-based nutrient supplements for prevention of child undernutrition: when less may be more

BACKGROUND

Both small-quantity and medium-quantity lipid-based nutrient supplements (LNS) have been used for the prevention of child undernutrition. A meta-analysis of 14 trials of small-quantity lipid-based nutrient supplements (SQ-LNS) - no LNS showed effects on length-for-age z-score {LAZ, +0.14 [95% confidence interval (CI): 0.11, 0.16]} and weight-for-length z-score [WLZ, +0.08 (0.06, 0.10)] z-scores, as well as prevalence ratios (95% CI) for stunting [LAZ < -2, 0.88 (0.85, 0.91)] and wasting [WLZ < -2, 0.86 (0.80, 0.93)]. However, little is known about the effects of medium-quantity lipid-based nutrient supplements (MQ-LNS) on growth.

OBJECTIVES

We aimed to examine the effects of preventive MQ-LNS (∼250-499 kcal/d) provided at ∼6-23 mo of age on growth outcomes - no LNS or provision of SQ-LNS.

METHODS

We conducted a systematic review of studies of MQ-LNS for prevention, and categorized them as providing <6 mo - ≥6 mo of supplementation; for the latter category, we conducted a meta-analysis, with the main outcomes being change in WLZ and LAZ, and prevalence of wasting and stunting.

RESULTS

Three studies provided MQ-LNS for 3-5 mo (seasonal) for children 6-36 mo of age, and did not show consistent effects on growth outcomes. Eight studies provided MQ-LNS for 6-18 mo, generally starting at 6 mo of age; in the meta-analysis (max total n = 13,954), MQ-LNS increased WLZ [+0.09 (95% CI: 0.05, 0.13)] and reduced wasting [0.89 (0.81, 0.97)], but had no effect on LAZ [+0.04 (-0.02, 0.11)] or stunting [0.97 (0.92, 1.02)] - no LNS. Two studies directly compared SQ-LNS and MQ-LNS and showed no significant differences in growth outcomes.

CONCLUSIONS

The current evidence suggests that MQ-LNS offer no added benefits over SQ-LNS, although further studies directly comparing MQ-LNS with SQ-LNS would be useful. One possible explanation is incomplete consumption of the MQ-LNS ration and thus lower than desirable intake of certain nutrients.

TRIAL REGISTRATION NUMBER

Registry and registry number for systematic reviews or meta-analyses: Registered with PROSPERO as CRD42022382448 on December 18, 2022: =https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022382448.

Do crop diversity and livestock production improve smallholder intra-household dietary diversity, nutrition and sustainable food production? Empirical evidence from Pakistan

Crop diversification and livestock production is an important strategy to enhance nutrition, sustainable food production, and improve food security, especially at the smallholder household level. However, existing evidences are mixed and there are limited information about the relationship among agriculture crops, household income diversification (HID), and household dietary diversity (HDD) among smallholder farmers in developing country setting like Pakistan. Therefore, this study aims to understand the role of crop diversification (CD) on HDD, nutrition, and sustainable agriculture and food production in the context of smallholder households in Punjab, Pakistan. The study employed ordered probit regression and cross-sectional data from 450 households collected using 24-h recall method. Regression results indicate that crop diversity and intra-household dietary diversity are positively associated across adults, adolescents, and children in all the study districts. Moreover, annual income, key crops grown by the household and family education are also the significant drivers of dietary diversity. Greater travel distance between markets was the most crucial factor in all regions which significantly affect dietary diversity. The overall research findings indicated that crop diversification and livestock production in the selected areas is significantly contributing to improve nutrition and sustainable food production. Therefore this study recommends for promoting crop diversification and livestock production for sustainable agricultural development and improving nutrition in the context of developing countries like Pakistan.