Stunting is not a synonym of malnutrition.

BACKGROUND: WHO documents characterize stunting as, "…impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation." The equation of stunting with malnutrition is common. This contrasts with historic and modern observations indicating that growth in height is largely independent of the extent and nature of the diet. SUBJECTS: We measured 1716 Indonesian children, aged 6.0-13.2 years, from urban Kupang/West-Timor and rural Soe/West-Timor, urban Ubud/Bali, and rural Marbau/North Sumatra. We clinically assessed signs of malnutrition and skin infections. RESULTS: There was no relevant correlation between nutritional status (indicated by skinfold thickness) and height SDS (hSDS). In total 53% of boys, and 46% girls in rural Soe were stunted, with no meaningful association between mean of triceps and subscapular skinfolds (x̅SF) and height. Skinfold thickness was close to German values. Shortest and tallest children did not differ relevantly in skinfold thickness. The same applied for the association between hSDS and mid-upper-arm circumference (MUAC) using linear mixed effects models with both fixed and random effects. In total 35.6% boys and 29.2% girls in urban Ubud were overweight; 21.4% boys and 12.4% girls obese, but with mean hSDS = -0.3, still short. Relevant associations between hSDS and x̅SF and MUAC were only found among the overweight urban children confirming that growth is accelerated in overweight and obese children. There were no visible clinical signs of malnutrition or chronic infection in the stunted children. CONCLUSION: The present data seriously question the concept of stunting as prima facie evidence of malnutrition and chronic infection.

Correction: Stunting is not a synonym of malnutrition.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Cost effectiveness of a community based prevention and treatment of acute malnutrition programme in Mumbai slums, India.

Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously. This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action's Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted. The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246-17,843) at an estimated cost of $23 per DALY averted (95%UI:19-28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition.

Stunting, starvation and refeeding: a review of forgotten 19th and early 20th century literature.

AIM: To scrutinize to what extent modern ideas about nutrition effects on growth are supported by historic observations in European populations. METHOD: We reviewed 19th and early 20th century paediatric journals in the Staatsbibliothek zu Berlin, the third largest European library with an almost complete collection of the German medical literature. During a three-day visit, we inspected 15 bookshelf meters of literature not available in electronic format. RESULTS: Late 19th and early 20th century breastfed European infants and children, independent of social strata, grew far below World Health Organisation (WHO) standards and 15-30% of adequately-fed children would be classified as stunted by the WHO standards. Historic sources indicate that growth in height is largely independent of the extent and nature of the diet. Height catch-up after starvation was greater than catch-up reported in modern nutrition intervention studies, and allowed for unimpaired adult height. CONCLUSION: Historical studies are indispensable to understand why stunting does not equate with undernutrition and why modern diet interventions frequently fail to prevent stunting. Appropriateness and effect size of modern nutrition interventions on growth need revision.

Deep data science to prevent and treat growth faltering in Maya children.

The Maya people are descended from the indigenous inhabitants of southern Mexico, Guatemala and adjacent regions of Central America. In Guatemala, 50% of infants and children are stunted (very low height-for-age), and some rural Maya regions have >70% children stunted. A large, longitudinal, intergenerational database was created to (1) provide deep data to prevent and treat somatic growth faltering and impaired neurocognitive development, (2) detect key dependencies and predictive relations between highly complex, time-varying, and interacting biological and cultural variables and (3) identify targeted multifactorial intervention strategies for field testing and validation. Contributions to this database included data from the Universidad del Valle de Guatemala Longitudinal Study of Child and Adolescent Development, child growth and intergenerational studies among the Maya in Mexico and studies about Maya migrants in the United States.

Adolescent growth: genes, hormones and the peer group. Proceedings of the 20th Aschauer Soiree, held at Glücksburg castle, Germany, 15th to 17th November 2013.

