Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis

The cost of inaction: a global tool to inform nutrition policy and investment decisions on global nutrition targets

At present, the world is off-track to meet the World Health Assembly global nutrition targets for 2025. Reducing the prevalence of stunting and low birthweight (LBW) in children, and anaemia in women, and increasing breastfeeding rates are among the prioritized global nutrition targets for all countries. Governments and development partners need evidence-based data to understand the true costs and consequences of policy decisions and investments. Yet there is an evidence gap on the health, human capital, and economic costs of inaction on preventing undernutrition for most countries. The Cost of Inaction tool and expanded Cost of Not Breastfeeding tool provide country-specific data to help address the gaps. Every year undernutrition leads to 1.3 million cases of preventable child and maternal deaths globally. In children, stunting results in the largest economic burden yearly at US$548 billion (0.7% of global gross national income [GNI]), followed by US$507 billion for suboptimal breastfeeding (0.6% of GNI), US$344 billion (0.3% of GNI) for LBW and US$161 billion (0.2% of GNI) for anaemia in children. Anaemia in women of reproductive age (WRA) costs US$113 billion (0.1% of GNI) globally in current income losses. Accounting for overlap in stunting, suboptimal breastfeeding and LBW, the analysis estimates that preventable undernutrition cumulatively costs the world at least US$761 billion per year, or US$2.1 billion per day. The variation in the regional and country-level estimates reflects the contextual drivers of undernutrition. In the lead-up to the renewed World Health Assembly targets and Sustainable Development Goals for 2030, the data generated from these tools are powerful information for advocates, governments and development partners to inform policy decisions and investments into high-impact low-cost nutrition interventions. The costs of inaction on undernutrition continue to be substantial, and serious coordinated action on the global nutrition targets is needed to yield the significant positive human capital and economic benefits from investing in nutrition.

The Cost and Cost-Effectiveness of an Integrated Wasting Prevention and Screening Intervention Package in Burkina Faso and Mali

BACKGROUND

Little is known about costs and cost effectiveness of interventions that integrate wasting prevention into screening for child wasting.

OBJECTIVES

This study's objective was to estimate the cost and cost-effectiveness of an intervention that integrated behavior change communication (BCC) and small-quantity lipid-based nutrient supplements (SQ-LNS) into platforms for wasting screening in Burkina Faso (a facility-based platform, where BCC was enhanced compared with standard care) and Mali (a community-based platform, with standard BCC).

METHODS

Activity-based costing was used to estimate the cost per child-contact for the intervention and the comparison group, which did not receive the intervention. Costs were ascertained from accounting records, interviews, surveys, and observations. The number of child-contacts was calculated using population size estimates and average attendance rates for each service. Costs per disability-adjusted life year (DALY) averted were estimated using a Markov model populated with data from the parent trials on impact of wasting incidence and treatment coverage.

RESULTS

In the intervention group in Burkina Faso, the cost per child-contact of facility-based screening was $0.85 of enhanced BCC was $4.28, and of SQ-LNS was $8.86. In Mali, the cost per child-contact of community-based screening was $0.57, standard BCC was $0.72, and SQ-LNS was $4.14. Although no SQ-LNS costs were incurred in the comparison groups (hence lower total costs), costs per child-contact for screening and BCC were higher because coverage of these services was lower. The intervention package cost $1073 per DALY averted in Burkina Faso and $747 in Mali.

CONCLUSIONS

Integration of wasting prevention into screening for child wasting led to higher total costs but lower unit costs than standard screening due to increased coverage. Greater cost-effectiveness could be achieved if BCC were strengthened and led to improved caregiver health and nutrition practices and if screening triggered appropriate use of services and higher treatment coverage.

Child growth faltering dynamics in food insecure districts in rural Ethiopia

Child undernutrition disproportionally affects children in low- and middle-income countries. In Ethiopia, both wasting and stunting are serious public health concerns, with high human and economic costs. Understanding the dynamics in ponderal and linear growth faltering is critical to inform the design of innovative interventions that can prevent both wasting and stunting in poor and complex settings. Using two longitudinal studies conducted in 2017 and 2019 in four highland regions of Ethiopia, we evaluated the dynamics and drivers of child growth faltering in children 6-23 months of age (N = 5003). Child wasting prevalence peaked during the first 6 months of life, whereas stunting increased significantly after 6 months of age. Male sex, child illnesses (i.e., diarrhoea or fever) and low consumption of fruits and vegetables were associated with higher odds of acute undernutrition (P < 0.05). The consumption of animal source foods (ASF) was associated with increases (β: 95% CI) in weight-for-length Z-score (WLZ; 0.12: 0.0002; 0.242), whereas fruit or vegetables consumption was associated with increases in midupper arm circumference (MUAC; 0.11 cm: 0.003; 0.209). Only consumption of ASF was the statistically significant predictor of future linear growth (0.14: 0.029; 0.251). Distinct trends in WLZ and MUAC were observed by child sex and age. Improving diet quality through improved nutrition knowledge and increased access and affordability of ASFs, along with effective infection prevention/control measures could prevent both child wasting and stunting concurrently.

Feasibility of caregiver-administered anthropometric measurements of children under age 5: evidence from Zambia

BACKGROUND

Accurate measurement of children's anthropometry is of central importance for the assessment of nutritional status as well as for the evaluation of nutrition-specific interventions. Social distancing requirements during the recent Covid-19 pandemic made administration of standard assessor-led measurement protocols infeasible in many settings, creating demand for alternative assessment modalities.

