USAID’s investment in the WaSt TIG
Erin Boyd is a Nutrition Advisor at the United States Agency of International Development’s Bureau for Humanitarian Assistance.
Why has the United States Agency of International Development (USAID) invested in wasting-stunting (WaSt)?
USAID’s multi-sectoral nutrition strategy (USAID, 2014) was finalised in 2014 and serves to guide USAID on investing in interventions to address malnutrition. The strategy includes goals in line with the World Health Assembly targets for reducing stunting and wasting but the focus on wasting has remained primarily in humanitarian settings. Through monitoring trips and working with data from wasting programming, several USAID nutrition advisors noted that there were many humanitarian contexts where both stunting and wasting were a problem. Since humanitarian resources are expected to be directed toward mortality reduction, wasting treatment was the focus for humanitarian nutrition interventions. Similarly, it was recognised that in settings with a high stunting burden, many of the activities to reduce or prevent stunting may also prevent wasting. However, little was understood about how these two forms of undernutrition manifested in populations or at an individual level and how the two forms of undernutrition might be related. There was also limited data to determine whether stunting and wasting had similar causes.
USAID sought to understand the literature on how wasting and stunting were related and how they differed through an analysis produced in 2015/16 (Khara et al, 2017) which was the first analysis that the WaSt Technical Interest Group (WaSt TIG) published using existing data. Following this work, we wanted to determine whether the same children were affected by both forms of undernutrition, quantify mortality risk and define the extent to which children had both forms of undernutrition. A grant was awarded to ENN to analyse the available data (Myatt et al, 2018) to examine the extent to which concurrent wasting and stunting existed.
USAID has invested in Standardised Monitoring and Assessment of Relief and Transitions (SMART) nutrition surveys for over 15 years and while weight-for-height and height-for-age data on the same children is available, the prevalence of each form of undernutrition was reported at an aggregate level, presenting a missed opportunity to look at the degree of overlap in the forms of undernutrition within individual children. We were able to access data from SMART surveys, Multiple Indicator Cluster Surveys and Demographic and Health Surveys to perform this analysis (Myatt et al, 2018). Additionally, prevalence estimates are only a snapshot at one point in time and do not capture whether the same child may experience stunting or wasting at different times. The ENN analysis highlighted the need to also look at mortality risk and to do that, cohort data was critical.
Analysing the manifestation of both stunting and wasting in the same child helps us to understand the implications and better target USAID resources as well as to advocate for more programming to address wasting in non-humanitarian settings.
How has WaSt work to date influenced USAID’s approach?
To date, the WaSt work has influenced the USAID Nutrition Technical Working Group (NTWG) to examine geographic areas where overlapping wasting and stunting might require additional resource commitment. The Bureau for Global Health and the Bureau for Humanitarian Assistance jointly supported ENN to develop a study protocol (ENN, 2019) to test whether weight-for-age is a possible diagnostic criterion for entry into wasting treatment programmes. Weight-for-age is measured through growth monitoring and promotion programmes and might be a useful platform particularly in non-emergency or longer-term protracted emergency settings. Revisiting weight-for-age provides an opportunity to better link growth monitoring and promotion and other nutrition interventions toward a common goal of optimal growth.
Within USAID, there is an overall recognition that manifestations of malnutrition can co-exist in the same children and limiting programmes to focusing on one form can also limit their impact. The analysis completed by ENN, through the WaSt TIG, suggests that wasting can have a detrimental effect on linear growth. The work of the WaSt TIG has contributed to the overall framing of how USAID can better define and support the prevention of undernutrition.
In addition to webinars on the WaSt work for the NTWG, USAID has three bureaus focusing on nutrition: 1) The Bureau of Global Health, 2) The Bureau for Resilience and Food Security and 3) The Bureau for Humanitarian Assistance. USAID has also created an internal Wasting Technical Working Group which seeks to better support wasting programming in non-emergency countries. Having access to data related to both wasting and stunting provides an opportunity for all three bureaus to work together to identify ways that USAID programming can mitigate all forms of malnutrition.
Opportunities for WaSt at USAID
USAID greatly values the use of data for decision making. The WaSt story is a clear example of using available data to look at problems through a different lens. It is worth re-emphasising that the data used for all WaSt analyses were retrospective analyses re-analysed at an individual level to look at different research questions. The sharing of raw data between academic institutions and independent researchers is not unprecedented but should be more common to facilitate additional, needed analyses. USAID appreciates the role that ENN and the WaSt TIG members were able to play in accessing the raw data, particularly considering some data was from the 1970s.
USAID continues to face a challenge in knowing which activities for the prevention of undernutrition are most effective in different contexts. As we begin to better understand the links between stunting and wasting, this will help us to better design programmes that can address all forms of undernutrition. The dichotomy of stunting and wasting has resulted in some missed opportunities to understand and support optimal child growth and the work of the WaSt TIG is helping to highlight some key areas where programming can be more inclusive and holistic.
References
ENN (2019) The WaSt study protocol and opportunities for collaboration: bringing new evidence on undernutrition and mortality risk into practice. Wasting and Stunting Technical Interest Group. https://www.ennonline.net/resource/newevidenceintopractice
Khara T, Mwangome M, Ngari M and Dolan C (2017) Children concurrently wasted and stunted: A meta-analysis of prevalence data of children6-59 months from 84 countries. Maternal & Child Nutrition, 14, e12516.
Myatt M, Khara T, Schoenbuchner S, Pietzsch S, Dolan C, Lelijveld N et al (2018) Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries. Archives of Public Health, 76, 28.
USAID (2014) Multi-sectoral nutrition strategy 2014-2025. https://www.usaid.gov/nutrition-strategy