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Doc James (talk · contribs · email) 21:36, 28 November 2016 (UTC)

Formatting needed for article on stunted growth
This still needs a lot of work so I have moved it here for you. Please read the above.

It is unclear what references support much of this.

Many of the refs do not work. Doc James (talk · contribs · email) 18:46, 15 December 2016 (UTC)

Ensuring proper nutrition of pregnant and lactating mothers is essential. Achieving so by helping women of reproductive age be in good nutritional status at conception is an excellent preventive measure. A focus on the pre-conception period has recently been introduced as a complement to the key phase of the 1000 days of pregnancy and first two years of life. An example of this is are attempts to control anemia in women of reproductive age. A well-nourished mother is the first step of stunting prevention, decreasing chances of the baby being born of low birth-weight, which is the first risk factor for future malnutrition. After birth, in terms of interventions for the child, early initiation of breastfeeding, together with exclusive breastfeeding for the first 6 months, are pillars of stunting prevention. Introducing proper complementary feeding after 6 months of age together with breastfeeding until age 2 is the next step. In summary, key policy interventions for the prevention of stunting are: -	Improvement in nutrition surveillance activities to identify rates and trends of stunting and other forms of malnutrition within countries, a necessary condition for effectively addressing the problem. This should be done with an equity lens, as it is likely that stunting rates will vary greatly between different population groups and the most vulnerable should be prioritized. The same should be done for risk factors such as anemia, maternal under-nutrition, food insecurity, low birth-weight, breastfeeding practices etc. This can help better target interventions to etiological factors. -	Political will to develop and implement national targets and strategies in line with evidence-based international guidelines as well as contextual factors. -	Designing and implementing policies promoting nutritional and health well-being of mothers and women of reproductive age. The main focus should be on the 1000 days of pregnancy and first two years of life, but the pre-conception period should not be neglected as it can play a significant role in ensuring the fetus and baby’s nutrition. -	Designing and implementing policies promoting proper breastfeeding and complementary feeding practices (focusing on diet diversity for both macro and micronutrients). This can ensure optimal infant nutrition as well as protection from infections that can weaken the child’s body. Labor policy ensuring mothers have the chance to breastfeed should be considered where necessary. -	Introducing interventions addressing social and other health determinants of stunting, such as poor sanitation and access to drinking water, early marriages, intestinal parasite infections, malaria and other childhood preventable disease (referred to as “nutrition-sensitive interventions”), as well as the country’s food security landscape. Interventions to keep adolescent girls in school can be effective at delaying marriage with subsequent nutritional benefits for both women and babies. Regulating milk substitutes is also very important to ensure that as many mothers as possible breastfeed their babies, unless a clear contraindication is present. -	Broadly speaking, effective policies to reduce stunting require multisectoral approaches, strong political commitment, community involvement and integrated service delivery.

As of 2015, it was estimated that there were 156 million stunted children under 5 in the world, 90% of them living in low and low-middle income countries. 56% of these were in Asia, and 37% in Africa. It is possible that some of these children concurrently had other forms of malnutrition, including wasting and stunting, and overweight and stunting. No statistics are currently available for these combined conditions. Stunting has been on the decline for the past 15 years, but this decline has been too slow. As a comparison, there were 255 million stunted children in 1990, 224 in 1995, 198 in 2000, 182 in 2005, 169 in 2010, and 156 in 2016.

