Child Undernutrition in Sudan: The Social and Economic Impact and Future Perspectives.

The nutrition situation in Sudan is one of the worst in northeast Africa and it is characterized by persistently high levels of acute and chronic malnutrition that have increased over the last two decades. The underlying causes of malnutrition are multi-sectoral and are mainly due to inequalities, inadequate food practices, and limited access to healthcare services. Based on the report The Economic and Social Impacts of Child Undernutrition in Sudan, this study assesses the impact that malnutrition has on health, education, and productivity in Sudan. The country is estimated to have lost an equivalent of about 11.6 billion Sudanese pound (1 United States dollar = 55.3 Sudanese pound) in 2014, which represented 2.6% of the gross domestic product (GDP). Productivity-related losses contributed the largest costs at 1.5% of GDP followed by health and education sectors at 1.1% and 0.1%, respectively. In 2020, the outbreak of the COVID-19 pandemic further exposed the fragility of Sudan's health, social, and economic system. It is mandatory that all stakeholders address child nutrition as a main concern and stunting is incorporated in the center of the development agenda. In particular, the national development frameworks should be updated to ensure the reduction of the stunting prevalence and to put in place a comprehensive multi-sectoral nutrition policy, strategy, and plan of action.

Drivers of stunting reduction in Nepal: a country case study.

BACKGROUND: Chronic child malnutrition represents a serious global health concern. Over the last several decades, Nepal has seen a significant decline in linear growth stunting - a physical manifestation of chronic malnutrition - despite only modest economic growth and significant political instability. OBJECTIVE: This study aimed to conduct an in-depth assessment of the determinants of stunting reduction in Nepal from 1996 to 2016, with specific attention paid to national-, community-, household-, and individual-level factors, as well as relevant nutrition-specific and -sensitive initiatives rolled out within the country. METHODS: Using a mixed-methods approach, 4 types of inquiry were employed: 1) a systematic review of published peer-reviewed and gray literature; 2) retrospective quantitative data analyses using Demographic and Health Surveys from 1996 to 2016; 3) a review of key nutrition-specific and -sensitive policies and programs; and 4) retrospective qualitative data collection and analyses. RESULTS: Mean height-for-age z-scores (HAZ) improved by 0.94 SDs from 1996 to 2016. Subnational variation and socioeconomic inequalities in stunting outcomes persisted, with the latter widening over time. Decomposition analysis for children aged under 5 y explained 90.9% of the predicted change in HAZ, with key factors including parental education (24.7%), maternal nutrition (19.3%), reduced open defecation (12.3%), maternal and newborn health care (11.5%), and economic improvement (9.0%). Key initiatives focused on decentralizing the health system and mobilizing community health workers to increase accessibility; long-standing nationwide provision of basic health interventions; targeted efforts to improve maternal and child health; and the prioritization of nutrition-sensitive initiatives by both government and donors. National and community stakeholders and mothers at village level highlighted a mixture of poverty reduction, access to health services, improved education, and increased access to water, sanitation, and hygiene as drivers of stunting reduction. CONCLUSIONS: Improvements in both nutrition-specific and nutrition-sensitive sectors have been critical to Nepal's stunting decline, particularly in the areas of poverty reduction, health, education, and sanitation.

Cash and voucher assistance and children's nutrition status in Somalia.

To address ongoing food insecurity and acute malnutrition in Somalia, a broad range of assistance modalities are used, including in-kind food, food vouchers, and cash transfers. Evidence of the impact of cash and voucher assistance (CVA) on prevention of acute malnutrition is limited in humanitarian and development settings. This study examined the impact of CVA on prevention of child acute malnutrition in 2017/2018 in the context of the Somalia food crisis. Changes in diet and acute malnutrition were measured over a 4-month period among children age 6-59 months from households receiving household transfers of approximately US$450 delivered either as food vouchers or a mix of in-kind food, vouchers, and cash. Baseline to endline change in children's dietary diversity, meal frequency, minimum acceptable diet (MAD), mid-upper arm circumference (MUAC), and acute malnutrition (MUAC < 12.5 cm) were compared using difference-in-difference analysis with inverse probability weighting. There were no statistically significant changes in dietary diversity, meal frequency, or the proportion of children with MAD for either intervention group. Adjusted change in mean MUAC showed increases of 0.5 cm (confidence interval [CI; 0.0, 0.7 cm]) in the food voucher group and 0.1 cm (CI [-0.1, 0.4]) in the mixed transfer group. In adjusted analysis, prevalence of acute malnutrition among children under 5 years increased by 0.7% (CI [-13.4, 14.4%]) among food voucher recipients and decreased by 4.8% (CI [-9.9, 8.1%]) in mixed transfer recipients. The change over time in both mean MUAC and acute malnutrition prevalence was similar for both interventions, suggesting that cash and vouchers had similar effects on child nutrition status.

