Preventing chronic malnutrition in children under 2 years in rural Angola (MuCCUA trial): protocol for the economic evaluation of a three-arm community cluster randomised controlled trial

INTRODUCTION

Chronic malnutrition is a serious problem in southern Angola with a prevalence of 49.9% and 37.2% in the provinces of Huila and Cunene, respectively. The MuCCUA (Mother and Child Chronic Undernutrition in Angola) trial is a community-based randomised controlled trial (c-RCT) which aims to evaluate the effectiveness of a nutrition supplementation plus standard of care intervention and a cash transfer plus standard of care intervention in preventing stunting, and to compare them with a standard of care alone intervention in southern Angola. This protocol describes the planned economic evaluation associated with the c-RCT.

METHODS AND ANALYSIS

We will conduct a cost-efficiency and cost-effectiveness analysis nested within the MuCCUA trial with a societal perspective, measuring programme, provider, participant and household costs. We will collect programme costs prospectively using a combined calculation method including quantitative and qualitative data. Financial costs will be estimated by applying activity-based costing methods to accounting records using time allocation sheets. We will estimate costs not included in accounting records by the ingredients approach, and indirect costs incurred by beneficiaries through interviews, household surveys and focus group discussions. Cost-efficiency will be estimated as cost per output achieved by combining activity-specific cost data with routine data on programme outputs. Cost-effectiveness will be assessed as cost per stunting case prevented. We will calculate incremental cost-effectiveness ratios comparing the additional cost per improved outcome of the different intervention arms and the standard of care. We will perform sensitivity analyses to assess robustness of results.

ETHICS AND DISSEMINATION

This economic evaluation will provide useful information to the Angolan Government and other policymakers on the most cost-effective intervention to prevent stunting in this and other comparable contexts. The protocol was approved by the República de Angola Ministério da Saúde Comité de Ética (27C.E/MINSA.INIS/2022). The findings of this study will be disseminated within academia and the wider policy sphere.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05571280).

Preventing Child Wasting in Africa's Dryland: An Exploratory Review of the Enabling Environment in 8 Sub-Saharan Countries Using a Food Systems Lens

Persistent child wasting is evident across the Sahel and Horn of Africa, much of which is typically dryland and dependent on agropastoralism. Two events in 2021, the United Nations (UN) Food Systems Summit and the Tokyo Nutrition for Growth Summit, represented a watershed moment for the alignment of food systems and nutrition. Against this backdrop, the costed country operational roadmaps, developed in 22 countries as part of the joint UN Global Action Plan on Child Wasting (UNICEF 2021), recognized the importance of preventing child wasting using a multisectoral approach. We use a food systems lens to assess how current governance mechanisms, policies, and programming priorities in 8 sub-Saharan countries are responsive to the food security and nutritional needs of the most vulnerable people. For governance mechanisms, we draw from a narrative review of joint annual assessments conducted by the Scaling Up Nutrition Movement's national multistakeholder platforms since 2016. For policy frameworks, we analyze recommendations included in operational roadmaps and findings from the review of national multisectoral nutrition plans. For programming priorities, we analyze the typologies of costed interventions in the food and social protection systems. We present how nutrition and healthy diets were factored into national food systems pathways and how Government commitments to Nutrition for Growth integrate food systems and resilience. Results of this exploratory review suggest opportunities offered by the implementation of the country roadmaps should rely on a fundamental understanding of context-specific risks and vulnerabilities embedded in the systems and their dynamics.

Effect of Drinking Water and Sanitation on Child Undernutrition and Diarrhea in Lao PDR

Childhood undernutrition and diarrhea remain a global health burden in the 21st century. We assessed the effect of access to basic drinking water and sanitation at home on reducing children's likelihood of being undernourished and experiencing diarrhea in Laos. We pooled two rounds of nationally representative cross-sectional household surveys: the Lao Social Indicator Surveys 2011/2012 and 2017, encompassing 23 070 children aged <5 years. We employed multivariate multilevel logistic regression for the analysis. The results showed that access to basic drinking water was associated with a reduced likelihood of undernutrition and was effective in improving child undernutrition. Moreover, access to basic sanitation reduced diarrhea in addition to undernutrition. Notably, sanitation facilities only mitigated childhood stunting and diarrhea when basic drinking water facilities were present in the household. We also confirmed that socio-economic disparities existed among children accessing basic drinking water and sanitation. Consequently, further efforts are needed toward equitable access to these facilities in Laos.

Protocol for integrated solutions for healthy birth, growth and development: a cluster-randomised controlled trial to evaluate the effectiveness of a mixed nutrition intervention package in reducing child undernutrition in Lao People's Democratic Republic

INTRODUCTION

While Lao People's Democratic Republic has seen economic gains in recent years, one-third of children aged 5 years and under are stunted. There is a need for evidence around clinically effective and cost-effective integrated nutrition-specific and nutrition-sensitive interventions in the local context.

METHODS AND ANALYSIS

We aim to conduct a cluster-randomised control trial to test the effectiveness of an integrated package of community-based nutrition-specific and nutrition-sensitive interventions compared with the standard government package of nutrition actions. The trial will be in six districts within the province of Vientiane. We will recruit pregnant women in their third trimester and follow the children born to them every 6 months until 18 months of age. A total of 256 villages (serviced by 34 health centres) will be randomised to a control arm or an intervention arm using a minimisation algorithm. The primary outcome is the prevalence of stunting among children aged 6, 12 and 18 months. The secondary outcomes include prevalence of low birth weight and wasting among children aged 6, 12 and 18 months. Analyses for the primary and secondary outcomes will be conducted at the mother-infant dyad level and adjusted for the cluster randomisation. The difference in prevalence of low birth weight, wasting and stunting between control and intervention groups will be assessed using Pearson's χ2 tests and 95% CIs for the group difference, adjusted for clustering.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Alfred Human Research Ethic Committee (Ref: 227/16) and the Lao National Ethics Committee for Health Research (Ref: 81). The trial was registered with the Australian New Zealand Clinical Trials Registry on 28 April 2020 (ACTRN12620000520932). The results will be disseminated at different levels: study participants; the local community; other Lao stakeholders including policymakers; and an international audience.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry: ACTRN12620000520932.

Understanding Sex Differences in Childhood Undernutrition: A Narrative Review

Complementing a recent systematic review and meta-analysis which showed that boys are more likely to be wasted, stunted, and underweight than girls, we conducted a narrative review to explore which early life mechanisms might underlie these sex differences. We addressed different themes, including maternal and newborn characteristics, immunology and endocrinology, evolutionary biology, care practices, and anthropometric indices to explore potential sources of sex differences in child undernutrition. Our review found that the evidence on why sex differences occur is limited but that a complex interaction of social, environmental, and genetic factors likely underlies these differences throughout the life cycle. Despite their bigger size at birth and during infancy, in conditions of food deprivation, boys experience more undernutrition from as early as the foetal period. Differences appear to be more pronounced in more severe presentations of undernutrition and in more socioeconomically deprived contexts. Boys are more vulnerable to infectious disease, and differing immune and endocrine systems appear to explain some of this disadvantage. Limited evidence also suggests that different sociological factors and care practices might exert influence and have the potential to exacerbate or reverse observed differences. Further research is needed to better understand sex differences in undernutrition and the implications of these for child outcomes and prevention and treatment programming.

