Advisory groups

The WHO Steering Committee for Nutrition Guidelines Development (see Annex 3), led by the Department of Nutrition for Health and Development, was established in 2009 with representatives from all WHO departments with an interest in the provision of scientific nutrition advice, including the Department of Maternal, Neonatal, Child and Adolescent Health and Development and the Department of Reproductive Health and Research. The WHO Steering Committee for Nutrition Guidelines Development meets twice yearly and both guided and provided overall supervision of the guideline development process.

The guideline development group, called guideline development group – nutrition actions, was established for the biennium 2013–2014 (see Annex 4). Its role was to advise WHO on the choice of important outcomes for decision-making and in the interpretation of the evidence and formulation of the recommendation. The group included experts from various WHO expert advisory panels (42) and those identified through open calls for specialists, taking into consideration a balanced mix of sex, multiple disciplinary areas of expertise, and representation from all WHO regions. Efforts were made to include content experts, methodologists, representatives of potential stakeholders (such as managers and other health professionals involved in the health-care process), and technical staff from ministries of health from Member States. Representatives of commercial organizations are not allowed to be members of a WHO guideline development group.

An external group of resource experts was also formed (see Annex 6) in order to assist the guideline development group – nutrition actions 2013–2014 in the assessment of the evidence, the identification of research priorities and programme considerations. Members of the external group of resource experts do not participate in or vote for final formulation of the recommendation.

The guideline development group – nutrition actions 2013–2014 agreed on a recommendation in the meeting held on 3–6 November 2014 in Cancun, Mexico. The WHO Secretariat prepared the guideline document containing the recommendation and the other sections, which reflect the discussions of the guideline development group.

The final draft guideline was peer-reviewed by three experts who provided technical feedback. These peer-reviewers were identified through various expert panels within and outside WHO (see Annex 7). Peer-reviewers received a finalized version of the guideline and were requested to comment or suggest changes restricted to errors of fact, clarifications, or considerations related to implementation, adaptation and the conditions in which the recommendation apply. If guideline users and readers wish to assess the methodological rigour for developing this global guideline, the Appraisal of Guidelines, Research and Evaluation II (AGREE II) Instrument can be used for this purpose (43).

Scope of the guideline

An initial set of questions (and the components of the questions) to be addressed in the guidelines was the critical starting point for formulating the recommendation. The questions were drafted by technical staff at the Evidence and Programme Guidance Unit, Department of Nutrition for Health and Development, based on policy and programme guidance needs of Member States and their partners. The population, intervention, control, outcomes (PICO) format was used (see Annex 8). The questions were discussed and reviewed by the WHO Steering Committee for Nutrition Guidelines Development.

A meeting of the guideline development group – nutrition actions 2013–2014 was held on 18–21 February 2013, in Geneva, Switzerland, to scope the guideline and rank the critical outcomes and populations of interest for the recommendation on the use of multiple micronutrient powders for point-of-use fortification of foods consumed by pregnant women. The guideline development group discussed the relevance of the questions and modified them as needed. The group scored the relative importance of each outcome from 1 to 9 (where 7–9 indicated that the outcome was critical for a decision, 4–6 indicated that it was important and 1–3 indicated that it was not important). The final key questions on the use of multiple micronutrient powders in pregnant women, along with the outcomes that were identified as critical and important for decision-making, are listed in PICO format in Annex 8.

A second meeting of the guideline development group – nutrition actions 2013–2014 was held on 23–26 June 2014, in Geneva, Switzerland, to review programmatic experiences, a presentation on the preliminary results of the systematic review and implementation research needs.

A third meeting of the guideline development group – nutrition actions 2013–2014 was held on 3–6 November 2014, in Cancun, Mexico. In this meeting, the members of the guideline development group were able to agree on the recommendation and its remarks, as well as on research priorities.

Evidence appraisal and decision-making

A systematic review (1) was used to summarize and appraise the evidence using the Cochrane handbook for systematic reviews of interventions (32) for randomized controlled trials and observational studies. This systematic review matched the PICO questions appropriately. Evidence profiles were prepared according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the overall quality of the evidence (6, 44). GRADE considers: the study design; the limitations of the studies in terms of their conduct and analysis; the consistency of the results across the available studies; the directness (or applicability and external validity) of the evidence with respect to the populations, interventions and settings where the proposed intervention may be used; and the precision of the summary estimate of the effect.

Both the systematic review (1) and the GRADE evidence profiles for each of the critical outcomes were used for drafting this guideline. The draft recommendation was discussed by the WHO Steering Committee for Nutrition Guidelines Development and with the guideline development group, at a consultation held on 3–6 November 2014 in Cancun, Mexico.

The procedures for decision-making are established at the beginning of the meetings, including a minimal set of rules for agreement and decision-making documentation. The guideline development group members secretly noted the direction and strength of the recommendation, using a form designed for this purpose, which also included a section for documenting their views on (i) the desirable and undesirable effects of the intervention; (ii) the quality of the available evidence; (iii) values and preferences related to the intervention in different settings; and (iv) the cost of options available to health-care workers in different settings (see Annex 2). These aspects were discussed openly in the meeting, followed by notation of each member's primary considerations in these areas on individual forms. Each member used one form, if not advised otherwise after managing any potential conflict of interests. Abstentions were not allowed. The process was improved with the availability of a predefined link to an online form prepared using survey software. Subsequent deliberations among the members of the guideline development group were of private character, i.e. only members of the guideline development group were allowed to be present during these deliberations and the external resource people had to leave the room. The WHO Secretariat collected the forms and disclosed a summary of the results to the guideline development group. If there was no unanimous consensus (primary decision rule), more time was given for deliberations and a second round of online voting took place. If no unanimous agreement was reached, a two-thirds vote of the guideline development group members present was required for the approval of the proposed recommendation (secondary decision rule). Divergent opinions could be recorded in the guideline. The results from voting forms are kept on file by WHO for 5 years. Although there was no unanimous consensus, more than 70% of the voting members of the guideline development group members decided it was a strong recommendation.

WHO staff present at the meeting, as well as other external technical experts involved in the collection and grading of the evidence, were not allowed to participate in the decision-making process. Two co-chairs with expertise in managing group processes and interpreting evidence were nominated at the opening of the consultation, and the nomination was approved by the guideline development group. Members of the WHO Secretariat were available at all times to help guide the overall meeting process, but did not vote and did not have veto power.