OBJECTIVE

To assess the feasibility and reliability of caregiver-administered anthropometric assessments of children under age 5.

DESIGN

We compared standard and caregiver-administered assessments within an ongoing nutrition trial in Zambia (NCT05120427). We developed a "no-contact" protocol whereby trained staff verbally instruct caregivers from an appropriate distance to measure the height, weight and MUAC of their children. We captured measurements of height, weight and MUAC among a sample of caregivers and infants in Zambia using both the "no-contact" protocol and a standard assessor-led protocol. We analyzed each anthropometric variable, comparing means between protocol group, the proportions yielding standardized z-scores outside the plausible ± 6SD range and the proportions of children classified stunted, underweight and wasted.

RESULTS

Anthropometric measurements were captured for 76 children using both the no-contact protocol and the standard protocol. An additional 1430 children were assessed by the standard protocol only and an additional 748 children by the no-contact protocol only. For the 76 children measured by both methods, we find no differences in average height, weight and MUAC between caregivers and interviewer assessments. The estimated kappa for the binary stunting and underweight classifications were 0.84 and 0.93, respectively. In the larger samples measured only following one protocol, we find no differences in average outcomes after adjusting for child, caregiver and household characteristics.

CONCLUSIONS

Anthropometric measurement protocols administered by caregivers with verbal instruction from trained assessors are a promising alternative to standard protocols in situations where study staff are unable to come in close contact with study participants. Clinical trials registration This study was conducted within a larger trial registered at clinicaltrials.gov as trial NCT05120427. https://clinicaltrials.gov/ct2/show/NCT05120427 .

Childhood undernutrition in North Africa: systematic review and meta-analysis of observational studies

BACKGROUND

Undernutrition remains a major public health issue in low- and middle-income countries. Objective Our aim for this study was to identify the factors contributing to undernutrition in children under five years old in North Africa.

METHODS

We searched five electronic bibliographic databases (Ovid MEDLINE, Web of Science, Embase (Ovid), ProQuest, and CINAHL) for eligible observational studies published after 2006. STATA version 17 software was used to calculate the odds ratios between associated factors and indicators of undernutrition, with 95% confidence intervals. For each factor, the overall odds were pooled using a forest plot. Due to the significant heterogeneity among the studies (I2 > 50%), a random-effects model was used, and sensitivity analysis was conducted to examine the effect of outliers.

RESULTS

Out of 1093 initially identified studies, 14 met the selection criteria. Our meta-analysis revealed that uneducated mothers were the most common factor associated with undernutrition in North African children. Children aged 0-23 months were significantly associated with stunting (odds ratios (OR) = 1.27; 95% CI: 1.18; 1.37) and wasting (OR = 1.68; 95% CI: 1.42; 1.99). Children living in rural areas were also at higher odds of being stunted (OR = 1.74; 95% CI: 1.64; 1.84) and underweight (OR = 1.59; 95% CI: 1.35; 1.88). These analyses also indicated that a lower wealth index, mothers' nutritional health, uneducated fathers, and low birth weight were other factors significantly associated with stunting.

CONCLUSION

Addressing undernutrition in Northern Africa requires a multidisciplinary approach prioritising mothers and young children, especially families in underprivileged areas.

Interventions to improve the nutritional status of children under 5 years in Ethiopia: a systematic review

OBJECTIVE

To conduct a systematic review of experimental or quasi-experimental studies that aimed to improve the nutritional status of children under 5 years of age in Ethiopia.

DESIGN

Embase, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, and Academic Search Database were used to locate peer-reviewed studies, and Google Scholar and Open Dissertation were used to locate grey literatures. All searches were conducted between 2000 and November 2022.

SETTING

Ethiopia.

PARTICIPANTS

Pregnant women and mothers with children aged 0-59 months.

RESULTS

Ten cluster randomised controlled trials (RCT), six quasi-experimental studies and two individual RCT were included. Out of the identified eighteen studies, three studies targeted pregnant mothers. Our findings showed that almost two-thirds of published interventions had no impact on childhood stunting and wasting, and more than half had no impact on underweight. Some behaviour change communication (BCC) interventions, food vouchers, micronutrient supplementation and quality protein maize improved stunting. Similarly, BCC and fish oil supplementation showed promise in reducing wasting, while BCC and the provision of quality protein maize reduced underweight. Additionally, water, sanitation and hygiene (WaSH) interventions provided to pregnant mothers and children under 2 years of age were shown to significantly reduce childhood stunting.

CONCLUSION

Future childhood nutritional interventions in Ethiopia should consider adopting an integrated approach that combines the positive effects of interdependent systems such as BCC, food supplemental programmes (e.g. boosting protein and micronutrients), health interventions (e.g. strengthening maternal and childcare), WaSH and financial initiatives (e.g. monetary support and income schemes).

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

Population-Modifiable Risk Factors Associated With Childhood Stunting in Sub-Saharan Africa

Importance

Identifying modifiable risk factors associated with childhood stunting in sub-Saharan Africa (SSA) is imperative for the development of evidence-based interventions and to achieve the Sustainable Development Goals.

Objective

To evaluate key modifiable risk factors associated with childhood stunting in SSA.

Design, Setting, and Participants

This cross-sectional study examined the most recent (2014-2021) Demographic and Health Surveys data for children younger than 5 years from 25 SSA countries.

Exposures

Modifiable risk factors included history of diarrhea within 2 weeks, consumption of dairy products, maternal body mass index, maternal educational level, antenatal care visits, place of birth, wealth index, type of toilet, and type of cooking fuel.

