PREVENTING EARLY CHILDHOOD UNDERNUTRITION IN THE SAHEL REGION: RECOMMENDATIONS FOR SMALL–QUANTITY LIPID–BASED NUTRIENT SUPPLEMENT INTERVENTIONS By Nakawala Lufumpa, Anne Hilger, Odyssia Ng, and Bénédicte de la Brière SASPP Policy Note Series NOTE 9 | JUNE 2023 SASPP Policy Note Series 2 NOTE 9 | JUNE 2023 KEY RECOMMENDATIONS This policy note presents evidence–based guidance for the effective design, implementation, and utilization of small–quantity lipid–based nutrient supplements (SQ–LNS) interventions in the Sahel region. SQ–LNS are food supplements containing essential nutrients and are intended for daily consumption alongside standard age–appropriate diets. SQ–LNS effectively prevent child undernutrition and improve child growth and development. The key recommendations for modifying SQ¬–LNS interventions in Sahel country contexts to maximize their impact on child health are as follows : • Provide SQ–LNS to children at age six–months or shortly after; and for a period of 12 months or longer. • Ensure complementary messaging is provided alongside SQ–LNS products that emphasizes their importance as a supplement to a safe, nutritious, and age–appropriate diet. • Provide SQ–LNS through community platforms to overcome barriers to accessing health care facilities. • Identify SQ–LNS products being produced regionally, where feasible, to minimize program costs. • Ensure adequate storage conditions to preserve the integrity of SQ–LNS products (i.e., 24–month shelf life and storage below 30° Celsius). • Implement SQ–LNS interventions alongside key social protection programs to minimize unintended product over–or under–use in close collaboration with health sectors. 1 Introduction Child undernutrition is a significant public health and life can impair cognitive and physical development, and development issue in Sub–Saharan Africa, with the result in significant costs to human capital2, including Sahel region bearing a disproportionate burden of health, education, and productivity costs to individuals, cases.1 In the Sahel, only 13 percent of children between households, and economies.3 It is estimated that childhood age 6 and 23 months have a diet that meets the World undernutrition costs Sahel countries between US$451 Health Organization (WHO) recommendation for minimum million and US$802 million annually.4,5,6 dietary diversity. Undernutrition in the first few years of SASPP Policy Note Series 3 NOTE 9 | JUNE 2023 2 Context for SQ–LNS Interventions in the Sahel Small–quantity lipid–based nutrient supplement (SQ–LNS) In lower–middle–income countries (LMICs), the provision interventions can effectively prevent undernutrition and of SQ–LNS to children between age 6 and 23 months, for improve child growth.7 SQ–LNS are food supplements that 3 months or longer, reduces undernutrition and mortality contain essential macronutrients and micronutrients and and improves child growth and development.8 Also among are intended for daily consumption alongside standard LMICs, SQ–LNS are more effective than conventional age–appropriate diets. SQ-LNS are for the prevention of interventions such as fortified blended foods, nutrition undernutrition, while other nutritional supplements are education, and micronutrient supplementation.9 SQ–LNS for the treatment of acute malnutrition. Large–quantity can either be consumed alone or used to fortify meals. Most lipid–based nutrient supplements (LQ–LNS) are an at–home SQ–LNS include a base of peanuts, chickpeas or lentils, treatment for severe acute malnutrition, and medium- milk, oil, sugar, and a ready–made blend of micronutrients. quantity lipid–based nutrient supplements (MQ–LNS) are However, the exact contents of SQ–LNS can vary in different an at–home treatment for moderate acute malnutrition or settings to reduce production costs or accommodate for are used to prevent malnutrition in emergency settings with local tastes. In two Sahel countries — Burkina Faso and severe levels of food insecurity. Importantly, both LQ-LNS Niger, the use of a peanut base has proven acceptable in and MQ-LNS are used in instances where children do not terms of local taste.10 have additional medical complications. 