Menu ENN Search

The current state of evidence and thinking on wasting prevention

Summary of research1


ENN produced a report, through the MQSUN+ programme, that synthesises existing evidence and stakeholder opinion on what works to prevent wasting. This report is one output of a multi-phase scope of work, commissioned and funded by the UK Department for International Development (DFID) on “adopting a strategic, evidence-based approach to wasting prevention” and follows a briefing paper produced by ENN titled “The aetiology ofwasting”.2 The current report set out to answer the following questions: What do we know about wasting prevention? What is the emerging evidence? What are the evidence gaps and key questions which cannot currently be answered? What new evidence will be available in coming years?


A detailed review of the evidence from both published and grey literature and from semi-structured interviews with stakeholders was conducted between December 2017 and February 2018. The prevention of wasting was considered across the main intervention contexts (humanitarian and development, those with low and high levels of wasting/low and high levels of stunting), along a ‘continuum’ of severity (moderate and severe wasting and prevention of relapse). The review looked at the evidence for so-called nutrition-specific and nutrition-sensitive actions.

In total 235 studies and articles from the literature search were included in the review, of which 55 were randomised control trials, 23 were protocols/ongoing studies and 17 were systematic reviews. Fifty-seven grey literature documents were reviewed and 46 experts/key stakeholders were interviewed.


Historically there has been more of a focus on research into the prevention of stunting, while the prevention of wasting has been a more neglected research area. This is largely because the focus on wasting has been on treatment. Encouragingly, the review found that the volume of studies relating to wasting prevention has increased in recent years. However, the evidence base for the prevention of wasting is both mixed and largely inconclusive.

The interventions with the largest body of evidence include the use of supplementary food products, cash-based interventions, behaviour change to improve infant and young child feeding, and where interventions are combined. There is a lack of research on whether interventions targeted towards women and girls preconception and during pregnancy prevent wasting (see box 1 below).

The stakeholders consulted felt confident in stating that acute periods of food insecurity and/or episodes of disease outbreak contribute to wasting, and that well designed early interventions will have a preventive effect in such contexts. Despite an inconsistent evidence base, a holistic approach based on the UNICEF Conceptual Framework and context-specific causal analysis was advocated, through a range of interventions to tackle both the immediate and underlying drivers of undernutrition. It was felt that this should be complemented by an improved understanding of the epidemiology and aetiology of wasting to better identify and target children at highest risk.

Stakeholder opinion also suggested that much less is known about the prevention of wasting in non-humanitarian contexts or in areas with persistently high levels of wasting. Key gaps in the understanding of the aetiology of wasting were highlighted, including: kwashiorkor/ nutritional oedema; the relationship/overlap between stunting and wasting; differences relating to age and geography; the role of interventions preconception; the relationship between maternal nutrition and health status and child nutrition status; the extent to which wasting in infants under six months of age reflects non-nutritional factors (such as low birth weight);  and mechanisms behind relapse after successful treatment for wasting. Other gaps included the role of infection and gut microbiota and the longer-term health and development impacts of childhood wasting.

Many stakeholders observed that there is an absence of a single organisation with an overall leadership role for wasting prevention. The divisions and silos which characterise wasting were also highlighted as a concern.

Box 1: Summary of state of evidence by intervention area


There is very little evidence of the impact of interventions to promote exclusive and continued breastfeeding on the prevention of wasting. Results are modest or difficult to attribute to an increase in breastfeeding alone.

Complementary feeding

Little evidence of the impact of complementary feeding interventions on preventing wasting was found. Some systematic reviews highlight the benefits, but studies including clear wasting outcomes are lacking.

Micronutrient supplementation

Only small impacts on wasting prevention were observed when using zinc supplements, despite some high-quality systematic reviews and clinical trials in this intervention area.

Nutrition counselling and nutrition education

A number of randomised clinical trials (RCTs) in this intervention area showed positive effects on the prevention of wasting, although many still fail to demonstrate a clear impact.


Treating children known to have worm infection may have some nutritional benefits for the individual. However, despite some good quality studies, direct effects on preventing wasting have not been proved.

Maternal education, women’s empowerment and gender

Results predominantly from association studies and programme evaluations suggest that women’s empowerment interventions and education could have a positive impact on infant feeding and wasting.


Few clear studies consider the relationship between health interventions and prevention of wasting. Only a few well designed studies found a limited impact on wasting reduction.

Water, sanitation and hygiene (WASH)

There is currently very little evidence as to the direct effect of WASH interventions in the prevention of wasting, with the exception of some studies on sanitation.

Agriculture and other livelihoods

Only limited impacts have been observed, suggesting that more needs to be done to link increased agricultural production with improving child nutritional status. Robust evidence relating to the impact of livelihoods interventions on wasting prevention is also lacking.

General food distribution (GFD)

Although a number of studies have shown an impact of GFD on wasting, it is difficult to attribute this to the intervention alone.

Cash transfers (CTs)

There is a growing body of well designed trials that are demonstrating a strong positive preventive effect of CTs on wasting.

Food supplementation

The highest number of studies was identified in this intervention area and evidence is growing quickly: well designed RCTs and systematic reviews have demonstrated the effect of food supplementation in preventing wasting, but questions around their cost-effectiveness and sustainability remain.

Combinations of interventions

The review found that a combination of interventions may be more effective at preventive wasting than separately implemented interventions, particularly when targeted to the same population.

