24 December 2015

For many countries a "Christmas mobile phone fast" would lead to hunger and malnutrition

The Archbishop of York, Dr John Sentamu, recently called for a UK “mobile phone fast” on Christmas Day so that families could reconnect and bond.  My kids are glued to their phones much of the time and I have been known to sneak a few looks at my email on the 25th, so I can definitely relate.  But many people around the world do not have the luxury of laying down their phones, because their mobiles are essential to their livelihoods and to their health.  

Consider the following: fishing communities rely on weather data from mobile phones to help them work out the best times to take their boats out; farmer clubs using text messaging to help farmers to share information about growing conditions; market traders who use apps to tell them which locations are offering the best prices for different commodities; medical staff who use cameras on mobile phones to remote diagnose and prescribe treatment; HIV positive individuals who are reminded to adhere to their antiretroviral regimes; and communities that can the world know if government services fail to reach them.  These mechanisms, if effective, are probably helpful to accelerating development and the reduction of hunger and malnutrition. 

But, with a few exceptions, there are far too few mobile services designed to focus exclusively on just that: the reduction of malnutrition. 

Why should such services exist?  Malnutrition in all its forms—children who can't realise their rights and develop to their full potential, women with not enough iron in their blood carry their children, adults who are at risk of diabetes, hypertension, strokes and heart disease due to obesity—affects 1 in 3 people world-wide.  The consequences of malnutrition are devastating.  45% of all under 3 mortality is related to malnutrition and the economic losses are enormous—trapping people, families and communities in poverty and acting as a drag on sustainable development.  

And the returns to the scaling up of high impact interventions are astonishing.  The Global Nutrition Report has shown that the median benefit-cost ratio of expanding programme coverage is 16 to 1.  In other words for every dollar, birr, rupee or peso invested in scaling up high impact nutrition interventions, 16 will flow back to individuals, communities and nations from improved schooling and labour force outcomes.

Despite these impressive returns, the scaling up of programmes is challenging.  Lack of finance and human capacity are familiar barriers.  Frontline health workers have heavy case loads and are burdened with paperwork.  Finance to develop messaging around preferred nutrition practices and to provide appropriate technology to record, aggregate and analyse nutrition measurements quickly and efficiently is hard to find from public sources. 

Can mobile operators help?  Mobile networks are re run for profit.  But they do offer a broad potential platform for the delivery of government approved nutrition messaging.   Can they be geared to reminding pregnant women about receiving antenatal care, to change the attitudes of mothers of newborns about the need to breastfeed within an hour of birth, and exclusively for 6 months thereafter? Can they be designed to help mothers wean their children onto the right semi-solid foods at 6 months of age? Can they help children understand what a balanced diet looks like?  Can they persuade and help adults to consume diets that are lower in sugar, salt and saturated fats?  We simply don’t know.
 
The nutrition community has been slow to experiment with (and then evaluate) mobile technology. Similarly mobile operators have been slow to recognize the potential for attracting customers to their services through offering nutrition information, free or even at a price.  Let’s be clear: mobiles are not a panacea. There are important and significant challenges to their effective use for nutrition. For example, will mothers be able to read the information sent?  Will they trust nutrition information via mobile services and will the quality be sufficiently good?  Will the information be acted on? And will mobile operators be able to find a sustainable business model? 

But the potential is great: mobiles offer a way to personalize information, to allow customers to engage with information services rather than simply be passive receivers of messages, to scale geographically and to generate knowledge spillovers for those who do not have direct access to phones.

As the 2015 Global Nutrition Report suggests, the mobile network industry offers the potential to scale up nutrition interventions that are reliant on behavior change.  These two communities – public nutrition professionals and private mobile operators-- need to begin innovating, piloting and evaluating their joint efforts to accelerate the reduction of malnutrition. 


Can we really “Dial N for Nutrition”?  Let’s at least try, and turn the conversation to the avoidance of enforced fasting of food, care and health services rather than the promotion of voluntary phone fasting.

18 December 2015

Catching up with the debate on catch up growth and development for young children

Below are two posts from important researchers working on infant and young child growth.  They both agree that the first 1000 day period after conception is a key intervention opportunity because growth velocity is so high.  They also agree that we should not restrict interventions to this period—we should take whatever opportunity in the life cycle that presents itself to invest in better nutrition.

Where the 2 sets of authors part company is on the nature of the evidence that supports their arguments for investments post the first 1000 day period.  Both authors think such investment is essential (we should never give up on a child!), but the Young Lives authors’ bolster their argument with the fact that for the children in their cohort studies, their standardised height for age scores (HAZ) improve between ages 5 and 8. 