Stunting: an overlooked problem in Myanmar - an economic evaluation.

OBJECTIVES: Stunting increases a child's susceptibility to diseases, increases mortality, and is associated over long term with reduced cognitive abilities, educational achievement, and productivity. We aimed to assess the most effective public health nutritional intervention to reduce stunting in Myanmar. METHODS: We searched the literature and developed a conceptual framework for interventions known to reduce stunting. We focused on the highest impact and most feasible interventions to reduce stunting in Myanmar, described policies to implement them, and compared their costs and projected effect on stunting using data-based decision trees. We estimated costs from the government perspective and calculated total projected cases of stunting prevented and cost per case prevented (cost-effectiveness). All interventions were compared to projected cases of stunting resulting from the current situation (e.g., no additional interventions). RESULTS: Three new policy options were identified. Operational feasibility for all three options ranged from medium to high. Compared to the current situation, two were similarly cost-effective, at an additional USD 598 and USD 667 per case of stunting averted. The third option was much less cost-effective, at an additional USD 27,741 per case averted. However, if donor agencies were to expand their support in option three to the entire country, the prevalence of 22.5 percent would be reached by 2025 at an additional USD 667 per case averted. CONCLUSIONS: A policy option involving immediate expansion of the current implementation of proven nutrition-specific interventions is feasible. It would have the highest impact on stunting and would approach the WHO 2025 target.

Effects in spite of tough constraints - A theory of change based investigation of contextual and implementation factors affecting the results of a performance based financing scheme extended to malnutrition in Burundi.

BACKGROUND: From January 2015 to December 2016, the health authorities in Burundi piloted the inclusion of child nutrition services into the pre-existing performance-based financing free health care policy (PBF-FHC). An impact evaluation, focused on health centres, found positive effects both in terms of volume of services and quality of care. To some extent, this result is puzzling given the harshness of the contextual constraints related to the fragile setting. METHODS: With a multi-methods approach, we explored how contextual and implementation constraints interacted with the pre-identified tracks of effect transmission embodied in the intervention. For our analysis, we used a hypothetical Theory of Change (ToC) that mapped a set of seven tracks through which the intervention might develop positive effects for children suffering from malnutrition. We built our analysis on (1) findings from the facility surveys and (2) extra qualitative data (logbooks, interviews and operational document reviews). FINDINGS: Our results suggest that six constraints have weighted upon the intervention: (1) initial low skills of health workers; (2) unavailability of resources (including nutritional dietary inputs and equipment); (3) payment delays; (4) suboptimal information; (5) restrictions on autonomy; and (6) low intensity of supervision. Together, they have affected the intensity of the intervention, especially during its first year. From our analysis of the ToC, we noted that the positive effects largely occurred as a result of the incentive and information tracks. Qualitative data suggests that health centres have circumvented the many constraints by relying on a community-based recruitment strategy and a better management of inputs at the level of the facility and the patient himself. CONCLUSION: Frontline actors have agency: when incentives are right, they take the initiative and find solutions. However, they cannot perform miracles: Burundi needs a holistic societal strategy to resolve the structural problem of child malnutrition. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered).

Rojiroti microfinance and child nutrition: a cluster randomised trial.