The association between poverty, malnutrition, illness and poor socioeconomic conditions on the one side, and poor growth and short adult stature on the other side, is well recognized. Yet, the simple assumption by implication that poor growth and short stature result from poor living conditions, should be questioned. Recent evidence on the impact of the social network on adolescent growth and adult height further challenges the traditional concept of growth being a mirror of health. Twenty-nine scientists met at Glücksburg castle, Northern Germany, November 15th - 17th 2013, to discuss genetic, endocrine, mathematical and psychological aspects and related issues, of child and adolescent growth and final height.

Diversity in auxology: between theory and practice. Proceedings of the 18th Aschauer Soiree, 13th November 2010.

Auxology has developed from mere describing child and adolescent growth into a vivid and interdisciplinary research area encompassing human biologists, physicians, social scientists, economists and biostatisticians. The meeting illustrated the diversity in auxology, with the various social, medical, biological and biostatistical aspects in studies on child growth and development.

The role of taste and appetite regulation in the understanding of overweight and obesity. Proceedings of the 16th Aschauer Soiree, 26th April 2008.

Overweight and obesity have developed into major illnesses in most Western societies and significantly contribute to the financial burden of modern public health systems. Almost daily, new therapeutic proposals are published in the lay press, and also the scientific literature has increased dramatically in recent years. E.g., when searching MEDLINE (1966 - May 2008 (1)), the key word "obesity" meanwhile appears in more than 108,000 articles. Primary focus however, is put upon aspects of treatment, neglecting the role of taste and appetite regulation. Combining keywords like "obesity + treatment" results in over 50.000 citations, "obesity + diet" in over 23.000, "obesity + energy + expenditure" in over 13.000 citations (even "obesity + gastric + bypass" still evoke 2.600 citations), whereas "obesity + appetite + regulation" result in some 3.000, "obesity + NPY" - neuropeptid Y being one of the major chemical stimulators of appetite - evoke some 500 and "obesity + Arc + nucleus" - the arcuate nucleus being the anatomical centre of appetite regulation - no more than 370 scientific publications. The apparent scarcity of literature about taste and appetite regulation and the amazing lack of interest in neuronal information processing in overweight and obesity, has prompted the authors to brainstorm new aspects of the world-wide derailment of weight control.

Rapid change in height and body proportions of Maya American children.

Maya families from Guatemala migrated to the United States in record numbers from the late 1970s to the early 1990s. Births to Maya immigrant women have created a sizable number of Maya American children. The height and sitting height of 5 to 12 years children (n = 431) were measured in 1999 and 2000. Leg length was estimated and the sitting height ratio was calculated. These data were compared with a sample of Maya children living in Guatemala measured in 1998 (n = 1,347). Maya American children are currently 11.54 cm taller and 6.83 cm longer-legged, on average, than Maya children living in Guatemala. Consequently, the Maya Americans have a significantly lower average sitting height ratio (i.e., relatively longer legs in proportion to length of the head and trunk) than do the Maya in Guatemala. These results add support to the hypothesis that both the height and body proportions of human populations are sensitive indicators of the quality of the environment for growth.

Eight thousand years of economic and political history in Latin America revealed by anthropometry.

Human growth in height may be used as a cumulative record of the nutritional and health history of a person or a population, and often reflects the economic, social and political environment in which those people live. This paper explores the relationship between growth in height and the economic, social and political environment in Latin American populations. Adult height is analysed over an 8250 year period. It is shown that economic, social and political change prior to the European conquest of the Americas resulted in positive and negative trends in mean stature. Following the European conquest, there was a decline in mean adult stature in Middle and South America that continued until about 1939. From 1940 to 1989 there was a trend for increasing mean stature. A negative trend in stature for children is found in a second analysis. Economic decline and political unrest in Guatemala since 1978 is associated with a significant decline in the mean stature of 10- and 11-year-old children from families from very high, moderate, and very low socioeconomic status.

Evolutionary perspective on human growth.

