21 October 2014

Catch up growth? Yes, but what does it signify? New paper from Young Lives

A new study by Young Lives researchers measures height for age of a cohort of children at  ages 1, 5 and 8 years, in 4  countries: Ethiopia, India, Peru and Vietnam.

The study uses WHO multicentre growth study standards at age 1 and WHO NCHS standards for ages 5 and 8 to generate normalised height for age z-scores (HAZ).

An HAZ of less than -2  means a child is stunted.  

The results?

Ethiopia, mean HAZ: -1.51 (age 1), -1.46 (age 5), -1.21 (age 8)
India, mean HAZ:       -1.30 (age 1), -1.63 (age 5), -1.43 (age 8)
Peru, mean HAZ:        -1.29 (age 1), -1.51 (age 5), -1.13 (age 8)
Vietnam, mean HAZ: -1.08 (age 1), -1.33 (age 5), -1.09 (age 8)

Notice the declines from age 1 to age 8 in Ethiopia and Peru and the declines in all 4 countries between ages 5 and 8 (when the growth standards are strictly comparable, i.e. both NCHS).

The authors conclude:

"Our data demonstrate that while child growth trajectories throughout the pre-school and early school-age years are predicted in part by size at age 1 year, there is significant variation in growth after 1 year of age. This includes catch- up growth in some children and faltering in others. These results suggest that while prevention of early-life stunting must continue to be a top priority, programme planners and implementers should consider identifying and targeting for further nutritional interventions children who nevertheless become stunted during infancy, as well as children at risk for later growth faltering. An important area for future research is identifying the factors that contribute to these later variations in growth."

I do think it is important to find out why some kids catch up in growth and others do not (since, as the authors report, 40-74% of HAZ at year 5 is not predicted by HAZ at year 1). 

I think it is also important to work out what is catching up.  Is it more than height?  Cognitive functioning, for example? 

We're interested in height not because it is intrinsically important but because it is a marker for other things that are stunted in the first 1000 days of life.  

An interesting study that reminds us not to give up on kids after the first 1000 days, but does not detract from the focus on this time period, it seems to me.  Interested in your thoughts. 

Evidence on the impact of research on international development? New DFID literature review.

A new DFID literature review hit the streets in July: 

"What is the evidence on the impact of research on international development?  New DFID literature review". 

It is written by DFID staff, reviewed by 7 external experts.   

This is the concluding chapter in full:

"Investment in research activities can lead to development impacts. However, research is not a panacea; Investments in some research projects will lead to large development gains while investment in some activities will lead to little or no impact.

Having said that, it is possible to consider the general theory of change by which we expect research to lead to impacts and to draw some conclusions on what type of research activity we should invest in to achieve different outcomes.

Key findings

This literature review reveals some general principals regarding investment in research:
  • Investment in public research in low-income countries is unlikely to lead to substantial levels of direct commercialisation of research outputs in the short to medium term. Informal academic engagement with industry may be more economically important but some activities (particularly consultancy contracts) may have negative impacts on research capacity. While the generation of new innovations within low-income countries is unlikely to be a major driver of growth, the absorptive capacity of industry (i.e. the ability to adapt and make use of existing research knowledge) will be a vital driver of growth and interventions which would increase this absorptive capacity (e.g. strengthening of tertiary education) are likely to have large impacts.

  • Research from developed economies reveals that, in contrast to the beliefs of most academics, there is no strong link between the research outputs and teaching quality of tertiary education establishments. As yet there is no evidence to indicate if such a link exists in low-income countries so efforts to improve tertiary education through investment in research should be treated with caution. The human capital developed through investment in research and research capacity building can have multiple positive impacts on development including via the spill-over of former researchers into government and industry and the generation of research experts who can act as policy advisors. Research suggests that investment in doing research in low-income countries on its own will not lead to improved research capacity and that an effective and explicit capacity building strategy must be developed.

  • Investment from both developed and low-income countries in research in public institutions and/or public-private partnerships can generate pro-poor products and technologies. Some of these products and technologies have had dramatic impacts on development. However, there are also multiple products and technologies which have not had the expected impact. When investing in the development of products and technologies, it is vital to carry out research to ensure there is a demand for it and that there are no barriers which will prevent it from having positive impacts. 