Main Outcomes and Measures

Stunting and severe stunting, measured using the height-for-age z score, were the main outcomes. Children who scored below -2.0 SDs or -3.0 SDs were classified as having stunted or severely stunted growth, respectively. Relative risks and 95% CIs were computed using generalized linear latent and mixed models and log-binomial link functions. Population-attributable fractions (PAFs) were calculated using adjusted relative risks and prevalence estimates for key modifiable risk factors.

Results

This study included 145 900 children from 25 SSA countries. The mean (SD) age of the children was 29.4 (17.3) months, and 50.6% were male. The highest PAFs of severe childhood stunting were observed for mothers lacking a formal education (PAF, 21.9%; 95% CI, 19.0%-24.8%), children lacking consumption of dairy products (PAF, 20.8%; 95% CI, 16.8%-24.9%), unclean cooking fuel (PAF, 9.5%; 95% CI, 2.6%-16.3%), home birth (PAF, 8.3%; 95% CI, 6.3%-10.0%), and low-income household (PAF, 5.8%; 95% CI, 3.4%-8.0%). These 5 modifiable risk factors were associated with 51.6% (95% CI, 40.5%-60.9%) of the severe childhood stunting in SSA.

Conclusions and Relevance

This cross-sectional study identified 5 modifiable risk factors that were associated with 51.6% of severe childhood stunting in SSA. These factors should be a priority for policy makers when considering future child health interventions to address chronic malnutrition in SSA.

The cost-effectiveness of small-quantity lipid-based nutrient supplements for prevention of child death and malnutrition and promotion of healthy development: modelling results for Uganda

OBJECTIVE

Recent meta-analyses demonstrate that small-quantity lipid-based nutrient supplements (SQ-LNS) for young children significantly reduce child mortality, stunting, wasting, anaemia and adverse developmental outcomes. Cost considerations should inform policy decisions. We developed a modelling framework to estimate the cost and cost-effectiveness of SQ-LNS and applied the framework in the context of rural Uganda.

DESIGN

We adapted costs from a costing study of micronutrient powder (MNP) in Uganda, and based effectiveness estimates on recent meta-analyses and Uganda-specific estimates of baseline mortality and the prevalence of stunting, wasting, anaemia and developmental disability.

SETTING

Rural Uganda.

PARTICIPANTS

Not applicable.

RESULTS

Providing SQ-LNS daily to all children in rural Uganda (> 1 million) for 12 months (from 6 to 18 months of age) via the existing Village Health Team system would cost ∼$52 per child (2020 US dollars) or ∼$58·7 million annually. SQ-LNS could avert an average of > 242 000 disability-adjusted life years (DALYs) annually as a result of preventing 3689 deaths, > 160 000 cases of moderate or severe anaemia and ∼6000 cases of developmental disability. The estimated cost per DALY averted is $242.

CONCLUSIONS

In this context, SQ-LNS may be more cost-effective than other options such as MNP or the provision of complementary food, although the total cost for a programme including all age-eligible children would be high. Strategies to reduce costs, such as targeting to the most vulnerable populations and the elimination of taxes on SQ-LNS, may enhance financial feasibility.

Multi-Level Correlates of the Nutritional Status of Nigerian Women of Reproductive Age

Poor nutrition compromises the capacity of women to perform their vital roles as mothers and productive workers in their families, communities and society. Using a conceptual framework developed by the United Nations Children's Fund, this study determines individual-, household- and community-level factors associated with the nutritional status of Nigerian women of reproductive age. A secondary analysis of pooled data from the Nigeria Demographic and Health Survey (NDHS) for 2003, 2008, 2013 and 2018 was conducted involving 82,734 non-pregnant women aged 15-49 years. Multinomial logistic regression was used to determine predictors of nutritional status. Study results show that a significant proportion of the women had poor nutritional status; the prevalence of underweight, overweight and obesity were 12.1%, 16.8% and 7.2% respectively. Statistically significant factors associated with poor nutritional status were found at all three levels, highlighting the need for effective multidimensional, multisectoral policy interventions to address the double burden of malnutrition among women in Nigeria.

Assessing rural household's food groups-and-sources and dietary diversity pattern in Malaita Province

Access to and availability of various food sources is not an issue in rural communities. However, there is no guarantee that households are not affected by nutritional inadequacy, which is still a problem in most underdeveloped nations. A mixed-methods study was conducted to determine the HDDS through the snowballing method for the last 12 months' food groups-and-sources and the 48-h diet recall. Ninety-eight households in two rural communities surrounding Sikwafta (zone one) and Malu'u (zone two) participated in the interview between April and May 2019. The results were then analyzed through SPSS and QDA MINER. The aim is to analyze the household dietary patterns of the communities between the two zones. The study also hypothesizes that the dietary pattern of households has not changed. Results showed that a total of nine food groups were consumed: grain, white roots, tubers, plantains, oils/fats (95.90%), condiments (83.70%), and meat/poultry/sea foods (77.60%). The majority of the food consumed comes from the gardens, followed by other food sources, which make up the average HDDS of five. A correlation analysis found a statistically significant relationship between HDDS and total meal (0.504*), with no relationships between demographics. When comparing 48-h food sources-and-groups to the previous year, there was little to no difference in accessibility and availability. This implies that the majority of households are likely to achieve their nutritional needs within the parameters of their dietary trend. Even though households have adequate access to food, there is a significant need to improve their nutritional needs, even if they consume the average amount of the required food groups.

