USAID: How should we address wasting and stunting?

Lisez cet article en français ici

This is a summary of two Field Exchange articles published in issue 67. The original articles were a views article written by Erin Boyd and a summary of the following report: USAID Advancing Nutrition (2021) Stunting: Considerations for use as an indicator in nutrition projects. Arlington, VA: USAID Advancing Nutrition. Available at: https://www.advancingnutrition.org/resources/stunting-considerations-use-indicator-nutrition-projects

Erin Boyd is a Nutrition Advisor at the United States Agency of International Development’s Bureau for Humanitarian Assistance.

- Addressing wasting and stunting separately rather than jointly has resulted in missed opportunities to better understand and address undernutrition.

- The United States Agency of International Development (USAID) has invested in the work of the Wasting and Stunting Technical Interest Group to analyse the co-occurrence of wasting and stunting using existing data.

- These findings have been instrumental in informing USAID’s framework for defining and supporting the prevention of undernutrition.

- USAID has also contributed to discussions around the utility of stunting as an indicator, suggesting a need to incorporate a broader range of nutrition, health and development indicators when assessing nutrition programmes.

United States Agency of International Development (USAID) investments in Wasting and Stunting (WaSt)

USAID investments in nutrition include addressing wasting and stunting. For wasting, the focus has been on humanitarian contexts since resources and interventions target mortality reduction. Conversely, stunting has been equated with chronic undernutrition and has remained the focus in development contexts. However, USAID programme experiences and data have highlighted many humanitarian contexts where both wasting and stunting are a problem. In addition, many activities aiming to reduce or prevent stunting may also prevent wasting. Thus, there is an ongoing need to explore how wasting and stunting manifest at population and individual levels and how they might be related.

USAID sought to understand the relationships between wasting and stunting through an analysis of existing data in 2015/16 – the first analysis undertaken by the Wasting and Stunting Technical Interest Group (WaSt TIG). They then awarded a grant to ENN to explore the available data regarding the co-occurrence of wasting and stunting as well as the associated risk of mortality. Data was accessed from Standardised Monitoring and Assessment of Relief and Transitions (SMART) nutrition surveys, Multiple Indicator Cluster Surveys and Demographic and Health Surveys.

USAID has been investing in SMART nutrition surveys for over 15 years which include both weight-for-height (a measure of wasting) and height-for-age (a measure of stunting) data on the same children. However, the prevalence of each form of undernutrition had only been reported at an overall level, presenting a missed opportunity to look at the degree of overlap within individual children. Such analyses have contributed to an understanding of the implications of concurrent wasting and stunting, facilitated better targeting of USAID resources and supported advocacy for wasting programmes in non-humanitarian settings.

Influence of WaSt on the USAID approach

• Findings from the WaSt TIG work have prompted the USAID Nutrition Technical Working Group (NTWG) to examine geographic areas where overlapping wasting and stunting might require additional resources.
• The Bureau for Global Health and the Bureau for Humanitarian Assistance jointly supported ENN to develop a study protocol to test weight-for-age as a possible diagnostic criterion within wasting treatment programmes. Since weight-for-age is measured in growth monitoring and promotion programmes, it may improve links between these programmes and other nutrition interventions towards a common goal of optimal growth.
• USAID recognises that manifestations of malnutrition can co-exist. Thus, limiting programmes to one form of malnutrition may limit their impact. The analysis completed by ENN, through the WaSt TIG, has helped USAID to frame how it defines and supports the prevention of undernutrition.
• USAID has three bureaus focusing on nutrition, the Bureau of Global Health, the Bureau for Resilience and Food Security and the Bureau for Humanitarian Assistance. USAID has also created an internal Wasting Technical Working Group to better support wasting programming in non-humanitarian settings. Access to data on wasting and stunting supports collaboration between these entities towards addressing all forms of malnutrition.  

Rethinking ‘stunting’ as an indicator in nutrition programmes

The separate approach to wasting and stunting in humanitarian and development contexts, respectively, has also led to a focus on stunting as a primary objective in development programmes. Together with its relative ease of collection and interpretation, this has promoted the use of stunting reduction as the primary indicator of programme success in many national and donor-funded nutrition programmes. Recent challenges to this approach led to the release of a report by USAID in 2021 which discussed how stunting has been misused as an indicator for the following reasons:

• Stunting is often equated with chronic undernutrition. In reality, stunting is a marker of a deficient environment in which a number of potential factors, including diet, caregiving, frequency and severity of illness and the use of health services, limit child growth and development. Thus, multiple and multi-sector interventions that address all causes are needed to improve the long-term outcomes for children.
• Stunting is a statistical measure and not necessarily indicative of healthy growth. Since the risks associated with stunting increase across a continuum, many children who are not classified as stunted may not be achieving their full growth potential while some children who are classified as stunted may not be in poor health.
• Not all nutrition interventions should be expected to reduce the prevalence of stunting. Improvements in linear growth are difficult to achieve over the short term in many contexts. In addition, some nutrition interventions have little effect on linear growth while many non-health-sector interventions such as poverty alleviation and education have substantially contributed to declines in stunting prevalence, especially for girls.
• Stunting does not capture the many important benefits of nutrition programmes. Assessing only stunting fails to reflect the many other positive effects of improved nutrition for biological, cognitive and behavioural outcomes.

While stunting is still a useful indicator in some cases, USAID proposed using a broader set of indicators to monitor and evaluate nutrition programmes, highlighting that:

• Nutrition programmes should measure a broad set of indicators that can be directly attributed to programme activities
• Selection of indicators should be informed by a logic model that reflects the full pathway between interventions and results incorporating a range of nutrition, health and development outcomes
• Stunting prevalence remains a useful population measure that reflects overall living conditions and welfare
• It is also useful to track progress at population level and to identify sub-groups of vulnerable children who may benefit from nutrition programmes

Conclusion

USAID greatly values the use of data for decision making. The WaSt story is a clear example of how available data can be used to answer different research questions. ENN and the WaSt TIG members played an important role in accessing the raw data. More common data-sharing between academic institutions and independent researchers would enable such analyses.

USAID continues to face a challenge in identifying the most effective activities for the prevention of undernutrition in different contexts. Better understanding of the links between stunting and wasting will support USAID (and others) to design programmes that address all forms of undernutrition. Ensuring that such programmes incorporate appropriate indicators is critical to tracking progress and supporting advocacy and scale-up.