Priority-setting in the normative work of the WHO Department of Nutrition for Health and Development Results of the revised process for prioritizing topics for NHD guideline development, implemented in 2017 July 2018
This document was produced by the Nutrition Policy and Scientific Advice Unit of the Department of Nutrition for Health and Development at the World Health Organization. July 2018. Nutrition Policy and Scientific Advice Unit Department of Nutrition for Health and Development World Health Organization 20, Avenue Appia, CH-1211 Geneva 27, Switzerland Fax: +41 22 791 4156 e-mail: NPUinfo@who.int
Results of the process for prioritizing topics for NHD guideline development 1 I. Public Consultation The first public consultation on priority setting in nutrition guideline development was held 7 June 21 July 2017. The public at large was invited to provide suggested topics for guideline development via an online consultation tool. Seventeen participants submitted 24 topics for guideline development (Table 1), including justifications for their suggested topics, based on five criteria (see Annex 1). Fourteen of the participants submitted one topic, one submitted two, one submitted three, and one submitted five. Information about the participants can be found in Annex 2. Topics for which guidelines are currently being developed or are already covered wholly or in part by existing or forthcoming WHO guidelines, or considered inappropriate for guideline development by NHD (e.g. topic too vague or broad, guideline not the right type of guidance product, etc.) were removed, leaving a total of 15 topics as possible priority topics (see Table 1). This list was supplemented by Category 2 and 3 topics 2 from the WHO e-library of Evidence for Nutrition Actions (elena), resulting in a list of 66 topics (see Annex 3). Table 1. Topics submitted during the public consultation (7 June 21 July 2017) Nutrition-specific interventions Anthropometric cutoffs and treatment of severe and moderate acute malnutrition in adults and adolescents, including individuals co-infected with HIV and/or TB Adherence to and promotion of Essential Nutrition Actions Essential Nutrition and Hygiene Actions training modules and reference materials Public health recommendation on iron intervention(s) for genetic trait carriers (e.g., haemoglobinopathy) Vitamin D (with or without calcium) supplementation in the older adult Guidelines for human milk banking Breastfeeding infants with cleft lip and/or palate Use of low maternal BMI as indicator/measure for maternal malnutrition Guidelines for feeding and nutrition needs for sick children (mainly in diarrhoea cases), including increased food intake during and after illness Feeding of sick and small newborns Recommendations for starting iron & vitamin D supplementation in full-term, healthy, breast-fed infants (2 topics) Guidelines on the use of MUAC and height-for-weight measurements in emergency and development contexts Nutrition sensitive interventions Nutrition sensitive homestead-based agricultural production Dietary goals for prevention of obesity and diet-related NCDs 1 Detailed information about the prioritization process can be found at http://www.who.int/nutrition/topics/guideline-development/prioritization-process/en/. 2 Interventions in elena are organized into three categories based on whether or not guidelines have been recently developed and level of evidence available to assess the interventions. Category 2 and 3 interventions are those interventions that are not yet covered by recent WHO guidelines (http://www.who.int/elena/using/en/). 1
Nutritional care for prevention and management of NCDs Dietary patterns and food based guidelines/ recommendations Nutrient requirements Nutrient requirements of healthy and sick people during the life cycle Learning about member countries efforts to track intake of dietary phosphorous at the population level, and effects of consumption of dietary phosphorous in excess of the RDA on bone health Nutrition indicators (including biomarkers, functional indicators) Develop and standardize screening and assessment for malnutrition among those older than 60 years of age Indicators for iron status and anaemia for defining iron deficiency and iron deficiency anaemia Revision and update of Assessment of iodine deficiency disorders and monitoring their elimination: A guide for programme managers Policy actions A catalogue of best-practices regarding sodium