3 Design of SQ–LNS Interventions in the Sahel 3.1 Timing of Supplementation 3.2 Complementary Services and Interventions SQ–LNS are most effective when introduced at age 6– months and consumed for a minimum duration of 12 SQ–LNS must be implemented alongside complementary months. The optimal age to introduce SQ–LNS for children is services and interventions that address context–specific age six–months or shortly after. WHO recommends exclusive causes and constraints of child undernutrition at the breastfeeding until age six–months, at which point the risk household level.12,13,14 SQ–LNS is not a standalone program, of undernutrition increases significantly due to poor food and in the Sahel, complementary services and interventions safety or inadequate supplementary diets — specifically, should include the provision of health education, information inadequate dietary diversity or meal frequency. Providing about how to prevent and manage child illness, and how SQ–LNS for a duration of at least 12 months or longer to improve dietary diversity alongside the consumption of significantly increases the impact on child undernutrition SQ–LNS. In different settings, complementary interventions and growth.11 can include nutrition education, or behavior change communication focused on improving WASH behavior and infant and young child feeding. At a macro level, complementary interventions may include improving WASH infrastructure, strengthening health systems, and improving household food security. SASPP Policy Note Series 4 NOTE 9 | JUNE 2023 Box 1: Case Study — Madagascar15 of primary caregivers (largely mothers) on safe WASH practices and clinically recommended child feeding In Madagascar, a SQ–LNS intervention was introduced to and care practices. Primary caregivers were also given address a high prevalence of childhood undernutrition. one month’s supply of SQ–LNS to prevent childhood Caregivers of children between age 6 and 18 months undernutrition, and child body measurements were were given SQ–LNS products weekly over a 12-month assessed. Within each community, leaders and elders period and were encouraged to use them to fortify 2 were identified to encourage primary caregivers to attend of the child’s meals daily. monthly behavior change communication sessions and assist in the implementation of the program. This The provision of SQ–LNS was integrated into the monthly intervention improved coverage of acute malnutrition provision of community–based growth monitoring screening and aided the prevention of new acute and promotion clinics. During these clinics mothers malnutrition cases. were educated about infant and young child feeding and WASH behavior. Community health workers also regularly conducted cooking demonstrations using local and affordable food items. Community health workers also regularly visited homes to educate mothers about infant and young child feeding, as well as subsistence farming of crops and livestock. The frequency of home visits was child age–dependent, with more frequent visits scheduled for households with younger children. 3.3 Delivery Mechanism In the Sahel, providing SQ–LNS through communities instead of through healthcare facilities can lower costs and increase impact on child growth and nutrition outcomes.16,17 Providing SQ–LNS through communities addresses key barriers to accessing healthcare services, including distance to healthcare facilities, and time and opportunity costs.18 Empowering community members with basic health knowledge alongside the provision of supplementary food can be an effective delivery mechanism, particularly in the Sahel where conflict has disrupted the functioning of healthcare facilities. Additionally, where feasible, more frequent visits or sessions increase impact, for example through weekly distribution of SQ–LNS instead of monthly. Box 2: Case Study — Mali19 In Mali, community health volunteers scheduled monthly behavior change communication sessions in their communities. During these interactive sessions, the community health volunteers educated small groups SASPP Policy Note Series 5 NOTE 9 | JUNE 2023 4 Implementation of SQ–LNS Interventions in the Sahel 4.1 Supply and Distribution Chain 4.2 Storage Requirements Most LMICs currently procure lipid-based nutrient Due to the climatic conditions among Sahel countries, supplements (LNS) and other ready–to–use supplementary stringent storage conditions must be met to preserve the food through World Food Programme (WFP) or UNICEF. safety and nutritional value of SQ–LNS products. Most LNS products are largely manufactured outside of Africa, SQ–LNS products have a 24–month shelf life and must be purchased by institutions such as WFP or UNICEF, and stored below 30° Celsius. The quality of SQ–LNS products transported to regional warehouses.20 They are also must be reassessed if they are kept above 30° Celsius available through the PlumpyField