CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIAImplications for sustainable development post 2015

The findings, interpretations and conclusions expressed in this report are those of the authors and do not necessarily reflect the policies and views of UNICEF.

Permission to copy, disseminate or otherwise use the information in this report is granted as long as appropriate acknowledgement is given.

Suggested citation: UNICEF (2018). Child Stunting, Hidden Hunger and Human Capital in South Asia: Implications for Sustainable Development Post 2015. UNICEF: Kathmandu, Nepal.

© United Nations Children’s Fund (UNICEF), Regional Office for South Asia (ROSA), June 2018.

Design by: EKbana Solutions

Photograph credits:Cover page: © UNICEF/2010/PirozziPages vi: © UNICEF/2014/QadriPage x, 21, 22: © UNICEF/2016/GiacomoPage 36: © UNICEF/2017/Brown

Contributors:

Aguayo, Victor M.: United Nations Children's Fund (UNICEF), New York, USA.

Corsi, Daniel: Harvard Center for Population and Development Studies, Cambridge, MA, USA.*

Harding, Kassandra L.: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA.

Kim, Rockli: Harvard Center for Population and Development Studies, Cambridge, MA, USA.

Krishna, Aditi: Harvard Center for Population and Development Studies, Cambridge, MA, USA.*

McGovern, Mark E.: Harvard Center for Population and Development Studies, Cambridge, MA, USA.*

Mejía-Guevara, Iván: Harvard Center for Population and Development Studies, Cambridge, MA, USA.*

Perkins, Jessica M.: Harvard Center for Population and Development Studies, Cambridge, MA, USA.*

Rasheed, Rishfa: South Asian Association for Regional Cooperation (SAARC) Secretariat, Kathmandu, Nepal.

Subramanian, S.V.: Harvard Center for Population and Development Studies, Cambridge, MA, USA.

Torlesse, Harriet: UNICEF Regional Office for South Asia (ROSA), Kathmandu, Nepal.

Webb, Patrick: Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA.

*Contributor’s affiliation at the start of the research and/or when the bulk of the research was conducted

CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIAImplications for sustainable development post 2015

III

Forward V

Executive summary VII

Child stunting and human capital in South Asia 1

Introduction 1

Child stunting and human capital in South Asia: a review of the evidence 3

Child stunting and national development: a review of the evidence 7

Trends and inequalities in child stunting in South Asia 9

Drivers of child stunting in South Asia 14

Implications for action 19

Hidden hunger and human capital in South Asia 23

Introduction 23

Hidden malnutrition and the development of nations: a review of evidence 24

Women’s education and hidden malnutrition: a review of evidence 25

Trends in hidden malnutrition in South Asia 28

Drivers of hidden malnutrition in South Asia: a focus on anaemia 31

Implications for action 33

References 37

CONTENTS

Figure 1. Summary of the pathways linking stunting to economic growth 10

Figure 2. Prevalence of stunting (95% confidence intervals) by dietary diversity score groups

(limited data for India and Pakistan) 12

Figure 3. Prevalence of stunting (95% confidence intervals) by mother’s education 12

Figure 4. Prevalence of stunting (95% confidence intervals) by household wealth quintile 13

Figure 5. Fully adjusted odds ratios and 95% confidence intervals for risk factors of stunting among children

aged 6-8 months in South Asia (pooled sample) 16

Figure 6. Fully adjusted odds ratios and 95% confidence intervals for risk factors of stunting among children

aged 6-23 months in South Asia (pooled sample) 17

Figure 7. Prevalence of micronutrient deficiencies by average years of women’s schooling at the country level 26

Figure 8. Prevalence of micronutrient deficiencies globally and in South Asia and Sub-Saharan Africa. 28

Figure 9. Prevalence of anaemia among women of reproductive age across time (1990 to 2012), by country 29

Figure 10. Prevalence of vitamin A deficiency (VAD) among children 6-59 months old across time (1991 to 2013), by country 30

Figure 11. Median urinary iodine excretion (µg/L) by country (2015) 31

LIST OF FIGURES

IV CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

AARR Average annual rate of reduction

BMI Body mass index

CI Confidence interval

DHS Demographic and Health Survey

GDP Gross domestic product

HAZ Height for age z-score

IFPRI International Food Policy Research Institute

IQ Intelligence quotient

LMIC Low and middle income countries

OR Odds ratio

SD Standard deviation

SDG Sustainable Development Goal

SUN Scaling Up Nutrition

UIE Urinary iodine excretion

UNICEF United Nations Children’s Fund

VAD Vitamin A deficiency

WHO World Health Organization

YLD Years lived with disability

ACRONYMS

V

South Asia’s policy decision makers today have vital choices for the economic growth and prosperity of the region.

With inequality rising, the demographic dividend diminishing and middle income traps threatening, the social

and economic options have never been more daunting, or more promising. Today, the most prominent source of

economic growth lies in cognitive and human capital.

Cognitive and human capital cannot be mined or traded, but rather must be carefully cultivated by forward-looking

policies. Investments in children, particularly in the earliest years, yield dividends that help pave the way to an

economic prosperity characterized by the achievement of cognitive and human capital.

