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Global Nutrition Targets 2025

Reduce and maintain childhood wasting to less than 5%

WHATS AT STAKE

The World Health Assembly Resolution 65.6 (2012) endorsed a comprehensive implementation plan on
maternal, infant and young child nutrition, which specified six global nutrition targets for 2025. This
policy brief covers the sixth target: to reduce and maintain childhood wasting to less than 5%. The global
target for 2025 will be achieved if high-burden countries take stock of their current prevalence,
projected population growth, underlying causes of wasting and the resources available to address them;
set target annual reduction rates to guide intervention efforts; mobilize necessary resources, and
develop and implement systematic wasting reduction plans. Countries need to examine inequalities
among populations and identify for priority action particular vulnerable or marginalized groups where
large numbers of wasted children cluster. Such an equity-inspired approach is both an ethical imperative
and a judicious investment strategy.

Addressing wasting is of critical importance because of the heightened risk of disease and death for
children who lose too much of their body weight. It will be difficult to continue improving rates of child
survival without improvements in the proportion of wasted children receiving timely and appropriate
lifesaving treatment, alongside reductions in the number of children becoming wasted in the first place
(prevention).

WHO classifies wasting as severe or moderate, according to the WHO growth reference for weight-for-
height.1 Wasting is a reduction or loss of body weight (or ponderal growth) in relation to height. Acute
malnutrition in children 6 to 59 months can be either moderate or severe. Severe acute malnutrition is
defined as severe wasting and/or mid-upper arm circumference (MUAC) < 115 mm and/or bilateral
pitting oedema. Moderate acute malnutrition is defined as moderate wasting and/or MUAC >= 115 mm
and less than 125 mm). It is estimated that 52 million children under-five years are wasted in the world
at any point in time, with 17 million estimated to be severely wasted, based on national level prevalence
data (ref. WHO/UNICEF/WB Global estimates). It is important to note that these estimates may miss a
relatively large proportion of incident wasting cases occurring over time and, depending on the timing of
the survey on which they are based, seasonal peaks may also be missed. This means that the current
global estimates underestimate the actual annual wasting burden (ref. ENN Technical Brief on Wasting).

The majority of all moderately wasted children (69%) and severely wasted children (71%) live in Asia2.
Just over one quarter of all moderately (28%) and severely (28%) wasted children live in Africa,. Of note

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here is that the majority of wasted children live outside of the humanitarian context, which is more
commonly associated with high levels of wasting and where treatment programmes have traditionally
focussed. It is estimated that globally less than 15% of wasted children are currently being reached by
treatment services, see Table 1 below, and in some countries this percentage is considerably lower.
These statistics are of serious global concern given the well-established link between wasting and
mortality.

Wasting accounts for 7.4% of <5 deaths globally and that repeated or prolonged bouts of untreated
wasting can lead to stunting (add ref). Severely wasted children are on average 11 times more likely to
die than their healthy counterparts.3 The current global levels of severe wasting are responsible for up
to 2 million deaths annually.4 Furthermore, even higher mortality has been reported when children are
both wasted and stunted (with low height-for-age).5

Suboptimum growth indicative of wasting has been shown to increase the risk of death in childhood
from infectious diseases such as diarrhoea, pneumonia, and measles.6 With regard to how wasting links
with other nutrition and health issues in general and the WHA targets in particular, it is not yet well
understood how much wasting contributes to conditions such as stunting, low birth weight and
anaemia. Evidence does suggest, however, that episodes of wasting negatively affect linear growth and
as such undermine child growth and development (ref). The global targets for nutrition are synergistic,
as different forms of undernutrition (wasting and stunting, or wasting and anaemia, for example) often
co-exist, in individuals, households and communities; improvements in one will therefore be highly likely
to have an effect on the others, and conversely, inaction on one aspect will likely hinder progress on the
others. It is in policy makers interest, therefore, to make necessary investments in wasting reduction
now as a means to promote human capital development and their nations economic growth and long
term health, wealth and wellbeing.

