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Stunting: An over-diagnosed condition?
The new president and vice president will take up office upon their inauguration this October
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span>The new president and vice president will take up office upon their inauguration this October. It is a relief that both presidential candidates have demonstrated attention to the nutritional status of Indonesian children, one focusing on reducing the prevalence of stunting starting before conception, and the other focusing on dietary intervention.
Stunting has become one of the most popular medical issues to date. The frequently asked questions from parents at pediatric clinics nowadays include, “Does my child suffer from stunting?” As stunting has devastating effects on child development and growth, it is understandable that parents keenly ask such questions.
But first we need to understand that stunting is only one of several forms of malnutrition. First, there is underweight that literally means having too low a bodyweight for one’s age, defined by the World Health Organization (WHO) as a bodyweight “more than 2 standard deviations below the median of a standard population”. Second, there is wasting, or being thin for one’s height, defined by the WHO as having a weight for height below -2 SD.
Third, overweight, defined as weight for height above +2 SD. You may be underweight according to your age, but you can be normal or even overweight according to your height. Last but not least is stunting. By this standard, stunting is having height for age below -2 SD or simply being too short for one’s age.
Stunted linear growth, especially in children below 2 years of age (the first 1,000 days) affects brain growth, as the development of neuron cells is at its peak during the first two years. Children who are stunted in early life also bear an increased risk of developing obesity, diabetes, cancer or cardiovascular disease in later phases of childhood or in adulthood.
According to the WHO, stunting is impaired growth and development children experience because of poor nutrition, repeated infections or inadequate opportunities to play and learn. The WHO has developed a normal standard growth chart it claims is applicable to any child, regardless of ethnicity, socio-economic status or type of feeding.
The WHO standard growth chart was developed after the completion of the WHO Multicenter Growth Reference Study (MGRS), which was implemented between 1997 and 2013, to develop a new growth chart that would show how children should grow in all countries, rather than merely describing how they grew at a particular time and place.
It was developed to create a standard, not a reference. Any deviation from the pattern observed is abnormal growth.
The study was set in Brazil, Ghana, India, Norway, Oman and the United States and followed privileged healthy children. The WHO argued that by choosing those privileged healthy children, environment factors could be minimized.
Furthermore, the WHO insisted that the MGRS sample has built-in ethnic or genetic variability in addition to cultural variations in how children are nurtured, which strengthens the standards’ universal applicability.
The adoption of the WHO’s standard growth chart in many developing countries tends to over-diagnose stunting and wasting. In a nationwide study on healthy, affluent Indian children, the percentage of stunting was 13.6 percent for boys and 11.2 percent for girls, and for wasting it was 8.5 percent for boys versus 10.4 percent for girls.
Meanwhile a similar study in Indonesia by Madarina Julia of Gadjah Mada University (UGM), found that, of 1,374 children studied, who had started breastfeeding and were still being breastfed when the data was collected, the prevalence of stunting and underweight rose steadily with age. Although the proportion of children found to be wasting to those being underweight was relatively constant, the contribution of stunting increased as the children grew. This result contradicted the definition of stunting by the WHO, in which reduced linear growth was a result of poor nutrition or repeated infection.
Furthermore, Indonesia’s 2018 National Basic Health Survey (Riskesdas) revealed that, among the national sample of children under 5 years of age, the prevalence of stunting reached 30.8 percent and only 10.2 percent are “wasted”. These figures did not differ much from the 2013 Riskesdas, which found stunting in 37.2 percent of the children below 5 and wasting in 12.1 percent.
Only 2.5 percent suffered from both wasting and stunting, while the rest were mostly either short with normal weight or short but overweight.
Discrepancy between the prevalence of stunting and the prevalence of wasting, and the very low prevalence of both together, raises skepticism. To say that children suffer from stunting without suffering from wasting first, suggests that perhaps the lack of height for age in these children was not caused by nutritional or other health reasons. Perhaps these children are just short, not stunted.
Unfortunately, Indonesia’s government has uncritically used the WHO growth standard to assess the problem of stunting in Indonesian children. Based on this standard, about 37 percent of Indonesian children were said to be stunted. Using this number, the government, with the help of the World Bank, plans to spend millions of US dollars under the National Strategy to Accelerate Stunting Prevention (StraNas Stunting) to “cure” what might only be shortness, not stunting.
Before continuing the program, the newly elected government should review carefully the stunting status of Indonesian children to get the right figures of children who are truly stunted, not just short.
By reviewing the data, the government will get the right picture of the stunting problem among children. Second, it will save the government a lot of money, as the number of children supposedly suffering from stunting today is likely a result of over-diagnosing.
Third, it will help the government focus on other health problems that might be of bigger magnitude yet lack adequate attention.
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The writer is a pediatric resident with Cipto Mangunkusumo Hospital/University of Indonesia (UI). She was also an Indonesian civil society representative for the UN General Assembly in 2011 and Asia Pacific regional coordinator for the standing committee on public health in the International Federation of Medical Students’ Association.