Jef Leroy argues that the movements of HAZ do not reflect improvements in linear growth but are simply due to bigger standard deviations of HAZ as we move up the age groups.  Leroy says a better marker of any catch up growth would be the absolute difference between measured height and the median age- and sex-specific height obtained from the growth standards (HAD).  In addition, Leroy says while height is important for human development, the main story is in the things height is a marker for such as cognitive development and attainment.

If I were the Young Lives research team I would see if I can replicate my HAZ results with HAD.  I would also look at potential catch up in other markers of development such as cognitive attainment scores. 

Either way the policy implications are not very different for the 1000 Day period, but they could be for the post 1000 Day period: interventions to stimulate catch up in growth may be different from those to stimulate catch up in, say, cognitive attainment.  So it is important to air contrasting views.

Thanks to both blog authors and let the debate continue! 

Early is best… but it’s never too late to help stunted children

Paul Dornan and Andreas Georgiadis, Young Lives

The scale of the problem is immense: WHO global estimates suggest 162 million children under five are stunted (that is, too short for their age). Stunting is an indicator of chronic under-nutrition resulting from inadequate food intake, poor health, and poor child care. It is hard to underestimate the consequences of under-nutrition for child survival, health, and development, as it contributes to the deaths of 3.1 million children per year. Improving children’s nutrition should be at the heart of development policy.

There is consensus that good early nutrition is the foundation of children’s survival, growth, and learning. The Sustainable Development Goals reiterate earlier commitments to reduce the number of stunted children under-5 by 40% by 2025. How would it be possible to achieve and surpass this target? Considerable recent attention has been given to nutrition and care during the first 1000 days after conception. Although this period of time is critical, there is growing evidence that improvements in children’s nutrition beyond that early period could yield additional benefits in terms of child development and well-being. That’s encouraging, as we need to make use of every opportunity to improve children’s nutrition. The evidence for this is set out in a new policy brief from Young Lives.

The good news is the attention nutrition has received in recent years. The London Olympics of 2012 was used by the British and Brazilian Governments, along with the Children’s Investment Fund Foundation to initiate the Global Nutrition for Growth Compact, with the stated aim of putting nutrition at the centre of development policy, which has now been signed by 26 Governments. Rio 2016 marks the point at which governments have committed to check in on the progress and to gather more supporters. The same initiative also saw the launch of the Global Nutrition Report, an authoritative advocacy tool providing strong evidence that emphasises the importance of action to improve nutrition.

Powerful arguments have emerged suggesting that experiences during the first 1000 days after conception (up to 2 years old) are critical for children’s later development. Some go further, arguing that beyond the first 1000 days, stunting and its implications for development are irreversible. The prioritisation of a focus on nutrition during infancy has important merits: children are most vulnerable and more likely to die as a result of poor nutrition and diseases during this period. And for those who survive, there are other important reasons to increase the focus on the very early years – with James Heckman, for example, identifying this period as the most efficient point to intervene to secure long-term benefits.

But while prevention is better than cure, there are increasing reasons to think that alone it isn’t enough. The evidence produced from analysis of the Young Lives cohort data, summarised in the policy brief, suggests that – first, while child growth is more plastic in infancy and early childhood, there is still potential for recovery of growth deficits and there is a risk for growth faltering  after the first 1000 days.

Therefore, interventions implemented during the first 1000 days should be sustained in order to promote growth recovery and prevent further faltering. Among the factors found to be associated with changes in growth after the first 1000 days were parental schooling, household poverty, maternal height, and community health infrastructure and these are some of the factors to be prioritised by policy interventions aiming to promote child growth and nutrition.

Alongside Young Lives, other studies have also produced evidence of post infancy growth changes. Analysis of the Cebu cohort study in the Philippines identified change in stunting and growth between age 2 and age 8 years and a recent multi-country analysis published by UNICEF’s Office of Research also emphasised the potential for catch-up growth. Evidence from Young Lives indicates that post-infancy physical recovery is associated with school attainment, suggesting that the gains may extend to other domains of children’s lives. While prevention of under-nutrition during the early days should be prioritised, there is still potential for interventions in later periods to tackle early nutrition and growth deficits.
Headlines from the YL policy brief

So what does this evidence mean for policy and what should change?