Events in early life influence cognitive and human capital. During the first one thousand days between conception

and a child’s second birthday, the brain is developing at an enormous rate. Vitamins, minerals and other nutrients

are essential for healthy brain development. If they are in short supply to the mother during pregnancy or the child

following birth, there can be considerable consequences for growth, brain development, learning and productivity.

This regional report raises a serious concern that poor nutrition in early life is very common in South Asia and

is holding back children, their families and nations from prosperity. The region has a higher percentage (35%)

and number (59.4 million) of stunted children than any other region in the world. Stunted children are short for

their age, and stunting signals that they have been deprived of nutrients for linear growth and for the growth of

essential organs, including the brain. There has also been insufficient progress in reducing vitamin and mineral

deficiencies (known as ‘hidden hunger’) in women and children in the region.

Poor nutrition in early life is not only very common, it is also extremely costly. The annual economic losses from

low weight, poor growth, and vitamin and mineral deficiencies average 11% of GDP in Asia and Africa. Yet, the

returns on investments to prevent stunting and hidden hunger are considerable. Every one centimetre increase in

height is associated with a 4% increase in wages for men and 6% increase in wages for women, and every US$ 1

invested in interventions to reduce stunting will have an average return of US$ 18.

These findings highlight that investments in cognitive and human capital must begin in early life if children

are to achieve their learning potential and benefit from education and training opportunities in later life. These

investments should address the main drivers of stunted growth and hidden hunger, including the poor nutritional

status of adolescent girls and women, both before and during pregnancy, poor diets of children in the first two

years of life, and poor sanitation and hygiene. Cost-effective interventions are available but they need to reach all

children, particularly those who are most marginalized and disadvantaged, as articulated in SAARC’s South Asia

Action Framework for Nutrition.

FOREWORD

Amjad Hussain B. SialSecretary General

South Asian Association for Regional Cooperation

Jean GoughRegional Director

UNICEF Regional Office for South Asia

VI CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

VII

Introduction

The early years of a child’s life provide the best

opportunity to nourish physical and brain development.

There is mounting evidence that poor nutrition in early

life can have long lasting consequences for learning

and future productivity (Victora et al., 2008). When a

girl or boy becomes stunted, it signals that they have

been deprived of nutrients for linear growth and for the

growth of essential organs, including the brain. These

links explain why nutrition has the potential to transform

the lives of the world’s most vulnerable citizens and why

it is so central to the achievement of the Sustainable

Development Goals (Development Initiatives, 2017).

Policy makers require evidence on the impact of poor

nutrition on human capital and the long-term benefits

associated in investments to improve nutrition so that

they can take informed decisions on the allocation of

resources. Nowhere is this more crucial than South

Asia, which bears the highest prevalence (35.0%)

EXECUTIVE SUMMARY

Harriet Torlesse, Rishfa Rasheed, and Victor M. Aguayo

and burden (59.4 million) of stunted children of all

regions in the world (UNICEF et al., 2018) and where

micronutrient deficiencies, known colloquially as

hidden hunger, continue to be a public health concern.

The aim of this report is to review the evidence on the

human and economic impacts of stunting and hidden

hunger and the implications for South Asia. Chapter 1

reviews the current evidence linking stunting with child

development, economic outcomes in adulthood and

economic growth in low- and middle-income countries.

It then examines where to focus policy and programme

attention in South Asia by exploring recent temporal

trends, socioeconomic inequities and predictors of

stunting in children aged 6- 23 months in the five

South Asian countries that account for over 95% of the

region’s stunting burden: Afghanistan, Bangladesh,

India, Nepal and Pakistan. Chapter 2 presents an

overview of the evidence on the human and economic

impacts of micronutrient deficiencies, and recent

patterns and trends in micronutrient deficiencies across

VIII CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

South Asia. It draws on the most recent surveys and

datasets to highlight where gains have been made and

where a lack of progress continues to be of concern

Key findings

There is considerable evidence from many low- and

middle-income countries that support a plausible

link between stunting and poor child development.

The effect sizes vary by development domain, with

greater effects indicated for cognitive and schooling

outcomes. There is also evidence of positive

synergistic interactions between nutrition and early

stimulation on child development. These effects on

child development in early life appear to have long-

lasting economic impacts. For example, two long-run

evaluations found that child nutrition interventions

increased adult wages by 25% (Hoddinott et al., 2008)

and 46% (Gertler et al., 2014), while a one centimetre

increase in stature is associated with a 4% increase in

wages for men and 6% increase in wages for women

(McGovern et al., 2017).

The most common micronutrient deficiencies in South

Asia – iron, vitamin A, iodine and zinc – cause so

much impairment to intellectual development, physical

growth, health and productivity that their hidden

impacts on the economy can also be considerable.

Iron-deficiency anaemia costs low-income countries

an estimated 4% of national income (Horton & Ross,

2003), while low vitamin A status is associated

with an annual loss of 1% of gross national product

(Meenakshi et al., 2010). More often than not, multiple

micronutrient deficiencies combine together in the

same individual, and with other nutrition deficits.

