Stunting, starvation and refeeding: a review of forgotten 19th and early 20th century literature

Stop stunting-A misguided campaign by well-meaning nutritionists

OBJECTIVE

"Stop stunting" is the central focus of the national Indonesian campaign to improve child health. We provide an autoethnographic statement on the currently practiced strategy that commits 23 ministries and an estimated $3.9 billion per year to coordinating nutrition interventions that are supposed to address the underlying causes of stunting.

METHODS

We visited six community health posts (posyandus) in West Timor and in Java and participated in routine child health examinations. We documented our impressions and discussed them with Indonesian colleagues, health officials, and local physicians.

RESULTS

Routine health checks for children include anthropometry (height, weight, head, and mid-upper arm circumference), immunizations, and documentation in the children's health records. The examinations do not include a physical examination, vision and hearing tests of the child, health questionnaires, or information on nutrition. No specific information or recommendations are given to the mothers.

CONCLUSION

Stunting is highly prevalent in Indonesia and "Stop-stunting" campaigns have become a national issue. Yet, their impact is disillusioning. Stunting is associated with a way of life that differs from that in developed Western countries today and was prevalent in feudal and other nondemocratic societies. We do not want to throw away policies that try to improve growth in children, but instead of spending money for dubious interventions as we have encountered in Indonesia, we rather suggest spending thoughts on the political and emotional causes of poor growth in otherwise healthy Indonesian children.

Strategic growth in social vertebrates

Individual differences in growth and size of vertebrates often represent adaptive, plastic responses to contrasts in ecological conditions. Recent studies show that vertebrates can also modify their growth and size in an adaptive fashion in response to fine-grain changes in social conditions (which we refer to as strategic growth). Here, we review experimental evidence for strategic growth in social vertebrates. We describe a set of conditions under which strategic growth commonly occurs, and highlight potential examples of convergent evolution of strategic growth across the tree of life. This synthesis has implications for the way we think about organismal growth and size, because it underscores that the size of individuals can often be fine-tuned to their social environment.

Stunting as a Synonym of Social Disadvantage and Poor Parental Education

Socially, economically, politically and emotionally (SEPE) disadvantaged children are shorter than children from affluent background. In view of previous work on the lack of association between nutrition and child growth, we performed a study in urban schoolchildren. We measured 723 children (5.83 to 13.83 years); Kupang, Indonesia; three schools with different social background. We investigated anthropometric data, clinical signs of malnutrition, physical fitness, parental education, and household equipment. Subjective self-confidence was assessed by the MacArthur test. The prevalence of stunting was between 8.5% and 46.8%. Clinical signs of under- or malnutrition were absent even in the most underprivileged children. There was no delay in tooth eruption. Underprivileged children are physically fitter than the wealthy. The correlation between height and state of nutrition (BMI_SDS, skinfold_SDS, MUAC_SDS) ranged between r = 0.69 (p < 0.01) and r = 0.43 (p < 0.01) in private school children, and between r = 0.07 (ns) and r = 0.32 (p < 0.01) in the underprivileged children. Maternal education interacted with height in affluent (r = 0.20, p < 0.01) and in underprivileged children (r = 0.20, p < 0.01). The shortness of SEPE disadvantaged children was not associated with anthropometric and clinical signs of malnutrition, nor with delay in physical development. Stunting is a complex phenomenon and may be considered a synonym of social disadvantage and poor parental education.

Age dependency of body mass index distribution in childhood and adolescent inpatients with anorexia nervosa with a focus on DSM-5 and ICD-11 weight criteria and severity specifiers

Both DSM-5 and ICD-11 have provided weight cut-offs and severity specifiers for the diagnosis of anorexia nervosa (AN) in childhood, adolescence and adulthood. The aims of the current study focusing on inpatients aged < 19 years were to assess (1) the relationship between age and body mass index (BMI; kg/m²), BMI-centiles, BMI-standard deviation scores (BMI-SDS) and body height-SDS at referral, (2) the percentages of patients fulfilling the DSM-5 and ICD-11 weight criteria and severity categories for AN, and (3) the validity of the AN severity specifiers via analysis of both weight related data at discharge and inpatient treatment duration. The German Registry for Anorexia Nervosa encompassed complete data sets for 469 female patients (mean age = 15.2 years; range 8.9-18.9 years) with a diagnosis of AN (n = 404) or atypical AN (n = 65), who were ascertained at 16 German child and adolescent psychiatric hospitals. BMI at referral increased up to age 15 to subsequently plateau. Approximately one tenth of all patients with AN had a BMI above the fifth centile. The ICD-11 specifier based on a BMI-centile of 0.3 for childhood and adolescent AN entailed two equally sized groups of patients. Discharge data revealed limited validity of the specifiers. Height-SDS was not correlated with age thus stunting had no impact on our data. We corroborate the evidence to use the tenth instead of the fifth BMI-centile as the weight criterion in children and adolescents. Weight criteria should not entail major diagnostic shifts during the transition from adolescence to adulthood. The severity specifiers based on BMI or BMI-centiles do not seem to have substantial clinical validity.

