The WHO ELibrary for Nutrition Programmes Guidance: Recommendations, Evidence and Best Practices

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The WHO E-Library for Nutrition Programmes
Guidance Recommendations, Evidence and Best
Practices
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The Rationale

• Need of guidance on
• Evidence-based nutrition policy making
• Best practices for implementation
• Programme experiences repository
• Where it is implementing lessons learned
• Cost-effective nutrition interventions
• They want/need to know NOW
• "More research is needed" is not helpful

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WHO NUTRITION GUIDELINESDifferent formats,
Different locations
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How do you know which WHO Guideline is current?
2001
1998
1989
2001
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List of Publicationsis an alternative but may
not be complete
WHO statements may not be in Library!
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Supplements in peer-reviewed journalsare these
WHO guidelines?
Special Issue on Vitamin A Supplementaion and the
Control of Vitamin A Deficiency. Eds de Benoist
B, Martines JC, Goodman T. Based on informal WHO
technical Consultation on Vitamin A
Supplementation held in Yverdon-les-Bains,
Switzerland, 1-3 March 2000. Volume 22, Number
3, September 2001. Report of a
WHO/UNICEF/IAEA/IZINCG inter-agency meeting on
Zinc Status Indicators, held in IAEA
headquarters, Vienna, December 9, 2005. Eds de
Benoist B, Darnton-Hill I, Davidsson L, Fontaine
O. Volume 28, Number 3, September 2007 Report
of the World Health Organization Technical
Consultation on Prevention and Control of Iron
Deficiency in Infants and Young Children in
Malaria-endemic Areas. Lyon, France, 12-14 June
2006. eds. de Benoist B, Fontaine O, Lynch S,
Allen L. Volume 28, Number 4, December 2007.
Folate and Vitamin B12 Deficiencies
Proceedings of a WHO technical Consultation held
18-21 October 2005 in Geneva, Switzerland. Eds
de Benoist B, Allen L, Rosenberg I. Volume 29,
Number 2, June 2008. Not yet available online.
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WHO RECOMMENDATIONS PROCESS CRITICIZED IN
2007WHO guidelines are insufficiently
transparent and not evidence based

• Lack of use of systematic reviews
• Lack of transparency about judgements
• Too much dependence on expert opinion
• Lack of emphasis on adapting global guidelines to
  end users' needs
• Tension between time taken and when advice needed
• Lack of resources

Oxman, Lavis Fretheim. Lancet.
2007369(9576)1883-9.
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Solution 2007 - Effective as of 2008

• Development of a Guidelines Review Committee
• Minimum standards for
• Reporting
• Processes
• Use of evidence
• Revised WHO Handbook for Guideline Development
• Different processes for documents to fit
  different purposes
• Rapid advice guidelines
• Standard guidelines
• Full guidelines

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WHO standards for guidelines Principles

• Initial definition of scope and target audience
• Development of 'questions'
• Systematic and comprehensive evidence retrieval
  and synthesis
• Development of recommendations based on
  interpretation of evidence
• Management of conflicts of interest
• Standards for reporting
• Plan for implementation and update

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Minimum standards for reporting in WHO guidelines

• Who was involved and their declaration of
  interests
• How the guideline was developed, including
• How the evidence was identified
• How the recommendations were made
• Use by date (review by date)

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Standards for evidencePrinciples

• For recommendations
• Synthesis of all available evidence
• Evidence summaries for group meetings using
  standard template
• Formal assessment of quality of evidence
• Consideration of resource use and costs
• Linked evidence to recommendations, explaining
  reasons for judgements
• System for assessing evidence for interventions
  GRADE

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The WHO E-Library for Nutrition Programmes
Guidance Recommendations, Evidence and Best
Practices

• ELECTRONIC RESOURCE
• With link to documents and tools (i.e. ME
  framework, implementation guidelines)
• TARGET AUDIENCE
• Policy Makers
• Program implementers and others
• WHO CURRENT RECOMMENDATIONS

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The WHO E-Library for Nutrition Programmes
Guidance Recommendations, Evidence and Best
Practices
Reaching Optimal Iodine Nutrition in Pregnant and
Lactating Women and Young Children. Revised 20th
November 2007 Full text pdf 207kb
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Biological and Behavioural Basis for the
Intervention

• One page "plain English" summary of causal
  associations and mechanisms by which intervention
  would be biologically and conceptually plausible
  in resulting in the expected outcome
• By biology experts and/or program planners on the
  for the intervention
• Considers
• physiological aspects of the population group(s)
  being targeted
• variety of contexts where this intervention may
  be particularly beneficial or harmful (i.e.
  deplete or replete populations premature
  infants etc)

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Systematic Reviews of Evidence

• Various levels of evidence on the effects of the
  intervention for specific outcomes
• By nutrition experts together with
  methodologists, epidemiologists and program
  experts.
• Systematic reviews from the Cochrane Library as
  well as those published in peer reviewed journals
  
• A specific methodology to assure a standardized
  approach review of efficacy, effectiveness and
  safety of interventions in different contexts
• Formal consultative process on definition of
  questions and methods are considered early in the
  process

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Commentaries/Practical Aspects

• By nutrition experts, program implementers, or
  field staff, especially from developing countries
  revised when the corresponding systematic reviews
  are updated
• Includes discussion of practical aspects that
  need consideration before scaling up the
  intervention
• Commentaries selected for publication are edited
  for technical accuracy and compliance with WHO
  language style and sent to author(s) for final
  clearance

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Commentaries/Practical Aspects

• Evidence Summary (summary of systematic review of
  evidence)
• Relevance to Under-Resourced Settings
• Magnitude of the problem
• Applicability of the results
• Safety Aspects
• Research Gaps
• References
• Practical Aspects
• Economic Considerations
• Logistics for Implementation of the intervention
• Inter-sectoral Aspects and Social Participation
• Sustainability
• Implications for Practice
• First Contact (Primary Care Level)
• Referral Hospital (Secondary Care Level)
• At Home or in The Community
• National Programs
• About the Authors. Short Bio of the
  Reviewers/Commentators

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Best Practices for Implementation

• By established Working Group consisting mostly
  program implementers and field staff
• Includes documents or guidelines (with links)
  related to
• Successful implementation evaluation of various
  delivery options (when recommended, to be
  consistent)
• Monitoring and Evaluation guidelines
• Factors affecting impact
• Types of compounds/supplements micronutrient
  analysis and dosages
• Compliance
• Implementation (How best to? question)
• Experiences in integration to existing programs
  in other areas (database with countries where
  program is /has implemented)
• Lessons Learned
• Additional sources of information (link to
  partners and to existing documents)

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Commentaries/Practical Aspects

• By nutrition experts, program implementers, or
  field staff, especially from developing countries
  revised when the corresponding systematic reviews
  are updated
• Include a discussion of the practical aspects
  that need consideration before scaling up the
  intervention .
• Commentaries selected for publication are edited
  for technical accuracy and compliance with WHO
  language style and sent to author(s) for final
  clearance.