OBJECTIVE: To determine whether Rojiroti microfinance, for poor Indian women, improves child nutrition. DESIGN: Cluster randomised trial. SETTING: Tolas (village communities) in Bihar State. PARTICIPANTS: Women and children under 5 years. INTERVENTIONS: With Rojiroti microfinance, women form self-help groups and save their money to provide loans to group members. After 6 months, they receive larger external loans. Tolas were randomised to receive Rojiroti immediately or after 18 months. OUTCOME MEASURES: The primary analysis compared the mean weight for height Z score (WHZ) of children under 5 years in the intervention versus control tolas who attended for weight and height measurement 18 months after randomisation. Secondary outcomes were weight for age Z score (WAZ), height for age Z score, mid-upper arm circumference (MUAC), wasting, underweight and stunting. RESULTS: We randomised 28 tolas to each arm and collected data from 2469 children (1560 mothers) at baseline and 2064 children (1326 mothers) at follow-up. WHZ was calculated for 1718 children at baseline and 1377 (674 intervention and 703 control) at follow-up. At 18 months, mean WHZ was significantly higher for intervention (-1.02) versus controls (-1.37; regression coefficient adjusted for clustering ß=0.38, 95% CI 0.16 to 0.61, p=0.001). Significantly fewer children were wasted in the intervention group (122, 18%) versus control (200, 29%; OR=0.46, 95% CI 0.28 to 0.74, p=0.002). Mean WAZ was better in the intervention group (-2.13 vs -2.37; ß=0.27, 95% CI 0.11 to 0.43, p=0.001) as was MUAC (13.6 cm vs 13.4 cm; ß=0.22, 95% CI 0.03 to 0.40, p=0.02). In an analysis adjusting for baseline nutritional measures (259 intervention children and 300 control), only WAZ and % underweight showed significant differences in favour of the intervention. CONCLUSION: In marginalised communities in rural India, child nutrition was better in those who received Rojiroti microfinance, compared with controls. TRIAL REGISTRATION NUMBER: NCT01845545.

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys.

BACKGROUND: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025. METHODS: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. RESULTS: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. CONCLUSIONS: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition.

Double burden of maternal and child malnutrition and socioeconomic status in urban Sri Lanka.

Child malnutrition and maternal obesity are serious public health issues in Sri Lanka. This study explores the associations between socioeconomic status and the double burden of malnutrition among school-aged children and within their household. A total of 543 primary school children aged 5-10 years (204 boys and 339 girls) in Gampaha District, Sri Lanka, were included in the analysis. The nutritional statuses of thinness, normal, overweight, and obesity for children and mothers were defined according to WHO growth references and body mass index. Maternal education, household equivalent income, and maternal employment were used as socioeconomic status indicators. The proportion of child thinness and overweight was 19.3% and 13.4%, respectively, and that of maternal overweight (body mass index ≥ 25 kg/m2) was 36.5%. A positive correlation was found between maternal body mass index and the child's body mass index for age z-score in older boys and younger girls. A multivariate stepwise logistic regression analysis showed that lower education of mothers posed a higher association with child thinness (adjusted odds ratio = 2.33, 95% confidence interval: 1.08-5.00). Mothers with overweight and obesity were less likely to have a child with thinness (adjusted odds ratio = 0.30, 95% confidence interval: 0.16-0.58). Maternal employment status and household equivalent income were not significantly, but marginally, associated with child overweight and obesity. Socioeconomic inequality combined with maternal nutritional status affected child malnutrition. These findings suggest that the underlying circumstances within households should be considered to improve child malnutrition.

Integrated and simplified approaches to community management of acute malnutrition in rural Kenya: a cluster randomized trial protocol.