Adaptation of the small intestine to microbial enteropathogens in Zambian children with stunting

Environmental enteropathy is a major contributor to growth faltering in millions of children in Africa and South Asia. We carried out a longitudinal, observational and interventional study in Lusaka, Zambia, of 297 children with stunting (aged 2-17 months at recruitment) and 46 control children who had good growth (aged 1-5 months at recruitment). Control children contributed data only at baseline. Children were provided with nutritional supplementation of daily cornmeal-soy blend, an egg and a micronutrient sprinkle, and were followed up to 24 months of age. Children whose growth did not improve over 4-6 months of nutritional supplementation were classified as having non-responsive stunting. We monitored microbial translocation from the gut lumen to the bloodstream in the cohort with non-responsive stunting (n = 108) by measuring circulating lipopolysaccharide (LPS), LPS-binding protein and soluble CD14 at baseline and when non-response was declared. We found that microbial translocation decreased with increasing age, such that LPS declined in 81 (75%) of 108 children with non-responsive stunting, despite sustained pathogen pressure and ongoing intestinal epithelial damage. We used confocal laser endomicroscopy and found that mucosal leakiness also declined with age. However, expression of brush border enzyme, nutrient transporter and mucosal barrier genes in intestinal biopsies did not change with age or correlate with biomarkers of microbial translocation. We propose that environmental enteropathy arises through adaptation to pathogen-mediated epithelial damage. Although environmental enteropathy reduces microbial translocation, it does so at the cost of impaired growth. The reduced epithelial surface area imposed by villus blunting may explain these findings.

Trends in growth and developmental tempo in boys aged 7 to 18 years between 1966 and 2012 in Poland

OBJECTIVES

To assess trends in growth in different developmental periods and trends in developmental tempo in Polish boys between 1966 and 2012.

METHODS

Data on 34 828 boys aged 7 to 18 years were collected during Polish Anthropological Surveys conducted in 1966, 1978, 1988, and 2012. Biological parameters, related to onset of adolescent growth spurt (OGS) and peak height velocity (PHV), were derived from a Preece-Baines 1 model (PB1). Childhood (height at 7 years of age), pre-adolescent (height at OGS) and adolescent growth (adult height minus height at OGS) were identified.

RESULTS

Positive secular trend between 1966 and 2012 in adult height accounted for, on average, 1.5 cm/decade, with varying intensity between the Surveys. Decline in both age at OGS and APHV between 1966 and 2012 (1.5 and 1.4 years, respectively) indicated an acceleration in developmental tempo, on average, by 0.3 year/decade. Increases in the contribution to the trend in adult height gained during growth in particular developmental periods between 1966 and 2012 were as followed-childhood: 0.6%, pre-adolescent growth: -3.1%, adolescent growth: 3.1%.

CONCLUSIONS

Secular trend in developmental tempo and growth among boys reflects changes in living conditions and socio-political aspirations in Poland during nearly 50 years. Acceleration in tempo is already visible at age at OGS, whereas the trend in adult height occurs largely during adolescence, pointing to different regulation of developmental tempo and growth in body height. This finding emphasizes the importance of extending public health intervention into children's growth up until adolescence.

Indonesian National Growth Reference Charts Better Reflect Height and Weight of Children in West Java, Indonesia, than WHO Child Growth Standards

OBJECTIVE

The Indonesia Basic Health Research 2018 indicates that Indonesian children are still among the shortest in the world. When referred to World Health Organization Child Growth Standards (WHOCGS), the prevalence of stunting reaches up to 43% in several Indonesian districts. Indonesian National Growth Reference Charts (INGRC) were established in order to better distinguish between healthy short children and children with growth disorders. We analyzed height and weight measurements of healthy Indonesian children using INGRC and WHOCGS.

