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Wasting and Stunting: Overcoming the divide

Wasting-Stunting (WaSt) Technical Interest Group (TIG)

Donor: Irish Aid, USAID, OFDA

Collaborators: Technical Interest Group

ENN project lead: Tanya Khara

Timeframe: 2014 - ongoing

Background

Since the 1970s, nutritionists have categorised undernutrition in two major ways, children are either wasted or stunted.

There has very rarely been consideration for the relationship between these two types of undernutrition with limited evidence to describe the associations between wasting and stunting. Little has previously been known on:  

• Whether one precedes, or predisposes, the other.
• The biochemical and physiological processes through which the relationship between wasting and stunting can be mediated and /or magnified.
• The scale of the problem on concurrent wasting and stunting.
• The link between concurrent wasting and stunting and its impact on child mortality.

The WaSt Technical Interest Group (TIG) was formed to examine this relationship. The group, coordinated by ENN is made up of 42 experts in child growth, nutrition, epidemiology. 

ENN’s main role since the group's formation has been to harness the skills and enthusiasm of the TIG and facilitate a number of influential project workstreams. The backbone of the expert group is the maintenance of a creative, transparent forum to scrutinise and explore the relationship between wasting and stunting, allowing it to serve the nutrition and wider humanitarian and development sectors as a hub for evidence and expert opinion which is free from organisational agendas.

A governance note outlines the mechanisms for ways of working.

What we now know as a result of the WaSt Project and the WaSt TIG: In the past 4 years, research has shown that individual children are at risk of both conditions, might be born with both, pass from one state to the other over time, and accumulate risks to their health and life through their combined effects. Country level data suggests that up to 8% of children under 5 may be both wasted and stunted at the same time, global estimates translate to around 16 million children. Our reanalysis of data on survival shows that mortality risk for children concurrently wasted and stunted is equal to that of the most severe form of being wasted, and that there are opportunities for identifying these children at community level. Evidence also indicates that seasonal stresses might underlie the connections between weight faltering and linear growth faltering.

The work so far:

We have had three phases of work thus far and are currently in the fourth

Phase 1 (2013- 2015):

The WaSt TIG completed the following pieces of work 

• A narrative review of the relationship between wasting and stunting to the understanding of the links between the two conditions.
• A research prioritisation exercise was conducted and subsequently published.
• An analysis of five high burden country datasets to estimate the burden of concurrent wasting and stunting for the 2015 Global Nutrition Report.

Phase 2 (2016- 2017):

The WaSt TIG completed the following pieces of work

• A re-analysis of DHS and MICS datasets from 84 countries to generate a pooled prevalence estimate of the burden of concurrent of wasting and stunting in those countries. (Open access paper published in Maternal and Child Nutrition Journal).
• These findings were also used by the Global Nutrition Report 2016 (p.23).
• An analysis of cross-sectional datasets (SMART surveys) to examine concurrence in more detail and look at how best to identify concurrently wasted and stunted children (findings have been published in Archives of Public Health).
• A related analysis focusing on identifying those children at most risk of mortality using cohort data from Niakhar, Senegal (published in Public Health Nutrition).
• An additional paper which specifically explores the patterns of concurrent wasting and stunting in children under 5yrs of age in the Niakhar Senegal cohort, highlighting the increased risk in boys (published in Maternal and Child Nutrition).

Phase 3 (2018- 2019):

The WaSt TIG developed the following pieces of work:

• A policy brief ‘Child wasting and stunting: Time to overcome the separation (2018)’ (also available in French, Spanish and Arabic)- a culmination of the research and discussion of the group over the last 4 years.
• A viewpoint article in the Lancet Child and Adolescent Health 'Beyond Wasted and Stunted - a paradigm shift is needed to fight child undernutrition'. (read more on a blog written by the WaSt TIG Coordinators)
• Data from the Medical Research Council (MRC) Gambia surveillance programme has been another key focus on the WaSt work with detailed analysis carried out on cohorts of 0-24 month age groups in relation to seasonality and growth, wasting as a risk factor for stunting and vice versa
• The very first WaSt TIG podcast featuring members of the group discussing some of the analysis the group has produced over the last few years 
• The development of a concept for a research study aiming to bring this learning on the relationship between wasting and stunting and their combined impact on mortality into existing programme practices.
• The links between the WaSt Project and the MAMI Special Interest Group were explored in a face to face meeting between the two working groups. A meeting report was produced.
• We evaluated the work within the WaSt Project through a Stories of Change report.
• A sub-working group of the WaSt TIG met in December 2019 to discuss their multiple cohort mortality analysis and related work exploring wasting stunting and mortality risk. Revisiting mortality and anthropometric deficits/reconsidering 'risk'.

