Jef L. Leroy

The impact of conditional cash transfer programmes on child nutrition: a review of evidence using a programme theory framework

The authors reviewed the evidence regarding the impact of conditional cash transfer (CCT) programmes on child nutrition outcomes, using a programme theory framework. They developed a programme impact model and synthesised evidence regarding the pathways through which CCTs may improve child nutrition. CCT programmes significantly improve child anthropometry but have very little impact on micronutrient status. The programmes also have a positive impact on several of the outcomes in the pathways to improved nutrition. The authors found an enormous gap in knowledge about the mechanisms by which CCT programmes improve nutrition. In order to reach their full potential, the programmes need to have a better defined set of nutrition actions grounded in programme theory.

Effectiveness of preventive school-based obesity interventions in low- and middle-income countries: a systematic review

BACKGROUND The prevalence of childhood obesity is increasing rapidly in low- and middle-income countries, and informed policies to tackle the problem must be defined. OBJECTIVE We systematically reviewed the evidence on the effectiveness of school-based interventions targeting dietary behavior and/or physical activity for the primary prevention of obesity in children and adolescents aged 6-18 y in low- and middle-income countries. DESIGN We searched the MEDLINE, EMBASE, Web of Science, CENTRAL, ERIC, Cochrane Library, and Centre for Reviews and Dissemination databases for peer-reviewed controlled studies published in English, Spanish, French, German, or Dutch between January 1990 and July 2011. The quality of the included studies was appraised independently by 2 authors who used the Effective Public Health Practice Project tool. RESULTS From a total of 7218 unique references, we retained 22 studies. Most of the interventions (82%) had a positive effect on dietary behavior and physical activity behavior (effect size ranged from -0.48 to 1.61). BMI decreased in 8 studies (effect size ranged from -0.7 to 0.0). Effective interventions targeted both diet and physical activity, involved multiple stakeholders, and integrated educational activities into the school curriculum. CONCLUSIONS School-based interventions have the potential to improve dietary and physical activity behavior and to prevent unhealthy body weights in low- and middle-income countries. To reach their full potential, interventions should conduct process evaluations to document program implementation. The effect and the pathways through which interventions have this effect need to be better documented through rigorous evaluation studies.

Current Priorities in Health Research Funding and Lack of Impact on the Number of Child Deaths per Year

We determined the proportion of research on childhood mortality directed toward better medical technology (i.e., by improving old technology or creating new technology) compared with research on technology delivery and utilization. We also estimated mortality reductions from a research-funding strategy focusing primarily on developing technology compared with one that also focused on delivery and utilization. Ninety-seven percent of grants were for developing new technologies, which could reduce child mortality by 22%. This reduction is one third of what could be achieved if existing technologies were fully utilized. There is a serious discrepancy between current research and the research needed to save childrens lives. In addition to increased research on the efficacy of treatment, there is an even greater need for increased research on delivery and use of technology.

Cash and In-Kind Transfers in Poor Rural Communities in Mexico Increase Household Fruit, Vegetable, and Micronutrient Consumption but Also Lead to Excess Energy Consumption

Conditional transfer programs are increasingly popular, but the impact on household nutrient consumption has not been studied. We evaluated the impact of the Programa de Apoyo Alimentario (PAL), a cash and in-kind transfer program, on the energy and nutrient consumption of poor rural households in Mexico. The program has been shown to reduce poverty. Beneficiary households received either a food basket (including micronutrient-fortified milk) or cash. A random sample of 206 rural communities in Southern Mexico was randomly assigned to 1 of 4 groups: a monthly food basket with or without health and nutrition education, a cash transfer with a cost to the government equivalent to the food basket (14 USD/mo) with education, or control. The impact after 14 mo of exposure was estimated in a panel of 5823 households using a double difference regression model with household fixed effects. PAL was associated with increases (P < 0.01) in the consumption of total energy (5-9%), energy from fruits and vegetables (24-28%), and energy from animal source foods (24-39%). It also affected iron, zinc, and vitamin A and C consumption (P < 0.05). The consumption of energy and all nutrients was greater in the food basket group (P < 0.05). Cash and in-kind transfers in populations that are not energy-deficient should be carefully redesigned to ensure that pulling poor families out of poverty leads to improved micronutrient intake but not to increased energy consumption.

