How countries can reduce child stunting at scale: lessons from exemplar countries

Addressing Stunting in Children Under Five: Insights and Opportunities from Nepal, Bangladesh, and Vietnam-A Review of Literature

Background: Stunting remains a significant global health issue, particularly in low- and middle-income countries (LMICs). Globally, around 22% of children under five are affected, with high rates persisting in South and Southeast Asia. This review examines government-led programs in high-performing LMICs (Nepal, Bangladesh, and Vietnam) to identify key strategies and opportunities for effective intervention. Methods: A literature search was conducted on PubMed using keywords and Medical Subject Heading terms, including "stunting", "child undernutrition", "malnutrition" and the names of the three specified countries. Articles were evaluated for relevance based on their focus on stunting prevalence, risk factors, and interventions in these countries, without restrictions on publication date or language. Results: Stunting prevalence among children under five has significantly declined in Nepal, Bangladesh, and Vietnam over the past two decades, reflecting the impact of sustained nutrition and health interventions. Nepal reduced stunting from 55.8% in 2000 to 26.7% in 2022, Bangladesh from 54.7% to 26.4%, and Vietnam from 41.5% to 19.3%. Successful strategies included multisectoral approaches integrating nutrition-specific and nutrition-sensitive interventions, enhanced policy frameworks, and strong governance. Despite progress, challenges remain, such as high wasting prevalence in Nepal and disparities among marginalized communities in Vietnam, emphasizing the need for targeted, context-specific interventions. Conclusions: Effective stunting reduction requires multisectoral strategies addressing underlying, intermediate, and immediate determinants. Insights from Nepal, Bangladesh, and Vietnam highlight the importance of sustained government commitment, robust policies, and coordinated interventions. Adapting these successful strategies to local contexts can support stunting prevention and management, promoting healthier and more resilient communities.

Risk factors for undernutrition and poor growth during the first 6 months of life in sub-Saharan Africa: A scoping review

BACKGROUND & AIMS

Early infant undernutrition and suboptimal growth represent significant public health challenges in many low- and middle-income countries, yet information regarding the risk factors for poor growth remains limited. A scoping review was conducted to map the existing evidence on indicators of undernutrition and poor growth and related risk factors among infants aged 0-6 months in sub-Saharan Africa.

METHODS

This scoping review was conducted in accordance with the Joanna Briggs Institute framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. MEDLINE, Embase, and Scopus were systematically searched for eligible studies, with no restrictions on time or language.

RESULTS

A total of 50 studies met the inclusion criteria for this review. The most frequently reported indicator of undernutrition was stunting, followed by underweight and wasting. Sex, feeding, illness, and birth size were the most studied infant risk factors for poor growth. The maternal risk factors most frequently investigated included age, education, human immunodeficiency virus infection, and occupation. Socioeconomic status and factors related to water, sanitation, and hygiene were the most studied household risk factors.

CONCLUSIONS

Several indicators of undernutrition and poor growth were identified, with stunting being the most frequently reported. Associated risk factors included multiple infant-, maternal-, and household factors, highlighting the need for complex multilayered interventions to address undernutrition and poor growth among these vulnerable infants.

Policies and programmes to improve preconception nutrition in South Asia

The health and health behaviours of women before conception significantly influence maternal and child health outcomes. Despite growing evidence supporting preconception nutrition care, data on the implementation of related policies and programmes remains limited. This paper reviews public policies and programmes delivering preconception nutrition interventions in eight South Asian countries, targeting married pre-pregnant women aged 15-49 years and identifies the systems bottlenecks in programme implementation. Most countries, except Sri Lanka, lack universal programmes for health and nutrition screening, provision of essential micronutrients, counselling on healthy eating and treatment for at-risk women. Even in countries, where supportive policies exist, implementation of comprehensive nutrition services for pre-pregnant women faces significant bottlenecks across six health system building blocks. Addressing these barriers is critical to improving intervention effectiveness, programme implementation, and informed decision-making. Further testing of a proposed comprehensive algorithm for preconception nutrition in diverse country contexts across South Asia is necessary.

Unveiling subgroup trends of stunting and wasting in Indian children: a serial cross-sectional analysis from National Family Health Surveys 3-5

BACKGROUND

India grapples with a dual burden of child wasting and stunting and stark socio-economic and regional disparities.

OBJECTIVES

We aimed to better understand trends in the prevalence of childhood stunting and wasting, with an emphasis on its disproportionate effects on marginalized populations, by analyzing National Family Health Surveys (NFHS) data from 2005 to 2020.

METHODS

We analyzed trends in the distribution of childhood height-for-age Z (HAZ) and weight-for-height Z (WHZ) scores using anthropometric data from 3 surveys, NFHS 3, 4, and 5. We examined disparities by wealth, caste, tribe, area of residence (rural compared with urban), and sex and mapped trends against India's evolving policy landscape. We also conducted a regression analysis of HAZ and WHZ risk factors.

RESULTS

In the context of an evolving nutrition-centered policy landscape, disparities by level of wealth in both HAZ and WHZ decreased in the study period (HAZ: estimate = 0.27, confidence interval [CI]: 0.16, 0.38; and WHZ: estimate = 0.11, CI: 0.01, 0.22), though there were no improvements in disparities for marginalized castes (HAZ: estimate = 0.07, CI: 0.00, 0.13; and WHZ: estimate = 0.02, CI: -0.04, 0.08). Though they have narrowed, disparities by wealth, caste, tribe, and area of residence persist, with undernutrition at birth, as measured by HAZ and WHZ, a particularly acute problem.

CONCLUSIONS

Although there have been significant reductions in disparities by wealth in mean HAZ and WHZ scores in India, persistent disparities by caste, tribe, and area of residence necessitate reinvestments in targeted interventions. Further, despite this narrowing of disparities and overall progress against stunting, anthropometric scores in early childhood continue to be low in India, especially with regard to wasting, indicating the importance of not only maternal nutrition and care for newborns but more comprehensive efforts to address poverty and other factors that contribute to undernutrition, with a focus on vulnerable populations.

Mitigating the Impact of Intergenerational Risk Factors on Stunting: Insights From Seven of the Most Food Insecure Districts in South Africa

A large body of research investigates the determinants of stunting in young children, but few studies have considered which factors are the most important predictors of stunting. We examined the relative importance of predictors of height-for-age z-scores (HAZ) and stunting among children under 5 years of age in seven of the most food-insecure districts in South Africa using data from the Grow Great Community Stunting Survey of 2022. We used dominance analysis and variable importance measures from conditional random forest models to assess the relative importance of predictors. We found that intergenerational and socioeconomic factors-specifically maternal height (HAZ: Coef. 0.02, 95% CI 0.01-0.03; stunting: OR 0.96, 95% CI 0.94-0.98), birth weight (HAZ: Coef. 0.3, 95% CI 0.16-0.43; stunting: OR 0.5, 95% CI 0.35-0.72) and asset-based measures of socioeconomic status (HAZ: Coef. 0.17, 95% CI 0.10-0.24; stunting: OR 0.77, 95% CI 0.67-0.89)-were the most important predictors of HAZ and stunting in these districts. We explored whether any other factors moderated (weakened) the relationship between these intergenerational factors and child height using conditional inference trees and moderation analysis. We found that being on track for vitamin A and deworming, adequate sanitation, a diverse diet and good maternal mental health moderated the effect of birth weight or mother's height. Though impacts are likely to be small relative to the impact of intergenerational risk factors, these moderating factors may provide promising avenues for helping to mitigate the intergenerational transmission of stunting risk in South Africa.

What works for reducing stunting in low-income and middle-income countries? Cumulative learnings from the Global Stunting Exemplars Project

BACKGROUND

Impaired linear growth and stunting in children under 5 y is a marker of multiple deprivations in low-income and middle-income countries.

OBJECTIVES

We aimed to assess drivers and policies influencing improvements in linear growth and stunting reduction in 10 countries with annual rates of reduction in childhood stunting averaging 1.1% (range: 0.4%-1.7%) at national-level or subnational-level, and to improve a framework of action for other countries to follow.

METHODS

We used mixed methods to assess trends and patterns of improvement in linear growth in children under 5 y using available household-level data and in-depth analysis of programs and their implementation. We assessed patterns of change with multivariate regression analyses of risk factors driving stunting and affecting change. We compared results from the Oaxaca-Blinder decomposition analyses using a hierarchical approach and retrospectively assessed the appropriateness of a previously proposed 10-step process for country-level planning and implementation processes. Limited data precluded robust serial assessment of dietary intake at individual level for children and mothers.

RESULTS

Rapid reduction in childhood stunting is possible and findings across exemplar countries underscore the benefits of indirect and direct interventions in health and other social sectors. These include programs focusing on poverty alleviation; water, sanitation, and hygiene; promotion of girls' education and empowerment; and maternal nutrition. The potential benefits of family planning programs and factors contributing to gains in maternal nutrition were noted. In malarial endemic areas, malaria control programs were associated with improved childhood growth, and patterns of growth indicated continued benefits of childhood disease prevention and management strategies.

CONCLUSIONS

A systematic, evidence-informed approach to improve maternal and child health and nutrition is feasible and, with targeting, can accelerate reduction in linear growth faltering in childhood.

What works for anemia reduction among women of reproductive age? Synthesized findings from the exemplars in anemia project

BACKGROUND

Few countries have succeeded to decrease the prevalence of anemia in women of reproductive age (WRA), and where improvements have been observed, contributing factors are not well understood.

OBJECTIVES

To synthesize cross-cutting findings from specific exemplar studies in Uganda, Senegal, the Philippines, and Pakistan by reviewing anemia trends, policies, and programs, comparing drivers of change, and proposing strategies to achieve further reductions in WRA anemia.

