Effects of nutritional interventions to increase nutritional status in children living in urban slums in low- and middle-income countries

UN-Habitat estimates that there are at least one billion people living in urban slums, that is, places in cities without adequate access to health care, clean water, and sanitation. For this review, we defined low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure. More than 90% of these slums are in low- and middle-income nations and the residents are usually living in poverty, with little food security. One consequence of an inadequate diet is growth stunting, that is, very short stature for age. Stunting is associated with greater susceptibility to infection, cognitive (memory and thinking skills) and behavioural problems, and lower adult work performance and earnings. About 25% of children living in urban settings in low- and middle-income countries are stunted. In slum areas, this figure is higher. For example, in Dhaka, Bangladesh it is 48%, and in Pune, India it is 59% of children under five years old.

Nutritional methods (interventions) to improve infant and young children's growth have not been comprehensively or systematically assessed for urban slums. We included 15 studies in the review, involving 9261 children less than five years old and 3664 pregnant women. About 73% of children were less than one year old. The interventions provided maternal education; nutrient supplementation of mothers, infants, and children; improving nutrition systems; or a combination of these but not dietary modification. The reliability of the studies was very low to moderate overall because studies were not designed to cope with research problems linked to urban slum communities, such as high mobility and high loss of participants to follow-up. This meant that the effectiveness of the intervention could not be properly assessed at later dates.

We assessed the effect of results using statistics combined with the biological/health importance of the effect. Where intervention outcomes were statistically insignificant, we conclude there was 'unclear effect'.

There was no effect of giving mothers nutrient supplementation on birth weight and length, there were inconclusive results for nutrient supplementation in infants and children on improving children's height or stunting status, there was a positive impact on birth weight of maternal education interventions where there was a positive difference in birth weight of 478 g in infants exposed to the intervention, and inconclusive results of improving health systems that support nutrition on children's stunting status and a positive effect on height. There were no reported side effects from these interventions.

The review showed the need to better understand urban slum environments and their people as evidence showed that interventions included in this review were successful in other locations outside of urban poor areas. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations (NGOs), and the business sector to improve low birth weight and stunting in poor urban environments.

Authors' conclusions: 

All the nutritional interventions reviewed had the potential to decrease stunting, based on evidence from outside of slum contexts; however, there was no evidence of an effect of the interventions included in this review (very low- to moderate-certainty evidence). Challenges linked to urban slum programming (high mobility, lack of social services, and high loss of follow-up) should be taken into account when nutrition-specific interventions are proposed to address LBW and stunting in such environments. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations, and the business sector on nutrition-related outcomes such as stunting.

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Background: 

Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low- and middle-income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN-Habitat 2004 definitions for low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure.

Objectives: 

To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non-nutritional outcomes (socioeconomic, health and developmental) in addition to stunting.

Search strategy: 

The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non-English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018.

Selection criteria: 

Research designs included randomised (including cluster-randomised) trials, quasi-randomised trials, non-randomised controlled trials, controlled before-and-after studies, pre- and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition-specific or maternal education. The primary outcomes were length or height expressed in cm or length-for-age (LFA)/height-for-age (HFA) z-scores, and birth weight in grams or presence/absence of low birth weight (LBW).

Data collection and analysis: 

We screened and then retrieved titles and abstracts as full text if potentially eligible for inclusion. Working independently, one review author screened all titles and abstracts and extracted data on the selected population, intervention, comparison, and outcome parameters and two other authors assessed half each. We calculated mean selection difference (MD) and 95% confidence intervals (CI). We performed intervention-level meta-analyses to estimate pooled measures of effect, or narrative synthesis when meta-analyses were not possible. We used P less than 0.05 to assess statistical significance and intervention outcomes were also considered for their biological/health importance. Where effect sizes were small and statistically insignificant, we concluded there was 'unclear effect'.

Main results: 

The systematic review included 15 studies, of which 14 were randomised controlled trials (RCTs). The interventions took place in recognised slums or poor urban or periurban areas. The study locations were mainly Bangladesh, India, and Peru. The participants included 9261 infants and children and 3664 pregnant women. There were no dietary intervention studies. All the studies identified were nutrient supplementation and educational interventions. The interventions included zinc supplementation in pregnant women (three studies), micronutrient or macronutrient supplementation in children (eight studies), nutrition education for pregnant women (two studies), and nutrition systems strengthening targeting children (two studies) intervention. Six interventions were adapted to the urban context and seven targeted household, community, or 'service delivery' via systems strengthening. The primary review outcomes were available from seven studies for LFA/HFA, four for LBW, and nine for length.

The studies had overall high risk of bias for 11 studies and only four RCTs had moderate risk of bias. Overall, the evidence was complex to report, with a wide range of outcome measures reported. Consequently, only eight study findings were reported in meta-analyses and seven in a narrative form. The certainty of evidence was very low to moderate overall. None of the studies reported differential impacts of interventions relevant to equity issues.

Zinc supplementation of pregnant women on LBW or length (versus supplementation without zinc or placebo) (three RCTs)

There was no evidence of an effect on LBW (MD –36.13 g, 95% CI –83.61 to 11.35), with moderate-certainty evidence, or no evidence of an effect or unclear effect on length with low- to moderate-certainty evidence.

Micronutrient or macronutrient supplementation in children (versus no intervention or placebo) (eight RCTs)

There was no evidence of an effect or unclear effect of nutrient supplementation of children on HFA for studies in the meta-analysis with low-certainty evidence (MD –0.02, 95% CI –0.06 to 0.02), and inconclusive effect on length for studies reported in a narrative form with very low- to moderate-certainty evidence.

Nutrition education for pregnant women (versus standard care or no intervention) (two RCTs)

There was a positive impact on LBW of education interventions in pregnant women, with low-certainty evidence (MD 478.44g, 95% CI 423.55 to 533.32).

Nutrition systems strengthening interventions targeting children (compared with no intervention, standard care) (one RCT and one controlled before-and-after study)

There were inconclusive results on HFA, with very low- to low-certainty evidence, and a positive influence on length at 18 months, with low-certainty evidence.

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