PIP: This article explores the evolution of growth patterns among mammals in general and primates in particular to better understand the shared and special features of human growth. Special attention is given to several competing hypotheses concerning the adaptive value of the juvenile stage to the life history of the social mammals. The unification hypothesis claims that all growing organisms and populations or organisms could be modeled with one curve of growth. Brody tried to show that in essence all animals, parts of animals, colonies of cells, and even populations of animals follow a common pattern of growth. However, one main problem regarding this hypothesis is that some animals, especially humans, have more than one phase of self-acceleration and self-inhibition of growth rate. In addition, the controversy as to whether the adolescent growth spurt is a uniquely human feature has been solved on the basis of empirical observations and evolutionary considerations. The author concludes that the human adolescent growth spurt in stature and skeletal maturation is species-specific and not found in any other primate species. Finally, data and theory are used to advance a philosophy of human growth.^ieng

Growth in height and weight of South African urban infants from birth to five years: The Birth to Ten Study.

The Birth To Ten (BTT) birth cohort study was designed to investigate the health and growth of children living in the Soweto-Johannesburg Metropole, South Africa. During 1990-1991, 4034 singleton births, from a total birth population of 5449 that occurred between 23 April and 8 June, 1990, were enrolled into the study. Anthropometric, socioeconomic, health, nutritional, and demographic data were collected at birth and at 3, 6, 12, 24, 48, and 60 months. Socioeconomic data relating to household commodities, maternal education, and paternal occupation were combined to create socioeconomic status (SES) groups for comparative purposes. Mean birth weights were less than American norms and demonstrated significant differences between the sexes. The percentage of low birth weight children of normal gestational age (7.1%) was similar to that of developed countries. Growth in weight exceeded that of the National Center for Health Statistics (NCHS) reference during the first 6 months and then fell to -0.43 Z-scores by 4 years. Height growth was consistently less than the NCHS reference and the prevalence of stunting and wasting increased to 22.4% and 6.8%, respectively, by 2 years. Catch-up occurred between 4 and 5 years resulting in a reduction in the prevalence of stunting and wasting to 5.4% and 0.8%, respectively, at 5 years. SES differences were apparent throughout the time period but only reached significance in height and weight after 4 years of age. Am. J. Hum. Biol. 10:495-504, 1998. © 1998 Wiley-Liss, Inc.

Plasticity, political economy, and physical growth status of Guatemala Maya children living in the United States.

Migration of Maya refugees to the United States since the late 1970s affords the opportunity to study the consequences of life in a new environment on the growth of Maya children. The children of this study live in Indiantown, Florida, and Los Angeles, California. Maya children between 4 and 14 years old (n = 240) were measured for height, weight, fatness, and muscularity. Overall, compared with reference data for the United States, the Maya children are, on average, healthy and well nourished. They are taller and heavier and carry more fat and muscle mass than Maya children living in a village in Guatemala. However, they are shorter, on average, than children of black, Mexican-American, and white ethnicity living in Indiantown. Children of Maya immigrants born in the United States tend to be taller than immigrant children born in Guatemala or Mexico. Families that invest economic and social resources in their children have taller children. More economic successful families have taller children. Migration theory and political economy theory from the social sciences are combined with plasticity theory and life history theory (parental investment) from biology to interpret these data.

Longitudinal analysis of adolescent growth of ladino and Mayan school children in Guatemala: effects of environment and sex.

The rate of growth in height and the timing of adolescent growth events are analyzed for two samples of Guatemalan children. One sample includes Mayan school children, 33 boys and 12 girls between the ages of 5.00 to 17.99 years, living under poor conditions for growth and development. The second sample includes ladino children, 78 boys and 85 girls of the same age range, living under favorable conditions for growth. The Preece-Baines model I function is used to estimate mean values for rates and timing of childhood and adolescent growth events for the two groups. Significant statistical contrasts (t-tests) of these means show Mayan boys reach the age of "take-off" (TO; the onset of the adolescent growth spurt) 1.45 years later, achieve peak height velocity (PHV) 1.68 years later, and continue growing for about 2.0 years longer than do the ladino boys. Despite the Mayan boys' increased duration for growth they grow significantly more slowly than the ladinos. Mayan boys are 6.60 cm shorter than ladinos at the age of TO and are estimated to be 7.71 cm shorter than the ladinos at adulthood. Mayan girls reach the age of TO 0.93 years later than do the ladina girls, but the two groups do not differ in the age at PHV or the age at adulthood. The mean height of Mayan girls is significantly less than that of ladinas at the age of TO (6.5 cm), and this difference increases to an estimated 11.14 cm at adulthood. Possible causes of these ethnic and sex-related differences in amounts and rates of growth are discussed in relation to hypotheses about the genetic and environmental determinants of human development.

