Undernutrition in children
below five years of age is conventionally measured by three indices:
underweight (low weight; weight for age below 2 standard
deviations [SD] of World Health Organization [WHO] growth
reference), stunting (short child; length or
height for age below 2 SD of WHO growth reference), and wasting
(thin child; weight for length or height below 2 SD of WHO growth
reference). Weight for age represents a composite measure of height
for age and weight for height. A low weight for height (wasting) is
used to define acute undernutrition in populations, for
example, severe acute malnutrition (weight for height below 3 SD of
WHO growth reference; SAM), which necessitates immediate
intervention to prevent mortality and severe morbidity. A low height
for age or linear growth retardation (stunting) is however believed
to represent a relatively longer lasting deprivation. It is
important to realize that the three indicators reflect different
biological facets of undernutrition and interventions aimed at
reducing one may not necessarily ameliorate another.
Need to Focus on Stunting
Stakeholders invariably relate childhood
undernutrition to underweight. Consequently all policy discussions
revolve around underweight only, thereby eroding the public health
importance of stunting and wasting. However, wasting has recently
gained recognition for identification of SAM while stunting still
remains neglected. Evidence indicates that height-for-age at 2 years
is the best predictor of human capital in low and middle income
countries (LMICs). Further, stunting in the first 2 years of life
causes irreversible damage, including shorter adult height, lower
attained schooling, reduced adult income, and decreased offspring
birth weight . In view of the increasing importance of human
resource development, it is imperative that stunting be now viewed
as a primary indicator of childhood undernutrition by policy and
The ensuing sections explore the major challenges
and priority public health options for accelerating linear growth in
Recent Trends and Current Magnitude of Stunting
Epidemiological analyses of regional and national
datasets document a sustained increase in mean height with a
concomitant decline in stunting over the past four decades amongst
children below five years of age , with some evidence of a faster
decline during the past decade.
A comparison of undernutrition indices, defined
as per the WHO growth reference, is possible between 1998-99 and
2005-6 from the National Family Health Surveys (NFHS) , only in
children below three years age (Fig. 1). There was a
substantial decline in stunting (51% to 45%), a marginal reduction
in underweight (43% to 40%), but a rise in wasting (20% to 23%).
This trend was evident for both urban and under-privileged rural
regions; in fact, the greater decline in stunting in rural rather
than urban areas (54% to 47% vs 41% to 37%) is inspiring.
However, the marginal rise in wasting has often been misinterpreted
as worsening of undernutrition.
Fig. 1 Comparison of
undernutrition indices defined as per the WHO growth
reference between 1998-99 and 2005-6 from the National
Family Health Surveys  in children below three years age.
Considering the biological perspective, linear
growth (exemplified by an increase in length of a cylinder) and an
increase in weight for height (exemplified by an increase in padding
of the cylinder) are two distinct processes. The logical biological
interpretation of the recent time trend is that the increase in
length has outstripped the simultaneous growth in weight, resulting
in taller but thinner (less padded) children with a consequential
increase in wasting. This recent trend also reaffirms that over time
(surrogate of invisible specific interventions), the changes in the
three anthropometric indicators can vary both in direction and
magnitude. However, generally in populations, linear growth
acceleration has been more difficult to achieve than an increase in
weight for height. This recent trend in national nutritional status
should thus be viewed as an improvement rather than worsening of
undernutrition. This inference is further substantiated by an
increase in the composite anthropometric measure (weight for
age) with a concomitant reduction of underweight prevalence (43% to
40%), albeit to a lesser extent. It is virtually impossible to
dissect out the individual factors that facilitated preferential
linear or weight growth from this data. Nevertheless, it is evident
that measures to improve underweight may not improve linear growth
and therefore specific interventions must be sought for and targeted
to ameliorate stunting.
In summary, the current national estimate of
stunting in children below five years of age is disconcerting
(urban: 39.6% and rural: 50.7%) . However, stunting has declined
at a relatively greater pace during the past decade, even in the
underprivileged rural areas. Further, linear growth,
disproportionately greater than weight gain, is also feasible in
India. The key issue pertains to consolidating and accelerating
these gains at the population level.
