The end of the silver bullet: A holistic approach to stunting research

The end of the silver bullet: A holistic approach to stunting research

Stunting a significant public health problem worldwide, affects over 144 million children under five[1]. In 2015,  WHO’s World Health Assembly set up the ambitious target of reducing the number of stunted children by 40% by 2025. Sustainable Development Goals later adopted the target to end all forms of malnutrition by 2030. Against the backdrop of the COVID-19 pandemic, it becomes increasingly unlikely that the 2025 goal will be reached. The most recent WHO report indicates that numbers are rising again[2].

Over the past three decades, there has been a one-sided focus on searching for the ‘silver bullet’ or the specific driver to solve stunting, the only essential element that, if addressed, could explain the insoluble problem. This has weakened praxis. Although some encouraging results have been achieved, this approach has not succeeded. It has also ignored the need to merge different disciplinary advances.

Action Against Stunting Hub

The UKRI GCRF Action Against Stunting Hub[3] is a programme that aims to challenge and redefine the existing paradigm of child stunting research. The Hub believes that we need to rethink stunting: child undernutrition is a mosaic where different individual elements play a role in creating the picture. We need a holistic, pan-disciplinary understanding of the problem to end stunting globally.

For example, we must consider that stunted children often have an immature gut microbiome, which enhances the likelihood of catching infectious agents, ranging from viruses and bacteria to protozoa and helminths. Food-borne toxins also have an impact on stunting. On the other hand, we need to research the elements that we believe can prevent stunting, including behavioural elements, dietary choices such as feeding animal source foods (ASF), feeding practices and improvements to water, sanitation and hygiene (WASH).

Health does not operate in a silo

Suppose we want to stop considering undernutrition as ‘siloed’ and non-relational (Perkins et al., 2017). In that case, we need to grasp the mosaic’s shape and structure and the components’ synergies. We shall think:

• What is the cascade of factors driving child stunting?
• What are the synergies and inter-relationships between drivers?
• What are the critical points along this cascade where healthy linear growth diverges to slow or no growth?

To answer the questions, the Hub has developed a new approach to shift the focus from the single parts to the “whole child”. We call this the Whole Child Approach.

The Whole Child Approach

The priority is understanding the biological, social, environmental and behavioural context of stunting and the synergies and inter-relationships between drivers. In other words, we aim to understand the ‘bio-developmental’ niche governing child growth, focusing on the interaction between the child’s biological, physical and social environment.

Once the primary paradigm is set, we can argue that child undernutrition results from four interlinked ‘environments’ radiating from the physical to the immediate/home environment to the educational and broader food system. However, these domains are linked by the social values that directly shape a child’s lived experience. In applying this paradigm, the path ahead is clear: we must radically change our perspective from the related parts to the Whole Child.

Working with communities and partners

To test and action the Whole Child Approach, The Hub works in over 50 communities across three countries: India, Indonesia and Senegal. We aim to decrease stunting by up to 10% in these communities. Throughout the project, we expect to impact the lives of up to 1 million children positively.

The Hub comprises 17 partner organisations in six countries coordinated by the London International Development Centre (LIDC) and the London School of Hygiene Tropical Medicine. Professor Claire Heffernan (LIDC) is the Principal Investigator (PI), and Professor Paul Haggarty (Rowett Institute of Nutrition and Health at the University of Aberdeen – UK) is the Deputy Principal Investigator.

Interdisciplinary research excellence

Working collectively doesn’t mean that individual elements of the Hub will not be innovative and groundbreaking. The Hub also aims to impact the academic community. The Whole Child Approach will change the ‘frame’ on which our historical understanding of stunting is based. The new conceptual understanding of stunting and the related typology will benefit the academic community differently.

First, new perspectives on stunting will open up innovation processes.

Second, we will be serving the wider stakeholder community by embedding the findings in the programmatic priorities of multilateral institutions, non-governmental organisations, and civil society.

The interdisciplinarity of the project ensures that the direct beneficiaries of this work intersect eight disciplines: biology, clinical medicine, psychology, sociology, veterinary medicine, nutrition, economics and anthropology.

On top of this, by leveraging networks across the UK and internationally, we will be able to engage with an even bigger academic community.

Broader implications for the scientific community

Finally, during the lifetime of The Hub, we will produce an interdisciplinary data set that will be a unique resource for researchers working on issues relating to child undernutrition. The data will underpin the development of a decision-support tool that will be freely available to the academic community and policymakers. In addition to generating solutions based on the core Hub hypotheses, this rich and extensive data set will make possible the second wave of discovery by allowing cross-disciplinary suggestions arising in one centre to be tested using the data from another.

Ultimately, all of the activities occurring across The Hub and all the data generated contribute to our ambitious overall goal: to fundamentally change the landscape of child stunting for millions of affected children globally.

Originally published in RECFON AWESOME Magazine