A Randomized Controlled Study to Test Front-of-Pack (FOP) Nutrition Labels in the Kingdom of Saudi Arabia.

One common strategy for governments to tackle the non-communicable disease (NCD) epidemic is front-of-package (FOP) nutrition labeling. The Kingdom of Saudi Arabia (KSA) is considering implementing a new FOP label that is based on either France's Nutri-Score (NS), which labels all foods (A = healthiest to E = least healthy) based on overall nutritional quality, or the Chilean warning label (WL) approach, which identifies foods to avoid based on select nutritional characteristics. Using a fully functional online grocery store, this study aimed to test these two promising FOP strategies by randomizing 656 KSA adults into one of the three versions of the store to complete a hypothetical grocery shop: no-label (control), NS, and WL. The NS was modified with a sugar percentage tag given that reducing sugar consumption is one of KSA's public health goals. We found that both modified NS labels and Chilean warning labels positively influenced food and beverage choices among KSA participants, but there were differential effects across the two labels. Relative to the control, NS improved the overall diet quality of the shopping baskets, measured by the weighted (by the number of servings) average NS point (ranging from 0, least healthy, to 55, healthiest), by 2.5 points [95% CI: 1.7, 3.4; p < 0.001], whereas results for WL were not statistically significant (0.6 points [95% CI: -0.2,1.5]). With respect to each nutritional attribute, we found that NS reduced sugar intake per serving, whereas WL was effective at decreasing energy and saturated fat intake per serving from food and beverages purchased. Our results suggest that the NS approach that identifies the healthiness of all foods using a holistic approach appears preferable if the purpose of the label is to improve overall diet quality as opposed to addressing select nutrients to avoid.

Innovative financing for nutrition.

Given the constraints of both overseas development aid and domestic financing for nutrition, innovative financing is critical-yet nutrition lags behind other sectors in catalysing it. Here, we argue that the framing for nutrition must evolve and critical actions must be taken to generate more money for nutrition and more nutrition for money. Food systems hold some of the most powerful opportunities to improve human and planetary health while increasing productivity-and the private sector has a key role to play in this.

Economic costs of childhood stunting to the private sector in low- and middle-income countries.

Background: Stunting during childhood has long-term consequences on human capital, including decreased physical growth, and lower educational attainment, cognition, workforce productivity and wages. Previous research has quantified the costs of stunting to national economies however beyond a few single-country datasets there has been a limited number of which have used diverse datasets and have had a dedicated focus on the private sector, which employs nearly 90% of the workforce in many low- and middle-income countries (LMICs). We aimed to examine (i) the impact of childhood stunting on income loss of private sector workforce in LMICs; (ii) to quantify losses in sales to private firms in LMICs due to childhood stunting; and (iii) to estimate potential gains (benefit-cost ratios) if stunting levels are reduced in select high prevalence countries. Methods: This multiple-methods study engaged multi-disciplinary technical advisers, executed several literature reviews, used innovative statistical methods, and implemented health and labor economic models. We analyzed data from seven longitudinal datasets (up to 30+ years of follow-up; 1982-2016; Peru, Ethiopia, India, Vietnam, Philippines, Tanzania, Brazil), 108 private firm datasets (spanning 2008-2020), and many global datasets including Joint Malnutrition Estimates, and World Development Indicators to produce estimates for 120+ LMICs (with estimates up to 2021). We studied the impact of childhood stunting on adult cognition, education, and height as pathways to wages/productivity in adulthood. We employed cloud-based artificial intelligence (AI) platforms, and conducted comparative analyses using three analytic approaches: traditional frequentist statistics, Bayesian inferential statistics and machine learning. We employed labour and health economic models to estimate wage losses to the private sector worker and firm revenue losses due to stunting. We also estimated benefit-cost ratios for countries investing in nutrition-specific interventions to prevent stunting. Findings: Across 95 LMICs, childhood stunting costs the private sector at least US$135.4 billion in sales annually. Firms from countries in Latin America and the Caribbean and East Asia and Pacific regions had the greatest losses. Totals sales losses to the private sector accumulated to 0.01% to 1.2% of national GDP across countries. Sectors most affected by childhood stunting were manufacturing (non-metallic mineral, fabricated metal, other), garments and food sectors. Sale losses were highest for larger sized private firms. Across regions (representing 123 LMICs), US$700 million (Middle East and North Africa) to US$16.5 billion (East Asia and Pacific) monthly income was lost among private sector workers. Investing in stunting reduction interventions yields gains from US$2 to US$81 per $1 invested annually (or 100% to 8000% across countries). Across sectors, the highest returns were in elementary occupations (US$46) and the lowest were among agricultural workers (US$8). By gender, women incurred a higher income penalty from childhood stunting and earned less than men; due to their relatively higher earnings, the returns for investing in stunting reduction were consistently higher for men across most countries studied. Interpretation: Childhood stunting costs the private sector in LMICs billions of dollars in sales and earnings for the workforce annually. Returns to nutrition interventions show that there is an economic case to be made for investing in childhood nutrition, alongside a moral one for both the public and private sector. This research could be used to motivate strong public-private sector partnerships to invest in childhood undernutrition for benefits in the short and long-term.

