PRESCHOOL FEEDING PROGRAMMES FOR IMPROVING THE HEALTH OF DISADVANTAGED CHILDREN: NUTRITIONAL QUALITY ASSESSMENT

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1 PRESCHOOL FEEDING PROGRAMMES FOR IMPROVING THE HEALTH OF DISADVANTAGED CHILDREN: NUTRITIONAL QUALITY ASSESSMENT On behalf of the review team Contact for questions: Selma Liberato

2 FORMAT BACKGROUND (OBJECTIVES, PICO, FRAMEWORK) METHODS (NUTRIONAL ADEQUACY) RESULTS PRELIMARY CONCLUSIONS

3 BACKGROUND Under-nutrition is the single biggest cause of the global burden of disease (Lopez A, 2006) 27% of children under 5 years of age (171 million) were stunted and 16% (104 million) were underweight (Lutter C, 2011) Contributes to 35% of child deaths and 11% of the global burden of disease, particularly in developing countries (Black R, 2008 )

4 Poverty is "the leading cause of hunger (World Hunger Education Service 2012) Feeding programs for children are intended to mitigate this problem In certain settings, a universal approach is required to improve the health of the poorest children (van de Poel 2008) Interventions targeted to disadvantaged children provides the opportunity to maximize developmental potential and lifelong health.

5 OBJECTIVES Primary objective To assess studies that evaluate the effectiveness of programmes that provide energy, nutrients, or micronutrients, or both through food or drink to improve the physical and psychosocial health of disadvantaged children. Secondary objectives To assess the potential of such programmes to reduce socioeconomic inequalities in under-nutrition and its consequences. To evaluate the process of implementation and to understand how this may impact on outcomes.

6 POPULATION Participants: children aged three months to five years all countries of the world; stratified by low- and lower-middle income countries and higher-income countries (World bank 2011) Can also be from socioeconomically disadvantaged groups; OR both high and low socioeconomic groups stratified by some indicator of SES (e.g. high/low income, rural/urban).

7 TYPES OF INTERVENTIONS Provision of energy, nutrients or micronutrients, or both through: hot or cold meals (breakfast or lunch) snacks (such as milk or milk substitutes) meals or snacks in combination with take-home rations take-home rations These interventions must be delivered in a preschool, in daycare, or in the community. Co-interventions (for example, nutrition education No treatment controls (no feeding) or placebo controls or low energy foods (less than 5% of energy provided by intervention)

8 PRIMARY OUTCOMES Physical health 1. Growth (weight, height, WAZ, HAZ, WHZ) Psychosocial health 2. Intelligence 3. Attention 4. Language 5. Memory 6. Psychomotor development (the ability to turn over, crawl, and walk). Adverse effects 7. Substitution (where the family cuts rations for the child who has been fed in order to spread food to the other family members)

9 SECONDARY OUTCOMES Physical health 1. Biochemical markers of nutrition (vitamin A, haemoglobin, haematocrit) 2. Physical activity 3. Morbidity (physician diagnosis of acute illness such as pneumonia, diarrhoea, malaria) 4. Mortality (death) 5. Overweight/obesity (adverse outcome) Psychosocial outcomes 6. Stigmatization 7. Behaviour problems

10 Context: Political systems, Economic development, Food insecurity. Setting: Preschool, Daycare, Community. Household (HH) factors (family SES, HH size, Intra-HH food distribution etc.) Child factors (Baseline nutritional status, child preferences, individual food security etc.) Unfortified and fortified meals Substitution (harm) Child physical health (e.g. anthropometric measures, plasma nutrient levels, reduced infections, etc.) Feeding programmes Fortified foods (optional) Child development (e.g. growth, cognitive outcomes) Child dietary intake (harm or benefit) Child psychosocial health Nutrition education (optional) Implementation and process (nutritional adequacy, acceptability, supervision, place to eat, time to eat, distance to feeding centre, etc. ) Program (intervention & implementation issues /process issues) Underlying causes Immediate outcomes Outcomes

11 METHODS Types of studies Randomised controlled trials, Cluster randomised control trials, Clinical control trials, Control before and after studies, Interrupted time series With at least three time points after the intervention, with or without a control group

12 NUTRITIONAL ADEQUACY ENERGY AND PROTEIN Total kilocalories/protein or % Recommended Daily Allowance (RDA) of energy/protein provided in the text of the study When it was not provided but the descriptions of food were sufficient (quantity and type of food), the kilocalorie content of the meal/snack was estimated using the Food and Agriculture Organization of the United States (FAO) international food composition table.