METHODS

A mixed-methods approach was used for exemplar case studies: 1) descriptive analyses of Demographic and Health Surveys and national survey data; 2) review of relevant policies/programs; 3) stakeholder in-depth interviews and focus group discussions with WRA and community members; and 4) Oaxaca-Blinder decomposition to identify determinants of hemoglobin change over time. This cross-country analysis performs triangulation of qualitative and quantitative analyses.

RESULTS

Compound annual change rates for anemia from the ∼2005-2018 period were -0.7% in Senegal, -2.4% in Uganda, -3.4% in Pakistan, and -6.2% in the Philippines. Despite these reductions, WRA anemia burden in Senegal and Pakistan continues to be a severe public health problem. Direct and indirect health sector strategies, such as iron-folic acid supplementation in pregnancy, vitamin A supplementation during lactation, malaria control (Uganda and Senegal), investments in family planning, and better access to health services through community-based approaches, contributed to a median of 36.5% (range: 30%-66%) change in hemoglobin. Nonhealth sector strategies, including social protection and poverty alleviation schemes, empowering of girls and women, and improving household conditions, contributed to a 21% (18%-58%) change in hemoglobin. Large-scale food fortification (for example, wheat flour with iron) could have also contributed to improved micronutrient intakes and reduction in iron deficiency anemia.

CONCLUSIONS

A context-specific, multisectoral approach is needed to decrease WRA anemia, incorporating direct nutritional interventions and indirect strategies within the health and nonhealth sectors. Lessons from the successes and challenges from exemplar countries could help accelerate global anemia reduction.

A mixed-methods study of the drivers of stunting reduction among children under-5 in Sierra Leone, 2005-2017

BACKGROUND

Childhood stunting prevalence declined dramatically in Sierra Leone after the end of the civil war in 2002, despite major challenges of postwar recovery and the West Africa Ebola epidemic in 2014-2016.

OBJECTIVES

This study aims to identify the factors associated with declining stunting prevalence among children under-5 in Sierra Leone between 2005 and 2017.

METHODS

Mixed methods including literature review, primary qualitative research, narrative policy and program review, and secondary analysis of household survey data on children under-5 with valid height-for-age z-scores (HAZ) (n = 4915 in 2005, n = 7736 in 2010, and n = 11,447 in 2017), including Oaxaca-Blinder decomposition analysis.

RESULTS

Under-5 stunting prevalence declined from 46.9% in 2005 to 26.4% in 2017 and mean HAZ increased from -1.75 to -1.13, with some narrowing of inequalities in child growth by wealth, maternal education, and sex, but not between urban and rural children. Stakeholders highlighted several policies and programs that evidenced government commitment to improving maternal and child health and nutrition and likely contributed to improved child growth over time, including the Free Health Care Initiative introduced in 2010. Our quantitative modeling predicted only 29% of the observed 0.62 HAZ increase over the study period but highlighted expanded coverage of antenatal care, increased urbanization, and increased household wealth as key drivers of nutritional change over time.

CONCLUSIONS

Rapid reduction in under-5 stunting in Sierra Leone coincided with strong economic growth and declining urban poverty, along with high-profile health and development policies supported by external partners that targeted and/or benefited poorer and rural populations especially. Had the Ebola and COVID-19 epidemics not occurred, positive pre-2014 trajectories in child growth and other maternal and child health and nutrition outcomes in Sierra Leone may well have continued, yielding gains even larger than those observed over the study period.

Strengthening nutrition policy and service delivery: Lessons learned from a six-country assessment of Alive and Thrive's technical assistance

Alive & Thrive (A&T) provides strategic technical assistance (TA) to develop effective policies; improve maternal, infant, and young child nutrition (MIYCN) programme design and implementation and enhance system capacity to sustain quality MIYCN service delivery at scale. A qualitative assessment was conducted using document review and stakeholder interviews (n = 79) to describe a selection of A&T's TA in six countries and systematically assess the contextual and TA process-related factors that influenced the results achieved and document the lessons learned about MIYCN TA design and implementation. To facilitate the selection of different types of TA, we classified TA into two levels of stakeholder engagement and intensity. Under the Technical Advisor TA category, we assessed A&T's support to strengthen national policy formulation, monitoring, and implementation of the International Code of Marketing of Breast-milk Substitutes. For Capacity Development TA, we assessed A&T support to scale-up maternal nutrition services and to increase strategic use of data. Factors important for TA provision included identifying and engaging with the right people, using evidence to support advocacy and decision-making, using multiple ways to strengthen capacity, developing packages of tools to support programme scale-up, and reinforcing feedback mechanisms to improve service provision and data quality. Challenges included shifts in the political context, poorly functioning health systems, and limited resources to replicate or sustain the progress made. Continued investment in evidence-based and practical TA that strengthens the institutionalization of nutrition across all stakeholders-including government, medical associations, civil society and development partners-is essential. Future TA must support governments to strengthen system capacity for nutrition, including financial and human resource gaps that hamper full scale-up.

A mixed-methods study of the drivers of stunting reduction among children under five in Nigeria, 2008-2018

BACKGROUND

Although stunting reduction at the national level in Nigeria has been modest in recent decades, especially considering the country's rapid economic growth, there is much subnational variation.

OBJECTIVES

The objective of this study was to identify the factors associated with declining stunting prevalence in those states in Nigeria where the most progress was made between 2008 and 2018.

METHODS

This mixed-methods study included quantitative analysis of household survey data using regression-based Oaxaca-Blinder decomposition analysis to identify factors associated with a change in mean height-for-age z-score (HAZ) over time; deductive thematic analysis of qualitative data collected through key informant interviews and focus group discussions; and policy and program review.

RESULTS

Improvement in child linear growth over the past decade is evident in exemplar states in both the north and south of Nigeria, driven largely by the same factors. Our modeling predicted 66% of the observed +0.25 increase in mean HAZ over time in exemplar states, with nearly 60% of the predicted increase associated with improvements in non-health sector factors: parental education (43%), household wealth (8%), and household sanitation (3%). Malaria prevention was associated with an additional 29% of the predicted HAZ change. Qualitative participants highlighted insecurity, poverty, and lower education levels in some parts of the country as barriers to improving child health and nutritional status, along with insufficient human resources for health despite an increase in the number of healthcare facilities in the country. Participants identified a range of policies and programs across multiple sectors as having likely contributed to the decline in stunting prevalence.

CONCLUSIONS

A multisectoral approach to stunting reduction in Nigeria appears to have been key, with progress having been driven by both the health sector and, especially, non-health sector action.

Social sector drivers and stunting reduction in Pakistan: A subnational analysis

BACKGROUND

Poor nutrition remains a problem in Pakistan, and despite economic growth, stunting reduction is slow with subnational variations. Generally, stunting prevalence is lower in Khyber Pakhtunkhwa (KP) and Northern Punjab than in Sindh and Balochistan.

OBJECTIVES

Our study aimed to identify and explore key drivers and barriers underlying subnational changes in stunting between 2011 and 2018.

METHODS

We used a mixed-methods approach to determine the drivers of and barriers to change in stunting [height-for-age z-score (HAZ) < -2], including Oaxaca-Blinder decomposition and multivariable hierarchical modeling, using representative household nutrition surveys in 2011 and 2018. These findings were triangulated with a literature review, program and policy analysis, and primary qualitative research to generate a narrative of change.

RESULTS

National decline in stunting prevalence was limited (2011: 42.3%, 2018: 40.2%); however, progress varied between provinces with significant stunting declines in KP and Northern and Southern Punjab [0.49 standard deviation (SD) gain in HAZ between 2011 and 2018 (43.0% to 38.3%)]. Factors driving HAZ increases were improvements in socioeconomic status (0.13 SD), coverage of Pakistan's income support program targeting females (0.05 SD), and a combination of other direct and indirect health and nutrition investments (0.1 SD). Our policy analysis and qualitative findings also supported these findings by identifying poverty and increased food prices as a barrier to accessing nutritious foods.

CONCLUSIONS

Although national progress in stunting reduction remains slow, regions of KP, Northern, and Southern Punjab have demonstrated significant reductions in child stunting prevalence between 2011 and 2018. Our analysis supports continued investments in social sector programs targeting females' health and status and strengthening the reach and quality of existing maternal and child health and nutrition programs.

Factors influencing concurrent wasting, stunting, and underweight among children under five who suffered from severe acute malnutrition in low- and middle-income countries: a systematic review

Background

Wasting, stunting, and underweight in children are complex health challenges shaped by a combination of immediate, underlying, and systemic factors. Even though copious data demonstrates that the causation routes for stunting and wasting are similar, little is known about the correlations between the diseases in low- and middle-income nations.

Objective

The objective of this study is to evaluate the factors that concurrently affect wasting, stunting, and underweight in <5-year-olds with severe acute malnutrition (SAM).

Method

This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched every electronic database that was available, from the medRxiv pre-print site, PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, Google Scholar, and Scopus, in addition to the Science Direct search engine. We considered research conducted in low- and middle-income nations on <5-year-olds with SAM. The Newcastle Ottawa Scale was used to assess the quality of the studies.

