Tag Archives: hygiene

What is Stunting?

In today’s post, I wanted to revisit stunting. Over and over again, stunting emerges as one of the most critical hurdles to achieving full economic and social development in a global context. The condition affects over 162 million children under the age of 5 (Stunting Policy Brief, WHO and 1,000 Days). There is a significant amount of research into the causes and effects of this state of malnutrition, and a growing body of evidence-based interventions to combat it. So what is stunting?


Technically, the condition of stunting is defined as “a height that is more than two standard deviations below the World Health Organization (WHO) child growth standards median.” (Stunting Policy Brief, WHO and 1,000 Days) As any statistician might tell you, that’s quite extreme. It is important to recognize that so many hundreds of millions of children persist in this condition despite the extremity of its definition. However, the real tragedy of stunting is the irreversible long-term damage it inflicts including “diminished cognitive and physical development, reduced productive capacity and poor health, and an increased risk of degenerative diseases such as diabetes.” (Stunting Policy Brief, WHO and 1,000 Days)

Research has demonstrated the correlation between stunting before the age of 2 with diminished cognitive and educational ability later in life. Stunting is associated with fewer years of school completed, and significantly lower academic performances compared to non-stunted peers. In addition, stunting in women is associated with lower age at first childbirth and a higher number of total pregnancies. Stunting has been estimated by economists to reduce a country’s GDP by up to 3%. Furthermore it is associated with lower household income and a greater chance of living in poverty. One of the most shocking data points I came across is that stunted children earn an “estimated 20% less as adults compared to non-stunted individuals”. (Investing in Nutrition, World Bank)

Think about that for a minute – in India, the average GDP per capita in 2015 was roughly USD 1,581 (World Bank). If you were unfortunate enough to be stunted as a child, something that you had no control over, you can expect to earn on average USD 316 less every year, a truly significant amount of money at the margins. If you take into consideration the mean individual income of only the bottom 50% of income earners, you can imagine how disenfranchising that 20% diminishment in income really is.

One of the most important developments in the fight against malnutrition, including stunting, occurred in 2012 when the 194 member states of the World Health Assembly (WHA) endorsed six global targets to improve nutrition by 2025. (Interestingly enough, the world is currently not on track to meet even a single one of these targets…more on that later). The nutrition target for stunting is a 40% reduction in the number of children under 5 who are stunted. This translates roughly to at least 65 million fewer children who are stunted in 2025 and an estimated 2.8 million child lives saved. (Investing in Nutrition, World Bank)

As part of the effort to successfully reach the target goal for stunting, the WHO recommends the following actions to drive progress:

  1. Improve the identification, measurement and understanding of stunting and scale up coverage of stunting-prevention activities.
  2. Enact policies and/or strengthen interventions to improve maternal nutrition and health, beginning with adolescent girls.
  3. Implement interventions for improved exclusive breastfeeding and complementary feeding practices.
  4. Strengthen community-based interventions including improved water, sanitation and hygiene (WASH), to protect children from diarrheal diseases and malaria, intestinal worms and environmental causes of subclinical infection.


To learn more about stunting, please visit and donate generously to 1,000 Days.


Malnutrition and the First 1,000 Days

Let’s start with the big picture – every year, nearly 7.6 million children will die before they turn five years old (UNICEF). That’s 7,600,000 children, just shy of the total population of a country the size of Israel, or Honduras, or the entire combined populations of Kansas, Nevada, and New Mexico. Imagine the scale of this problem. Imagine if EVERY year, these countries or states saw their entire population wiped out – each and every year, over and over again. Except it’s not an entire population, but exclusively the most vulnerable members of human society – poor children who aren’t even five years old yet.

This is, unfortunately, the world we find ourselves currently living in hard as it may seem. It is worth pausing here to note that the under-5 mortality (a measure of the probability of dying between birth and five years of age per 1,000 live births) is at its lowest ever, historically. We have a lot to be proud of in terms of how far we have come in the past half century below as the graph below indicates:


According to Save the Children’s State of the World’s Mothers 2012 (and can be found here), malnutrition is an underlying cause of death for nearly 2.6 million children each year. Malnutrition is a significant problem, not just because of the mortality rates it induces in young children and mothers but also because of the morbidity and suffering it causes to those who survive it. Every year, 20 million babies are born into this world with low birth weight, some because they are born too prematurely and others because of inadequate growth and nutrients while developing in the womb.

