Tag Archives: Nutrition

Beyond Malnutrition: The Role of Sanitation in Stunted Growth

Below are the 3 latest posts to the WASH Nutrition Library, http://blogs.washplus.org/washnutrition that is maintained by the USAID Community of Practice on WASH and Nutrition. If your organization has recent studies that we can add to the library, please let us know.

  • ​Beyond Malnutrition: The Role of Sanitation in Stunted Growth
  • Reframing Undernutrition: Faecally-Transmitted Infections and the 5 As
  • Understanding the Rapid Reduction of Undernutrition in Nepal, 2001–2011:​

Beyond Malnutrition: The Role of Sanitation in Stunted GrowthEnv Health Perspect, Nov 2014

Author: Charles W. Schmidt

An excerpt from the article: Beyond Nutrition – Nutritionists have tried dozens of approaches to prevent stunting, such as micronutrient supplements for pregnant women and children (especially growth promoters including iron, zinc, calcium, and folate); increased availability of fat-fortified commercial products such Nutributter and Plumpy’nut; a concerted push to encourage breastfeeding during the first six months of life; and efforts to improve the nutritional quality of the complementary foods babies eat while weaning.6

But Jean Humphrey, a professor of human nutrition at the Johns Hopkins Bloomberg School of Public Health, says none of these interventions has been able to eliminate stunting completely. At best, she says, they improve growth by about a third of the typical height deficit in stunted Asian and African children. “This tells us that dietary improvements are important but not sufficient,” she says. “If we really want to eliminate stunting, we need to do more.”

Meanwhile, mounting evidence has shown that poor hygiene and sanitation also constrain linear growth in children. One study found that Bangladeshi children who had access to clean drinking water, improved toilets, and facilities for handwashing with soap, for instance, had a roughly 50% improvement in HAZ scores compared with control children who didn’t.18 Similar results emerged from studies in Sudan19 and Mexico,20 yet it was unclear exactly why poor WASH would contribute to stunting and WASH improvements would help to ameliorate it.

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Reframing Undernutrition: Faecally-Transmitted Infections and the 5 As, October 2014.

Robert Chambers and Gregor von Medeazza, Institute of Development Studies.

The dominant nutrition discourse concerns access to adequate food and its quality. It now includes food security, food rights and justice, governance and agriculture. Despite many initiatives to assure food access, and growing economies, high levels of undernutrition persist in much of Asia. It is increasingly suggested that much of this ‘Asian enigma’ can now be explained by open defecation (OD) combined with population density. However, the insight that ‘shit stunts’ remains a widespread blind spot. The persistence of this blind spot can in part be explained by factors which are institutional, psychological and professional.

Reductionist focus on the diarrhoeas, which are serious, dramatic, visible and measurable, has led to the relative neglect of many other often subclinical and continuously debilitating faecally-transmitted infections (FTIs) including environmental enteropathy (EE), other intestinal infections, and parasites. These are harder to measure but together affect nutrition much more: the diarrhoeas are only the tip of the much larger sub-clinical iceberg. How OD and FTIs, poverty and undernutrition reinforce each other is illustrated in this paper by looking at the case of India, which has about 60 per cent of the OD in the world, around a third of the undernourished children, and approximately a third of the people living in poverty. Through OD, FTIs and in other ways, lack of sanitation leads to losses, which may be estimated, in the range of 1 to 7 per cent of GDP in various countries.

To reframe undernutrition for a better balance of understanding and interventions, we propose two inclusive concepts: the FTIs and the 5 As. The first two As – availability and access – are oral, about food intake, while the last three As – absorption, antibodies and allopathogens – are novel categories, anal and internal, about FTIs and what happens inside the body. These concepts have implications for research, professional teaching and training, and policy and practice. While other countries make rapid progress towards becoming open-defecation free, India remains obstinately stuck, making undernutrition in India one of the great human challenges of the twenty first century. The concepts of FTIs and the 5 As reframe more inclusively how undernutrition is perceived, described and analysed. Our hope is that this reframing will contribute however modestly to a cleaner, healthier and happier world in which all children and adults are well-nourished and can grow and live to their full potential.

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Understanding the Rapid Reduction of Undernutrition in Nepal, 2001–2011: IFPRI Discussion Paper 01384, 
October 2014.