A rapid landscape review of postpartum anaemia measurement: challenges and opportunities

BACKGROUND

Anaemia is a reduction in haemoglobin concentration below a threshold, resulting from various factors including severe blood loss during and after childbirth. Symptoms of anaemia include fatigue and weakness, among others, affecting health and quality of life. Anaemic pregnant women have an increased risk of premature delivery, a low-birthweight infant, and postpartum depression. They are also more likely to have anaemia in the postpartum period which can lead to an ongoing condition and affect subsequent pregnancies. In 2019 nearly 37% of pregnant women globally had anaemia, and estimates suggest that 50-80% of postpartum women in low- and middle-income countries have anaemia, but currently there is no standard measurement or classification for postpartum anaemia.

METHODS

A rapid landscape review was conducted to identify and characterize postpartum anaemia measurement searching references within three published systematic reviews of anaemia, including studies published between 2012 and 2021. We then conducted a new search for relevant literature from February 2021 to April 2022 in EMBASE and MEDLINE using a similar search strategy as used in the published reviews.

RESULTS

In total, we identified 53 relevant studies. The timing of haemoglobin measurement ranged from within the immediate postpartum period to over 6 weeks. The thresholds used to diagnose anaemia in postpartum women varied considerably, with < 120, < 110, < 100 and < 80 g/L the most frequently reported. Other laboratory results frequently reported included ferritin and transferrin receptor. Clinical outcomes reported in 32 out of 53 studies included postpartum depression, quality of life, and fatigue. Haemoglobin measurements were performed in a laboratory, although it is unclear from the studies if venous samples and automatic analysers were used in all cases.

CONCLUSIONS

This review demonstrates the need for improving postpartum anaemia measurement given the variability observed in published measures. With the high prevalence of anaemia, the relatively simple treatment for non-severe cases of iron deficiency anaemia, and its importance to public health with multi-generational effects, it is crucial to develop common measures for women in the postpartum period and promote rapid uptake and reporting.

Effect of oral nutritional supplements on outcomes in children presenting with, or at risk of, faltering growth in clinical settings: A systematic review and meta-analysis

This systematic review summarises evidence regarding oral nutritional supplement (ONS) use in children with, or at risk of, faltering growth (FG). Ten randomised controlled trials (RCTs), compared changes in outcomes amongst children receiving ONS versus control were included. Overall, 1116 children (weighted mean (WM) age 5 years; n658 (59%) male) were recruited, of which 585 (52%) received ONS (WM intake contribution 412 kcal, 16.3 g protein, 395 ml) for 116 days (WM). ONS use was associated with significantly greater gains in weight (mean difference (MD) 0.4 kg, 95% CI [0.36, 0.44]) and height (MD 0.3 cm, 95% CI [0.03, 0.57]), likely related to improvements in nutritional intake. Mean compliance to prescribed dose was 98%. Data suggested an association between ONS use and reduced infections. Further research is warranted to establish ONS dosage and effects upon other outcomes. This review provides evidence to support use of ONS in the management of children with, or at risk of, FG.

Triple burden of malnutrition among mother-child pairs in low-income and middle-income countries: a cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence and determinants of the triple burden of malnutrition among mother-child pairs in low-income and middle-income countries.

DESIGN

Cross-sectional study.

SETTING

Low-income and middle-income countries.

PARTICIPANTS

Women and children.

PRIMARY OUTCOME

Triple burden of malnutrition (overweight/obese mother with undernourished and anaemic under 5 years child).

METHODS

Data for this study were drawn from recent 22 low-income and middle-income countries Demographic and Health Surveys. A total weighted sample of 116 795 mother-child pairs was included in the study. STATA V.14.2 was used to clean, code and analyse the data. Multilevel logistic regression was employed to identify factors associated with the problem. Adjusted OR (AOR) with 95% CI and a p<0.05 was reported to indicate statistical association. Model fitness and comparison were done using intraclass correlation coefficient, median OR, proportional change in variance and deviance.

RESULT

The pooled prevalence of the triple burden of malnutrition among mother-child pairs was 11.39%. It showed statistically significant positive associations with mothers aged ≥35 years (AOR 2.25, 95% CI 2.08 to 2.44), family size >10 (AOR 1.17, 95% CI 1.08 to 1.26), delivery by caesarean section (AOR 1.93, 95% CI 1.83 to 2.03), the richest household (AOR 1.72, 95% CI 1.56 to 1.88), grand multiparous (AOR 1.62, 95% CI 1.46 to 1.81), age of child 36-47 months (AOR 1.77, 95% CI 1.64 to 1.90), at a p<0.05. Whereas breast feeding (AOR 0.94, 95% CI 0.89 to 0.99), married mothers (AOR 0.87, 95% CI 0.78 to 0.96), female children (AOR 0.88, 95% CI 0.84 to 0.92), improved toilet (AOR 0.23, 95% CI 0.17 to 0.29), improved source of drinking water (AOR 0.28, 95% CI 0.21 to 0.35), rural residents (AOR 0.66, 95% CI 0.62 to 0.69) had a contrasting relationship with the triple burden of malnutrition.

CONCLUSION

About 1 out of 10 households suffer from the triple burden of malnutrition in low-income and middle-income countries. This study revealed that several maternal, child, household and community-level factors have a significant impact on the triple burden of malnutrition among mother-child pairs.

