Expert Commentary – Eliminating the Scourge of Stunting

By Rae Galloway

Ms. Rae Galloway works for PATH and is the Lead for Nutrition at the USAID-funded, Jhpiego-led Maternal and Child Health Integrated Program (MCHIP). She has worked for 25 years to reduce maternal, infant, and young child malnutrition in developing countries, where more than one-fourth of children younger than five years of age are stunted in their growth and nearly half of pregnant women are anemic.

Much of the malnutrition in the world today is invisible to policy makers, politicians, and families.  The most overlooked form of malnutrition is stunting (short stature) or chronic malnutrition which affects one-fourth of the world’s children younger than five years of age.  Because it is a process, taking place in the child’s first 1,000 days (from conception through the second year of life), stunting is difficult to identify by just looking at a child.  Most parents are not aware of the problem.  Even if parents notice their child is not growing like their other children, they often are not aware of the infant and young child feeding, hygiene, and sanitation practices that would reverse the problem.  And yet, if a child does not attain her/his potential for growth and height, it has serious life-long implications for the child and her or his family. 

Stunting increases risk of illness and mortality (contributing to half of child deaths globally), delays school enrollment, reduces the ability to learn, and decreases grade completion.  Like the families they serve, national governments in developing countries are unaware that a stunted population impedes national development.  The stunted adult cannot work as hard, earns less, and is sick more often than taller adults, reducing gross domestic product. The time lost in productive activities, the cost of health care, and the risk of premature death increases for both stunted children and adults, particularly for women during child bearing. 

In most countries, there is a belief that the solution to malnutrition is giving food to poor families.  Efforts continue to find the perfect food product to prevent and reverse malnutrition, even though many families have food on hand that could reduce much of the stunting in the world—children are just not being fed what is available in the household.  This is good news, because giving food and commercial food products is too costly to prevent all stunting.  Instead, evidence suggests that community-based nutrition programs with strong behavior change communication components can effectively reduce stunting. 

These programs, which cost less than $10 per child per year, have been implemented in some countries nationally and in many countries in smaller geographic areas by non-governmental organizations.  They are most effective when they reach pregnant mothers and children frequently, empower mothers and fathers and other family members on a variety of levels, involve multiple public and private sector actors, and employ robust monitoring systems that track barriers to optimal nutrition, and adjust program implementation accordingly.  Community workers are essential to reaching high coverage and frequent contacts with families.  To provide the proper “intensity” of nutrition counseling, a ratio of a part-time community worker to children younger than two years of age is 1:50. To effectively reduce stunting, workers need to make contact with families frequently, probably on a monthly basis, and reach at least 80% of families.  Until the level of investment is made in countries to provide support for a trained community cadre in sufficient numbers, rates of stunting and other forms of malnutrition will remain static.

A major barrier to reducing stunting continues to be the dearth of information in developing countries about what women should eat during pregnancy and how and what to feed children under two years of age.  An example of this comes from something that happened to me several years ago when I was visiting the developing country office of the international organization I was working for at the time.  Knowing that my profession is nutrition, a colleague in the office and also a mother of an eight-month-old boy asked me to confirm that babies her son’s age only need to eat porridge while it is adults who need animal foods, nuts, legumes, fruits and vegetables.  I told her that, in fact, the opposite is true! 

Unfortunately, the belief of my colleague persists throughout the developing world because most parents do not receive credible information about optimal nutrition practices.  Lack of income to buy certain types of nutritious foods is a problem in some households, but even in the poorest of families, adults and older children receive a more diverse diet than children 6-23 months.  In many countries, families purchase commercial foods of low nutritional value such as biscuits, cakes, sugary drinks, and chips for babies.  These foods are replacing traditional, nutritious foods which children could be eating.  These commercial “junk foods” are on the rise and are causing both stunting and overweight in children and overweight and obesity in adults.  For more information about infant and young child feeding practices, visit the MCHIP website and read about a study conducted in Egypt by MCHIP.

Admittedly, not every household has access to a diverse diet throughout the year.  Ministries of Agriculture and their partners play important roles in increasing the production of staple crops and nutrient-dense foods, reducing crop loss, and expanding markets to increase the availability of a diverse diet to all families.  The USAID-funded Feed the Future Initiative has set a goal to not only improve the production and availability of food but also to reduce malnutrition in women and children as part of its support to agriculture. 

Other public and private sectors such as education, health, the private food industry and others are important channels to disseminate messages about what pregnant women should consume and how to feed infants and young children.  Only until all public and private sector players have a common goal, work together to leverage resources, and monitor progress will stunting and other forms of malnutrition be eliminated globally.  Fortunately, new efforts by the Scaling-Up Nutrition movement (SUN) to coordinate these types of partnerships are underway in many countries. 

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[Scott Bleggi]

Bundled nutrition interventions, including community-based behavior change communications, are the highest return development investments. Let's scale up successful outcomes!