AUTHORS: Derek D. Headey (d.headey@cgiar.org) is a senior research fellow in the Poverty, Health, and Nutrition
Division of the International Food Policy Research Institute (IFPRI), Washington, DC.

John Hoddinott is a senior research fellow in the Poverty, Health, and Nutrition Division of IFPRI,  Washington, DC.

Abstract: South Asia has long been synonymous with unusually high rates of undernutrition. In the past decade, however, Nepal has arguably achieved the fastest recorded decline in child stunting in the world and has done so in the midst of civil war and postconflict political instability. Given recent interest in reducing undernutrition–particularly the role of nutrition-sensitive policies–this paper aims to quantitatively understand this surprising success story by analyzing the 2001, 2006, and 2011 rounds of Nepal’s Demographic Health Surveys.

To do so, the authors first construct and test basic models of the intermediate determinants of child and maternal nutritional change and then decompose predicted changes in nutrition outcomes over time. They identify four broad drivers of change: asset accumulation, health and nutrition interventions, maternal educational gains, and improvements in sanitation.

Many of these changes were clearly influenced by policy decisions, including increased public investments in health and education and community-led health and sanitation campaigns. Other factors, such as rapid growth in migration-based remittances, are more a reflection of household responses to changing political and economic circumstances.

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Water, sanitation, hygiene, and nutrition: successes, challenges, and implications for integration

Water, sanitation, hygiene, and nutrition: successes, challenges, and implications for integration. Int J Public Health, 2014 Jul 11.

Authors: Teague J, Johnston EA, P Graham J.
Author email: jteague@washadvocates.org

OBJECTIVES: This study explores the integration of water, sanitation, and hygiene (WASH) and nutrition programming for improved child health outcomes and aims to identify barriers to and necessary steps for successful integration.

METHODS: Sixteen semi-structured in-depth interviews were conducted with key stakeholders from both the WASH and nutrition sectors, exploring barriers to integration and potential steps to more effectively integrate programs.

RESULTS: Key barriers included insufficient and siloed funding, staff capacity and interest, knowledge of the two sectors, coordination, and limited evidence on the impact of integrated programs. To achieve more effective integration, respondents highlighted the need for more holistic strategies that consider both sectors, improved coordination, donor support and funding, a stronger evidence base for integration, and leadership at all levels.

CONCLUSIONS: Organizations desiring to integrate programs can use these results to prepare for challenges and to know what conditions are necessary for successfully integrated programs. Donors should encourage integration and fund operational research to improve the efficiency of integration efforts. Knowledge among sectors should be shared and incentives should be designed to facilitate better coordination, especially where both sectors are working toward common goals.

Jan 2014 – WASH/Nutrition Literature Updates

WASH/Nutrition Literature Update – January 2014

This update contains recent studies and reports on WASH and nutrition issues plus updates on new publications and resources from members of the USAID Community of Practice on WASH and Nutrition. Please contact WASHplus if you have new publications or upcoming events you would like to feature in the February 2014 update. Most of the studies below can also be found on the WASH/Nutrition Library at: http://blogs.washplus.org/washnutrition.

UPDATES FROM COP MEMBERS – New Publications, Upcoming Events, etc.

Alive & Thrive - Ensuring Adequate Nutrient IntakeInsight, Issue 7, 2013.  (Link)
This issue examines why infants require a much higher quality diet than other members of the household, identifies nutrient gaps in typical complementary food diets, and describes strategies for achieving adequate nutrient intake among children 6-24 months old.

FANTA III - Nutrition Assessment, Counseling, and Support (NACS): A User’s Guide, 2013. (Link)
The NACS User’s Guide is a series of modules that provide program managers and implementers with a package of essential information and resources. These modules are living documents and will be updated as appropriate when new evidence, guidelines, or field experience emerges.

London School of Hygiene & Tropical Medicine (LSHTM) - Water, Sanitation and Hygiene (WASH), Nutrition and Infection: Learning Module Update(Link)
The latest evidence from a Cochrane systematic review found a small but significant improvement in the growth of children under the age of 5 who have access to clean water and soap. Analysis of the data from 14 studies conducted in low and middle income countries suggested that interventions to improve the quality of the water in the household and provide soap resulted in an average 0.5 cm increased height growth in children under the age of 5.

USAID SPRING Project - The Nigeria Community and Facility Infant and Young Child Feeding Package, 2013. (Link)
This Infant and Young Child Feeding Package is a necessary tool to ensure uniform training and information sharing throughout Nigeria.

