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.

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.

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.

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.

Social mobility of the father influences child growth: A three-generation study.

OBJECTIVES: The association between body height and social status is known. We were interested in the effect of intergeneration changes in social status on height. METHODS: Body height was measured in 2008 paternal grandfather-father-son and 1803 paternal grandfather-father-daughter triplets. The sample consisted of four child cohorts born in 1988, 1985, 1983, and 1980, and was measured annually from 6 to 11, 9 to 14, 11 to 16, and 14 to 18 years of age. Triplets were dichotomized according to grandfathers' occupation, into one "lower" and one "upper" grandparental class; and according to paternal education, into one "lower" and "upper" paternal class, resulting in four "family histories": two nonmobile (grandfathers and fathers stayed in the same social class), and two mobile histories (social class of fathers and grandfathers differed). RESULTS: "Upper" class fathers are taller than "lower" class fathers. This class effect on height persists into the third generation. Upward social mobility ("lower" class fathers receive secondary or university education) results in taller stature both in the fathers and in the children. The opposite applies for downward social mobility. "Upper" class fathers with only basic or vocational education lose the social advantage and remain shorter. So do their children. CONCLUSIONS: The class effect on height tends to persist into the next generation, but depends on education. Upward social mobility measured as a "better" education, results in taller stature, up to the third generation. The study highlights the importance of education as a major regulator of body height.

Height SDS Changes (ΔhSDS) in Healthy Children from Birth to 18 Years, with Correction Factors for Measurement Intervals of Less than One Year.

BACKGROUND: Growth is volatile and non-linear. Assessing the instantaneous speed of growth (momentary height velocity) depends on the precision and the number of measurements and the duration of the observation period. Measurements at short intervals reflect both the non-linearity of growth and the technical error of measurements (TEM). MATERIAL: We reanalyzed longitudinal measurements of body length at age 0, 3 months, 6 months, 9 months, 12 months, 18 months, and 24 months, from 1879 healthy infants (956 girls, 923 boys) from France (180 girls, 173 boys), Vilnius, Lithuania (507 girls, 507 boys), Lublin, Poland (67 girls, 56 boys), Zürich, Switzerland (94 girls, 102 boys) and Spain (108 girls, 95 boys); and longitudinal measurements of annual body height from age 2 to 18 years from 1528 healthy children and adolescents (774 girls, 754 boys) from France (41 girls, 47 boys), Vilnius, Lithuania (23 girls, 27 boys), Lublin, Poland (70 girls, 58 boys), Zürich, Switzerland (111 girls, 120 boys), Spain (94 girls, 74 boys), the Czech Republic (65 girls, 69 boys), Hungary (316 girls, 320 boys), and Berkeley, USA (54 girls, 39 boys). RESULTS: We calculated age - and sex-specific mean values for height and SD for height separately for each country. In addition, we defined the instantaneous speed of growth by the difference of two measures of hSDS Formulas References A1 , or in the case of multiple measurements, by the slope of the linear regression (ßhSDS(t)). Based on the longitudinal measurements of body length, we present reference values for annual growth velocity given in the form of SD of annual hSDS changes (ΔhSDS), from birth to maturity. Correction factors are added for validating measurements obtained at intervals of less than one year. The correction factors depend on number of measurements, and duration of the observation period.

Meeting Report: The Role of Beliefs and Perception on Body Size. Proceedings of the 26th Aschauer Soiree, Held at Aschauhof, Altenhof, Germany, May 26th, 2018.

Thirty-one scientists met at Aschauhof, Germany to discuss the role of beliefs and self-perception on body size. In view of apparent growth stimulatory effects of dominance within the social group that is observed in social mammals, they discussed various aspects of competitive growth strategies and growth adjustments. Presentations included new data from Indonesia, a cohort-based prospective study from Merida, Yucatan, and evidence from recent meta-analyses and patterns of growth in the socially deprived. The effects of stress experienced during pregnancy and adverse childhood events were discussed, as well as obesity in school children, with emphasis on problems when using z-scores in extremely obese children. Aspects were presented on body image in African-American women, and body perception and the disappointments of menopause in view of feelings of attractiveness in different populations. Secular trends in height were presented, including short views on so called 'racial types' vs bio-plasticity, and historic data on early-life nutritional status and later-life socioeconomic outcomes during the Dutch potato famine. New tools for describing body proportions in patients with variable degrees of phocomelia were presented along with electronic growth charts. Bio-statisticians discussed the influence of randomness, community and network structures, and presented novel tools and methods for analyzing social network data.