BACKGROUND: In many low income countries, the majority of acutely malnourished children are either brought to the health facility late or never at all due to reasons related to distance and associated costs. Integrated community case management (iCCM) is an integrated approach addressing disease and malnutrition through use of community health volunteers (CHVs) in children under-5 years. Evidence on the potential impact and practical experiences on integrating community-based management of acute malnutrition as part of an iCCM package is not well documented. In this study, we aim to investigate the effectiveness and cost effectiveness of integrating management of acute malnutrition into iCCM. METHODS: This is a two arm parallel groups, non-inferiority cluster randomized community trial (CRT) employing mixed methods approach (both qualitative and quantitative approaches). Baseline and end line data will be collected from eligible (malnourished) mother/caregiver-child dyads. Ten community units (CUs) with a cluster size of 24 study subjects will be randomized to either an intervention (5 CUs) and a control arm (5 CUs). CHV in the control arm, will only screening and refer MAM/SAM cases to the nearby health facility for treatment by healthcare professionals. In the intervention arm, however; CHVs will be trained both to screen/diagnose and also treat moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) without complication. A paired-matching design where each control group will be matched with intervention group with similar characteristics will be matched to ensure balance between the two groups with respect to baseline characteristics. Qualitative data will be collected using key informant and in-depth interviews (KIIs) and focused group discussions (FGDs) to capture the views and experiences of stakeholders. DISCUSSION: Our proposed intervention is based on an innovative approach of integrating and simplifying SAM and MAM management through CHWs bring the services closer to the community. The trial has received ethical approval from the Ethics Committee of AMREF Health Africa - Ethical and Scientific Review Committee (AMREF- ESRC), Nairobi, Kenya. The results will be disseminated through workshops, policy briefs, peer-reviewed publications, and presented to local and international conferences. TRIAL REGISTRATION: PACTR201811870943127 ; Pre-results. 26 November 2018.

Strong effect of Ecuador's conditional cash transfer program on childhood mortality from poverty-related diseases: a nationwide analysis.

BACKGROUND: The mortality rate in children under 5 years old (U5MR) has decreased considerably in Ecuador in the last decade; however, thousands of children continue to die from causes related to poverty. A social program known as Bono de Desarrollo Humano (BDH) was created to guarantee a minimum level of consumption for families and to reduce chronic malnutrition and preventable childhood diseases. We sought to evaluate the effect of the BDH program on mortality of children younger than 5 years, particularly from malnutrition, diarrheal diseases, and lower respiratory tract infections. METHODS: Mortality rates and BDH coverage from 2009 to 2014 were evaluated from the 144 (of 222) Ecuadorian counties with intermediate and high quality of vital information. A multivariable regression analyses for panel data was conducted by using a negative binomial regression model with fixed effects, adjusted for all relevant demographic and socioeconomic covariates. RESULTS: Our research shows that for each 1% increase in BDH county coverage there would be a decrease in U5MR from malnutrition of 3% (RR 0.971, 95% CI 0.953-0.989). An effect of BDH county coverage on mortality resulting from respiratory infections was also observed (RR 0.992, 95% CI 0.984-0.999). The BDH also reduced hospitalization rates in children younger than 5 years, overall and for diarrhea. CONCLUSIONS: A conditional cash transfer program such as BDH could contribute to the reduction of mortality due to causes related to poverty, such as malnutrition and respiratory infections. The coverage should be maintained -or increased in a period of economic crisis- and its implementation strengthened.

Cash transfer programmes in lower-income and middle-income countries: understanding pathways to nutritional change-a realist review protocol.

INTRODUCTION: Child malnutrition continues to be a significant global public health concern. Nutrition-related interventions have changed and diversified over the last two decades, with increasing emphasis on nutrition-sensitive programmes that address underlying determinants of child malnutrition. Cash transfer programmes (CTPs) are used with increasing popularity in lower-income and middle-income countries to improve both food/nutrition insecurity and resilience. Available studies, however, provide mixed findings on the outcomes of CTPs for child nutritional status. This review is the first stage of a research project to develop evidence-informed theories of how CTPs affect child malnutrition. These will be empirically tested in the field and contribute to a better understanding of how, why, for whom and in what circumstances CTPs can be implemented to optimise impacts on child nutritional status. METHODS AND ANALYSIS: This realist review is informed by available standards for realist reviews and follows a five-step process. In step 1, an initial scoping of literature identified potential contextual factors and underlying mechanisms that influence nutritional outcomes, and potential theories developed to address our research question. In step 2, a systematic literature search using multiple databases will be undertaken with papers screened using defined inclusion/exclusion criteria. In step 3, included studies will be appraised, data extracted into a bespoke data extraction tool and used to test and further refine our explanatory framework. The fourth step will synthesise, using a mix of inductive and deductive analytical processes to identify patterns, link chains of inference and tracking and linking of articles. The final step involves dissemination of a preliminary theory for feedback prior to empirically testing it in Kenya and Ethiopia where large-scale CTPs are being implemented. ETHICS AND DISSEMINATION: This review will not involve primary data collection. Findings will be presented in accordance with Realist and Meta-Narrative Evidence Synthesis: Evolving Standards guidelines and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: CRD42018110735.