Wasting and stunting, in particular, share common direct and underlying causal factors and preventative
services tackling these causes are therefore likely to impact both conditions. Black et al (2012) found
associations between highly variable weight for height and lower linear growth (a history of episodes of
wasting, different than saying episodes of wasting). There must be a clear recognition that wasting
confers double the risk of mortality conveyed by stunting, and being both stunted and wasted an even
higher risk. The lack of recognition and emphasis for increased mortality risks means policy makers may
also not be aware of how important it is to tackle wasting as a priority and the positive effect this may
have on child mortality rates.

The WHA wasting target has two aspects - reducing and then maintaining levels of childhood wasting to
below 5% - both major challenges. Currently some (highly populated) countries report a prevalence of
wasting of more than 10% throughout the year, such as Nigeria (10%), Pakistan (15%) and India (20%)
with these levels likely to rise during the hungry seasons, as rates of wasting tend to surge seasonally
during the year in hungry or lean seasons7 8.

Of the 118 countries that reported wasting prevalence in 2013, only 49 (42%) reported a national
average prevalence of less than 5%. This leaves 69 countries currently falling short of the target, with a
further 78 countries for which data are not available9. Furthermore, in the 49 countries that reported
wasting of less than 5%, data was not available to confirm that levels did not rise above 5%, at any point
during that year.

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Table 1 Estimated global numbers and percentage of children under-five with severe and moderate
wasting treated in 201210

Severe Wasting Moderate Wasting


Estimated number of children at 17 million 34 million
any given time11
Number of children reached with 2.6 million 4.6 million
treatment services in 2012
Percentage of case load <15% <13.5%
reached12

A challenge in the interpretation of the above estimates of both the wasting burden and the reach of
services is that they use prevalence measures (e.g. a measure of how widespread the problem is at one
point in time), rather than incidence (a measure of cases occurring during the year). Wasting is a
relatively short-term condition compared to stunting and, as described above, is also highly affected by
seasonality. Using prevalence to measure the burden of wasting therefore risks underestimating the
number of children affected and, in turn, overestimating the percentage of the yearly caseload being
reached. Surveys of coverage (i.e. percentage of those found to be wasted that are reached by
treatment services) are required to accurately estimate how many wasted children are being reached,
yet few countries have carried out national coverage assessments to date.

WHAT CAUSES WASTING


Children become wasted when they lose weight, usually as a result of a combination of infection and
WHAT CAUSES WASTING
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lot of the wasting starts very early and is tied to this.

The main underlying causes of wasting are in common with all forms of undernutrition (see the WHO
conceptual framework for stunting):
High rates of infection and poor access to appropriate, timely and affordable health care
Inadequate caring and feeding practices (e.g. exclusive breastfeeding or quantity and quality of
complementary food)
Poor food security not only in humanitarian situations, but also an ongoing lack of food
quantity and diversity; characterised by a monotonous diet with low nutrient density in many
resource poor settings

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These causal factors vary in terms of emphasis in different situations, but the result is the same; thin,
sick children, at high risk of death if they do not, or cannot, access appropriate treatment.

FRAMEWORK FOR ACTION

1. Improve the identification, measurement, understanding, and treatment of wasting and scale up
coverage of wasting identification and treatment services

The global extent and consequences of wasting, particularly in some high burden countries, has been
recognized through the issuing of joint statements by the United Nations. These have endorsed the
community-based approach for improving coverage of treatment of wasting, including use of mid upper
arm circumference (MUAC), as an alternative to assessing weigh-for-height, to aid timely
identification13. Decentralised outpatient treatment services are offered for those with severe acute
malnutrition (severe wasting and/or low MUAC and/or bilateral oedema) , from a basis of community
identification and referral of cases, with inpatient care also provided for those with poor appetite,
severe bilateral oedema and/or additional medical complications. Supplementary foods are provided to
those who are moderately wasted and who do not have access to diets that cover their nutrient needs,
and their medical conditions are treated.