Elucidating the sustained decline in under-three child linear growth faltering in Nepal, 1996-2016

Childhood linear growth faltering remains a major public health concern in Nepal. Nevertheless, over the past 20 years, Nepal sustained one of the most rapid reductions in the prevalence of stunting worldwide. First, our study analysed the trends in height-for-age z-score (HAZ), stunting prevalence, and available nutrition-sensitive and nutrition-specific determinants of linear growth faltering in under-three children across Nepal's Family Health Survey 1996 and Nepal's Demographic and Health Surveys 2001, 2006, 2011, and 2016. Second, we constructed pooled multivariable linear regression models and decomposed the contributions of our time-variant determinants on the predicted changes in HAZ and stunting over the past two decades. Our findings indicate substantial improvements in HAZ (38.5%) and reductions in stunting (-42.6%) and severe stunting prevalence (-63.9%) in Nepalese children aged 0-35 months. We also report that the increment in HAZ, across the 1996-2016 period, was significantly associated (confounder-adjusted p < .05) with household asset index, maternal and paternal years of education, maternal body mass index and height, basic child vaccinations, preceding birth interval, childbirth in a medical facility, and prenatal doctor visits. Furthermore, our quantitative decomposition of HAZ identified advances in utilisation of health care and related services (31.7% of predicted change), household wealth accumulation (25%), parental education (21.7%), and maternal nutrition (8.3%) as key drivers of the long-term and sustained progress against child linear growth deficits. Our research reiterates the multifactorial nature of chronic child undernutrition and the need for coherent multisectoral nutrition-sensitive and nutrition-specific strategies at national scale to further improve linear growth in Nepal. [Correction added on 6 November 2020, after first online publication: in abstract, the citation year in the fourth sentence has been changed from '2001' to '2011'.].

Household Food Insecurity, Dietary Diversity, and Stunting in Sub-Saharan Africa: A Systematic Review

BACKGROUND

The significant public health problem in Sub-Saharan Africa of household food insecurity is an underlying cause of malnutrition in Sub-Saharan Africa. This study aims to systematically study the association between household food insecurity, dietary diversity, and stunting.

METHODS

This review was carried out based on the recommendations of PRISMA (2015). We searched the literature in six bibliographic databases: PubMed, EMBASE, Science Direct, Web of Science, Google Scholar, and Scopus. The research was based on studies conducted in Sub-Saharan Africa about household food insecurity, dietary diversity, and stunting and was published between 2009 and 2020.

RESULTS

Out of 2398 original articles identified, only 21 articles met the specific requirements of this review. Two-thirds of the articles selected showed that stunting was linked to household food insecurity and dietary diversity.

CONCLUSIONS

This study found that household food insecurity and dietary diversity are significantly associated with stunting in Sub-Saharan Africa. This review recommends that in order to yield a sustainable fight against childhood malnutrition in Sub-Saharan Africa, reliable guidelines and strategies are needed to address these factors related to malnutrition.

Midday meals as an early childhood nutrition intervention: evidence from plantation communities in Sri Lanka

BACKGROUND

High rates of child malnutrition are a major public health concern in developing countries, particularly among vulnerable communities. Midday meals programs can be effective for combatting childhood malnutrition among older children. However, their use in early childhood is not well documented, particularly within South Asia. Anthropometric measures and other socioeconomic data were collected for children below the age of 5 years living in selected Sri Lankan tea plantations, to assess the effectiveness of midday meals as a nutrition intervention for improving growth among young children.

METHODS

The study exploits a natural experiment whereby the provision of the midday meals program is exogenously determined at the plantation level, resulting in comparable treatment and control groups. Longitudinal data was collected on heights and weights of children, between 2013 and 2015. Standardized weight-for-age, height-for-age and weight-for-height, and binary variables for stunting, wasting and underweight are constructed, following WHO guidelines. All modelling uses STATA SE 15. Random-effects regression with instrumental variables is used for modelling standardized growth while random-effects logistic regression is used for the binary outcomes. Robustness analysis involves different estimation methods and subsamples.

RESULTS

The dataset comprises of longitudinal data from a total of 1279 children across three tea plantations in Sri Lanka, with 799 children in the treatment group and 480 in the control group. Results show significant positive effects of access to the midday meals program, on the growth of children. A child with access to the midday meals intervention reports an average standardized weight-for-age 0.03 (±0.01) and height-for-age 0.05 (±0.01) units higher than a similar child without access to the intervention. Importantly, access to the intervention reduces the likelihood of being underweight by 0.45 and the likelihood of wasting by 0.47. The results are robust to different model specifications and across different subsamples by gender, birthweight and birth-year cohort.

CONCLUSIONS

Midday meals programs targeting early childhood can be an effective intervention to address high rates of child malnutrition, particularly among vulnerable communities in developing countries like Sri Lanka.

Dietary intake of sulfur amino acids and risk of kwashiorkor malnutrition in eastern Democratic Republic of the Congo

BACKGROUND

Kwashiorkor is an often-fatal type of severe acute malnutrition affecting hundreds of thousands of children annually, but whose etiology is still unknown. Evidence suggests inadequate sulfur amino acid (SAA) status may explain many signs of the condition but studies evaluating dietary protein intake in relation to the genesis of kwashiorkor have been conflicting. We know of no studies of kwashiorkor that have measured dietary SAAs.

OBJECTIVES

We aimed to determine whether children in a population previously determined to have high prevalence of kwashiorkor [high-prevalence population (HPP)] have lower dietary intakes of SAAs than children in a low-prevalence population (LPP).

METHODS

A cross-sectional census survey design of 358 children compared 2 previously identified adjacent populations of children 36-59 mo old in North Kivu Province of the Democratic Republic of the Congo. Data collected included urinary thiocyanate (SCN), cyanogens in cassava-based food products, recent history of illness, and a 24-h quantitative diet recall for the child.

RESULTS

The HPP and LPP had kwashiorkor prevalence of 4.5% and 1.7%, respectively. A total of 170 children from 141 households in the LPP and 169 children from 138 households in the HPP completed the study. A higher proportion of HPP children had measurable urinary SCN (44.8% compared with 29.4%, P < 0.01). LPP children were less likely to have been ill recently (26.8% compared with 13.6%, P < 0.01). Median [IQR] intake of SAAs was 32.4 [22.9-49.3] mg/kg for the LPP and 29.6 [18.1-44.3] mg/kg for the HPP (P < 0.05). Methionine was the first limiting amino acid in both populations, with the highest risk of inadequate intake found among HPP children (35.1% compared with 23.6%, P < 0.05).

CONCLUSIONS

Children in a population with a higher prevalence of kwashiorkor have lower dietary intake of SAAs than children in a population with a lower prevalence. Trial interventions to reduce incidence of kwashiorkor should consider increasing SAA intake, paying particular attention to methionine.

Poverty and childhood malnutrition: Evidence-based on a nationally representative survey of Bangladesh

BACKGROUND

Malnutrition contributes to children's morbidity and mortality, and the situation undermines the economic growth and development of Bangladesh. Malnutrition is associated with lower levels of education that decrease economic productivity and leads to poverty. The global burden of malnutrition continues to be unacceptably high amid social and economic growth, including in Bangladesh. Therefore, identifying the factors associated with childhood malnutrition and poverty is necessary to stop the vicious cycle of malnutrition leaded poverty.

METHODS

The study utilized the 2017-18 Bangladesh Demographic and Health Survey (BDHS), accumulating 7,738 mother-child pairs. Associations between potential risk factors and nutritional status were determined using chi-square tests, and multivariate logistic regression models were utilized on significant risk factors to measure their odds ratio (OR) with their 95% confidence intervals (CI).

