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"Alderman, Harold"
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Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition?
Acceleration of progress in nutrition will require effective, large-scale nutrition-sensitive programmes that address key underlying determinants of nutrition and enhance the coverage and effectiveness of nutrition-specific interventions. We reviewed evidence of nutritional effects of programmes in four sectors—agriculture, social safety nets, early child development, and schooling. The need for investments to boost agricultural production, keep prices low, and increase incomes is undisputable; targeted agricultural programmes can complement these investments by supporting livelihoods, enhancing access to diverse diets in poor populations, and fostering women's empowerment. However, evidence of the nutritional effect of agricultural programmes is inconclusive—except for vitamin A from biofortification of orange sweet potatoes—largely because of poor quality evaluations. Social safety nets currently provide cash or food transfers to a billion poor people and victims of shocks (eg, natural disasters). Individual studies show some effects on younger children exposed for longer durations, but weaknesses in nutrition goals and actions, and poor service quality probably explain the scarcity of overall nutritional benefits. Combined early child development and nutrition interventions show promising additive or synergistic effects on child development—and in some cases nutrition—and could lead to substantial gains in cost, efficiency, and effectiveness, but these programmes have yet to be tested at scale. Parental schooling is strongly associated with child nutrition, and the effectiveness of emerging school nutrition education programmes needs to be tested. Many of the programmes reviewed were not originally designed to improve nutrition yet have great potential to do so. Ways to enhance programme nutrition-sensitivity include: improve targeting; use conditions to stimulate participation; strengthen nutrition goals and actions; and optimise women's nutrition, time, physical and mental health, and empowerment. Nutrition-sensitive programmes can help scale up nutrition-specific interventions and create a stimulating environment in which young children can grow and develop to their full potential.
Journal Article
The 1.5 billion people question : food, vouchers, or cash transfers?
This book addresses the thorny and fascinating question of how food and voucher programs, despite theory and evidence generally favoring cash, remain relevant, have evolved, and, in most circumstances, have improved over time. In doing so, we take an evolutionary and pragmatic view; we are interested in understanding why food-based programs exist and how countries can benefit from transformations such as that of Chhattisgarh, not in determining whether those programs should exist.
Book
The timing of growth faltering has important implications for observational analyses of the underlying determinants of nutrition outcomes
Growth faltering largely occurs in the first 23 months after birth and is thought to be largely determined by various harmful or protective socioeconomic conditions. Children 23 months or younger, however, have only been partially exposed to these conditions, implying that statistical associations between these conditions and child growth may be substantially smaller in samples that include younger children.
To test the prediction that associations between child anthropometric outcomes and various socioeconomic conditions are systematically different for older and younger children.
We analyzed data for 699,421 children aged 0-59 months, drawn from 125 DHS implemented between 1992 and 2014 in 57 countries. The outcome variables were height-for-age Z scores (HAZ) and stunting (HAZ<-2), and weight-for-height z scores (WHZ) and wasting (WHZ<-2). Independent variables included household wealth, parental education, maternal height, demographic factors, and exposure to WASH and health services. We used age-disaggregated regressions to examine how the associations between dependent and independent variables vary across different child age ranges.
Non-parametric regression results reaffirmed that most linear growth faltering and wasting takes place prior to 23 months of age. Estimates of the magnitude of association with wealth, education and improved toilet use from HAZ regressions are systematically larger in the sample of children 24-59 months than in the 0-23 month or 0-59 month samples; the reverse is true for WHZ regressions.
Previous observational analyses appear to substantially underestimate the protective impacts of a wide range of underlying determinants on stunting. Conversely, wasting rates are typically low for children 24-59 months, implying that associations between underlying conditions and wasting may be stronger for children 0-23 months of age. Such analyses should pay closer attention to age disaggregation; researchers should be aware of the age effect reported in the current study and present analysis stratified by age.
Journal Article
Strategies and interventions for healthy adolescent growth, nutrition, and development
Adolescence is a pivotal point in the life course, characterised by transformative physical, cognitive, and emotional growth, an openness to change, and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems, including micronutrient deficiencies, food insecurity, and poor-quality diets, persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation, with few taking into account the multiple drivers of adolescent diets. This Series paper highlights that effective interventions and policies will need to cut across sectors; be supported by multifaceted and multilevel policy; and extend across education, health, food systems, social protection, and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.
Journal Article
Intergenerational nutrition benefits of India’s national school feeding program
India has the world’s highest number of undernourished children and the largest school feeding program, the Mid-Day Meal (MDM) scheme. As school feeding programs target children outside the highest-return “first 1000-days” window, they have not been included in the global agenda to address stunting. School meals benefit education and nutrition in participants, but no studies have examined whether benefits carry over to their children. Using nationally representative data on mothers and their children spanning 1993 to 2016, we assess whether MDM supports intergenerational improvements in child linear growth. Here we report that height-for-age z-score (HAZ) among children born to mothers with full MDM exposure was greater (+0.40 SD) than that in children born to non-exposed mothers. Associations were stronger in low socioeconomic strata and likely work through women’s education, fertility, and health service utilization. MDM was associated with 13–32% of the HAZ improvement in India from 2006 to 2016.
India’s national school feeding program is the largest of its kind in the world, but the long-term program benefits on nutrition are unknown. Here, the authors show intergenerational program benefits, in that women who received free meals in primary school have children with improved linear growth.