Anemia and iodine deficiency was associated with

a 1% annual fall in national economic growth rates

(Madsen, 2016), and annual economic losses from low

weight, poor growth, and micronutrient deficiencies

average 11% of GDP in Asia and Africa (IFPRI, 2016).

The returns on investments to prevent stunting and

micronutrient deficiencies are considerable. An

analysis of country-specific cost-benefit ratios for

interventions that reduce stunting had a mean value of

1:18 (Hoddinott et al., 2013a), while a separate study

found that a combination of investments to prevent

micronutrient deficiencies could generate annual

benefits of US$ 15.3 billion at a cost:benefit ratio of

1:13 (FAO, 2013).

This body of evidence has immense implications for

South Asia. Although stunting has declined in the

region, the current prevalence remains unacceptably

high. Socio-economic disparities have not declined

over time and in some cases increased for the most

deprived children. In the pooled analysis for the five

countries, short maternal stature and the delayed

introduction of complementary foods are associated

with a significantly higher odds of stunting in infants

aged 6-8 months. In children aged 6-23 months, short

maternal stature, low household wealth, maternal

underweight, failure to meet children’s minimum

dietary diversity, lack of maternal education and

mother’s low age at marriage were the strongest

correlates of child stunting. In addition, children who

are not fully vaccinated or are not fed with a minimum

frequency are at a higher risk of being severely stunted.

In addition, there has been little progress across South

Asia in resolving hidden malnutrition. Several countries

have seriously high levels of micronutrient deficiencies

and others have pockets of unusual severity. The

region has the highest burden of vitamin A deficiency

in children and anaemia in children and women in the

world (Stevens et al., 2013, Stevens et al., 2015), and

the per capita supply of zinc is highly inadequate (Marc

et al., 2016). The underlying and proximate drivers of

deficiencies are numerous, and their respective roles

vary by country context. However, lower household

wealth, lower maternal education, pregnancy status

and increasing parity, and poor quality diets are

common drivers of anaemia in women.

Implications for South Asia

South Asia’s insufficient progress in resolving stunting

and hidden hunger affects the survival, growth,

development and future livelihoods of children,

and continues to hamper the region’s attempts to

accelerate human capital formation. Improvements

in child linear growth and micronutrient nutrition will

allow young children to reach their full growth and

development potential and expand their economic

opportunities as adults, generating substantial

economic returns at the individual and society level, as

well as significant increases in economic growth.

Preventing child stunting and micronutrient

deficiencies should be moved to the forefront of

advocacy, policy, programme, and research agendas in

the region. This renewed attention should focus on the

following priorities:

South Asian countries need to universalize evidence-based policies and programmes designed to improve the nutrition situation of young children and their mothers as a national development priority. Nutrition investments that

IX

focus on adolescence and the 1000 days from

conception to age two years are cost-beneficial.

Research evidence indicates that packages that

combine context-specific nutrition, care, and

stimulation interventions may bring about the

greatest impact on stunting.

Greater attention needs to be paid to ensure that economic growth reduces persistent inequities and addresses the drivers of child stunting and hidden hunger among the most vulnerable population groups. There is increasing

consensus that economic growth will only be

effective in addressing child stunting if increases in

national income are directed at improving the diets

of children, strengthening the status of women,

addressing inequities, and reducing poverty.

Nutrition-specific and nutrition-sensitive programmes should be implemented jointly to address the main drivers of stunted growth and hidden hunger in South Asian children. Nutrition-

specific interventions, such as the protection,

promotion and support of breastfeeding, appropriate

complementary foods and feeding, care and hygiene

practices, adolescent girls’ and maternal nutrition,

micronutrient supplementation, food fortification,

and the prevention and treatment of severe acute

malnutrition and infectious diseases, should be

combined with nutrition-sensitive programmes

that address the more distal determinants of

undernutrition through agriculture, water, sanitation

and hygiene, education and social protection.

There is a need for research and programmatic evidence to better understand how to drive faster and larger declines in stunting and hidden hunger in South Asian countries, particularly among the most vulnerable children: the youngest, poorest, and the socially excluded. Understanding how best to scale up programmes

to improve children’s growth and development is

key area of further inquiry.

X CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

1

CHILD STUNTING AND HUMAN CAPITAL IN SOUTH ASIA

Rockli Kim, Aditi Krishna, Mark E. McGovern, Iván Mejía-Guevara, Jessica M. Perkins, Daniel Corsi, S.V. Subramanian, and Victor M. Aguayo

Introduction

In 2017, there were 151 million stunted children

worldwide. Importantly, about 24% of children younger

than five years in low and middle income countries

(LMICs) had stunted growth (UNICEF et al., 2018).

