Understanding Stunting: not all in the height 

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Our genetics play a significant role in how long a height we attain. But can we always ignore short stature as mere genetics? What if there is some sinister intergenerational play going on? The World Health Organization (WHO) defines shortness as a description of low height for the age
that could be normal or abnormal. A baby and mother classify as short if their length and height are less than 45 cm and 145 cm, respectively (WHO, 2023; Subramanian, 2009).

But why should we care about the underlying phenomenon? Let us dive in and discover this complex phenomenon’s significance and etiologies.

Does short height always indicate stunting?

Short height in one or both parents could be genetic, a physical feature passed down to generations. Hence mere short size in a child should not be narrowed down to stunting (Banudi et al., 2020). The child becomes stunted when short height results from insufficient nutrition from the pregnant mother or during infancy (Susyani et al., 2022).

Understanding stunting as a cause and result

Short stature and stunting have been used interchangeably, even in recent literature. Their delineation is essential for assessing short length as a marker of childhood stunting prevalence. Some studies identify stunting as short stature for an age solely in terms of height, while others claim that stunting is a growth deficiency that is a dynamic process. It is not just a point/period measure of slow length/height gain to age.

All stunted children may face retarded growth linearly; however, all those with linear growth retardation alone cannot be labelled as stunted.

Stunting is growth retardation that is not limited to short height but also includes social and environmental inadequacies that cannot be reversed by providing adequate nutrition alone (Leroy et al., 2019).

Outcomes of stunting: more than height 

Being short for age could mean more than just height. Research in past indicated stunted children, besides low height, also tend to have lower cognition, motor, and adaptive behavioural abilities than their non-stunted counterparts. It means undernutrition negatively affects mental and behavioural abilities even before short height sets in. Stunted children also face developmental challenges and are more likely to be overweight or obese when they grow up, leading to many health problems like non-communicable diseases (Guh et al.).

How to measure stunting: a necessary challenge

A 2006 analysis of the Brazilian Demographic Health Survey (DHS) revealed that stunting is an intergenerational malnutrition series, wherein “the stunted child becomes a stunted mother who would again deliver a stunted child”. Nevertheless, the authors concluded that this theory is subject to further research.

A systematic review by Vaivada et al. in 2020 assessing global determinants and drivers of decline in stunting recommended future mixed-method studies for consolidating measures of reducing stunting in children, especially in highly prevalent areas.

For instance, a thematic analysis of participants (mothers and caregivers) in Africa, with high rates of stunting prevalence, revealed that short stature could not be taken as an absolute growth indicator due to cultural nomenclature differences between natural/average short stature and stunting.

A systematic review by Alfianti in 2023 identified that stunting’s burden and distribution is a byproduct of dyadic communication and practices within families, not just communities. Recent studies highlight a gap in the need to evaluate linear height assessment for childhood stunting.

Evaluating stunting

As per the key findings of the ‘UNICEF / WHO / World Bank Group Joint Child Malnutrition Estimate’ (2019), the global prevalence of stunting is 21.9%, wherein at least 1 in 4 children under five years are stunted.

A study among Indonesian children with determining factors of stunting, such as those aged 0-23 months in whom the birth weight was at least 3000 gm, length was at least 48 cm, and maternal height was at least 150 cm, observed higher median survival rates towards not stunting.

The parents/caregivers in this study felt that short height was primarily a non-modifiable hereditary trait and not necessarily pointed towards disease. Instead, they believed modifiable factors such as weight changes could indicate nutritional deficiencies and growth problems. Using the term stunted growth was better than mere stunted regarding height alone.  

A critical review of evidence by Leroy et al. points out that stunting results from environmental insufficiency but is not limited to cognitive impairment and heightened risk of infections. The scientific community has been advised to think beyond the causal association of stunting and its outcomes.

The results-based financing (RBF) Indicator compendium for Reproductive, Maternal, New-born, Child, and Adolescent Health (RMNCAH) initiatives advise taking stunting only as a long-term evaluation tool but not for short-term monitoring of the past 6-12 months.

Role of parental height

Studies by Kelly et al. and Wu et al. revealed that the father’s height influenced stunting in a child, with the mother’s height having more impact on the height of a girl and the father’s height having more effect on the height of a boy child. However, the influence of the mother’s height on the child is, in general, more than paternal height.

A mother’s height determines if her child will experience stunted growth. However, it cannot be used for policymaking because it cannot be changed. To account for other factors, such as poor nutrition and infection, maternal height standardised prevalence (SPS) should be used instead of the crude prevalence of stunting (CPS) to estimate stunting. This is a better option when looking at stunting in a general sense, without separating by gender.

Conclusion

In conclusion, stunting is a severe phenomenon beyond physical height. It can have long-term effects on a child’s cognitive and behavioural abilities and even increase their risk for obesity and non-communicable diseases later in life. While genetics play a role in determining height, stunting is often caused by undernutrition during pregnancy and infancy, highlighting the importance of proper nutrition for both mother and child.

Measuring stunting can be challenging, as cultural differences and misconceptions about short stature can lead to misinterpretation of data. However, recent studies have emphasised the need to reconsider how stunting assessment is defined and done, considering both height and social and environmental factors contributing to stunted growth.

As a society, we must take action to address stunting and its underlying causes. It includes advocating for better nutrition during pregnancy and early childhood and promoting education and awareness about the long-term effects of stunting. By working together, we can help ensure that all children have the opportunity to reach their full potential, both physically and mentally.

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