REPORTS

USAID DRAFT Agency-wide Nutrition Strategy [public comment sought], December, 2013. (Link)
A technical working group, comprising individuals across USAID, has developed a draft nutrition strategy and is seeking public comment.

Cyclosporiasis: An Emerging Potential Threat for Water Contamination. Water and Health 2014. H Ahmad. (Abstract)
Cyclospora cayetanensis is an emerging protozoan parasite that causes small intestine gastroenteritis. There is apparently a worldwide distribution, including regions of endemicity, for example, in Nepal, Haiti, and Peru. Due to the lack of a quantification technique, there is limited information on the prevalence of Cyclospora in water environments, necessitating the need for further research on pathways and transmission dynamics and encouraging innovative research in water treatment for improving sanitation and public health.

Public Health and Social Benefits of At-House Water Supplies, 2013. (Link)
B Evans et al.
The headline conclusion from this research is that at-home water supply has significant, measurable benefits when compared with shared water supply outside the home provided that the service is reliable enough to ensure access to adequate quantities of water when required. Reliable at-home water supply results in higher volumes of water consumption, greater practice of key hygiene behaviors, a reduction in musculoskeletal impacts associated with carrying water from outside the home, and improved water quality.

Sanitation and Externalities: Evidence from Early Childhood Health in Rural India, 2014. The World Bank. (Link)
This paper examines two sources of benefits related to sanitation infrastructure access on early childhood health: a direct benefit a household receives when moving from open to fixed-point defecation or from unimproved sanitation to improved sanitation, and an external benefit (externality) produced by the neighborhood’s access to sanitation infrastructure.

Social Protection and Resilient Food Systems: The Role of Cash Transfers, 2013. Overseas Development Institute. (Link)
If linked to education and awareness-raising, cash transfer programs can improve water and sanitation hygiene practices.

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December 2013 WASH/Nutrition Literature Update

Below are updates on news and events from members of the USAID Community of Practice (COP) on WASH and Nutrition and links to recent studies and reports added to the WASH/Nutrition Library. Please send an email if you have a recent publication or an upcoming event that we can feature in the update. The aim is to send these out every 1 to 2 months.

REPORTS

Growing Tall and Smart with Toilets, 2013. Water and Sanitation Program. (Link)
The research in Cambodia found that open defecation not only affects one’s own health, but it also affects the health of one’s neighbors. The extent of open defecation in a community is more important for a child’s development than whether the child’s household itself openly defecates.

Integrating WASH into NTD Programs: A Desk Review, 2013. WASHplus. (Link)
Soil-transmitted helminthes, schistosomiasis, and trachoma are all clearly linked to inadequate sanitation, contaminated food and water, and poor hygiene, providing an opportunity for water, sanitation, and hygiene related approaches to help change behavior and the environment.

Research Priorities for the Environment, Agriculture and Infectious Diseases of Poverty, 2013. WHO. (Link)
This report provides an evaluation of challenges presented by interactions between environment, agriculture and infectious diseases of public health importance. It explores the benefits and limitations of a more systems-based approach to conceptualizing and investigating this problem.

Sanitation Combinations: Water, Sanitation, Hygiene, and Nutrition in Kenya, 2013. G Christensen. (Link)
This research provides evidence that demand for health is highly income elastic, and easy habit formation is essential for high uptake of health interventions.

JOURNAL ARTICLES

Determinants of Moderate-to-Severe Anaemia Among Women of Reproductive Age in Tanzania: Analysis of Data from the 2010 Tanzania Demographic and Health Survey.Trop Med Intl Health, Dec 2013. C Wilunda. (Abstract)
Prevention interventions should target women with lower education or without proper sanitation facilities, and women who are pregnant, particularly if they are uneducated or in lower wealth groups.

Handwashing before Food Preparation and Child Feeding: A Missed Opportunity for Hygiene PromotionAm J Trop Med Hyg, Dec 2013. F Nizame. (Abstract)
Enteric diseases are often caused by poor hygiene and can contribute to stunting. In 50 randomly selected villages in Bangladesh, researchers collected quantitative and qualitative data on handwashing linked to child feeding to integrate handwashing promotion into a young child complementary feeding program.

