Questions – and answers – on making better nutrition decisions

Chronic child undernutrition and stunting remain significant public health challenges. There is a need to leverage investments in the prevention of stunting, with quality data for strategic decision-making. Learning from countries where success has been documented is a way to accelerate progress. And concrete opportunities exist to engage with partners in generating and analyzing data to develop effective evidence-based strategies.

These were the key messages to emerge from a recent webinar hosted by UNICEF called Making Better Decisions for Nutrition: Understanding Positive Outliers to Reducing Stunting which discussed the research by Exemplars in Global Health in Peru, Senegal, Kyrgyz Republic, Nepal, and Ethiopia, as well as soon to be published research findings from Pakistan and Uganda. The event was moderated by Andreas Hasman, a Nutrition Specialist in UNICEF HQ, and the speakers were Dr. Zulfiqar Bhutta, Co-director of the Center for Global Child Health at The Hospital for Sick Children, Toronto; Dr Víctor Aguayo, Director Nutrition and Child Development in UNICEF Programme Group, NYHQ; Dr. Baseer Achakzai Director of Pakistan's Ministry of National Health Services, Regulation & Coordination; and Dr. Richard Kajura, Research Fellow, Makerere University School of Public Health. The audience included over 140 UNICEF nutrition staff from across the globe.

The following is a summary of the question-and-answer session between audience members and panelists following the presentation. The session helped explain how the Exemplars programs work and how country narratives can be applied to create new interventions in different contexts. Questions were answered by the Exemplars in Global Health Nutrition Team.

Question: How are Exemplar countries selected for the analysis – for example a threshold on change on stunting? Or are there other factors? It seems the findings are context-specific.

Exemplars in Global Health Nutrition Team: We looked at a variety of factors when selecting Exemplars to study. First and foremost, LMICs were selected based on their ability to make progress on stunting prevalence over time at a greater rate than national wealth or broader developmental gains might otherwise explain – as measured by gross domestic product per capita and/or sustainable development indicator. Countries were also selected with a desire to identify relevant countries to extrapolate findings to a global audience, and hence additional considerations. This meant ensuring that the countries selected as Exemplars reflected regional representation for high-burden geographies in particular and had a minimum population of more than five million. Finally, feasibility to conduct the research played a role in final country selection as well. This is related to data availability, data quality, and strength of in-country institutional partners to help conduct the research.

Question: Interventions which matter are one thing; strategies that matter are another. How much depth was given for 'political landscape' and its influencers?

Exemplars in Global Health Nutrition Team: To a large extent, that was what the qualitative studies aimed to understand. Political economy certainly played a significant role in many of the Exemplars we studied, although a comprehensive quantitative assessment of its contribution remains outside the scope of our core work. That said, details around the sequencing of key political commitments, complementary programs and policies, and participation of broader civil society organizations are highlighted in our country narratives and have been raised repeatedly as part of our qualitative work as key drivers of progress.

Question: Is economic improvement the indicator that raises the other parameters? If the economy improves, then other indicators are likely to improve automatically. For example, WASH, household crowding, and other metrics are likely to improve automatically. For Pakistan, stagnation could be due to inequity especially in land ownership.

Exemplars in Global Health Nutrition Team: Good question – much of our hierarchical modelling aims to address this by establishing improvements in wealth as a distal factor. As a result, when we see other drivers contributing to a decline in stunting, this relationship is independent of improvements in wealth alone. Pakistan in many ways highlights that those improvements in wealth are not commensurate with improvements in stunting – as progress on the former has been paired with stagnation in the latter – emphasizing the need to proactively invest at scale in these areas adjacent to nutrition and health (e.g., WASH) as well. The decomposition analysis also shows the relative contribution of investments in WASH independent of change in household wealth or socioeconomic improvement.

Question: It looks like breastfeeding contributed to stunting reduction in just one or two countries. Are there any other studies that show strong contribution of breastfeeding to stunting reduction?

Exemplars in Global Health Nutrition Team: Breastfeeding has repeatedly been shown to be one of the most costeffective interventions to reduce child morbidity and mortality. It has also been flagged as one of the best preventative measures against the double-burden of malnutrition. With the exception of a few countries though, there have not been clear stories of improvement across exclusive breastfeeding that have emerged – and this is consistent with what systematic reviews of breastfeeding show; namely impacts on child health and survival but not on linear growth in the medium to short-term.

