Risk Factors for Childhood Stunting in 137 Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels

Abstract

Background

Stunting affects one-third of children under 5 y old in developing countries, and 14% of childhood deaths are attributable to it. A large number of risk factors for stunting have been identified in epidemiological studies. However, the relative contribution of these risk factors to stunting has not been examined across countries. We estimated the number of stunting cases among children aged 24–35 mo (i.e., at the end of the 1,000 days’ period of vulnerability) that are attributable to 18 risk factors in 137 developing countries.

Methods and Findings

We classified risk factors into five clusters: maternal nutrition and infection, teenage motherhood and short birth intervals, fetal growth restriction (FGR) and preterm birth, child nutrition and infection, and environmental factors. We combined published estimates and individual-level data from population-based surveys to derive risk factor prevalence in each country in 2010 and identified the most recent meta-analysis or conducted de novo reviews to derive effect sizes. We estimated the prevalence of stunting and the number of stunting cases that were attributable to each risk factor and cluster of risk factors by country and region.

The leading risk worldwide was FGR, defined as being term and small for gestational age, and 10.8 million cases (95% CI 9.1 million–12.6 million) of stunting (out of 44.1 million) were attributable to it, followed by unimproved sanitation, with 7.2 million (95% CI 6.3 million–8.2 million), and diarrhea with 5.8 million (95% CI 2.4 million–9.2 million). FGR and preterm birth was the leading risk factor cluster in all regions. Environmental risks had the second largest estimated impact on stunting globally and in the South Asia, sub-Saharan Africa, and East Asia and Pacific regions, whereas child nutrition and infection was the second leading cluster of risk factors in other regions.

Although extensive, our analysis is limited to risk factors for which effect sizes and country-level exposure data were available. The global nature of the study required approximations (e.g., using exposures estimated among women of reproductive age as a proxy for maternal exposures, or estimating the impact of risk factors on stunting through a mediator rather than directly on stunting). Finally, as is standard in global risk factor analyses, we used the effect size of risk factors on stunting from meta-analyses of epidemiological studies and assumed that proportional effects were fairly similar across countries.

Conclusions

FGR and unimproved sanitation are the leading risk factors for stunting in developing countries. Reducing the burden of stunting requires a paradigm shift from interventions focusing solely on children and infants to those that reach mothers and families and improve their living environment and nutrition.

Abstract

Using risk factor and height data from population-based surveys, Goodarz Danaei estimate the greatest contributors to childhood stunting worldwide.

Author Summary

Why Was This Study Done?

• Even though child mortality is decreasing, children around the world are still suffering from delayed physical growth. In fact, 30% of children in developing countries are stunted (i.e., have heights more than two standard deviations below the global standard median height for their age).

• The first 1,000 days of life (up until a child turns two) are most important because development during this period impacts a child for the rest of his or her life. Stunting during this period is related to poor outcomes in health, cognitive development, and educational and economic attainment later in life.

• In order to reduce stunting, it is important to understand its determinants and their relative effect, to help priority-setting in designing policies to improve childhood growth.

What Did the Researchers Do and Find?

• We identified 18 key risk factors for stunting and grouped them into five clusters (maternal nutrition and infection, teenage motherhood and short birth intervals, fetal growth restriction and preterm birth, child nutrition and infection, and environmental factors).

• We used data on the prevalence of each risk factor in each country and its effect on stunting. We then estimated the prevalence and number of cases of stunting among children aged 24 to 35 months in 2010 that were attributable to each of these risk factors, and to each cluster of risk factors combined, in 137 developing countries.

• We found that the leading risk for stunting worldwide was being “term, and small for gestational age” (that is, being born at or after 37 weeks of pregnancy, but being too small), to which 10.8 million cases of stunting among two-year-olds were attributable (out of 44.1 million). This was followed by poor sanitation (7.2 million cases) and diarrhea (5.8 million cases).

• When we grouped the risks together, fetal growth restriction and preterm birth was the leading risk factor cluster in all regions, but there were differences in the ranking of other risk factor clusters across regions. For example, environmental risk factors (i.e., poor water quality, poor sanitary conditions, and use of solid fuels) had the second largest impact on stunting globally and in South Asia, sub-Saharan Africa, and East Asia and Pacific, whereas risk factors related to child nutrition and infection were the second leading risk factors in other regions.

What Do These Findings Mean?

• Efforts to further reduce stunting should be focused on fetal growth restriction and poor sanitation, and this will require refocusing prevention programs on interventions that reach mothers and families and improve their living environment and nutrition.