    Using evidence to inform policy and practice decisions can help ensure policies and practice achieve their desired impact. Two categories of decisions can be informed by evidence. Firstly, research to understand what works and why can be used to inform decisions on specific interventions. Secondly, evidence which describes the existing context can inform general theories of change. Major barriers to use of evidence are the low capacity of policy makers and practitioners to understand and use research evidence, and the absence of incentives to drive research usage. Interventions which succeed in increasing use of evidence by policy makers and practitioners may lead to important impacts. 

    There are a number of methods which have been used to quantify the economic benefits of investment in research. All methods suggest positive rates of return to research however individual figures are highly sensitive to the assumptions used in the calculations and therefore need to be interpreted cautiously."
A few observations:

1.  For such an important question it is surprising that this was not a systematic review.  The search strategy is listed in Chapter 8, and it seems quite partial.  Key literature like S. Fan et. al. on the impact of investments in agricultural R&D (compared to other investments) on poverty in India, China and Africa is missing.

2. The report would have been much more helpful if it could have said more about the features and attributes of research that give it more of an impact. Some research will have an impact, some won't. No surprise there.  The reasons for impact may relate to relevance, rigour,  originality, timing, sheer luck or some combination of these.  Also, what does the evidence say about the timescales over which we should expect to see impacts?

3. Barriers to use of research.  Good points on the barriers to research uptake although with an over-focus on capacity.  Of course the most relevant, brilliant and accessible research might be ignored if it gives an inconvenient political answer.  So this is more than a capacity issue, it is also a governance issue.  It is not just about demand but about a balance of (sometimes) competing interests (within the public and private sector spheres).

4. The comment that "all methods suggest positive rates of return to research however individual figures are highly sensitive to the assumptions used in the calculations and therefore need to be interpreted cautiously" seems to vaguely cast aspersions on the research community--i.e. we have a vested interest in a certain outcome and we cannot be trusted to assess returns to our work (perhaps why DFID chose to do this review themselves).  Maybe I am misinterpreting, but that is how it reads to me. 

Overall, an interesting and intriguing study.  I wonder what impact it will have? 

Who has Coverage covered? Learning from the SAM side of the big tent

This might just be me catching up with the rest of the nutrition community.  But the more I find out about SAM (severe acute malnutrition) coverage thinking, the more I think the rest of the nutrition community--so concerned with scaling up--has a thing or two to learn from our SAM colleagues.

I'm just reading the latest Coverage Matters report from the Coverage Monitoring Network and ENN.   There are several articles which interrogate the naive assumption of serene coverage increases over time.

The articles are short and accessible and cover things like:

* the Tanahashi coverage diagram (from availability coverage, accessibility coverage, acceptability coverage, contact coverage, to effectiveness)  

* active outreach to generate early admissions--the context is SAM prevention and treatment, but the principle obviously extends to early trimester and early childhood interventions on the chronic side

* the role of audits (programme and social) to identify barriers to coverage scale up and to generate solutions for overcoming them

* reasons for non-attendance: from lack of awareness of the programme or the problem, to family members barring participation

* the relationship between coverage and effectiveness (don't assume effectiveness stays constant)

* the SQUEAC (semi-quantitative evaluation of access and coverage) tools (e.g. for creating "mind maps" of assumptions about how programmes work and people engage with them) seem to have usefulness beyond the SAM programmes

Just another reason to close the "chronic" - "emergency" divide.

17 October 2014

Ebola means there should be a greater focus on nutrition, not less

The Second International Conference on Nutrition (ICN2) is scheduled for Nov 19-21.

I have heard some people talk about how Ebola may take the focus away from nutrition, but I think it strengthens (unfortunately) the case for more attention to nutrition.

First, people with poor malnutrition will have weaker immune systems and so--all other things being equal--it is plausible that they will be more likely to contract the disease given the same exposures (note, as a number of you have pointed out since I originally published this, it is hard to find any actual evidence to support this statement, it just seems plausible--but if you have seen any evidence supporting or refuting this, please let me know and I will edit the blog).

Second, health systems are going to be decimated because health workers are most at risk and the health system will be working overtime to deal with Ebola in countries with high levels of infection (see this harrowing account in the New England Journal of Medicine from an MSF staff member).  This means fewer resources to prevent malnutrition to stifle infection.

Third, because the infection is spread through touching, it becomes more difficult to give very young children the care they need for healthy growth, even without the virus.