1.     Nothing should undermine the central importance of the first 1000 days for child nutrition. But, the focus on the first 1000 days should not inhibit efforts to improve child nutrition in later periods.
2.     While it’s a traditional complaint that researchers always call for more research, in this case not enough is known about interventions which might bring about post-infancy recovery. Improving the knowledge base by trialling or testing post-infancy nutrition interventions may help to open up new opportunities to remedy under-nutrition and some of its consequences.
3.     One stand-out conclusion is that there is more potential in the role of the school for improving children’s nutrition, and that doing so can support better school attainment. Young Lives evidence suggests that school feeding programmes may promote growth recovery, particularly for children who were severely under-nourished in infancy. There is also evidence that nutritional supplementation in school-aged children can yield benefits in terms of children’s learning and performance in school. In short – let us have more thinking about the role of schools as a platform for interventions to support better nutrition.

Our new policy brief summarises the latest findings from an ongoing programme of work. We hope this work will open up new opportunities for sustaining and supporting children’s healthy development, showing that opportunities exist for a longer time window than sometimes thought. For the central message we end where we began: early is best, but it’s never too late.

Counterpoint

Jef Leroy, IFPRI

I read the Dornan and Georgiadis post with great interest.  I strongly agree with their bottom-line conclusions (1) we should continue to focus on the first 1,000 Days (2) but there is a need to also study children’s potential to benefit from interventions after 2 years of age (and pre-pregnancy).  This is the conclusion my coauthors and I reached after analyzing growth of around 300,000 children from 51 countries (see Journal of Nutrition).  

However, I don’t think that the evidence cited by Dornan and Georgiadis really supports this conclusion.

Here is my thinking:

* Height-for-age Z-scores (HAZ) are a useful tool to (1) describe groups of children at a specific point in time (e.g., “mean HAZ in Burundi in 2010 was -2.2”), (2) compare groups of children (e.g., “mean HAZ in 2010 in Burundi was higher than in Rwanda”), and (3) assess changes in groups of children over time (e.g. “mean HAZ in Rwanda decreased from -1.8 in 2010 to -1.6 in 2014/5”).

* But, as we demonstrated in two recent publications (Journal of Nutrition and BMC Pediatrics), HAZ is not the right tool to assess changes in children’s height as they age.  Why?  First, the standard deviations (SDs) used to construct HAZ (they are in the denominator) are cross-sectional in nature (they reflect the variance in height for children of specific age and sex). As a consequence, they are inappropriate to measure changes in linear growth over time (i.e. as children age).  Second, the SDs of HAZ increase as we move up age groups, so we do not know whether changes in HAZ as children grow older are due to changes in the numerator (the difference in the child’s height for age from the median age- and sex- specific height for age of a healthy reference population) or the denominator (SD).  Changes in linear growth as children age should be analyzed using height-for-age differences (HAD), the absolute difference between measured height and the median age- and sex-specific height obtained from the growth standards.

* As far as I can tell, none of the articles referred to in the blogpost (Young Lives analyses, CEBU work, UNICEF study) look at child growth. They assess changes in HAZ as children grow older. The problem with the analyses of these “HAZ trajectories” is that there is no evidence showing that growing children track along specific HAZ-trajectories.

* As there is no “expected HAZ trajectory”, I do not see how one can formulate meaningful hypotheses to be tested or how one can interpret deviations from HAZ trajectories.  If there is literature on HAZ trajectories, the authors should refer to it.

* None of the articles cited define catch-up growth properly. My view is that the only meaningful definition of catch-up growth is (partial) recovery from a linear growth deficit accumulated in the past (see BMC Pediatrics). Catch-up growth in height is only possible when children grow faster than the expected velocity (for their age and sex) so they can make up for the lost growth in height (see this video for a visual demonstration with Duplo blocks). The only way then to assess catch-up growth is in absolute terms (that is, cm), as expected velocity can only be defined in absolute terms (there is no “expected HAZ trajectory”). As a consequence, none of the articles referred to in the post provide evidence of catch-up growth.
Jef Leroy explaining how lost growth can be made up

* Given that HAZ cannot be used to establish catch-up growth, the YL findings boil down to the following. First, children who have a taller mother, whose parents have gone to school longer, who live in less poor households based in communities with better health infrastructure are taller. Second, taller children do better in school. These findings are interesting and relevant, and they confirm what we have known for long time. The studies do not provide evidence, however, of catch-up growth, they do not identify the determinants of catch-up growth, nor do they establish that catch-up growth has long-term consequences in other domains.