Cash and in-Kind Transfers Lead to Excess Weight Gain in a Population of Women with a High Prevalence of Overweight in Rural Mexico

There is a growing concern that food or cash transfer programs may contribute to overweight and obesity in adults. We studied the impact of Mexicos Programa de Apoyo Alimentario (PAL), which provided very poor rural households with cash or in-kind transfers, on womens body weight. A random sample of 208 rural communities in southern Mexico was randomly assigned to 1 of 4 groups: food basket with or without health and nutrition education, cash with education, or control. The impact on womens weight was estimated in a cohort of 3010 women using a difference-in-difference model. We compared the impact between the food basket and cash groups and evaluated whether the impact was modified by womens BMI status at baseline. With respect to the control group, the program increased womens weight in the food basket (550 ± 210 g; P = 0.004) and the cash group (420 ± 230 g; P = 0.032); this was equivalent to 70 and 53% increases in weight gain, respectively, over that observed in the control group in a 23-mo time period. The greatest impact was found in already obese women: 980 ± 290 g in the food basket group (P = 0.001) and 670 ± 320 g in the cash group (P = 0.019). Impact was marginally significant in women with a preprogram BMI between 25 and 30 kg/m2: 490 ± 310 g (P = 0.055) and 540 ± 360 g (P = 0.067), respectively. No program impact was found in women with a BMI <25 kg/m2. Providing households with a considerable amount of unrestricted resources led to excess weight gain in an already overweight population. Research is needed to develop cost-effective behavior change communication strategies to complement cash and in-kind transfer programs such as PAL and to help beneficiaries choose healthy diets that improve the nutritional status of all family members.

Only Children of the Head of Household Benefit from Increased Household Food Diversity in Northern Ghana

In many societies, foods are preferentially channeled to certain members of the household. We studied whether being the child of a powerful household member (head of household or first wife in a polygynous family) was associated with greater child stature in Northern Ghana and how this association varied with differences in household food availability. We used a sample of 464 children between 9 and 36 mo of age in extended households in rural Northern Ghana. Child stature was regressed on household food availability, the status of the childs father (head of household or other male), the status of the childs mother (marital order in a polygynous marriage), and the interaction terms between household food availability and parental status. The models were controlled for child age, sex, maternal height, parity, household size, and potential intra-community clustering. Household dietary diversity was associated with child stature (P < 0.05), but this association was limited to children of the head of household. For children of other males, there was no quantifiable association between household dietary diversity and child stature. Children of monogamous mothers were taller than children of second wives (P < 0.05). Our findings show that studies of intra-household allocation need to investigate beyond gender differences. Other structural household factors need to be considered in designing interventions, because they affect impact and even lead to increased intra-household inequality. Our results are relevant for Northern Ghana and as well as for similar settings elsewhere in the world.

Maternal Education Mitigates the Negative Effects of Higher Income on the Double Burden of Child Stunting and Maternal Overweight in Rural Mexico

Globally, the rate at which maternal overweight and obesity increase with rising wealth is higher than the accompanying decline in the prevalence of child stunting, resulting in the double burden of malnutrition. The positive association between household wealth and child linear growth is larger in households with a more educated mother. However, whether a similar positive and synergistic association between maternal education and household wealth is observed for maternal body weight is unknown. Our objective was to assess the potential protective role of maternal education in the etiology of the double burden of malnutrition (stunted child with an overweight mother). We used data on 1547 nonpregnant mothers (aged 18-49 y) and their children (aged 0-5 y) collected in a cross-sectional survey in 235 rural communities in southern Mexico. Child height-for-age Z-score and maternal body weight were regressed on household wealth, womens schooling, and the interaction between both, controlling for relevant covariates. A similar model was used for the prevalence of double-burden pairs (stunted child with an overweight mother). In mothers with less than primary school, a doubling in wealth was not associated with improved childs height but was associated with an increase in mothers weight (3.7%, P < 0.01). In mothers who had completed primary school, the reverse was found: a doubling in wealth score was associated with improved child height-for-age Z-score (0.32 SD, P < 0.01) but not with mothers weight. As a result, a 100% increase in wealth among households with less schooled mothers was associated with a 4.5 percentage point increase (P < 0.05) in double-burden pairs; in households with mothers with primary schooling or more, it was not associated with the occurrence of double-burden pairs. Maternal schooling effectively mitigated the negative effects of household wealth on the prevalence of double-burden households in rural Mexico. Where maternal schooling is low, poverty reduction must be accompanied by effective behavior change communication to prevent child stunting and to protect women from unhealthy weight gain.

