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Ranking global risk factors for childhood stunting

November 01, 2016

The leading risk factor for childhood stunting is being born at term but small for gestational age, according to a 137-country analysis published in PLOS Medicine. The study, conducted by Goodarz Danaei of the Harvard T.H. Chan School of Public Health, Boston, U.S.A., and colleagues, indicated that unimproved sanitation, poor nutrition, and infection were other important contributors to the burden of stunting.

Thirty percent of children in developing countries have stunted growth. In order to reduce stunting, it is important to understand its determinants, to help design policies to improve childhood growth. In this study, Danaei and colleagues used data from 137 developing countries on the prevalence of 18 known key risk factors and their associations with stunting, and estimated the attributable number of cases for each risk factor among children aged 24 to 35 months in 2010. The researchers found that the leading risk for stunting worldwide was being "term, and small for gestational age," to which 10.8 million (95% confidence interval [CI] 9.1 million-12.6 million) cases of stunting among two-year-olds were attributable (out of 44.1 million). This was followed by poor sanitation (7.2 million cases; 95% CI 6.3 million-8.2 million) and diarrhea (5.8 million cases; 95% CI 2.4 million-9.2 million). Fetal growth restriction and preterm birth was the leading risk factor cluster in all regions, but environmental risk factors (i.e., poor water quality, poor sanitary conditions, and use of solid fuels) had the second largest impact on stunting globally and in South Asia, sub-Saharan Africa, and East Asia and Pacific, whereas risk factors related to child nutrition and infection were the second leading cluster in Central Asia, North Africa and the Middle East, and Latin America and the Caribbean.

This global study relied on approximations, and analysis was limited to risk factors with known statistical associations with stunting and country-level exposure data. Nonetheless, the findings suggest an order of priority for policymaking. The authors state, "[r]educing the burden of stunting requires a paradigm shift from interventions focusing solely on children and infants to those that reach mothers and families and improve their living environment and nutrition."

Grand Challenges Canada under the Saving Brains program (grant # 0073-03). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing Interests:

The authors have declared that no competing interests exist.


Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC, Peet E, et al. (2016) Risk Factors for Childhood Stunting in 137 Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels. PLoS Med 13(10): e1002164. doi:10.1371/journal.pmed.1002164

Author Affiliations:

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston,
Massachusetts, United States of America
Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
Harvard Graduate School of Education, Cambridge, Massachusetts, United States of America
RAND Corporation, Pittsburgh, Pennsylvania, United States of America
Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, United Kingdom
Wellcome Centre for Global Health Research, Imperial College London, London, United Kingdom
Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America



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