WASH and Nutrition

This article is based on a factsheet that provides an overview on existing evidence and remaining research gaps regarding the link between inadequate sanitary conditions and its underestimated impact on undernutrition and stunting, particularly for children under five years of age. It is a clear plea for more rigorous research, policy coherence and cooperation between Health and Nutrition, WASH, Mental Health, Care Practices and Food Security sectors, and the need to adequately address and consider WASH as an integral part of nutrition interventions. It particularly highlights the impact of WASH interventions on mothers and children’s (under five years of age) nutritional and health status. An estimated 30% of all children in low-income countries suffer from undernourishment and WASH services can help to alleviate this:

More than 3.5 million mothers and children under five die unnecessarily each year due to the underlying causes of undernutrition, and millions more children are permanently disabled by the physical and mental effects of a poor dietary intake in the earliest months of life.
The Lancet’s Series on Maternal and Child Undernutrition, 2013.

Child health, nutrition, growth, and development are interlinked, and are influenced by the hygiene of the immediate environment in which the baby begins to explore the world. In addition to expanding the scope of interventions, it is also important to broaden the conceptual structure of WASH as an aspect of child nutrition and development interventions, and not simply as the sum of toilets, caregiver hand washing, and water purification. WASH should be defined holistically as broadly encompassing the hygiene-related aspects of the physical and behavioral environment in which children are being raised.
Ngure et al., WASH and ECD: Making the Links, 2014. Ann. N.Y. Acad. Sci. 1308 (2014) 118–128 C 2014 New York Academy of Sciences

The aim of this fact sheet is to offer a compilation of relevant studies showing evidence on the link between sectors and to lobby for more cooperation between them.

2. Key Facts about WASH and nutrition

Globally, there are 1.7 billion cases of diarrheal disease annually, resulting in 628,500 (9.5%) of children deaths.
60% of children’s deaths from diarrhea are caused by unsafe water, pathogen-contaminated foods, lack of sanitation, and poor hygiene practices, and are therefore preventable.
Malaria results in 476,192 children deaths, which is 7% of the annual children death toll.
Pneumonia and Acute Respiratory Infections (ARI), strongly related to an improper environment, accounts for 996,520 (15%) of children death toll.
47% of children deaths are estimated to be linked with undernutrition, accounting for 3.1 million per year.
161 million (24.5%) children are affected by stunting (low height for age).
51 million (8%) by wasting (low weight for height).
99 million (15%) by underweight (low weight for age).

3. Interventions

WASH interventions can impact positively on stunting incidence rates (Cochrane, 2013).
WASH intervention effect is an equivalent to a reduction of 15% in global prevalence of stunting (Cochrane, 2013).
There is a significant impact of sanitation on stunting (Spears & Hammer, 2013).
Growth faltering is strongly associated with diarrheal disease cases (Weitz, 2011).
There is strong evidence of a positive impact of WASH interventions on child infections (Fewtrell Review , 2005).
Improved WASH conditions can reduce parasitic intestinal infections such as worm infestation that impacts nutritional status (Pruss-Ustun, 2006).
Symptoms from nematode parasites (such as hookworm) include loss of blood and consequently increased anemia prevalence leading to chronic fatigue and stunting (Black, 2013).
High pathogen environments induce recurring infections in the gut that limit proper absorption of nutrients, known as Environmental Enteropathy (Humphrey, 2009).
Children younger than 5 years old in households that received plain soap and handwashing promotion had a 50% lower incidence of pneumonia than in control groups (Luby, 2005).

4. Main WASH routines

The 5 A’s is a new framework of analysis for undernutrition :

Availability: Nutritious food should be readily available and sufficient.
Access: People must be able to obtain food.
Absorption: Much of food that is ingested is not absorbed due to infections that cause damage to small intestine leading to reduced capacity to absorb nutrients. Diarrhea cases dehydrate and evacuate nutrients unabsorbed.
Antibodies: Producing antibodies to fight infections diverts nutritional energy from growth to defense.
Allopathogens: Numerous other FTIs take their toll, including Hepatitis A, B and E, typhoid fever, etc.

The last three “A’s” can be impacted positively by improved WASH facilities and services. Nutrition interventions typically focus on quantity and quality of food, feeding programs, and issues of governance and rights. This new framework of 5 A’s presents a more comprehensive analysis of undernutrition with attention to the role of fecal-transmitted infections (FTI) represented in the last 3 A’s. Among FTIs, diarrhea incidences received the most attention, but environmental enteropathy (damage of small intestine wall due to ingestion of fecal bacteria) is also nutritionally very significant. Recent research establishes the direct link with undernutrition and open defecation (OD) as well as its associated unhygienic conditions and practices.

5. Links between sanitation and child height

“A child’s height is one of the most important indicators of her well-being. Height reflects the accumulated total of early-life health, net nutrition, and disease. Because problems that prevent children from growing tall also prevent them from growing into healthy, productive, and smart adults. Child height is strongly associated with the average number of people per square kilometer in a country who practice open defecation. The density of open defecation per square kilometer, in this simple linear graph, can account for 64% of international variation in child height.”

6. Five main axes

Ensure geographical / programatic integration of WASH and Nutrition projects by focusing WASH projects in high undernutrition prevalence areas
Prioritize the ‘mother / child’ unit
Ensure a WASH minimum package (kit, messages & standards) both in health & nutrition centers and at the household level
Place emphasis on behavior change
Ensure that both coordination bodies (WASH and Nutrition) include representation from the other sector

7. Remaining key questions

Does a safe WASH environment at household- or community-level have an impact upon the prevalence of Global Acute Undernutrition?
Can a short-term WASH intervention have an effect upon Global Acute Undernutrition incidence rates?
Does a WASH intervention, implemented during the treatment of a Severe Acute Malnourished (SAM) child, improve effectiveness and efficiency of the treatment (time and cost reduction) and reduce risks of post-recovery relapse?
What is the impact of the “quantity of water available at household level” indicator on undernutrition?