Wasting Prevention

Background

The global burden of wasting (50.5 million children 0-59 months of age)¹ is a major global public health crisis and progress in reducing levels towards World Health Assembly (WHA) targets has been poor. Wasting not only contributes to child deaths but also affects children’s subsequent prospects of surviving and thriving in all areas of their lives. The treatment of wasting has expanded beyond humanitarian emergencies, with more services integrated into health systems, but treatment coverage remains way below needs. Expanding treatment capabilities is only part of the solution however and there is an urgent need to focus on the prevention of wasting. An understanding of the factors that cause wasting and robust evidence of effective interventions to prevent it are currently lacking.

For this reason, the UK Department for International Development (DFID), through the MQSUN+ programme, is investing in efforts to support the wider nutrition community to accelerate coordinated action to address this gap. These efforts began with a review of the current thinking and evidence of what works to prevent wasting which culminated in two key documents; A summary of current thinking on ‘The Aetiology of Wasting’ and a report on 'The Current State of Evidence and Thinking on Wasting Prevention'.

The next stage is to prioritise the main outstanding research questions to guide wasting prevention research investments for the coming five years. To do this we are using the well-known Child Health and Nutrition Research Initiative (CHNRI) methodology.

Methods 

An international Expert Group (EG) (Bob Black, Helen Young, Professor Bhutta, Sheila Isanaka, Jeanette Bailey, Marko Kerac, Paluku Bahwere, Nicola Connell, Amy Mayberry, Phil James, Saskia van de Pee, Emily Smith, Mark Myatt, Andre Briend, Andrew Hall and Bridget Fenn) in the areas of child nutrition and research has already:  

1. Organised existing research gaps into 40 key questions: Drawing on recent evidence reviews, and other research prioritisation exercises the EG has compiled and then, through focussed discussion, honed down identified research gaps into 40 relevant, specific, clear and answerable research questions.
2. Defined criteria to judge these questions: The EG group discussed all potential criteria laid out in the CHNRI methodology and agreed upon four appropriate criteria against which each question will be judged.  

These questions and judging criteria have been developed into an online survey which we are inviting you and a broad range of stakeholders to complete.

Important information on the scope of this exercise

1. Time frame: Questions have been included in this research prioritisation exercise (RP) that could produce results within a five-year research period.
2. Target group: The questions in this RP refer primarily to infants and children aged 0 to 59 months living in low and middle-income countries (LMIC). In some cases, research to be carried out in high income countries has been included where there is direct relevance to understanding how to prevent wasting in LMIC. Some questions also concern those groups indirectly affected by wasting in this age group (including adolescent girls, caretakers and communities where wasting is prevalent).
3. Focus on prevention: The questions are focussed on wasting prevention and not on treatment (which has been comprehensively covered in previous global research prioritisation exercises).
4. Anthropometric outcomes of interest: Wasting (characterised by low weight-for-height/length) can be relatively rapid in onset and resolution on an individual level, hence, the term acutely malnourished (divided into moderate and severe) is often used to describe children who are wasted. Other forms of acute undernutrition (characterised by the presence of bilateral oedema, low mid-upper arm circumference or low weight-for-age) are also considered due to the evidence of their relationship with mortality in infants and children. These measures are therefore all outcomes of interest for this RP despite being outside of the standard WHO definition of ‘wasted’ (WHO and UNICEF 2009).
5. Definition of prevention: Wasting is a process which may or may not lead to a child becoming wasted. Anthropometric measures and indices are only proxies for this process, designed mainly to be applied to populations rather than individuals. Therefore, this RP considers two dimensions of prevention: primary prevention (prevention of any degree of wasting including from the initiation of the process that leads to an infant/child becoming wasted) and secondary prevention (prevention of worsening degrees of wasting).
6. Relationship between wasting and stunting: Due to recent advances in understanding of the relationship between wasting and stunting, the RP questions also emphasise the importance of not researching wasting in isolation from other outcomes of undernutrition, stunting in particular.

Intended outputs and outcomes

The results of this RP exercise will be collated, presented and discussed within the EG and with DFID. Thereafter, a peer review journal paper will be prepared, in which all who participate in the survey and who wish to will be included in a list of group authors.

It is hoped that the results will inform the direction of research and investments in this important area of nutrition. Your views are needed to ensure the next five years of research helps us to make the advances we need to see.