Meeting Report: Growth and Social Environment. Proceedings of the 25th Aschauer Soiree, held at Krobielowice, Poland, November 18th 2017.

Twenty-two scientists met at Krobielowice, Poland, to discuss the impact of the social environment, spatial proximity, migration, poverty, but also psychological factors such as body perception and satisfaction, and social stressors such as elite sports, and teenage pregnancies, on child and adolescent growth. The data analysis included linear mixed effects models with different random effects, Monte Carlo analyses, and network simulations. The work stressed the importance of the peer group, but also included historic material, some considerations about body proportions, and growth in chronic liver, and congenital heart disease.

The association between weight, height, and head circumference reconsidered.

BACKGROUND: Under normal nutritional and health conditions, body height, weight and head circumference are significantly related. We hypothesize that the apparent general association between weight, height, and head circumference of the growing child might be misleading. METHODS: We reanalyzed data of 7,444 boys and 7,375 girls measured in East-Germany between 1986 and 1990, aged from 0 to 7 y with measurements of body length/height, leg length, sitting height, biacromial shoulder breadth, thoracic breadth, thoracic depth, thoracic circumference, body weight, head volume, percentage of body fat, and hip skinfold vertical, using principal component analysis. RESULTS: Strong associations exist between skeletal growth, fat accumulation, and head volume increments. Yet in spite of this general proportionality, skeletal growth, fat acquisition, and head growth exhibit different patterns. Three components explain between almost 60% and more than 75% of cumulative variance between birth and age 7 y. Parameters of skeletal growth predominantly load on the first component and clearly separate from indicators of fat deposition. After age of 2 y, head volume loads on a separate third component in both sexes indicating independence of head growth. CONCLUSION: Under appropriate nutritional and health circumstances, nutritional status, body size, and head circumference are not related.

Global effects of income and income inequality on adult height and sexual dimorphism in height.

OBJECTIVES: Average adult height of a population is considered a biomarker of the quality of the health environment and economic conditions. The causal relationships between height and income inequality are not well understood. We analyze data from 169 countries for national average heights of men and women and national-level economic factors to test two hypotheses: (1) income inequality has a greater association with average adult height than does absolute income; and (2) neither income nor income inequality has an effect on sexual dimorphism in height. METHODS: Average height data come from the NCD-RisC health risk factor collaboration. Economic indicators are derived from the World Bank data archive and include gross domestic product (GDP), Gross National Income per capita adjusted for personal purchasing power (GNI_PPP), and income equality assessed by the Gini coefficient calculated by the Wagstaff method. RESULTS: Hypothesis 1 is supported. Greater income equality is most predictive of average height for both sexes. GNI_PPP explains a significant, but smaller, amount of the variation. National GDP has no association with height. Hypothesis 2 is rejected. With greater average adult height there is greater sexual dimorphism. CONCLUSIONS: Findings support a growing literature on the pernicious effects of inequality on growth in height and, by extension, on health. Gradients in height reflect gradients in social disadvantage. Inequality should be considered a pollutant that disempowers people from the resources needed for their own healthy growth and development and for the health and good growth of their children.

Synthetic growth reference charts.

OBJECTIVES: To reanalyze the between-population variance in height, weight, and body mass index (BMI), and to provide a globally applicable technique for generating synthetic growth reference charts. METHODS: Using a baseline set of 196 female and 197 male growth studies published since 1831, common factors of height, weight, and BMI are extracted via Principal Components separately for height, weight, and BMI. Combining information from single growth studies and the common factors using in principle a Bayesian rationale allows for provision of completed reference charts. RESULTS: The suggested approach can be used for generating synthetic growth reference charts with LMS values for height, weight, and BMI, from birth to maturity, from any limited set of height and weight measurements of a given population. CONCLUSION: Generating synthetic growth reference charts by incorporating information from a large set of reference growth studies seems suitable for populations with no autochthonous references at hand yet.

