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Saskia de Pee & Martin W Bloem, World Food Programme, Rome, Italy
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Stunting deprives a child as young as two years of age of the inherent right to reach his or her full biologic potential and ability to have a healthy and prosperous life, as it is caused by early-childhood undernutrition which has irreversible effects on physical and cognitive development, educational attainment, and future productivity. There is an urgent need to give every child equal opportunities by ensuring that his/her needs for optimal nutrition during the first 1,000 days of life, starting at conception, are met.

Stunting, or short-for-age, is due to inadequate nutrient intake and absorption compared to needs. The inadequacy of nutrient intake does not just affect linear growth, but also other processes, such as development of the brain and the immune system. Furthermore, the brain of a young child who interacts little with the surrounding environment due to tiredness caused by anemia develops fewer neuron connections resulting in a different brain structure and lower brain weight compared to a child that has been able to develop to full potential. The outcome of brain development by the age of two years, in which nutrition plays a large role, determines to a large extent a person’s mental capacity for the rest of life (Hoddinott 2008; Victora 2008).

Stunting has been linked to increased morbidity and mortality, delayed mental development, poor school performance, and reduced intellectual capacity (Hoddinott 2008; Victora 2008). This affects income in adult life as well as economic productivity at national level. Furthermore, stunting is also related to increased risk of non-communicable disease later in life, such as diabetes, overweight and obesity, and cardiovascular disease (Victora 2008). And women of short stature are at greater risk of obstetric complications and of delivering an infant with low birth weight, which contributes to the intergenerational cycle of malnutrition (Özaltin 2010).

Not only stunted children are affected by undernutrition. Non-stunted children of populations with a considerable prevalence of stunting are also likely to be affected, just not to the extent that their height is below the cut-off for being classified as stunted.

Furthermore, when we consider that the current prevalence (26 per cent) of stunting among under-fives is lower than it was in recent decades, we can deduct that approximately one-third of the world population today suffers the consequences of having been stunted in early childhood. This is considerably more than the 12%, or 865 million people, that have inadequate caloric intake (‘undernourished’).

Due to the severe consequences of stunting developed during early life, and the fact that much of this damage cannot be undone later in life, its prevention is essential.

The etiology of stunting is complex, however. According to UNICEF’s conceptual framework of malnutrition, dietary intake (in the first 1000 days) and disease are the direct causes, representing nutrient intake, and nutrient needs and utilization, respectively. In turn, these direct factors are dependent on underlying factors: access to food, caring practices, and health care services and environmental hygiene (water and sanitation), which are all related to basic causes at individual and household level, such as education and income, as well as societal factors including economic situation, gender roles, governance etc.

Recent data on child survival show that many countries have made considerable progress in preventing childhood illnesses and improving environmental hygiene, thereby decreasing the incidence of infectious diseases and child mortality. Despite this, the progress in stunting has remained slow. Therefore there should be more emphasis on ensuring that nutrient requirements are met, starting during pregnancy, continuing through exclusive breastfeeding during the first 6 months of life, and then from breast milk and complementary foods between 6 to 24 months of age.

A recent publication compared data of five cohorts from low and middle income countries on birth weight, growth of length and weight during early and middle childhood and health, nutritional status and risk factors of non-communicable disease as adults (Adair 2013). Faster linear growth in the first 2 years of life were associated with increased adult height and duration of schooling, while adverse associations with fast relative weight gain (unrelated to length gain) were largely confined to mid-childhood and adulthood. This supports a strong focus on preventing undernutrition during the first 1000 days of life and preventing rapid weight gain thereafter.

An individual needs approximately 40 different nutrients to grow, develop, and remain healthy (Golden, 2009). This requires consumption of an adequately diverse diet, including breast milk, plant source foods (vegetables, fruits, staples), animal source foods (dairy, eggs, fish, meat), and fortified foods, and a variety of foods from each category needs to be consumed (de Pee, 2009).