Day clinic vs. hospital care of pneumonia and severe malnutrition in children under five: a randomised trial.

OBJECTIVES: To evaluate the clinical outcomes and costs of managing pneumonia and severe malnutrition in a day clinic (DC) management model (outpatient) vs. hospital care (inpatient). METHODS: Randomised clinical trial where children aged 2 months to 5 years with pneumonia and severe malnutrition were randomly allocated to DC or inpatient hospital care. We used block randomisation of variable length from 8 to 20 and produced computer-generated random numbers that were assigned to one of the two interventions. Successful management was defined as resolution of clinical signs of pneumonia and being discharged from the model of care (DC or hospital) without need for referral to a hospital (DC), or referral to another hospital. All the children in both DC and hospital received intramuscular ceftriaxone, daily nutrition support and micronutrients. RESULTS: Four hundred and seventy children were randomly assigned to either DC or hospital care. Successful management was achieved for 184 of 235 (78.3%) by DC alone, vs. 201 of 235 (85.5%) by hospital inpatient care [RR (95% CI) = 0.79 (0.65-0.97), P = 0.02]. During 6 months of follow-up, 30/235 (12.8%) in the DC group and 36/235 (15.3%) required readmission to hospital in the hospital care group [RR (95% CI) = 0.89 (0.67-1.18), P = 0.21]. The average overall healthcare and societal cost was 34% lower in DC (US$ 188 ± 11.7) than in hospital (US$ 285 ± 13.6) (P < 0.001), and costs for households were 33% lower. CONCLUSIONS: There was a 7% greater probability of successful management of pneumonia and severe malnutrition when inpatient hospital care rather than the outpatient day clinic care was the initial method of care. However, where timely referral mechanisms were in place, 94% of children with pneumonia and severe malnutrition were successfully managed initially in a day clinic, and costs were substantially lower than with hospital admission.

OBJECTIFS: Evaluer les résultats cliniques et les coûts de la prise en charge de la pneumonie et de la malnutrition sévère dans un modèle de prise en charge en clinique de jour (CJ) (patients ambulatoires) par rapport à des soins hospitaliers (patients hospitalisés). MÉTHODES: Essai clinique randomisé où les enfants âgés de 2 mois à 5 ans avec une pneumonie et une malnutrition sévère ont été répartis de façon aléatoire en CJ ou à des soins hospitaliers. Nous avons utilisé la randomisation par blocs de longueur variable de 8 à 20 et avons généré des nombres aléatoires par ordinateur qui ont été attribués à l'une des deux interventions. Une prise en charge réussie a été définie comme la résolution des signes cliniques de pneumonie et la sortie du modèle de soins (CJ ou hospitalisation) sans nécessiter un transfert à un hôpital (CJ), ni à un autre hôpital. Tous les enfants du bras CJ et du bras soins hospitaliers ont reçu de la ceftriaxone par voie intramusculaire, un soutien nutritionnel quotidien et des micronutriments. RÉSULTATS: 470 enfants ont été assignés aléatoirement soit à des soins en CJ ou hospitaliers. Une prise en charge réussie a été obtenue pour 184 patients sur 235 (78,3%) en CJ seule contre 201 sur 235 (85,5%) en soins hospitaliers [RR (IC95%) = 0,79 (0,65 - 0,97), p = 0,02]. Au cours des six mois de suivi, 30/235 (12,8%) du groupe CJ et 36/235 (15,3%) du groupe soins hospitaliers ont nécessité une réadmission à l'hôpital [RR (IC95%) = 0,89 (0,67 - 1,18), p = 0,21]. Le coût moyen global des soins de santé et pour la société était de 34% plus faible dans le groupe CJ (188 ± 11,7 USD) que dans le groupe soins hospitaliers (285 ± 13,6 USD) (p < 0,001) et les coûts pour les ménages étaient de 33% inférieurs. CONCLUSIONS: La probabilité d'une prise en charge réussie de la pneumonie et de la malnutrition sévère était 7% plus élevée lorsque les soins hospitaliers plutôt que les soins en CJ étaient les moyens initiaux. Cependant, là où des mécanismes de référence rapides étaient en place, 94% des enfants atteints de pneumonie et de malnutrition sévère ont été pris en charge avec succès dans une clinique de jour et les coûts étaient nettement inférieurs à ceux de soins hospitaliers.

