Stop stunting-A misguided campaign by well-meaning nutritionists.

OBJECTIVE: "Stop stunting" is the central focus of the national Indonesian campaign to improve child health. We provide an autoethnographic statement on the currently practiced strategy that commits 23 ministries and an estimated $3.9 billion per year to coordinating nutrition interventions that are supposed to address the underlying causes of stunting. METHODS: We visited six community health posts (posyandus) in West Timor and in Java and participated in routine child health examinations. We documented our impressions and discussed them with Indonesian colleagues, health officials, and local physicians. RESULTS: Routine health checks for children include anthropometry (height, weight, head, and mid-upper arm circumference), immunizations, and documentation in the children's health records. The examinations do not include a physical examination, vision and hearing tests of the child, health questionnaires, or information on nutrition. No specific information or recommendations are given to the mothers. CONCLUSION: Stunting is highly prevalent in Indonesia and "Stop-stunting" campaigns have become a national issue. Yet, their impact is disillusioning. Stunting is associated with a way of life that differs from that in developed Western countries today and was prevalent in feudal and other nondemocratic societies. We do not want to throw away policies that try to improve growth in children, but instead of spending money for dubious interventions as we have encountered in Indonesia, we rather suggest spending thoughts on the political and emotional causes of poor growth in otherwise healthy Indonesian children.

The socio-endocrine regulation of human growth.

AIM: Growth is a multifarious phenomenon that has been studied by nutritionists, economists, paediatric endocrinologists; archaeologists, child psychologists and other experts. Yet, a unifying theory of understanding growth regulation is still lacking. METHOD: Critical review of the literature. RESULTS: We summarise evidence linking social competition and its effect on hierarchies in social structures, with the neuronal networks of the ventromedial hypothalamus and body size. The endocrine signalling system regulating growth hormone, Insulin-like-Growth-Factor1 and skeletal growth, is well conserved in the evolution of vertebrata for some 400 million years. The link between size and status permits adaptive plasticity, competitive growth and strategic growth adjustments also in humans. Humans perceive size as a signal of dominance with tallness being favoured and particularly prevalent in the upper social classes. CONCLUSION: Westernised societies are competitive. People are tall, and "open to change." Social values include striving for status and prestige implying socio-economic domination. We consider the transition of political and social values following revolutions and civil wars, as key elements that interact with the evolutionarily conserved neuroendocrine competence for adaptive developmental plasticity, overstimulate the hypothalamic growth regulation and finally lead to the recent historic increases in average height.

Bergmann's rule is a "just-so" story of human body size.

Carl Bergmann was an astute naturalist and physiologist. His ideas about animal size and shape were important advances in the pre-Darwinian nineteenth century. Bergmann's rule claims that that in cold climates, large body mass increases the ratio of volume-to-surface area and provides for maximum metabolic heat retention in mammals and birds. Conversely, in warmer temperatures, smaller body mass increases surface area relative to volume and allows for greater heat loss. For humans, we now know that body size and shape are regulated more by social-economic-political-emotional (SEPE) factors as well as nutrition-infection interactions. Temperature has virtually no effect. Bergmann's rule is a "just-so" story and should be relegated to teaching and scholarship about the history of science. That "rule" is no longer acceptable science and has nothing to tell us about physiological anthropology.

Locally structured correlation (LSC) plots describe inhomogeneity in normally distributed correlated bivariate variables.