reduction efforts at the population level (including any recorded effects on health), along with monitoring efforts on sodium intake Guidance on multisectoral action at the community level to reduce obesity and promote nutritious diets Best practices and strategies for education and outreach efforts regarding use of nutrition labelling information Nutrition standards for school feeding programs Topics in green font were included in the final list of topics to be ranked. Other topics were considered too vague, broad or inappropriate for guideline development (i.e. guideline is not the right type of guidance product), or already covered wholly or in part by existing WHO guidelines II. Ranking of topics by the Expert Advisory Panel in Nutrition Members of the Expert Advisory Panel in Nutrition 3 were invited to rank the list of 66 topics, providing a maximum of ten highest priority topics. Eleven members of the Expert Advisory Panel in Nutrition (four from AMRO/PAHO, two from EMRO, three from EURO, and two from WPRO) participated in the ranking of topics. Members were asked to rank the top 10 topics in order of priority based on the same five criteria participants in the public consultation used in justifying their submitted topics (see Annex 1). Topics were compiled and weighted by: Position on each of the top ten lists; and Number of times the topic appeared in all top ten lists (i.e. the number of members that included it in their individual top ten lists). The top 15 topics as ranked by the Expert Advisory Panel in Nutrition are listed in Table 2. 3 The selection of an expert to serve on an expert advisory panel is made by the Assistant Director General concerned on the recommendation of the technical unit responsible for the panel following consultations at the regional level. The national authorities concerned are consulted on all proposed initial appointments to panels, the letter to the government being signed according to normal procedure by the Assistant Director General for Innovation, Information, Evidence and Research (ADG/IER). Subsequent decisions on the renewal of an appointment, or on the transfer of an expert between panels, are made by the responsible assistant director general, who signs the relevant correspondence with the panel member. Currently WHO has about 47 expert advisory panels working on a wide variety of technical areas. The Expert Advisory Panel in Nutrition (N3/136/3) was the first panel established within WHO on 5 January 1952 and its membership is reviewed and updated periodically. Currently the Expert Advisory Panel on Nutrition includes 36 experts. (WHO emanual. IX.1 Expert Advisory Panels. Geneva: World Health Organization, http://apps.who.int/gb/bd/pdf/bd47/en/regufor expert en.pdf). 2
Table 2. Top 15 priority topics for guideline development ranked by the Expert Advisory Panel in Nutrition Topic Weighted rank Importance 1 Need 2 Targets 3 Evidence 4 Suitability 5 Appropriate complementary feeding practices/education 5.07 3/4 2/4 3/4 3/4 2/4 Guidance on multisectoral action at the community level to reduce obesity and promote nutritious diets 4.62 4/5 6 2/5 4/5 1/5 4/5 Biofortification of staple crops 4.20 4/5 2/5 3/5 2/5 2/5 Continued breastfeeding for healthy growth and development of children 3.38 4/4 1/4 2/4 1/4 0/5 Workplace interventions to support breastfeeding 3.36 1/3 1/3 2/3 0/3 0/3 Conditional/unconditional cash transfer programmes to improve nutritional status 3.12 3/4 1/4 3/4 3/4 2/4 Iron supplementation in full-term, healthy, breast-fed infants 3.12 2/3 2/3 1/3 1/3 2/3 Periconceptional folic acid supplementation to prevent neural tube defects 3.12 2/3 2/3 0/3 1/3 2/3 Guidance on nutrition labelling 2.70 4/6 3/6 3/6 3/6 3/6 Agricultural interventions to improve nutritional status 2.52 3/3 1/3 2/3 1/3 2/3 Indicators for iron status and anaemia for defining iron deficiency and iron deficiency anaemia (other than ferritin) 2.28 1/3 2/3 0/3 1/3 1/3 Nutrition standards for school feeding programmes 2.28 2/3 7 2/3 1/3 1/3 0/3 Zinc supplementation and growth in children 1.95 3/4 1/4 2/4 2/4 2/4 Vitamin D supplementation in those with low 25-hydroxyvitamin D levels 1.68 3/3 2/3 1/3 1/3 1/3 Regulatory actions to reduce industrially-produced trans- fatty acids in the food supply 1.65 1/2 6 0/2 1/2 1/2 1/2 Top 15 topics for guideline development, ordered from high to low priority, based on weighted rank (weighted for position on lists of top ten and for frequency in