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Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Nutritional Epidemiology".

Deadline for manuscript submissions: closed (30 November 2019) | Viewed by 65536

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Special Issue Editors

Dr. Arnaud Laillou

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Guest Editor

UNICEF
Interests: Nutrition; Micronutrients; Nutritional Biochemistry; Nutritional Epidemiology; Vitamin A

Prof. Dr. Ian Darnton Hill

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Guest Editor

1. The Boden Institute of Obesity, Nutrition, Exercise & Eating Disorders, University of Sydney, Sydney, NSW 2006, Australia 2. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 021111, USA
Interests: public health nutrition; national nutrition policies; micronutrients policies and planning
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Dear Colleagues,

The prevention and treatment of childhood stunting remain substantial challenges. Stunted children have impaired growth, increased mortality, impaired cognitive development, largely remain stunted as adolescents, and have reduced earning capacity as adults. Approximately 165 million people under five years of age are stunted, and most of these are in low- and middle-income countries (LMIC). Although there has been an impressive global reduction in the prevalence of stunting, there is a recognized need for more information on causes, interventions, and outcomes. Part of the challenge is the multiple biological, social, and environmental causes that interact at different intersections, suggesting that multisectoral approaches are needed. Considerable experience has been accumulated, but more is needed, as are increased resource allocation and resources.

The proposed Issue will examine causes and prevalence, current controversies (e.g., the impact of WASH), the theoretical basis of interventions, and examples of actual programmes. There will be an introduction examining the prevalence and distribution and trends to set the stage. A review of current approaches will be given, as well as a discussion of some of the factors involved, including dietary approaches and the need for an inter-sectoral approach (e.g., both nutrition-specific and -sensitive, the situation for adolescents, and some examples from some of the most affected populations), and a conclusion with possible next steps.

Dr. Arnaud Laillou
Prof. (Adj.) Ian Darnton-Hill AO
Guest Editors

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Keywords

stunting
prevalence and distribution of stunting
current interventions
diet and nutrients
low- and middle-income countries (LMIC)
first 1000 days
adolescents
nutrition-specific and nutrition-sensitive interventions

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Published Papers (10 papers)

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20 pages, 924 KiB

Open AccessArticle

The Forgotten Agenda of Wasting in Southeast Asia: Burden, Determinants and Overlap with Stunting: A Review of Nationally Representative Cross-Sectional Demographic and Health Surveys in Six Countries

by Mueni Mutunga, Severine Frison, Matteo Rava and Paluku Bahwere

Nutrients 2020, 12(2), 559; https://doi.org/10.3390/nu12020559 - 20 Feb 2020

Cited by 18 | Viewed by 5003

Abstract

Childhood wasting is among the most prevalent forms of undernutrition globally. The Southeast Asia region is home to many wasted children, but wasting is not recognized as a public health problem and its epidemiology is yet to be fully examined. This analysis aimed to determine the burden of wasting, its predictors, and the level of wasting and stunting concurrence. Datasets from Demographic and Health Surveys and Multiple Indicator Cluster Surveys in six countries in the region were analyzed. The pooled weighted prevalence for wasting and concurrent wasting and stunting among children 0–59 months in the six countries was 8.9%, 95% CI (8.0–9.9) and 1.6%, 95% CI (1.5–1.8), respectively. This prevalence is approximately 12-fold higher than the 0.7% prevalence of high-income countries; and translated into an absolute number of 1,088,747 children affected by wasting and 272,563 concurrent wasting and stunting. Wasting prevalence was 50 percent higher in the 0–23-month age group. Predictors for wasting included source of drinking water, wealth index, urban residence, child’s age and history of illness and mother’s body mass index. In conclusion, our analysis showed that wasting is a serious public health problem in the region that should be addressed urgently using both preventive and curative approaches. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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11 pages, 1428 KiB