network. Once at the for over six months or above 40° Celsius for over three regional warehouses, local NGOs or UN country offices months.27 This is especially important in the Sahel where purchase their desired amount of LNS products and use temperatures regularly reach above 30° Celsius and given local distribution chains to deliver products.21 In many the rise of pre–positioning of supplements. The quantity instances, to enable reliable access to supplementary of pre–positioned supplements should meet the existing foods, institutions like WFP and UNICEF have relied on or anticipated demand to ensure that products are used the pre–positioning of supplements that are procured in before expiration. Appropriate storage conditions should advance and stored in national or regional warehouses. exist both within warehouses and during distribution. These requirements may affect program costs. Localizing the production of LNS products within African countries has been identified as a key opportunity, with projected viability having factored in establishment costs.22 4.3 Integrating SQ-LNS Initiatives that seek to locally produce internationally Interventions into Existing formulated SQ–LNS products must meet existing international standards and guidelines.23 Initiatives that seek Policy to formulate and manufacture new SQ–LNS products locally, must also consider ingredients, nutritional standards, food SQ–LNS interventions can either be integrated into safety, quality standards, and packaging.24 Meeting these existing policy or introduced cohesively alongside existing requirements will enable countries to reduce production policy, depending on country–specific intervention aims. costs and ensure that products align with local taste. If LNS For example, in settings where the primary goal was to products are being formulated for both local use and export, encourage attendance at growth monitoring and promotion products must also meet the requirements of large buyers clinics, SQ–LNS programs have partnered with the health such as UNICEF and WFP. WFP has developed guidelines sector. USAID has identified several sectors or existing and requirements for the manufacturing, safety, and quality programs for integration or cohesive implementation, of SQ–LNS products.25 including nutrition, health, food assistance, agriculture, WASH, social protection, and education.28 For social A short–term initiative to avoid or minimize fixed costs protection or food assistance platforms, SQ–LNS can be could be to introduce the formulation and/or manufacturing supplied alongside the provision of cash transfers, vouchers, of SQ–LNS at West African facilities where larger quantities or food items. Beyond identifying relevant government of other LNS products are already being produced. A platforms, it may be beneficial to partner with various small number of African countries currently manufacture implementing partners, such as NGOs, UNICEF, WFP, LQ–LNS and MQ–LNS. In Niger, LQ– and MQ–LNS are etc., which are well-versed in LNS program design and produced through Société de Transformation Alimentaire implementation. In Burkina Faso, for example, Hellen Keller (STA), and in Burkina Faso through InnoFaso. In the late International carried out the first SQ-LNS pilot. 2000s, STA, in partnership with Nutriset — a French firm which formulates and manufactures supplements, piloted the commercial production of a SQ–LNS product in Niger known as Grandibien.26 Production of Grandibien has since been introduced in Burkina Faso through InnoFaso. InnoFaso is currently opening another plant in Northern Nigeria. SASPP Policy Note Series 6 NOTE 9 | JUNE 2023 Ensuring the Uptake and Appropriate Use of SQ-LNS at the House- 5 hold Level Ensuring the uptake and appropriate use of SQ-LNS within than the recommended daily amount. Overuse affects households will maximize the impact of interventions on program efficiency more than having direct impacts on child growth and undernutrition. In LMICs, LNS products populations. In settings where overuse is driven by food are generally accepted although with varied levels of insecurity, SQ–LNS programs should be implemented consumption. For example, consumption patterns in Malawi alongside relevant social protection interventions — i.e., and Mozambique reveal both overuse and underuse of cash transfers, vouchers, and food distribution schemes. supplements29. Underuse affects the potential impact of In addition, and where feasible, SQ–LNS programs should the product and is a serious concern. Overuse