METHODS

6972 boys and 5800 girls (n=12,772), aged 0-59 months old, from Bandung District were measured. Z-scores of length/height and body mass index were calculated based on INGRC and WHOCGS.

RESULTS

Under 5-year-old Indonesian children raised in Bandung are short and slim. Mean height z-scores of boys is -2.03 [standard deviation (SD) 1.31], mean height z-scores of girls is -2.03 (SD 1.31) when referred to WHOCGS indicating that over 50% of these children are stunted. Bandung children are heterogeneous, with substantial subpopulations of tall children. Depending on the growth reference used, between 9% and 15% of them are wasted. Wasted children are on average half a SD taller than their peers.

CONCLUSION

WHOCGS seriously overestimates the true prevalence of undernutrition in Indonesian children. The present investigation fails to support evidence of undernutrition at a prevalence similar to the over 50% prevalence of stunting (WHOCGS) versus 13.3% (INGRC). We suggest refraining from using WHOCGS, and instead applying INGRC that closely mirror height and weight increments in Bandung children. INGRC appear superior for practical and clinical purposes, such as detecting growth and developmental disorders.

Emotional Deprivation in Children: Growth Faltering and Reversible Hypopituitarism

Emotional deprivation can lead to growth faltering of infants and children. The mechanism(s) involved differ in that for infants, the major metabolic problem is inadequate energy intake for growth. In young children, it is likely that the emotional deprivation causes a syndrome not only of growth faltering, but with bizarre behaviors, especially with regard to food: hoarding, gorging and vomiting, hyperphagia, drinking from the toilet, and eating from garbage pails. Other disturbed behaviors include, poor sleep, night wanderings, and pain agnosia. The pathophysiology appears to be reversible hypopituitarism, at least for the growth hormone and hypothalamic-pituitary- adrenal axes. The review begins with an historical perspective concerning stress, children and growth and then moves to the issue of hospitalism, where young infants failed to thrive (and died) due to inadequate stimulation and energy intake. Refeeding programs at the end of World Wars I and II noted that some children did not thrive despite an adequate energy intake. It appeared that in addition taking care of their emotional needs permitted super-physiologic (catch-up) growth. Next came the first notions from clinical investigation that hypopituitarism might be the mechanism of growth faltering. Studies that address this mechanism from a number of observational and clinical research studies are reviewed in depth to show that the hypopituitarism was relieved upon removal from the deprivational environment and occurred much too quickly to be due to adequate energy alone. These findings are then compared to those from malnourished children and adoptees from emerging countries, especially those from orphanages where their psychosocial needs were unmet despite adequate caloric intake. Together, these various conditions define one aspect of the field of psychoneuroendocrinology.

Catch-up growth is a better indicator of undernutrition than thresholds for stunting

Objective:

Stunting (height-for-age < −2 sd) is one of the forms of undernutrition and is frequent among children of low- and middle-income countries. But stunting perse is not a synonym of undernutrition. We investigated association between body height and indicators of energetic undernutrition at three critical thresholds for thinness used in public health: (1) BMI SDS < −2; (2) mid-upper arm circumference divided by height (MUAC (mm) × 10/height (cm) < 1·36) and (3) mean skinfold thickness (SF) < 7 mm and to question the reliability of thresholds as indicators of undernutrition.

Design:

Cross-sectional study; breakpoint analysis.

Setting:

Rural and urban regions of Indonesia and Guatemala – different socio-economic status (SES).

Participants:

1716 Indonesian children (6·0–13·2 years) and 3838 Guatemalan children (4·0–18·9 years) with up to 50 % stunted children.

Results:

When separating the regression of BMI, MUAC or SF, on height into distinguishable segments (breakpoint analysis), we failed to detect relevant associations between height, and BMI, MUAC or SF, even in the thinnest and shortest children. For BMI and SF, the breakpoint analysis either failed to reach statistical significance or distinguished at breakpoints above critical thresholds. For MUAC, the breakpoint analysis yielded negative associations between MUAC/h and height in thin individuals. Only in high SES Guatemalan children, SF and height appeared mildly associated with R² = 0·017.

