Jeremy Shoham

Prevention of acute malnutrition: Distribution of special nutritious foods and cash, and addressing underlying causes—what to recommend when, where, for whom, and how

Acute malnutrition is associated with increased morbidity and mortality risk. When episodes are prolonged or frequent, acute malnutrition is also associated with poor growth and development, which contributes to stunting. Nutrition-specific and nutrition-sensitive strategies to prevent undernutrition during the first 1,000 days from conception to 24 months of age can reduce the risks of wasting, stunting, and micronutrient deficiencies. Under circumstances that exacerbate the underlying causes of undernutrition and increase the incidence of wasting, such as food insecurity related to lean seasons or emergencies, or increased incidence of illness, such as diarrhea or measles, additional efforts are required to prevent and treat wasting. Special nutritious foods directly meet the increased nutrient requirements of children at risk for wasting; assistance to vulnerable households, in the form of cash or food, enables households to better meet the food, health, and other needs of household members and may increase resilience; water, sanitation, and hygiene (WASH) and health interventions help prevent and address illness and hence reduce wasting risk. The contributions of specific interventions to reducing the incidence of wasting are difficult to assess under emergency conditions, due to ethical constraints and to the fact that multiple strategies are implemented at the same time. However, pragmatic studies under real-life circumstances, using different designs, e.g., including a group receiving “best possible” treatment, can provide evidence about what works, to what extent, at what cost, and under which circumstances. Programs should address the most important causes in given contexts, be feasible to implement at scale, and assess implementation, coverage, and outcomes.

Impact evaluation of different cash-based intervention modalities on child and maternal nutritional status in Sindh Province, Pakistan, at 6 mo and at 1 y: A cluster randomised controlled trial

Background Cash-based interventions (CBIs), offer an interesting opportunity to prevent increases in wasting in humanitarian aid settings. However, questions remain as to the impact of CBIs on nutritional status and, therefore, how to incorporate them into emergency programmes to maximise their success in terms of improved nutritional outcomes. This study evaluated the effects of three different CBI modalities on nutritional outcomes in children under 5 y of age at 6 mo and at 1 y. Methods and findings We conducted a four-arm parallel longitudinal cluster randomised controlled trial in 114 villages in Dadu District, Pakistan. The study included poor and very poor households (n = 2,496) with one or more children aged 6–48 mo (n = 3,584) at baseline. All four arms had equal access to an Action Against Hunger–supported programme. The three intervention arms were as follows: standard cash (SC), a cash transfer of 1,500 Pakistani rupees (PKR) (approximately US

Factors Associated With the Risk of Acute Malnutrition Among Children Aged 6 to 36 Months in Households Targeted by an Emergency Cash Transfer Program

14; 1 PKR = US

Quality and potential use of data collected during nutrition surveys: an analysis of surveys in Ethiopia

0.009543); double cash (DC), a cash transfer of 3,000 PKR; or a fresh food voucher (FFV) of 1,500 PKR; the cash or voucher amount was given every month over six consecutive months. The control group (CG) received no specific cash-related interventions. The median total household income for the study sample was 8,075 PKR (approximately US

The risk of acute malnutrition among children aged 6-36 months in households targeted by an emergency cash transfer program in Niger (251.2)