Results

After screening and selecting 12 eligible studies, 1,434,207 records were included for analysis. The prevalence of factors influencing concurrent wasting, stunting, and being underweight was 26.42% in low-middle -income countries (LMI). The prevalence was higher in men, with wasting, stunting, and underweight at 14.2, 4.1, and 27.6%, respectively. Unprotected drinking water was associated with stunting [odds ratio = 0.68; 95CI (0.50, 0.92)]. Being male is another factor (aOR = 2.04, 95% CI: 1.13, 3.68). Lack of prenatal care follow-up was associated with a lower risk of wasting (OR = 2.20, 95% CI: 1.04, 4.64), while low birth weight (<2.5 kg), diarrhea, having a younger child, and being from a poor household were associated with wasting, stunting, and underweight. Other factors included body mass index (BMI) for age aOR = 2.11, 95% CI: (0.07, 0.895); maternal education: stunting [aOR = 1.52, 95% CI: (0.09, 0.89)], underweight [aOR = 1.97, 95% CI: (0.01, 0.73)], and open defecation, stunting [aOR = 1.62, 95% CI: (0.06, 0.32)], underweight [aOR = 1.92, 95% CI: (0.042, 0.257)]). Likelihood of being underweight increased with birth order (second born, aOR = 1.92, 95% CI 1.09-3.36; third born, aOR = 6.77, 95% CI 2.00-22.82).

Conclusion

Inadequate dietary intake, illness, food insecurity, poor maternal and child care, poor hygiene and sanitation, and healthcare inaccessibility contribute to SAM.

Sex differences in growth and neurocognitive development in infancy and early childhood

Undernutrition in early life remains a significant public health challenge affecting millions of infants and young children globally. Children who are wasted, stunted or underweight are at increased risk of morbidity and mortality. Undernutrition at critical periods also impacts on aspects of neurodevelopment, with longer-term consequences to educational performance and mental health outcomes. Despite consistent evidence highlighting an increased risk of neonatal and infant mortality among boys, a common assumption held across many disciplines is that girls are more vulnerable with respect to early-life exposures. In relation to undernutrition, however, recent evidence indicates the reverse, and in contexts of food insecurity, boys are at increased risk of undernutrition in early life compared to girls, with sex-specific risks for neurodevelopmental deficits. These effects appear independent of social factors that may favour boys, such as gender disparities in infant feeding practices and health-seeking behaviours. The observed vulnerability among boys may therefore be underpinned by biological processes such as differential energy requirements during periods of rapid growth. As boys have greater needs for growth and maintenance, then, in times of nutritional hardship, these needs may not be met resulting in risk of undernutrition and subsequent health consequences. In view of this emerging evidence, a greater understanding of the mechanisms behind this vulnerability among boys is needed and policy considerations to protect boys should be considered. This review will explore sex differences in risk of undernutrition and consider these in the context of existing programmes and policies.

Implementation outcomes of convergence action policy to accelerate stunting reduction in Pidie district, Aceh province, Indonesia: a qualitative study

OBJECTIVES

The research aims to understand the challenges and opportunities in policy and programme convergence to accelerate interventions for reducing stunting at the district, subdistrict and the 10 focused villages.

DESIGN

Data were collected through qualitative methods (in-depth interviews and document reviews), and then analysed using thematic processes with NVivo V.11 software, by QSR International The process included coding, categorising and linking to the eight implementation outcome variables (as determined themes), namely acceptability, adoption, appropriateness, feasibility, compliance, implementation cost, coverage and sustainability. The variables of convergence action policies were implemented differently by stakeholders at different layers of governance.

SETTING

Pidie district, Aceh province, Indonesia.

PARTICIPANTS

106 respondents from provincial to village levels were selected and interviewed, including leaders and policymakers (n=10); and convergence action implementers from the province to the villages (n=96).

RESULTS

Stunting reduction policies were generally acceptable to local leaders and policymakers as a policy imperative. Implementation costs were considered sufficient by stakeholders, although focusing only on nutrition-specific interventions. However, in terms of adoption, feasibility, compliance, nutrition-sensitive intervention coverage and sustainability aspects were insufficiently implemented in all the focused villages due to inadequate collaboration between health and non-health sectors and limited experts.

CONCLUSIONS

This study offers key recommendations for policy and practice changes and considerations. The utilisation of methods and findings from this study in other areas in Indonesia or other low- and middle-income countries is important to explore more about the applicability, benefits and weaknesses of this study.

Social realities in remote villages: Infant and young child feeding in Kirewa, Uganda

Understanding infant and young child feeding (IYCF) practices in Africa requires an examination of the social context. Social relationships influence people through mechanisms such as social support, social influence, social engagement, access to resources and negative social interactions. This study explores how these mechanisms manifest in IYCF in remote villages in Uganda. In 2018, we conducted two focus group discussions each with mothers, fathers and grandparents, ande interviews with two clan leaders, six village health teamers (VHT) and four healthcare workers (HCW). We deductively searched the data for any indications of elements that could influence child feeding and health using the psychosocial mechanisms of social support, social influence, social engagement, access to resources and negative social interactions as the broader themes. The manifestation of social support involved practical help from mothers-in-law (MIL), financial contributions from fathers, and informational, instrumental, emotional and appraisal support from VHTs. Social influence by MILs mainly concerned the transmission of food-related beliefs and pressure to have many children. The social engagement of young mothers was restricted. Access to resources was stratified and affected by poverty, patriarchy, and knowledge of HCWs and VHTs. Negative social interactions included physical abuse, alcoholism, and fear-based relationships. We found the different psychosocial mechanisms to construct a useful framework for describing the social reality surrounding IYCF. Changing attitudes towards family planning, involving fathers in IYCF, and strengthening the position of VHTs as family advisers can potentially improve IYCF in rural Uganda.

Quality of nutritional status assessment and its relationship with the effect of rainfall on childhood stunting: a cross-sectional study in rural Burkina Faso

OBJECTIVES

In Burkina Faso, one in every four children under 5 years is stunted. Climate change will exacerbate childhood stunting. Strengthening the health system, particularly the quality of nutrition care at primary health facilities, can minimise the adverse climate effect on stunting. Thus, we examined the quality of nutritional status assessment (QoNA) during curative childcare services in primary health facilities in rural Burkina Faso and its relationship with rainfall-induced childhood stunting.

STUDY DESIGN

We conducted a cross-sectional analysis using anthropometric, rainfall, and clinical observation data.

METHODS

Our dependent variable was the height-for-age z-score (HAZ) of children under 2 years. Our focal climatic measure was mean rainfall deviation (MRD), calculated as the mean of the difference between 30-year monthly household-level rainfall means and the corresponding months for each child from conception to data collection. QoNA was based on the weight, height, general paleness and oedema assessment. We used a mixed-effect multilevel model and analysed heterogeneity by sex and socio-economic status.

RESULTS

Among 5027 young (3-23 months) children (mean age 12 ± 6 months), 21% were stunted (HAZ ≤ -2). The mean MRD was 11 ± 4 mm, and the mean QoNA was 2.86 ± 0.99. The proportion of children in low, medium, and high QoNA areas was 10%, 54%, and 36%, respectively. HAZ showed a negative correlation with MRD. Higher QoNA lowered the negative effect of MRD on HAZ (β = 0.017, P = 0.003, confidence interval = [0.006, 0.029]). Males and children from poor households benefited less from the moderating effect of QoNA.

CONCLUSION

Improving the quality of nutrition assessments can supplement existing efforts to reduce the adverse effects of climate change on children's nutritional well-being.

Indian fathers' perceptions of young childcare and feeding - A qualitative study

The role of parents in fostering children's healthy habits is a robust area of research. However, most of the existing literature predominantly focuses on mothers' parenting practices. Given the emergence of nuclear, dual earning families and the recent surge in maternal employment in urban India, fathers' engagement in child rearing and feeding warrants attention. The purpose of this research was to document the views of Indian fathers about paternal parenting practices, with an emphasis on children's diet among other health behaviors. Thirty-three fathers of children aged 6-59 months from Kolkata, India took part in semi-structured interviews conducted either face-to-face or over Zoom/telephone in Hindi, Bengali, and English. The interviews were audio recorded, transcribed verbatim, and translated to English. The transcribed data were subjected to thematic analysis informed by the Template Analysis technique. Themes were detected using the NVivo software program. Overall, these Indian fathers played an important role in early childhood care and feeding as reflected in the following seven themes: (i) Involvement of fathers in various childcare activities; (ii) Implementation of responsive and non-responsive feeding practices; (iii) Concerns regarding fussy and slow eating; (iv) Concerns regarding excessive screen time; (v) Paternal vs maternal parenting; (vi) Barriers to routine engagement of fathers in childcare; (vii) Desire for more nutrition and health knowledge. This enhanced understanding of paternal parenting behavior supports the inclusion of fathers in future family-focused lifestyle interventions aimed at improving children's health outcomes, including their dietary habits.

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

The Impact of Vaccination Status on Anthropometric Indices of Growth Among Children: A Cross-Sectional Study

Background Childhood immunization programs in underdeveloped nations can improve children's growth and nutritional status and prevent growth delays while protecting against infectious diseases and meeting growth norms. This study aimed to assess the impact of vaccination status on the anthropometric indices of children aged 12-18 months at an Expanded Programme on Immunization vaccination center and compare the anthropometric indices of growth in children with complete and incomplete vaccination statuses. Methodology This study was conducted at the rural health center in Kala Shah Kaku, Pakistan, from November 2023 to December 2023. Children aged 12-18 months were enrolled and their vaccination status was recorded. Height and weight were measured using World Health Organization growth charts. The data were analyzed using descriptive statistics and chi-square and Fisher's exact tests. A p-value <0.05 was considered statistically significant. Results The mean age of the 110 children who visited the vaccination site for this study was 16.36 months ± 2.415. There were 28 (25.5%) stunted children. In the study, 17.6 (16%) participants were underweight, and 15.95 (14.5%) were wasted. Of the children, 79% had received all recommended vaccinations. A statistically significant (p < 0.05) association was found between vaccination and nutritional status. Conclusions This study emphasizes the significance of vaccination in promoting child health and nutrition, reducing stunting risk, and ensuring equitable access to vaccination services and comprehensive healthcare interventions. This can help mitigate the malnutrition burden and promote optimal growth, contributing to global health and development goals.