 

WASHplus Weekly: Focus on WASH & Nutrition

Issue 117 – September 20, 2013 | Focus on WASH and Nutrition

This issue contains some of the most recent studies and resources that discuss the integration of WASH (water, sanitation, and hygiene) with nutrition. Included are a recent webinar on environmental enteropathy, an online tutorial about nutrition programming that has a WASH component, and studies on child height and open defecation. Another resource is the WASHplus online library of WASH and nutrition, which is still under development but contains the resources listed below as well as other recent studies and reports. washplusweekly

EVENTS

USAID Webinar on Environmental Enteropathy (EE) and WASH, Sept 11, 2013. (Link)
This webinar discussed the latest EE findings, including how WASH can be integrated into USAID nutrition and other programs.  The webinar was sponsored by the USAID Community of Practice: The Nexus between WASH, Nutrition and Food Security with support from the USAID-funded TOPS program and the WASHplus project. The presenters were Laura Smith, Cornell University and Helen Petach from USAID; Tom Davis of the TOPS Program/Food for the Hungry moderated the program.

TUTORIALS

Programming for Nutrition Outcomes. London School of Hygiene & Tropical Medicine/DFID. (Link)
Programming for Nutrition Outcomes is a free open-access educational resource, supported by the UK’s Department for International Development. This Master’s-level module has been designed to explore the complicated problem of undernutrition, highlight its multisectoral causes, and identify potential programmatic solutions.

REPORTS (Alphabetical by Title)

Clean, Fed & Nurtured: Joining Forces to Promote Child Growth and Development: A Report on a Consultative Meeting, 2013. (Link, pdf)
This report presents the results of a consultative meeting held on May 2–3, 2013, at FHI 360 in Washington, DC, on the topic Clean, Fed & Nurtured: Joining Forces to Promote Child Growth and Development. Forty-eight practitioners, researchers, and academicians attended the meeting to begin creating linkages across their disciplines of WASH, including hand washing; nutrition, infant and young child feeding in particular; and early childhood development.

Growing Taller Among Toilets: Evidence from Changes in Sanitation and Child Height in Cambodia, 2005–2010. 2013. P Kov, et al. Rice Institute. (Link, pdf)
Child height is an important indicator of human capital and human development, in large part because early life health and net nutrition shape both height and adult economic productivity and health. Recent medical evidence suggests that exposure to poor sanitation and specifically to widespread open defecation can pose a critical threat to child growth. Cambodia saw a significant decline in open defecation and increase in child height between its 2005 and 2010 Demographic and Health Surveys. Results suggest that reduction in children’s exposure to open defecation statistically accounted for much or all of the increase in average child height during this period.

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Making hygiene the central issue

I’ve just had the luxury of sitting down and reading a pile of reports that have been accumulating over the last few months.   A group of these relates to the clear links between sanitation and under-nutrition, especially, how the prevalence of open defecation (OD) in India is clearly correlated with stunting in children in that country. The relevant documents, being a report by Dean Spears (How much international variation in child height can sanitation explain) and an article by Robert Chambers and Gregor von Medeazza (Sanitation and stunting in India: undernutrition’s blind spot) are a must-read for all WASH practitioners and child health specialists, and provide ammunition by the bucket load for advocates of better sanitation and hygiene.

One comment in the Chambers/von Medeazza paper, however, stirred up a problem that has been gnawing away at me for a while: “OD is particularly harmful where population density is high”. There is nothing surprising there, we would all agree. So, here is the troubling thought: you might think that the converse applies: perhaps OD is not especially harmful where population density is not particularly high? The situation where someone defecates in a remote field, in a very dry location, and buries the faeces under a desiccating sun is one that has probably occurred to all of us as being not hugely problematic, especially if that person has and uses an effective method of washing his/her hands quickly afterwards.

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USAID Webinar on Environmental Enteropathy and WASH!

Thank you to all who attended the USAID Webinar on Environmental Enteropathy and WASH!

You can find a recording of the webinar and materials from our presenters, Laura Smith from Cornell University and Helen Petach from USAID, at www.fsnnetwork.orgusaid2

Are you interested in opportunities to continue the discussion on integrated programming opportunities for WASH, nutrition and food security? Then consider joining the Community of Practice: The Nexus between WASH, Nutrition and Feed the Future. Contact Dan Campbell (dacampbell@fhi360.org)

This event was sponsored by the USAID Community of Practice: The Nexus between WASH, Nutrition and Feed the Future with support from the USAID-funded TOPS program and WASHplus project.