The review identified numerous ongoing studies in the area of wasting prevention and some which are pending funding. Further evidence is anticipated in the coming years relating both to aetiology/epidemiology of wasting and effectiveness of various nutrition-specific and nutrition-sensitive interventions. Stakeholders stressed the importance of longer-term funding to facilitate research which encompasses the full 1,000 days window and a need for more longitudinal studies, including consideration of where existing data can be used (e.g. retrospective cohort studies). The need to improve the evidence base on drivers and effective approaches to wasting prevention through well designed programme monitoring and evaluation activities was also highlighted and several stakeholders supported the idea of a research prioritisation exercise.

ENN’s continued work in this area

ENN is continuing its focus on wasting prevention through the MQSUN+ mechanism by working with a team of experts to carry out a research prioritisation exercise on wasting prevention. This work will conclude in July 2019. Information on how you can participate in the exercise is available here.

ENN also continues to generate research publications and short briefs about the links between wasting and stunting (WaSt). Information about the WaSt project can be found here.



1ENN (2018) The current state of evidence and thinking on wasting prevention: MQSUN+ report.

2ENN (2018) The aetiology of wasting: MQSUN+ report.

More like this

Blog post: Wasted opportunity? What we do know about preventing wasting

Today, over 50 million children are wasted, which comes with an elevated risk of death. Even more, wasting prevalence hasn't declined in recent years. The United Kingdom's...

Wasting Prevention Survey - Introduction

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...

Wasting Prevention

Donors: DFID funded MQSUN+ facility Collaborators: MQSUN+/PATH; Rebecca Brown and Jose Luis Álvarez Morán (ENN Consultants) ENN project lead and contact: Carmel...

en-net: Request for contributions of grey literature on wasting prevention

Dear all,

ENN is currently conducting a review on behalf of DFID (via MQSUN+) on the prevention of wasting. Nutrition-specific and nutrition-sensitive activities to...

FEX: Research priorities on the relationship between wasting and stunting

Summary of research* Location: Global. What we know: There is global momentum to bring down levels of undernutrition. Wasting and stunting frequently co-exist, but are often...

FEX: The cost of a knowledge silo: A systematic re-review of water, sanitation and hygiene interventions

Summary of research1 By Michael Loevinsohn Michael Loevinsohn is a research fellow at the Institute of Development Studies, UK. An ecologist and epidemiologist, he has worked...

FEX: Special Section: Research for Nutrition Conference - Editorial

Myriam Ait Aissa leads the Action Against Hunger Research and Analyses Department, which overall aim is to produce evidence for better action. Before joining Action Against...

FEX: Effects of nutrition interventions during pregnancy on low birth weight

Summary of research1 Location: Global What we know: Low birth weight (LBW) is a major underlying cause of infant mortality and childhood morbidity; LBW is greatly affected by...

FEX: Nutrition in emergencies: Do we know what works?

Summary of paper1 Location: Global What we know: Nutrition action in emergencies is well accepted and attracts significant resources. There is a lack of evidence on what are...

Blog post: Research on multi-sectoral programming: reflections on a cash and WASH, nutrition integrated approach

Cliquez ici pour lire en français Some time ago I had the opportunity to attend a regional event for sharing multi-sectoral nutrition approaches, organized by ACF and...

FEX: WASH interventions and their effects on the nutritional status of children

Summary of research1 Location: Global What we know: Water, sanitation and hygiene (WASH) interventions are frequently implemented to improve health and reduce infectious...

FEX: The relationship between wasting and stunting: policy, programming and research implications

Summary of review1 This summary was prepared by Tanya Khara, an independent consultant engaged by the ENN on this review. The review was made possible by the generous support...

en-net: Blanket Supplementary Feeding Programs

Use of blanket Supplementary feeding programs is more and more being used to either prevent undernutrition in general as well as prevention of seasonal peaks of acute...

FEX: Treatment of SAM and MAM in low- and middle-income settings: a systematic review

Summary of research1 Location: Global What we know: Worldwide, 33 million children under 5 years are moderately malnourished and 19 million are severely malnourished. The...

FEX: Letter challenging conclusions and analysis of Lancet Undernutrition Series, by Fiona Watson and Carmel Dolan

Challenging conclusions and analysis of the Lancet Undernutrition Series Dear Editor, We welcome the opportunity provided by the Lancet to highlight the “desperately...

FEX: Robust evidence for an evidence-based approach to humanitarian action

Research By Mike Clarke, Jeroen Jansen and Claire Allen Mike Clarke is one of the founders of Evidence Aid and is now voluntary Research Director and Chair of the Board of...

FEX: WHO consultation on management of moderate malnutrition in U5s

The WHO, in collaboration with UNICEF, WFP and UNHCR, hosted a second consultation to discuss the programmatic aspects of the management of moderate malnutrition in children...

FEX: Introduction to the special issue

The most recent Lancet series on maternal and child undernutrition (Bhutta et al, 2013) calculated that even with 90% coverage of specific nutrition interventions (addressing...

FEX: The REFANI Project in Pakistan: adapting research to a multi-sectoral programme for impact measurement

By Zvia Shwirtz, Bridget Fenn, Riccardo Mioli, Ghulam Murtaza Sangrasi and Maureen Gallagher Zvia Shwirtz is currently the REFANI Communications and Research Uptake Officer,...

FEX: Editorial

View this article as a pdf In this issue of Field Exchange we are delighted to feature, for the second year running, a special section that shares key outputs of Action...


Reference this page

The current state of evidence and thinking on wasting prevention. Field Exchange 59, January 2019. p29.