Effect of nutrition assessment, counselling and support integration on mother-infant nutritional status, practices and health in Tororo and Butaleja districts, Uganda: A comparative non-equivalent quasi-experimental study

BACKGROUND

Malnutrition remains a health challenge for women aged 15 to 49 years and their infants. While Nutrition Assessment Counselling and Support (NACS) is considered a promising strategy, evidence of its effectiveness remains scanty. This study assessed the effect of the comprehensive NACS package on the mother-infant practices, health and nutrition outcomes in two districts in Eastern Uganda.

METHODS

A comparative non-equivalent quasi-experimental design was employed with two groups; Comprehensive NACS (Tororo) and Routine NACS (Butaleja). Pregnant mothers were enrolled spanning various trimesters and followed through the antenatal periods and post-delivery to monitor their health and nutrition status. Infants were followed for feeding practices, health and nutritional status at birth and weeks 6, 10, 14 and at months 6, 9 and 12 post-delivery. Propensity score matching ensured study group comparability. The NACS effect was estimated by nearest neighbour matching and the logistic regression methods. Statistical analysis utilised STATA version 15 and R version 4.1.1.

RESULTS

A total of 666/784 (85%) with complete data were analysed (routine: 412, comprehensive: 254). Both groups were comparable by mothers' age, Mid Upper Arm Circumference, prior antenatal visits, meal frequency, micronutrient supplementation and instances of maternal headache, depression and diarrhoea. However, differences existed in gestation age, income, family size, education and other living conditions. Comprehensive NACS infants exhibited higher infant birth weights, weight-for-age z-scores at the 3rd -6th visits (p < 0.001), length-for-age z scores at the 4th -7th visits (p < 0.001) and weight-for-length z-scores at the 3rd - 5th (p < = 0.001) visits. Despite fewer episodes of diarrhoea and fever, upper respiration infections were higher.

CONCLUSIONS

The comprehensive NACS demonstrated improved mother-infant nutritional and other health outcomes suggesting the need for integrated and holistic care for better maternal, infant and child health.

Can women empowerment boost dietary diversity among children aged 6-23 months in sub-Saharan Africa?

BACKGROUND

The empowerment of women has implications on the health and dietary needs of children. Using the survey-based women's empowerment index (SWPER), we examined the association between women's empowerment and dietary diversity among children aged 6-23 months in sub-Saharan Africa.

METHODS

Data from the Demographic and Health Surveys of 21 countries were utilized. Descriptive spatial map was used to present the proportions of dietary diversity among the children. Multilevel binary logistic regression was used to examine the association between SWPER and dietary diversity.

RESULTS

Overall, 22.35% of children aged 6-23 months had adequate minimum dietary diversity (MDD) in sub-Saharan Africa. The countries with the highest proportions of adequate MDD were Angola, Benin, Madagascar, Rwanda, Sierra Leone, and South Africa. South Africa had the highest proportion of MDD (61.00%), while Liberia reported the least (9.12%). Children born to mothers who had high social independence were more likely to have adequate MDD compared to those with low social independence [aOR = 1.31, 95% CI 1.21, 1.41]. In addition, children born to women with medium [aOR = 1.12; 95% CI 1.03, 1.21] and high decision-making [aOR = 1.25, 95% CI 1.14, 1.37] were more likely to receive MDD than those with low decision-making.

CONCLUSIONS

Insufficient dietary diversity is evident among children aged 6-23 months in sub-Saharan Africa. MDD in children is influenced by women's empowerment. Policies and interventions promoting women's empowerment can enhance MDD, especially for vulnerable groups in rural and poorer households. It is crucial to leverage media and poverty reduction strategies to improve MDD among children in sub-Saharan African countries.

Drivers of success in global health outcomes: A content analysis of Exemplar studies

Applying a positive outlier lens is one effective approach for generating evidence to inform global health policy, program, and funding decisions. Exemplars in Global Health (EGH) is a program that studies positive outlier countries that have made extraordinary progress in health outcomes (despite limited resources) and disseminates their successes through multiple types of outputs. To date, EGH has studied, or is studying, 14 global health topics in 28 countries. This paper aims to identify findings, summarized as themes and sub-themes, that appear among all completed EGH studies. We developed a conceptual framework and used a content analysis approach to identify the top thematic areas that appear as drivers for programmatic success across EGH studies that were completed between June 2020-May 2023. The EGH studies (N = 31) spanned six topics including under-five child mortality (n = 6), childhood stunting (n = 5), community health workers (CHW) (n = 4), vaccine delivery (n = 3), COVID-19 response (n = 6), and newborn and maternal mortality reduction (n = 7) across 19 countries in sub-Saharan Africa, Latin America, South and Central Asia, and the Caribbean regions. Top drivers of success were defined as those critical or catalytic in achieving the intended outcome. Eight key drivers were identified: (1) efficient data collection and use for decision-making, (2) strong political commitment and health leadership, (3) effective stakeholder coordination, (4) a local, connected, and capacitated workforce, (5) intentional women's empowerment and engagement, (6) effective adoption and implementation of national policies, (7) effective and sustainable financing, and (8) equitable, efficient outreach and targeting. These cross-cutting drivers span a broad range of development outcomes, sectors, and populations, and indicate a need to effectively integrate people, systems, and sectors to improve global health outcomes. Findings from this study aim to support peer learning among countries and support evidence-based decision-making for funders, policymakers, and other key stakeholders.

Influence of maternal and neonatal continuum of care on the risk of intergenerational cycle of stunting: a cross-sectional study

OBJECTIVES

This study aimed to analyse the influence of the continuum of care during pregnancy and neonatal periods on the risk of intergenerational cycle of stunting.

DESIGN

This study was a cross-sectional study, with data analysed from the 2018 Basic Health Research in Indonesia.

SETTINGS

Basic Health Research 2018 was conducted throughout 513 cities/regencies in 34 provinces in Indonesia. The households were selected through two-stage sampling methods. First, census blocks (CB) were selected using probability proportional to size methods in each urban/rural stratum from each city/regency. Ten households were then selected from each CB using systematic sampling methods. All family members of the selected households were measured and interviewed.

PARTICIPANTS

This study analyses 31 603 children aged 0-24 months.

OUTCOMES MEASURES

The dependent variable was the risk of the intergenerational cycle of stunting. Mothers who had a height less than 150.1 cm (short stature mothers) and had children (≤ 24 months of age) with length-for-age Z-score less than -2 Standard Deviation (SD) of the WHO Child Growth Standard (stunted children) were defined as at risk of the intergenerational cycle of stunting.

RESULTS

Mothers with incomplete maternal and neonatal care visits were 30% more likely to be at risk on the intergenerational cycle of stunting (OR (95% CI): 1.3 (1.00 to 1.63)) after adjusting for economic status.

CONCLUSION

The continuum of maternal and neonatal healthcare visits could potentially break the intergenerational cycle of stunting, especially in populations where stunted mothers are prevalent.

Analyzing the impact of an MDG-Fund program on childhood malnutrition in Timor-Leste

BACKGROUND

Timor-Leste's food insecurity, propelled by political conflicts, a fragile economy and biophysical limitations that characterize mountainous Small Island Developing States (SIDS), is expressed in a high incidence (50%) of stunted children. Hence, the Millennium Development Goals Achievement Fund's Joint Program's (MDG-F JP) in 2009 was a timely intervention to reduce prevalence of underweight among under-fives. Since the impact of the program remains largely unclear, the current study investigates the contributions of the MDG-F JP on improving children's nutritional status in Timor-Leste, in order to inform policymakers on how to make future programs more effective.

METHODS

Using bivariate analyses and multiple linear regression models we analyzed Demographic and Health Survey (DHS) data from under-fives in 2009-2010 and 2016, combined with spatially explicit data from geographic information systems (GIS). The analyses generated trends and factors associated with undernutrition, which were used in a quasi-experimental setting to compare districts that received the MDG-F JP with similar districts that did not receive MDG-F JP interventions.

RESULTS

A comprehensive set of factors dependent on seasons, locations, and individuals determine undernutrition in Timor-Leste. A positive impact of the MDG-F JP was found for the average severity of wasting, but not for stunting and underweight.

CONCLUSIONS

The findings reinforce the pressing need for integrated and cross-sectoral programs, aimed especially at agricultural workers, mothers, and children. The agricultural challenge is to sustainably select, produce and conserve higher-yield and nutrient-rich crops, and educational enhancement should be aligned with local practices and research.

Association between household food insecurity and stunting in children aged 0-59 months: Systematic review and meta-analysis of cohort studies

Household food insecurity (HFI) during childhood is associated with poor dietary diversity and malnutrition, placing children's growth at risk. Children with growth disorders, such as stunting, are more likely to have poor cognition and educational performance, lower economic status, and an increased risk of nutrition-related chronic diseases in adulthood. Our study aimed to systematically review and conduct a meta-analysis of cohort studies investigating the association between HFI and stunting in children aged 0-59 months. Peer-reviewed and grey literature were systematically searched in electronic databases with no language or date restrictions. Two reviewers independently assessed the studies for pre-established eligibility criteria. Data were extracted using a standard protocol. Random-effects meta-analysis models were used, and I2 > 40% indicated high heterogeneity across studies. We used the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of the evidence. Nine cohort studies comprising 46,300 children were included. Approximately 80% (n = 7) of the studies found a positive association between HFI and stunting. Pooled odds ratio was 1.00 (95% confidence interval [CI]: 0.87-1.14; I2: 76.14%). The pooled hazard ratio between moderate and severe HFI and stunting was 1.02 (95% CI: 0.84-1.22; I2: 85.96%). Due to high heterogeneity, the quality of evidence was very low. Individual studies showed an association between HFI and stunting in children aged 0-59 months; however, this association was not sustained in the pooled analysis, possibly because of high heterogeneity across studies.