The recent focus on catch-up growth potentially distracts from the most important issues. We care about growth faltering as a development outcome per se because short stature increases the odds of obstructed labor; stunted mothers also have smaller babies. That is it. Linear growth is not a causal determinant of poor development, schooling, productivity, etc.  It is a marker.  So if we care about these last outcomes (we do), we should focus on them directly, and not get sidetracked with doing more and more catch-up in linear growth analyses.

17 December 2015

The GNR Favorite Reads of 2015


I asked my fellow members of the Global Nutrition Report’s Independent Expert Group two questions: (1) what was your favorite read of 2015 and (2) why?  Here is what they said:

Mohamed Ag Bendech

Favorite read: Healthy Meals in Schools: Policy Innovations linking Agriculture, Food Systems and Nutrition from the Global Panel on Agriculture and Food Systems for Nutrition

Why?

* Increasing risk of overweight and obesity among schoolchildren
* Relevance of promoting Lifelong Healthy Eating Habits at the Schools
* Relevant recommendations to policymakers

Policy Brief No 2. September 2015: Healthy Meals in Schools: Policy Innovations linking Agriculture, Food Systems and Nutrition


Jessica Fanzo

Favorite read: A multifaceted program causes lasting progress for the very poor: Evidence from six countries

Why?

* Important question that needed to be answered: Six randomized trials in Ethiopia, Ghana, Honduras, India, Pakistan, and Peru suffering from extreme poverty to test the the impact of a productive asset grant (of their choosing) with training and support, aka a livelihood booster.
* The design was excellent: An RCT with two end lines - one at the end of the two -year intervention and a second endline, 1 year after the first endline. 
* Little nudges matter: One year after the end of the intervention, 36 months after the productive asset transfer, 8 out of 10 indices (consumption, food security, productive and household assets, financial inclusion, time use, income and revenues, physical health, mental health, political involvement, and women’s empowerment) still showed statistically significant gains, and there was very little or no decline in the impact of the program.
* Relevant for nutrition: I think so. Although they did not explicitly measure nutrition, they do capture indirect or maybe even direct, determinants that could impact nutrition. Food security gains were high with elasticity for food consumption being greater than 1. Agriculture income (particularly livestock) and asset and time allocation indices improved, along with other effects.

Poverty trap or poverty flat: The discussion section is a worthy read for anyone working in development.

Banerjee, A., Duflo, E., Goldberg, N., Karlan, D., Osei, R., Parient√©, W., ... & Udry, C. (2015). A multifaceted program causes lasting progress for the very poor: Evidence from six countries. Science, 348(6236), 1260799. 

Patrizia Fracassi

Favorite read: Listening to Leaders: Which Development Partners Do They Prefer and Why?

The report examines the interactions that decision-makers in low and middle-income countries have with development partners, pulling from their invaluable insights into the most pressing problems they face, their top policy priorities, and thoughts on how aid agencies and other external actors can partner with them most effectively.

The report is based on the first wave of the 2014 Reform Efforts Survey, which benefited from the participation of nearly 6,750 development policymakers and practitioners in 126 low- and middle-income countries who provided information about the influence and performance of 100+ Western and non-Western development partners. The report gives voice to those who are actually making and shaping policy providing in-country decision-makers with an opportunity to tell external development partners which sources of advice and assistance are most and least useful to them.

Why?

Main take away messages for me are: 1) A development partner’s financial weight is seemingly unrelated to the perceived usefulness of its policy advice; 2) Aligning with host country priorities increases the development partner’s influence; 3) Development partners might better direct their efforts where they can enjoy policy influence multiplier effects (meaning where they are likely to forge meaningful alliances with national champions) and 4) There is a clear connection between agenda setting influence and subsequent involvement in reform implementation pointing to the importance of getting a ‘seat at the table’ during policy deliberations.

The findings from the report provide interesting clues for the nutrition community on how to navigate these changing times and bring value in the era of the 2030 Agenda for Sustainable Development. Establishing feedback loops should enable better learning from governmental and non-governmental leaders on the ground and, in the long run, ensure that nutrition is truly regarded as a global issue concerning everyone and not only as a developing countries’ problem.

Custer, Samantha, Zachary Rice, Takaaki Masaki, Rebecca Latourell and Bradley Parks. 2015. Listening to Leaders: Which Development Partners Do They Prefer and Why? Williamsburg, VA: AidData.


Lawrence Haddad

Favorite read: Dietary quality among men and women in 187 countries in 1990 and 2010: a systematic assessment by Imamura et al. Lancet Global Health.

Why?