The COVID-19 crisis will exacerbate maternal and child undernutrition and child mortality in low- and middle-income countries.

The economic crisis and food and health system disruptions related to the COVID-19 pandemic threaten to exacerbate undernutrition in low- and middle-income countries (LMICs). We developed pessimistic, moderate and optimistic scenarios for 2020-2022 and used three modelling tools (MIRAGRODEP, the Lives Saved Tool and Optima Nutrition) to estimate the impacts of pandemic-induced disruptions on child stunting, wasting and mortality, maternal anaemia and children born to women with a low body mass index (BMI) in 118 LMICs. We estimated the cost of six nutrition interventions to mitigate excess stunting and child mortality due to the pandemic and to maximize alive and non-stunted children, and used the human capital approach to estimate future productivity losses. By 2022, COVID-19-related disruptions could result in an additional 9.3 million wasted children and 2.6 million stunted children, 168,000 additional child deaths, 2.1 million maternal anaemia cases, 2.1 million children born to women with a low BMI and US$29.7 billion in future productivity losses due to excess stunting and child mortality. An additional US$1.2 billion per year will be needed to mitigate these effects by scaling up nutrition interventions. Governments and donors must maintain nutrition as a priority, continue to support resilient systems and ensure the efficient use of new and existing resources.

Ending malnutrition in all its forms requires scaling up proven nutrition interventions and much more: a 129-country analysis.

BACKGROUND: Sustainable Development Goal (SDG) 2.2 calls for an end to all forms of malnutrition, with 2025 targets of a 40% reduction in stunting (relative to 2012), for wasting to occur in less than 5% of children, and for a 50% reduction in anaemia in women (15-49 years). We assessed the likelihood of countries reaching these targets by scaling up proven interventions and identified priority interventions, based on cost-effectiveness. METHODS: For 129 countries, the Optima Nutrition model was used to compare 2019-2030 nutrition outcomes between a status quo (maintained intervention coverage) scenario and a scenario where outcome-specific interventions were scaled up to 95% coverage over 5 years. The average cost-effectiveness of each intervention was calculated as it was added to an expanding package of interventions. RESULTS: Of the 129 countries modelled, 46 (36%), 66 (51%) and 0 (0%) were on track to achieve the stunting, wasting and anaemia targets respectively. Scaling up 18 nutrition interventions increased the number of countries reaching the SDG 2.2 targets to 50 (39%), 83 (64%) and 7 (5%) respectively. Intermittent preventative treatment of malaria during pregnancy (IPTp), infant and young child feeding education, vitamin A supplementation and lipid-based nutrition supplements for children produced 88% of the total impact on stunting, with average costs per case averted of US$103, US$267, US$556 and US$1795 when interventions were consecutively scaled up, respectively. Vitamin A supplementation and cash transfers produced 100% of the total global impact on prevention of wasting, with average costs per case averted of US$1989 and US$19,427, respectively. IPTp, iron and folic acid supplementation for non-pregnant women, and multiple micronutrient supplementation for pregnant women produced 85% of the total impact on anaemia prevalence, with average costs per case averted of US$9, US$35 and US$47, respectively. CONCLUSIONS: Prioritising nutrition investment to the most cost-effective interventions within the country context can maximise the impact of funding. A greater focus on complementing nutrition-specific interventions with nutrition-sensitive ones that address the social determinants of health is critical to reach the SDG targets.

Individuals with obesity and COVID-19: A global perspective on the epidemiology and biological relationships.