Open AccessArticle

Socio-Economic Inequalities in Child Stunting Reduction in Sub-Saharan Africa

by Kaleab Baye, Arnaud Laillou and Stanley Chitweke

Nutrients 2020, 12(1), 253; https://doi.org/10.3390/nu12010253 - 18 Jan 2020

Cited by 29 | Viewed by 5502

Abstract

Stunting in children less than five years of age is widespread in Sub-Saharan Africa. We aimed to: (i) evaluate how the prevalence of stunting has changed by socio-economic status and rural/urban residence, and (ii) assess inequalities in children’s diet quality and access to maternal and child health care. We used data from nationally representative demographic and health- and multiple indicator cluster-surveys (DHS and MICS) to disaggregate the stunting prevalence by wealth quintile and rural/urban residence. The composite coverage index (CCI) reflecting weighed coverage of eight preventive and curative Reproductive, Maternal, Neonatal, and Child Health (RMNCH) interventions was used as a proxy for access to health care, and Minimum Dietary Diversity Score (MDDS) was used as a proxy for child diet quality. Stunting significantly decreased over the past decade, and reductions were faster for the most disadvantaged groups (rural and poorest wealth quintile), but in only 50% of the countries studied. Progress in reducing stunting has not been accompanied by improved equity as inequalities in MDDS (p < 0.01) and CCI (p < 0.001) persist by wealth quintile and rural-urban residence. Aligning food- and health-systems’ interventions is needed to accelerate stunting reduction more equitably. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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14 pages, 725 KiB

Open AccessArticle

Age-Appropriate Feeding Practices in Cambodia and the Possible Influence on the Growth of the Children: A Longitudinal Study

by Gabriela Hondru, Arnaud Laillou, Frank T. Wieringa, Etienne Poirot, Jacques Berger, Dirk L. Christensen and Nanna Roos

Nutrients 2020, 12(1), 12; https://doi.org/10.3390/nu12010012 - 19 Dec 2019

Cited by 14 | Viewed by 5413

Abstract

Age-appropriate feeding practice (ADF) during early childhood are vital for optimal nutrition. This longitudinal study determined the effect of selected risk factors and ADF, as described by the National Nutritional Recommendations, on linear and ponderal growth of children below 24 months of age. Weight and length measures were used to calculate z-scores of anthropometric measures by WHO standards. The prevalence of stunting increased from 13.2% to 32.4% over time, while prevalence of wasting remained stable (14.5%). At first visit, 43% of children of all ages complied with ADF criteria, a proportion which decreased to 7.1% in follow-up. The quality of feeding practices for children above 12 months of age was the poorest, where at the last visit, only 6% complied with the criteria for ADF. The linear mixed-effect models found the association between ADF and ponderal growth to be significant (weight-for-height estimate: 0.05 SD). In Cambodia, Ratanakiri province, ADF was the second largest determinant for ponderal growth. We recommend province specific public health actions. For children above 6 months, the quantity of food given needs to be increased, followed by the meal frequency. Mothers’ educational level, improved sanitation, and drinking water quality were among strongest predictors of a child’s growth. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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9 pages, 1329 KiB

Open AccessArticle

Prioritizing the Scale-Up of Evidence-Based Nutrition and Health Interventions to Accelerate Stunting Reduction in Ethiopia

by Kaleab Baye

Nutrients 2019, 11(12), 3065; https://doi.org/10.3390/nu11123065 - 16 Dec 2019

Cited by 9 | Viewed by 4067

Abstract

Despite some progress, stunting prevalence in many African countries including Ethiopia remains unacceptably high. This study aimed to identify key interventions that, if implemented at scale through the health sector in Ethiopia, can avert the highest number of stunting cases. Using the Lives Saved Tool (LiST), the number of stunting cases that would have been averted, if proven interventions were scaled-up to the highest wealth quintile or to an aspirational 90% coverage was considered. Stunting prevalence was highest among rural residents and households in the poorest wealth quintile. Coverage of breastfeeding promotion and vitamin A supplementation were relatively high (>50%), whereas interventions targeting women were limited in number and had particularly low coverage. Universal coverage (90%) of optimal complementary feeding, preventive zinc supplementation, and water connection in homes could have each averted 380,000–500,000 cases of stunting. Increasing coverage of water connection to homes to the level of the wealthiest quintile could have averted an estimated 168,000 cases of stunting. Increasing coverage of optimal complementary feeding, preventive zinc supplementation, and Water, Sanitation and Hygiene (WASH) services is critical. Innovations in program delivery and health systems governance are required to effectively reach women, remote areas, rural communities, and the poorest proportion of the population to accelerate stunting reduction. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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12 pages, 424 KiB

Open AccessArticle

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

by Alemayehu Argaw, Giles Hanley-Cook, Nathalie De Cock, Patrick Kolsteren, Lieven Huybregts and Carl Lachat

Nutrients 2019, 11(10), 2485; https://doi.org/10.3390/nu11102485 - 16 Oct 2019

Cited by 25 | Viewed by 6848

Abstract

Background: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly’s global target of 40% stunting reduction by 2025. Methods: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. Results: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women’s decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households’ access to improved sanitation facilities and drinking water sources, and children’s access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. Conclusions: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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15 pages, 439 KiB