Stunting is a linear growth failure that has severe short-

term and long-term consequences (Aguayo & Menon,

2016; Onis & Branca, 2016). For instance, stunting is

associated with increased morbidity and mortality from

infections, in particular pneumonia and diarrhea (Black

et al., 2008; Kossmann et al., 2000; Olofin et al., 2013),

and is the cause of about one million child deaths

annually (Aguayo & Menon, 2016). Furthermore,

growth failure in infancy and early childhood is

associated with reduced stature in adulthood (Coly et

al., 2006; Stein et al., 2010), increased risk of maternal,

perinatal and neonatal mortality (Lawn et al., 2005;

Özaltin et al., 2010), and increased risk of chronic

diseases, including elevated blood pressure, renal

dysfunction and altered glucose metabolism (Huxley

et al., 2000; Victora et al., 2008; Whincup et al.,

2008), especially when accompanied by rapid weight

gain in later childhood (Gluckman et al., 2007). In

addition, evidence shows that stunting has functional

consequences that hamper the development of entire

societies. Stunting in early childhood is associated with

poor cognition (Prendergast & Humphrey, 2014) and

worse educational performance in school-age children

(Adair et al., 2013; Martorell et al., 2010a), as well as

lower productivity and reduced earnings in adult men

and women (Hoddinott et al., 2013a).

To understand the full impact of stunting in early

childhood, we review current evidence linking stunting

to child development and individual and national

2 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

we provide a comprehensive analysis of social and

economic inequalities in stunting prevalence, within

and among South Asian countries and stunting rates

over time. We also investigate inequalities in stunting

due to multiple dimensions of deprivation (poor child

diets, low maternal education, and household poverty).

Based on a time-series analysis using multiple, cross-

sectional Demographic and Health Surveys (DHS) on

children aged 6 to 23 months in Bangladesh, India,

Nepal, and Pakistan from 1991-2014, we find that all

countries had markedly high stunting prevalences and

that, although stunting rates declined in all countries,

Bangladesh and Nepal recorded the largest reductions.

Moreover, we find that there were heterogeneous

changes over time between countries and among

groups defined by multiple dimensions of deprivation

within countries. For instance, there was greater

stunting among children who had poorer diets, had

mothers with low educational attainment, and/or lived

in poor households within all South Asian countries.

Although there were marked declines in stunting in

the most deprived groups in some countries, socio-

economic differences in the prevalence of stunting

were largely preserved over time, and in some cases

worsened, namely among wealth quintiles.

In Section four, we assess the relative importance of 13

correlates of child stunting and severe stunting selected

based on a collective review of existing multi-factorial

frameworks: breastfeeding, complementary feeding

(timely introduction, feeding frequency and dietary

diversity), maternal height, body mass index (BMI),

education, and age at marriage, child vaccination,

access to improved drinking source and sanitation

facilities, household indoor air quality, and household

wealth. We use the most recent DHS from Bangladesh

(2014), India (2006), Nepal (2011), and Pakistan (2013),

and the National Nutrition Survey from Afghanistan

(2013), and find that in South Asia (combined sample),

short maternal stature and delayed introduction of

complementary foods are associated with a significantly

higher risk of stunting in infants aged 6-8 months. In

children aged 6-23 months, failure to meet children’s

minimum dietary diversity, mothers’ short stature,

underweight, lack formal education, or underage at

marriage, and poor household wealth are statistically

significant risk factors for child stunting. In addition,

children who are not fully vaccinated or are not fed

with a minimum frequency are at a higher risk of being

severely stunted. Some differences were found in the

relative ordering and statistical significance of the

correlates in country-specific analyses.

Our findings make important contributions to the existing

evidence demonstrating that eliminating child stunting

economic outcomes. In Section 1, we summarize

the evidence on stunting and child development in

low- and middle-income countries and discuss the

issues for further research. We focus on studies

measuring low height-for-age caused by experiences

of chronic nutritional deprivation among children less

than 5 years old as the exposure and gross/fine motor

skills, psychosocial competencies, cognitive abilities,

or schooling and learning milestones as outcomes.

This review highlights three key findings. First, the

variability in child development tools and metrics used

among studies and the differences in the timing and

frequency of the assessments complicate comparisons

across study findings. Second, despite methodological

differences and differential associations, considerable

evidence from across many countries supports

an association between stunting and poor child

development. Effect sizes differ by development domain

with greater effects shown for cognitive/schooling

outcomes. How stunting influences child development,

which domains of child development are more affected,

and how the various domains of child development

influence one another require further research. Finally,

there is some evidence of positive synergistic interaction

between nutrition and stimulation on child development.

However, understanding how best to improve child

developmental outcomes – either through nutrition

programs or integrated nutrition and psychosocial

stimulation – is a key area of further inquiry.

Focusing on the costs of stunting to children and

societies supports the case for investing in childhood

nutrition. In Section 2, we review the literature on the

association between stunting in early childhood and

economic outcomes in adulthood. At the national

level, we also evaluate the evidence linking stunting

to economic growth. Two long-run evaluations of

randomized childhood nutrition interventions indicate

substantial returns to the programs (a 25% and 46%

increase in wages for those affected as children).