The linkage of individuals with obesity and COVID-19 is controversial and lacks systematic reviews. After a systematic search of the Chinese and English language literature on COVID-19, 75 studies were used to conduct a series of meta-analyses on the relationship of individuals with obesity-COVID-19 over the full spectrum from risk to mortality. A systematic review of the mechanistic pathways for COVID-19 and individuals with obesity is presented. Pooled analysis show individuals with obesity were more at risk for COVID-19 positive, >46.0% higher (OR = 1.46; 95% CI, 1.30-1.65; p < 0.0001); for hospitalization, 113% higher (OR = 2.13; 95% CI, 1.74-2.60; p < 0.0001); for ICU admission, 74% higher (OR = 1.74; 95% CI, 1.46-2.08); and for mortality, 48% increase in deaths (OR = 1.48; 95% CI, 1.22-1.80; p < 0.001). Mechanistic pathways for individuals with obesity are presented in depth for factors linked with COVID-19 risk, severity and their potential for diminished therapeutic and prophylactic treatments among these individuals. Individuals with obesity are linked with large significant increases in morbidity and mortality from COVID-19. There are many mechanisms that jointly explain this impact. A major concern is that vaccines will be less effective for the individuals with obesity.

How countries can reduce child stunting at scale: lessons from exemplar countries.

BACKGROUND: Child stunting and linear growth faltering have declined over the past few decades and several countries have made exemplary progress. OBJECTIVES: To synthesize findings from mixed methods studies of exemplar countries to provide guidance on how to accelerate reduction in child stunting. METHODS: We did a qualitative and quantitative synthesis of findings from existing literature and 5 exemplar country studies (Nepal, Ethiopia, Peru, Kyrgyz Republic, Senegal). Methodology included 4 broad research activities: 1) a series of descriptive analyses of cross-sectional data from demographic and health surveys and multiple indicator cluster surveys; 2) multivariable analysis of quantitative drivers of change in linear growth; 3) interviews and focus groups with national experts and community stakeholders and mothers; and 4) a review of policy and program evolution related to nutrition. RESULTS: Several countries have dramatically reduced child stunting prevalence, with or without closing geographical, economic, and other population inequalities. Countries made progress through interventions from within and outside the health sector, and despite significant heterogeneity and differences in context, contributions were comparable from health and nutrition sectors (40% of change) and other sectors (50%), previously called nutrition-specific and -sensitive strategies. Improvements in maternal education, maternal nutrition, maternal and newborn care, and reductions in fertility/reduced interpregnancy intervals were strong contributors to change. A roadmap to reducing child stunting at scale includes several steps related to diagnostics, stakeholder consultations, and implementing direct and indirect nutrition interventions related to the health sector and nonhealth sector . CONCLUSIONS: Our results show that child stunting reduction is possible even in diverse and challenging contexts. We propose that our framework of organizing nutrition interventions as direct/indirect and inside/outside the health sector should be considered when mapping causal pathways of child stunting and planning interventions and strategies to accelerate stunting reduction to achieve the 2030 Sustainable Development Goals.

The Case for Investing in Young Children: Contributions of the INCAP Longitudinal Study.

This article highlights the important contributions that the Institute of Nutrition of Central America and Panama longitudinal study has made to global development efforts. The studies have made a unique contribution to our understanding of the role of early life nutrition on many outcomes of interest to the global nutrition community and have strengthened narratives such as human capital.

Promoting Child Growth and Development in the Sustainable Development Goals Era: Is It Time for New Thinking?

Growth monitoring and promotion (GMP) programs have been implemented worldwide for decades. Consistent evidence of their effectiveness is lacking and complicated by design and operational differences. Nevertheless, tracking child growth and development is a fundamental component of routine preventive child health care, and governments in 178 countries implement some form of GMP. This article makes the point that despite implementation challenges, there is a compelling need for GMP. It enables a crucial dialogue with families and communities about how to support the healthy growth and development of their children and can be a powerful tool for stimulating action and accountability for child nutrition and development at household, community, subnational, and national levels. We propose that GMP deserves a fresh rethink, with a paradigm shift that tailors GMP programs and activities for different development, geographic, and cultural contexts and considers how to optimize implementation for scalability.

Correction to: Optima nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

It has been highlighted that the original manuscript [1] contains a typesetting error in the name of Meera Shekar. This had been incorrectly captured as Meera Shekhar in the original article which has since been updated.

Optima Nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions.

