Written by Marinella Capriati and Andrew Martin

GiveWell has made several grants in the nutrition space to date—we’ve funded vitamin A supplementation through Helen Keller International for many years, and have made grants supporting both iron fortification and supplementation and community-based management of acute malnutrition. This year, we started systematically exploring nutrition as a grantmaking area.

Our key goal for the year is to learn more about the space. To discipline ourselves, we put down a few hypotheses about nutrition grantmaking. It is quite likely we will change our mind on these as we learn more.

Hypothesis 1: Iron and vitamin A deficiency are the most promising areas for grantmaking

Overall, we think iron and vitamin A deficiency are the most promising areas for grantmaking because of their high burden and because there are programs (fortification and supplementation) that offer tractable and cost-effective ways of addressing this burden.

Iron deficiency is a major cause of anemia, which causes symptoms like fatigue and shortness of breath. It also reduces economic productivity by lowering physical capacity in adults and by harming brain development in children.¹For more information on the consequences of iron deficiency, see our intervention reports on iron fortification and iron supplementation for school-age children.

The Institute for Health Metrics and Evaluation (IHME) estimates there were 1.9 billion cases of anemia globally across all ages in 2021—that’s approximately one-quarter of the entire global population. Of these cases, 800 million occur in South Asia, and 500 million of those affected in South Asia are women.²These statistics are from Institute for Health Metrics and Evaluation, Global Burden of Disease 2021, Global Health Data Exchange, Anemia prevalence (login required).

We estimate that providing additional iron through supplementation or fortification can cost less than a dollar per person per year.³We estimated that iron fortification could be provided at an annual cost per person of $0.35 in our 2020 cost-effectiveness analysis of iron fortification.

To date, we have made grants for iron fortification and supplementation but did not have a big-picture strategy guiding our selection of programs and geographies. We are especially excited about opportunities to fund programs in South Asia, primarily because of the high burden of iron-deficiency anemia in the region.

We’d also be excited to fund technical assistance programs to support fortification of food delivered through social safety nets—that is, government programs that provide assistance to people experiencing poverty, unemployment, illness, or other challenges. These often reach a very large number of people, which means even small changes in quality or coverage can have very large benefits, and they often target lower-income citizens, who are most likely to suffer from iron deficiency.

Meanwhile, vitamin A deficiency (VAD) increases the chances of developing infectious diseases, especially measles and diarrhea. Infectious diseases are a leading cause of death among children in Africa,⁴Communicable, maternal, neonatal, and nutritional diseases are the cause of approximately 82% of under-5 mortality in Africa, from Institute for Health Metrics and Evaluation, Global Burden of Disease 2021, Global Health Data Exchange, Communicable, maternal, neonatal, and nutritional diseases (login required). where child mortality is the highest. As a result, we are especially interested in addressing VAD in that region.

We estimate it costs around two dollars to provide vitamin A supplementation (VAS) to a child for a year.⁵We estimated that it costs between $0.80 and $1.39 per child per VAS round, and there are generally two VAS rounds per year.

For vitamin A, we want to explore whether funding stand-alone VAS programs is the best way of increasing vitamin A status. For example, it might be possible to improve the cost-effectiveness of VAS programs by layering them on existing platforms for delivering other health programs.

We also want to look at vitamin A fortification as an alternative to VAS. We’re working on an analysis that suggests that providing the micronutrient more frequently (while keeping the total dose fixed) increases its effectiveness. Since VAS is usually delivered twice a year and fortification provides daily doses of vitamin A, this would be a point in favor of fortification. This work is in its very early stages (and there are other reasons why fortification might not work), but we’re excited to look into this.

Hypothesis 2: There may be ways of improving diets to tackle the increasing burden of cardiovascular disease

We are excited about the possibility of decreasing cardiovascular disease by engaging in technical assistance and advocacy work to improve diets. Cardiovascular disease (like heart attack or stroke) is the leading cause of death globally, causing 17.9 million deaths each year.⁶“Cardiovascular diseases (CVDs) are the leading cause of death globally, taking an estimated 17.9 million lives each year.” World Health Organization, “Cardiovascular diseases.”

We expect the burden of cardiovascular disease to become worse in large middle-income countries like China, India, and Indonesia due to lifestyle and diet changes. Finding ways to modify nutrition to decrease this risk could have extremely large benefits, and we think progress can be made through advocacy and technical assistance.

Some of the areas we are considering include replacing regular salt with salt substitutes that use potassium (which may lower blood pressure) in place of part of the sodium, and reducing the consumption of sugar-sweetened beverages.

Advocacy work could support legislation aimed at reducing the consumption of unhealthy foods and increasing the consumption of healthy ones (for example, by mandating food labeling and regulating advertisement). Technical assistance could help manufacturers identify inefficiencies and reduce the cost of producing healthier food products, like low-sodium salt.

Such programs could be highly cost-effective because of their catalytic nature (one-off, likely small investments that could unlock long-term benefits for a large number of people), but opportunities may be limited.

Hypothesis 3: We can make progress on key uncertainties by generating additional evidence

We have a number of open questions and are looking to generate additional evidence to answer them.

For example, we think that tackling iron deficiency would increase economic productivity, but our estimates rely on scarce evidence. As we discussed above, the burden of iron deficiency is large, so we could direct a large amount of funding to this area. This means there is substantial value in improving our ability to model the benefits of tackling anemia.

Unfortunately, there are some practical constraints to generating evidence in the nutrition space. For example, we expect it would take decades to get results on the effect that iron supplementation has on children’s development and, ultimately, their income as adults. However, we think there could be creative ways of estimating this (for example, gathering data on children who participated in trials decades ago), and we would be excited to look into these methods.

We’re also interested in funding research to estimate the impact of VAS on child mortality in modern settings, since most of the evidence supporting a large impact of VAS on child mortality is several decades old. There are ethical concerns with implementing new placebo-controlled trials of an established intervention like VAS, so we are interested in exploring other creative ways of estimating the mortality impact of VAS that have strong causal inference value, possibly including a stepped-wedge trial.

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These hypotheses will likely evolve as we learn more, but we’re excited to dive into the nutrition space further. We believe that nutrition is a promising grantmaking area with room for expansion, and we think the programs identified through this work will effectively reduce illness and deaths.

If you work in any of the areas mentioned above, we’d love to hear from you. Email us at info@givewell.org.