Abstract
Motivated by the lack of randomized controlled trials with an intervention-free control arm in the area of child undernutrition, we fit a trivariate model of weight-for-age z score (WAZ), height-for-age z score (HAZ) and diarrhea status to data from an observational study of supplementary feeding (100 kCal/day for children with WAZ ) in 17 Guatemalan communities. Incorporating time lags, intention to treat (i.e., to give supplementary food), seasonality and age interactions, we estimate how the effect of supplementary food on WAZ, HAZ and diarrhea status varies with a child’s age. We find that the effect of supplementary food on all 3 metrics decreases linearly with age from 6 to 20 mo and has little effect after 20 mo. We derive 2 food allocation policies that myopically (i.e., looking ahead 2 mo) minimize either the underweight or stunting severity – i.e., the sum of squared WAZ or HAZ scores for all children with WAZ or HAZ . A simulation study based on the statistical model predicts that the 2 derived policies reduce the underweight severity (averaged over all ages) by 13.6–14.1% and reduce the stunting severity at age 60 mo by 7.1–8.0% relative to the policy currently in use, where all policies have a budget that feeds % of children. While these findings need to be confirmed on additional data sets, it appears that in a low-dose (100 kCal/day) supplementary feeding setting in Guatemala, allocating food primarily to 6–12 mo infants can reduce the severity of underweight and stunting.
Highlights
With over 3 M deaths per year of children under 5 years attributable to undernutrition [1] and the level of food aid far less than required [2,3], it is vital to optimally allocate food to the appropriate children in the appropriate amounts
weight-for-age z score (WAZ) exhibits global mean reversion, which is more pronounced in younger children, and local mean reversion, which is more pronounced in older children
height-for-age z score (HAZ) exhibits global mean reversion that is more prominent in younger children and local mean reversion that is more prominent in older children, and the magnitude of global mean reversion for HAZ is larger than it is for WAZ
Summary
With over 3 M deaths per year of children under 5 years attributable to undernutrition [1] and the level of food aid far less than required [2,3], it is vital to optimally allocate food to the appropriate children in the appropriate amounts To address this problem in a rigorous manner requires knowledge about three key aspects [4]: (i) the evolution of weight and height (and perhaps disease) of children under 5 years in the absence of food aid; (ii) the impact that weight and height (and perhaps other factors such as age, sex and disease) have on morbidity and mortality, and (iii) the impact of supplementary or therapeutic food on weight and height (and perhaps other factors such as disease). The ethical issues inherent in using a control group that does not receive food suggests that there may not be any large randomized control trials with intervention-free arms performed in the future
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