Cost-benefit analyses of nutrition interventions using

calibrated return estimates have been found to range

from 3.5:1 to 42.7:1 per child, with a median of

17.9:1. Assessing the wage premium associated with

adult height, we find that the median return to a 1

centimetre increase in stature is associated with a 4%

increase in wages for men and a 6% increase in wages

for women in the set of studies that have attempted to

address unobserved confounding and measurement

error. In contrast, the evidence on the impact of

economic growth on stunting is mixed.

South Asia bears 40 percent of the global burden of

child stunting. Hence, the third and fourth sections

specifically focus on trends in stunting rates and risk

factors of stunting in South Asia. In Section three,

3

needs to be moved to the forefront of the advocacy,

policy, programmatic and research agendas. In Section

5, we conclude with a summary of the implications for

sustainable development (universal education, poverty

reduction, improved equity and shared prosperity),

policy formulation, strategy design, programme scale

up, and research post 2015 in South Asia.

Child stunting and human capital in South Asia: a review of the evidence

Introduction

Establishing a causal relationship between stunting

and child cognitive development is complicated.

Stunted children are more likely to grow up in

conditions of overall deprivation (Grantham-McGregor

et al., 2007) that affect physical growth and child

development, potentially confounding the relationship

between stunting and child cognition. Yet, if stunting

causes developmental deficits, the consequences

at the population-level are immense considering the

151 million children who are stunted (UNICEF et al.,

2018). Moreover, global development priorities (e.g.,

the 2015 Sustainable Development Goals) and experts

in child development have set the stage for further

prioritizing research and interventions to address the

global challenge of poor child development (Black et

al., 2016; Britto et al., 2016; Dua et al., 2016; Richter

et al., 2016). Therefore, if there is a strong evidence

base linking stunting and child development, this

strengthens the case for investing in programmes

targeted at reducing the prevalence of stunting.

We provide a substantive review of the association

between stunting and child development across

the world, citing both correlational evidence as

well as studies that aim to address causality,

including interventions. Our intention is to create a

useful repository of information for policymakers,

practitioners, and program managers, or researchers

new to these fields, who seek to address stunting and

child development challenges and consequences,

particularly in low- and middle-income countries.

Thus, this review summarizes the literature on

stunting and child development with the objective of

understanding the conceptual relationships between

stunting as a measure of nutritional deprivation and

child development, which can generally be defined as

the attainment of gross motor and fine motor skills,

psychosocial competencies, and cognitive abilities.

Identifying peer-review evidence on stunting and child development

We conducted a comprehensive review of key

databases in public health, economics, social science,

and psychology (PubMed, Web of Science, PsycInfo

and Embase) to identify studies on stunting and child

development to include in this review. We searched

for studies or reviews of studies assessing height (or

length) among 0-5 year old children as an exposure

for child development. Height could be measured as

(a) height-for-age, which is a linear growth measure

standardized into z-scores using international growth

standards or (b) stunting, which is a widely used

binary indicator of chronic undernutrition in infancy

and early childhood (WHO, 2006). We further required

studies and reviews to have focused on at least one

measure of child development as the outcome. Most

child development assessment tools focus on major

educational milestones, measure a specific individual

developmental domain (e.g., gross motor skills,

fine motor skills, or psychosocial development), or

represent a battery of skills tests. The following search

terms were used: cognition, cognitive, awareness,

consciousness, cognitive disorder, intelligence,

intelligence tests, mental tests, achievement,

achievement tests, school readiness, psychosocial,

behavior, attitude, height, stunting, stunt, height-for-

age, anthropometry, anthropometric, growth, growth

disorders, infant, infancy, child, childhood, adolescent,

adolescence, teenage, youth. Only studies published in

English were included.

Challenges with child development assessments

Most child development assessments were designed

for use with English-speaking populations in high-

income countries. Thus, there are challenges with

using them with children in low- and middle-income

countries (Grantham-McGregor, 1984, 1993). Although

many of the metrics have been adapted for local

contexts, they may not be appropriate for children

living in poverty and lead to biased testing results

(Isaacs & Oates, 2008; Prado & Dewey, 2014). In

addition, studies on child development often evaluate

learning and schooling outcomes such as grade

completion or years of schooling in lieu of cognitive

tests as the more specific tests are difficult to adapt

and administer in diverse contexts and even more

challenging to compare across these different settings.

Yet, the quality of education, the selection of material

that is taught, and the amount of learning that occurs

during years of education, vary both within and

between countries (Behrman & Birdsall, 1983).

4 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

Moreover, the use of different child development tools

and metrics across studies and differences in the

timing and frequency of the assessments complicate

comparisons of findings in the literature (Grantham-

McGregor & Baker-Henningham, 2005; Sudfeld et al.,

2015). In addition, implementation of assessments

varies in practice. For cognitive assessments, children

most often engage in the testing. In contrast, to

assess motor and psychosocial development,

parents, teachers, or an observer often assess a

child’s skills. Therefore, children’s performance on

these assessments is not only a measure of their

abilities, but also reflects their interactions with the

test administrator and the testing situation (Isaacs &

Oates, 2008). Lastly, there are also differences in how

test results are analyzed. Some studies use number

of successes as measures of cognitive ability (e.g.,

number of objects correctly identified by children

taking the Peabody Picture Vocabulary Test) while

others transform the raw numbers of successes into

age-standardized z-scores or percentiles (Cheung et

al., 2008). Given this background, these differences

in testing approaches and methodology need to be

considered when interpreting findings in the literature

(Cheung et al., 2008).