The impact of daycare programmes on child health, nutrition and development in developing countries: a systematic review

The authors conducted a systematic review of impact evaluations of daycare interventions on the health, nutrition and development of children under five in low-income and middle-income countries. The review was limited to intervention studies controlling for potential self-selection of beneficiaries. Papers were excluded based on study scope, type and quality. Only six studies (conducted in Latin America) met the inclusion criteria. Large positive effects on child development were found. Because of the limited evidence, no conclusions can be drawn regarding the impact on child health and nutrition. More rigorously conducted studies on the impact of daycare programmes in developing countries are needed.

Serum aflatoxin B1-lysine adduct level in adult women from Eastern Province in Kenya depends on household socio-economic status: A cross sectional study

BACKGROUND Notwithstanding the growing concern about the negative impact of aflatoxin (AF) on human health, there is a dearth of evidence on the socio-economic determinants of AF exposure in low and middle income countries. OBJECTIVES We used detailed socio-economic data to quantify to what extent socio-economic characteristics explained differences in serum AFB1-lysine adduct level in adult women from a rural area in Kenyas Eastern Province. METHODS We first explored the relationship between serum aflatoxin level and a number of household, farm, and individual characteristics using cross-sectional data on 884 mothers (pregnant or with a child under 24 months). We then used regression analyses to estimate the extent to which the combined characteristics could predict serum aflatoxin levels. We finally used the estimated regression models to predict changes in AF level when changing a womens characteristics from the most disadvantaged group (setting all socio-economic characteristics to the lowest tertile) to the most advantaged group (highest tertile). RESULTS AF was detected in all women. The median level of serum AB1-lysine adduct was 7.47 pg/mg albumin. Higher exposure levels were significantly associated with poverty: predicted serum aflatoxin levels in women living in the worst socio-economic conditions were 4.7-7.1 times higher than those with the best socio-economic status. CONCLUSIONS The results of our study, the first to show the significant association between poverty and aflatoxin exposure, highlight the need to better understand the strategies used by better-off families to mitigate AF exposure.

The Oportunidades Program’s Fortified Food Supplement, but Not Improvements in the Home Diet, Increased the Intake of Key Micronutrients in Rural Mexican Children Aged 12–59 Months

Mexicos Oportunidades program provides conditional cash transfers, nutrition education, health services, and fortified food supplements for the young children of poor families. We have documented the effects of the program on growth and reduction of anemia. To better understand the impact pathways and disentangle the relative effects on dietary intake of the food supplements compared with other program components, we analyzed data from a randomized effectiveness evaluation of the Oportunidades program in rural children aged 12-59 mo. All Oportunidades beneficiaries received the cash transfers and the health and education components, but some children did not consume the supplements. The childrens diet was evaluated using a single 24-h recall. The impact was estimated using multiple linear regression models with community-level random effects. Comparisons were made among children who received all the benefits of Oportunidades, including the fortified food supplement (SG), beneficiaries of the program who did not consume the food supplement (NSG), and the control group (CG). Relative to the NSG and CG, respectively, the SG consumed greater amounts of [mean (95% CI)]: energy, 94 (28, 160) and 111 (43, 180) kcal/d; iron, 7.6 (6.3, 8.9) and 7.7 (6.5, 9.0) mg/d; zinc, 7.5 (6.4, 8.6) and 7.6 (6.5, 8.7) mg/d; and vitamin A, 0.109 (0.071, 0.147) and 0.120 (0.080, 0.159) mg retinol equivalents/d. No differences were found between the NSG and CG (P > 0.05). To conclude, the Oportunidades program had a positive impact on the diet of children. The effects of the program on dietary intake resulted from the food supplement and not from improvements in the home diet. Our findings are useful for identifying which program components contributed to the effects on the nutritional status of children.