RESULTS

The prevalence of moderate and severe wasting was 7.0% and 1.8%, respectively, whereas the prevalence of moderate and severe stunting was 19.2% and 8.0%, while 16.4% and 3.6% of children were moderately and severely underweight. Children from the poorest and poor households were suffering from at least one form of malnutrition. Adjusted ORs were estimated by controlling socio-economic and demographic risk factors, such as poor maternal body mass index, parents' lower education level, use of unhygienic toilet, child age in months, and recent experience of diarrhea and fever. The pattern was almost similar for each malnutrition status (i.e., stunting, underweight, and wasting) in the poorest and poor households.

CONCLUSION

Bangladesh achieved the Millennium Development Goals, focusing primarily on health-related indicators and working to achieve the Sustainable Development Goals. Even considering this success, the prevalence of malnutrition and poverty in same household remains relatively high compared to other developing countries. Therefore, the study recommends the implementation of nationwide systematic measures to prevent poverty and malnutrition.

Child Undernutrition following the Introduction of a Large-Scale Toilet Construction Campaign in India

BACKGROUND

Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition.

OBJECTIVES

We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India.

METHODS

In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates.

RESULTS

Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM.

CONCLUSIONS

An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.

The risk to child nutrition during and after COVID-19 pandemic: what to expect and how to respond

OBJECTIVE

The current study aimed to address the key areas of concern for child nutrition, both during and after the COVID-19 pandemic, and proposes strategic responses to reduce child undernutrition in the short and long term.

DESIGN

A descriptive literature review was performed. The search of the literature was conducted through using electronic databases including PubMed, Web of Science, Google Scholar and Cochrane library.

SETTING

A wide range of published articles focused on child malnutrition were reviewed.

PARTICIPANTS

The study was focused on children especially those under 5 years.

RESULTS

The current study proposes strategic responses to reduce child undernutrition. These responses include strengthening access to community-based nutrition services that support the early detection and treatment of undernourished children and emergency food distribution, including fortified foods with vitamins and minerals, to vulnerable households, particularly those with children under 5 years. Moreover, counseling and promotion programmes should be reinforced to revitalise community nutrition education in areas such as gestation, exclusive breast-feeding and complementary feeding, and hygienic practices involving handwashing, proper sanitation and other basic behavioural changes.

CONCLUSIONS

The COVID-19 pandemic has affected many countries especially those in the regions of South Asia and sub-Saharan Africa in which there has been an ongoing burden of child undernutrition. However, malnutrition is preventable and can be eliminated through a multisectoral strategic approach. The effective execution of a multisectoral approach towards preventing childhood malnutrition will require not only a financial investment but also the collective efforts from different ministries of the governments, UN-affiliated agencies and non-governmental organisations.

A randomised controlled feasibility trial of a BabyWASH household playspace: The CAMPI study

Background

Water, sanitation and hygiene (WASH) interventions should support infant growth but trial results are inconsistent. Frequently, interventions do not consider behaviours or transmission pathways specific to age. A household playspace (HPS) is one intervention component which may block faecal-oral transmission. This study was a two-armed, parallel-group, randomised, controlled feasibility trial of a HPS in rural Ethiopia. It aimed to recommend proceeding to a definitive trial. Secondary outcomes included effects on infant health, injury prevention and women’s time.

Methods

November 2019−January 2020 106 households were identified and assessed for eligibility. Recruited households (N = 100) were randomised (blinded prior to the trial start) to intervention or control (both n = 50). Outcomes included recruitment, attrition, adherence, and acceptability. Data were collected at baseline, two and four weeks.

Findings

Recruitment met a priori criteria (≥80%). There was no loss to follow-up, and no non-use, meeting adherence criteria (both ≤10%). Further, 48.0% (95% CI 33.7−62.6; n = 24) of households appropriately used and 56.0% (41.3−70.0; n = 28) cleaned the HPS over four weeks, partly meeting adherence criteria (≥50%). For acceptability, 41.0% (31.3−51.3; n = 41) of infants were in the HPS during random visits, failing criteria (≥50%). Further, the proportion of HPS use decreased during some activities, failing criteria (no decrease in use). A modified Barrier Analysis described good acceptability and multiple secondary benefits, including on women’s time burden and infant injury prevention.

Interpretation

Despite failing some a priori criteria, the trial demonstrated mixed adherence and good acceptability among intervention households. A definitive trial to determine efficacy is warranted if recommended adjustments are made.

Funding

People In Need; Czech Development Agency.

Trial registration

RIDIE-ID-5de0b6938afb8.

This research tested a new way to protect infants and young children from infections that are caused by pathogens in human and animal faeces. It tested the feasibility of using a household playspace to reduce infection by creating a hygienic environment for children to play-in in rural Ethiopia. The results show that the household playspace was well accepted, used regularly and cleaned well by participants in the study. The study also suggests a potential positive impact in reducing diarrhoea. Based on these results, we suggest that a larger scale trial be conducted to conclusively assess whether a household playspace can protect young children and infants from infection in rural Ethiopia or similar contexts.

Multi-Nutrient Fortified Dairy-Based Drink Reduces Anaemia without Observed Adverse Effects on Gut Microbiota in Anaemic Malnourished Nigerian Toddlers: A Randomised Dose-Response Study

Prevalence of anaemia among Nigerian toddlers is reported to be high, and may cause significant morbidity, affects brain development and function, and results in weakness and fatigue. Although, iron fortification can reduce anaemia, yet the effect on gut microbiota is unclear. This open-label randomised study in anaemic malnourished Nigerian toddlers aimed to decrease anaemia without affecting pathogenic gut bacteria using a multi-nutrient fortified dairy-based drink. The test product was provided daily in different amounts (200, 400 or 600 mL, supplying 2.24, 4.48 and 6.72 mg of elemental iron, respectively) for 6 months. Haemoglobin, ferritin, and C-reactive protein concentrations were measured to determine anaemia, iron deficiency (ID) and iron deficiency anaemia (IDA) prevalence. Faecal samples were collected to analyse gut microbiota composition. All three dosages reduced anaemia prevalence, to 47%, 27% and 18%, respectively. ID and IDA prevalence was low and did not significantly decrease over time. Regarding gut microbiota, Enterobacteriaceae decreased over time without differences between groups, whereas Bifidobacteriaceae and pathogenic E. coli were not affected. In conclusion, the multi-nutrient fortified dairy-based drink reduced anaemia in a dose-dependent way, without stimulating intestinal potential pathogenic bacteria, and thus appears to be safe and effective in treating anaemia in Nigerian toddlers.

Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action

As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.

Revisiting maternal and child undernutrition in low-income and middle-income countries: variable progress towards an unfinished agenda

13 years after the first Lancet Series on maternal and child undernutrition, we reviewed the progress achieved on the basis of global estimates and new analyses of 50 low-income and middle-income countries with national surveys from around 2000 and 2015. The prevalence of childhood stunting has fallen, and linear growth faltering in early life has become less pronounced over time, markedly in middle-income countries but less so in low-income countries. Stunting and wasting remain public health problems in low-income countries, where 4·7% of children are simultaneously affected by both, a condition associated with a 4·8-times increase in mortality. New evidence shows that stunting and wasting might already be present at birth, and that the incidence of both conditions peaks in the first 6 months of life. Global low birthweight prevalence declined slowly at about 1·0% a year. Knowledge has accumulated on the short-term and long-term consequences of child undernutrition and on its adverse effect on adult human capital. Existing data on vitamin A deficiency among children suggest persisting high prevalence in Africa and south Asia. Zinc deficiency affects close to half of all children in the few countries with data. New evidence on the causes of poor growth points towards subclinical inflammation and environmental enteric dysfunction. Among women of reproductive age, the prevalence of low body-mass index has been reduced by half in middle-income countries, but trends in short stature prevalence are less evident. Both conditions are associated with poor outcomes for mothers and their children, whereas data on gestational weight gain are scarce. Data on the micronutrient status of women are conspicuously scarce, which constitutes an unacceptable data gap. Prevalence of anaemia in women remains high and unabated in many countries. Social inequalities are evident for many forms of undernutrition in women and children, suggesting a key role for poverty and low education, and reinforcing the need for multisectoral actions to accelerate progress. Despite little progress in some areas, maternal and child undernutrition remains a major global health concern, particularly as improvements since 2000 might be offset by the COVID-19 pandemic.