Care groups in an integrated nutrition education intervention improved infant growth among South Sudanese refugees in Uganda's West Nile post-emergency settlements: A cluster randomized trial

OBJECTIVE

This study examined the effects of a peer-led integrated nutrition education intervention with maternal social support using Care Groups on infant growth among South Sudanese refugees in Uganda.

METHODS

A community-based cluster-randomized trial (RCT) was conducted among 390 pregnant women (third trimester). Two intervention study arms were Mothers-only(n = 131) and Parents-combined (n = 142) with a Control (n = 117). WHO infant growth standards defined length-for-age z-scores (LAZ) for stunting, weight-for-age z-scores (WAZ) for underweight and weight-for-length z-scores (WLZ) for wasting. The Medical Outcomes Study (MOS) social support index was a proxy measure for social support. A split-plot ANOVA tested the interaction effects of social support, intervention, and time on infant growth after adjusting for covariates. Further, pairwise comparisons explained mean differences in infant growth among the study arms.

RESULTS

The mean infant birth weight was 3.1 ± 0.5 kg. Over the study period, infant stunting was most prevalent in the Control (≥ 14%) compared to Mothers-only (< 9.5%) and Parents-combined (< 7.4%) arms. There were significant interaction effects of the Care Group intervention and social support by time on infant mean LAZ (F (6, 560) = 28.91, p < 0.001), WAZ (F (5.8, 539.4) = 12.70, p = < 0.001) and WLZ (F (5.3, 492.5) = 3.38, p = 0.004). Simple main effects by the end of the study showed that the intervention improved infant mean LAZ (Mothers-only vs. Control (mean difference, MD) = 2.05, p < 0.001; Parents-combined vs. Control, MD = 2.00, p < 0.001) and WAZ (Mothers-only vs. Control, MD = 1.27, p < 0.001; Parents-combined vs. Control, MD = 1.28, p < 0.001).

CONCLUSION

Maternal social support with an integrated nutrition education intervention significantly improved infant stunting and underweight. Nutrition-sensitive approaches focused on reducing child undernutrition among post-emergency refugees may benefit from using Care Groups in programs.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT05584969.

Global disability-adjusted life years and deaths attributable to child and maternal malnutrition from 1990 to 2019

Background

Child and maternal malnutrition (CMM) caused heavy disability-adjusted life years (DALY) and deaths globally. It is crucial to understand the global burden associated with CMM in order to prioritize prevention and control efforts. We performed a comprehensive analysis of the global DALY and deaths attributable to CMM from 1990 to 2019 in this study.

Methods

The age-standardized CMM related burden including DALY and death from 1990 to 2019 were accessed from the Global Burden of Disease study 2019 (GBD 2019). The changing trend were described by average annual percentage change (AAPC). The relationship between sociodemographic factors and burden attributable to CMM were explored by generalized linear model (GLM).

Results

Globally, in 2019, the age-standardized DALY and death rates of CMM were 4,425.24/100,000 (95% UI: 3,789.81/100,000-5,249.55/100,000) and 44.72/100,000 (95% UI: 37.83/100,000-53.47/100,000), respectively. The age-standardized DALY rate (AAPC = -2.92, 95% CI: -2.97% to -2.87%) and death rates (AAPC = -3.19, 95% CI: -3.27% to -3.12%) presented significantly declining trends during past 30 years. However, CMM still caused heavy burden in age group of <28 days, Sub-Saharan Africa and low SDI regions. And, low birth weight and short gestation has identified as the primary risk factors globally. The GLM indicated that the highly per capita gross domestic product, per capita current health expenditure, physicians per 1,000 people were contributed to reduce the burden attributable to CMM.

Conclusion

Although global burden attributable to CMM has significantly declined, it still caused severe health burden annually. To strengthen interventions and address resources allocation in the vulnerable population and regions is necessary.

Effects of Cooking with Liquefied Petroleum Gas or Biomass on Stunting in Infants

BACKGROUND

Household air pollution is associated with stunted growth in infants. Whether the replacement of biomass fuel (e.g., wood, dung, or agricultural crop waste) with liquefied petroleum gas (LPG) for cooking can reduce the risk of stunting is unknown.

METHODS

We conducted a randomized trial involving 3200 pregnant women 18 to 34 years of age in four low- and middle-income countries. Women at 9 to less than 20 weeks' gestation were randomly assigned to use a free LPG cookstove with continuous free fuel delivery for 18 months (intervention group) or to continue using a biomass cookstove (control group). The length of each infant was measured at 12 months of age, and personal exposures to fine particulate matter (particles with an aerodynamic diameter of ≤2.5 μm) were monitored starting at pregnancy and continuing until the infants were 1 year of age. The primary outcome for which data are presented in the current report - stunting (defined as a length-for-age z score that was more than two standard deviations below the median of a growth standard) at 12 months of age - was one of four primary outcomes of the trial. Intention-to-treat analyses were performed to estimate the relative risk of stunting.

RESULTS

Adherence to the intervention was high, and the intervention resulted in lower prenatal and postnatal 24-hour personal exposures to fine particulate matter than the control (mean prenatal exposure, 35.0 μg per cubic meter vs. 103.3 μg per cubic meter; mean postnatal exposure, 37.9 μg per cubic meter vs. 109.2 μg per cubic meter). Among 3061 live births, 1171 (76.2%) of the 1536 infants born to women in the intervention group and 1186 (77.8%) of the 1525 infants born to women in the control group had a valid length measurement at 12 months of age. Stunting occurred in 321 of the 1171 infants included in the analysis (27.4%) of the infants born to women in the intervention group and in 299 of the 1186 infants included in the analysis (25.2%) of those born to women in the control group (relative risk, 1.10; 98.75% confidence interval, 0.94 to 1.29; P = 0.12).

CONCLUSIONS

An intervention strategy starting in pregnancy and aimed at mitigating household air pollution by replacing biomass fuel with LPG for cooking did not reduce the risk of stunting in infants. (Funded by the National Institutes of Health and the Bill and Melinda Gates Foundation; HAPIN ClinicalTrials.gov number, NCT02944682.).

A cluster randomized controlled trial of a community-based initiative to reduce stunting in rural Indonesia

We evaluate the impacts of a $120 million project in Indonesia conducted between 2014 and 2018 that sought to reduce stunting through a combination of (1) community-driven development grants targeted at health and education outcomes, (2) training for health providers on infant and young child feeding and growth monitoring and (3) training for sanitarians on a local variation of community-led total sanitation. This cluster randomized controlled trial involved 95 treatment and 95 control subdistricts across South Sumatra, West Kalimantan, and Central Kalimantan provinces. Overall, we find no significant impacts on stunting, the study's primary outcome measure (0.5 pp; 95% confidence interval [CI]: -3.0 to 4.1 percentage points [pp]), or other longer-term undernutrition outcomes about 1 year after the end of the project. The project had a modest impact on some secondary, more proximal outcomes related to maternal and child nutrition, including the percentage of mothers consuming the recommended number of iron-folic acid pills during pregnancy (8.7 pp; 95% CI: 4.1-13.3 pp), 0-5-month-olds being exclusively breastfed (8.7 pp; 95% CI: 1.8-15.6 pp) and 6-23-month-olds receiving the number of recommended meals per day (8.5 pp; 95% CI: 3.8-13.2 pp). However, there were no significant impacts on other proximal outcomes like the number of pre-natal and post-natal checkups, child dietary diversity, child vitamin A receipt or the incidence of child diarrhoea. Our findings highlight that successfully implementing an integrated package of interventions to reduce child stunting may be challenging in practice. Project design needs to consider implementation reality along with best practice-for example, by piloting the synchronous implementation of multifaceted interventions or phasing them in more gradually over a longer timeframe.

Stunting Among Children Under Two Years in the Islands Areas: A Cross-sectional Study of the Maluku Region in Indonesia, 2021

BACKGROUND

The Maluku region encompasses thousands of islands. The study analyzed factors related to stunting among children under two years old in the Maluku Region of Indonesia. Study Design: A cross-sectional study.

METHODS

This cross-sectional study examined 4764 children under two years. In addition to nutritional status (stature), the study analyzed ten independent variables (province, residence, maternal age, marital status, maternal education, employment, wealth, children's age, gender, and early initiation of breastfeeding [EIBF]). Finally, the contribution of various factors to stunting was examined using logistic regression.

RESULTS

Children in Maluku province were 1.13 times more likely than those in North Maluku province to become stunted. In addition, children aged 12-13 months were 4.09 times more likely than<12 months, and boys were 1.87 times more likely than girls to have the patterns of stunting. Children in rural areas were 1.10 times more likely to become stunted than those in urban areas (95% confidence interval: 1.06, 1.14). Divorced/widowed mothers were 1.88 times more likely than married mothers. Mothers of all education levels were more likely than those without formal education, and unemployed mothers were 1.07 times more likely than employed mothers to have stunted children. The possibility of becoming stunted was lower when the children were wealthier.

CONCLUSION

Nine variables were related to stunted incidence, including province, residence, maternal age, marital status, maternal education, employment, wealth, children's age, and gender.

