How Can Countries Reduce Stunting?  Evidence from a Global Review and Country Examples of Progress

Stunting is a physical manifestation of chronic malnutrition that begins in utero.  It has been linked to suboptimal development as well as higher rates of morbidity and mortality among young children.  Moreover, childhood stunting is associated with poor health outcomes that often persist into adulthood.  The burden of stunting falls largely on low-income countries as it is linked to poverty, high rates of childhood infection, and poor-quality diet.

Published in The American Journal of Clinical Nutrition (AJCN), “How Can Countries Reduce Stunting? Evidence from a Global Review and Country Examples of Progress” is an open-access supplement shedding new light on stunting.  Together, the nine articles explore core issues in stunting research, review the latest scientific findings, and present country-level case studies that help nutrition scientists and public health professionals design and implement programs to combat stunting that are tailored to the needs of local populations.

Childhood stunting has decreased globally from 39.3% to 21.3%.

Fortunately, childhood stunting has decreased globally from 39.3% to 21.3% between 1990 and 2019.  Tyler Vaivada et al., authors of “Stunting in Childhood: An Overview of Global Burden, Trends, Determinants, and Drivers,” conducted a comprehensive review of 89 studies to uncover the determinants and drivers underlying the decline in stunting among low- and middle-income countries.  The authors concluded that “determinants identified to be particularly impactful include improvements in maternal and paternal education, household socioeconomic status, sanitation conditions, maternal health services access, and family planning.”

To help further understand what has driven the global reduction in stunting, the Exemplars in Stunting Reduction project sought to determine the factors that enabled five countries to achieve a rapid rate of stunting reduction relative to their economic growth.  The results of these five country-level studies have been published in the AJCN supplement: Ethiopia, Kyrgyz Republic, Nepal, Peru, and Senegal.  Each of these countries managed to decrease childhood stunting by almost 50% over a 15- to 20-year period.

Child stunting reduction is possible even in diverse and challenging contexts.

Examining these five exemplar studies, ASN member Zulfiqar A. Bhutta et al., authors of “How Countries Can Reduce Child Stunting at Scale: Lessons from Exemplar Countries,” concluded that “child stunting reduction is possible even in diverse and challenging contexts.” 

Roadmap to child stunting reduction at scale. NGO, nongovernmental organization; WASH, water, sanitation, and hygiene.

The authors found that “improvements in child growth faltering and reductions in stunting were related to investments from both within and outside the health sector.”  In particular, “improvements in maternal nutrition, maternal education, broad maternal and child health care, and fertility practices yielded some of the greatest gains.”

Understanding Multifactorial Drivers of Child Stunting Reduction in Exemplar Countries: A Mixed-Methods Approach,” authored by Nadia Akseer et al., explains how the Exemplar country studies were designed and implemented.  The authors detail the standardized mixed-methods framework that was applied to all the Exemplar country studies, beginning with the development of a technical advisory group of global experts in health, nutrition, and evaluation methods.

One of the key lessons learned has been that, in order to reduce stunting, researchers must understand its extent by gathering and analyzing anthropometric data.  The quality of anthropometric data, however, often varies among studies.  In response “Anthropometric Data Quality Assessment in Multi-survey Studies of Child Growth,” authored by ASN member Nandita Perumal et al., developed composite indices of anthropometric data quality for use in multi-survey analyses of child health and nutritional status.  The authors found that “a composite index of anthropometric data quality using a parsimonious set of individual indicators can effectively discriminate among surveys with excellent and poor data quality.”  Moreover, “such indices can be used to account for variations in anthropometric data quality in multi-survey epidemiologic analyses of child health.”

This body of work remains of paramount importance to guide countries…to mitigate the effects of the pandemic on their population.

In an introduction to this nine-part supplement, Rebecca Roediger et al. note, “as the current pandemic is predicted to worsen malnutrition worldwide, this body of work remains of paramount importance to guide countries as they work to implement programs to mitigate the effects of the pandemic on their population.”