Phase 4 (2020-):

In 2020, the WaSt TIG entered its fourth phase of the project, with work on key workstreams continuing. These include:

• A paper from Scientia on the work of the WaSt TIG which unpacks the story of the WaSt TIG to date and some of the key findings for a broader audience. 
• An update to the systematic review which explores the latest evidence on the relationship between wasting and stunting, the interconnected physiological processes, the burden, aetiology and timing of wasting and stunting as well as concurrent wasting and stunting. A related technical briefing paper aims to unpack some of the key findings from the review, highlighting the programmatic and policy implications of some of the findings.
• Work exploring the sex differences in relation to wasting and stunting. A systematic review and meta-analysis explored sex differences in undernutrition and concluded that boys are more likely to be undernourished than girls. An additional paper explores changing sex differences in undernutrition of African children specifically and a complementary narrative review explores the early life mechanisms which might underlie these sex differences. Listen to the WaSt TIG authors discuss the findings of these interesting papers here.
• Work on the prevention of child wasting within the wider context of undernutrition, which updates previous reports on wasting by ENN and is accompanied by three podcasts, two podcasts exploring what Malawi and Pakistan are doing to prevent wasting as well as an interview to understand UNICEF's prevention plans. 
• Further analysis on multiple cohort datasets on the identification of children at highest risk of mortality (in light of previous work on concurrent wasting and stunting and risk). Listen to the some of the reflections on this work in a presentation by Tanya Khara at the USAID Future of Food Assistance for Nutrition: Evidence Summit II
• We also published our WaSt study protocol entitled ‘Bringing new evidence on undernutrition and mortality risk into practice: Protocol for a prospective cohort study'. This outlines a study protocol to test whether weight-for-age and mid-upper arm circumference can be effectively utilised in existing programmes to capture children with single and dual nutritional deficits and reach considerably more children at a high risk of death. 
• We wrote a technical brief to capitalise on and share the extensive experience of the WaSt-TIG in scrutinising data through the lens of the relationship between wasting and stunting in the hope that it will inspire and facilitate others to do the same. 

As these pieces of work progress, we will update this page accordingly.

Further work planned for the next two years is outlined in the workplan. 

For more information please contact Tanya Khara.

Publications

Best Practice in Preventing Child Wasting within the Wider Context of Undernutrition.

The Wasting & Stunting Technical Interest Group: Generating Evidence to Challenge the Divide in Nutrition

The relationship between wasting and stunting in young children: A Systematic review

Boys are more likely to be undernourished than girls: a systematic review and meta-analysis of sex differences in undernutrition.

Wasting and Stunting Technical Interest Group Meeting. 12-13 May 2020.

Story of change: Wasting and stunting project

The relationship between wasting and stunting: a retrospective cohort analysis of longitudinal data in Gambian children from 1976 to 2016

Improving screening for malnourished children at high risk of death: a study of children aged 6–59 months in rural Senegal

Concurrent wasting and stunting among under-five children in Niakhar, Senegal

Children who are both wasted and stunted are also underweight and have a high risk of death: a descriptive epidemiology of multiple anthropometric deficits using data from 51 countries

Child wasting and stunting: Time to overcome the separation (2018) (also available in French, Spanish and Arabic)

Technical Briefing Paper: The relationship between wasting and stunting: policy, programming and research implications (2014)

Research Priorities on the Relationship between Wasting and Stunting

Children concurrently wasted and stunted: A meta-analysis of prevalence data of children 6 – 59 months from 84 countries

Wasting and stunting - similarities and differences: Policy and programmatic implications

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Reference this page

LD (). Wasting and Stunting: Overcoming the divide. www.ennonline.net/ourwork/reviews/wastingstunting

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