Conclusions:

Currently used lower thresholds of height-for-age (stunting) do not show relevant associations with anthropometric indicators of energetic undernutrition. We recommend using the catch-up growth spurt during early re-feeding instead as immediate and sensitive indicator of past undernourishment. We discuss the primacy of education and social-economic-political-emotional circumstances as responsible factors for stunting.

Taller but thinner: trends in child anthropometry in Senegal, 1990-2015

OBJECTIVE

To investigate trends in child anthropometry in Senegal between 1990 and 2015 and relate them with potential causes. Several hypotheses were tested: changes in health status, income, diet and socio-economic status.

DESIGN

Statistical analysis of trends in anthropometric data: height, weight, BMI and associated Z-scores calculated with the CDC-2000 standard (Centers for Disease Control and Prevention): height-for-age (HAZ), weight-for-age (WAZ) and weight-for-height (WHZ). Trends were fitted with linear regression models and were related with changes in health and socio-economic status.

SETTING

Nine nationally representative samples of Senegalese children aged 12-59 months, taken between 1986 and 2017 by Demographic and Health Surveys (DHS).

PARTICIPANTS

Children aged 12-59 months.

RESULTS

Over the 25 years of investigation, the average height of children increased by +1·88 cm, their average weight by +0·10 kg, but their BMI decreased by -0·53 kg/m2. Corresponding changes expressed in Z-scores were +0·454 in HAZ, +0·109 in WAZ and -0·302 in WHZ. This pattern of decreasing stunting while increasing wasting was correlated with decreasing child mortality, despite small changes in income per capita and in adult heights or BMI. Largest improvements in HAZ were among the lower socio-economic strata, while largest declines in WHZ were among higher socio-economic strata.

CONCLUSIONS

Decline in stunting appeared associated primarily with the control of infectious diseases, also responsible for the mortality decline. Increase in wasting was surprising. It appears associated with small changes in income per capita, and therefore in diet, in a context of increasing height.

Community-based clustering of height in Ethiopia, India, Peru, and Vietnam

OBJECTIVES

Human growth and final height are influenced by many factors such as genetics, nutrition, living conditions, socioeconomic background and, as recently proposed, by social peer groups and the community. In this paper, we aim to evaluate the extent to which spatial proximity, acting as a proxy for the social community, causes height clustering in low and middle income countries.

MATERIAL AND METHODS

We analyzed data from the study "Young Lives-Measuring Child Poverty and Health", a study performed in four low and middle income countries (Ethiopia, India, Peru and Vietnam) to describe the health situation of children. We used linear mixed effects models with different random effect structures to analyze the influence of the community on clustering of height in boys and girls.

RESULTS

In all analyzed low and middle income countries, linear mixed effects with hierarchical structures with communities nested within regions provide a better fit than the basic models neglecting community-based clustering (p < .001).

DISCUSSION

Although the underlying mechanisms require future research, spatial proximity arising from clustering needs to be integrated into explorative modelling of height variability in humans.

Weight and height growth of malnourished school-age children during re-feeding. Three historic studies published shortly after World War I

BACKGROUND

In view of the ongoing debate on "chronic malnutrition" and the concept of "stunting" as "a better measure than underweight of the cumulative effects of undernutrition and infection (WHO)", we translate, briefly comment and re-publish three seminal historic papers on catch-up growth following re-feeding after severe food restriction of German children during and after World War I. The observations were published in 1920 and 1922, and appear to be of particular interest to the modern nutritionist.

RESULTS

The papers of Abderhalden (1920) and Bloch (1920) describe German children of all social strata who were born shortly before World War I, and raised in apparently "normal" families. After severe long-standing undernutrition, they participated in an international charity program. They experienced exceptional catch-up growth in height of 3-5 cm within 6-8 weeks. Goldstein (1922) observed 512 orphans and children from underprivileged families. Goldstein described very different growth patterns. These children were much shorter (mean height between -2.0 and -2.8 SDS, modern WHO reference). They mostly failed to catch-up in height, but tended to excessively increase in weight particularly during adolescence.

CONCLUSION

Whereas Abderhalden and Bloch illustrate rapid height catch-up in children from intact social background, Goldstein's observations in orphans and children from poor social background parallel the growth patterns observed in children of modern middle and low-income countries. The historic observations question the current concept of stunting as prima facie evidence of malnutrition and chronic infection, and support the view that "the child's longitudinal growth is largely independent of the extent and nature of the diet".