Question: When Exemplars identifies something – for example if, hypothetically, 20 percent of a reduction in stunting is explained by bed nets – does that mean a similar geography would achieve a 20 percent reduction in stunting by applying bed nets as an intervention? If not, then what factors should be considered for interpreting these findings and how can these findings be taken to action?

Exemplars in Global Health Nutrition Team: No, it means exactly what it shows; that in this context 20 percent of the reduction in stunting could be explained by changes in bed net coverage. This may differ in other malarial contexts depending upon what else was going on, baseline status etc. The relative contribution of specific improvement in historical reduction in stunting often varies by context and starting burden. We have seen insecticide-treated net distribution emerge consistently as a key driver of stunting reduction in countries where the malaria burden has been relatively high (e.g., Zambia, Uganda, Nigeria). On the flip side, in instances where progress has been made, there may be diminishing returns to outsized investments (e.g., WASH investments in the Kyrgyz Republic).

Question: It’s very interesting that even the use of insecticide treated nets prevents stunting. How has it contributed?

Exemplars in Global Health Nutrition Team: The pathway to impact on reducing stunting through managing malarial burden is multi-fold and suggested by other supportive evidence. The primary biological pathway flagged was through managing rates of maternal infection and preventing infection during pregnancy in particular – reflected in the improvements observed in status at birth across HAZ curves, and likely fetal growth patterns. This is also consistent with the observed effects of malaria during pregnancy, with higher rates of preterm as well as small-for-gestational-age births and perinatal mortality. Additionally, improvements in the 6 to 23-month age group were at least partly attributable to reduced incidence of childhood infection (which could also include malaria), incidences of diarrhea, and corresponding improvements in nutritional or caloric retention. Finally, additional aspects raised in our qualitative work were focused on reduced additional healthcare expenditure in treating and/or managing infection. These resources could then be reserved for other key drivers of improved nutrition (e.g., improving food security / dietary intake).

Question: How have direct and indirect causes linked with the first 1,000 days reduced stunting in Exemplar countries?

Exemplars in Global Health Nutrition Team: The link here to the published AJCN Supplement is provided here (all open access). In most Exemplar countries, these contribute a reasonable proportion of change (around 15 to 30 percent). This is what we can impute from existing data. However, the effect could be greater in reality given the potential pathways for which we lack data in national surveys, such as dietary intake information (food security and quality), micronutrient intake, and status – including the use of fortified foods and/or staples and gestational weight gain (given lack of information on prepregnancy status and factors).

Question: We all agree that the prevention of all forms of malnutrition is important, and when prevention fails, we need to treat wasting and micronutrient deficiencies, but how much can the treatment of wasting be linked with the reduction in stunting?

Exemplars in Global Health Nutrition Team: There are certainly instances of double burden where disadvantaged communities are experiencing concurrent stunting and wasting. It is a topic we are actively studying in select geographies (e.g., Nigeria). Key early lessons show that while there is some overlap, wasting is a fundamentally different outcome with differing epidemiology – a fact also noted from studies in South Asia – and needs to be studied separately as there are specific interventions, for example ready-to-use therapeutic foods, related to wasting patterns.

Question: It's an interesting finding that some countries have reduced inequity along with reduction in stunting while some have not. Were there any leads from the analysis on why inequity has not been reduced in some countries? I believe these countries have pro-poor policies targeting vulnerable population.

Exemplars in Global Health Nutrition Team: Some of this dichotomous performance might be attributable to level of initial burden. In countries like Ethiopia or Nepal, where stunting prevalence was as high as around 60 to 70 percent in 1990, and basic coverage was not yet at scale, rapid institutional investment was not always accompanied by thoughtful targeting to ensure programs outside of social safety nets would direct interventions to the most marginalized populations. Data-driven successful targeting, by contrast, was a key aspect of implementation flagged in Peru and the Kyrgyz Republic. This investment, along with thoughtful extensions of health insurance coverage in more mature health systems, emerged as an important driver of equitable progress. The point to drive home is that thoughtful investments in reducing inequities could enhance the observed reduction in stunting burden.

Question: What would be a minimum standard (acceptable) stunting reduction rate per percent per year at a national level?

Exemplars in Global Health Nutrition Team: I think we ought to aspire for an annual rate of reduction in excess of 3 percent per year to accelerate global progress – current global rates are around 2.2 percent reduction year over-year.