Fourth, agriculture is going to suffer, just as it did with HIV/AIDS.  There will be a labour shortage effect, but perhaps the bigger effect will be an inability to transport food due to curfews and lockdowns -- hence the very real risk of food price spikes.

Of course, much more investment is needed NOW to deal with the infection.  But once the case loads have peaked, more attention is needed to building resilience to future outbreaks-and that means better nutrition and stronger health systems.

15 October 2014

Telegram SAM: Children of the Nutrition Data Revolution

For those of you too young to get the T-Rex reference, this is a post to highlight a great blog by Andre Briend that may have gotten lost in the summer holidays.  

Andre reminds us that many children with Severe Acute Malnutrition (SAM), as defined by the UN, may be omitted from current prevalence estimates. 

SAM is defined by WHO and UNICEF by a weight-for-height index (WHZ) less than -3 z-score OR a mid-upper arm circumference (MUAC) less than 115 mm OR presence of oedema (significant observable swelling due to fluid accumulation).  In other words if any one of those 3 conditions holds, then the child is severely acutely malnourished.  

So what's the problem?  Well current estimates of children under 5 suffering from SAM are based on prevalence surveys counting children with a WHZ less than -3 z-score.   In other words, if a child has WHZ greater than -3 but has low MUAC or oedema, then the child is not classified as SAM when they should be--so the estimate based purely on WHZ less than -3 is a lower bound.    

So how big an underestimate of SAM do we get from relying solely on WHZ less than -3?  Well, Andre cites studies showing factors of discrepancy from 1.6 to 8!  

I'm not an expert, but I would imagine measuring MUAC is easier than measuring oedema.  Can we not have a few Demographic and Health Surveys that assess MUAC in addition to the usual WHZ so we can get an idea of how badly we are getting it wrong?

More of the world's children need to benefit from a nutrition data revolution. The Global Nutrition Report has a whole chapter devoted to this.   

14 October 2014

Global Hunger Index 2014: Uncloaking Hidden Hunger

Last night Concern Worldwide UK and Fiona Twycross, an elected London Assembly member, hosted a launch of the Global Hunger Index (GHI) Report of 2014 at London's City Hall.

I was on the panel along with Richard Mwape from Zambia (speaking on Realigning Agriculture to Improve Nutrition, RAIN), Baroness Northover and Lord Collins from the UK Parliament.  It was chaired by Chris Elliot, Chair of Concern Worldwide UK.

The theme of the 2014 GHI is "Hidden Hunger" (micronutrient malnutrition). 

My 8 minute slot had 6 points:

1.  The GHI is an annual hunger index.  It is intended to mark country level progress, incentivise and guide action and strengthen accountability.  

2. The GHI is a composite measure of hunger.  It combines 3 measures: undernourishment (food supply based); underweight of under 5's (capturing food, care and health) and under 5 mortality rates (capturing the interplay of diet and infection).  So the GHI is a fairly well rounded indicator of hunger.

3.  Progress.  The 120 "developing countries" have made good progress: scores declining from 20.6 in 1990 to 12.5 in 2014.  There has been progress in all regions, especially in South Asia.  The South Asian figures are driven by a new Indian national government survey which shows that underweight rates declined by 13 percentage points (from 44% to 31% between 2005 and 2013).  I also noted that while this is fantastic (if the numbers hold up to further scrutiny) there is plenty of room for improvement: The Report notes that India moved from 127th/128 on underweight rates to 120th/128 for countries with data.

Sub-Saharan  Africa has highest scores and in the past 5 years they have been coming down faster than before.  Reasons for the acceleration? The Report suggests success in fighting Malaria and HIV/AIDS, more antenatal visits, immunisations, expanded access to improved water and sanitation and income growth (interestingly few mentions of contributions made by agriculture).

4.  The GHI is a good measure of hidden hunger as well as of hunger.  Hidden hunger refers to deficits in the intake of vitamins and minerals (micronutrients) in the diet. Food intake may stave off hunger pangs but if diets are low in nutritional diversity and quality this will have consequences.  Micronutrient deficits  have clinical manifestations that show when the deficiency is already significant (e.g. night blindness, cataracts, goitre, weak immune systems, poor birth outcomes), but there are no warning pangs of hunger to alert us to these deficits in quality.  Hence  the "hidden".