A Cluster Randomized Controlled Trial of a Home-Delivered Food Box on Children's Diet Quality in the Chickasaw Nation Packed Promise Project

BACKGROUND

Poor diet quality among children can lead to poor health, development, and academic achievement. Child nutrition assistance programs aim to improve diet quality among children.

OBJECTIVE

This study tested the impact of the Packed Promise intervention on diet quality among low-income children in Chickasaw Nation territory.

DESIGN

This study was a cluster randomized controlled trial of 40 school districts and 4,750 eligible, consented households within treatment and control districts.

PARTICIPANTS/SETTING

Household data were collected at baseline (n = 2,859) and follow-up (n = 2,852) in 12 rural Oklahoma counties.

INTERVENTION

Packed Promise treatment households chose from 5 types of home-delivered food boxes that contained nutritious foods ($38 food value) and a $15 check for purchasing fruits and vegetables.

MAIN OUTCOME MEASURES

Key outcomes included children's daily consumed amounts of fruits and vegetables, whole grains, and added sugars collected by a dietary screener questionnaire. Other outcomes included food shopping frequency, type of grocery store used, distance traveled from home to grocery stores, and the number of weekly family dinners. All outcomes in this article are secondary to the study's primary outcome-food insecurity among children.

STATISTICAL ANALYSES PERFORMED

Differences between the treatment and control groups were estimated by a regression model controlling for baseline characteristics and population-based average portion sizes.

RESULTS

Children's mean daily consumption of fruits and vegetables combined was about 2.35-cup equivalents in the treatment group and 2.25-cup equivalents in the control group (P < 0.001). Mean consumption of whole grains was 0.73-ounce equivalents in the treatment group compared with 0.67-ounce equivalents in the control group (P < 0.001). Other outcomes were not statistically significant.

CONCLUSION

Packed Promise led to significant but small improvements in children's daily consumption of fruits and vegetables and whole grains. Several factors, including household participation levels in Packed Promise, may have moderated the size of impacts.

FUNDING/SUPPORT

This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

A Randomized Controlled Trial Measuring Effects of Extra Supplemental Nutrition Assistance Program (SNAP) Benefits on Child Food Security in Low-Income Families in Rural Kentucky

BACKGROUND

To reduce childhood hunger, the US Department of Agriculture funded several innovative demonstration projects, including the Kentucky Ticket to Healthy Food project.

OBJECTIVE

The study tested the hypothesis that Ticket to Healthy Food would reduce child food insecurity (FI-C) among rural, low-income households.

DESIGN

The study used a randomized controlled trial in which households were randomly assigned to treatment and control groups. Outcomes were measured using household surveys and administrative data. Survey data were collected at baseline (n=2,202) and follow-up (n=1,639) 8 to 11 months into the project.

PARTICIPANTS/SETTING

Households in 17 counties in southeastern Kentucky that had at least 1 child younger than 18 years and received a Supplemental Nutrition Assistance Program (SNAP) benefit amount less than the maximum at baseline.

INTERVENTION

Between January 2017 and March 2018, treatment households on SNAP received additional monthly benefits ranging from $1 to $122 based on distance to grocery store and earned income.

MAIN OUTCOME MEASURES

Key outcomes included FI-C (primary), food insecurity among adults and households, and food expenditures (secondary).

STATISTICAL ANALYSES PERFORMED

Logistic and linear regression models were used to estimate differences between the treatment and control groups, controlling for baseline characteristics. Socioeconomic subgroups were also analyzed.

RESULTS

The Kentucky Ticket to Healthy Food project did not reduce the primary outcome, FI-C (treatment=37.1%, control=35.2%; P=0.812), or secondary outcomes of very low food security among children (treatment=3.7%, control=4.4%; P=0.204) or food insecurity among adults (treatment=53.9%, control=53.0%; P=0.654). The project increased households' monthly food spending by $20 (P=0.030) and led more households to report that monthly benefits lasted at least 3 weeks (treatment=65%, control=56%; P=0.009).

CONCLUSION

A demonstration project to reduce FI-C by raising SNAP benefits for Kentucky households with children did not reduce FI-C or other food insecurity measures. Future research should explore the effect of different increases in SNAP benefits and collect repeated measures of FI-C to assess whether intervention effects change over time.

FUNDING/SUPPORT

This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

Improving maternal and child nutrition in China: an analysis of nutrition policies and programs initiated during the 2000-2015 Millennium Development Goals era and implications for achieving the Sustainable Development Goals

BACKGROUND

Although good progress was made in maternal and child nutrition during the Millennium Development Goals (MDGs) era, malnutrition remains one of the major threats on global health. Therefore, the United Nation set several nutrition-related goals in the Sustainable Development Goals (SDGs). There is much to be learned from individual countries in terms of efforts and actions taken to reduce malnutrition. China, as a developing country, launched a number of nutrition improvement policies and programs that resulted in dramatic progress in improving maternal and child nutrition during the MDGs era. This study explored the impact, experiences, and lessons learned from the nutrition policies and programs initiated in China during the MDGs era and implications to achieve the SDGs for China and other developing countries.

METHOD

The CNKI database and official websites of Chinese government were searched for reviews on nutrition-related policies and intervention programs. A qualitative study was conducted among key informants from the Chinese government, non-governmental organizations (NGOs), and universities for two major national nutrition intervention programs.

RESULTS

The literature review documented that during the MDGs era, six nutrition policies and eight trans-province and nationwide nutrition intervention programs collectively made good progress in improving maternal and child nutrition in China. Nutrition policies tended to be targeted at infants and children, with less attention on reproductive and maternal nutrition. Nutrition intervention programs focused primarily on undernutrition and have achieved positive results, while for breastfeeding improvement and prevention and control on overweight and obesity were limited. Results from the qualitative study indicated that effective nutrition program implementation was facilitated through the cooperation of multiple sectors and by the government and NGO partnerships, however, still face challenges of insufficient operational funds from local governments and inadequacy of program monitoring and management.

CONCLUSION

Nutrition policies and intervention programs promulgated in China during the MDGs era have made major contributions to the rapid decline of undernutrition and are in line to achieve the SDGs related to child wasting, stunting, low birth weight, and anemia in reproductive-age women. However, appropriate policies and program implementation are needed to improve exclusive breastfeeding rates and reduce obesity to achieve the SDGs in years to come.