When did the substantial loss of child linear growth occur?

BACKGROUND

Epidemiological studies show that the height-for-age Z-scores (HAZ) falter dramatically shortly after birth until the end of the first two years. Understanding these changes in linear growth in the first two years can help us understand the critical period of child linear growth and propose interventions.

OBJECTIVES

This study objectives were to describe the pattern of linear growth faltering and analyze the changes in length-for-age Z-scores (LAZs) throughout the first two years based on birthweight and length status.

METHODS

This study analyzed 408 children, participants in Longitudinal Study on Child Growth and Development in Bogor, Indonesia. The linear growth pattern was described based on birthweight and length status. Birthweight and length status was categorized into normal and Small for Gestational Age (SGA). Changes in LAZs (Δ LAZs) in 0-6 months, 6-12 months, and 12-23 months were calculated. General Linear Model Univariate analysis was conducted to analyze the difference of Δ LAZ between SGA and normal children.

RESULTS

Though full-term SGA children have significantly higher linear growth velocity during the first 6 months of the infancy period, full-term SGA children could not catch up with the attained growth/height of normal children throughout the first two years. Thus, full-term SGA children ended up with a higher prevalence of stunted. Both in SGA and normal children, the substantial loss of LAZ occurred between 0-6 months.

CONCLUSION

The finding in this study showed that the first 1000 days of life is still the best period in stunting prevention; however, the stunting prevention program should start earlier, focusing on the first 500 days of life, and potentially the prenatal period.

Causes and consequences of child growth faltering in low-resource settings

Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.

Factors associated with recovery from stunting at 24 months of age among infants and young children enrolled in the Pediatric Development Clinic (PDC): A retrospective cohort study in rural Rwanda

INTRODUCTION

Stunting (low height/length-for-age) in early life is associated with poor long-term health and developmental outcomes. Nutrition interventions provided during the first 1,000 days of life can result in improved catch-up growth and development outcomes. We assessed factors associated with stunting recovery at 24 months of age among infants and young Children enrolled in Pediatric Development Clinics (PDC) who were stunted at 11 months of age.

METHODS

This retrospective cohort study included infants and young children who enrolled in PDCs in two rural districts in Rwanda between April 2014 and December 2018. Children were included in the study if their PDC enrollment happened within 2 months after birth, were stunted at 11 months of age (considered as baseline) and had a stunting status measured and analyzed at 24 months of age. We defined moderate stunting as length-for-age z-score (LAZ) < -2 and ≥-3 and severe stunting as LAZ <-3 based on the 2006 WHO child growth standards. Stunting recovery at 24 months of age was defined as the child's LAZ changing from <-2 to > -2. We used logistic regression analysis to investigate factors associated with stunting recovery. The factors analyzed included child and mother's socio-demographic and clinical characteristics.

RESULTS

Of the 179 children who were eligible for this study, 100 (55.9%) were severely stunted at age 11 months. At 24 months of age, 37 (20.7%) children recovered from stunting, while 21 (21.0%) severely stunted children improved to moderate stunting and 20 (25.3%) moderately-stunted children worsened to severe stunting. Early stunting at 6 months of age was associated with lower odds of stunting recovery, with the odds of stunting recovery being reduced by 80% (aOR: 0.2; 95%CI: 0.07-0.81) for severely stunted children and by 60% (aOR: 0.4; 95% CI: 0.16-0.97) for moderately stunted children (p = 0.035). Lower odds of stunting recovery were also observed among children who were severely stunted at 11 months of age (aOR: 0.3; 95% CI: 0.1-0.6, p = 0.004). No other maternal or child factors were statistically significantly associated with recovery from stunting at 24 months in our final adjusted model.

CONCLUSION

A substantial proportion of children who were enrolled in PDC within 2 months after birth and were stunted at 11 months of age recovered from stunting at 24 months of age. Children who were severely stunted at 11 months of age (baseline) and those who were stunted at 6 months of age were less likely to recover from stunting at 24 months of age compared to those with moderate stunting at 11 months and no stunting at 6 months of age, respectively. More focus on prevention and early identification of stunting during pregnancy and early life is important to the healthy growth of a child.

A bibliometric analysis of sustainable development goals (SDGs): a review of progress, challenges, and opportunities

The Sustainable Development Goals (SDGs) are a global appeal to protect the environment, combat climate change, eradicate poverty, and ensure access to a high quality of life and prosperity for all. The next decade is crucial for determining the planet's direction in ensuring that populations can adapt to climate change. This study aims to investigate the progress, challenges, opportunities, trends, and prospects of the SDGs through a bibliometric analysis from 2015 to 2022, providing insight into the evolution and maturity of scientific research in the field. The Web of Science core collection citation database was used for the bibliometric analysis, which was conducted using VOSviewer and RStudio. We analyzed 12,176 articles written in English to evaluate the present state of progress, as well as the challenges and opportunities surrounding the SDGs. This study utilized a variety of methods to identify research hotspots, including analysis of keywords, productive researchers, and journals. In addition, we conducted a comprehensive literature review by utilizing the Web of Science database. The results show that 31% of SDG-related research productivity originates from the USA, China, and the UK, with an average citation per article of 15.06. A total of 45,345 authors around the world have contributed to the field of SDGs, and collaboration among authors is also quite high. The core research topics include SDGs, climate change, Agenda 2030, the circular economy, poverty, global health, governance, food security, sub-Saharan Africa, the Millennium Development Goals, universal health coverage, indicators, gender, and inequality. The insights gained from this analysis will be valuable for young researchers, practitioners, policymakers, and public officials as they seek to identify patterns and high-quality articles related to SDGs. By advancing our understanding of the subject, this research has the potential to inform and guide future efforts to promote sustainable development. The findings indicate a concentration of research and development on SDGs in developed countries rather than in developing and underdeveloped countries.

Graphical abstract

A whole system approach to childhood obesity: how a supportive environment was created in the city of Brighton and Hove, United Kingdom

Childhood obesity is a growing global challenge, and no country has yet reversed the upward trend in prevalence. The causes are multifaceted, spanning individual, societal, environmental, and political spheres. This makes finding solutions complex as traditional linear models of treatment and effect have proven only minimally successful or unfeasible at the population level. There is also a paucity of evidence of what works, and few examples of intervention that operate on a 'whole systems' level. The city of Brighton in the United Kingdom has experienced a downward trend in child obesity rates compared to national figures. The aim of this study was to explore what has led to successful change in the city. This was done through a review of local data, policy and programs, and thirteen key informant interviews with key stakeholders involved in the local food and healthy weight agenda. Our findings highlight key mechanisms that have plausibly contributed to a supportive environment for obesity reduction in Brighton according to key local policy and civil society actors. These mechanisms include; a commitment to early years intervention such as breastfeeding promotion; a supportive local political context; the ability to tailor interventions to community needs; governance structures and capacity that enable cross-sectoral collaboration; and a citywide framing of obesity solutions in the context of a 'whole system' approach. However, substantial inequalities persist in the city. Engaging families in areas of high deprivation and operating in an increasingly difficult context of national austerity are persistent challenges. This case study sheds light on some mechanisms of what a whole systems approach to obesity looks like in practice in a local context. This is of relevance to both policymakers and healthy weight practitioners across a spectrum of sectors who need to be engaged to tackle child obesity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-023-01361-9.

A Peer-Led Integrated Nutrition Education Intervention through Care Groups Improved Complementary Feeding of Infants in Postemergency Settlements in the West-Nile Region in Uganda: A Cluster Randomized Trial

Background

Complementary feeding of infants in refugee settlements remains inadequate. Furthermore, there has been limited evaluation of interventions addressing these nutrition challenges.

Objective

This study examined the effects of a peer-led integrated nutrition education intervention on infant complementary feeding by South Sudanese refugee mothers in the West-Nile region in Uganda.

Methods

A community-based randomized trial enrolled 390 pregnant women (during third trimester) as the baseline. Two arms [mothers-only and parents-combined (both mothers and fathers)] comprised treatments with a control. Infant feeding was assessed using WHO and UNICEF guidelines. Data were collected at Midline-II and Endline. The medical outcomes study (MOS) social support index was used to measure social support. An overall mean score of >4 was considered optimal social support, a score of ≤2 was none or little support. Adjusted multivariable logistic regression models determined the effects of the intervention on infant complementary feeding.

Results

At the end of the study, infant complementary feeding improved significantly in both mothers-only and parents-combined arms. There was a positive effect on the introduction of solid, semisolid, and soft foods (ISSSF) in the mothers-only arm at both Midline-II {adjusted odds ratio (AOR) = 4.0]} and Endline (AOR = 3.8). Likewise, ISSSF was better for the parents-combined arm at both Midline-II (AOR = 4.5) and Endline (AOR = 3.4). Minimum dietary diversity (MDD) was significantly better at the Endline for the parents-combined arm (AOR = 3.0). Minimum acceptable diet (MAD) was significantly better at Endline for both mothers-only (AOR = 2.3) and parents-combined arms (AOR = 2.7). Infant consumption of eggs and flesh foods (EFF) was improved only in the parents-combined arm at both Midline-II (AOR = 3.3) and Endline (AOR = 2.4). Higher maternal social support was associated with better infant MDD (AOR = 3.3), MAD (AOR = 3.6), and EFF (AOR = 4.7).

Conclusion

Engaging both fathers and mothers in care groups benefited complementary feeding of infants. Overall, this peer-led integrated nutrition education intervention through care groups improved infant complementary feeding in the West-Nile postemergency settlements in Uganda.This trial was registered at clinicaltrials.gov as NCT05584969.