The GHI is well linked, statistically, to specific measures of hidden hunger (such as anemia rates).  Interestingly the undernourishment component of GHI is the least well linked (not surprising since it is based on aggregate food supply)  and this shows the value added of including the other 2 dimensions of the GHI (underweight and under 5 mortality rates). 

5.  Progress on some micronutrient deficiencies is shockingly slow.  There are some success stories--vitamin A supplementation for under 5s and salt iodisation but, as the Global Nutrition Report will show on its release at ICN2 (Nov 20), only 5 of 185 countries in the world are on course to meet the global anaemia reduction targets (for women of reproductive age).  Why so slow?  For anaemia I would guess a mix of lack of awareness of the magnitude of the problem, lack of awareness of our inability to make progress, the fact that it affects women more than men, lack of appreciation of the economic consequences, and the lack of platforms to deliver interventions to key target groups.  This lack of progress affects nearly all countries--countries should make common cause to share experiences about why some are making progress and some are not. 

6.   As researchers, civil society and government, it is our responsibility to make this issue less hidden.  We need to be open to working with the private sector around fortification (they are neither absolute heroes or villains--it all depends on context).  We need to be open to a range of interventions: agriculture for diet diversity, biofortification, supplements, fortification and food subsidies and public agricultural research that incentivises the consumption and production of healthier foods.  There is no silver bullet. We need more data (we only have anaemia data for 185 countries because so few countries have their own survey data it has to be modelled for everyone else) and we need more studies that quantify consequences in ways that Ministers of Finance can understand.  

Ultimately malnutrition reduction is about social change, and civil society has always been at the forefront of that, so civil society needs to educate, organise, advise and agitate.  

Most malnutrition is hidden.  Micronutrient malnutrition is cloaked in invisibility.  We can change that.

09 October 2014

The recent ENN meeting--helping break down the boundaries in nutrition


I was at the Emergency Nutrition Network (ENN) technical meeting in Oxford this week.  

The meeting was organized to fill a perceived gap – not enough technical meetings on nutrition to address problems we talk about a lot but never make time to grapple with.

The 100 or so participants were mostly from implementing agencies (not so many researchers).  

The issues addressed were quite practical:

* what does nutrition-sensitive WASH actually look like (still not terribly clear to me despite some great presentations)?

* What forms does multistakeholder coordination take (e.g. co-location of programmes, embedding of nutrition programmes in broader programmes, hybrid or integrated approaches) and when is which form the most appropriate? 

* What are some of the new innovations in cash transfer programming (vouchers, cash, direct bank account transfers, cash transfers in emergency situations)?

* What are some of the new global developments to be aware of (e.g. the ICN2, Sustainable Development Goals, the Global Nutrition Report, WHO/UNICEF’s new Global Monitoring Framework etc.)? 

* What are some of the disconnects that stop the nutrition community working as effectively as possible (e.g. bureaucratic imperatives that lead to competition for funding, wanting to brand individual work, very different languages, seemingly arbitrary divisions of responsibility – WFP leads on moderate acute malnutrition and UNICEF leads on severe acute malnutrition--duplication of effort: e.g. 10 different infant and young child feeding programmes going on in one district)?

* Was the initial humanitarian response in Syria too African-centric (i.e. too focused on acute malnutrition? Yes.)

I really enjoyed the meeting, which was very well organised.  It was great to interact with lots of very thoughtful people I usually do not get to talk to with, although it made me sad that there are so many nutrition professionals working behind a wafer thin but seemingly impenetrable wall from those working on more chronic forms of nutrition.  (One example: I bet not many of the latter camp know the definition of Global Acute Malnutrition—a key summary indicator for this community).

Somehow we need to get beyond the labels of “emergency” and “development”. 

First, poor development choices generate emergencies, and poor emergency responses can set back or propel development.  The boundaries are not substantive.   

Second, these labels do not describe what each community does.  “Chronic” does not equal development (stunting rates can be profoundly affected by shocks) and “acute” does not equal emergency (e.g. India has very high levels of wasting).  

Finally, stunting and wasting go hand in hand at the national level and perhaps at the individual level (for the Global Nutrition Report we could not find estimates for 50 plus surveys answering the question “what percent of stunted children are also wasted and vice versa?”). 

Perhaps we could just talk about "one nutrition".  Perhaps ENN could call itself the Enabling Nutrition Network!