BACKGROUND: The association between bivariate variables may not necessarily be homogeneous throughout the whole range of the variables. We present a new technique to describe inhomogeneity in the association of bivariate variables. METHODS: We consider the correlation of two normally distributed random variables. The 45° diagonal through the origin of coordinates represents the line on which all points would lie if the two variables completely agreed. If the two variables do not completely agree, the points will scatter on both sides of the diagonal and form a cloud. In case of a high association between the variables, the band width of this cloud will be narrow, in case of a low association, the band width will be wide. The band width directly relates to the magnitude of the correlation coefficient. We then determine the Euclidean distances between the diagonal and each point of the bivariate correlation, and rotate the coordinate system clockwise by 45°. The standard deviation of all Euclidean distances, named "global standard deviation", reflects the band width of all points along the former diagonal. Calculating moving averages of the standard deviation along the former diagonal results in "locally structured standard deviations" and reflect patterns of "locally structured correlations (LSC)". LSC highlight inhomogeneity of bivariate correlations. We exemplify this technique by analyzing the association between body mass index (BMI) and hip circumference (HC) in 6313 healthy East German adults aged 18 to 70 years. RESULTS: The correlation between BMI and HC in healthy adults is not homogeneous. LSC is able to identify regions where the predictive power of the bivariate correlation between BMI and HC increases or decreases, and highlights in our example that slim people have a higher association between BMI and HC than obese people. CONCLUSION: Locally structured correlations (LSC) identify regions of higher or lower than average correlation between two normally distributed variables.

Metabolic-endocrine disruption due to preterm birth impacts growth, body composition, and neonatal outcome.

Despite optimized nutrition, preterm-born infants grow slowly and tend to over-accrete body fat. We hypothesize that the premature dissociation of the maternal-placental-fetal unit disrupts the maintenance of physiological endocrine function in the fetus, which has severe consequences for postnatal development. This review highlights the endocrine interactions of the maternal-placental-fetal unit and the early perinatal period in both preterm and term infants. We report on hormonal levels (including tissue, thyroid, adrenal, pancreatic, pituitary, and placental hormones) and nutritional supply and their impact on infant body composition. The data suggest that the premature dissociation of the maternal-placental-fetal unit leads to a clinical picture similar to panhypopituitarism. Further, we describe how the premature withdrawal of the maternal-placental unit, neonatal morbidities, and perinatal stress can cause differences in the levels of growth-promoting hormones, particularly insulin-like growth factors (IGF). In combination with the endocrine disruption that occurs following dissociation of the maternal-placental-fetal unit, the premature adaptation to the extrauterine environment leads to early and fast accretion of fat mass in an immature body. In addition, we report on interventional studies that have aimed to compensate for hormonal deficiencies in infants born preterm through IGF therapy, resulting in improved neonatal morbidity and growth. IMPACT: Preterm birth prematurely dissociates the maternal-placental-fetal unit and disrupts the metabolic-endocrine maintenance of the immature fetus with serious consequences for growth, body composition, and neonatal outcomes. The preterm metabolic-endocrine disruption induces symptoms resembling anterior pituitary failure (panhypopituitarism) with low levels of IGF-1, excessive postnatal fat mass accretion, poor longitudinal growth, and failure to thrive. Appropriate gestational age-adapted nutrition alone seems insufficient for the achievement of optimal growth of preterm infants. Preliminary results from interventional studies show promising effects of early IGF-1 supplementation on postnatal development and neonatal outcomes.

Stunting is the natural condition of human height.

OBJECTIVES: Human body height differs within a wide range and has conventionally been associated with genetic, nutritional, and environmental conditions. In this study, we try to broaden this perspective and add the evolutionary aspect of height differences. SAMPLE AND METHOD: We revisited height from archeological data (10 000-1000 BC), and historical growth studies (1877-1913). We analyzed height, weight, and skinfold thickness of 1666 Indonesian schoolchildren from six representative rural and urban elementary schools in Bali and West Timor with a stunting prevalence of up to 50%. RESULTS: Stature in the Holocene prehistory of the Near East and Europe varied with maxima for women usually ranging below 160 cm, and maxima for men between 165 and 170 cm. Stature never rose above 170 cm. European and white US-American schoolchildren of the 19th and 20th century were generally short with average height ranging between -1.5 and -2.2 hSDS, yet in the absence of any evidence of chronic or recurrent undernutrition or frequent illness, poverty, or disadvantageous living conditions. The same is found in contemporary Indonesian schoolchildren. CONCLUSION: Stunting is frequently observed not only in the poor, but also in affluent and well-nourished social strata last 10 000 years. Only in very recent history, and only in a few democratic, modern societies, stature has increased beyond the long-lasting historic height average. Viewed from an evolutionary perspective, and considering adaptive plasticity of and community effects on growth, competitive growth and strategic growth adjustments, stunting appears to be the natural condition of human height.