77) at baseline. We hypothesized that, compared to the CG in each case, FFVs would be more effective than SC, and that DC would be more effective than SC—both at 6 mo and at 1 y—for reducing the risk of child wasting. Primary outcomes of interest were prevalence of being wasted (weight-for-height z-score [WHZ] < −2) and mean WHZ at 6 mo and at 1 y. The odds of a child being wasted were significantly lower in the DC arm after 6 mo (odds ratio [OR] = 0.52; 95% CI 0.29, 0.92; p = 0.02) compared to the CG. Mean WHZ significantly improved in both the FFV and DC arms at 6 mo (FFV: z-score = 0.16; 95% CI 0.05, 0.26; p = 0.004; DC: z-score = 0.11; 95% CI 0.00, 0.21; p = 0.05) compared to the CG. Significant differences on the primary outcome were seen only at 6 mo. All three intervention groups showed similar significantly lower odds of being stunted (height-for-age z-score [HAZ] < −2) at 6 mo (DC: OR = 0.39; 95% CI 0.24, 0.64; p < 0.001; FFV: OR = 0.41; 95% CI 0.25, 0.67; p < 0.001; SC: OR = 0.36; 95% CI 0.22, 0.59; p < 0.001) and at 1 y (DC: OR = 0.53; 95% CI 0.35, 0.82; p = 0.004; FFV: OR = 0.48; 95% CI 0.31, 0.73; p = 0.001; SC: OR = 0.54; 95% CI 0.36, 0.81; p = 0.003) compared to the CG. Significant improvements in height-for-age outcomes were also seen for severe stunting (HAZ < −3) and mean HAZ. An unintended outcome was observed in the FFV arm: a negative intervention effect on mean haemoglobin (Hb) status (−2.6 g/l; 95% CI −4.5, −0.8; p = 0.005). Limitations of this study included the inability to mask participants or data collectors to the different interventions, the potentially restrictive nature of the FFVs, not being able to measure a threshold effect for the two different cash amounts or compare the different quantities of food consumed, and data collection challenges given the difficult environment in which this study was set. Conclusions In this setting, the amount of cash given was important. The larger cash transfer had the greatest effect on wasting, but only at 6 mo. Impacts at both 6 mo and at 1 y were seen for height-based growth variables regardless of the intervention modality, indicating a trend toward nutrition resilience. Purchasing restrictions applied to food-based voucher transfers could have unintended effects, and their use needs to be carefully planned to avoid this. Trial registration ISRCTN registry ISRCTN10761532

Multi-sector programmes at the sub-national level: A case study in Homa Bay and Makueni counties in Kenya

Background: Assessing whether and how the expenditure of emergency cash transfer programs (CTPs) relates to child nutritional status is a necessary step for informed program design and targeting. Objective: We hypothesized that greater child food expenditures would have a protective effect against the risk of acute malnutrition in the context of a food crisis in Niger. Methods: We investigated the relationship between food and medical expenditures and acute malnutrition in children aged 6 to 36 months through an observational cohort study of 420 households enrolled in an emergency CTP in Niger. A Cox proportional hazards model was used to estimate the risk of acute malnutrition while adjusting for relevant child and household characteristics. Results: Seventy-four (18% of the cohort) children developed acute malnutrition. The risk was 1.79 times higher among ill children than healthy children (hazard ratio [HR]: 1.79; 95% confidence interval [CI]: 1.10-2.92; P < .05), nearly 3 times higher among children in the poorest households than those in wealthier households (HR: 2.98; 95% CI: 1.86-4.78; P < .001), and 2.85 times lower with each unit increase in baseline weight-for-height Z score (HR: 0.35; 95% CI: 0.23-0.53; P < .001). Food expenditures were not associated with risk (HR: 0.97; 95% CI: 0.87-1.07; P > .05). Conclusion: Our findings highlight the importance of the health-related determinants of child undernutrition and suggest that a potential role of emergency CTPs may be to enable and promote health service access where services exist. They also indicate a need for more sustained poverty reduction and undernutrition prevention activities in concert with well-timed and strategic use of emergency interventions.

Multi-sector programming at the sub-national level in 3 case studies french

Humanitarian agencies regularly carry out nutrition surveys to estimate the prevalence of acute malnutrition (wasting) and mortality as well as to collect data on a wide range of contributory or aggravating factors in order to identify interventions and to direct aid where it is most needed. In this study, the case of Ethiopia was used (i) to assess the proportion of 291 nutrition surveys conducted between 2003 and 2008 that used the recommended sampling method to estimate the prevalence of wasting, (ii) to assess how and what data on indicators of aggravating factors were collected, (iii) to examine whether data on such factors can be used to establish priorities for emergency assistance based on Ethiopian Government guidelines and (iv) to discuss the general value of such data. All but one survey used the recommended methods to estimate the prevalence of wasting. Data were collected on more than 40 indicators of aggravating factors related to health, caring practices, food security and coping strategies, but no consistent methods or indicators were used, resulting in inconsistent data. This illustrates the need to develop and agree upon a set of core indicators of aggravating factors and then thresholds to describe the humanitarian situation in Ethiopia and elsewhere and to indicate priorities for interventions.