Reducing malnutrition in Cambodia. A modeling exercise to prioritize multisectoral interventions

Undernutrition is a major contributor to child morbidity and mortality and poses a large burden to the economy, in Cambodia. This study explored factors contributing to child stunting and wasting and their regional inequalities among 1,938 Cambodian children aged 6-23.9 months. Data were drawn from a longitudinal study (year 2017) conducted in six districts of two north-eastern provinces and the capital and used as cross-sectional. Socio-demographic and household characteristics, children's feeding practices during the previous 24 hr, and children's length and weight measurements were collected. Gradient boosting models were used to calculate the contribution of determinants to child undernutrition whereas concentration index was used to assess the impact of those determinants on stunting and wasting inequalities among socioeconomic groups. It was found that low-household wealth could predict 21% to 45% of child stunting and 23% to 36% of wasting across regions. After wealth, source and treatment of drinking water were found the second major predictor for stunting (15%) and wasting (21%). Combining child nutrition and household water, sanitation and hygiene indicators predicted around 30% of child undernutrition, either in the form of stunting or wasting. Mothers' education predicted >30% of stunting in the north-eastern region. Results highlight that a complex interplay of factors contributes to child stunting and wasting. An integrated, intersectoral, equity-focused approach that addresses children's dietary quality, household's water, sanitation and hygiene conditions, mother's education, and poverty is likely to yield the highest impact in achieving further gains in nutritional status among Cambodian children.

Assessing inequalities and regional disparities in child nutrition outcomes in India using MANUSH - a more sensitive yardstick

BACKGROUND

India is strongly committed to reducing the burden of child malnutrition, which has remained a persistent concern. Findings from recent surveys indicate co-existence of child undernutrition, micronutrient deficiency and overweight/obesity, i.e. the triple burden of malnutrition among children below 5 years. While considerable efforts are being made to address this challenge, and several composite indices are being explored to inform policy actions, the methodology used for creating such indices, i.e., linear averaging, has its limitations. Briefly put, it could mask the uneven improvement across different indicators by discounting the 'lagging' indicators, and hence not incentivising a balanced improvement. Signifying negative implications on policy discourse for improved nutrition. To address this gap, we attempt to develop a composite index for estimating the triple burden of malnutrition in India, using a more sensitive measure, MANUSH.

METHODOLOGY

Data from publicly available nation-wide surveys - National Family Health Survey (NFHS) and Comprehensive National Nutrition Survey (CNNS), was used for this study. First, we addressed the robustness of MANUSH method of composite indexing over conventional aggregation methods. Second, using MANUSH scores, we assessed the triple burden of malnutrition at the subnational level over different periods NHFS- 3(2005-06), NFHS-4 (2015-16) and CNNS (2106-18). Using mapping and spatial analysis tools, we assessed neighbourhood dependency and formation of clusters, within and across states.

RESULT

MANUSH method scores over other aggregation measures that use linear aggregation or geometric mean. It does so by fulfilling additional conditions of Shortfall and Hiatus Sensitivity, implicitly penalising cases where the improvement in worst-off dimension is lesser than the improvement in best-off dimension, or where, even with an overall improvement in the composite index, the gap between different dimensions does not reduce. MANUSH scores helped in revealing the gaps in the improvement of nutrition outcomes among different indicators and, the rising inequalities within and across states and districts in India. Significant clusters (p < 0.05) of high burden and low burden districts were found, revealing geographical heterogeneities and sharp regional disparities. A MANUSH based index is useful in context-specific planning and prioritising different interventions, an approach advocated by the newly launched National Nutrition Mission in India.

CONCLUSION

MANUSH based index emphasises balanced development in nutritional outcomes and is hence relevant for diverse and unevenly developing economy like India.

Housing and child health in sub-Saharan Africa: A cross-sectional analysis

BACKGROUND

Housing is essential to human well-being but neglected in global health. Today, housing in Africa is rapidly improving alongside economic development, creating an urgent need to understand how these changes can benefit health. We hypothesised that improved housing is associated with better health in children living in sub-Saharan Africa (SSA). We conducted a cross-sectional analysis of housing conditions relative to a range of child health outcomes in SSA.

METHODS AND FINDINGS

Cross-sectional data were analysed for 824,694 children surveyed in 54 Demographic and Health Surveys, 21 Malaria Indicator Surveys, and two AIDS Indicator Surveys conducted in 33 countries between 2001 and 2017 that measured malaria infection by microscopy or rapid diagnostic test (RDT), diarrhoea, acute respiratory infections (ARIs), stunting, wasting, underweight, or anaemia in children aged 0-5 years. The mean age of children was 2.5 years, and 49.7% were female. Housing was categorised into a binary variable based on a United Nations definition comparing improved housing (with improved drinking water, improved sanitation, sufficient living area, and finished building materials) versus unimproved housing (all other houses). Associations between house type and child health outcomes were determined using conditional logistic regression within surveys, adjusting for prespecified covariables including age, sex, household wealth, insecticide-treated bed net use, and vaccination status. Individual survey odds ratios (ORs) were pooled using random-effects meta-analysis. Across surveys, improved housing was associated with 8%-18% lower odds of all outcomes except ARI (malaria infection by microscopy: adjusted OR [aOR] 0.88, 95% confidence intervals [CIs] 0.80-0.97, p = 0.01; malaria infection by RDT: aOR 0.82, 95% CI 0.77-0.88, p < 0.001; diarrhoea: aOR 0.92, 95% CI 0.88-0.97, p = 0.001; ARI: aOR 0.96, 95% CI 0.87-1.07, p = 0.49; stunting: aOR 0.83, 95% CI 0.77-0.88, p < 0.001; wasting: aOR 0.90, 95% CI 0.83-0.99, p = 0.03; underweight: aOR 0.85, 95% CI 0.80-0.90, p < 0.001; any anaemia: aOR 0.87, 95% CI 0.82-0.92, p < 0.001; severe anaemia: aOR 0.89, 95% CI 0.84-0.95, p < 0.001). In comparison, insecticide-treated net use was associated with 16%-17% lower odds of malaria infection (microscopy: aOR 0.83, 95% CI 0.78-0.88, p < 0.001; RDT: aOR 0.84, 95% CI 0.79-0.88, p < 0.001). Drinking water source and sanitation facility alone were not associated with diarrhoea. The main study limitations are the use of self-reported diarrhoea and ARI, as well as potential residual confounding by socioeconomic position, despite adjustments for household wealth and education.

CONCLUSIONS

In this study, we observed that poor housing, which includes inadequate drinking water and sanitation facility, is associated with health outcomes known to increase child mortality in SSA. Improvements to housing may be protective against a number of important childhood infectious diseases as well as poor growth outcomes, with major potential to improve children's health and survival across SSA.

Individual-level predictors of practices of nutrition-specific and nutrition-sensitive interventions for infants and young children in West and Central Africa: a cross-sectional study

OBJECTIVES

To explore the role of individual-level and household-level characteristics for practice of nutrition-specific and nutrition-sensitive interventions.

DESIGN

Secondary data analysis (cross-sectional).

SETTING

West and Central Africa.

PARTICIPANTS

Data are from the Demographic and Health Surveys in the time period between 1986 and 2016. The final sample included between 116 325 and 272 238 observations depending on the outcome.

PRIMARY AND SECONDARY OUTCOME MEASURES

Nutrition-specific and nutrition-sensitive interventions were identified based on the UNICEF Conceptual Framework for child undernutrition. These were early breastfeeding initiation, minimum dietary diversity, full age-appropriate immunisation, iodised salt usage, vitamin A supplementation, iron supplementation, deworming in children aged 1 to 5, clean cooking fuel, safe drinking water and improved sanitation. Explanatory variables include household, mother and child characteristics. Linear probability models were fitted for each outcome, both unadjusted as well as fully adjusted including primary sampling unit fixed effects.

