WaSt Special Section Editorial
Dear readers,
Our aim with this special section of Field Exchange (FEX) is to convey to you the scope of work that the Wasting and Stunting Technical Interest Group (WaSt TIG), and individuals and agencies in the wider nutrition sector, have been doing to explore the relationship between child wasting and stunting and what that means for how research is conducted, programmes are designed and policies are framed.
The WaSt TIG sprang into life in 2014, stimulated by an ENN paper that explored global and country level financing for community-based management of acute malnutrition. The paper highlighted the siloing of wasting as a humanitarian issue and stunting as a development one and questioned the gap this created between programming, financing and policies to deal with these two forms of malnutrition (Shoham, Dolan & Gostelow, 2013). The initiative began with a small group of people (including the three of us) who wanted to better understand the connections between these two widespread forms of undernutrition with a view to identifying ways to break down the siloes and, in so doing, make better progress to tackle wasting and stunting together. Irish Aid and USAID championed this work from the outset and continue to do so and for this we are extremely grateful, as we are to the members of the group who give of their time and expertise – often freely.
The first article in this issue of FEX, is a summary of the last eight years of the work of the WaSt TIG taking you through the phases of this exploration. As you will see, much has been achieved in building and influencing the sector’s understanding of the issues including evidence reviews, defining and filling evidence gaps and exploring the implications of findings for further research, policy and practice.
The second article focuses on key research findings. It summarises a recently published systematic review that updates the evidence on the relationship between wasting and stunting generated by the WaSt group and by others. The review highlights the co-existence of wasting and stunting in children, the high mortality risk associated with this, the detrimental effect of wasting on linear (height) growth and the need for further exploration of how wasting treatment might better support that growth. An accompanying views article on linear growth goes on to explore the latter question and offers suggestions for research and practice. The findings of the systematic review are significant as they strongly indicate that approaches that focus on wasting or stunting in isolation, or on prevention or treatment in isolation, are missing opportunities for greater impact on preventing both child undernutrition and the associated mortality.
Two summaries of ‘hot off the press’ research complement the findings of the systematic review. The first is an analysis of 12 mortality cohorts to determine the anthropometric criteria best suited to identifying malnourished children at most risk of dying including those who are concurrently wasted and stunted. The highlight of this analysis is that weight-for-age, a measure of underweight that is used in clinic-based and community-based growth monitoring in many contexts, accompanied by existing mid-upper-arm circumference criteria may best identify those children most in need of treatment. The second summary builds on the published work of the group exploring the patterns of sex difference in child wasting and stunting, previously summarised in FEX1, which indicated that boys are more likely to be wasted and stunted than girls. It explores the origins, pathways and consequences of these sex differences.
This special section also includes a number of articles illustrating country experiences of trying to bring together approaches to wasting and stunting or at least to start thinking through the opportunities to do so. The Government of Indonesia highlights its programme to end stunting which includes wasting treatment through the health system as an integral component. The non-governmental organisation, GOAL, describes its Nutrition Impact and Positive Practice approach in Sudan for the prevention of moderate acute malnutrition (moderate wasting) and the opportunities its holistic approach to address the underlying behavioural drivers of malnutrition offers for a joint wasting and stunting prevention approach. Other country examples, from Angola and Somalia, focus on the collection of data on both forms of malnutrition and their overlap and highlight the question of what is required next to shape the integrated approaches that the data suggests are needed. World Vision’s analysis of the prevalence of concurrent wasting and stunting in Angola poses the question of how programmes may better target this high risk group. An interesting article by ACF details the findings of a Link NCA in Somalia exploring the risk factors for wasting, stunting and underweight and highlights both the overlap of the risk factors between wasting and stunting (something that was highlighted in an early review of evidence by the WaSt TIG) and some divergence in that specific context. It speaks to the need for context specific joint approaches to malnutrition that can capitalise on opportunities to reduce co-existing risk factors.
The influence of the work of the group on research and policy in the wider community has been a key feature over the years. This is illustrated in a number of articles including a commentary exploring the content of the 2021 Lancet nutrition series and a views piece in which USAID’s Erin Boyd shares the donor’s experience both with supporting the work of the WaSt TIG and how the work has influenced and supported USAID’s recognition of the importance of a more integrated approach to achieve impacts on both wasting and stunting across their Bureaus.