Open AccessArticle

Assessing the Intergenerational Linkage between Short Maternal Stature and Under-Five Stunting and Wasting in Bangladesh

by Wajiha Khatun, Sabrina Rasheed, Ashraful Alam, Tanvir M. Huda and Michael J. Dibley

Nutrients 2019, 11(8), 1818; https://doi.org/10.3390/nu11081818 - 7 Aug 2019

Cited by 35 | Viewed by 4329

Abstract

Short maternal stature is identified as a strong predictor of offspring undernutrition in low and middle-income countries. However, there is limited information to confirm an intergenerational link between maternal and under-five undernutrition in Bangladesh. Therefore, this study aimed to assess the association between short maternal stature and offspring stunting and wasting in Bangladesh. For analysis, this study pooled the data from four rounds of Bangladesh Demographic and Health Surveys (BDHS) 2004, 2007, 2011, and 2014 that included about 28,123 singleton children aged 0–59 months born to mothers aged 15–49 years. Data on sociodemographic factors, birth history, and anthropometry were analyzed using STATA 14.2 to perform a multivariable model using ‘Modified Poisson Regression’ with step-wise backward elimination procedures. In an adjusted model, every 1 cm increase in maternal height significantly reduced the risk of stunting (relative risks (RR) = 0.960; 95% confidence interval (CI): 0.957, 0.962) and wasting (RR = 0.986; 95% CI: 0.980, 0.992). The children of the short statured mothers (<145 cm) had about two times greater risk of stunting and three times the risk of severe stunting, 1.28 times the risk of wasting, and 1.43 times the risk of severe wasting (RR = 1.43; 95% CI: 1.11, 1.83) than the tall mothers (≥155 cm). These findings confirmed a robust intergenerational linkage between short maternal stature and offspring stunting and wasting in Bangladesh. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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14 pages, 279 KiB

Open AccessArticle

Dietary Diversity and Child Development in the Far West of Nepal: A Cohort Study

by Andrew L. Thorne-Lyman, Merina Shrestha, Wafaie W. Fawzi, Monica Pasqualino, Tor A. Strand, Ingrid Kvestad, Mari Hysing, Neena Joshi, Mahendra Lohani and Laurie C. Miller

Nutrients 2019, 11(8), 1799; https://doi.org/10.3390/nu11081799 - 3 Aug 2019

Cited by 31 | Viewed by 4794

Abstract

Poverty adversely affects child development through multiple pathways in low- and middle-income countries. Relationships between diet and child development are poorly understood. In this study, we aimed to explore these associations in a longitudinal cohort of 305 children in rural Nepal (baseline mean age 14 months), evaluating dietary diversity and the consumption of specific food groups at three timepoints over 1.5 years. Child development was assessed using the Ages and Stages questionnaire-version 3 (ASQ-3). Associations between the number of days that children consumed minimum dietary diversity (MDD) (≥4/8 items) and specific food groups over time (range 0–3) and total and subscale ASQ scores at age 23–38 months were estimated using multiple linear and logistic regression, dichotomizing scores at the lowest quartile. After adjusting for confounders, each additional day of consuming MDD was associated with a 35% reduction in the odds of low total ASQ score [OR 0.65, 95% CI (0.46, 0.92)]. The consumption of animal source foods [OR 0.64, (0.46, 0.89)], and vegetables/fruits [OR 0.60, (0.41, 0.90), but not processed foods [OR 0.99, (0.62, 1.59)] was associated with lower odds of low total development. Vegetables, fruits and animal source foods may be important for child development in this setting. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

12 pages, 424 KiB

Open AccessArticle

The Interaction between Morbidity and Nutritional Status among Children under Five Years Old in Cambodia: A Longitudinal Study

by Gabriela Hondru, Frank T. Wieringa, Etienne Poirot, Jacques Berger, Somphos V. Som, Chan Theary and Arnaud Laillou