RESULTS

Prevalence of early breastfeeding initiation was 54.31% (95% CI: 53.22% to 55.41%), minimum dietary diversity 13.89% (95% CI: 13.19% to 14.59%), full age-appropriate immunisation 13.04% (95% CI: 12.49% to 13.59%), iodised salt usage 49.66% (95% CI: 46.79% to 52.53%), vitamin A supplementation 52.87% (95% CI: 51.41% to 54.33%), iron supplementation 10.73% (95% CI: 10.07% to 11.39%), deworming 31.33% (95% CI: 30.06% to 32.60%), clean cooking fuel usage 3.02% (95% CI: 2.66% to 3.38%), safe drinking water 57.85% (95% CI: 56.10% to 59.59%) and improved sanitation 42.49% (95% CI: 40.77% to 44.21%). There was a positive education and wealth gradient for the practices of all interventions except deworming. Higher birth order was positively associated with the practice of early breastfeeding initiation, minimum dietary diversity, vitamin A supplementation and negatively associated with full immunisation and improved sanitation.

CONCLUSIONS

Household, maternal, and child-level characteristics explain practices of nutrition-specific and nutrition-sensitive interventions beyond intervention delivery at the regional level.

Contribution of Milk Beverages to Nutrient Adequacy of Young Children and Preschool Children in the Philippines

Malnutrition is a major public health concern in the Philippines. Milk and dairy products are important sources of energy, protein, and micronutrients for normal growth and development in children. This study aims to assess the contribution of different types of milk to nutrient intakes and nutrient adequacy among young and preschool children in the Philippines. Filipino children aged one to four years (n = 2992) were analysed while using dietary intake data from the 8th National Nutrition Survey 2013. Children were stratified by age (one to two years and three to four years) and by milk beverage consumption type: young children milk (YCM) and preschool children milk (PCM), other milks (mostly powdered milk with different degrees of fortification of micronutrients), and non-dairy consumers (no milks or dairy products). The mean nutrient intakes and the odds of meeting nutrient adequacy by consumer groups were compared, percentage of children with inadequate intakes were calculated. Half (51%) of Filipino children (all ages) did not consume any dairy on a given day, 15% consumed YCM or PCM, and 34% consumed other milks. Among children one to two years, those who consumed YCM had higher mean intakes of iron, magnesium, potassium, zinc, B vitamins, folate, and vitamins C, D, and E (all p < 0.001) when compared to other milk consumers. Non-dairy consumers had mean intakes of energy, total fat, fibre, calcium, phosphorus, iron, potassium, zinc, folate, and vitamins D and E that were far below the recommendations. Children who consumed YCM or PCM had the highest odds in meeting adequacy of iron, zinc, thiamin, vitamin B6, folate, and vitamins C, D, and E as compared to other milks or non-dairy consumers, after adjusting for covariates. This study supports the hypothesis that dairy consumers had higher intakes of micronutrients and higher nutrient adequacy than children who consumed no milk or dairy products. Secondly, YCM or PCM have demonstrated to be good dairy options to achieve nutrient adequacy in Filipino children.

Using Group Model Building to Describe the System Driving Unhealthy Eating and Identify Intervention Points: A Participatory, Stakeholder Engagement Approach in the Caribbean

Many Small Island Developing States of the Caribbean experience a triple burden of malnutrition with high rates of obesity, undernutrition in children, and iron deficiency anemia in women of reproductive age, driven by an inadequate, unhealthy diet. This study aimed to map the complex dynamic systems driving unhealthy eating and to identify potential points for intervention in three dissimilar countries. Stakeholders from across the food system in Jamaica (n = 16), St. Kitts and Nevis (n = 19), and St. Vincent and the Grenadines (n = 6) engaged with researchers in two group model building (GMB) workshops in 2018. Participants described and mapped the system driving unhealthy eating, identified points of intervention, and created a prioritized list of intervention strategies. Stakeholders were also interviewed before and after the workshops to provide their perspectives on the utility of this approach. Stakeholders described similar underlying systems driving unhealthy eating across the three countries, with a series of dominant feedback loops identified at multiple levels. Participants emphasized the importance of the relative availability and price of unhealthy foods, shifting cultural norms on eating, and aggressive advertising from the food industry as dominant drivers. They saw opportunities for governments to better regulate advertising, disincentivize unhealthy food options, and bolster the local agricultural sector to promote food sovereignty. They also identified the need for better coordinated policy making across multiple sectors at national and regional levels to deliver more integrated approaches to improving nutrition. GMB proved to be an effective tool for engaging a highly diverse group of stakeholders in better collective understanding of a complex problem and potential interventions.

Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.

Experimental evidence on post-program effects and spillovers from an agriculture-nutrition program

Integrated agricultural-nutrition programs are often implemented under the premise that program effects are durable and spillover. This paper estimates one year post-program effects, three-year aggregate program effects and spillover effects using treated and untreated household cohorts. Two treatment interventions implemented agricultural interventions with behavior change communication strategies varying implementers using either village health committees or older female leaders. In the post-program period, program effects deteriorated relative to program period impacts documented in Olney et al. (2015), but the three-year agricultural, nutrition knowledge, health care practices and severe anemia impacts remained statistically significant. Despite the non-rival nature of nutrition education and promoted production techniques, there is little evidence of agricultural technology or health knowledge spillovers to non-treated households within treatment communities. Spillover effects measured for appropriate treatment of diarrhea (10 pp increase in giving rehydration salts rather than traditional medicine), wasting (20 pp lower probability of wasting) and children's anemia status (7 pp reduction in severe anemia) significantly improve in later cohorts. The aggregate program effects and spillovers are generally robust to multiple hypothesis testing.

Maternal determinants of optimal breastfeeding and complementary feeding and their association with child undernutrition in Malawi (2015-2016)

BACKGROUND

Optimal breastfeeding and complementary feeding practices are critical to prevent child undernutrition. Despite the occurrence of child undernutrition and widespread suboptimal feeding practices in Malawi, the association of breastfeeding and complementary feeding practices and undernutrition among Malawian children remains unclear. The purpose of the study was to determine the current breastfeeding and complementary feeding practices, to identify maternal determinants of each practice, and to analyze the associations between breastfeeding and complementary feeding practices with stunting, underweight, and wasting.

METHODS

The most recent Malawi Demographic Health Survey (2015-2016) was used and data for 2294 children aged 0-23 months were included. A conceptual framework of five maternal domains: sociodemographic, health status, health behaviors, women's empowerment, and media exposure was used. Each domain contained exposure variables and the WHO Infant and Young Child Feeding indicators were used as outcome variables. All analyses were adjusted for clustering, and variables that reached a p-value of < 0.05 were considered significant in the final model.

RESULTS

Among children, 30.8% were stunted, 9.9% were underweight, and 3.7% were wasted. Many (78%) were breastfed within the first hour of birth, 89% were breastfed until their first birthday, yet 40% were not exclusively breastfed to 6 months. Only 32% met minimum dietary diversity, 23% met minimum meal frequency, 12% met minimum acceptable diet and 12% consumed iron-rich foods. Children whose mothers lived in urban areas were less likely to be breastfed within 1 hour of birth but more likely to meet minimum dietary diversity. Children whose mothers listened to radio were more likely to meet minimum meal frequency. Children (13-23 months) who met minimum meal frequency and minimum acceptable diet were less likely to be underweight.