Chain Reversion for Detecting Associations in Interacting Variables-St. Nicolas House Analysis.

(1) Background: We present a new statistical approach labeled as "St. Nicolas House Analysis" (SNHA) for detecting and visualizing extensive interactions among variables. (2) Method: We rank absolute bivariate correlation coefficients in descending order according to magnitude and create hierarchic "association chains" defined by sequences where reversing start and end point does not alter the ordering of elements. Association chains are used to characterize dependence structures of interacting variables by a graph. (3) Results: SNHA depicts association chains in highly, but also in weakly correlated data, and is robust towards spurious accidental associations. Overlapping association chains can be visualized as network graphs. Between independent variables significantly fewer associations are detected compared to standard correlation or linear model-based approaches. (4) Conclusion: We propose reversible association chains as a principle to detect dependencies among variables. The proposed method can be conceptualized as a non-parametric statistical method. It is especially suited for secondary data analysis as only aggregate information such as correlations matrices are required. The analysis provides an initial approach for clarifying potential associations that may be subject to subsequent hypothesis testing.

Stunting as a Synonym of Social Disadvantage and Poor Parental Education.

Socially, economically, politically and emotionally (SEPE) disadvantaged children are shorter than children from affluent background. In view of previous work on the lack of association between nutrition and child growth, we performed a study in urban schoolchildren. We measured 723 children (5.83 to 13.83 years); Kupang, Indonesia; three schools with different social background. We investigated anthropometric data, clinical signs of malnutrition, physical fitness, parental education, and household equipment. Subjective self-confidence was assessed by the MacArthur test. The prevalence of stunting was between 8.5% and 46.8%. Clinical signs of under- or malnutrition were absent even in the most underprivileged children. There was no delay in tooth eruption. Underprivileged children are physically fitter than the wealthy. The correlation between height and state of nutrition (BMI_SDS, skinfold_SDS, MUAC_SDS) ranged between r = 0.69 (p < 0.01) and r = 0.43 (p < 0.01) in private school children, and between r = 0.07 (ns) and r = 0.32 (p < 0.01) in the underprivileged children. Maternal education interacted with height in affluent (r = 0.20, p < 0.01) and in underprivileged children (r = 0.20, p < 0.01). The shortness of SEPE disadvantaged children was not associated with anthropometric and clinical signs of malnutrition, nor with delay in physical development. Stunting is a complex phenomenon and may be considered a synonym of social disadvantage and poor parental education.

Trends in growth and developmental tempo in boys aged 7 to 18 years between 1966 and 2012 in Poland.

OBJECTIVES: To assess trends in growth in different developmental periods and trends in developmental tempo in Polish boys between 1966 and 2012. METHODS: Data on 34 828 boys aged 7 to 18 years were collected during Polish Anthropological Surveys conducted in 1966, 1978, 1988, and 2012. Biological parameters, related to onset of adolescent growth spurt (OGS) and peak height velocity (PHV), were derived from a Preece-Baines 1 model (PB1). Childhood (height at 7 years of age), pre-adolescent (height at OGS) and adolescent growth (adult height minus height at OGS) were identified. RESULTS: Positive secular trend between 1966 and 2012 in adult height accounted for, on average, 1.5 cm/decade, with varying intensity between the Surveys. Decline in both age at OGS and APHV between 1966 and 2012 (1.5 and 1.4 years, respectively) indicated an acceleration in developmental tempo, on average, by 0.3 year/decade. Increases in the contribution to the trend in adult height gained during growth in particular developmental periods between 1966 and 2012 were as followed-childhood: 0.6%, pre-adolescent growth: -3.1%, adolescent growth: 3.1%. CONCLUSIONS: Secular trend in developmental tempo and growth among boys reflects changes in living conditions and socio-political aspirations in Poland during nearly 50 years. Acceleration in tempo is already visible at age at OGS, whereas the trend in adult height occurs largely during adolescence, pointing to different regulation of developmental tempo and growth in body height. This finding emphasizes the importance of extending public health intervention into children's growth up until adolescence.

