Food supplementation programmes for improving the health of socio-economically disadvantaged children: What's the evidence?

Welcome!Food supplementation

programmes for improving the health of socio-

economically disadvantaged children: What's the evidence?You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the

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What’s the evidence? Kristjansson E., Francis D.K., Liberato S., Benkhalti J.M., Welch V., Batal M., et al. (2015). Food supplementation for improving the physical and psychosocial health of socio‐economically disadvantaged children aged three months to five years. Cochrane Database of Systematic Reviews, 2015(2), Art. No.: CD009924  

http://www.healthevidence.org/view-article.aspx?a=28630

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Poll Question #2

Dr. Elizabeth Kristjansson is an Associate Professor in the School of Psychology at the University of Ottawa.

Elizabeth Kristjansson

ReviewKristjansson E., Francis D.K., Liberato S., Benkhalti J.M., Welch V., Batal M., et al. (2015). Food supplementation for improving the physical and psychosocial health of socio‐economically disadvantaged children aged three months to five years. Cochrane Database of Systematic Reviews, 2015(2), Art. No.: CD009924

Food supplementation programmes improve the health of socio-economically disadvantaged childrenA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

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Poll Question #3

• Undernutrition is the single biggest cause of the global burden of disease

• Every hour, 300 children under 5 die because of undernutrition– Affects growth, current and future health– Undernutrition lowers cognitive performance

and learning in school– Almost half a billion children are at risk of

permanent damage over the next 15 years

The issue

• For infants and young children– Given in day-care,

preschool, feeding centres or delivered to home

• But no comprehensive synthesis of their effectiveness

One intervention: Feeding programs for young children

Objectives• Primary objective:– To assess effectiveness of feeding programs

for improving the health of disadvantaged children aged three months to five years.

– To undertake a process evaluation (including realist review) to understand the mechanisms underlying success or failure.

• Secondary objectives– To assess the potential of such programmes

to reduce socioeconomic inequalities in undernutrition and its consequences.

Our Conceptual model

• 2 reviews integrated into one synthesis– Effectiveness review and process evaluation

(including analysis of subgroups). Set up hypotheses in advance

– Realist review to help untangle mechanisms of action (led by Trish Greenhalgh)

• Followed standard Cochrane and RAMSES guidelines

Methods

Search up to January, 2015. 32,983 records found -> 302 studies retrieved•31 from LMIC, 3 from HIC (1 Aboriginal children)•Study size ranged from 30 to 3166•34 studies met inclusion criteria; 15 were excluded.

• Realist review: all included and 14 Excluded (Close to criteria) studies + 12 theoretical papers

• Characteristics of Included Studies–31 from LMIC, 3 from HIC (1 Aboriginal children)–21 RCTs, 11 CBAs and 2, which used propensity score matching. 26 of these (16 RCTs and 10 CBAs) were in meta-analyses.

Results

• Participants– Ages ranged from

3 to 60 months– Low SES: from

urban slums, poor rural areas, little running water, parents low education

– Study size ranged from 30 to 3166

Characteristics of included studies

• Lower income countries (N = 31)– 9 in Day-cares or feeding centres– 22 Take-home or Home Delivered Rations

• Provision of energy, with nutrients/micronutrients

• Some gave local food (veg, legumes), others gave milk or cereal with milk, others RUTF

• Energy content ranged from 8% to 136% of RDA

The interventions

• Weight – RCTs: (8 studies) 0.12 over six months

or 0.24 over a year– CBAs (7 studies) 0.24 a year

• Height– RCTs: 0.32 cm. more than those who

were not supplemented – CBAs non-significant

Effectiveness: Growth

• WAZ – RCTS (6 studies): 0.11 in

six months– CBA (4): n. s.

• HAZ – RCTs (7): Children who

were fed gained 0.15 more than controls

– CBAS (4) n.s.

• Hemoglobin– Five RCTs with 300

children. Increases in hemoglobin of half a standard deviation (0.49)

Effectiveness: Growth

Forest plot: height

Psychomotor Development• 3 of 5 studies in LMIC; higher scores on

standardized psychomotor tests.– E.g. (SMD = 0.45 (nearly half a standard deviation),

95% C.I. = 0.23 to 1.02).– Another: Supplemented children 6.5 points on

overall DQ. Supplemented + stimulated 13.7 points.–Mental Development.• 2 out of 3 studies in LMIC showed effectiveness

for mental and cognitive development. • E.g. MacKay (supp + stim).

