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

Published: 15th September 2020

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


Stunting is a significant public health problem worldwide. In 2019, over 144 million children under the age of five were stunted[1]. In 2015,  WHO’s World Health Assembly set up the ambitious target of reducing the number of stunted children by 40% by 2025. This target was later adopted by the Sustainable Development Goals that aim to end all forms of malnutrition by 2030. Against the backdrop of the current COVID-19 pandemic, it becomes more and more unlikely that the 2025 goal will be reached. The most recent WHO report indicates that numbers are on the rise 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 key element that, if addressed, could explain the insoluble problem. This has weakened praxis. Although there have been some encouraging results, this approach has not been fully successful. It has also ignored the need to merge different disciplinary advances.


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 under-nutrition is a mosaic, where different individual elements play a role in creating the picture. What we need to end stunting globally is a holistic, pan-disciplinary understanding of the problem. For example, we have to take into account that children who are stunted 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 from happening, including behavioural elements, dietary choices such as feeding animal source foods (ASF), feeding practices and improvements to water, sanitation and hygiene (WASH).


If we want to stop considering under-nutrition as ‘siloed’ and non-relational (Perkins et al., 2017), we need to grasp the shape and structure of the mosaic and the synergies between the components. 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 that aims to shift the focus from the single parts to the “whole child”. We call this the Whole Child Approach. The priority is to understand the biological, social, environmental and behavioural context in which stunting occurs, 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 biological, physical and social environment of the child. Once the primary paradigm is set, we can now argue that child under-nutrition is an outcome of four inter-linked ‘environments’ radiating from the physical to the immediate/home environment, to the educational and broader food system. These domains, however, are linked by the social values which 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.



However, working collectively doesn’t mean that individual elements of the Hub will not be innovative and ground breaking. For example, the Epigenetics workstream will address the biology of stunting, looking beyond the simple height-for-age definition to develop better methods of defining and identifying stunting type based on epigenetic status. Here we will define epigenetic markers that can be used to identify the children and pregnancies that have a high risk of stunting. A full understanding of the epigenetic changes will along with the outputs of the other work streams, help the study to predict the ability of stunted children to respond to specific interventions based on the ‘type’ of stunting involved.


The Hub will use two epigenetic methodologies: 1) a targeted hypothesis-driven analysis of selected regions of the genome using Next Generation Bisulphite Amplicon Sequencing (BSAS) and 2) a genome-wide analysis of epigenetic states using the Illumina Infinium Methylation EPIC 850k Bead Chip (EPIC array). The EPIC array measures the epigenetic state of a large number of genes. This capability makes the EPIC method useful for drawing interdisciplinary comparisons with multiple workstreams across the Hub. However, it is limited in genomic coverage, and it does not include key regions critical to stunting. The ability of the BSAS method to target specific regions within the genome allows The Hub to focus on specific epigenetic markers of birth anthropometry, adult stature, metabolic state, and cognitive ability. All samples will be analysed using BSAS in targeted regions of the genome. The EPIC array will be used for selected samples from within the core cohort study.


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 positively impact the lives of up to 1 million children. The Hub consists of 17 partner organisations in six countries coordinated by London International Development Centre (LIDC) and 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.


For each country, the Hub has identified a leading institution: in Indonesia, SEAMEO RECFON is the chosen partner. The Indonesian Hub comprises of interdisciplinary researchers led by Dr Umi Fahmida as Country Lead. The team consists of senior and early career researchers in diverse disciplines, i.e. nutrition, medicine, biomedicine, food safety, agriculture, psychology and education. The RECFON’s team is also supported by SEAMEO CECCEP for the education component. As our PI Professor Claire Heffernan noted: ‘To change the frame around child stunting requires that our Hub is a true collaboration which leverages our collective expertise. RECFON has been a brilliant partner and the whole Hub has gained by Umi and her teams’ extensive experience in best practice around data collection and management.


The Hub also aims to impact the academic community. The Whole Child Approach will change the ‘frame’ by which our historical understanding of stunting is based. The new conceptual understanding of stunting and the related typology will benefit the academic community in different ways. First, new perspectives on stunting will open up to innovation processes. Second, by embedding the findings in the programmatic priorities of multilateral institutions, non-governmental organisations and civil society, we will be serving the wider stakeholder community. 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.


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 under-nutrition. 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 taking place across The Hub and all the data generated are contributing to our ambitious overall goal: to fundamentally change the landscape of child stunting for millions of affected children globally.


Article originally published on RECFON AWESOME Magazine