BACKGROUND: Child stunting due to chronic malnutrition is a major problem in low- and middle-income countries due, in part, to inadequate nutrition-related practices and insufficient access to services. Limited budgets for nutritional interventions mean that available resources must be targeted in the most cost-effective manner to have the greatest impact. Quantitative tools can help guide budget allocation decisions. METHODS: The Optima approach is an established framework to conduct resource allocation optimization analyses. We applied this approach to develop a new tool, 'Optima Nutrition', for conducting allocative efficiency analyses that address childhood stunting. At the core of the Optima approach is an epidemiological model for assessing the burden of disease; we use an adapted version of the Lives Saved Tool (LiST). Six nutritional interventions have been included in the first release of the tool: antenatal micronutrient supplementation, balanced energy-protein supplementation, exclusive breastfeeding promotion, promotion of improved infant and young child feeding (IYCF) practices, public provision of complementary foods, and vitamin A supplementation. To demonstrate the use of this tool, we applied it to evaluate the optimal allocation of resources in 7 districts in Bangladesh, using both publicly available data (such as through DHS) and data from a complementary costing study. RESULTS: Optima Nutrition can be used to estimate how to target resources to improve nutrition outcomes. Specifically, for the Bangladesh example, despite only limited nutrition-related funding available (an estimated $0.75 per person in need per year), even without any extra resources, better targeting of investments in nutrition programming could increase the cumulative number of children living without stunting by 1.3 million (an extra 5%) by 2030 compared to the current resource allocation. To minimize stunting, priority interventions should include promotion of improved IYCF practices as well as vitamin A supplementation. Once these programs are adequately funded, the public provision of complementary foods should be funded as the next priority. Programmatic efforts should give greatest emphasis to the regions of Dhaka and Chittagong, which have the greatest number of stunted children. CONCLUSIONS: A resource optimization tool can provide important guidance for targeting nutrition investments to achieve greater impact.

Reaching the global target to reduce stunting: an investment framework.

Childhood stunting, being short for one's age, has life-long consequences for health, human capital and economic growth. Being stunted in early childhood is associated with slower cognitive development, reduced schooling attainment and adult incomes decreased by 5-53%. The World Health Assembly has endorsed global nutrition targets including one to reduce the number of stunted children under five by 40% by 2025. The target has been included in the Sustainable Development Goals (SDG target 2.2). This paper estimates the cost of achieving this target and develops scenarios for generating the necessary financing. We focus on a key intervention package for stunting (KIPS) with strong evidence of effectiveness. Annual scale-up costs for the period of 2016-25 were estimated for a sample of 37 high burden countries and extrapolated to all low and middle income countries. The Lives Saved Tool was used to model the impact of the scale-up on stunting prevalence. We analysed data on KIPS budget allocations and expenditure by governments, donors and households to derive a global baseline financing estimate. We modelled two financing scenarios, a 'business as usual', which extends the current trends in domestic and international financing for nutrition through 2025, and another that proposes increases in financing from all sources under a set of burden-sharing rules. The 10-year financial need to scale up KIPS is US$49.5 billion. Under 'business as usual', this financial need is not met and the global stunting target is not reached. To reach the target, current financing will have to increase from US$2.6 billion to US$7.4 billion a year on average. Reaching the stunting target is feasible but will require large coordinated investments in KIPS and a supportive enabling environment. The example of HIV scale-up over 2001-11 is instructive in identifying the factors that could drive such a global response to childhood stunting.

Reaching the Global Target to Increase Exclusive Breastfeeding: How Much Will It Cost and How Can We Pay for It?

There is an urgent need for global action to increase the rates of exclusive breastfeeding. In 2012, the World Health Assembly (WHA) set a global target to increase the rate of exclusive breastfeeding in the first 6 months up to at least 50% by 2025. However, current investment levels are insufficient to drive the kind of progress that is needed to meet the target. Reaching the global nutrition target of increasing exclusive breastfeeding to 50% will require an average annual investment of $570 million over 10 years in addition to what is currently being spent. This investment is projected to result in an additional 105 million children being exclusively breastfed and at least 520,000 child deaths prevented over the next 10 years. This analysis was part of an investment framework developed by the World Bank, Results for Development Institute, and 1,000 Days to provide policy makers with a roadmap for how to reach four of the six WHA global nutrition targets: decreasing childhood stunting, decreasing childhood wasting, decreasing rates of anemia in women of reproductive age, and increasing exclusive breastfeeding in the first 6 months.