Birth deficit persists
Longitudinal data from developing countries
indicates that newborns with low birth weight (LBW; <2500 grams) are
substantially predisposed to become undernourished children. In the
New Delhi Birth Cohort (NDBC) longitudinal database , LBW
increased the risk of being underweight (3 to 5 times), stunted (2.1
to 4.3 times), and wasting (2.2 to 2.9 times) in the first five
years of life, and the risk generally decreased with increasing age
. A short newborn (12% in NDBC) is at a greater risk of
developing stunting (2.5 to 8.1 times). In the NDBC, stunting
attributable to LBW was 28% at 6 months and ranged between 8% and
16% from 1 to 5 years of age. With a LBW prevalence of 30% in India
in comparison to 21% in the NDBC, these estimates increase to 37% at
6 months and between 13% and 22% from 1 to 5 years of age (Fig.
2). It is therefore imperative to intervene before birth to
address linear growth retardation in children.
Fig. 2 Proportion of
undernutrition in children below five years of age
attributable to being born low birth weight: data from the
New Delhi Birth Cohort (NDBC). A similar projection has
been done for stunting assuming a national low birth weight
(LBW) prevalence of 30%.
Interventions Before Conception and Birth
On the basis of current evidence , it would be
pertinent to briefly examine the appropriateness of the ongoing
major national initiatives for increasing birth size, and explore
the need for incorporating any modifications or adopting novel
Early marriage and child-birth are important risk
factors for delivering a LBW newborn. NFHS3 data indicates that
infants born to mothers married before the age of 18 years are at
1.22 higher risk of stunting  and child birth before 20 years age
increases the risk of delivering a LBW newborn (1.5 times) and
stunting . Longitudinal unpublished data from NDBC documented
that early child birth resulted in lower birth weight and length,
and these deficits persisted till 6 months, 2 years, and 11 years of
age and even into adulthood. This observation supports the
possibility of an inter-generational handicap  for developing
stunting. Indian law prohibits child marriage and some states also
offer additional socio-economic incentives to delay early marriage
and child birth. However, NFHS-3 data  indicates that 73% of
births still occur to mothers married before age 18 years. The
median age at first delivery is 19.9 years while 22% of all
child-births occur before age 20 years It is evident that urgent
efforts are required to provide appropriate socio-cultural
interventions to effectively delay early marriage and child-birth,
which could prove to be a sustainable remedy.
Provision of adequate antenatal care, including
detection and treatment of illnesses, improves the birth size .
However, in the NFHS-3 survey, one-fifth pregnant women did not
receive any antenatal care while one out of four women had only 1 or
2 antenatal care visits during pregnancy . In this context, the
recently introduced Janani Suraksha Yojana (JSY), a conditional cash
transfer programme to increase births in health facilities, is a
welcome initiative. It is hoped that increased institutionalization
of births will improve the quantity and quality of routine antenatal
care. A recent evaluation  documented that implementation of JSY
in 2007-08 was highly variable by State - from less than 5% to 44%
of women giving birth receiving cash payments. The poorest and least
educated women did not always have the highest chance of receiving
JSY payments. However, JSY had a significant effect on increasing
antenatal care and in-facility births. The findings of this
assessment are encouraging but do not provide any direct evidence of
effects on birth size. The data emphasizes the need for improving
targeting of the poorest women and quality of obstetric care in
health facilities .
Evidence is convincing that maternal iron
supplementation improves birth weight . Iron-folic acid
supplementation of pregnant women is being practiced as a national
policy for several decades. However, the NFHS-3 data indicates that
65% pregnant women received (or bought) iron-folic acid supplements
for their most recent birth, and only 23% took the supplements for
at least 90 days, as recommended . As multiple micronutrient
deficiencies are common in developing countries, multiple
micronutrient supplements are now being advocated in pregnant women
to improve maternal and fetal outcomes. In a recent pooled analysis
of 12 randomized controlled trials from developing countries ,
compared with control supplementation (mainly with iron-folic acid),
multiple micronutrient supplementation was associated with a 22
grams increase in birth weight and 11% reduction in risk of LBW.
However, there was an increased risk of excessively large babies
prone to complications (13%), early neonatal mortality (23%) and
perinatal mortality (11%) . The current data are thus
unconvincing for replacing supplementation of antenatal iron-folic
acid with multiple micronutrients. It would therefore be prudent to
focus on increasing the coverage of iron-folic acid supplementation
rather than introducing multiple micronutrient supplements, which
would also entail novel logistic and financial issues.