Measurement of growth variability and environmental quality in Guatemalan children.

The measurement of within-population growth variability may be a sensitive indicator of environmental quality. Specifically, it is hypothesized that within-population variability will increase in adverse environments. To evaluate this hypothesis the variability in stature growth of three samples of Guatemala school children (5-10 years old) is assessed. These samples include high socioeconomic status (SES) ladinos (84 boys and 98 girls) and low SES ladinos (136 boys and 101 girls) living in Guatemala City and very low SES Mayan Indians (139 boys and 73 girls) living in a rural town near the city. SES is used as a proxy for environmental quality. The coefficient of variation (CV) for distance achieved at each age, or for the increment of growth from age to age, is used as the measure of variability. The three samples differ significantly for variability in stature growth, both for the distance and the increments of growth. Low SES urban ladinos have the largest variability. Very low SES Mayan children have coefficients of variation that are sometimes equal to, and sometimes either larger or smaller than, CVs for the high SES ladinos. The results show that degree of environmental adversity does not correlate uniformly with growth variability. Factors such as rates of infant and early childhood mortality and the greater heterogeneity of the low SES urban environment, compared with the high SES urban or low SES rural environments, may account for differences in the CV in these three samples.

Growth status, age, and grade as predictors of school continuation for Guatemalan Indian children.

Schooling is considered by many researchers and agencies as an important contributor to individual and national development for populations living in the less developed countries. Accordingly, programs to increase school enrollment and continuation from grade to grade are being developed for many of these countries. This paper investigates the relationship of physical growth status (height, weight, and body composition), grade in school, and age to school continuation for a sample of Indian children living in a village near Guatemala City. It was found that physical growth status, a reflection of health and nutritional status, does not predict school continuation. A child's age and current grade in school do predict continuation. Most children leave school after reaching 9 years of age or after completing the second grade. It is suggested that children may learn enough to satisfy their parents' expectations by this age or grade. Also, the child's economic value to his or her family may be a significant reason for school drop-out.

Socioeconomic status, sex, age, and ethnicity as determinants of body fat distribution for Guatemalan children.

The distribution of subcutaneous fat at the triceps and subscapular skinfold sites is described for four groups of children living in Guatemala. These groups are high socioeconomic status (SES) children of Ladino (mixed Spanish and Indian) ancestry, high SES children of European ancestry, low SES Ladino children, and very low SES Indian children. The method of Healy and Tanner (1981) is used, employing regression and principal components analysis of log transformed skinfold values to divide "fatness" into two uncorrelated variables: size (amount of fat) and shape (fat pattern). Significant differences exist between groups in size, with lower SES groups having less fat than higher SES groups. No significant difference in fat pattern exists between the high SES Ladino and high SES European children. Significant differences do exist between the high SES groups and the low SES groups. The relative amount of subscapular fat increases from the high SES Ladinos and high SES Europeans, to the low SES Ladinos, to the very low SES Indians. In the high SES European and high SES Ladino samples, girls have significantly more arm fat than boys. There is no significant difference in fat patterning between boys and girls in the two low SES samples. Finally, the relative amount of subscapular fat tends to increase with age in all four samples. These results indicate that fatness and fat patterning are independent anatomical characteristics, SES influences fat patterning; low SES children of both Ladino and Indian ancestry show greater reductions in arm fat than in trunk fat compared to high SES children, sexual dimorphism in fat patterning is SES dependent.(ABSTRACT TRUNCATED AT 250 WORDS)