There are also economic factors impacted by malnutrition – adults who were malnourished as children earn an estimated 20% less on average over the course of their lives than those who weren’t. Imagine how quickly that adds up, and how cyclical that poverty trap becomes. Malnutrition can also cost developing countries an estimated 2-3% of their GDP every year, a significant amount for any country let alone ones grappling with severe poverty.

As might be reasonably inferred, malnutrition disproportionately affects the poor and disenfranchised. Across South Asia, “the poorest children are almost three times as likely to be underweight as their wealthiest peers.” That number becomes a lot more alarming in Latin America, where in countries like Honduras the poorest children are eight times as likely, or El Salvador and Peru where they are 13 and 16 times as likely to be underweight.

The report compares what a typical girl can expect between the highest and lowest ranked countries on their Mother’s Index list, which compares the well-being of mothers in 165 countries. The difference is stark:

“A typical Norwegian girl can expect to receive 18 years of formal education and to live to be 83 years old. Eighty-two percent of women are using some modern method of contraception, and only 1 in 175 is likely to lose a child before his or her fifth birthday. At the opposite end of the spectrum, in Niger, a typical girl receives only 4 years of education and lives to be only 56. Only 5 percent of women are using modern contraception, and 1 child in 7 dies before his or her fifth birthday. At this rate, every mother in Niger is likely to suffer the loss of a child.”

That level of suffering is beyond difficult to read – it is almost impossible to comprehend. The report goes on to state, point blank, that “Persistent and worsening malnutrition in developing countries is perhaps the single biggest obstacle to achieving many of the Millennial Development Goals (MDGs).”

Fortunately, Save the Children and other organizations have begun focusing on a set of interventions that could significantly improve the current malnutrition crisis. These are focused around a concept known as the First 1,000 Days, which is the period between conception and the start of pregnancy to a child’s second birthday. Research shows that adequate and sufficient nutrition in this window of time “can have a profound impact on a child’s ability to grow, learn, and rise out of poverty.” The report goes on to lay out the foundation for why we should focus on the First 1,000 Days:

“Mothers and babies need good nutrition to lay the foundation for the child’s future cognitive, motor and social skills, school success and productivity. Children with restricted brain development in early life are at risk for later neurological problems, poor school achievement, early school dropout, low-skilled employment and poor care of their own children, thus contributing to the intergenerational transmission of poverty.”

There are six key solutions with immense potential to save the lives of our children in their nascence, and well beyond. It is the intention of the author and this blog to dive deeper into the weeds and study different programs around the world to assess where successful programs are running, how they are able to do so, and the impact that has generated. For now, let us highlight in brief the six solutions:

  1. Provide iron folate supplements to cure iron deficiency anemia, the most common nutritional disorder in the world. Anemia is a “significant cause” of maternal mortality and can cause premature birth and low birthweight. It is estimated that 25% of the world’s population, or 1.6 billion people, are anemic – the vast majority of whom are women.
  2. Improve knowledge and practice of exclusive breastfeeding in the first 6 months provides comprehensive nutrition and immunity development for newborns against common childhood illness. Breastfed children are 6 times more likely to survive the early months of their life than non-breastfed children
  3. Improve complementary feeding knowledge and practice, adding other foods and liquids to a child’s diet between the ages of 6-23 months of age.
  4. Provide Vitamin A supplements to bolster the human body’s ability to counteract the debilitating consequences of diarrhea. Vitamin A deficiency affects nearly a third of all preschool aged children, which is a major contributing factor to diarrhea and measles, and can cause irreversible corneal damage.
  5. Provide Zinc supplements along with oral rehydration solution to help children with diarrhea recover more quickly and protect them and their communities from recurrences.
  6. Improve knowledge and practice of water, sanitation, and hygiene (WASH) best practices to prevent diarrheal diseases at the source, the cause of 1.3 million children deaths each year.

What is most impressive about all of these interventions is their relatively low cost (cents to a few dollars per individual), their track record of successful scaling, and their long-term payback on investment. For these reasons alone, we should look more closely at programs, organizations, and governments around the world that are implementing successful interventions based on these solutions, learn from their successes and mistakes, and replicate or scale up with additional resources.