There are several important elements of the work of the WaSt TIG not represented in this special section of FEX but which we wanted to highlight for you here. A significant body of work on wasting prevention in the context of stunting prevention, highlighting the opportunities for integrating approaches, has been completed and was recently used as a basis for a multi-agency call to action at the Nutrition for Growth Summit. Several pieces of research from the group have thrown new light on the question of which undernourished children are at most risk of dying and suggest that the intensity of treatment (therapeutic/supplementary) could be gauged by that level of risk. These papers have influenced the initiation of a risk stratification exercise by the World Health Organization alongside its wasting treatment and prevention guideline process which will re-examine multiple datasets in relation to mortality risk. Finally, the group’s mortality analysis finding on the utility of severely low weight-for-age for identifying at risk children has generated the development of an implementation study research protocol to test the appropriate intensity and duration of treatment for that group. A complementary analysis of existing treatment programme datasets exploring the response to treatment for this at risk group is under review for publication. Looking ahead, there are also two new pieces (a paper and a brief) that communicate to other interested researchers the learnings of the group’s work for the design and methodology of research that reflects and/or further explores the relationship between wasting and stunting. More information on these and all the work of the group can be found on our website, https://www.ennonline.net/ourwork/reviews/wastingstunting
By the middle of this year the WaSt TIG will be coming to the end of its current workplan. This will mean convening as a group to take stock of what has been achieved and discussing where to best focus energies in the next period. We expect there will be priority evidence gaps to fill, some by the group and others by the wider community, that are essential to underpin an even stronger case for addressing undernutrition and for maximising how investments are used. Evidence of the wider impacts that wasting has on growth and development and the longer-term implications strengthens the importance of addressing this issue not just to save lives, but also to ensure children go on to thrive and get the most out of their lives. Questions raised in the articles you will read in this special section are going to require concerted investment to answer. The call for content for this sub section yielded few examples from country level which perhaps highlights the challenges of translating this work into more effective policy and programming on the ground. The country examples that are included suggest that there is a way to go in working together with you the reader and others to do exactly that.
One of the biggest and most satisfying lessons we have learned from being part of the WaSt TIG is that we can achieve a remarkable amount with relatively few resources when we have had a committed coalition of individuals working together in an open and coordinated way. We see the next phase of the work as an opportunity to expand this out to the wider sector, building a common understanding of priority areas for research and a common vision of where we need to get to. In times when international and national resources are extremely stretched, yet the challenges to achieving the sustainable development goals and the ‘leave no one behind’ agenda are considerable, this next phase feels particularly important. We hope this essential work demonstrating the interrelationships between wasting and stunting can continue to shed new light on where the biggest risks to child undernutrition, mortality and longer-term development are. In turn, we trust that this will provide a stronger basis for advancing actions at greater scale and more rapidly to accelerate progress towards improving outcomes for children.
We would like to keep engaged with our FEX readers so, to get involved with the work of the group or to discuss how to bring the lens of the relationship between wasting and stunting into your own work, please get in touch with the WaSt TIG coordinators, Tanya Khara and Natalie Sessions (tanya@ennonline.net, natalie@ennonline.net).
Wishing you all a good read.
Tanya Khara (ENN), Abigail Perry (WFP & WaSt TIG member), Carmel Dolan (N4D & WaSt TIG member)
This paper is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of ENN and do not necessarily reflect the views of USAID or the United States Government.
We thank the ongoing contributions of the WaSt TIG members:
Abigail Perry
André Briend
Andrew Hall
Andrew Mertens
Andy Prendergast
Anne Walsh
Bernadette
Cichon
Carlos Grijalva-Eternod
Carmel Dolan
Caroline Wilkinson
Casie Tesfaye
Dominque Robenfroid
Erin Boyd
Heather Stobaugh
Hedwig Deconinck
Jay Berkley
Jeanette Bailey
Jonathan Wells
Kay Dewey
Ken Maleta
Kevin Phelan
Kieran O'Brien
Leisel Talley Mija Ververs
Mark Manary
Mark Myatt
Marko Kerac
Martha Mwangome
Michel Garenne
Natasha Lelijveld
Paluku Bahwere
Patrick Webb
Robert Black
Saul Guerrero
Sheila Isanaka
Silke Pietzsch
Sophie Moore
Stephanie Richards
Henry M Jackson
Susan Thurstons
William Checkley
Zita Weise-Prinzo
Zulfiqar Bhutta
References
Shoham J, Dolan C, Gostelow L, ENN (2013) The Management of Acute Malnutrition at Scale: A Review of Donor and Government Financing Arrangements. Summary Report. March 2013.