of SQ–LNS cover entire communities instead of targeting individual products is rarer and can be due to caregivers or children households to address the tendency of households to above age 23–months consuming the SQ–LNS products, depend on each other and share supplements. and children between age 6 and 23 months being fed more 6 CONCLUSION SQ–LNS interventions can significantly improve child nutrition and health among Sahelian countries, which continue to experience high levels of child undernutrition. Initiatives that incorporate the Sahel–specific recommendations outlined in this policy note can better ensure the effective, design, implementation, and utilization of SQ–LNS interventions in this region. Furthermore, there are key opportunities to localize the formulation and/or production of SQ–LNS products within African countries, which may reduce costs even when factoring in the required short–term capital investments. SASPP Policy Note Series 7 NOTE 9 | JUNE 2023 ENDNOTES 1 UNICEF, WHO, and World Bank Group “Levels and Trends in Child.” 2 Victora, Adair, Fall, Hallal, Martorell, Richter, Sachdev, and Maternal and Child Undernutrition Study Group, “Maternal and Child Undernutrition,” 340–357. 3 AU and WFP, “The Cost of Hunger in Africa.” 4 AU, “Le coût de la faim au Burkina Faso.” 5 AU, “Le coût de la faim en Afrique: L’incidence sociale et économique de la malnutrition chez l’enfant au Mali.“ 6 AU, “Le coût de la faim en Afrique: L’incidence sociale et économique de la malnutrition chez l’enfant au Niger.“ 7 Keats, Das, Salam, Lassi, Imdad, Black, and Bhutta, “Effective Interventions to Address,” 367–384. 8 Dewey, Stewart, Wessells, Prado, and Arnold, “Small–Quantity Lipid–Based Nutrient,” 3S–14S. 9 Dewey, Stewart, Wessells, Prado, and Arnold, “Small–Quantity Lipid–Based Nutrient,” 3S–14S. 10 Arimond, Zeilani, Jungjohann, Brown, Ashorn, Allen, and Dewey, “Considerations in developing lipid–based,” 31–61. 11 Das, Salam, Hadi, Sheikh, Bhutta, Prinzo, and Bhutta, “Preventive Lipid‐Based Nutrient.” 12 Das, Salam, Hadi, Sheikh, Bhutta, Prinzo, and Bhutta, “Preventive Lipid‐Based Nutrient.” 13 Das, and Salam, “Addressing Childhood Undernutrition,” e1160-e1161. 14 USAID. 2021. “Lipid-Based Nutrient Supplements.” 15 Stewart, Fernald, Weber, Arnold, and Galasso, “Lipid-Based Nutrient Supplementation,” 958–966. 16 Huybregts, Le Port, Becquey, Zongrone, Barba, et al, “Impact on Child Acute Malnutrition,” e1002892. 17 Becquey, Huybregts, Zongrone, Le Port, Leroy, et al, “Impact on Child Acute Malnutrition,” e1002877. 18 Huybregts, Becquey, Leroy, Ruel, “Incorporating Prevention into Community–Based.” 19 International Food Policy Research Institute, “The Effect of Integrated Prevention.” 20 WFP, “SNF Procurement Update.” 21 WFP, “SNF Procurement Update.” 22 Segrè, Liu, and Komrska “Local Versus Offshore,” e12376. 23 Arimond, Zeilani, Jungjohann, Brown, Ashorn, Allen, and Dewey, “Considerations in Developing,” 31–61. 24 Segrè, Liu, and Komrska “Local Versus Offshore Production,” e12376. 25 WFP, “Lipid-Based Nutrient Supplement.” 26 Fernandez, Sauguet, Da Costa, Claeyssens, Lescanne, Lescanne, “Social Marketing of a Nutritional.” 27 WFP, “Managing the Supply Chain.” 28 USAID, “Lipid-Based Nutrient Supplements.” 29 Kodish, Aburto, Nseluke Hambayi, Dibari, and Gittelsohn, “Patterns and Determinants of Small–Quantity,” e12234. REFERENCES • AU (African Union), & WFP (World Food Programme). 2022. The Cost of Hunger in Africa (COHA) Continental Report: Social and Economic Impact of Child Undernutrition. • AU (African Union). Le coût de la faim au Burkina Faso: Implications pour le développement national. L'incidence sociale et économique de la sous–nutrition chez l'enfant au Burkina Faso. • AU (African Union). Le coût de la faim en Afrique: L’incidence sociale et économique de la malnutrition chez l’enfant au Mali. • AU (African Union). Le coût de la faim en Afrique: L’incidence sociale et économique de la malnutrition chez l’enfant au Niger. • Arimond, M., Zeilani, M., Jungjohann, S., Brown, K. H., Ashorn, P., Allen, L. H., & Dewey, K. G. 2015. “Considerations in Developing Lipid-Based Nutrient Supplements for Prevention of Undernutrition: Experience from the International Lipid-Based Nutrient Supplements (iLiNS) Project.” Maternal & Child Nutrition 11(suppl 4): 31–61. • Becquey, E., Huybregts, L., Zongrone, A., Le Port, A., Leroy, J.L., et al. 2019. “Impact on Child Acute Malnutrition of Integrating a Preventive Nutrition Package into Facility–Based Ccreening for Acute Malnutrition During Well–Baby