Since the issuing of the joint statements and development of guidance documents, some countries have
rapidly scaled up treatment services to national level, with Ethiopia perhaps the most successful
example of effective service decentralisation, as described in Box 1, below.

Box 1

Ethiopia decentralized, scaled-up, treatment of Severe Acute Malnutrition

Since 2008, the Ethiopian Ministry of Health (with partner support) has massively decentralized
treatment services, to ensure wider access to, and coverage of, services to treat severe acute
malnutrition. Following simplification of protocols and training of 8,500 front line health
workers (Health Extension Workers), the service was decentralized to health posts. During
2013 (a year of good harvest), a total of 267,500 children were admitted for therapeutic care
(250,000 to outpatient care, a further 17,500 to inpatient). Results are continually above
internationally recommended standards, with an 86% recovery rate reported for the year.
During the early stages of the service, staff turnover was an issue (especially for ensuring all
staff received appropriate training) and the reporting rate was poor. These challenges have
been overcome, with 86% of facilities providing regular reports during 2013.

Treatment for severe wasting is not only vital but is also cost-effective, with estimates given at $200 to
treat each severely wasted child14. In fact, the Lancet Series on Undernutrition (2013) recognized the
treatment of SAM as the most cost effective of the various direct nutrition interventions. The earlier the
child accesses treatment, the cheaper it will be, as they will be less likely to have developed additional
medical complications and recovery times will be shorter. It makes economic sense to invest in nutrition,
as services generally offer one of the best returns on investment; overall, every $1 invested in nutrition
including the treatment of SAM generates as much as $138 in better health and increased productivity.
At the other end of the scale not investing in nutrition right now will perpetuate the economic losses,

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both to individuals and to countries at an estimated cost of up to 11% of annual GDP in lost
productivity15.

2. Develop improved methods and linkages of wasting identification and treatment, both within the
health sector and cross-sectorally

While the treatment of severe wasting is a well-established evidence-based intervention16, integrating it


into essential health packages at national level has proven to be more challenging. This is partly due to
existing weaknesses in health systems and challenges with securing sufficient long-term funding to
adequately scale up the service to national level. It is also partly due to perceptions of where
responsibilities lie; the international community has often supported the treatment of wasting during
emergency situations. However, in order to reach the majority of children suffering from wasting in high
burden contexts, it is vital for wasting treatment to be integrated into a countrys essential health
package and for routine training and supervision of health staff in wasting treatment protocols and
community mobilization and early identification to be included as part of the curriculum.17

In many countries where the burden of wasting is high, there are no specific activities for either
treatment or prevention of moderate wasting. To manage children 0 to 24 months with moderate
wasting, the package of Essential Nutrition Actions should be implemented, including activities such as
breastfeeding promotion and support, and nutrition counselling for families regarding complementary
feeding practices. For older children, the focus should be on improving family foods (diversity, quality
and safety). Moderately wasted children need to have access to health services and be treated for any
medical condition they might have. In emergency contexts, including food insecure settings, treatment
of moderate wasting usually consists of provision of a supplementary food. Linear programming is a
tool that can be used to assess whether specific available foods can a) meet nutrient intake
recommendations and b) can be afforded by households and c) are part of the current diet (Optifood).
Besides nutrition counselling or making available appropriate supplementary foods, the provision of
cash vouchers/transfers is being explored further by a number of actors and may present advantages
over product-based strategies to address moderate wasting, although there is limited consensus yet
amongst the international community about the best approaches for either the treatment or the
prevention of moderate wasting.

The nature of nutrition is that it spans many sectors; as such improved nutrition has the potential to be
a catalytic cross-sectoral force for reaching towards targets. At present however, evidence is limited
regarding the best ways to integrate nutrition within other sectors to achieve the desired
improvements. The impact of nutrition-sensitive interventions on wasting (e.g. agriculture, social
protection, education, water and sanitation, etc.) has not been estimated. Improvements in the design
of nutrition-sensitive services will increase our ability to;
Identify which of these indirect programmes have the greatest effect on improving nutrition
outcomes
Attribute any improvement in nutritional status to the investments made

The number of countries that have developed multisectoral plans that include the treatment and
prevention of wasting is limited, but increasing. Nepal provides a good example, see box 2, below.