A systematic review and meta-analysis of the prevalence of childhood undernutrition in North Africa

Undernutrition (stunting, wasting and underweight) among children remains a public health concern in North Africa, especially following recent conflicts in the region. Therefore, this paper systematically reviews and meta-analyses the prevalence of undernutrition among children under five in North Africa to determine whether efforts to reduce undernutrition are on track to achieving the Sustainable Development Goals (SDGs) by 2030. Eligible studies published between 1st January 2006 and 10th April 2022 were searched for, using five electronic bibliographic databases (Ovid MEDLINE, Web of Science, Embase (Ovid), ProQuest and CINAHL). The JBI critical appraisal tool was used, and a meta-analysis was conducted using the 'metaprop' command in STATA, to estimate the prevalence of each undernutrition indicator in the seven North African countries (Egypt, Sudan, Libya, Algeria, Tunisia, Morocco, and Western Sahara). Due to the significant heterogeneity among studies (I2 >50%), a random effect model and sensitivity analysis were conducted to examine the effect of outliers. Out of 1592 initially identified, 27 met the selection criteria. The prevalence of stunting, wasting and being underweight were 23.5%, 7.9% and 12.9%, respectively. Significant variations between the countries with the highest rates of stunting and wasting were reported in Sudan (36%, 14.1%), Egypt (23.7%, 7.5%), Libya (23.1%, 5.9%), and Morocco (19.9%, 5.1%). Sudan also had the highest prevalence of underweight (24.6%), followed by Egypt (7%), Morocco (6.1%), and Libya (4.3%) with more than one in ten children in Algeria and Tunisia having stunted growth. In conclusion, undernutrition is widespread in the North African region, particularly in Sudan, Egypt, Libya, and Morocco, making it challenging to meet the SDGs by 2030. Nutrition monitoring and evaluation in these countries is highly recommended.

Development and validation of a new set of indicators to assess the quality of maternal and child nutritional care at the primary care

Introduction

Maternal and child malnutrition is a worldwide public health problem with short, medium, and long-term adverse consequences for both mother and child. In Mexico, maternal and child malnutrition represents a serious public health problem that must be urgently addressed. In this context, Primary Health Care (PHC) plays an important role in the prevention, detection, monitoring, and treatment of the different forms of maternal and child malnutrition. Assessing the quality of nutritional care offered at this level of care is necessary in order to improve it; however, there are no indicators for the evaluation of this quality. Therefore, this study aimed at developing a set of indicators to assess the quality of maternal and child nutritional care at PHC.

Methods

We developed indicators for different stages of life: preconception, pregnancy, infancy, and preschool age. A systematic review of the literature on clinical guidelines for the prevention, diagnosis, and treatment of the different forms of malnutrition was carried out; the recommendations of the guidelines evaluated with good quality were extracted.

Results

Based on these recommendations, 22 indicators were constructed. A pilot study was carried out to validate the indicators and 16 indicators were selected to assess the maternal and child nutritional care at PHC.

Severe acute malnutrition’s recovery rate still below the minimum standard: predictors of time to recovery among 6- to 59-month-old children in the healthcare setting of Southwest Ethiopia

Background

Despite currently available, scientifically proven treatments and national guideline, the SAM recovery rate is still considerably behind expectations, and it continues to have a devastating impact on under-five children. Identifying predictors of time to recovery might help to reach the minimal criterion established by the WHO and the national Sphere which decreases child mortality. Therefore, the current study assessed time to recovery and its predictors among children aged 6–59 months admitted with SAM in the Healthcare Setting of Southwest Ethiopia, 2021.

Methods

An institutional-based multicenter retrospective follow-up study was conducted on 486 children aged 6 to 59 months admitted with SAM cases. Data were entered into Epi-Data version 4.6 and exported to Stata version 14 for further analysis. Cox–Snell residual plot was used to assess the final model’s overall goodness of fit. Finally, a significant predictor of time to recovery was identified using Weibull survival regression model, at 0.05 significance level.

Result

Overall, 68.72 (95% CI 64.8, 73) of the children recovered and 4.32% died. The overall incidence density was 3.35/100-person day. Independent predictors of time to recovery were, starting complementary feeding at six months (AHR = 1.44; 95%, CI 1.073, 1.935), pneumonia at baseline (AHR = 1.33, 95%, CI 1.049, 1.696), amoxicillin (AHR = 1.31, 95%, CI 1.021, 1.685), and folic acid supplementation (AHR = 1.82, 95% CI 1,237, 2.665).

Conclusion

The recovery from SAM at study area after a maximum of 60 days of treatment was below the accepted minimum standard. Complementary feeding, pneumonia, treated by amoxicillin, and folic acid supplementation were predictors of time to recovery. Therefore, providing folic acid and amoxicillin for those in need as well as the earliest possible treatment of concomitant conditions like pneumonia is highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41043-022-00331-9.