» (SMD = 0.58; 95% C.I. = )

Impact on Psychosocial Development

Preschool feeding works best for

• Children who are lower income/ have poorer nutritional status.

• Generally, grew more relative to controls than those with better nutritional status

• In two, lower income children only grew more IF they were younger.

• But in one study, children in lower SES neighbourhoods did worse; poor environmental conditions.

• Children who are youngerFeeding more effective for younger children for growth, possibly for cognition. BUT still effective for older children, especially for cognition

Preschool feeding works best for

• Children who are younger• Feeding more effective for younger children

for growth, cognition. • In two studies, only effective for younger children

from low SES backgrounds. BUT still effective for older children, especially for cognition

• Possibly, for girls• Mixed evidence. Subgroup analyses showed

no differences but three primary studies showed more effectiveness for girls.

Process AnalysesProbable important factors

• Leakage and substitution within family.• If home delivered, children only benefit from 1/3

of energy of supplement (e.g. 200 of 600 calories)

• Day-care: Children benefit from 2/3 of energy given (e.g. 400 of 600 calories)

• Why? • Home delivered. Parents redistribute supplement

within family.• Day-care or school, child may get somewhat less

at home. • Losses in the supply chain

• Not enough energy given• Programs which

gave more than 30% of RDI tended to be more effective.

• Level of supervision– More leakage with

less supervision. Not enough data from RCTs to fully test hypothesis of low effectiveness

Factors that may be important

• For younger children, seems to be best to have food that is energy dense– Small children can only consume small

volumes• Multiple interventions (e.g. caregiver

nutrition education, child stimulation) tended to be more effective for weight, perhaps for psychomotor development

Other factors

Realist Analysis• Five mechanisms that seem to

characterize successful programs– Physiological mechanisms.– Other mechanisms in the child– General caregiver capacity to learn and

respond– Caregiver capacity to respond to this

intervention– Staff readiness/capability of delivering

intervention

Physiological mechanisms

• Children have clear nutritional needs. Program matches their needs

• Higher % RDI given

• Child has normal appetite– If ill, poor home conditions, less appetite

• Food needs to be palatable• Food should be energy dense– Young children can’t always eat high

volumes

Mechanisms in child Supplement must be given and eaten

consistently

• Caregiver capacity crucial. Things that can compromise capacity– Abject Poverty– Challenging home environment (no space, no

time, lack of clean water)– Low health and nutritional literacy – Need to overcome traditions of favouring

males or of giving everyone the same, regardless of nutritional status • In some studies, part of ration was shared with rest of

family (1 full ration went to child 1/3 of the time)• Must understand need to give most undernourished

child more food

Caregiver capacity in general

• Need a high level of trust, high cultural synergy

• Caregiver has to find that supplement is acceptable, affordable and easy to obtain/prepare– Dropout rate in one study proportional

to distance to feeding centre

Caregiver response to specific intervention

Programme Staff

• Supply chains must be consistent– One study: failure to reach families 20-

30% of time– Another one: 50% of caregivers reported

at least one delivery gap• Caregiver education/capacity

building seems to help• Programme staff must be flexible

• Before implementing programs, work with communities, parents to develop programs and decide on supplements

• Closely supervise distribution and intake

How can we improve effectiveness?

Improving Effectiveness

• Target most undernourished children• Areas with a high proportion of malnutrition

• Give high (at least 40 – 60%) of percent RDA for energy• Consider child’s age

• Foods should be palatable and energy dense

• Fortify the foods

Improving Effectiveness

Provide extra rations for family to reduce sharing

Work with caregivers/ teachers to encourage feeding and stimulation of child

Encourage continued breastfeeding for young children

Supplementation should begin early and continue for several years

Need for more research

• More: • Research on feeding programs and psychosocial

development• Research that studies the effectiveness of single

versus multiple, various % RDI, delivery mechanisms

• Research on impact of feeding on older preschool children

• More research on the question of feeding on gender and income inequity

Review team • Elizabeth

Kristjansson • Damian Francis• Selma Liberato• Maria Benkhalti-

Jandu• Vivian Welch• Beverley Shea• Malek Batal

• Trish Greenhalgh

• Laura Janzen• Mark Petticrew• Eamonn

Noonan• Tamara Radar• George Wells

• 3ie • Global

Development Network

Thank you!

Funding and Support

Thank you!

Food supplementation programmes improve the health of socio-economically disadvantaged childrenA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Poll Question #4

Poll Question #5Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree

Questions?

A Model for Evidence-Informed Decision

Making

National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]

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