Nutrition in emergencies: Do we know what works?

Summary of paper¹

Location: Global

What we know: Nutrition action in emergencies is well accepted and attracts significant resources. There is a lack of evidence on what are effective interventions. Closer links are needed between emergency and development programming.

What this article adds: The contribution of emergency response programming to nutrition goals is rarely considered in the assessment of global nutrition agendas, target-setting, or budgeting. Representation of more geographical and operational contexts in research is needed. High coverage of effective treatment of wasting in crisis affected countries is needed to reduce child mortality.  Global targets for stunting require attention in humanitarian ‘hotspots’. Investment in high quality research for a list of gap areas and on ‘delivery’ science is needed. Emergency interventions should dovetail with longer term programming. Commitments to effective emergency preparedness and response should be fully incorporated into worldwide plans of action for nutrition in the post-2015 agenda. 

A recent paper reviews empirical evidence that currently underpins consensus positions on ‘what works’ in terms of nutrition actions in emergency settings. The authors aim to highlight important knowledge gaps, while sharing valuable lessons to a broader non-nutritionist audience, and to nutritionists who work mainly in non-emergency settings. Some of the ‘headlines’ of this paper are summarised below. 

The scale of donor funding for nutrition actions in humanitarian contexts now dwarfs that of non-emergency programming, suggesting a need for greater engagement of, and learning among, professionals who work in these two related but still largely siloed fields of practice. 

In 2012, nutrition-specific actions (listed as free-standing proposals for defined nutrition activities with their own budget lines) represented 11% (US$437 million) of the total funding requirements (US$7.7 billion) under the United Nations’ Consolidated Appeals Process (UN/OCHA, 2012). That does not include amounts dedicated to food aid in general (including micronutrient fortified cereal flours or emergency high-energy biscuits). In addition, around 2.6 million children under 5 years of age were reached with 32,000 metric tons of specialized food products by UNICEF in 2012, in emergency and non-emergency settings. If all forms of nutrient delivery, and complementary actions to address undernutrition, were combined, the total allocated toward nutrition actions in emergencies in 2012 can be estimated as more than half a billion US dollars. This significant focus on nutrition in emergencies contrasts with 1992 (the first year of consolidated multi-agency appeals), when there was no specific mention of nutrition at all among the 27 appeals that generated US$257 million in emergency response resources. 

Since mortality during crises is often mediated by a serious deterioration in nutritional status, it has long been accepted that nutritional rehabilitation and maintenance of adequate nutritional levels can be one of the most effective interventions to decrease mortality. As a result, the goals of nutrition action in emergencies typically include: 

(a) Reducing levels of wasting (GAM and SAM with or without oedema) to below conventionally-defined emergency rates or thresholds

(b) reducing and/or preventing micronutrient deficiencies 

(c) reducing the specific vulnerability of infants and young children in crises through the promotion of appropriate child care, with special emphasis on infant and young child feeding (IYCF) practices 

(d) preventing a life-threatening deterioration of nutritional status by ensuring access by emergency-affected populations to adequate, safe and nutritious foods that meet minimum nutrient needs. 

Increasing attention is also being paid to preventing a crisis-driven deterioration of nutritional status by protecting and enhancing baseline levels of nutritional status, promoting enhanced nutrition knowledge and behaviours that may enhance a child’s linear growth trajectory (and hence prevent stunting), and focusing on maternal and infant nutrition in the context of the broader thousand days agenda. However, the contribution of emergency response programming to nutrition goals is rarely considered in the assessment of global nutrition agendas, target-setting, or budgeting. For example, the influential Roadmap to Scaling Up Nutrition document makes no mention of humanitarian interventions.  This is unfortunate given the scale of resources at play and the reality that many of the countries carrying the highest burden of stunting or micronutrient deficiencies are fragile states that have recently had, or continue to face, acute and/or chronic emergencies. What is more, many nutrition innovations have been explored in emergency contexts and these should at least inform, if not be linked explicitly with, actions promoted in post-emergency and in non-emergency settings. 

A major hurdle to documenting successful innovation is the fact that measuring the effectiveness of nutrition actions in emergencies is beset with difficulty. It is not possible deliberately to withhold an intervention in order to achieve a comparison or control group. This means that the evidence of a beneficial impact can rarely be obtained experimentally; usually it can only be derived from data that provide plausible evidence of an effect. 

It is possible to argue that combined humanitarian responses are increasingly effective in saving lives, given that the numbers of people dying in the disaster contexts have halved between the early 1990s and 2011, despite a doubling of reported crisis events and a more than doubling of the number of people affected by such emergencies. However, the contribution of nutrition actions to mortality reduction, let alone to defined nutritional outcomes, is at present poorly investigated. 

The difficulty and expense of conducting high quality data collection in most sudden-onset, and even many chronic, humanitarian emergencies cannot be underestimated. 

Cost-effectiveness studies of various strategies are also scarce. So too are studies of alternatives; what might work differently or better in different contexts. To date, such studies have been concentrated in just a handful of countries (such as Niger, Malawi and Bangladesh), suggesting a need for replication and elaboration in more regional and operational contexts. Such analyses are essential if programming decisions are to be more empirically underpinned in coming years and able to document convincingly the value-added of recent innovations. 

Inevitably, the trend towards ‘bundling’ of activities into complex multifaceted programming responses also adds to the difficulty of separating out the effectiveness of individual components. 