CONCLUSIONS

Optimal breastfeeding and complementary feeding practices in Malawi remain suboptimal and child undernutrition remains problematic. Maternal characteristics from the five domains were significantly associated with optimal breastfeeding and complementary feeding indicators. Knowledge of these maternal determinants can assist in improving nutrition policies and interventions that aim to impact breastfeeding and complementary feeding practices and child growth in Malawi.

The fidelity and dose of message delivery on infant and young child feeding practice and nutrition sensitive agriculture in Ethiopia: a qualitative study from the Sustainable Undernutrition Reduction in Ethiopia (SURE) programme

BACKGROUND

In Ethiopia, 38% of children under 5 years of age are stunted (low height for age). A novel government-led intervention called the Sustainable Undernutrition Reduction in Ethiopia (SURE) aims to tackle the burden of stunting by improving complementary feeding and dietary diversity among young children. The SURE programme design applies a transtheoretical model of behaviour change, whereby exposure to recommended infant and young child feeding (IYCF) and nutrition-sensitive agriculture messages is a first stage to adopting key behaviours. This qualitative study explored the fidelity and dose of the IYCF and nutrition-sensitive agriculture messages delivered by extension workers.

METHODS

A qualitative study was conducted across four regions in Ethiopia (Oromiya, Amhara, SNNP and Tigray) between April and October 2017. Across the four regions, 81 key informant interviews, 90 FGDs and 81 observations were conducted with 180 extension workers, 18 development agents and 54 mother-father pairs. Digitally recorded audio files were transcribed verbatim, and the data were analysed based on a framework analysis approach using NVivo (version 12) by coding and categorising texts into major themes and sub-themes.

RESULTS

SURE target households had the intended exposure to messages about exclusive breastfeeding, timing of initiation of complementary feeding, food groups, diversified food consumption, irrigation, rearing small animals and vegetables. Few households reported receiving messages on the content or frequency of complementary feeding of a child beyond 6 months of age. Frequency of household visits and hence exposure to SURE messages was also variable. Agricultural messages delivered during household visits focussed on improving standard agricultural practices and rarely covered the importance of nutrition-sensitive agriculture to improve household or child nutrition.

CONCLUSION

Despite variability observed in the breadth and depth of messages delivered, large-scale behaviour change communication programmes can achieve moderate to good message exposure among target groups. Qualitative data provide an in-depth insight into fidelity and may supplement our understanding of programme roll-out and implementation. Further research is required to understand longer-term message saturation including frequency and reach.

Estimating the Double Burden of Malnutrition among 595,975 Children in 65 Low- and Middle-Income Countries: A Meta-Analysis of Demographic and Health Surveys

INTRODUCTION

Given the changing global nutrition landscape, the double burden of malnutrition is a major public health challenge in many developing countries. The main aim of this study is to estimate the double burden of malnutrition among children in low- and middle-income countries (LMICs).

METHODS

This study used cross-sectional data from Demographic and Health Surveys (2001-2016). A meta-analysis was conducted to estimate the prevalence of malnutrition indicators in 595,975 children under five years from 65 LMICs. Significant heterogeneity was detected among the various surveys (I2 >50%), hence a random-effect model was used. Sensitivity analysis was also performed, to examine the effects of outliers.

RESULTS

The pooled estimate for stunting, wasting, underweight, and overweight/obesity was 29.0%, 7.5%, 15.5%, and 5.3% respectively. Countries with the highest coexistence of undernutrition and overweight/obesity were: South Africa (stunting 27.4% (95% CI: 25.1, 29.8); overweight/obesity 13.3% (95% CI: 11.5, 15.2)), Sao Tome and Principe (stunting 29.0% (95% CI: 26.8, 31.4); overweight/obesity 10.5% (95% CI: 9.0, 12.1)), Swaziland (stunting 28.9% (95% CI: 27.3, 30.6); overweight/obesity 10.8% (95% CI: 9.7, 12.0)), Comoros (stunting 30.0% (95% CI: 28.3, 31.8); overweight/obesity 9.3% (95% CI: 8.3, 10.5)), and Equatorial Guinea (stunting 25.9% (95% CI: 23.4, 28.7); overweight/obesity 9.7% (95% CI: 8.0, 11.6)).

CONCLUSIONS

There is an urgent need to strengthen existing policies on child malnutrition to integrate and scale up opportunities for innovative approaches which address the double burden of malnutrition in children under five years in LMICs.

Nutrition for women and children-Are we doing the right things in the right way?

The Guest Editors for the PLOS Medicine Special Issue on Maternal and Child Health & Nutrition discuss the published research in the context of global priorities for women's and children's health.

A Systematic Review of the Evaluation of Interventions to Tackle Children's Food Insecurity

Purpose of Review

To synthesise the research which has sought to evaluate interventions aiming to tackle children’s food insecurity and the contribution of this research to evidencing the effectiveness of such interventions.

Recent Findings

The majority of studies in this review were quantitative, non-randomised studies, including cohort studies. Issues with non-complete outcome data, measurement of duration of participation in interventions, and accounting for confounds are common in these evaluation studies. Despite the limitations of the current evidence base, the papers that were reviewed provide evidence for multiple positive outcomes for children participating in attended and subsidy interventions, inter alia, reductions in food insecurity, poor health and obesity. However, current evaluations may overlook key areas of impact of these interventions on the lives and outcomes of participating children.

Summary

This review suggests that the current evidence base which evaluates food insecurity interventions for children is both mixed and limited in scope and quality. In particular, the outcomes measured are narrow, and many papers have methodological limitations. With this in mind, a systems-based approach to both implementation and evaluation of food poverty interventions is recommended.

The whole is more than the sum of the parts: establishing an enabling health system environment for reducing acute child malnutrition in a rural South African district

There is a gap in understanding of how national commitments to child nutrition are translated into sub-national implementation. This article is a mixed methods case study of a rural South African health district which achieved accelerated declines in morbidity and mortality from severe acute malnutrition (SAM) in young children, following a district health system strengthening (HSS) initiative centred on real-time death reporting, analysis and response. Drawing on routine audit data, the declining trends in under-five admissions and in-hospital mortality for SAM over a 5-year period are presented, comparing the district with two others in the same province. Adapting Gillespie et al.'s typology of 'enabling environments' for Maternal and Child Nutrition, and based on 41 in-depth interviews and a follow-up workshop, the article then presents an analysis of how an enabling local health system environment for maternal-child health was established, creating the conditions for achievement of the SAM outcomes. Embedded in supportive policy and processes at national and provincial levels, the district HSS interventions and the manner in which they were implemented produced three kinds of system-level change: knowledge and use of evidence by providers and managers ('ways of thinking'), leadership, participation and coordination ('ways of governing') and inputs and capacity ('ways of resourcing'). These processes mainstreamed responsibility, deepened accountability and triggered new service delivery and organizational practices and mindsets. The article concludes that it is possible to foster enabling district environments for the prevention and management of acute malnutrition, emphasizing the multilevel and simultaneous nature of system actions, where action on system 'software' complements the 'hardware' of HSS interventions, and where the whole is more than the sum of the parts.

Cash transfer programmes in lower-income and middle-income countries: understanding pathways to nutritional change-a realist review protocol

INTRODUCTION

Child malnutrition continues to be a significant global public health concern. Nutrition-related interventions have changed and diversified over the last two decades, with increasing emphasis on nutrition-sensitive programmes that address underlying determinants of child malnutrition. Cash transfer programmes (CTPs) are used with increasing popularity in lower-income and middle-income countries to improve both food/nutrition insecurity and resilience. Available studies, however, provide mixed findings on the outcomes of CTPs for child nutritional status. This review is the first stage of a research project to develop evidence-informed theories of how CTPs affect child malnutrition. These will be empirically tested in the field and contribute to a better understanding of how, why, for whom and in what circumstances CTPs can be implemented to optimise impacts on child nutritional status.

