Stunting appears on the global stage

The first global commitment related to childhood stunting was the 1989 Convention on the Rights of the Child. Article 24 of this convention committed country governments to “combat disease and malnutrition” in children.

At the time, stunting was not explicitly mentioned in the global convention; instead, underweight (low weight-for-age) was the indicator of choice. It was, nonetheless, a watershed moment for efforts to eliminate stunting. As the closest proxy available for long-term malnutrition, stunting rates eventually became a key metric for measuring progress. Governments had been held accountable neither for tracking the numbers nor for reducing prevalence. The convention pushed governments to collect data on the number of children affected and report on their efforts to eliminate stunting.

These efforts gained greater urgency when the Millennium Development Goals (MDGs) included a commitment to reduce the percent of underweight children by 2015. The Sustainable Development Goals (SDGs) further elevated the issue by explicitly including a target on stunting. Sustainable Development Goal 2 committed countries to eliminate hunger. It includes target 2.2, which commits countries to “end all forms of malnutrition,” with stunting as an explicit target.

By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women and older persons.

- SDG Goal 2.2

The targets referenced in the SDGs refer to the WHO’s 2012 resolution to reduce the number of stunted children by 40 percent by 2025. Achieving this goal would bring the total number of stunted children down from 171 million in 2010 to 100 million in 2025.1

Of note, the SDGs also emphasize the importance of reducing inequalities. SDG 17.18 supports building capacity to collect “data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographic location and other characteristics relevant in national contexts” to track progress on outcomes for children of marginalized or otherwise disadvantaged backgrounds.2

Global efforts to reduce stunting

Nutrition most recently rose to the top of the global health agenda in the late 2000s, with stunting at the forefront. Building on a solid foundation of scientific research, new nutrition initiatives pushed a globally cohesive approach to addressing stunting and other forms of malnutrition.

The Lancet Nutrition series

In 2008, the Lancet published a landmark series of papers on Maternal and Child Undernutrition. The series made it clear that the first 1,000 days of life (from pregnancy through two years of age) are the most critical time to intervene; after this, damage caused by malnutrition is largely irreversible. It also drew attention to the scale of the problem: according to the series, over a third of child deaths and 11 percent of total disease burden worldwide is due to maternal and child undernutrition.3

Despite this, nutrition, in the words of Richard Horton, editor in chief of the Lancet, was “a desperately neglected aspect of maternal, newborn, and child health.” While other maternal and child health interventions had received additional resources and attention in recent years, “somehow, nutrition [had] slipped through the gap."4

The Lancet series brought nutrition into the global consciousness, advocated for an investment-oriented perspective on preventing maternal and child undernutrition, and provided a scientific foundation for intervention. In doing so, it spurred a host of global initiatives that followed shortly after its publication.

In 2013, the Lancet published an update to the series, this time re-evaluating issues around undernutrition while examining the growing problem of overnutrition. The research found that malnutrition was responsible for even more child deaths than previously noted – nearly half of all child mortality each year. This time, the series also modeled a series of ten nutrition-specific interventions that could address up to 20 percent of stunting if coverage for all of them were to reach 90 percent.5

Stunting interventions in undernutrition

Stunting interventions in undernutrition
Data source: The Lancet

Scaling Up Nutrition (SUN)

Inspired in part by the Lancet Nutrition series, the Scaling Up Nutrition (SUN) Movement was formed in 2010. Led by governments of participating countries, SUN unites civil society, the United Nations, donors, researchers, and the private sector in a cohesive effort to eliminate malnutrition. SUN aims to end malnutrition in all forms by 2030.

Each participating government nominates a SUN Government Focal Point. Globally, SUN convenes stakeholders, fosters commitments to behavior change, and mobilizes resources to scale up coverage of nutrition-specific and -sensitive interventions.