As of 2011, there were still 165 million stunted children under the age of 5, as well as 52 million children who were wasted in both emergency and non-emergency settings. It is therefore vital to recognize that the goal of addressing stunting and wasting is unlikely to be achieved without progress in countries requiring large-scale humanitarian action, as well as the appropriate investments needed to move rapidly on a post-crisis trajectory. One of the interventions with the largest predicted effect on mortality in individual children is the treatment of severe wasting because it has the highest mortality risk, Thus expanding the coverage and effectiveness of both institutional and community-based programs focused on treatment and prevention of wasting is needed to reduce child mortality. Moderately wasted children are at increased risk of mortality, and since their number is much larger than the number affected by severe wasting, more deaths occur among the moderately malnourished. Furthermore, the first 1000 days of life in many countries may occur in the context of an emergency (be it a seasonal peak in nutrition and health insults or a full-blown humanitarian crisis). Therefore, emergency responses cannot afford to ignore the importance of prevention. 

On the other hand, global targets for stunting reduction also require attention to the institutional, human and budgetary capacities needed for scaling up evidence-based nutrition-specific actions in countries that are still humanitarian hotspots. For example, the Lancet’s 2013 set of 34 countries with a high burden of stunting (with greater than 20% prevalence rates) in which 90% coverage of effective interventions would help achieve required global stunting reduction targets includes Afghanistan, Yemen, the Democratic Republic of Congo (DRC), Niger, Chad, Iraq and Mali. Achieving 90% coverage of any of the 10 recommended essential actions in nutrition would be a major, costly challenge in any of these countries. That is partly because they represent fragile if not failing states in which the institutional and human capacity to support universal coverage of health and nutrition services remains severely compromised. It is also because countries like Niger and the DRC have seen increases, rather than decreases, in stunting rates since 1985. 

Actions to prevent stunting, while addressing very high levels of both wasting and micronutrient deficiencies in such countries will require a much closer linking of nutrition strategies, programming approaches and funding initiatives across the conceptual divide that still separates development activities from emergency response. In other words, the specific contribution of actions addressing nutritional deficiencies in humanitarian contexts has to be understood as an essential contribution to the international community’s overall nutrition agenda. 

There remain important knowledge gaps that require priority attention. While the literature on nutrition interventions in emergency settings has been growing, there are still many knowledge gaps. 

For example, more attention must be paid to study designs so that practical questions framed by cost and choice among alternatives can be answered. Much recent research relating to nutritionally enhanced food aid products seeks to compare multiple products that are not designed, packaged or programmed in identical ways. As a result, basic questions of importance to managers about effective modes of distribution, logistics, qualified supervision needs, instruction requirements for caregivers, sharing, acceptability and potential displacement of other elements of the local diet are typically not adequately addressed. 

More work is also needed on the appropriate uses of products created with specific nutritional goals in mind, including the use of Ready to Use Foods (RUFs) in programming aimed at preventing stunting, multiple micronutrient powders as vehicles to address maternal anaemia, and lipid-based supplements as potential complements to local complementary foods. 

At the same time, a focus in a lot of recent research on product performance should not obscure the critical importance of improving our understanding of how best to deliver products and services. Detailed cost-effectiveness analyses are needed of alternative approaches to achieving specified goals, including sustaining impacts (i.e. ensuring that children who recovered after severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) interventions remain well.

Other elements of emergency responses promoted by the international community have so far received too little scrutiny and require empirical study. These include, the effectiveness of various recommendations on infant and young child feeding (IYCF) approaches in emergencies; the aetiology of oedema in MAM and SAM and how/where best to treat it; the relevance of joint distributions of wasting and stunting among populations repeatedly affected by crises and the relative importance of focusing on rapidity of weight gain in treatment versus other measures of nutritional wellbeing; how best to assess and address the needs of adults (particularly the elderly) in emergency settings; how to implement effective SAM and MAM interventions for breastfed infants under 6 months; how to assess the contribution of delivered food products to local diets and dietary practices; the potential for differentiating needs of, and programming approaches to, children 6–24 months relative to those 25–59 months; the sensitivity of Mid Upper Arm Circumference (MUAC) for assessing SAM in children under 6 months or for establishing entry into/exit from programmes dealing with wasting; validation of proxy measures for diet quality, household and individual food security and nutritional wellbeing in the dynamic and often volatile contexts of emergencies; how to assess and best deal with intra-household sharing of resources (particularly those derived from food-based interventions); and appropriate cut-offs in wasting measures for determining emergency thresholds for adults versus children and potentially for pastoralists versus sedentary populations. 

Investment in high quality research around these topics will be returned in its contribution to more cost-effective programming during emergencies as well as, potentially, in non-emergency settings. Effective action requires an expanded research agenda to understand implementation and cost-effectiveness at scale/ However, this is hindered by the ‘absence’ of research on the delivery sciences including operational research, lack of, or poor-quality, assessments, scarce funding for delivery research, and the reluctance of journals to publish it. 

Wasting, stunting, micronutrient deficiencies, maternal undernutrition and even obesity can be found in both emergency and non-emergency settings and should be tackled wherever they are found. Thus, while high quality programmatic research must help further improve the design and impact of effective emergency nutrition interventions, these should be seen as entry points that dove-tail with, rather than supplant, longer-term actions that seek to resolve and prevent underlying causes of poor nutrition. The significant resources applied to nutrition actions in emergency contexts should be recognized within broader assessments of efforts taken to combat malnutrition. As such, commitments to effective emergency preparedness and response should be fully incorporated into worldwide plans of action for nutrition in the post-2015 agenda.

¹ Webb. P et al (2014). Nutrition in emergencies: Do we know what works? Food Policy 49 (2014) p33–40. http://dx.doi.org/10.1016/j.foodpol.2014.03.016?