METHODS AND ANALYSIS

This realist review is informed by available standards for realist reviews and follows a five-step process. In step 1, an initial scoping of literature identified potential contextual factors and underlying mechanisms that influence nutritional outcomes, and potential theories developed to address our research question. In step 2, a systematic literature search using multiple databases will be undertaken with papers screened using defined inclusion/exclusion criteria. In step 3, included studies will be appraised, data extracted into a bespoke data extraction tool and used to test and further refine our explanatory framework. The fourth step will synthesise, using a mix of inductive and deductive analytical processes to identify patterns, link chains of inference and tracking and linking of articles. The final step involves dissemination of a preliminary theory for feedback prior to empirically testing it in Kenya and Ethiopia where large-scale CTPs are being implemented.

ETHICS AND DISSEMINATION

This review will not involve primary data collection. Findings will be presented in accordance with Realist and Meta-Narrative Evidence Synthesis: Evolving Standards guidelines and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42018110735.

Monitoring and evaluation design of Malawi's Right Foods at the Right Time nutrition program

Child stunting is a public health problem in Malawi. In 2014, the Government of Malawi launched the Right Foods at the Right Time (RFRT) program in Ntchisi district delivering nutrition social and behavior change communication, a small-quantity lipid-based nutrient supplement to children 6-23 months, and nutrition sensitive activities. Monitoring and evaluation (M&E) systems are key aspects of successful program implementation. We describe these and the methodology for an impact evaluation that was conducted for this program. Two monitoring systems using traditional and electronic platforms were established to register and track program delivery and processes including number of eligible beneficiaries, worker performance, program participation, and to monitor input, output, and outcome indicators. The impact evaluation used comparative cross-sectional and longitudinal designs to assess impact on anthropometric and infant and young child feeding outcomes. Three cross-sectional surveys (base-, mid-, and end-line) and two longitudinal cohorts of children followed in 6-month intervals from 6 to 24 months of age, were conducted in sampled households in the program and a neighboring comparison district. Additional M&E included qualitative studies, a process evaluation, and a cost-effectiveness study. The current paper describes lessons from this program's M&E, and demonstrates how multiple implementation research activities can inform course-correction and program scale-up.

Malnutrition in children and its determinants: a study from east India

Malnutrition continues to be a major killer of children, predominantly in low- and middle-income countries such as India. An ecological study was undertaken to correlate different demographic factors with the prevalence of underweight children. Based on findings from the National Family Health Survey 4 (2015-2016), 81 districts were analysed from three states in the eastern part of India. The findings suggest that female literacy (r = -0.556) and improved sanitation (r = -0.741) reduces the burden of malnutrition. Regarding childbirth, four antenatal visits (ANC), institutional deliveries, full immunisation, early breast feeding and adequate diet also reduce the degree of malnutrition among children. For preventing malnutrition, emphasis should be laid on improving social determinants and maternal health awareness.

Young maternal age is a risk factor for child undernutrition in Tamale Metropolis, Ghana

OBJECTIVE

Malnutrition is a common cause of morbidity and mortality in children. The aim of this study was to compare the nutritional status of children under 5 years of teenage and adult mothers in Tamale Metropolis, Ghana. A case-control study involving 300 (150 cases, 150 controls) mother-child pairs was carried out. A questionnaire was used to collect data on socio-demographic characteristics of mothers and children and anthropometry was used to assess the nutritional status of children. Anthropometric z-scores derived based on WHO Child Growth Standards were used to determine stunting, wasting and underweight statuses of children. Logistic regression analysis was used to compare the nutritional status of children of teenage and adult mothers.

RESULTS

Children of teenage mothers, compared to those of adult mothers, were 8 times more likely to be stunted [Adjusted Odds Ratio (AOR) = 7.56; 95% confidence interval (CI) 4.20-13.63], 3 times more likely to be wasted (AOR = 2.90; 95% CI 1.04-8.04), and 13 times more likely to be underweight (AOR = 12.78; 95% CI 4.69-34.81) after adjusting for potential confounders. The risk of child malnutrition increases with young maternal age; interventions should be targeted at teenage mothers and their children to reduce the risk of malnutrition.

Environmental Risk Factors Associated with Child Stunting: A Systematic Review of the Literature

BACKGROUND

Stunting, a form of malnutrition characterized by impaired linear growth in the first two years of life, affects one quarter of children globally. While nutritional status remains the key cause of stunting, there is evidence that environmental risk factors are associated with stunting.

OBJECTIVE

The objective of this review is to explore the current literature and compile the environmental risk factors that have been associated with stunting. Further, we seek to discover which risk factors act independently of nutritional intake.

METHODS

A systematic search of the literature was performed using PubMed, EMBASE, Scopus, TOXNET, and CINAHL. A search of the grey literature was conducted. Papers were included in this review if they examined an association between childhood stunting and exposure to environmental risk factors.

FINDINGS

We included 71 reports in the final analysis. The included studies showed that foodborne mycotoxins, a lack of adequate sanitation, dirt floors in the home, poor quality cooking fuels, and inadequate local waste disposal are associated with an increased risk of childhood stunting. Access to safe water sources was studied in a large number of studies, but the results remain inconclusive due to inconsistent study findings. Limited studies were available for arsenic, mercury, and environmental tobacco, and thus their role in stunting remains inconclusive. The identified research did not control for nutritional intake. A causal model identified solid fuel use and foodborne mycotoxins as being environmental risk factors with the potential to have direct effects on childhood growth.

CONCLUSIONS

A diverse range of environmental risk factors are, to varying degrees, associated with stunting, demonstrating the importance of considering how the environment interacts with nutrition. Health promotion activities may be more effective if they consider environmental factors alongside nutritional interventions.

Impact and spill-over effects of an asset transfer program on child undernutrition: Evidence from a randomized control trial in Bangladesh

Targeting the Ultra-poor (TUP) is an integrated programme that combines the transfer of income-generating assets and multifaceted training on entrepreneurship, health-nutrition, and social awareness over a two-year period to graduate ultra-poor with mainstream poverty. While positive socioeconomic effects and spill-over effects are well-documented, this is the first paper to evaluate the effects of the programme on nutritional outcomes of under-5 children using data from a randomized control trial over a four-year period. We find notable improvements in nutritional outcomes of children in participating households. TUP is further seen to improve food-security, sanitation and duration of exclusive-breastfeeding. Nutrition status of children living in poor non-participant households are also positively affected though no effects were found on children from non-poor households. We conclude that programmes that combine asset transfer with multifaceted training such as TUP can have significant long-term positive health effects.

Household demand persistence for child micronutrient supplementation

Addressing early-life micronutrient deficiencies can improve short- and long-term outcomes. In most contexts, private supply chains will be key to effective and efficient preventative supplementation. With established vendors, we conducted a 60-week market trial for a food-based micronutrient supplement in rural Burkina Faso with randomized price and non-price treatments. Repeat purchases - critical for effective supplementation - are extremely price sensitive. Loyalty cards boost demand more than price discounts, particularly in non-poor households where the father is the cardholder. A small minority of households achieved sufficient supplementation for their children through purely retail distribution, suggesting the need for more creative public-private delivery platforms informed by insights into household demand persistence and heterogeneity.