Persistent Global Acute Malnutrition: A discussion paper on the scope of the problem, its drivers, and recommendations for policy, practice, and research
In many protracted emergencies, the prevalence rates of global acute malnutrition (GAM) regularly exceed the emergency threshold of > 15% of children with acute malnutrition (< -2 weight-for-height z-scores (WHZ) or with nutritional edema), despite ongoing humanitarian interventions. The widespread scale and long-lasting nature of “persistent GAM” means that it is a policy and programming priority.
Drawing on a literature review and a series of key informant interviews, this paper describes the scale and duration of the persistent GAM problem, the perceived causal pathways, the methodological challenges in identifying trends and understanding drivers, and the implications for current practice and policies as well as for future research.
Our interviewees identified 25 countries as places where persistent GAM is widely recognized as an issue. The most frequently referenced were Somalia, Ethiopia, and South Sudan. The Sahel belt and Horn of Africa were the two most consistently highlighted regions. South Asia, including India, Pakistan, and Bangladesh, was also mentioned, indicating this problem is not limited to humanitarian contexts but is also evident in more stable development settings despite wider global improvements in stunting and under-five mortality. Using available survey data, four case studies are presented (see Annex 2), where the prevalence of GAM generally remains above 15%: Chad, Bangladesh, South Sudan, and Niger.
Informants generally agreed that an understanding of the drivers of GAM must inform the design of interventions that address it. The UNICEF conceptual framework—“causes of malnutrition and death”—remains the most well-known and widely adopted conceptual framework and has been reproduced many times. Informants noted that in a protracted crisis, the drivers of persistent GAM are often unclear, in part because the three underlying causes—food, care, and health—all potentially play a role, so there may be no single reason accounting for persistent GAM.
However, a “food-first” focus still tends to dominate thinking and practice in preventing malnutrition in acute emergencies despite the recognized importance of public health in controlling disease and increasing awareness of care for children and women. However, evidence in protracted persistent GAM settings indicates that food security may not be the main driver.
The UNICEF framework provides a starting point for understanding malnutrition causality, but it needs to be elaborated on to understand the basic causes that apply in protracted emergency contexts, including potentially protracted war, conflict, and insecurity; marginalization; inequalities and poverty; governance of natural resources; and migration and displacement. In addition, four cross-cutting themes emerged from the interviews, ones that are not explicit in the UNICEF framework but are felt to be crucial in understanding persistent GAM, including: gender; livelihood systems; the history of vulnerability and long-term trends driving acute malnutrition; and seasonal fluctuations in acute malnutrition.
There are a number of methodological challenges in studying persistent GAM. First, there is limited availability of reliable and comparable data on acute malnutrition, across time and populations. Second, the switch from anthropometric reference data to WHO growth standards in 2006 had implications for comparability over time. Another potential challenge is the slight differences in body shape that have been observed among children over two years of age from different populations, which associates longerlimbed types with pastoralist populations in hotter, semi-arid environments.
Various approaches are used for analyzing the drivers of malnutrition, ranging from household surveys to qualitative approaches and mixed methods. While surveys can be used for testing correlations and regression analysis, a general lack of capacity and resources tends to limit this approach in practice. Both localized surveys and qualitative methods suffer in that results are not generalizable.
Recent methodological advances include a new participatory and response-oriented methodology known as Link-NCA, which has now been applied in more than 30 settings. Identified strengths of this approach are that it can bring together stakeholders, raise awareness, and build consensus. However, the issue of response analysis and uptake of findings remains a challenge not only for Link-NCA but also for all methodologies.
Addressing persistent GAM presents particular challenges for operational agencies, in part as a result of structural issues within the humanitarian system (focus on treatment of severe acute malnutrition, “siloed” sectors, short-term funding cycles that do not include nutrition causal analysis (NCA) or prioritize prevalence data).
The paper offers some potential strategies for moving forward. First, treatment and prevention should go hand in hand at all stages of an emergency; second, nutrition-sensitive programs based on partnership, localization, and more participatory ways of working should be adopted as common practice; third, the root causes of persistent GAM linked with the wider political economy and protracted crisis should be more seriously analyzed; fourth, a learning culture linked to research uptake and response analysis should be promoted.
This last point is linked to a proposed research agenda to strengthen the evidence base in order to guide programs and policies. Important research gaps highlighted in this review relate to further analysis of wasting trends and, linked with this analysis, the relationship between wasting, stunting, and mortality. A major area for future research is further investigations of specific pathways associated with wasting, including the role of environmental enteropathy pathogens, the microbiota, and the role of pre-existing nutritional status on child wasting