Evidence of a link between stunting and child development

Cross-sectional observational studies

A recent review found that across studies, height-for-

age z-scores (HAZ) among children three years old or

younger were positively associated with gross motor

scores (Sudfeld et al., 2015). Similarly, HAZ scores

were positively associated with cognitive scores

among children 0-23 months old, and, to a lesser

extent, also with cognitive scores among children aged

two and older (Sudfeld et al., 2015). Due to differences

in how psychosocial development was measured and

the small number of studies included, generalized

findings about the association between HAZ and

psychosocial development could not be established.

Overall, these studies show a positive relationship

between child height and child development.

(Abubakar et al., 2008; Avan et al., 2010; Bogale et

al., 2013; Crookston et al., 2011; Fernald et al., 2006;

Handal et al., 2007; Kariger et al., 2005; Ketema et al.,

2003; Kordas et al., 2004; Kuklina et al., 2006; Mohd

Nasir et al., 2012; Olney et al., 2009; Olney et al., 2007;

Siegel et al., 2005; Taneja et al., 2005)

Longitudinal observational studies

The same recent review study described above also

reported positive prospective associations between

HAZ at 3 years old or younger and gross motor

scores at age 5-8 years and also between HAZ at two

years old or younger and cognition at age 5-11 years

(Sudfeld et al., 2015). In addition, evidence across

several studies suggested that stunting was associated

with poor psychosocial development among children

who were stunted at age 9-24 months. Most studies

indicated an association between stunting or child

height and child development across each of the

developmental domains. (Adair et al., 2013; Alberto

Camargo-Figuera et al., 2014; Aubuchon-Endsley et

al., 2011; Aurino & Burchi, 2014; Berkman et al., 2002;

Casale et al., 2014; Chang et al., 2002; Chang et al.,

2010; Cheung & Ashorn, 2010; Cheung et al., 2008;

Cheung et al., 2001; Crookston et al., 2013; Hamadani

et al., 2012; Hamadani et al., 2014; Kuklina et al., 2004,

2006; Lima et al., 2004; Meeks Gardner et al., 1999;

Mendez & Adair, 1999; Niehaus et al., 2002; Pollitt et

al., 1993; Sanchez, 2013; Walker et al., 2007a; Walker

et al., 2000; Whaley et al., 1998; Yang et al., 2011).

Quasi-experimental studies

Quasi-experimental studies have provided some

evidence that stunting causes cognitive impairments.

These studies used instrumental variables, such as

rainfall or food price shocks, or natural experiments in

the form of social welfare programs (i.e., the Protective

Safety Nets Program, the National Rural Employment

Guarantee Scheme, or similar initiatives), which are not

randomly implemented but are plausibly exogenous to

stunting and cognitive status. Other quasi-experimental

studies use data from siblings to account for

unmeasured confounding at the household level. Most

of these studies have found negative effects of stunting

on cognitive development with varying effect sizes

(Dercon & Porter, 2014; Glewwe et al., 2001; Glewwe &

King, 2001; Leight et al., 2015; Outes-Leon et al., 2011;

Umana-Aponte, 2011).

Experimental studies on social welfare

Some experimental studies assess how program-

facilitated changes in nutritional status influence child

development by studying the effects of social welfare

programs, which enroll participants randomly. Two

out of five studies included in this review found that

improvements in cognitive development due to cash

transfer programs were mediated by increases in height

(Fernald et al., 2008; Fernald et al., 2009). In contrast,

the other three studies indicated that cash transfers

had no effect on height, but independently improved

cognition (Fernald & Hidrobo, 2011; Macours et al.,

2012; Paxson & Schady, 2010). However, follow-up

periods in these studies may not have been long enough

to observe changes in height or stunting status.

5

Experimental studies on nutrition supplementation

Only two out of seven studies included in this review

found improved motor development among children

who received nutrition supplementation and no study

found psychosocial development benefits. In contrast,

several studies included in this review found that

early nutrition supplementation appeared to influence

cognitive development (Chang et al., 2010; Grantham-

McGregor et al., 1991; Grantham-McGregor et al.,

1997; Grantham-McGregor et al., 1996; Meeks Gardner

et al., 1999; Nahar et al., 2012; Pollitt et al., 1993;

Pollitt et al., 1995; Pollitt et al., 1997; Vazir et al., 2012;

Waber et al., 1981; Walker, 2006). A recent review of

more than 20 postnatal nutrition intervention studies

among children under two years of age in low- and

middle-income countries found small effects on mental

development (Larson & Yousafzai, 2017). Although

some evidence suggests that nutrition supplementation

improves developmental outcomes, there is significant

heterogeneity in the design of the studies. Moreover,

the effects of supplementation may not be uniform

and may instead depend on many factors which non-

experimental studies have been found to be relevant

for child development, such as the timing and duration

of the intervention (Martorell, 1995; Pollitt et al., 1995),

child sex (Martorell, 1995; Waber et al., 1981) and

socioeconomic status (Pollitt, 2009; Pollitt et al., 1993;

Pollitt et al., 1995).