The decline is happening, but it is uneven geographically, it is unequal among different groups in society, and prevalence of stunting remains at unacceptably high numbers. Too many children who are not able to fulfill their genetic physical and cognitive developmental potential. Over the period 2000-2015, Asia reduced its stunting prevalence from 38 to 24%, Africa from 38 to 32%, and Latin America and the Caribbean from 18 to 11%. This equates to a relative reduction of 36, 17 and 39% respectively, indicating that Asia and Latin America and the Caribbean have displayed much larger improvements than Africa, which needs to address this issue with much more effort if it is to win the battle against a problem that has been crippling its development for decades. Of these regions, Latin America and the Caribbean are on track to achieve global targets set with global initiatives such as the United Nations Millennium Development Goals and the World Health Assembly targets (see following section on global targets). If we look at sub-regional stunting rates, we observe the following: In Africa, the highest rates are observed in East Africa (37.5%). All other Sub-Saharan sub-regions also have high rates, with 32.1% in West Africa, 31.2% in Central Africa, and 28.4% in Southern Africa. North Africa is at 18%, and the Middle East at 16.2%. In Asia, the highest rate is observed in South Asia at 34.4%. South-East Asia is at 26.3%. Pacific Islands also display a worrisome rate at 38.2%. Central and South America are respectively at 15.6 and 9.9%. South Asia, given its very high population at over 1 billion and high prevalence rate of stunting, is the region currently hosting the highest absolute number of children with stunting (60 million plus). If we look in more detail at absolute numbers of children under 5 affected by stunting, we realize why current efforts and reductions are insufficient. The absolute number of stunted children has increased in Africa from 50.4 to 58.5 million in the time 2000-2015. This is despite the reduction in percentage prevalence of stunting, and is due to the high rates of population growth. The data therefore indicate that the rate of reduction of stunting in Africa has not been able to counterbalance the increased number of growing children that fall into the trap of malnutrition, due to population growth in the region. This is also true in Oceania, unlike Asia and Latin America and the Caribbean where substantial absolute reductions in the number of stunted children have been observed (for example, Asia reduced its number of stunted children from 133 million to 88 million between 2000 and 2015). The reduction in stunting is closely linked to poverty reduction and the will and ability of governments to set up solid multisectoral approaches to reduce chronic malnutrition. Low income countries are the only group with more stunted children today than in the year 2000. Conversely, all other countries (high-income, upper-middle income, lower-middle income) have achieved reductions in the numbers of stunted children. This sadly perpetuates a vicious cycle of poverty and malnutrition, whereby malnourished children are not able to maximally contribute to economic development as adults, and poverty increases chances of malnutrition.

One study conducted in a rural area in Zimbabwe illustrates the impact malnutrition has on growth. The area is known for poor farming conditions and prevalent malnourishment. Children ages 6–17 in the area were assessed for height, weight, and body mass index (BMI). The data recorded was compared with both American and other African countries average heights. Compared with the American averages, the Zimbabwean boys' height and weight dropped as low as the 10th percentile in some age groups and showed no sign of catch-up growth during the mid-teens. Zimbabwean girls' height and weight were not as low, but did drop as low as the 25th percentile. However, catch-up growth did occur during mid-teens and by 16 and 17, the girls average was close to the 50th percentile. Olivier, Semproli, Pettener, and Toselli, sums it up by saying that "the adverse socioeconomic environment and the low levels of food availability compromise and probably delay the physical development of the affected children in all phases of growth." Also, these data support the theory that lower than average size at early ages could be due to an adaptive mechanism reacting to low food intake.

Global efforts and targets
The 2012 World Health Assembly, with its 194 member states, convened to discuss global issues of maternal, infant and young child nutrition, and developed a plan with 6 targets for 2025. The first of such targets aims to reduce by 40% the number of children who are stunted in the world, by 2025. This would correspond to 100 million stunted children in 2025. At the current reduction rate, the predicted number in 2025 will be 127 million, indicating the need to scale-up and intensify efforts if the global community is to reach its goals. The World Bank estimates that the extra cost to achieve the reduction goal will be $8.50 yearly per stunted child, for a total of $49.6 Billion for the next decade. Interestingly, stunting has been shown to be one of the most cost-effective global health problems to invest in, with an estimated return on investment of $18 for every dollar spent thanks to its impact on economic productivity. Despite the evidence in favor of investing in the reduction of stunting, current investments are too low at about $2.9 billion per year, with $1.6 billion coming from Governments, $0.2 billion from donors, and $1.1 paid out of pocket by individuals. Sustainable Development Goals In 2015, the United Nations and its member states agreed on a new sustainable development agenda to promote prosperity and reduce poverty, putting forward 17 sustainable development goals (SDGs) to be achieved by 2030. SDG 2 aims to “End hunger, achieve food security and improved nutrition, and promote sustainable agriculture”. Sub-goal 2.2. aims to “by 2030 end all forms of malnutrition, including achieving by 2025 the internationally agreed targets on stunting and wasting in children under five years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons”. The global community has recognized more and more the critical importance of stunting during the past decade. Investments to address it have increased but remain far from being sufficient to solve it and unleash the human potential that remains trapped in malnutrition. Scaling Up Nutrition Movement (SUN) Th scaling up nutrition movement is the main network of governments, non-governmental and international organizations, donors, private companies and academic institutions working together in pursuit of improved global nutrition and a world without hunger and malnutrition. It was launched at the UN General Assembly of 2010 and it calls for country-led multi-sectoral strategies to address child malnutrition by scaling-up evidence-based interventions in both nutrition specific and sensitive areas. As of 2016, 50 countries have joined the SUN Movement with strategies that are aligned with international frameworks of action.