Catch-up growth is a better indicator of undernutrition than thresholds for stunting.

OBJECTIVE: Stunting (height-for-age < -2 sd) is one of the forms of undernutrition and is frequent among children of low- and middle-income countries. But stunting perse is not a synonym of undernutrition. We investigated association between body height and indicators of energetic undernutrition at three critical thresholds for thinness used in public health: (1) BMI SDS < -2; (2) mid-upper arm circumference divided by height (MUAC (mm) × 10/height (cm) < 1·36) and (3) mean skinfold thickness (SF) < 7 mm and to question the reliability of thresholds as indicators of undernutrition. DESIGN: Cross-sectional study; breakpoint analysis. SETTING: Rural and urban regions of Indonesia and Guatemala - different socio-economic status (SES). PARTICIPANTS: 1716 Indonesian children (6·0-13·2 years) and 3838 Guatemalan children (4·0-18·9 years) with up to 50 % stunted children. RESULTS: When separating the regression of BMI, MUAC or SF, on height into distinguishable segments (breakpoint analysis), we failed to detect relevant associations between height, and BMI, MUAC or SF, even in the thinnest and shortest children. For BMI and SF, the breakpoint analysis either failed to reach statistical significance or distinguished at breakpoints above critical thresholds. For MUAC, the breakpoint analysis yielded negative associations between MUAC/h and height in thin individuals. Only in high SES Guatemalan children, SF and height appeared mildly associated with R2 = 0·017. CONCLUSIONS: Currently used lower thresholds of height-for-age (stunting) do not show relevant associations with anthropometric indicators of energetic undernutrition. We recommend using the catch-up growth spurt during early re-feeding instead as immediate and sensitive indicator of past undernourishment. We discuss the primacy of education and social-economic-political-emotional circumstances as responsible factors for stunting.

Traumatized women's infants are bigger than children of mothers without traumas.

Life history theory predicts that experiencing stress during the early period of life will result in accelerated growth and earlier maturation. Indeed, animal and some human studies documented a faster pace of growth in the offspring of stressed mothers. Recent advances in epigenetics suggest that the effects of early developmental stress might be passed across the generations. However, evidence for such intergenerational transmission is scarce, at least in humans. Here we report the results of the study investigating the association between childhood trauma in mothers and physical growth in their children during the first months of life. Anthropometric and psychological data were collected from 99 mothers and their exclusively breastfed children at the age of 5 months. The mothers completed the Early Life Stress Questionnaire to assess childhood trauma. The questionnaire includes questions about the most traumatic events that they had experienced before the age of 12 years. Infant growth was evaluated based on the anthropometric measurements of weight, length, and head circumference. Also, to control for the size of maternal investment, the composition of breast milk samples taken at the time of infant anthropometric measurements was investigated. The children of mothers with higher early life stress tended to have higher weight and bigger head circumference. The association between infant anthropometrics and early maternal stress was not affected by breast milk composition, suggesting that the effect of maternal stress on infant growth was independent of the size of maternal investment. Our results demonstrate that early maternal trauma may affect the pace of growth in the offspring and, in consequence, lead to a faster life history strategy. This effect might be explained via changes in offspring epigenetics.

Indonesian National Growth Reference Charts Better Reflect Height and Weight of Children in West Java, Indonesia, than WHO Child Growth Standards