Food supplementation has been often advocated as
an attractive social intervention for improving undernutrition. A
2010 update of Cochrane review on this subject  documented the
following findings. In 5 trials (1135 women), nutritional advice to
increase energy and protein intakes was successful in achieving
those goals, but no consistent benefit was observed on pregnancy
outcomes. In 13 trials (4665 women), balanced energy/protein
supplementation was associated with modest increases in birth size
(weight: 37.6 g, length: 0.1 cm) and a substantial reduction in risk
of small-for-gestational-age (SGA) birth (32%). However, these
effects did not appear greater in undernourished women. In 2 trials
(529 women), high-protein supplementation was associated with a
non-significant reduction in mean birth weight and a significantly
increased risk of SGA birth. These data, mostly from developed
country settings, suggest that food supplementation in all pregnant
women is unlikely to reduce linear growth retardation. However,
there may be a case to experiment with pilot programs of targeted
food supplementation to pregnant women in extremely deprived
settings through the Integrated Child Development Services or
In summary, the ongoing interventions outlined
above have proven benefit and no novel "magical" options appear on
the horizon. It would therefore be pragmatic to primarily
concentrate on improving the sub-optimal coverage of the existing
programs and ensure equitable access for the poorer and unreached
segments of society.
Narrow Window of Opportunity in Early Life
In conformity with global observational evidence,
in the cross-sectional NFHS-3  and the longitudinal NDBC data
too, the prevalence of stunting increased sharply between 6 and 23
months of age to nearly plateau thereafter (Fig. 3).
A recent pooled longitudinal analysis , from prospective cohorts
in five transitioning societies including NDBC in India, reaffirms
the narrow window of opportunity in early life. Linear growth
failure prior to age 12 months was strongly associated with shorter
adult stature while linear growth in the periods 1224 months and 24
months to mid-childhood were less so. These data emphasize the
importance of initiating interventions within the first two years of
life, and preferably within the first year of life. Unfortunately,
the primary focus and coverage of most interventions to improve
undernutrition is beyond the first two or five years of age (for
example, the Integrated Child Development Services and Mid-Day Meal
Fig. 3 Prevalence of stunting in
relation to age in the New Delhi Birth Cohort (NDBC)
longitudinal study and the cross sectional National Family
Health Survey (NFHS3) (3).
In carefully conducted systematic reviews,
several apparently "promising" interventions for improving growth
have proved ineffective in increasing length in children in
developing countries, particularly in the first two years of life.
These include community-based supplementary feeding , growth
monitoring , routine deworming , and individual
micronutrient supplementation including iron, vitamin A and zinc
[17,18]. Multiple micronutrient supplementation may increase linear
growth , but the benefits are small (0.09 standard deviations)
and need further substantiation in infants in our setting. This
option may not be viable because of trivial expected benefit, and
logistics and cost considerations of introducing a policy of daily
supplementation; however, increasing the micronutrient content of
complementary foods (including, through fortification) deserves
Some of the ongoing initiatives in child health
do have the potential to improve linear growth. These include
educational interventions to promote appropriate complementary
feeding practices [19,20]; treatment of infections, particularly
diarrhea; and prevention of infections through breast feeding,
immunization, and water supply, sanitation and hygiene interventions
. Observational data suggests that infections have a substantial
effect on linear growth ; intervention trials to explore this
hypothesis would be unethical. The coverage of most of these
interventions is sub-optimal. Further, the responsiveness of length
to these interventions in isolation is probably quite limited (0.1
to 0.2 standard deviations), which will not translate into sizeable
reductions in stunting in the short term.
In summary, individual interventions received in
isolation during the first two years of life have not demonstrated a
substantial impact on linear growth in the short-term. Maximizing
coverage of under twos with the full package of interventions
(breast feeding; immunization; appropriate complementary feeding;
treatment of infections, especially diarrhea; safe water supply; and
sanitation) may be pivotal for improving linear growth.
Competing interests: A substantially abridged
version of this manuscript has been published earlier in a
non-indexed limited circulation periodical published by the World
Bank and Public Health Foundation of India (India Health Beat
Early childhood stunting predicts poor
human capital. Stunting should be used as a primary
indicator of childhood undernutrition.
The current prevalence of stunting
(urban: 39.6% and rural: 50.7%) is disconcerting but there
has been a relatively faster decline recently, which needs
to be accelerated.
It is imperative to intervene before
birth to address stunting. Pertinent ongoing interventions
(delaying early child birth, adequate antenatal care and
maternal iron-folate supplementation) are beneficial but
have sub-optimal coverage.
There is only a narrow window of
opportunity in early life the first two years. Maximizing
coverage of under twos with the full package of
interventions (breast feeding; immunization; appropriate
complementary feeding; treatment of infections, especially
diarrhea; safe water supply; and sanitation) may be pivotal
for improving linear growth.
Policy should primarily concentrate on
improving the sub-optimal coverage of pertinent ongoing
interventions and ensure equitable access for the poorer and
unreached segments of society.
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