I like papers that are relevant, original and rigorous.   This paper is not particularly easy to read nevertheless it meets the first and second criteria easily.  Poor diets are the number one cause of the global burden of disease and yet we have very poor data on diets.  This paper attempts to fill that gap.  Relevance?  Check.  Moreover, it does it in a breathtakingly audacious way: let’s get all the diet/consumption surveys out there, pass them through some inclusion criteria and (somehow) stitch them together.  Rather than complain about the absence of perfect data, lets use the existing data we have.  Original? Check.  Rigorous?  Well the paper must have passed some minimum checks to get through the Lancet Global Health peer review process, but it is not clear how this cart of apples, oranges, grapefruit, kiwi, grapes etc. is blended into a data smoothie.   But the ultimate accolade from me is “I wish I had written it”.  And I wish I had.

Imamura, F., Micha, R., Khatibzadeh, S., Fahimi, S., Shi, P., Powles, J., ... & Global Burden of Diseases Nutrition and Chronic Diseases Expert Group (NutriCoDE. (2015). Dietary quality among men and women in 187 countries in 1990 and 2010: a systematic assessment. The Lancet Global Health, 3(3), e132-e142.


Corinna Hawkes

Favorite read: Milan Urban Food Policy Pact and Framework for Action, signed by 100 cities in October 2015

Why?

I wanted to choose something that I had really made me think this year about how to encourage and enable more effective action for nutrition  - as well as something I think needs more attention by the nutrition community. And one of those things is the work that is being done at the city level to improve food systems.

This Pact attempts to bring together the work that is being done at the City level (also reported in this report here http://www.foodpolicymilano.org/en/ebook-good-practice-en/) and motivate more action. Its extremely relevant to nutrition and I think there is huge potential for  the nutrition community to engage more with this city-level action. Another thing that impresses me is the view taken of food systems at the city level: I have been fortunate this year to meet several people working in this area, and they all have a very good understanding of what a food system is - its not just about production systems (important though that is), but how food gets into peoples hands.


Purnima Menon

Favorite read: Countdown to 2015 and beyond: fulfilling the health agenda for women and children

Why?

The paper is a great reminder of how far the world has come on delivering core health services (and nutrition) but how long the road ahead is on even assuring the very basics of health care in poor countries.  The coverage figure in that paper is my go-to figure when I open presentations on scaling up, implementation science, you name it.

Requejo, Jennifer Harris, et al. "Countdown to 2015 and beyond: fulfilling the health agenda for women and children." The Lancet 385.9966 (2015): 466-476.


Stineke Oenema

Favorite read: Towards a framework convention on healthy diets

I very much liked the article by Olivier de Schutter, former special rapporteur on the right to food.

Why?

Olivier points out in a very short and concise way the current problems of  of our food systems. At the same time he advocates for a solution: a convention for healthy diets. In his conclusion he also points out the importance of accountability!

Towards a framework convention on healthy diets.  SCN news 41. Nutrition and the Post 2015 development agenda. Seizing the Opportunity


Yves Martin Prevel

Favorite read: Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries.

Why?

* Environmental enteropathy has emerged a while ago as a potential important neglected contributor to stunting; this paper makes the case quite nicely and provides an interesting and useful causal framework (fig. 2)
* Good review of the literature on the topic
* Cross sectoral vision: how much can the WASH sector help in reducing stunting? Apparently a lot!

Mbuya MNN and Humphrey JH: Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. Matern Child Nutr 2015:n/a-n/a [doi: 10.1111/mcn.12220]


Jody Harris

(not an IEG member, but an IFPRI colleague with an interesting suggestion)

Favorite read: Conceptualizing Drivers of Policy Change in Agriculture, Nutrition, and Food Security: The Kaleidoscope Model

Why?

This paper was a relief for me: To see that not only are nutritionists attempting to grapple with the politics of nutrition, but political scientists are, too. It’s nice to see that people other than nutritionists find nutrition an interesting and important topic to research, and it’s good to do this from the perspective of other disciplines. The model in the paper is now being applied to research on the political processes for micronutrient and input subsidy policies in several countries, and I look forward to the findings in 2016, which will broaden and deepen the small but growing nutrition policy process literature.

Danielle Resnick, Suresh Babu, Steven Haggblade, Sheryl Hendriks, and David Mather, 2015. Conceptualizing Drivers of Policy Change in Agriculture, Nutrition, and Food Security: The Kaleidoscope Model. IFPRI Discussion Paper 01414. IFPRI, Washington DC