Selenium Status in Paediatric Patients with Neurodevelopmental Diseases

Neurodevelopmental diseases are often associated with other comorbidities, especially inflammatory processes. The disease may affect the trace element (TE) status, which in turn may affect disease severity and progression. Selenium (Se) is an essential TE required for the biosynthesis of selenoproteins including the transporter selenoprotein P (SELENOP) and extracellular glutathione peroxidase (GPX3). SELENOP deficiency in transgenic mice resulted in a Se status-dependent phenotype characterized by impaired growth and disturbed neuronal development, with epileptic seizures on a Se-deficient diet. Therefore, we hypothesized that Se and SELENOP deficiencies may be prevalent in paediatric patients with a neurodevelopmental disease. In an exploratory cross-sectional study, serum samples from children with neurodevelopmental diseases (n = 147) were analysed for total serum Se, copper (Cu), and zinc (Zn) concentrations as well as for the TE biomarkers SELENOP, ceruloplasmin (CP), and GPX3 activity. Children with epilepsy displayed elevated Cu and Zn concentrations but no dysregulation of serum Se status. Significantly reduced SELENOP concentrations were found in association with intellectual disability (mean ± SD (standard deviation); 3.9 ± 0.9 mg/L vs. 4.4 ± 1.2 mg/L, p = 0.015). A particularly low GPX3 activity (mean ± SD; 172.4 ± 36.5 vs. 192.6 ± 46.8 U/L, p = 0.012) was observed in phacomatoses. Autoantibodies to SELENOP, known to impair Se transport, were not detected in any of the children. In conclusion, there was no general association between Se deficiency and epilepsy in this observational analysis, which does not exclude its relevance to individual cases. Sufficiently high SELENOP concentrations seem to be of relevance to the support of normal mental development. Decreased GPX3 activity in phacomatoses may be relevant to the characteristic skin lesions and merits further analysis. Longitudinal studies are needed to determine whether the observed differences are relevant to disease progression and whether correcting a diagnosed TE deficiency may confer health benefits to affected children.

Nutrition-sensitive agriculture programs increase dietary diversity in children under 5 years: A review and meta-analysis

Background

Low-quality diets contribute to the burden of malnutrition and increase the risk of children not achieving their developmental potential. Nutrition-sensitive agriculture programs address the underlying determinants of malnutrition, though their contributions to improving diets do not factor into current nutrition impact modeling tools.

Objective

To synthesize the evidence on the effectiveness of nutrition-sensitive agriculture programs in improving dietary diversity in young children (6-23.9 months and 6-60 months).

Methods

A literature search was conducted for published trials through existing systematic reviews and individual database search of the ISI Web of Science. All dietary diversity measures in the studies selected to be in the analysis were extracted. Estimation of main pooled effects were conducted on outcomes of minimum diet diversity (MDD) and diet diversity score (DDS) using random-effects meta-regression models. We report pooled effect sizes as standardized mean differences (SMDs) or odds ratios (ORs).

Results

Nutrition-sensitive agricultural interventions have a significant positive impact on the diet diversity scores of children aged 6-23.9 months (SMD = 0.22, 95% confidence interval (CI) = 0.09-0.36) and on the odds of reaching minimum diet diversity (OR = 1.45, 95% CI = 1.20, 1.76). Similar impacts are found when analyses are expanded to include studies for children aged 6-60 months (DDS SMD = 0.22, 95% CI = 0.12-0.32) (MDD OR = 1.64, 95% CI:  = 1.38-1.94).

Conclusion

Nutrition-sensitive agriculture interventions consistently have a positive impact on child dietary diversity. Incorporating this evidence in nutrition modeling tools can contribute to decision-making on the relative benefits of nutrition-sensitive interventions as compared with other maternal, newborn, child health and nutrition (MNCHN) interventions.

Global, Regional, and National Estimates of Nutritional Deficiency Burden among Reproductive Women from 2010 to 2019

Women of reproductive age (15-49 years) are often considered a vulnerable population affected by nutritional deficiencies, impairing their health and that of their offspring. We briefly introduced (a) the incidence and disability-adjusted life years (DALYs) trends from 2010 to 2019 and (b) the correlation between sex differences and income levels and nutritional deficiencies of reproductive women firstly. Notably, the burden of overall nutritional deficiencies among reproductive women remained generally stable from 2010 to 2019, whereas the iodine and vitamin A deficiencies as a subcategory were associated with increased incidence rates and DALYs, respectively. A significant increasing trend occurred in South Asia, Southeast Asia, and Turkey for incidence, and Western Sub-Saharan Africa and Zimbabwe had a strong increase for DALYs. Further analysis of the correlation between nutritional deficiency incidence and economic capacity showed that they were not correlated with the income of women themselves, as was the result of income difference with men. The results of this study will help to identify gaps in nutritional deficiency burden among reproductive women and facilitate the development of regional or national responses. Compared with economic capital, macroscopic political guarantees and social and cultural capital are important measures to remedy the nutritional deficiencies of reproductive women.

Cost-effectiveness of antenatal multiple micronutrients and balanced energy protein supplementation compared to iron and folic acid supplementation in India, Pakistan, Mali, and Tanzania: A dynamic microsimulation study

BACKGROUND

Malnutrition among women of childbearing age is especially prevalent in Asia and sub-Saharan Africa and can be harmful to the fetus during pregnancy. In the most recently available Demographic and Health Survey (DHS), approximately 10% to 20% of pregnant women in India, Pakistan, Mali, and Tanzania were undernourished (body mass index [BMI] <18.5 kg/m2), and according to the Global Burden of Disease (GBD) 2017 study, approximately 20% of babies were born with low birth weight (LBW; <2,500 g) in India, Pakistan, and Mali and 8% in Tanzania. Supplementing pregnant women with micro and macronutrients during the antenatal period can improve birth outcomes. Recently, the World Health Organization (WHO) recommended antenatal multiple micronutrient supplementation (MMS) that includes iron and folic acid (IFA) in the context of rigorous research. Additionally, WHO recommends balanced energy protein (BEP) for undernourished populations. However, few studies have compared the cost-effectiveness of different supplementation regimens. We compared the cost-effectiveness of MMS and BEP with IFA to quantify their benefits in 4 countries with considerable prevalence of maternal undernutrition.