What we are asking of you

Please set aside 45 minutes between now and the February 28^th, 2019 to go through the following three stages:

1. Read through the instructions first
2. Familiarise yourself with the judging criteria
3. Complete the survey

¹UNICEF, WHO, World Bank Group. Joint Child Malnutrition Estimates: Levels and Trends in Child Malnutrition. Key findings of the 2018 Edition of the Joint Child Malnutrition Estimates. World Health Organisation, Geneva: World Health Organisation;2018.

How do I access the survey?

The survey is now closed.

How long will it take to complete the survey? 

We estimate that it will take between 45 minutes and one hour to complete the survey. 

What research questions will I be asked to judge? 

There are 40 research questions in total that we are asking you to judge. The questions have been grouped in the survey according to the ‘4 Ds’ defined by the CHNRI methodology:

1. Description: research to assess the burden of the problem (wasting/acute malnutrition) and its determinants.

2. Delivery: research to assist in the optimising of the nutrition status of the population using means that are already available (i.e. existing delivery models). 

3. Development: research to improve interventions that already exist but could be improved.

4. Discovery: research that leads to innovation i.e. entirely new health interventions. 

Please answer all of the questions in the survey. See below for a definition of key terms used within the research questions. 

How do I judge each research question? 

Please consider how far the research question meets each of the four criteria listed on the left-hand side. Here is a fuller description of these criterion to help you: 

1. Answerable? How answerable would this research question be? (i.e. is it feasible to answer within the given context and timeframe? Is it ethical?)
2. Efficacious? How likely is it that this research would lead to efficacious (i.e. likely to produce the desired outcome in ideal conditions) interventions/approaches/ policies?
3. Deliverable? How likely is it that this research would lead to deliverable (i.e. cost-effective, deliverable at scale and with necessary coverage) interventions/approaches/ policies?  
4. Fills a gap? Will this research question fill a key gap in knowledge that is required to prevent wasting?

This fuller description of hte criterion will appear at the top of each page within the survey. You can refer to this by scrolling bakc to the top of the page at any time. You may also find it helpful to print out these instructions or bring them up on another tab or device,  so that you can refer to them alongside the survey. 

How do I score each question?

For each research question and criterion being considered, you must choose one of four options:

'Yes': yes, the questions meets the criteria.

'No': no, the question does not meet the criteria

'Informed but undecided': I understand the question and possess sufficient knowledge to answer it, but the answer isn’t a clear ‘yes’ or ‘no’.

'Not sufficiently informed': I do not have sufficient knowledge or information to judge this research question.  

Please choose the ‘best fit’ option and try to be as intuitive as possible in your response. We don’t need to know how you arrived at your chosen response, or how you applied the question in your own context or thinking. The answer that you arrived at is all that we need.   

How do I know what the interventions/ policies/ approaches arising from the research are likely to be?

It is impossible to predict all outcomes of health research. CHNRI considers the value of the likely interventions/policies and approaches. Sometimes these are obvious. Other times they are not. Many questions only indirectly lead to interventions/ policies and approaches. It is important to think beyond just the simple endpoints of research questions and to keep in mind their broader scope and relevance. As an expert, you are allowed to speculate, and all speculation is valuable. The fact that different experts may be thinking of different interventions/policies/approaches when answering is not a problem but a feature of CHNRI. Final scorings will reflect such uncertainties and differences of opinion.

Surely context matters to the success/failure of the ‘intervention arising’?

We agree. This is why experts/stakeholders working in many different settings have been invited to take part. When answering questions, consider their meaning in the context(s) in which you usually work.

Will my contribution be recognised? 

We recognise and appreciate your expertise and perspective, as well as the time that you contribute to complete this questionnaire. As such, and to ensure transparency, we will include all survey respondents who wish to be included on a group author list for any publications resulting from this exercise. You will be asked to include your name, organisation and email address at the start of the survey and at the very end of the survey there will be a question that enables you to opt in or out of group authorship.

Can I review the research questions before starting the online survey?

Yes, you can. Download the full list here.

If I am unclear about a term that is used?

The next page contains a list of key terms used and their common definitions.

How long do I have to complete the survey?

The online survey link will close by close of business on Thursday 28^th February 2019. You are welcome to complete the survey at any point before then.