Today, the SUN Movement encompasses 61 countries and four Indian states. Its most recent Strategy and Roadmap, for 2016 through 2020, details four top priorities:

  • Expanding and sustaining an enabling political environment
  • Prioritizing and institutionalizing effective actions that contribute to good nutrition
  • Implementing effective actions aligned with common results frameworks
  • Effectively using and significantly increasing financial resources for nutrition6

Nutrition for Growth (N4G)

In 2013, 90 stakeholders representing governments, development partners, private sector actors, civil society groups, and scientists met at a summit in London to sign the Nutrition for Growth Compact. Nutrition for Growth generated a total of $4.15 billion pledged for nutrition-specific projects and $19 billion for nutrition-sensitive projects.7

Since then, Nutrition for Growth has continued to serve as a platform for governments, investors, and civil society to collaborate. An upcoming Nutrition for Growth summit in Tokyo, in 2021, promises to build on past successes.

Tracking our progress

Tracking progress consistently is vital for evaluating the success or failure of global efforts to reduce child malnutrition and for holding stakeholders accountable. Over the years, various mechanisms have been developed to estimate the global burden of stunting and other forms of malnutrition.

UNICEF State of the World’s Children

The State of the World’s Children, first published in 1980, is UNICEF’s flagship annual publication. Its 1982-1983 edition ignited the child survival revolution. The 1998 edition focused on nutrition and examined three factors that affect children’s ability to develop fully: access to food, basic health services, and caring practices.8

Today, The State of the World’s Children provides an annual, country-by-country update of stunting, wasting, severe wasting, and overweight prevalence, using data from the Joint Malnutrition Estimates. It also includes coverage of interventions aimed at improving infant and young child feeding (IYCF) (early initiation of breastfeeding, exclusive breastfeeding, introduction to solid, semi-solid or soft foods at 6-8 months of age, minimal acceptable diet during 6-23 months of age), as well as micronutrient supplementation and fortification (vitamin A supplementation and consumption of salt with iodine).9

Joint Malnutrition Estimates (JME)

An inter-agency team made up of representatives from UNICEF, WHO, and the World Bank collates data on childhood stunting, overweight, wasting, and severe wasting prevalence and develops estimates of child malnutrition (global, regional, and by income group). The data are taken from Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), national nutrition surveys, and other surveys deemed nationally representative and of high quality.10

These data and estimates, collected and modeled annually, are considered the authoritative source for malnutrition epidemiology.

Global Nutrition Report

The Global Nutrition Report was created in the wake of the first Nutrition for Growth Summit in 2013. First published in 2014, it has since become the world’s authoritative report on the state of nutrition. The report typically covers the following areas:

  • Global, regional, and country-level burden of various forms of malnutrition
  • Trends, especially relevant to SDG targets
  • Funding by governments and donors relative to commitments
  • Highlighted areas of progress and remaining challenges
  • Recommendations for the global community

The Global Nutrition Report is produced independently by (1) a Stakeholder Group, comprised of high-level representatives of governments, donors, civil society, multilaterals, and private sector entities, which guides the development of the report; (2) an Independent Expert Group, responsible for the quality of the report’s data, analysis, and conclusions; and (3) a Report Secretariat.11

Progress and pitfalls to date

The world has made significant progress on reducing stunting. Since 1990, when data was first collected consistently, the number of stunted children underage five has declined from over 250 million globally (40 percent prevalence) to 149 million (22 percent) in 2018.12,13

This is remarkable progress. But it is not enough for us to reach the WHO and SDG goal. Based on current trends, stunting is expected to affect 127 million children by 2025 - more than 25 percent higher than the WHO goal.14

Progress has been made, but has been highly uneven.

A global decline in prevalence of stunted growth

Large disparities in stunting reduction exist within regions between subregions
Data source: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2019 edition.
    