13 NUTRITIONAL ADEQUACY Recommended Daily Allowance (RDA) for energy The % RDA for energy was calculated by dividing the given or estimated average kilocalorie content of the meal/snack by the RDA for the age/sex specific target group in each study (Dietary Recommended Intake from Health Canada). For children aged 3 years and older, the estimated energy requirement was identified assuming an active physical activity level. When the intervention group of a study was comprised of various age and sex groups, and outcomes were given for the entire group only, a weighted average for the RDA was used to calculate the % RDA. When number of males and females was not reported, it was assumed that equal number of female and male children took part in the study and an average RDA for boys and females children was estimated.

14 NUTRITIONAL ADEQUACY Dietary Reference Intake (DRI) for protein The % DRI for protein was calculated by dividing the given or estimated average protein content of the meal/snack by the RDA for the age/sex specific target group in each study (DRI from Health Canada). DRI for protein given in g/kg/d and weight provided in the study was used to calculate DRI. When weight was not provided in the study, WHO weight (average of boys and girls) was considered to estimate the RDA. When there were more than one intervention (for example different products with different level of protein to different group) the protein adequacy was assessed for each of the foods.

15 PRELIMINARY RESULTS

16 Identified in electronic searches (n=27307) Retrieved for full text review (n= 233) + From reference lists (n = 44) Total Excluded Included studies (n= 23) RCT- (n= 14) CBA- (n= 9) A few studies to be decided on

17 CHARACTERISTICS OF INCLUDED STUDIES Participants Children s ages: from 4 to 60 months; Both gender were represented in most of the studies; Only one study reported participants from middle income SES

18 CHARACTERISTICS OF INCLUDED STUDIES - CONTEXT Lower income countries (N = 21) 6 in Day-cares or Preschools 6 in Feeding Centres with supervision 9 Take-home or Home Delivered Rations Higher income countries (N = 2) 2 Take-home rations

19 CHARACTERISTICS OF INCLUDED STUDIES - FEEDING TYPE Lower income countries 6 ready-to-use-foods 4 milk based formula or milk 5 snacks (cake, biscuits, bread) 2 cereals 2 spread 2 local foods High income countries 2 cereals

20 CHARACTERISTICS OF INCLUDED STUDIES - ENERGY AND PROTEIN CONTENT OF THE MEALS Lower income countries Energy: 23 kcal to 1125 kcal Protein: 1 to 40g High income countries not reported (authors to be contacted).

21 NUTRITIONAL ADEQUACY - ENERGY Age group Numb er of studie s Energy content (Kcal) Range Averag e Requireme nt Lower range Adequacy Avera ge < 6 mo to 12 mo to 24 mo to 36 mo to 48 mo to 60 mo

22 NUTRITIONAL ADEQUACY - PROTEIN Age group Numbe r of stud ies Protein content (Kcal) Range Average Require ment Lower range Adequacy Averag e < 6 mo to 12 mo to 24 mo to 36 mo to 48 mo to 60 mo

23 What about context and process issues? Realist approach will be utilized to identify theory and process factors on: Why feeding programmes work? Why feeding programmes don t work? What are some of the components of an effective programme? Etc. Realist synthesis to be included in review

24 Is it too early to tell? No conclusive statements can be made at this time as several comparisons are yet to be made on other outcomes In addition, other study designs were included in this presentation and may contribute valuable information

25 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

26 Funding and support 3ie Global Development Network Thank you!