Country success stories
Brazil Brazil displayed a remarkable reduction in the rates of child stunting under age 5, from 37% in 1974, to 7.1% in 2007. This happened in association with impressive social and economic development that reduced the numbers of Brazilians living in extreme poverty (less than $1.25 per day) from 25.6% in 1990 to 4.8% in 2008. The successful reduction in child malnutrition in Brazil can be attributed to strong political commitment that led to improvements in the water and sanitation system, increased female schooling, scale-up of quality maternal and child health services, increased economic power at family level (including successful cash transfer programs), and improvements in food security throughout the country.

Peru After a decade (1995-2005) in which stunting rates stagnated in the country, Peru designed and implemented a national strategy against child malnutrition called crecer (“grow”), which complemented a social development conditional cash-transfer program called juntos, which included a nutritional component. The strategy was multisectoral in that it involved the health, education, water, sanitation and hygiene, agriculture and housing sectors and stakeholders. It was led by the Government and the Prime Minister himself, and included non-governmental partners at both central, regional and community level. After the strategy was implemented, stunting went from 22.9% to 17.9% (2005-2010), with very significant improvements in rural areas where it had been more difficult to reduce stunting rates in the past.

Indian State of Mahrashtra The State of Maharashtra in Central-Western India has been able to produce an impressive reduction in stunting rates in children under 2 years of age from 44% to 22.8% in the 2005-2012 period. This is particularly remarkable given the immense challenges India has faced to address malnutrition, and that the Country host almost half of all stunted children under 5 in the world. This was achieved through integrated community-based programs that were designed by a central advisory body that promoted multisectoral collaboration, provided advice to policy-makers on evidence-based solutions, and advocated for the key role of the 1000 days (pregnancy and first two years of life).

Summary of the evidence: Lancet series on maternal and child malnutrition
The medical journal “The Lancet” has published two comprehensive series on maternal and child nutrition, in 2008 and 2013. The series review the epidemiology of global malnutrition and analyze the state of the evidence for cost-effective interventions that should be scaled-up to achieve impact and global targets. In the first of such series, investigators define the importance of the 1000 day and identify child malnutrition as being responsible for one third of all child deaths worldwide. This finding is key in that it points at malnutrition as a key determinant of child mortality that is often overlooked. When a child dies of pneumonia, malaria or diarrhea (some of the causes of child mortality in the world), it may well be that malnutrition is a key contributing factor that prevents the body from successfully fighting the infection and recovering from the disease. In the follow up series in 2013, the focus on undernutrition is expanded to the increasing burden of obesity in both high, middle and low income countries. Interestingly, several countries with high levels of child stunting and undernutrition are starting to display worrisome increasing trends of child obesity concurrently, due to increased wealth and the persistence of significant inequalities. The challenges these countries face are particularly difficult as they require intervening on two levels on what has come to be called “double burden of malnutrition”. As an example, in India 30% of children under 5 years of age are stunted, and 20% are overweight. Neglecting these nutritional problems is not an option anymore if countries are to escape poverty traps and provide opportunities to their people to live fulfilling productive lives without stunting.

Thanks for your work on stunted growth
Thanks for your work on the article stunted growth - much appreciated! Could you also add more about the connection with lack of sanitation, diarrhea and environmental enteropathy? See also here: https://en.wikipedia.org/wiki/Talk:Environmental_enteropathy EvMsmile (talk) 21:33, 30 January 2017 (UTC)