East Asia, Latin America, and the Middle East have achieved impressive gains: average stunting rates in those regions now fall at or below 15 percent.1 Meanwhile, the prevalence of stunting in sub-Saharan Africa has declined only slightly since 1990 and remains at close to 35 percent. In fact, the total number of stunted children in sub-Saharan Africa has actually increased since 2000, from 50 million to 59 million in 2018. While prevalence has declined some, the population has grown faster. While South Asia has seen more relative progress over time, its prevalence is still similarly high at 35 percent. Overall, the burden of stunting continues to fall disproportionately on the poorest and least developed countries, with three quarters of the global burden located in sub-Saharan Africa and South Asia; 91 percent of global stunting is clustered in low- and lower middle-income countries.13,15

Increase in stunting levels in Africa

Increase in stunting levels in Africa
Data source: UNICEF, WHO, World Bank Group joint malnutrition estimates, 2019.

There are large disparities in stunting rates within regions, as well. For example, at 44 percent, Laos has one of the world’s highest stunting rates. Its neighbor, Thailand, however, has a rate of just 11 percent.16  These disparities offer opportunities for policymakers to examine their neighbors’ progress when looking for appropriate models to adapt.

Finally, while child stunting prevalence has declined in most low- and middle-income countries, equity gaps have persisted within nations. Gaps between population subgroups, particularly between the richest and poorest wealth quintiles, have actually increased in many low-income countries over the last twenty years.17

What’s next?

Meeting the WHO and SDG targets would cost approximately $8.50 per child per year (~$50 billion total between 2015 and 2025), according to projections by the World Bank, in partnership with the Bill and Melinda Gates Foundation and Children’s Investment Fund Foundation.5 Global spending currently totals less than half of this: about $3 per child per year. Increased funding could cover necessary high-impact interventions within the first 1,000 days, including promotion of exclusive breastfeeding, supplementation of micronutrients, and provision of complementary foods.

“The reality is that the sum total of country actions and financial commitments thus far don’t add up to the size and scale we need to address the stunting crisis.”

- Jim Yong Kim, former World Bank Group President18

The economic case for additional spending on evidence-based interventions proven to reduce stunting is strong. According to recent estimates, $1 invested in stunting reduction generates at least $3 in economic returns (often much more), by also reducing child mortality and improving the quality of the workforce as children who reach their full growth potential enter adulthood.19

Reducing stunting is one of the best investments a country can make; however, just $2.9 billion per year - less than a third of the funding need - is currently being spent on stunting-specific interventions in high burden countries. Donors and governments must invest more in proven interventions or risk perpetuating the cycle of stunting.14

Estimated spending for scaling up stunting reduction interventions and business as usual scenario financial projections

But money alone will not get us across the finish line. Top-performing countries have combined financing with political commitment, which has then translated into effective policies and programs. To help other countries replicate these successes, the World Bank has recently created the Human Capital Project (HCP). The HCP does this through three primary means:

  1. Creation of a Human Capital Index (HCI), of which stunting is a key component
  2. Improvement of outcomes measurement and scaling of M&E initiatives
  3. Provision of direct technical assistance and strategic support for governments

Ultimately, achieving the WHO and SDG goal of a 40 percent reduction in stunting will require significant long-term investments, political commitment, improved understanding of the pathways leading to stunting reduction, and a focus on population subgroups that are disproportionately affected.

For an issue so critical to our future, there remains robust debate among experts on basic facts. Recent research, for instance, has challenged longstanding assumptions on the impact of improved water and sanitation on child growth. Outside the limited setting of a randomized controlled trial, there remains even more uncertainty as to what types of programs work at scale across diverse and geographically dispersed nations.

Yet, countries are making progress, both in identifying interventions most appropriate for their own geographies and in implementing complex programs that require broad collaboration across government ministries, economic sectors, and civil society. Adapting these lessons globally will accelerate our progress in reducing childhood stunting worldwide.