METHODS AND FINDINGS

Using nationally representative estimates from the 2017 GBD study, we conducted an individual-based dynamic microsimulation of population cohorts from birth to 2 years of age in India, Pakistan, Mali, and Tanzania. We modeled the effect of maternal nutritional supplementation on infant birth weight, stunting and wasting using effect sizes from Cochrane systematic reviews and published literature. We used a payer's perspective and obtained costs of supplementation per pregnancy from the published literature. We compared disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs) in a baseline scenario with existing antenatal IFA coverage with scenarios where 90% of antenatal care (ANC) attendees receive either universal MMS, universal BEP, or MMS + targeted BEP (women with prepregnancy BMI <18.5 kg/m2 receive BEP containing MMS while women with BMI ≥18.5 kg/m2 receive MMS). We obtained 95% uncertainty intervals (UIs) for all outputs to represent parameter and stochastic uncertainty across 100 iterations of model runs. ICERs for all scenarios were lowest in Pakistan and greatest in Tanzania, in line with the baseline trend in prevalence of and attributable burden to LBW. MMS + targeted BEP averts more DALYs than universal MMS alone while remaining cost-effective. ICERs for universal MMS compared to baseline IFA were $52 (95% UI: $28 to $78) for Pakistan, $72 (95% UI: $37 to $118) for Mali, $70 (95% UI: $43 to $104) for India, and $253 (95% UI: $112 to $481) for Tanzania. ICERs for MMS + targeted BEP compared to baseline IFA were $54 (95% UI: $32 to $77) for Pakistan, $73 (95% UI: $40 to $104) for Mali, $83 (95% UI: $58 to $111) for India, and $245 (95% UI: $127 to $405) for Tanzania. Study limitations include generalizing experimental findings from the literature to our populations of interest and using population-level input parameters that may not reflect the heterogeneity of subpopulations. Additionally, our microsimulation fuses multiple sources of data and may be limited by data quality and availability.

CONCLUSIONS

In this study, we observed that MMS + targeted BEP averts more DALYs and remains cost-effective compared to universal MMS. As countries consider using MMS in alignment with recent WHO guidelines, offering targeted BEP is a cost-effective strategy that can be considered concurrently to maximize benefits and synergize program implementation.

Unequal coverage of nutrition and health interventions for women and children in seven countries

OBJECTIVE

To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries.

METHODS

We used data from the most recent (2015-2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms.

FINDINGS

Only 15% of 231 113 mother-child pairs received all eight health interventions (weighted percentage). The percentage of mother-child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points.

CONCLUSION

Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.

The role of holistic nutritional properties of diets in the assessment of food system and dietary sustainability

Advancing sustainable diets for nutrition security and sustainable development necessitates clear nutrition metrics for measuring nutritional quality of diets. Food composition, nutrient requirements, and dietary intake are among the most common nutrition metrics used in the current assessment of sustainable diets. Broadly, most studies in the area classify animal-source foods (ASF) as having a substantially higher environmental footprint in comparison to plant-source foods (PSF). As a result, much of the current dietary advice promulgates diets containing higher proportions of PSF. However, this generalization is misleading since most of these studies do not distinguish between the gross and bioavailable nutrient fractions in mixed human diets. The bioavailability of essential nutrients including β-carotene, vitamin B-12, iron, zinc, calcium, and indispensable amino acids varies greatly across different diets. The failure to consider bioavailability in sustainability measurements undermines the complementary role that ASF play in achieving nutrition security in vulnerable populations. This article critically reviews the scientific evidence on the holistic nutritional quality of diets and identifies methodological problems that exist in the way the nutritional quality of diets is measured. Finally, we discuss the importance of developing nutrient bioavailability as a requisite nutrition metric to contextualize the environmental impacts of different diets.

Economic Evaluations of Child Nutrition Interventions in Low- and Middle-Income Countries: Systematic Review and Quality Appraisal

Economic evaluation is crucial for cost-effective resource allocation to improve child nutrition in low and middle-income countries (LMICs). However, the quality of published economic evaluations in these settings is not well understood. This systematic review aimed to assess the quality of existing economic evaluations of child nutrition interventions in LMICs and synthesize the study characteristics and economic evidence. We searched 9 electronic databases, including MEDLINE, with the following concepts: economic evaluation, children, nutrition, and LMICs. All types of interventions addressing malnutrition, including stunting, wasting, micronutrient deficiency, and overweight, were identified. We included economic evaluations that examined both costs and effects published in English peer-reviewed journals and used the Drummond checklist for quality appraisal. We present findings through a narrative synthesis. Sixty-nine studies with diverse settings, perspectives, time horizons, and outcome measures were included. Most studies used data from sub-Saharan Africa and South Asia and addressed undernutrition. The mortality rate, intervention effect, intervention coverage, cost, and discount rate were reported as predictors among studies that performed sensitivity analyses. Despite the heterogeneity of included studies and the possibility of publication bias, 81% of included studies concluded that nutrition interventions were cost-effective or cost-beneficial, mostly based on a country's cost-effectiveness thresholds. Regarding quality assessment, the studies published after 2016 met more criteria than studies published before 2016. Most studies had well-stated research questions, forms of economic evaluation, interventions, and conclusions. However, reporting the perspective of the analyses, justification of discount rates, and describing the role of funders and ethics approval were identified as areas needing improvement. The gaps in the quality of reporting could be improved by consolidated guidance on the publication of economic evaluations and the use of appropriate quality appraisal checklists. Strengthening the evidence base for child malnutrition across different regions is necessary to inform cost-effective investment in LMICs. Trial registration: PROSPERO CRD42020194445.