Interventions integrating nutrition supplementation and stimulation

Comprehensive summaries of existing studies that

examined integrated programs are provided in recent

reviews (Black et al., 2015; Grantham-McGregor

et al., 2014). In addition, one paper reviewed the

implementation of integrated nutrition and psychosocial

stimulation (Yousafzai & Aboud, 2014) and a more

recent study reviewed the benefits and challenges of

implementing integrated interventions to address early

childhood nutrition and development (Hurley et al.,

2016). Of the six studies included in the present review,

two found that the combined treatment effects (i.e.,

nutrition supplementation plus psychosocial stimulation)

were significantly more effective than either alone

for motor skills and cognitive development among

children in Bangladesh (Nahar et al., 2012) and Jamaica

(Grantham-McGregor et al., 1991). However, the additive

effect of combined treatments was no longer significant

four years after the end of the study in Jamaica

(Grantham-McGregor et al., 1997). Other studies

found no interaction between the two interventions on

stunting and child development (Chang et al., 2010;

Meeks Gardner et al., 1999; Walker et al., 2007a).

Potential pathways

The associations between stunting and child

development present in some of the papers we

reviewed may be due to a variety of different processes

linking the exposure and outcome. Although it is

a nascent area of work, several studies suggest

various mechanistic pathways, including neurological

pathways (Black, 1998; John et al., 2017; Lozoff,

2007; Vohr et al., 2017), hormonal (Berger, 2001;

Le Roith, 1997; van Pareren et al., 2004), functional

isolation pathways (Grantham-McGregor et al., 2007),

stress (Fernald & Grantham-McGregor, 1998; Soeters

& Schols, 2009; Wachs et al., 2013), stigma (Currie

& Vogl, 2013), and pathways related to infectious

diseases (Black et al., 2013; UNICEF, 2013; Walker et

al., 2007b). The research to date, however, is often

unclear on whether such factors act as mediators or as

precursors to stunting.

In addition, there may be dynamic interplays between

these processes. For example, impaired motor

development may mediate the relationships between

stunting and cognitive development (Larson &

Yousafzai, 2017). Stunted children with lower motor

activity are more likely to be carried by caregivers,

further handicapping motor development and

inhibiting cognitive and psychosocial development

attained through independent exploration of

environments (Adolph et al., 2003; Kariger et al., 2005;

Meeks Gardner et al., 1995; Olney et al., 2007; Siegel

et al., 2005). Greater apathy as well as distress in

stunted children (Grantham-McGregor, 1995; Pollitt,

2000) increase the likelihood that caregivers treat

stunted children as if they were younger, resulting in

a lack of age-appropriate stimulation (Kuklina et al.,

2004). This evidence supports the idea that children’s

motor, psychosocial, and cognitive development occur

in an interactive and dynamic manner with significant

influence from their social environments (Wachs et al.,

2013). However, the lack of study designs permitting

rigorous mechanistic study prohibits a definitive

layout of a complete framework for pathways and

mediators. Research on these pathways (as well as

other potential mechanisms) is still in its early stages,

and future work may be able to shed light on this

important issue, which will be of particular interest to

policy makers trying to identify potential interventions

designed to improve child development.

6 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

Further questions about stunting and child development

Timing of nutrition interventions

Nutrition intervention effects on cognition may be

greatest in the first two years of life (Pollitt et al.,

1993). This claim is supported by findings from several

observational studies (Pongcharoen et al., 2012; Sudfeld

et al., 2015). However, it is difficult to draw strong

conclusions on this issue, at least in respect to the pre

and postnatal periods, as some studies have found

either no difference in associations between prenatal

and postnatal linear growth and cognition (Yang et al.,

2011) while others have found that postnatal growth

is more salient (Adair et al., 2013; Kuklina et al., 2004).

Children who experience developmental impairments

due to nutritional deprivation in the first 1,000 days may

be able to recover later on (Levitsky & Strupp, 1995;

Strupp & Levitsky, 1995). Moreover, brain development

continues into adulthood (Thompson & Nelson, 2001)

with important periods of growth in adolescence and

early adulthood (Isaacs & Oates, 2008; Wachs et al.,

2013). Furthermore, growth faltering can also happen

after the first two years (Lundeen et al., 2013; Prentice

et al., 2013), suggesting that children may also be

vulnerable to impaired development later in later life

(Crookston et al., 2011).

Long-run associations and the role of catch-up growth

The degree to which associations between early

stunting and later cognition are mediated by later

growth remains unclear. While some studies find

that children who catch-up in growth are also able

to recover in development (Cheung & Ashorn, 2010;

Crookston et al., 2010a; Crookston et al., 2010b;

Crookston et al., 2013; Gandhi et al., 2011; Mendez

& Adair, 1999), other work finds that catch-up

growth does not help children recover cognitive

deficits (Sokolovic et al., 2014). Moreover, there is no

conclusive evidence about the best timing for catch-up

growth (Cheung & Ashorn, 2010; Gandhi et al., 2011).