Decomposing the Intraurban Malnutrition Gap Between Poor and Non-poor Children in Colombia : Decomposing the Intraurban Malnutrition Gap Between Poor and Non-poor Children in Colombia

In Colombia, although it can be said that, on average children living in urban areas have better quality of life than their rural peers, it is also true that within cities, there are high levels of socioeconomic inequality. Our objective is to identify the contribution of the factors that explain the gap in stunting and excess weight between poor and non-poor children under 5 years of age in urban areas of Colombia. We use data from the 2015 National Nutritional Status Survey, and two nonlinear decomposition techniques based on the classical decomposition method developed by Blinder-Oaxaca. With a sample of 6877 observations, the results show that the intraurban gap of stunting between poor and non-poor children in urban areas is 4.8 percentage points. Its main determinants are the mother's educational level (46.5%), affiliation to the health system by the mother (19.4%), and assisted delivery in a medical institution (16.6%). For excess weight, the gap is - 2.1 percentage points, and its main determinants are the mother's educational level (39.2%) and birth attended by a physician (21.8%). This study suggests the coexistence of a double burden of malnutrition (DBM) in children under 5 years of age living in urban areas of Colombia. Stunting is associated with low-income levels while excess weight is associated with higher income levels. The identification of the main determinants of DBM and its relative importance, constitutes a contribution for public policy makers aimed at reducing socioeconomic gaps.

Stories of change in nutrition in Burkina Faso 1992–2018: a macro-level perspective

Looking back at the development of successful enabling environments for nutrition may inform policymakers on how to accelerate progress to end all forms of malnutrition by 2030. As under-five stunting declined substantially in Burkina Faso, from a peak at 45% in 1998/99 to 25% in 2018, we analyzed through a stories of change approach the actors, ideas, initiatives, policies and capacities which enabled wide-scale nutrition progress. We triangulated findings from policy analysis, stakeholder mapping, and national-level semi-structured interviews (n = 20). We found that since 2002, nutrition has been anchored in the Ministry of Health, where leadership advocated for the creation of coordination bodies, enabling a coherent defining of nutrition and laying groundwork for better integration of nutrition into and prioritization of nutrition by the health and tangential ministries. Under the leadership of the Ministry of Health and its partners, horizontal and vertical coherence in nutrition action increased, through effective cooperation between nutrition actors; increasing intersectoral collaboration, particularly with the influential agriculture sector; and increasing funding to support nutrition-sensitive programming and build the capacity of nutrition staff. Nevertheless, sustainably organizing funding and human resources at the decentralized level remained challenging, in a context of emerging threats such as climate change and insecurity. Burkina Faso’s health sector’s success in creating an enabling environment for nutrition may have contributed to improvements in child nutrition alongside other sectoral improvements. Enhancing accountability of the Health, Agriculture, WASH, Education and Social Protection sectors and empowering decentralized bodies to take nutrition-relevant decisions may help accelerating progress in nutrition.

Growth and growth trajectory among infants in early life: contributions of food insecurity and water insecurity in rural Zimbabwe

Introduction

Stunting or linear growth faltering, measured by length-for-age Z-score (LAZ), remains a significant public health challenge, particularly in rural low-income and middle-income countries. It is a marker of inadequate environments in which infants are born and raised. However, the contributions of household resource insecurities, such as food and water, to growth and growth trajectory are understudied.

Methods

We used the cluster-randomised Sanitation Hygiene and Infant Nutrition Efficacy trial to determine the association of household-level food insecurity (FI) and water insecurity (WI) on LAZ and LAZ trajectory among infants during early life. Dimensions of FI (poor access, household shocks, low availability and quality) and WI (poor access, poor quality, low reliability) were assessed with the multidimensional household food insecurity and the multidimensional household water insecurity measures. Infant length was converted to LAZ based on the 2006 WHO Child Growth Standards. We report the FI and WI fixed effects from multivariable growth curve models with repeated measures of LAZ at 1, 3, 6, 12 and 18 months (M1-M18).

Results

A total of 714 and 710 infants were included in our analyses of LAZ from M1 to M18 and M6 to M18, respectively. Mean LAZ values at each time indicated worsening linear growth. From M1 to M18, low food availability and quality was associated with lower LAZ (β=-0.09; 95% -0.19 to -0.13). From M6 to M18, poor food access was associated with lower LAZ (β=-0.11; 95% -0.20 to -0.03). None of the WI dimensions were associated with LAZ, nor with LAZ trajectory over time.

Conclusion

FI, but not WI, was associated with poor linear growth among rural Zimbabwean infants. Specifically, low food availability and quality and poor food access was associated with lower LAZ. There is no evidence of an effect of FI or WI on LAZ trajectory.

Changes in Nigeria's enabling environment for nutrition from 2008 to 2019 and challenges for reducing malnutrition

Key 2025 global nutrition targets are unlikely to be met at current rates of progress. Although actions necessary to reduce undernutrition are already mostly known, knowledge gaps remain about how to implement these actions in contextually appropriate ways, and at scales commensurate with the magnitude of the problem. This study describes the nutrition enabling environment in Nigeria, a country that contributes significantly to the global undernutrition burden, and identifies potential entry points for improving the enabling environment that could facilitate implementation and scale-up of essential intervention coverage. Study data were obtained from two sources: content analysis of 48 policies/strategies from agriculture, economic, education, environment, health, nutrition, and water/sanitation/hygiene sectors; and interviews at federal level (16) and in two states (Jigawa (10) and Kaduna (9) States). The study finds that aspects of the enabling environment improved between 2008 and 2019 and facilitated improvements in implementation of nutrition-specific and nutrition-sensitive interventions. Enabling environment components that improved included the framing of nutrition as a multisectoral issue, nutrition advocacy, political attention, evidence around intervention coverage, civil society involvement, and activity of nutrition champions. These factors have been especially important in creating and sustaining momentum for addressing malnutrition. While challenges remain in these aspects, greater challenges persist for factors needed to convert momentum into improvements in nutrition outcomes. Research and data that facilitate shared understanding of nutrition; improved multisectoral and vertical coordination; increased and improved delivery and operational capacity; and increased resource mobilization will be especially important for achieving future progress in nutrition in Nigeria.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12571-022-01328-2.

Changes in Child Undernutrition and Overweight in India From 2006 to 2021: An Ecological Analysis of 36 States

OBJECTIVES

We evaluated changes in priority indicators of child growth from 2006 to 2021 and examined the role of human development measures in these changes.

METHODS

We estimated cumulative and annualized changes in state- and district-level child growth indicators using 3 rounds of National Family Health Surveys (2005-2006, 2015-2016, 2019-2021) in 36 states. Outcomes included stunting, underweight, wasting, and overweight. Human development was measured using a principal components analysis of 9 ecological indicators. We contrasted expected versus observed changes in district-level growth outcomes between 2016 and 2021 based on changes in development indicators using 2-way Blinder Oaxaca decomposition.

RESULTS

From 2006 to 2021, the prevalence of stunting, underweight, and wasting decreased by 12.3, 10.3, and 0.7 percentage points, respectively, while the prevalence of overweight increased by 1.9 percentage points. The annualized rate of within-state change for stunting was lower from 2016 to 2021 compared with the 2006 to 2016 period, while the rate of change in overweight was higher. Simultaneously, all 9 human development indicators improved between 2006 and 2021. A unit increase between 2016 and 2021 in the human development score predicted a -5.1 percentage point (95% confidence interval=-5.8, -4.4) change in stunting, yet observed stunting declined by just -2.5 percentage points.

CONCLUSIONS

From 2016 to 2021, population-level reduction in child stunting has slowed and the rise in child overweight has accelerated, relative to the 10 years preceding this period.

Implementation Outcomes of National Convergence Action Policy to Accelerate Stunting Prevention and Reduction at the Local Level in Indonesia: A Qualitative Study

The study aims to explore the implementation outcome variables of Indonesia's national policy convergence action in the stunting reduction intervention at district, sub-district, and village levels. The study design was qualitative with an implementation research approach at District Cirebon, Indonesia. Data were collected through in-depth interviews, focus group discussions, study documents, and 6 months of participant observation. We recruited 172 respondents. The assessment instrument used was formed on was implementation outcomes variables. Data were analyzed through coding, categorizing and thematic content analysis based on a predetermined theme. Comparative cross district activity-site analysis was applied between sub-districts and villages. The implementation outcome variables for the convergence action policy were performed well at the district level, in line with the central government's adequate regulation, control, and budget. Meanwhile, the sub-district and village levels only performed aspects of acceptability, appropriateness, and coverage for specific interventions. The acceptability level in the village was only partially running. The barriers at the sub-district and village levels were issues of commitment, staff capacity, and poor coordination. Superficial understanding and capacity weaknesses drove the convergence of the stunting reduction responsibility back into the burden of the health sector at the forefront. Local politics also colored the implementation in the village.

