What do we want to know?

The meta-review was aimed to summarise the findings from the selected Systematic Reviews (SRs) on the effectiveness of nutrition interventions (i.e. nutrition-specific and nutrition-sensitive) that have been implemented in LMICs on the World Health Assembly (WHA) global nutrition targets: reductions in the prevalence of stunting, and wasting in under five children; decrease in the prevalence of anemia in woman of reproductive age; reduction in the prevalence of low birthweight (LBW) babies; and an increase the rate of exclusive breastfeeding in the first 6 months of life.

Who wants to know and why?

The present meta-review was commissioned by the Department for International Development (DFID), United Kingdom (UK) to summarise the effectiveness of nutrition interventions in LMICs to identify the interventions that could be potentially scaled up to achieve the WHA targets. The policy makers, researchers, public health and nutrition professionals, people working with government and non-governmental agencies in LMICs who are involved in developmental activities, research and implementation of programmes will benefit from the present work. The meta-review was prepared with specific context to Bangladesh and other selected South Asian countries. The review level evidence would benefit the aforementioned group to design, implement, evaluate and monitor nutrition related interventions that would address the WHA targets by 2025.

What did we find?

A thorough literature search provided sixty one SRs that addressed the impact of several nutrition interventions on the WHA targets. The interventions with positive impact on the WHA targets are summarised below:

1. Stunting: Dietary diversity and complementary feeding practices
2. Wasting: Nutrition education on complementary feeding practices (Mixed impact)
3. Anemia in women of reproductive age: Supplementation with Iron fortified foods, Iron supplements (with or without folic acid) and Vitamin A and Carotenoids.
4. Low birthweight: Dietary intervention strategies and maternal supplementary feeding, multiple micronutrient supplementation/fortification, and Vitamin D supplementation.
5. Exclusive breastfeeding: Community interventions for the promotion of EBF, Kangaroo mother care for pre-term babies and peer group led breastfeeding programmes.

What are the implications?

1. Stunting: Targeted efforts to promote dietary diversity; timely and adequate introduction of nutritious, locally prepared complementary foods, and follow-up of complementary feeding practices during early childhood through nutrition counselling are essential, especially in low resource settings of LMICs to reduce stunting prevalence (acute and chronic malnutrition).
2. Wasting: Wasting should be prevented in normal children, and treated if children are malnourished and subsequently should be supported with adequate nutrient rich foods to sustain their growth and development. Continued supplies of nutrients are important to improve the nutritional status and to prevent wasting in young children. Nutrition education to improve complementary feeding practices, programmes addressing wasting in infants post breastfeeding and subsequently in young school children through improved nutrient intakes via school feeding programmes might strengthen using nutrient-rich snacks and beverages.
3. Anaemia: In LMICs where anaemia remains as a major public health challenge in women of reproductive ages, the existing anaemia control programmes should be strengthened with an emphasis on interventions such as supplementation with iron fortified foods; Vitamin A and carotenoids supplementation; and iron supplementation for pregnant women. In LMICs where iron supplementation and food fortification programmes are unavailable or sparse, supplementation of iron with or without folic acid could be introduced or up-scaled with provisions in accordance with internationally standardised guidelines (such as the WHO guidelines). Such programmes should focus on effective implementation strategies including availability, timely distribution and monitoring the consumption of these tablets. In populations where dietary intakes of Vitamin A/carotenoids are low, supplementation of Vitamin A might support reducing the prevalence of anaemia. Vitamin A deficiency influences in the absorption and utilisation of iron; thus, correction of Vitamin A deficiency may improve the utilisation of iron in the body. This approach should be considered with caution for pregnant women as large dose supplementation of Vitamin A in first trimester could have adverse effects on the fetus.
4. Low Birthweight: The existing IFA supplementation could be expanded to multiple micronutrients including Vitamin D in LMICs where substantial proportion of pregnant women have multiple micronutrient deficiencies or have poor intakes of micronutrients. The health programmes should include dietary intervention strategies such as dietary diversification together with nutrition education to optimise the use locally available foods which, improve the nutrient intakes and to support optimal weight gain during gestation. In HIV positive women supplementation of Vitamin A had significant effect in reducing LBW.
5. Exclusive breastfeeding: Community based and peer-led interventions could be used as a strategy for the implementation of interventions to promote breastfeeding. Such programmes could focus on pregnant women prior to and immediately after delivery, and during the first 6 months of infant age. A community-based peer support system would be a less resource intensive, feasible for promotion of EBF. Additionally, implementation and integration of Kangaroo mother care (KMC) programme as a part of the healthcare programme post-delivery at the health facility level may promote EBF rates. Community-based peer led groups could support the new mothers through timely, adequate, nutritious, responsive and appropriate complementary feeding programme for infants >6 months until 2 years.

How did we get these results?

We conducted a meta-review of all SRs to meta-synthesise the evidence on the effectiveness of nutrition interventions in LMICs towards achieving the WHA global nutrition targets. Following a comprehensive search of varied topic specific databases, we screened titles, abstracts and full texts using a two stage double blind screening process based on apriori inclusion/exclusion criteria. Quality and characteristics of SRs were considered during the evidence summary process. The included articles were appraised for quality using the standard AMSTAR tool. A total of 61 SRs was identified for the synthesis of the present meta-review. Based on the scores from the AMSTAR tool for each review, the majority of SRs were judged to be of either high (n=34) or medium quality (n=22), with only 5 reviews of low quality. Extracted data from the included SRs were synthesised to examine the impact and direction of impact of nutrition interventions. 

This review should be cited as: Menon K, Puthussery S , Ravalia A, Panchal P, Rana R, Mistry S, Tseng P,  Bhandol J, Mavalankar D (2018), Effectiveness of nutrition interventions in low and middle income countries: An evidence summary. London: EPPI Centre, Social Science Research Unit, UCL Institute of Education, University College London. ISBN: 978-1-907345-90-6