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USAID: How should we address wasting and stunting?

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This is a summary of two Field Exchange articles published in issue 67. The original articles were a views article written by Erin Boyd and a summary of the following report: USAID Advancing Nutrition (2021) Stunting: Considerations for use as an indicator in nutrition projects. Arlington, VA: USAID Advancing Nutrition. Available at: https://www.advancingnutrition.org/resources/stunting-considerations-use-indicator-nutrition-projects

Erin Boyd is a Nutrition Advisor at the United States Agency of International Development’s Bureau for Humanitarian Assistance.

- Addressing wasting and stunting separately rather than jointly has resulted in missed opportunities to better understand and address undernutrition.

- The United States Agency of International Development (USAID) has invested in the work of the Wasting and Stunting Technical Interest Group to analyse the co-occurrence of wasting and stunting using existing data.

- These findings have been instrumental in informing USAID’s framework for defining and supporting the prevention of undernutrition.

- USAID has also contributed to discussions around the utility of stunting as an indicator, suggesting a need to incorporate a broader range of nutrition, health and development indicators when assessing nutrition programmes.

United States Agency of International Development (USAID) investments in Wasting and Stunting (WaSt)

USAID investments in nutrition include addressing wasting and stunting. For wasting, the focus has been on humanitarian contexts since resources and interventions target mortality reduction. Conversely, stunting has been equated with chronic undernutrition and has remained the focus in development contexts. However, USAID programme experiences and data have highlighted many humanitarian contexts where both wasting and stunting are a problem. In addition, many activities aiming to reduce or prevent stunting may also prevent wasting. Thus, there is an ongoing need to explore how wasting and stunting manifest at population and individual levels and how they might be related.

USAID sought to understand the relationships between wasting and stunting through an analysis of existing data in 2015/16 – the first analysis undertaken by the Wasting and Stunting Technical Interest Group (WaSt TIG). They then awarded a grant to ENN to explore the available data regarding the co-occurrence of wasting and stunting as well as the associated risk of mortality. Data was accessed from Standardised Monitoring and Assessment of Relief and Transitions (SMART) nutrition surveys, Multiple Indicator Cluster Surveys and Demographic and Health Surveys.

USAID has been investing in SMART nutrition surveys for over 15 years which include both weight-for-height (a measure of wasting) and height-for-age (a measure of stunting) data on the same children. However, the prevalence of each form of undernutrition had only been reported at an overall level, presenting a missed opportunity to look at the degree of overlap within individual children. Such analyses have contributed to an understanding of the implications of concurrent wasting and stunting, facilitated better targeting of USAID resources and supported advocacy for wasting programmes in non-humanitarian settings.

Influence of WaSt on the USAID approach

Rethinking ‘stunting’ as an indicator in nutrition programmes

The separate approach to wasting and stunting in humanitarian and development contexts, respectively, has also led to a focus on stunting as a primary objective in development programmes. Together with its relative ease of collection and interpretation, this has promoted the use of stunting reduction as the primary indicator of programme success in many national and donor-funded nutrition programmes. Recent challenges to this approach led to the release of a report by USAID in 2021 which discussed how stunting has been misused as an indicator for the following reasons:

While stunting is still a useful indicator in some cases, USAID proposed using a broader set of indicators to monitor and evaluate nutrition programmes, highlighting that:

Conclusion

USAID greatly values the use of data for decision making. The WaSt story is a clear example of how available data can be used to answer different research questions. ENN and the WaSt TIG members played an important role in accessing the raw data. More common data-sharing between academic institutions and independent researchers would enable such analyses.

USAID continues to face a challenge in identifying the most effective activities for the prevention of undernutrition in different contexts. Better understanding of the links between stunting and wasting will support USAID (and others) to design programmes that address all forms of undernutrition. Ensuring that such programmes incorporate appropriate indicators is critical to tracking progress and supporting advocacy and scale-up.

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Erin Boyd (). USAID: How should we address wasting and stunting?. FEX 67 Digest, May 2022. www.ennonline.net/fexdigest/67/wastusaid

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