Journal Article
Do Cash Transfer Programmes Affect Child Anaemia? Results From a Meta‐Analysis
Childhood anaemia is common and debilitating. Nutrition‐specific policies are effective for addressing anaemia in many contexts but less is known about nutrition‐sensitive policies such as cash transfers. We reviewed over 4000 studies and gathered 26 estimates of the effect of cash transfer programmes on childhood haemoglobin and anaemia. Overall, neither the impact of cash on haemoglobin (0.065 d/L, CI [−0.054, 0.184]) nor on anaemia prevalence (−0.092, CI [−1.227, 1.042]) were significant. While cash on its own had basically a null effect, programmes that provided cash in combination with other interventions such as behaviour change communication or nutritional supplements were more successful. The impact of social protection on haemoglobin and anaemia is surprisingly understudied compared to height, on which a previous study found well over 100 impacts of cash transfer programmes. Overall impacts of cash transfer programmes on haemoglobin and anaemia are weak: evidence is inconclusive at best. Cash transfer programmes are more successful in combination with other programmes providing education and/or nutritional supplements. We gathered 26 estimates from 4000 studies of cash transfer programmes' impacts on childhood haemoglobin and anaemia prevalence. Effects of cash alone on either outcome were insignificant, but programmes that provided cash in combination with other interventions such as health care, behaviour change communication, or nutritional supplements were more successful. Summary We conducted a broad search of the literature on cash transfers and child health, locating 26 estimates of programme impacts on haemoglobin and/or anaemia. Meta‐analysis found that estimated programme impacts were not statistically different from zero, but meta‐regression analysis showed that programme characteristics such as nutritional supplements and access to health care predicted improvements in Hb and anaemia. Surprisingly few studies include anaemia or haemoglobin as outcomes of interest. More research could help improve programme effectiveness.
Journal Article
Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries
This report is the second in a Series on early child development in low-income and middle-income countries and assesses the effectiveness of early child development interventions, such as parenting support and preschool enrolment. The evidence reviewed suggests that early child development can be improved through these interventions, with effects greater for programmes of higher quality and for the most vulnerable children. Other promising interventions for the promotion of early child development include children's educational media, interventions with children at high risk, and combining the promotion of early child development with conditional cash transfer programmes. Effective investments in early child development have the potential to reduce inequalities perpetuated by poverty, poor nutrition, and restricted learning opportunities. A simulation model of the potential long-term economic effects of increasing preschool enrolment to 25% or 50% in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 6·4 to 17·6, depending on preschool enrolment rate and discount rate.
Journal Article
More evidence on cash transfers and child nutritional outcomes: a systematic review and meta-analysis
BackgroundCash transfer (CT) programmes are an increasingly common approach to alleviate poverty and inequality and improving child health and nutrition, as well as supporting other goals such as education. Evidence indicates that CTs can be effective, but overall impacts are small in magnitude. This paper substantially updates the evidence base on the effectiveness of CTs and moderating factors.MethodsBuilding on a prior search done in 2018, we searched articles published between January 2018 and March 2021 using Agris, Econlit, Eldis, IBSS, IDEAS, IFPRI, Google Scholar, PubMed and World Bank databases. We included studies using quantitative impact evaluation methods of CTs with sample sizes over 300, targeted to households with children under 5 years conducted with clear counterfactuals in countries with gross domestic product below US$10 000 at baseline. We performed meta-analysis using random effects models to assess the impact of CT programme on selected child nutrition outcomes.FindingsOut of 1561 articles identified, 55 additional articles were eligible for inclusion for a total of 129 estimates. We find that CTs have significant although modest effects on height-for-age z-scores (HAZ) (0.024, 95% CI 0.004 to 0.044; p<0.02); stunting (−1.35%, 95% CI −2.35 to − 0.35; p<0;01); wasting (−1.31%, 95% CI −2.16% to 0.46%; p<0.01); animal-source foods (6.72%, 95% CI 5.24% to 8.20%; p<0.01); diet diversity (0.55, 95% CI 0.30 to 0.81; p<0.01) and diarrhoea incidence (− 1.74%, 95% CI −2.79% to −0.68%; p<0.05). There was no significant effect of CTs on weight-for-height (WHZ) or weight-for-age z-scores (WAZ). Well-targeted behaviour change communication was also effective in improving HAZ and decreasing the prevalence of diarrhoea.InterpretationCT programmes improved linear growth among young children, reducing wasting and stunting, but effects are heterogeneous and somewhat small overall. More evidence indicates that effects on dietary diversity and the consumption of animal-source foods are increasingly pronounced.
Journal Article
Home environment and nutritional status mitigate the wealth gap in child development: a longitudinal study in Vietnam
Background
Inequity in child development is found at early age, but limited evidence exists on whether these gaps change over time and what are the mediators.
Objective
We aim to (1) quantify wealth related gaps in cognitive and socio-emotional development in early and middle childhood; (2) examine how these gaps were mitigated by maternal, child factors and home environment.
Methods
We assessed the offspring of women who participated in a randomized controlled trial of preconception micronutrient supplementation in Vietnam (n = 1599). Child development was measured by the Bayley Scales of Infant Development-III (at 1-2y) and the Wechsler Intelligence Scale for Children®—IV (at 6-7y). We used multivariable regression to estimate the changes in wealth gaps for child development over time, adjusting for potential factors that potentially influence cognitive development.
Results
We found significant wealth gaps in cognitive development during early childhood (gaps between top and bottom quintiles: 0.5 SD); these gaps increased substantially in middle childhood (0.9 SD). Wealth disparity in social emotion did not change over time (0.26–0.28 SD). Maternal factors, quality of home environment, and child nutritional status mitigated the wealth gap in cognitive development (7-42%) in early childhood. The contribution of these mitigating factors was smaller in middle childhood (2- 15%). Wealth gap in social emotion reduced by 13% and 43% among children with better nutritional status at 2y and higher quality of home environment at 6-7y, respectively.
Conclusion
Interventions focusing on improving quality of home environment, maternal education, wellbeing, and child nutrition status may help reduce developmental deficits associated with poverty.
Journal Article