Box 2

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Nepal experiences high levels of undernutrition, with wasting levels at 11%. The management of severe
wasting has been included in the Multi Sector Nutrition Plan (MSNP) developed by the Government of
Nepal. A high level steering committee oversees the operationalisation of this plan and reports into the
Prime Ministers office, hence there is good government buy-in and commitment. The plan will be
monitored and results measured from the details outlined in the plans logical framework.

3. Rapidly develop evidence for effective prevention strategies to reduce the burden of wasting,
which can then be translated into policy actions.

Progress to achieve this target will depend not only on the scale up of interventions to treat severe
wasting but also on the strength and effectiveness of prevention strategies. While Ethiopia is having
stellar success in treating hundreds of thousands of children each year, the large numbers of children
becoming wasted is not yet reducing and seasonal surges of wasting are still occurring, even in years of
good harvest. Better links with prevention services, which are tailored to the context and which
encompass a range of different services, e.g. promotion of improved infant and young child feeding,
promotion of good hygiene, sanitation and preventive health services, and better social protection
policies and programs (ie., targeted to the poorest families who need social support to have access to
diets that cover nutritional needs the year round)are urgently required, to reduce the numbers of
wasted children presenting for treatment. Country level contextualisation is essential as strategies that
are successful in Asia might not be in Africa, for example. With India accounting for approximately one
half of the global wasting burden18, reductions in the overall burden of wasting will be highly dependent
on the extent to which India places treatment and prevention of wasting as a national priority.

4. Encourage and commission research to better understand the links between wasting and
stunting to ensure maximum leverage is realised from the current investments in nutrition
programming

Programmes, policy, research and financing for wasting and stunting have been separate. Both wasting
and stunting (and micronutrient deficiencies) share causal pathways, suggesting that action on one will
very likely impact the other and indeed interventions to prevent stunting have also shown benefit in
terms of wasting reduction in populations where wasting is highly prevalent (ref). For this reason it is
important to include treatment and prevention of wasting into development plans and goals. Wasting is
a condition that millions of children are developing each year, with a large burden of these numbers
being in non emergency situations. It is vital that policy makers understand the importance of viewing
the problem of wasting not only from the humanitarian perspective, but that a wider lens is required, if
the dramatic and consistent reductions in wasting that are urgently needed are to be achieved.

ACTIONS THAT CAN DRIVE PROGRESS IN REDUCING WASTING

1. Improve the identification, measurement and understanding of wasting and scale up coverage of
wasting identification and treatment services

Develop national wasting targets that are in line with and will contribute to the achievement of
the global WHA targets (target tracking tool link here) Strengthen methods to accurately assess
the burden of acute malnutrition for service planning, design and monitoring, including

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assessment according to the criteria used for admission (including bilateral oedema and MUAC);
as well as support the widespread assessment of national treatment coverage to allow for
accurate assessment of the uptake and effectiveness of treatment services, for both SAM and
MAM.
Promote a holistic view of malnutrition through understanding that stunting, wasting and
micronutrient deficiencies can occur in the same child, family and community and ensure
services for undernutrition are implemented in a more cohesive fashion.
Develop national advocacy strategies to ensure that policy makers understand that wasting is
not a condition that only occurs in emergency contexts, but is an ongoing and serious cause of
child mortality and morbidity.
Develop better understanding of the major causal factors of wasting, including patterns
according to the time of year and ensure there is available resources and capacity to analyse the
data. Intensify prevention strategies leading up to lean/hungry periods and ensure treatment
services have been scaled up to treat caseloads during the seasonal surges of wasting.

