Program in Bolivia improves nutrition practices but increases prevalence of overweight children. Where did it go wrong?

By Gastón Gertner, Julia Johannsen, and Sebastián Martínez

Stunting and wasting, just like anemia, have been persistent problems in several Latin American and Caribbean countries for decades. Bolivia is no exception. About three out of every 10 Bolivian children under the age of five are affected by malnutrition, the result of which is delayed growth. However, despite advances in recent years, Bolivian children, especially those in rural and poor peri-urban areas are still affected by malnutrition.

One of Bolivia’s efforts to combat child malnutrition included  a program implemented in El Alto, Bolivia, between 2008 and 2011 and consisted of a series of home visits to monitor children’s growth. Through this effort, participating children were measured and weighed and their parents were offered counseling on nutrition, hygiene, and diarrhea prevention. In addition, group workshops on cooking classes were held monthly for the children’s caregivers (e.g., primarily mothers). The program also encouraged local authorities to provide micronutrients and nutritional supplements through community health centers.

However, despite the  good intention of the project, the results of our evaluation of this program concluded that that the children participating in the program are more likely to be overweight.

What worked well and what did not work with the program?

Taking advantage of the program’s strictly defined geographical area of implementation, we use regression discontinuity to evaluate the impact evaluation.

With the evaluation we found that:

• the actual participation of the eligible population in the project was very high (93%), which shows a high household interest in receiving nutritional counseling services through home visits;
• the caregivers of the children who participated in the project showed significantly more knowledge about the topics covered in childhood health and nutrition; and,
• the participating households showed significant changes in hygiene habits and nutritional practices in line with the advice received.

Notwithstanding,

• we did not find changes in the desired nutritional status indicators of the children in terms of growth (height for age) or in the prevalence of stunting; and,
• we observed an unintended impact on children’s weight. In fact, we found that the children undergoing the intervention were 12.5 percentage points more likely to be overweight than their counterparts in the control group, which means a relative increase of 245%.

 

What did we learn?

First, caregivers may have followed the advice of feeding children with more recommended micro- and macro-nutrients (such as iron-rich animal protein) without having received the message of eliminating other unwanted components from their diets (such as sugars, white flours and excess fats). Therefore, projects of nutritional counseling to households should consider not only advising on what should be done but also on what should not be done.

Second, caregivers may have felt pressured to “show the child’s progress” by monthly weight and height monitoring, focusing on the variable that is most easily influenced in the short term, from one visit to the next: weight. Therefore, it is recommended to consider eliminating child measurements from home visits and instead to train health center staff to make more precise measurements a part of regular health checkups.

Third, in many cultures in Latin America and the Caribbean, the notion that “a chubby child is a healthy child” prevails. The Aymara population of the city of El Alto in Bolivia is probably no exception. To counteract the cultural and social value of weight rather than growth in size that is much slower and harder to perceive, nutritional counseling projects for indigenous populations could explore the use of the latest playful, creative and culturally relevant socio-educational methods (such as puppets, theater, songs or poems based on local characters and legends) to convey more effective and positive messages about the size of children.

Preventing unwanted effects from programs intended to reduce malnutrition is a task that requires careful monitoring and rigorous program evaluations. Considering that many countries in the region already face the double nutritional burden of chronic malnutrition and anemia that coexist in a population with an increasing prevalence of obesity and being overweight, this is especially important. Due to the results found with this evaluation, the program has been redesigned, retaining the positive aspects and revising the content and messaging strategies to be more effective with respect to the goals of reducing chronic malnutrition while avoiding excess weight gain. The redesigned project is currently under implementation and will undergo a prospective evaluation with a randomized controlled experimental design (RCT). In an upcoming article we will tell you about the results of the baseline survey of the redesigned project!

About the Authors:

Gastón Gertner is an impact evaluation consultant at the Office of Strategic Planning and Effective Development of the Inter-American Development Bank.

Julia Johannsen is a senior specialist in social protection at the offices of the Inter-American Development Bank in Ecuador.

Sebastián Martínez is a principal economist in the Office of Strategic Planning and Development Effectiveness of the Inter-American Development Bank where he supports the work of the unit in impact evaluations in the social sector, including topics related to human development and infrastructure.