Can I start the survey and return to it?

The survey will save your responses. As long as you use the same device you can re-use the same survey link and your previous responses will be remembered.

How will the personal information that I provide be stored and used?

We take your privacy seriously and will not use the details that you share for other ENN projects, nor will be pass it on to third parties. Your personal details (name and contact details) will also not be shared in the results of the study. For more information about this please read ENN's Privacy Notice.

Can I change my answers once I have submitted the survey?

You cannot change your answers once the survey has been submitted. If you need to make edits or have other problems completing the survey, please contact us.

Acute malnutrition: acute malnutrition is a state of malnutrition that includes wasting and oedematous malnutrition (kwashiorkor) (see definitions for wasting and oedematous malnutrition). 

Anthropometric: body measurements used as a measure of an individual’s nutritional (anthropometric) status.

Concurrent wasting and stunting (WaSt): when a child is wasted and stunted at the same time.

Coverage: the extent to which a programme covers the needs of its target population. 

Environmental enteric dysfunction: a disorder of chronic intestinal inflammation, common in children living in low-resource settings.

Epigenetic: the study of heritable changes in gene expression (phenotype changes) that do not involve changes to the underlying DNA sequence (genotype changes).

Foetal growth restriction: also known as intrauterine growth restriction – a condition in which the baby’s growth slows or stops during pregnancy.

Growth failure: a growth rate below the appropriate growth velocity for age.

Growth monitoring: an individual child’s growth (weight-for-age) is measured at intervals and the results plotted on a chart.

Height-for-age: a measure of stunting in children based on their height and age compared to an international standard.

Integrated management of childhood illness (IMCI): a strategy developed by UNICEF and the World Health Organization (WHO) in 1995 that promotes an integrated approach to child health, focusing on the well-being of the whole child implemented by families and communities and health facilities.

Incidence: occurrence of new cases.

MAMI: an acronym for “management of at-risk mothers and infants under six months of age” which concerns the identification and care of at risk mothers and infants under 6 months, with particular interest in nutrition vulnerability. 

Microbiome: the microorganisms in a particular environment (in this case the gut).

Mid-upper arm circumference (MUAC): a measure of acute malnutrition. The circumference of the mid-upper arm is measured on a straight left arm (in right handed people) midway between the tip of the shoulder (acromium) and the tip of the elbow (olecranon).

Multi-sectoral approaches: approaches to improving nutrition that involve multiple sectors, typically health; water, sanitation and hygiene (WASH); agriculture; education and child protection.

NCDs: acronym for “non-communicable diseases” which are medical conditions or diseases that are non-infectious and non-transmissible among people (such as diabetes or heart disease).

Nutrition-sensitive approaches: approaches/ interventions that address the underlying causes of malnutrition (e.g. a programme that aims to reduce malnutrition through the provision of clean water).

Nutrition-specific approaches: approaches/ interventions that address the immediate determinants of malnutrition (e.g. vitamin A supplementation or community-based management of acute malnutrition).

Oedematous malnutrition: a form of acute malnutrition defined by the presence of bilateral pitting oedema (excessive fluids under the skin and in certain tissues, at a minimum on the dorsum of both feet).

Prebiotics: a form of dietary fibre that humans cannot digest, that promote the growth of beneficial bacteria in the human gut.

Prevalence: proportion of a population with a specific characteristic or condition at a given point in time.

Probiotics: live bacteria found in certain foods or supplements that have numerous health benefits.

Stunting: chronic malnutrition, also known as stunting, is a sign of ‘shortness’ and develops over a long period of time. In children and adults, it is measured through the height-for-age nutritional index.

WASH: an acronym that stands for “water, sanitation and hygiene”. WASH programmes promote universal, affordable and sustainable access to WASH.

Wasting: a sign of ‘thinness’ that develops as a result of recent rapid weight loss or a failure to gain weight. In children, it is commonly measured through the weight for height nutritional index or mid-upper arm circumference (MUAC). In adults, it is measured by body mass index (BMI) or MUAC.

Weight-for-age: a measure of children based on their weight and age compared to an international standard.

Weight-for-height: a measure of acute malnutrition or wasting of children over two years of age based on their weight and height compared to an international standard.

Weight-for-length: a measure of acute malnutrition or wasting of children under two years of age based on their weight and length compared to an international standard.