2. Develop improved methods and linkages of wasting identification and treatment, both within the
health sector and cross-sectorally

Ensure treatment of severe wasting is an integral part of the health policy/system and link with
existing support for health systems strengthening, by e.g. building the national capacity. Pre-
service training is essential for all levels of health staff. In-service training is important when the
new service is introduced and as refresher thereafter.
Invest in health system strengthening, supply chain management of ready to use therapeutic
foods (RUTF), and other health technologies which are currently subject to stock outs and are
also expensive for national governments to procure. Failure to strengthen health systems to
integrate nutrition at scale will hamper progress and impact on reducing malnutrition.
Ensure identification of wasting is conducted at all entry points of the health system, including
vaccination services, child health days, etc.
Ensure that mortality due to wasting is recorded as such.
Decentralize treatment services to lower level health facilities and indeed health care workers
(as in iCCM) can dramatically improve access and coverage and open access for the hardest to
reach. Evidence shows it can be safe and effective, but it should be trialled in each new context
before wide scale-up.
Support the inclusion of nutrition outcomes in large multisectoral programmes, such as safety
nets, agricultural and educational initiatives, in order to establish whether services are
delivering results for nutrition.
Include nutrition in primary and secondary school education general curricula as a means of
sensitising the future mothers and fathers and for the children can take these messages home
and influence their own parents

3. Rapidly develop evidence for effective prevention strategies to reduce the burden of wasting, which
can then be translated into policy actions.

Develop practical links between treatment and prevention services, tailored to context.
Prevention strategies will often need to be delivered outside of the health system in other
sectoral programmes/services; use of simple key messages (such as the Essential Nutrition
Actions) will help ensure clear and consistent messages are provided, across all contexts.

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Promote more research into seasonal approaches for preventing moderate wasting, e.g. use of
cash transfers or the distribution of specific nutrient-dense food supplements during lean
seasons, and into sustainable solutions to improve year-round access to an appropriate diet for
the prevention of wasting.

4. Encourage and commission research to better understand the links between wasting and stunting, to
ensure maximum leverage is realised from the current investments in nutrition programming

Better define the associations that exist between stunting and wasting in the under-five
population and the synergistic effect of tackling wasting along -side other nutrition interventions
such as micronutrient deficiency control.
Investigate whether there are regions/countries in the world where the association between
wasting and stunting is more (or less) evident.
Support operational research to investigate the effects of wasting and wasting treatment on
linear growth.
Support operational research into joint approaches for prevention of stunting and wasting.

5. Encourage the increase of long-term funding for the prevention and treatment of acute malnutrition

Improve sustainable funding for acute malnutrition/wasting in national health budgets as a


priority, followed by national budgets in other sectors that include nutrition (nutrition-sensitive
long-term budgets in other sectors).

6. Coordination

Improve coordination between government ministries, UN agencies and other relevant


stakeholders to link treatment strategies for acute malnutrition to prevention strategies for
wasting and stunting throughout the life course.

Acknowledgements (to be added)


1
This definition does not include children with bilateral pitting oedema; a form of acute undernutrition that results from similar
causal pathways to wasting.
2
UNICEF, WHO, World Bank, 2012
3
McDonald et al, 2013.
4
Bhutta et al, 2009.
5
McDonald et al, 2013.
6
Pelletier et al, 2012.
7
Brown et al, 1982;
8
Maleta et al, 2003.
9
http://www.who.int/nutgrowthdb/estimates2012/en/ date accessed 26.3.14
10
UNICEF, 2012. WFP 2014 (in press).
11
UNICEF, WHO, World Bank, 2012
12
It should be noted that accurate reporting was identified as a weakness in both the severe and moderate wasting mapping
exercises.
13
UNICEF, WHO, World Bank, 2012
14
Horton et al, 2010.
15
Black et al, 2010, Black et al 2013.

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16
Black et al, 2008, 2013.
17
Khara & De Costa et al, 2012
18
UNICEF, WHO, World Bank, UN-DESA Population
Division.http://www.who.int/maternal_child_adolescent/documents/levels_trends_child_mortality_2013/en/

(Note: references will be listed according to the WHO Style Guide)