A Systematic Review of the Evaluation of Interventions to Tackle Children's Food Insecurity.

PURPOSE OF REVIEW: To synthesise the research which has sought to evaluate interventions aiming to tackle children's food insecurity and the contribution of this research to evidencing the effectiveness of such interventions. RECENT FINDINGS: The majority of studies in this review were quantitative, non-randomised studies, including cohort studies. Issues with non-complete outcome data, measurement of duration of participation in interventions, and accounting for confounds are common in these evaluation studies. Despite the limitations of the current evidence base, the papers that were reviewed provide evidence for multiple positive outcomes for children participating in attended and subsidy interventions, inter alia, reductions in food insecurity, poor health and obesity. However, current evaluations may overlook key areas of impact of these interventions on the lives and outcomes of participating children. This review suggests that the current evidence base which evaluates food insecurity interventions for children is both mixed and limited in scope and quality. In particular, the outcomes measured are narrow, and many papers have methodological limitations. With this in mind, a systems-based approach to both implementation and evaluation of food poverty interventions is recommended.

[Effectiveness and cost of management of severe acute malnutrition with complications in Kaya, Burkina Faso]. / Performance et coût de la prise en charge de la malnutrition aiguë sévère avec complications à Kaya, Burkina Faso.

INTRODUCTION: The consequences of severe acute malnutrition are measured in terms of health and survival, but also of cognitive development, its productivity and the overall national economy. Its management requires enormous financial resources. The purpose of this study was to assess the effectiveness of treating severe acute malnutrition versus cost of treatment of severe acute malnutrition in children. METHODS: We conducted a retrospective study of 199 children aged 0-59 months admitted to the Centre for Nutritional Recovery and Education in Kaya, Burkina Faso, from January to December 2014. The cost of treatment, the length of stay in the Centre for Nutritional Recovery and Education, daily weight gain and the speed of recovery were analyzed based on the standards calculation methods. Mann-Whitney test and Kruskall-Wallis test were used to compare the medians (0.05 threshold). RESULTS: As expected, children aged 6-23 months were the most affected (51.8%) and acute respiratory infections were the most associated diseases (57.9%). The median length of stay in the Centre for Nutritional Recovery and Education was 9.0 (7.0-13.0) days, the mean speed of recovery was 100.0 (65.8 - 143.3) g/day and the average daily weight gain was 18.1 (11.6 - 27.7) g/kg/day. The average cost of treatment in a malnourished child is estimated to be 15 715,3 FCFA (25.2 USD). CONCLUSION: The cost of treatment is hardly affordable by the parents of malnourished children; hence the necessity for government and development partners interventions.

Household food unavailability due to financial constraints affects the nutrient intake of children.