New reference centiles for boys' height, weight and body mass index used voice break as the marker of biological age.

AIM: We aimed to develop the first references for body height, body weight and body mass index (BMI) for boys based on the individual developmental tempo with respect to their voice break status. METHODS: We re-analysed data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS study) on body height, body weight and body mass index based on the voice break, or mutation, in 3956 boys aged 10-17 years. We used the LMS method to construct smoothed references centiles for the studied variables in premutational, mutational and postmutational boys. RESULTS: Body height, body weight and BMI differed significantly (p < 0.001) between the different stages of voice break. On average, boys were 5.9 cm taller, 5.8 kg heavier and had a 0.7 kg/m² higher BMI with every higher stage of voice break. Currently used growth references for chronological age in comparison with maturity-related references led to an average of 5.4% of boys being falsely classified as overweight. CONCLUSION: These newly developed growth references allowed convenient classifications of underweight and overweight or obese boys with respect to their voice break status. They should be added to currently used references centiles for the body mass index to avoid misclassifying boys' weight.

Stunted Growth. Proceedings of the 23rd Aschauer Soiree, Held at Aschauhof, Germany, November 7th 2015.

Twenty-four scientists met at Aschauhof, Altenhof, Germany, to discuss the associations between child growth and development, and nutrition, health, environment and psychology. Meta-analyses of body height, height variability and household inequality, in historic and modern growth studies published since 1794, highlighting the enormously flexible patterns of child and adolescent height and weight increments throughout history which do not only depend on genetics, prenatal development, nutrition, health, and economic circumstances, but reflect social interactions. A Quality of Life in Short Stature Youth Questionnaire was presented to cross-culturally assess health-related quality of life in children. Changes of child body proportions in recent history, the relation between height and longevity in historic Dutch samples and also measures of body height in skeletal remains belonged to the topics of this meeting. Bayesian approaches and Monte Carlo simulations offer new statistical tools for the study of human growth.

"Proceedings of the 22nd Aschauer Soiree on Growth and Health Screening", held at Altenhof, Germany, November 15th, 2014.

Twenty-five scientists met at Aschauhof, Altenhof, Germany, to discuss various aspects of the complex network of modern health screening, focusing on current scientific topics including medical sciences, human biology, and mathematics; on problems in implementing these results at the practical level of physicians, nurses, technicians, and engineers; and the level of administrative and political decisions. Whereas major scientific advancements have been published in the understanding and the bio-statistical evaluation of anthropometric screening parameters such as serial measurements of height and weight for preventive medical check-ups, BMI screening and surveillance in schools, etc., the implementation of these advancements into current health screening concepts, strategies and decision-making is poor. Fear of discrimination, misperception of body image, behavioural responses and political concerns, meanwhile dominate and negatively interfere with the implementation of recent scientific results into public health screening concepts and practices.

Is there an influence of modern life style on skeletal build?

OBJECTIVES: Modern human life style has led to significant decrease in everyday physical activity and bipedal locomotion. It has previously been shown that skeletal robustness (relative elbow breadth) is associated with daily step counts. The aim of the study was to investigate whether also other skeletal measures, particularly pelvic breadth may have changed in recent decades. METHODS: We re-analyzed elbow breadth, pelvic breadth (bicristal), and thoracic depth and breadth, of up to 28,975 healthy females and 28,288 healthy males aged 3-18 years from cross-sectional anthropological surveys performed between 1980 and 2012 by the Universities of Potsdam and Berlin, Germany. RESULTS: Relative elbow breadth (Frame index) significantly decreased in both sexes since 1980 (<0.001). The trend toward slighter built was even more pronounced in absolute and relative pelvic breadth. In contrast, equivalent changes of parts of the skeletal system that are not involved in bipedal locomotion such as thoracic breadth, thoracic depth, and the thoracic index were absent. CONCLUSIONS: The present investigation confirms the decline in relative elbow breadth in recent decades. Analogue, but even more pronounced changes were detected in pelvic breadth that coincides with the modern decline in upright locomotion. The findings underscore the phenotypic plasticity of humans while adapting to new environmental conditions.