Consultation: A Cluster–Randomized controlled Trial in Burkina Faso.” PLOS Medicine 16(8): e1002877. • Das, J. K., & Salam, R. A. 2019. “Addressing Childhood Undernutrition and Development through Education and Lipid-Based Supplements.” The Lancet Global Health 7(9): e1160-e1161. • Das, J. K., Salam, R. A., Hadi, Y. B., Sheikh, S. S., Bhutta, A. Z., Prinzo, Z. W., & Bhutta, Z. A. 2019. “Preventive Lipid‐Based Nutrient Supplements Given with Complementary Foods to Infants and Young children 6 to 23 Months of Age for Health, Nutrition, and Developmental Outcomes.” Cochrane Database of Systematic Reviews 5(5):CD012611. • Dewey, K. G., Stewart, C. P., Wessells, K. R., Prado, E. L., & Arnold, C. D. 2021. “Small–Quantity Lipid–Based Nutrient Supplements for the Prevention of Child Malnutrition and Promotion of Healthy Development: Overview of Individual Participant Data Meta–Analysis and Programmatic Implications.” The American Journal of Clinical Nutrition 114(suppl 1): 3S–14S. • Fernandez, A.B., Sauguet, I., Da Costa, F., Claeyssens, V., Lescanne, A., Lescanne, M. 2009. “Social Marketing of a Nutritional Supplement in Niger.” Food and Nutrition Bulletin 31(suppl2): S168-S178. https://www.ennonline.net/fex/35/social • Huybregts, L., Becquey, E., Leroy, J., Ruel, M. 2019. “Incorporating Prevention into Community–Based Management of Acute Malnutrition: Insights from Mali and Burkina Faso.” https://www.ifpri.org/blog/incorporating–prevention–community–based–management–acute–malnutrition–insights–mali–and • Huybregts L., Le Port, A., Becquey, E., Zongrone, A., Barba, F.M., et al. 2019. “Impact on Child Acute Malnutrition of Integrating Small–Quantity Lipid–Based Nutrient Supplements into Community–Level Screening for Acute Malnutrition: A Cluster–Randomized Controlled Trial in Mali.” PLOS SASPP Policy Note Series 8 NOTE 9 | JUNE 2023 Medicine 16(8): e1002892. • International Food Policy Research Institute. 2014. (accessed March 9, 2022). “The Effect of Integrated Prevention and Treatment on Child Malnutrition and Health in Mali: A Cluster Randomized Intervention Study (PROMIS–Mali).” Identifier NCT02323815. • Keats, E. C., Das, J. K., Salam, R. A., Lassi, Z. S., Imdad, A., Black, R. E., & Bhutta, Z. A. 2021. “Effective Interventions to Address Maternal and Child Malnutrition: An Update of the Evidence.” The Lancet Child & Adolescent Health, 5(5): 367–384. • Kodish, S. R., Aburto, N. J., Nseluke Hambayi, M., Dibari, F., and Gittelsohn, J. 2017. “Patterns and Determinants of Small–Quantity LNS Utilization in Rural Malawi and Mozambique: Considerations for Interventions with Specialized Nutritious Foods.” Maternal & Child Nutrition 13: e12234. • Segrè, J., Liu, G., & Komrska, J. 2017. “Local Versus Offshore Production of Ready‐to‐Use Therapeutic Foods and Small Quantity Lipid‐Based Nutrient Supplements.” Maternal & Child Nutrition 13(4): e12376. • Stewart, C. P., Fernald, L., Weber, A. M., Arnold, C., & Galasso, E. 2020. “Lipid-Based Nutrient Supplementation Reduces Child Anemia and Increases Micronutrient Status in Madagascar: A Multiarm Cluster-Randomized Controlled Trial.” The Journal of Nutrition 150(4): 958–966. • UNICEF (United Nations Children’s Fund), WHO (World Health Organization), World Bank Group. 2021. Levels and Trends in Child Malnutrition: Key findings of the 2021 edition. • USAID (United States Agency for International Development. 2021. Lipid-Based Nutrient Supplements: Evidence and Program Guidance. https:// www.usaid.gov/sites/default/files/documents/LNS_Evidence_and_Programming_Brief.pdf • Victora, C.G., Adair, L., Fall, C., Hallal, P.C., Martorell, R., Richter, L., Sachdev, H.S., & Maternal and Child Undernutrition Study Group. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” The Lancet 371(9609): 340–357. • WFP (World Food Programme). 2013. Managing the Supply Chain of Specialized Nutritious Foods. • WFP (World Food Programme). 2022. SNF Procurement Update. https://www.unicef.org/supply/media/3436/file/_NSF–2019–1210–WFP–SNF– Procurement–Update.pdf ACKNOWLEGEMENTS SASPP is a multi-donor trust fund managed by the World Bank that supports the strengthening of adaptive social protection systems in the Sahel (Burkina Faso, Chad, Mali, Mauritania, Niger and Senegal) to enhance the resilience of poor and vulnerable households and communities to the impacts of climate change. The program is supported by Denmark, France, Germany and the United Kingdom. NOTE DESIGN: ANDRES DE LA ROCHE / ADELAROCHEDESIGNS.COM For more information saspp@worldbank.org www.worldbank.org/saspp