Objective: The Indonesia Basic Health Research 2018 indicates that Indonesian children are still among the shortest in the world. When referred to World Health Organization Child Growth Standards (WHOCGS), the prevalence of stunting reaches up to 43% in several Indonesian districts. Indonesian National Growth Reference Charts (INGRC) were established in order to better distinguish between healthy short children and children with growth disorders. We analyzed height and weight measurements of healthy Indonesian children using INGRC and WHOCGS. Methods: 6972 boys and 5800 girls (n=12,772), aged 0-59 months old, from Bandung District were measured. Z-scores of length/height and body mass index were calculated based on INGRC and WHOCGS. Results: Under 5-year-old Indonesian children raised in Bandung are short and slim. Mean height z-scores of boys is -2.03 [standard deviation (SD) 1.31], mean height z-scores of girls is -2.03 (SD 1.31) when referred to WHOCGS indicating that over 50% of these children are stunted. Bandung children are heterogeneous, with substantial subpopulations of tall children. Depending on the growth reference used, between 9% and 15% of them are wasted. Wasted children are on average half a SD taller than their peers. Conclusion: WHOCGS seriously overestimates the true prevalence of undernutrition in Indonesian children. The present investigation fails to support evidence of undernutrition at a prevalence similar to the over 50% prevalence of stunting (WHOCGS) versus 13.3% (INGRC). We suggest refraining from using WHOCGS, and instead applying INGRC that closely mirror height and weight increments in Bandung children. INGRC appear superior for practical and clinical purposes, such as detecting growth and developmental disorders.

Association of anthropometric indices of nutritional status with growth in height among Limboo children of Sikkim, India.

Aim: Influence of nutrition in human growth failure, especially stunting, is a well-accepted idea. The present study assesses the influence of nutrition and non-nutritional factors on height growth in a short stature population. Material and methods: The present study was conducted among the children and adolescents of Sikkim, India. The sample size was 538 (boys and girls) of age 2-18 years. The anthropometric indices mid upper arm circumference-for-age Z-scores (MUACZ) and BMI-for-age Z-scores (BAZ) were utilised as proxy of nutritional status and growth was assessed using height-for-age Z-scores (HAZ). Associations were assessed using correlation, St. Nicolas house analysis (SNHA), principal component analysis (PCA) and regression. Results: Nutritional status of the participating children and adolescents as assessed by MUACZ and BAZ were largely normal. Despite variation in HAZ from -4 to +2 there was no influence of the nutritional indices on height. Further, there was clear lack of association between HAZ and socio-economic variables in the present study. Conclusion: The findings of the present study suggest nutrition is not the primary regulator of human growth. The possible influence of community effects on height is discussed.

No correlation between short term weight gain and lower leg length gain in healthy German children.

Background: Length-for-age is considered the indicator of choice in monitoring the long-term impact of chronic nutritional deficiency. Aim: We hypothesized that short term increments of body weight cross-correlate with increments of the lower leg length. Sample and methods: We re-analyzed the association between weekly measurements of weight and of lower leg length in 34 healthy German children, aged 2.9-15.9 years. The data are a subset of measurements originally published in 1988 (Hermanussen et al. 1988a). As the growth measurements were often not equally spaced in time due to interposed holidays and illness, the incremental rates for weight and lower leg length were smoothed using spline functions. Autocorrelation and cross-correlation functions were calculated for weight increments and lower leg length increments. Results: Height and weight increments are pulsatile. Autocorrelations indicated that mini growth spurts occur at irregular intervals. Lack of cross-correlations between weight and lower leg length indicated that mini spurts in weight gain do not coincide with mini spurts in length gain even when considering lag times of up to 10 weeks. Short term changes of weight gain and lower leg length gain in healthy children show no temporal association.

Plasticity of human growth - a systematic review on psychosocial factors influencing growth.

Background: This systematic review aimed at collecting, analyzing and summarizing scientific studies focusing on psychosocial factors that influence linear growth among humans. Methods: The online database "PubMed" was used in order to acquire suitable scientific studies. These studies were evaluated based on clearly defined criteria that determine whether a study was to be excluded or included in the literature review. In the end, a total sum of 36 studies remained, which were carefully analyzed and used to generate an overview of the association between psychosocial factors and linear growth. Results: In the 36 reviewed studies, different social and psychological factors, such as socioeconomic status, parental education or emotional deprivation were set in relation to physical growth among humans. The studies were listed and summarized, depending on the investigated psychosocial factor. A clear association between psychosocial factors and growth could be observed in most of the reviewed studies. Discussion: Based on the results of the reviewed studies it could be concluded that the regulation of linear growth is also subject to different psychosocial factors. The way in which the developing human and the specific social environment interact seemed to have a major impact on linear growth. Status-specific stress was discussed as one possible explanation for the regulating mechanism of human linear growth.