lists). The last five columns are the number of members (out of the total number who included the topic in their individual top ten lists) indicating the respective factor was important in their decision to rank the topic as they did. For example, in the first row, 3/4 for Importance indicates that out of the four members that ranked Appropriate complementary feeding practices/education among their top ten topics, three of them indicated that public health importance was a factor in their decision to include this topic in their top ten list. 1 Public health importance (the magnitude of the problem in terms of disease or condition burden or prevalence, taking into account regional differences and specification of the affected population) 2 Addresses an unmet need (guidelines developed on the topic should address an area of uncertainty and an unmet need for guidance; does WHO guidance already exist and if so, when was it published and does it needs updating?) 3 Level of contribution towards achieving one or more of the WHO global nutrition and/or diet related noncommunicable disease (NCD) targets as well as concerned SDGs (will producing guidelines on the topic help in reaching the global targets?) 4 Availability of evidence to support assessment of the topic (e.g. primary studies, systematic reviews, pooling studies, survey data, published in peer reviewed journals as well as unpublished reports and other evidence from the grey literature) 5 Suitability of WHO to produce the guideline (i.e. does the topic fall under the remit of WHO?) 6 One member did not indicate which criteria were included in the decision-making process 7 Two members did not indicate which criteria were included in the decision-making process 3
Annex 1. Criteria for guideline development The five criteria that participants in the public consultation and members of the Expert Advisory Panel in Nutrition were asked to consider when suggesting and ranking respectively, topics for NHD guideline development. Public health importance (the magnitude of the problem in terms of disease or condition burden or prevalence, taking into account regional differences and specification of the affected population) Addresses an unmet need (guidelines developed on the topic should address an area of uncertainty and an unmet need for guidance; does WHO guidance already exist and if so, when was it published and does it needs updating?) Level of contribution towards achieving one or more of the WHO global nutrition and/or diet related noncommunicable disease (NCD) targets as well as concerned SDGs (will producing guidelines on the topic help in reaching the global targets?) Availability of evidence to support assessment of the topic (e.g. primary studies, systematic reviews, pooling studies, survey data, published in peer reviewed journals as well as unpublished reports and other evidence from the grey literature) Suitability of WHO to produce the guideline (i.e. does the topic fall under the remit of WHO?) 4
Annex 2. Public consultation participant information Professional title Organization/affiliation Country Academic/research Scientist ETH Zurich Switzerland Associate Professor Institute of Nutrition, Mahidol University Thailand Government Senior Policy Advisor ACF/OHS United States of America National nutritionist Health and Human Services/Administration for Community Living/Administration on Aging Doctor Ministry of Health Sri Lanka Sri Lanka Professor Postgraduate Institute of Medical Education & Research, Chandigarh, India United States of America Senior Nutrition Advisor U.S. Agency for International Development United States of America Deputy Director US Food and Drug Administration United States of America UN agency Technical Officer Nutrition WHO country office, Rwanda Rwanda Non-governmental organization Senior Nutrition Advisor Helen Keller International United States of America Director MNCH Center John Snow Inc. United States of America Nutrition Advocate Nutrition For All Ireland Communications Officer PATH United States of America Private sector Senior Scientist Nutrition DSM Switzerland Manager, Global Strategies Grocery Manufacturers Association United States of America Technical Manager International Dairy Federation Belgium CEO RSD consulting Ltd Bangladesh India 5