The associations between women's empowerment measures, child growth and dietary diversity: Findings from an analysis of demographic and health surveys of seven countries in Eastern Africa

Evidence on the efficacy of women's empowerment to improve child growth and minimum dietary diversity (MDD) in the Eastern Africa (EA) region is limited. This cross‐sectional study used recent Demographic and Health Survey data of mother–child dyads from seven countries in EA to examine the associations between women's empowerment measures, child growth and MDD. Length‐for‐age z‐scores, weight‐for‐length z‐scores and weight‐for‐age z‐scores were used to categorize growth indicators of 6–23 months old children. Multivariable logistic regression was used to identify significant associations. Among all countries, 32%–59% of children experienced growth failure. Children meeting MDD were 18%–45%. Women having self‐esteem were associated with lower odds of stunting (adjusted odds ratio [AOR] = 0.62 in Rwanda), wasting (AOR = 0.38 in Uganda), underweight (AORs = 0.60 and 0.57 in Tanzania and Uganda, respectively) and growth failure (AOR = 0.64 in Rwanda). Having health decision control in Burundi was associated with lower odds of stunting (AOR = 0.49) and child growth failure (AOR = 0.52) and higher odds of meeting MDD (AOR = 2.50). Having Legal empowerment among women increased the odds of stunting (AOR = 1.79 in Burundi), underweight (AOR = 1.77 in Uganda) and growth failure (AOR = 1.87 in Burundi). Economic empowerment showed mixed associations with child growth and MDD among some countries. Women's self‐esteem and health decision control were associated with better child growth and MDD for some countries in EA. Nutrition‐sensitive interventions aimed at improving child growth and MDD should consider local contexts when addressing women's empowerment.

Understanding the associations between women's empowerment, child growth and child dietary diversity is important for most nutrition‐sensitive interventions seeking to improve child feeding practices and growth by targeting mothers.

In this study, for women to have self‐esteem and health decision control was consistently beneficial for child growth and minimum dietary diversity (MDD). Mixed associations existed among other women's empowerment measures, child growth and MDD across the seven East African countries investigated.

For improved child growth and better child dietary diversity, targeting specific women's empowerment measures based on local context may be beneficial in the East African region.

Head circumference as an epigenetic risk factor for maternal nutrition

Nutrition indicators for malnutrition can be screened by many signs such as stunting, underweight or obesity, muscle wasting, and low caloric and nutrients intake. Those deficiencies are also associated with low socioeconomic status. Anthropometry can assess nutritional status by maternal weight measurements during pregnancy. However, most studies have focused primarily on identifying changes in weight or Body Mass Index (BMI), and their effects on neonatal measures at present time. Whereas head circumference (HC) has been associated with nutrition in the past. When the mother was exposed to poor nutrition and unfavorable social conditions during fetal life, it was hypothesized that the intergenerational cycle was potentially mediated by epigenetic mechanisms. To investigate this theory, maternal head circumference (MHC) was associated with neonatal head circumference (NHC) in pregnant women without preexisting chronic conditions, differentiated by sociodemographic characteristics. A multiple linear regression model showed that each 1 cm-increase in MHC correlated with a 0.11 cm increase in NHC (β95% CI 0.07 to 0.15). Notwithstanding, associations between maternal and neonatal anthropometrics according to gestational age at birth have been extensively explained. Path analysis showed the influence of social status and the latent variable was socioeconomic status. A model of maternal height and head circumference was tested with effects on neonatal HC. The social variable lacked significance to predict neonatal HC in the total sample (p = 0.212) and in the South/Southeast (p = 0.095), in contrast to the Northeast (p = 0.047). This study highlights the potential intergenerational influence of maternal nutrition on HC, suggesting that maternal nutrition may be more relevant in families with major social vulnerability.

Secular Growth Trends in Early Childhood—Evidence from Two Low-Income Birth Cohorts Recruited over a Decade in Vellore, India

Stunting and extreme poverty are considered significant risk factors impacting child development in low-and-middle-income countries. We used two birth cohorts recruited 8–9 years apart in urban low-income (slum) settings in Vellore, south India and analyzed secular growth trends and their predictors. In the rotavirus cohort recruited between 2002 and 2003, 373 children completed the 3-year follow-up. “The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development” (MAL-ED) cohort recruited between 2010 and 2012 had 215 children completing follow-up. The MAL-ED cohort had better socio-economic status (SES) markers and mothers were better educated compared with the previous cohort. Children in the MAL-ED cohort had less stunting at 1, 2, and 3 years of age. The linear mixed effects model evaluating linear growth during the first 3 years of age showed that low birth weight and being a female child were associated with stunting in both cohorts. There was no association between SES and stunting in the rotavirus cohort, whereas SES was associated with linear growth in the MAL-ED cohort. Future studies could incorporate nutritional and nonnutritional interventions in vulnerable populations to evaluate their effect on birth weight as well as early childhood stunting.

Birth length is the strongest predictor of linear growth status and stunting in the first 2 years of life after a preconception maternal nutrition intervention: the children of the Women First trial

BACKGROUND

The multicountry Women First trial demonstrated that nutritional supplementation initiated prior to conception (arm 1) or early pregnancy (arm 2) and continued until delivery resulted in significantly greater length at birth and 6 mo compared with infants in the control arm (arm 3).

OBJECTIVES

We evaluated intervention effects on infants' longitudinal growth trajectory from birth through 24 mo and identified predictors of length status and stunting at 24 mo.

METHODS

Infants' anthropometry was obtained at 6, 12, 18, and 24 mo after the Women First trial (registered at clinicaltrials.gov as NCT01883193), which was conducted in low-resource settings: Democratic Republic of Congo, Guatemala, India, and Pakistan. Longitudinal models evaluated intervention effects on infants' growth trajectory from birth to 24 mo, with additional modeling used to identify adjusted predictors for growth trajectories and outcomes at 24 mo.

RESULTS

Data for 2337 (95% of original live births) infants were evaluated. At 24 mo, stunting rates were 62.8%, 64.8%, and 66.3% for arms 1, 2, and 3, respectively (NS). For the length-for-age z-score (LAZ) trajectory, treatment arm was a significant predictor, with adjusted mean differences of 0.19 SD (95% CI: 0.08, 0.30; P < 0.001) and 0.17 SD (95% CI: 0.07, 0.27; P < 0.001) for arms 1 and 2, respectively. The strongest predictors of LAZ at 24 mo were birth LAZ <-2 and <-1 to ≥-2, with adjusted mean differences of -0.76 SD (95% CI: -0.93, -0.58; P < 0.001) and -0.47 SD (95% CI: -0.56, -0.38; P < 0.001), respectively. For infants with ultrasound-determined gestational age (n = 1329), the strongest predictors of stunting were birth LAZ <-2 and <-1 to ≥- 2: adjusted relative risk of 1.62 (95% CI: 1.39, 1.88; P < 0.001) and 1.46 (95% CI: 1.31, 1.62; P < 0.001), respectively.

CONCLUSIONS

Substantial improvements in postnatal growth are likely to depend on improved intrauterine growth, especially during early pregnancy.

Child stunting starts in utero: Growth trajectories and determinants in Ugandan infants

Childhood stunting remains a public health burden worldwide. Although many studies have examined early life and in-utero risk factors; most have been observational and have used analytic techniques that make inferences limited to population means, thereby obscuring important within-group variations. This study addressed that important gap. Using data from a birth cohort of Ugandan infants (n = 4528), we applied group-based trajectory modelling to assess diverse patterns of growth among children from birth to 1-year old. A multinomial regression model was conducted to understand the relationship between risk factors and observed patterns across groups. We found that the onset of stunting occurred before birth and followed four distinct growth patterns: chronically stunted (Group 1), recovery (Group 2), borderline stunted (Group 3) and normal (Group 4). The average length-for-age z-score (LAZ) at birth was -2.6, -3.9, -0.6 and 0.5 for Groups 1-4, respectively. Although both Groups 1 and 2 were stunted at birth, stunting persisted in Group 1 while children in Group 2 recovered by the fourth month. Group 3 exhibited mild stunting while Group 4 was normal. Wasting and underweight were observed in all groups, with the highest prevalence of underweight in Group 1. Wasting gradually increased among children born already stunted (Groups 1 and 2). This showed the importance of distinguishing children by their growth patterns rather than aggregating them and only comparing population averages against global growth standards. The design of nutrition interventions should consider the differential factors and potential for growth gains relative to different risks within each group.

Malaria reduction drives childhood stunting decline in Uganda: a mixed-methods country case study

BACKGROUND

Uganda has achieved a considerable reduction in childhood stunting over the past 2 decades, although accelerated action will be needed to achieve 2030 targets.

OBJECTIVES

This study assessed the national, community, household, and individual-level drivers of stunting decline since 2000, along with direct and indirect nutrition policies and programs that have contributed to nutrition change in Uganda.

METHODS

This mixed-methods study used 4 different approaches to determine the drivers of stunting change over time: 1) a scoping literature review; 2) quantitative data analyses, including Oaxaca-Blinder decomposition and difference-in-difference multivariable hierarchical modeling; 3) national- and community-level qualitative data collection and analysis; and 4) analysis of key direct and indirect nutrition policies, programs, and initiatives.

RESULTS

Stunting prevalence declined by 14% points from 2000 to 2016, although geographical, wealth, urban/rural, and education-based inequalities persist. Child growth curves demonstrated substantial improvements in child height-for-age z-scores (HAZs) at birth, reflecting improved maternal nutrition and intrauterine growth. The decomposition analysis explained 82% of HAZ change, with increased coverage of insecticide-treated mosquito nets (ITNs; 35%), better maternal nutrition (19%), improved maternal education (14%), and improved maternal and newborn healthcare (11%) being the most critical factors. The qualitative analysis supported these findings, and also pointed to wealth, women's empowerment, cultural norms, water and sanitation, dietary intake/diversity, and reduced childhood illness as important. The 2011 Uganda Nutrition Action Plan was an essential multisectoral strategy that shifted nutrition out of health and mainstreamed it across related sectors.

CONCLUSIONS

Uganda's success in stunting reduction was multifactorial, but driven largely through indirect nutrition strategies delivered outside of health. To further improve stunting, it will be critical to prioritize malaria-control strategies, including ITN distribution campaigns and prevention/treatment approaches for mothers and children, and deliberately target the poor, least educated, and rural populations along with high-burden districts.