Nutrients 2019, 11(7), 1527; https://doi.org/10.3390/nu11071527 - 5 Jul 2019

Cited by 14 | Viewed by 4134

Abstract

Even though limited evidence is available, the relationship between morbidity and under-nutrition among children under-five is likely to be a strong two-way association. This study aims to explore this vicious cycle by employing longitudinal data of four periods within a 24 month follow-up, whereby morbidity was captured between two subsequent anthropometric measures. Malnutrition was classified according to z-scores of anthropometric measures and morbidity by number of sick days experienced in between. Mixed-effects models were used to assess this relation, where dependency of morbidity and nutritional status were interchanged; models were adjusted for province, age, gender, wealth index score, maternal education level, diet, and Water, Sanitation, and Hygiene indicators. Stunting and wasting prevalence were 29.9% and 8.9%, respectively, where 21.3% of the children had multiple anthropometric failures. Children identified as wasted were 35% more likely to experience prolonged illness periods (OR: 1.35, 95% CI: 1.02–1.56). Those experiencing high proportion of sick days were found to be 64% more likely to become stunted (OR: 1.64, 95% CI: 1.18–2.29). This study suggests that the link between wasting and stunting could be partly explained by acute illness, where wasting increases the likelihood of prolonged episodes of illness, which increases the risk of stunting. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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13 pages, 412 KiB

Open AccessArticle

Determinants of the Stunting of Children Under Two Years Old in Indonesia: A Multilevel Analysis of the 2013 Indonesia Basic Health Survey

by Christiana R. Titaley, Iwan Ariawan, Dwi Hapsari, Anifatun Muasyaroh and Michael J. Dibley

Nutrients 2019, 11(5), 1106; https://doi.org/10.3390/nu11051106 - 18 May 2019

Cited by 134 | Viewed by 15151

Abstract

Indonesia is ranked fifth among countries with the highest burden of stunting in children under five. This study aims to examine the determinants of stunting in children aged 0–2 years in Indonesia using data derived from the 2013 Indonesia Basic Health Survey. Twenty potential predictors of stunting, categorized into household and housing characteristics; maternal and paternal characteristics; antenatal care services and child characteristics were analyzed. Multilevel analyses were performed to examine the role of cluster/district/provincial differences, as well as individual/household level characteristics and stunting status. Of 24,657 children analyzed, 33.7% (95%CI: 32.8%–34.7%) were stunted. The odds of stunting increased significantly among children living in households with three or more children under five-years-old (aOR = 1.33, 95%CI: 1.03–1.72), households with five to seven household members (aOR =1.11; 95%CI: 1.03–1.20), children whose mothers during pregnancy attended less than four antenatal care services (aOR = 1.22, 95%CI: 1.08–1.39), boys (aOR = 1.33, 95%CI: 1.22–1.45), children aged 12–23 months (aOR = 1.89; 95%CI: 1.54–2.32), and children who weighed <2500 g at birth (aOR = 2.55; 95%CI: 2.05–3.15). The odds also increased significantly with the reduction of household wealth index. Integrated interventions to address environment, an individual level associated with stunting in Indonesia, from the environment- to individual-level factors are important. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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13 pages, 857 KiB

Open AccessFeature PaperConcept Paper

Exploring the Nutritional Ecology of Stunting: New Approaches to an Old Problem

by Daniel J. Raiten and Andrew A. Bremer

Nutrients 2020, 12(2), 371; https://doi.org/10.3390/nu12020371 - 31 Jan 2020

Cited by 31 | Viewed by 8563

Abstract

Despite a declining prevalence, stunting remains an elusive target for the global health community. The perception is that stunting represents chronic undernutrition (i.e., due to inadequate nutrient intake associated with food insecurity, low-quality diet, and suboptimal infant feeding practices in the first two years of life). However, other causes include maternal–fetal interactions leading to intrauterine growth retardation, poor maternal nutrition during pregnancy and lactation, and maternal and pediatric infections. Moreover, physical, economic, demographic, and social environments are major contributors to both food insecurity and conditions that limit linear growth. Overall, factors representing both the internal and external “nutritional ecologies” need to be considered in efforts to reduce stunting rates. Nutritional assessment requires better understanding of the mechanism and role of nutrition in growth, clear expectations about the sensitivity and specificity of the tools used, and inclusion of bio-indicators reflecting the extent and nature of the functional effect of poor nutrition and environmental factors contributing to human physical growth. We provide a perspective on current knowledge about: (i) the biology and contribution of nutrition to stunting/poor growth; (ii) our current nutritional assessment toolkit; (iii) the implications of current assessment approaches for clinical care and public interventions; and (iv) future directions for addressing these challenges in a changing global health environment. Full article

(This article belongs to the Special Issue Preventing Stunting during the Life Cycle through Integrated Nutrition Approaches)

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