Longitudinal assessments of child growth: A six-year follow-up of a cluster-randomized maternal education trial

Background & aims

Child growth impairments are rampant in sub-Saharan Africa. To combat this important health problem, long-term follow-up studies are needed to examine possible benefits and sustainability of various interventions designed to correct inadequate child growth. Our aim was to perform a follow-up study of children aged 60−72 months whose mothers participated in a two-armed cluster-randomized education intervention trial lasting 6 months in rural Uganda when their children were 6−8 months old with data collection at 20−24 and at 36 months. The education focused on nutrition, hygiene, and child stimulation.

Methods

We measured growth using anthropometry converted to z-scores according to WHO guidelines. We also included assessments of body composition using bioimpedance. We used multilevel mixed effect linear regression models with maximum likelihood method, unstructured variance-covariance structure, and the cluster as a random effect component to compare data from the intervention (receiving the education and routine health care) with the control group (receiving only routine health care).

Results

Of the 511 children included in the original trial, data from 166/263 (63%) and 141/248 (57%) of the children in the intervention and control group, respectively, were available for the current follow-up study. We found no significant differences in any anthropometrical z-score between the two study groups at child age of 60−72 months, except that children in the intervention group had lower (P = 0.006) weight-for-height z-score than the controls. There were no significant differences in the trajectories of z-scores or height growth velocity (cm/year) from baseline (start of original trial) to child age of 60−72 months. Neither did we detect any significant difference between the intervention and control group regarding body composition (fat mass, fat free mass, and total body water) at child age 60−72 months. Separate gender analyses had no significant impact on any of the growth or body composition findings.

Conclusion

In this long-term study of children participating in a randomized maternal education trial, we found no significant impact of the intervention on anthropometrical z-scores, height growth velocity or body composition.

Trial registration

Clinical Trials (clinical trials.gov) ClinicalTrials.gov ID NCT 02098031.

The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries

The economic crisis and food and health system disruptions related to the COVID-19 pandemic threaten to exacerbate undernutrition in low- and middle-income countries (LMICs). We developed pessimistic, moderate and optimistic scenarios for 2020-2022 and used three modelling tools (MIRAGRODEP, the Lives Saved Tool and Optima Nutrition) to estimate the impacts of pandemic-induced disruptions on child stunting, wasting and mortality, maternal anaemia and children born to women with a low body mass index (BMI) in 118 LMICs. We estimated the cost of six nutrition interventions to mitigate excess stunting and child mortality due to the pandemic and to maximize alive and non-stunted children, and used the human capital approach to estimate future productivity losses. By 2022, COVID-19-related disruptions could result in an additional 9.3 million wasted children and 2.6 million stunted children, 168,000 additional child deaths, 2.1 million maternal anaemia cases, 2.1 million children born to women with a low BMI and US$29.7 billion in future productivity losses due to excess stunting and child mortality. An additional US$1.2 billion per year will be needed to mitigate these effects by scaling up nutrition interventions. Governments and donors must maintain nutrition as a priority, continue to support resilient systems and ensure the efficient use of new and existing resources.

Child stunting concurrent with wasting or being overweight: A 6-y follow up of a randomized maternal education trial in Uganda

Objectives

There is paucity of longitudinal data on combined anthropometric deficiencies in children. Herein, we present data on child stunting concurrent with wasting or being overweight among children in a 6-y follow-up study of a maternal education trial in rural Uganda.

Methods

We previously performed a randomized controlled trial where half of 511 mothers of 6- to 8-mo children were given a 6-mo education concerning nutrition, hygiene, and child stimulation. Anthropometry and prevalence of stunting with wasting or being overweight were determined. We applied multilevel mixed-effect logistic regression models and χ² statistic to assess the effects of the intervention and trend in prevalence over time, respectively.

Results

Complete data sets were obtained from 307 of 511 children (60%). The prevalence of stunting and wasting or being overweight was <7% both, and did not change significantly over time. Notably, the prevalence of concurrent stunting and being overweight was significantly reduced in the intervention group compared with the controls among children age 36 mo and 60 to 72 mo, with corresponding odds ratios at 0.24 (95% confidence interval, 0.06−0.90) and 0.10 (95% confidence interval, 0.01−0.82), respectively.

Conclusions

The prevalence of stunting concurrent with wasting or being overweight remained low during the observation period. The intervention may have reduced concurrent stunting and being overweight over time.

Reducing the Burden of Anemia and Neural Tube Defects in Low- and Middle-Income Countries: An Analysis to Identify Countries with an Immediate Potential to Benefit from Large-Scale Mandatory Fortification of Wheat Flour and Rice

Using a predetermined set of criteria, including burden of anemia and neural tube defects (NTDs) and an enabling environment for large-scale fortification, this paper identifies 18 low- and middle-income countries with the highest and most immediate potential for large-scale wheat flour and/or rice fortification in terms of health impact and economic benefit. Adequately fortified staples, delivered at estimated coverage rates in these countries, have the potential to avert 72.1 million cases of anemia among non-pregnant women of reproductive age; 51,636 live births associated with folic acid-preventable NTDs (i.e., spina bifida, anencephaly); and 46,378 child deaths associated with NTDs annually. This equates to a 34% reduction in the number of cases of anemia and 38% reduction in the number of NTDs in the 18 countries identified. An estimated 5.4 million disability-adjusted life years (DALYs) could be averted annually, and an economic value of 31.8 billion United States dollars (USD) generated from 1 year of fortification at scale in women and children beneficiaries. This paper presents a missed opportunity and warrants an urgent call to action for the countries identified to potentially avert a significant number of preventable birth defects, anemia, and under-five child mortality and move closer to achieving health equity by 2030 for the Sustainable Development Goals.