Preventing child wasting is more urgent than ever before. Nearly 43 million children worldwide suffer from wasting at any given time, and severe wasting accounts for 20% of deaths among children under 5 years of age. This situation will likely worsen as conflicts and crises intensify poverty and food insecurity around the world.
Research on how to address child wasting has historically focused on treatment of severe wasting. While treatment remains critical, there is growing recognition that prevention is equally vital to reduce the high global burden and recurrent nature of wasting. For the first time, the 2023 WHO Guideline on wasting acknowledged the critical importance of preventing wasting, in addition to accelerating efforts to treat children suffering from wasting. Prevention is critically important if the world is to meet the global development goal of reducing wasting prevalence from 6.3% to less than 3% of children by 2030.
Two recent commentaries in BMJ Global Health by experts involved in formulating the 2023 WHO Guideline shed light on the critical evidence gaps that must be addressed to prevent wasting and to save lives. We were among the authors of these commentaries. The first commentary highlights three critical research gaps related to wasting prevention: 1) the lack of evidence on what works to prevent wasting; 2) a poor understanding of operational challenges related to implementing complex wasting prevention programs; and 3) the absence of simple, yet effective mechanisms to target prevention efforts. The second commentary highlights the absence of data on resource use and cost-effectiveness for preventive interventions, providing recommendations on how to fill this knowledge gap.
Four key evidence gaps to be filled
1. Generating evidence on the effectiveness of prevention programs
The UN Global Action Plan on Child Wasting and the WHO Guideline recommend multisectoral programs to address the multiple drivers of wasting. Multisectoral programs are those that integrate interventions delivered by different sectors including health, agriculture, food, water, sanitation, and hygiene (WASH), and/or social protection. These multisectoral programs are needed to address the poverty, inequity, lack of education, food insecurity, and lack of women’s empowerment that characterize environments with high levels of child wasting. Although necessary, bringing together different sectors comes with complexity and challenges related to program design, implementation, and evaluation. Figure 1 below illustrates a theory of change for integrated packages of prevention and treatment interventions that include screening for wasting, distribution of preventive supplements (small-quantity lipid-based supplements, or SQ-LNS) in Mali, and micronutrient-fortified cereal blends combined with WASH interventions in Chad.
Figure 1
Research is needed to strengthen the design, implementation, and evaluation of multisectoral programs that address the multiple underlying causes of child wasting in different settings. Experience with such multisectoral programs to reduce child stunting could provide the basis for guidelines for integrated interventions to address child wasting. Rigorous evaluation is also needed to inform policy and program designers and implementers on what works and how, and at what cost to reduce wasting.
2. Addressing operational challenges in implementing complex multisectoral programs to prevent wasting
Although necessary to prevent malnutrition, multisectoral programs that address the multifaceted nature of wasting can be complex and costly. Yet in places where wasting is most severe, many programs face resource shortages and bottlenecks, and they often rely on community volunteers with limited training and motivation. Behavior change communication (BCC)—essential for long-term changes in health, nutrition, and caregiving practices—is often the weakest component of wasting prevention and treatment programs. This is due to poor design, limited resources, and staffing constraints. Program participants likewise face obstacles that limit their participation in BCC or their adoption of recommended practices, including limited time or motivation and the high costs of providing nutritious foods for their young child and families.
Research is needed to carefully assess the quality and fidelity of program implementation to identify and address obstacles, especially for complex wasting prevention and treatment programs implemented in resource-poor settings where wasting is most common. In particular, better understanding is needed of how to improve both the quality and impact of BCC. Promising solutions include strengthening training, supervision, and incentives for staff; implementing complementary interventions to increase access to nutritious foods; and possibly developing a new cadre of nutrition education counselors with adequate training, pay, and respect.
3. Identifying and testing targeting mechanisms for reaching children most at risk of wasting while maximizing program cost-effectiveness
Wasting programs lack effective criteria for targeting prevention activities. In areas with a high burden of wasting or those facing humanitarian crises, programs should target all at-risk communities. But little is known about using simple indicators that could effectively target wasting prevention in areas with a lower, yet significant, burden of wasting.
Examples of such indicators include key socioeconomic and demographic indicators such as poverty, limited household asset ownership, lack of access to WASH infrastructure, or a history of child wasting. These types of indicators could also be discussed and selected through dialogue with knowledgeable community leaders. Certainly, any targeting criteria need to be transparent and implemented with attention to the context to avoid concerns of inequity.
Research to develop and test simple community-, household-, or child-level indicators (including seasonal triggers) associated with high prevalence of wasting is needed in diverse contexts. The cost-effectiveness and acceptability of using targeting criteria, as opposed to blanket implementation, also needs to be tested in select areas. Stakeholder engagement can help to ensure local contributions to and acceptance of any targeting decisions.
4. Generating data on resource use and cost-effectiveness to prevent wasting
When it comes to preventing child wasting, we have a clearer picture of the costs for some strategies than others. For instance, while there is some cost data on nutrition supplement programs, there is almost no information on what multisectoral approaches cost or whether they offer good value for money to prevent wasting. Estimating costs is generally more straightforward for monosectoral interventions, such as distributing nutrition supplements, than for complex programs that combine interventions in food security, healthcare, social support, and WASH—all key determinants of wasting. These broader programs often deliver multiple benefits beyond reducing wasting, such as reducing food insecurity, improving healthcare, and preventing waterborne diseases. If we judge them only on their impact on wasting, we risk underestimating their true value and overstating their costs. Therefore, any cost-effectiveness studies of such interventions should account for these outcomes in addition to wasting. Future studies that assess the impact of multisectoral approaches to reduce wasting should aim to evaluate resource use and cost-effectiveness to help close this critical knowledge gap.
Key takeaways
Despite these gaps in our knowledge, nutrition researchers, program implementers, policymakers, and donors should accelerate efforts to address the urgent need to reduce wasting among infants and children. Prevention should include the mother—starting from before pregnancy—and the newborn child during his early months, when wasting peaks. Establishing prevention as a key part of the continuum of care is critical to reaching the Sustainable Development Goal target on reducing wasting prevalence to less than 3%. Wasting prevention programs must be designed to address context-specific drivers of wasting across health, food, WASH, and social protection systems.
Research can help drive progress by providing robust studies of the effectiveness of new models for the prevention and treatment continuum of care for wasting. Such action research must also develop examples and guidance on best practices to reduce wasting-related mortality and improve long-term outcomes in diverse contexts around the world. Strengthening all aspects of programing and bringing interventions to scale is both a moral imperative and a critical investment in the future of today’s children.
Marie T. Ruel and Lieven Huybregts are Senior Research Fellows with IFPRI’s Nutrition, Diets, and Health Unit. Opinions are the authors’.
References:
Marie T Ruel, Per Ashorn, James A Berkley, Kathryn G Dewey, Kate Golden, Lieven Huybregts, Michael McCaul, Celeste E Naude, Zita Weise Prinzo, Allison I Daniel – Prevention of wasting and nutritional oedema: evidence gaps identified during WHO guideline development: BMJ Global Health 2025; https://doi.org/10.1136/bmjgh-2024-016314
Lieven Huybregts, James A Berkley, Mary Christine Castro, Kathryn G Dewey, Kate Golden, Julie Jemutai, Celeste E Naude, Michael McCaul, Allison I Daniel – Addressing prevention and management of wasting and nutritional oedema in children requires an improved evidence base on resource use and cost-effectiveness of interventions: BMJ Global Health 2025; https://doi.org/10.1136/bmjgh-2024-016220