  1. 1De Onis M, Branca F. Childhood stunting: a global perspective. Aguayo VM, Menon P, eds. Maternal & Child Nutrition. 2016;12(Suppl Suppl 1):12-26. doi:10.1111/mcn.12231. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5084763/pdf/MCN-12-12.pdf.
  2. 2Inter-Agency and Expert Group on SDG Indicators (IAEG-SDGs). Sustainable Development Goal 17: Strengthen the means of implementation and revitalize the global partnership for sustainable development. United Nations. https://sustainabledevelopment.un.org/sdg17. Accessed 11 May 2019.
  3. 3The Lancet series on Maternal and Child Undernutrition. World Health Organization. Accessed 20 August 2019. https://www.who.int/nutrition/publications/lancetseries_maternal_and_childundernutrition/en/.
  4. 4Horton, R. (2008). Maternal and child undernutrition: an urgent opportunity. The Lancet, 371(9608), p 179.
  5. 5Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, Webb P, Lartey A, Black R. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet, 283(9890), p 452-477.
  6. 6Scaling Up Nutrition. Accessed 20 August 2019. https://scalingupnutrition.org.
  7. 7Nutrition for Growth. Nutrition for Growth. Accessed 20 August 2019. https://nutritionforgrowth.org/nutrition-growth/.
  8. 8The State of the World's Children 1998: Focus on Nutrition. Unicef.org. Accessed 21 August 2019. https://www.unicef.org/nutrition/index_7591.html.
  9. 9The State of the World's Children reports. Unicef.org. Accessed 21 August 2019. https://www.unicef.org/sowc/.
  10. 10Joint child malnutrition estimates - Levels and trends (2019 edition). World Health Organization. Accessed 21 August 2019. https://www.who.int/nutgrowthdb/estimates2018/en/.
  11. 11Global Nutrition Report. Accessed 21 August 2019. https://globalnutritionreport.org.
  12. 12Onis, Blossner, Borghi. Prevalence and trends of stunting among pre-school children. Public Health Nutrition. 2012; 15: 142-8. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/6FDF3AC29E66FD148917CE2B26B84B2D/S1368980011001315a.pdf/prevalence_and_trends_of_stunting_among_preschool_children_19902020.pdf.
  13. 13Development Initiatives, 2017. Global Nutrition Report 2017: Nourishing the SDGs. Bristol, UK: Development Initiatives. https://globalnutritionreport.org/reports/2017-global-nutrition-report/.
  14. 14World Bank Group. Reaching the Global Target to Reduce Stunting: How Much Will it Cost and How Can we Pay for it? World Bank. http://pubdocs.worldbank.org/en/460861439997767818/Stunting-Costing-and-Financing-Overview-Brief.pdf. Accessed August 2017.
  15. 15United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2019 Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/nutgrowthdb/jme-2019-key-findings.pdf?ua=1.
  16. 16UNICEF-WHO-The World Bank Group. Joint child malnutrition estimates - Levels and trends (2019 edition). World Health Organization. https://www.who.int/nutgrowthdb/estimates2018/en/. Updated March 2019. Accessed 11 May 2019.
  17. 17da Silva ICM, França GV, Barros AJD, Amouzou A, Krasevec J, Victora CG. Socioeconomic Inequalities Persist Despite Declining Stunting Prevalence in Low- and Middle-Income Countries. J Nutr. 2018;148(2):254–258. doi:10.1093/jn/nxx050. https://academic.oup.com/jn/article/148/2/254/4913041.
  18. 18Kim JY. Remarks by World Bank Group President Jim Yong Kim at the Early Childhood Development Event. World Bank. http://www.worldbank.org/en/news/speech/2016/04/14/remarks-world-bank-group-president-jim-yong-kim-early-chilhood-development. Updated 14 April 2016. Accessed 11 May 2019.
  19. 19Hoddinott, J., Alderman, H., Behrman, J. R., Haddad, L. and Horton, S. (2013), The economic rationale for investing in stunting reduction. Maternal & Child Nutrition, 9: 69–82. https://onlinelibrary.wiley.com/doi/epdf/10.1111/mcn.12080.