Where such a variety of foods is not accessible, for example, due to financial constraints (Chastre et al., 2007), or is not available, specially formulated foods may be required that fill the so-called ‘nutrient gap’. A promising strategy is the home-fortification approach, where a small amount of a micronutrient powder (MNP) or lipid-based nutrient supplement (LNS, <20 grams, <120 kcal/day) is added to home-prepared foods, providing vitamins, minerals, and some other essential nutrients that are not available in adequate amounts from the prevailing diet. Another good option is the introduction of specially formulated complementary foods, such as infant porridges. For those who cannot afford such products, access may have to be facilitated through social protection systems.

The role of the private sector, particularly the food industry, is critical for achieving adequate nutrition and preventing stunting. The increase in the average height of populations in Europe and the United States, as well as parts of East Asia and Latin America, in the second half of the 20th century coincided with dramatic economic development. Because access to healthcare, water and sanitation, and primary education did not change much during this period in these parts of the world, the improvement of nutritional status was, to a large extent, due to better access among all economic strata of these populations to a more diverse diet, including improved, processed, complementary foods as well as animal source foods including dairy (Floud et al., 2011). For example, the average height of the Dutch male population increased from 165 cm in 1935 to 185 cm at the end of the 20th century (Larnkjær et al., 2006).

Yet at the same time, the world has seen an increase in prevalence of cardiovascular diseases, obesity, type-2 diabetes and cancers which are related to overconsumption of foods high in fats and/or sugars but low in vitamins, minerals, and other essential nutrients, and are also related to undernutrition in early life. There is an increasingly strong call to countries, agencies, and the private sector to put less emphasis on monoculture agribusiness and fast-food and more on food diversification, lowering intake of high-sugar and high-fat foods, and making more healthy and nutritious food options available.

While the private sector has to extend its contribution to preventing stunting in low- and middle-income countries, it also has to contribute to preventing the increase of nutrition-related chronic diseases. Both approaches require close cooperation with the public sector.

In summary, efforts to ensure that appropriate complementary foods, including home-fortificants, become available and affordable for consumption by children at risk of undernutrition need to be expanded in order to ensure that no child is deprived of his or her opportunities to realize their full potential in life.

References

Adair LA, Fall CHD, Osmond C et al for the COHORTS group (2013). Associations of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohort studies. Lancet doi 10.1016/S0140-6736(13)60103-8.
Chastre C, Duffield A, Kindness H et al. (2007). The Minimum Cost of a Healthy Diet: Findings from Piloting a New Methodology in Four Study Locations. Save the Children: Westport, CT. Available at: (accessed 2 April 2013).
De Pee S, Bloem MW (2009). Current and potential role of specially formulated foods and food supplements for preventing malnutrition among 6- to 23-month-old children and for treating moderate malnutrition among 6- to 59-month-old children. Food Nutr Bull, 30, S434-S463.
Floud R, Fogel RW, Harris B et al. (2011). The Changing Body, Health, Nutrition, and Human Development in the Western World since 1700. Cambridge University Press: Cambridge.
Golden MH (2009). Proposed recommended nutrient densities for moderately malnourished children. Food Nutrition Bull, 30, S267-S342.
Hoddinott J, Maluccio JA, Behrman JR et al. (2008). Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet, 371, 411-416.
Larnkjær A, Schrøder SA, Schmidt IN et al. (2006). Secular change in adult stature has come to a halt in northern Europe and Italy. Acta Paediatrica, 95, 754-755.
Özaltin E, Hill K, Subramanian SV (2010). Association of maternal stature with offspring mortality, underweight, and stunting in low- to middle-income countries. J Am Med Assoc, 303, 1507-1516.
Victora CG, Adair L, Fall C et al, for the Maternal and Child Undernutrition Study Group. (2008). Maternal and child undernutrition: consequences for adult health and human capital. Lancet, 371, 340-357.