BACKGROUND: A household's food unavailability due to financial constraints may act as a barrier to a healthy diet for children. This cross-sectional study aimed to examine the association between food unavailability due to financial constraints and the nutrient intake of children aged 1-15 years using data of a nationwide survey among the Japanese population. METHODS: Datasets from the National Health and Nutrition Survey and the Comprehensive Survey of Living Conditions in Japan, 2014 were used for this study. The dietary intakes of energy and nutrients were estimated using a one-day dietary record. Participants were categorized into four subgroups, according to their households' frequency of food unavailability due to financial constraints. The adjusted means and 95% confidential intervals of the energy and nutrient intakes in each subgroup were calculated using analysis of covariance. The statistical trends across the subgroups were examined using analysis of covariance. RESULTS: Of the 895 children included in the analysis, 202 (22.6%) were classified into subgroups with frequent food unavailability due to financial constraints. Significant decreases in the mean intakes of carbohydrate, calcium, retinol activity equivalents, riboflavin, folate and vitamin C were observed with increases in the frequency of households' food unavailability. In contrast, frequent food unavailability was associated with higher total fat and vitamin B12 intake. CONCLUSION: A substantial proportion of children in Japan experienced food unavailability due to financial constraints, and this affected their nutrient intake. Adopting a population approach may help overcome this problem.

Addressing malnutrition in low- and middle-income countries with double-duty actions.

Multiple forms of malnutrition co-exist (the double burden) in low- and middle-income countries, but most interventions and policies target only one form. Identifying shared drivers of the double burden of malnutrition is a first step towards establishing effective interventions that simultaneously address the double burden of malnutrition (known as double-duty actions). We identified shared drivers for the double burden of malnutrition, to assess which double-duty actions are likely to have the greatest reach in preventing all forms of malnutrition, in the context of the sustainable development goals. We reviewed existing conceptual frameworks of the drivers of undernutrition, obesity and environmental sustainability. Shared drivers affecting all forms of malnutrition and environmental sustainability were captured using a socio-ecological approach. The extent to which drivers were addressed by the five double-duty actions proposed by the WHO was assessed. Overall, eighty-three shared drivers for the double burden of malnutrition were identified. A substantial proportion (75·0%) could be addressed by the five WHO double-duty actions. 'Regulations on marketing' and 'promotion of appropriate early and complementary feeding in infants' addressed the highest proportion of shared drivers (65·1% and 53·0%, respectively). Twenty-four drivers were likely to be sensitive to environmental sustainability, with 'regulations on marketing' and 'school food programmes and policies' likely to have the greatest environmental reach. A quarter of the shared drivers remained unaddressed by the five WHO double-duty actions. Substantially more drivers could be addressed with minor modifications to the WHO double-duty actions and the addition of de novo actions.

Findings from a cluster randomised trial of unconditional cash transfers in Niger.

Unconditional cash transfers (UCTs) are used as a humanitarian intervention to prevent acute malnutrition, despite a lack of evidence about their effectiveness. In Niger, UCT and supplementary feeding are given during the June-September "lean season," although admissions of malnourished children to feeding programmes may rise from March/April. We hypothesised that earlier initiation of the UCT would reduce the prevalence of global acute malnutrition (GAM) in children 6-59 months old in beneficiary households and at population level. We conducted a 2-armed cluster-randomised controlled trial in which the poorest households received either the standard UCT (4 transfers between June and September) or a modified UCT (6 transfers from April); both providing 130,000 FCFA/£144 in total. Eligible individuals (pregnant and lactating women and children 6-<24 months old) in beneficiary households in both arms also received supplementary food between June and September. We collected data in March/April and October/November 2015. The modified UCT plus 4 months supplementary feeding did not reduce the prevalence of GAM compared with the standard UCT plus 4 months supplementary feeding (adjusted odds ratios 1.09 (95% CI [0.77, 1.55], p = 0.630) and 0.93 (95% CI [0.58, 1.49], p = 0.759) among beneficiaries and the population, respectively). More beneficiaries receiving the modified UCT plus supplementary feeding reported adequate food access in April and May (p < 0.001) but there was no difference in endline food security between arms. In both arms and samples, the baseline prevalence of GAM remained elevated at endline (p > 0.05), despite improved food security (p < 0.05), possibly driven by increased fever/malaria in children (p < 0.001). Nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs plus supplementary feeding to prevent malnutrition in this context. Caution is required in applying the findings of this study to periods of severe food insecurity.

The "ComPAS Trial" combined treatment model for acute malnutrition: study protocol for the economic evaluation.

BACKGROUND: Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child's weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM. METHOD: This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant. DISCUSSION: We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies. TRIAL REGISTRATION: ISRCTN 30393230 , date: 16/03/2017.