Interdisciplinary interventions for stunting and wasting in Zimbabwe, Zambia and Pakistan

Undernutrition underlies almost half of all child deaths and has far-reaching educational, economic and health impacts. We focus on stunting and wasting, the major forms of undernutrition, which are not explained simply by shortage of food. Stunting, or reduced height, impairs long-term educational attainment and earning potential in adulthood and has multiple underlying causes, but few effective preventive strategies. Wasting in its most serious form presents as severe acute malnutrition (SAM) and children have a high risk of dying in hospital or after discharge home. For children to survive, thrive and lead prosperous lives, we need new ways to tackle undernutrition. We aim to strengthen partnerships, draw on expertise beyond traditional nutrition disciplines, and conduct a long-term programme of research in three countries with a high burden of child undernutrition - Zimbabwe, Zambia and Pakistan. Our ambition is to improve child survival, health and potential by finding new ways of preventing stunting and treating wasting, to help reach the Sustainable Development Goals.

Our long-term research programme has three aims. Our first aim is to understand the network of environmental, social and biological factors that interact to cause undernutrition so we can find the most promising targets for intervention. Our second aim is to use this learning to evaluate new strategies for undernutrition. We will design packages of interventions that are often not used together, and test their effectiveness, first in small pilot studies and then in large clinical trials aimed at preventing stunting and treating wasting. Our third aim is to use the findings we generate to influence policy and development programmes so that new interventions are scaled up effectively to reduce undernutrition.

We plan to use this current grant opportunity to strengthen links with each country, build more south-south cooperation through collaborative meetings and a shared programme of work, and engage new investigators from outside the nutrition field. We will conduct four pilot projects to identify new approaches to undernutrition, which will start to inform our long-term programme. First, we will bring together experts in human, animal and environmental health to discuss the risks and benefits of livestock ownership for stunting and start to design a future intervention that increases the positive effects of livestock ownership whilst mitigating the negative effects. Second, we will work with social scientists to evaluate the attitudes and behaviours of mothers whose children are recovering from SAM. Strengthening the capacity of mothers to look after their children might help to deliver a package of care after discharge from hospital to improve the long-term outcomes of children with SAM. Third, we will explore whether giving high-dose vitamin D is a promising strategy to improve recovery of children with SAM in Zambia and Zimbabwe, as we recently found in Pakistan. We will measure vitamin D in our laboratory using blood samples collected from children with SAM during hospital admission and at discharge, to see whether vitamin D deficiency partly explains their poor outcomes. If so, high-dose vitamin D should be evaluated in a future trial. Finally, we will conduct a pilot study to treat maternal depression as a way of improving child growth. Poor maternal mental health can compromise caregiving and feeding practices and increases the risk of child stunting. Treatment of common mental disorders using a community-based intervention based on problem solving therapy, delivered by trained lay workers, is highly effective but is mostly used in urban areas currently. We will conduct pilot work to see if this intervention works for mothers in rural Zimbabwe, and whether it is a promising approach to improve child growth and development.

Undernutrition underlies almost half of all child deaths and has educational, economic and health impacts. We focus on stunting and wasting, which are in need of new interdisciplinary solutions. We aim to strengthen UK-LMIC partnerships, engage interdisciplinary expertise, and conduct a long-term programme of research in Zimbabwe, Zambia and Pakistan, with three aims. Aim 1 is to understand the determinants of undernutrition to identify new targets for intervention. Aim 2 is to evaluate new multisectoral approaches to prevent stunting and treat wasting. Aim 3 is to develop skills to turn science into practice, so that new interventions are scaled up effectively.

We will use this grant to strengthen links with each country, build more south-south cooperation and conduct four interdisciplinary pilot projects to identify new approaches to undernutrition. First, we will hold a meeting that will discuss the risks and benefits of livestock ownership for stunting. A 'One Health' approach to undernutrition could generate solutions at the interface of animal, human and ecological health. Second, we will work with social scientists to evaluate the attitudes, behaviours and capabilities of mothers whose children are recovering from SAM. Strengthening the capacity of mothers to look after their children might help to deliver a package of care after discharge from hospital to improve long-term outcomes. Third, we will explore whether high-dose vitamin D is a promising strategy to improve recovery of children with SAM. We will measure 25-hydroxyvitamin D by ELISA in 590 children to see whether vitamin D status is independently associated with morbidity, mortality and nutritional recovery. Finally, we will conduct a pilot study to treat maternal depression using a community-based intervention to assess feasibility, acceptability and efficacy for mothers in rural Zimbabwe. This would form part of a multisectoral intervention for stunting reduction in our long-term programme.

Our ambition is to improve child survival, health and potential by finding new ways of tackling undernutrition, to help reach the Sustainable Development Goals. Stunting affects 156 million children globally. Stunting therefore remains alarmingly prevalent and is declining too slowly to reach World Health Assembly targets. Over half the global stunting burden is concentrated in Asia, where 34.4% of children are stunted. In Africa, stunting prevalence remains remarkably stagnant and, due to population growth, absolute numbers of stunted children are increasing. Low-income countries have more stunted children today than 15 years ago. An estimated 43% of children fail to reach their developmental potential due to stunting and poverty, and in sub-Saharan Africa this rises to 66%. The effects of poor growth and development are far-reaching: stunted children are more likely to die from infections; enroll later and do less well at school; earn less money as adults; and have an elevated risk of chronic diseases in adult life. Wasting affects around 1 million children a year in its most serious form, severe acute malnutrition. Although many children can be managed in the community through nutrition programmes, those with clinical complications need to be admitted to hospital and mortality rates remain unacceptably high around 35%; there is a clear need for new approaches to improve outcomes.

New findings from our pilot projects will inform long-term research to test the impact of promising interventions in undernutrition and translate effective interventions from research tools to policy recommendations, ultimately benefiting children with stunting and wasting. Focusing interdisciplinary expertise on finding new evidence-based solutions to undernutrition has potential to benefit around one-third of children in low-income countries. Effective interventions will enhance health and wellbeing, educational attainment, economic prosperity and resilience across the life-course, conferring enormous individual and societal benefits, including national economic growth and stability. Improving child growth and development would be an effective way of preventing inequality, enhancing productivity and reducing poverty. Since stunting is intergenerational, investments in the current generation will be sustained into the next generation. Given the large number of stunted children, even interventions that have a small effect on growth at the individual level have the potential for large benefits at the population level.

To ensure that our research has impact, we have embedded south-south cooperation and knowledge exchange into our programme from the start, and we will ensure that our research agenda is based on local priorities. We aim to identify and include hard-to-reach populations in our research, by focusing on rural as well as urban undernutrition, and conducting home visits to reach caregivers of children with SAM who are difficult to follow up in inpatient settings. We will target both male and female family members in our focus group discussions. To maximise impact, one of our Research Themes specifically aims to bridge the evidence-action divide, by building capacity to engage and influence policymakers, bring data to implementation programmes and understand what works in different contexts. Advocacy, public engagement and research dissemination will be central to our long-term programme of work.

Our work has the potential to enhance the economy in each country by building a research agenda that requires human resources; training researchers in new skills, including the capacity to secure research grants; and enhancing the research ecosystem to retain talented individuals in each country. To ensure legacy, we will aim to establish a research 'cluster' through south-south collaboration and triangular cooperation to achieve more sustainable ways of working.