Annex 3. Topics provided to the Expert Advisory Panel in Nutrition for ranking 1. Workplace interventions to support breastfeeding 2. Financial incentives for breastfeeding 3. Breastfeeding infants with cleft lip and/or palate 4. Appropriate complementary feeding practices/education 5. Continued breastfeeding for healthy growth and development of children 6. Guidelines for human milk banking 7. Neonatal vitamin K administration 8. Periconceptional folic acid supplementation to prevent neural tube defects 9. Iodine supplementation in pregnant and lactating women 10. Dietary advice for women with gestational diabetes mellitus 11. Guidelines on the use of MUAC and height-for-weight measurements in emergency and development contexts 12. Vitamin D supplementation in full-term, healthy, breast-fed infants 13. Vitamin E supplementation for the prevention of morbidity and mortality in preterm infants 14. Zinc supplementation and growth in children 15. Vitamin D supplementation in those with low 25-hydroxyvitamin D levels 16. Calcium and vitamin D for increasing bone mineral density in premenopausal women 17. Iron supplementation in full-term, healthy, breast-fed infants 18. Iodine supplementation in children 19. Vitamin A supplementation in children with respiratory infections 20. Vitamin D supplementation and respiratory infections in children 21. Zinc supplementation in children with respiratory infections 22. Vitamin A supplementation in children with measles 23. Zinc supplements for preventing otitis media 24. Biofortification of staple crops 25. Vitamin A fortification of staple foods 26. Fortification of staple foods with zinc for improving zinc status and other health outcomes 27. Fortification of condiments and seasonings with vitamins and minerals 28. Preventing and controlling micronutrient deficiencies during emergencies 29. IYCF in emergencies 30. Adequate nutrition in refugee populations and displaced populations 31. Macronutrient supplementation for people living with HIV/AIDS 32. Micronutrient supplementation in HIV-infected women during pregnancy 33. Nutrition counselling for adolescents and adults with HIV/AIDS 34. Micronutrient supplementation in adults with HIV infection 35. Micronutrient supplementation in children with HIV infection 36. Vitamin A supplementation in HIV-infected adults 37. Vitamin A supplements for reducing mother-to-child HIV transmission 38. Oral protein calorie supplementation for children with chronic disease 39. Nutrition support in hospitalised adults at nutritional risk 40. Feeding and nutrition needs of acutely ill newborns and children (mainly in diarrhoea cases) 41. Nutritional interventions for preventing and treating pressure ulcers 42. Zinc supplementation in the management of diarrhoea 6
43. Probiotics in the management of acute and persistent diarrhoea 44. Standardized nutritional screening and assessment procedures for older adults 45. Vitamin D (with or without calcium) supplementation in the older adult 46. Antioxidant vitamin and mineral supplements to prevent/slow down the progression of age-related macular degeneration (AMD) 47. Vitamin E for Alzheimer's dementia and mild cognitive impairment 48. Public health recommendation on iron intervention(s) for genetic trait carriers (e.g., haemoglobinopathy) 49. Limiting portion sizes to reduce the risk of childhood overweight and obesity 50. Diets low in energy-density (for the prevention of unhealthy weight gain) 51. Guidance on multisectoral action at the community level to reduce obesity and promote nutritious diets 52. Water, sanitation and hygiene interventions to prevent diarrhoea 53. Insecticide-treated nets to reduce the risk of malaria in pregnant women 54. Conditional/unconditional cash transfer programmes to improve nutritional status 55. Household food production strategies (including homestead based agriculture) and nutritional status 56. Agricultural interventions to improve nutritional status 57. Intermittent preventive antimalarial treatment for children with anaemia 58. Inter-pregnancy interval and maternal and infant health outcomes 59. Cooking in iron pots and anaemia 60. Indicators for iron status and anaemia for defining iron deficiency and iron deficiency anaemia (other than ferritin) 61. Anthropometric cutoffs and treatment of severe and moderate acute malnutrition in adults and adolescents, including individuals co-infected with HIV and/or TB. 62. Guidance on nutrition labelling 63. Guidance on fiscal policies 64. Regulatory actions to reduce industrially-produced trans- fatty acids in the food supply 66. Nutrition standards for school feeding programmes 7