Further research is required to resolve the ambiguity

about critical windows for physical and cognitive

development as well as the role of catch-up growth.

Differential effects on development domains

Many of the nutrition studies report improvements in

cognitive development but no impact on gross or fine

motor development or psychosocial development.

While it is possible that there are heterogeneous

effects which differ by domain, perhaps current

assessments for gross and fine motor development

and psychosocial development do not adequately

reflect the positive impact of nutrition interventions.

Alternatively, there may be dynamic interactions not

captured by analyses. Advanced statistical techniques

such as structural equation models, which allow for

an investigation into interactions between multiple

determinants, may help illuminate the pathways by

which different developmental domains influence one

another and how nutritional status may directly or

indirectly influence developmental outcomes.

Integrating interventions

Child development occurs in a dynamic fashion in

which children’s characteristics interact with the social

environment to influence their development. Therefore,

impact of integrated interventions may be stronger

than any nutrition supplementation alone (Black et

al., 2015). Although evidence on synergy between

nutrition and stimulation interventions is inconsistent

and inconclusive, some evidence supports the addition

of stimulation to nutrition programs to improve child

growth as well as developmental outcomes in the long-

run (Alderman et al., 2014; Black et al., 2015; Christian

et al., 2015; DiGirolamo et al., 2014; Fernandez-Rao et

al., 2013; Grantham-McGregor et al., 2014). Moreover,

while studies have largely focused on integrated

interventions that combine macro- or micronutrient

supplementation with psychosocial stimulation to

improve child development outcomes, there is little

evidence on the interaction between child development

and other exposure variables such as sanitation, hygiene,

access to health care, and early responsive learning

interventions. Thus, there is a need for comprehensive

evaluations of a variety of integrated programs, including

those addressing macronutrient deficiencies combined

with child stimulation and hygiene and sanitation

intervention (Larson & Yousafzai, 2017), and especially

concerning the long-term sustainability of benefits.

Despite inconsistent evidence on synergistic interaction

between nutrition and stimulation on child development,

simultaneous implementation of cross-functional policies

and programs at the population level aimed at improving

food security, reducing poverty and social inequalities,

and improving maternal education has exhibited success

in reducing undernutrition in some countries in South

East Asia and Latin America (DiGirolamo et al., 2014).

Finally, a recent review concluded that multi-sectoral

approaches combining nutrition, health, education, child

protection, and social protection are critical for building

successful and sustainable interventions, and that

families and caregivers should be supported in providing

nurturing care (Britto et al., 2016).

7

Conclusion

Our comprehensive review of stunting and child

development has three salient findings. First, there is

considerable heterogeneity in the methodology used

to examine the relationship between child stunting

and child development. Such heterogeneity makes

comparisons of study findings difficult. Creating

a harmonized way to measure and evaluate the

relationship between stunting and child development is

one solution. Second, there is evidence that stunting is

plausibly linked to poor developmental outcomes among

children despite variability across studies. How stunting

influences child development, which domains of child

development are more affected, and how the various

domains of child development influence one another

all require further research. Finally, understanding

how best to improve developmental outcomes – either

through nutrition programs or integrated nutrition

and psychosocial stimulation – is a key area of further

inquiry. This process requires a better understanding

of the complex relationship between stunting and the

different domains of child development and scaling up

proven interventions to target these multiple, interacting

factors. Improving multiple aspects of the early life

environment that are critical for child development may

have synergistic effects. However, more research is

needed to rigorously evaluate the effects of these types

of integrated programs, particularly in the long-run.

Given that nearly 40% of children under age five

suffer from loss of developmental potential - for which

stunting is likely one of the key risk factors - reductions

in stunting could have tremendous implications for child

development and human capital formation, particularly

in low- and middle-income countries. If interventions are

able to address the etiology of stunting, or preferably

the etiologies of stunting and other determinants of

poor child development such as poor child stimulation

or poverty simultaneously, all of which are concentrated

in resource-poor settings, they are likely to be more

effective in targeting the root causes of developmental

deficits in young children than interventions which focus

solely on educational outcomes.

Child stunting and national development: a review of the evidence

Introduction

Assessments of the effects of child stunting on

economic outcomes provide an evidence base for

interventions targeted at preventing stunting and assist

in identifying priorities for national and international

efforts (Halim et al., 2015). Despite the potential

substantial returns of programs aimed at reducing

stunting (Gertler et al., 2014; Hoddinott et al., 2008),

progress in reducing stunting has been sub-optimal

in many countries (Stevens et al., 2012). The aim of

Section 2 is to provide a comprehensive review of the

evidence of the long run economic impact of child

undernutrition, as measured by stunting. Assessing

the potential economic benefits of investments in child

nutrition will inform whether these programs are an

efficient use of public funds. We also consider the

evidence linking child undernutrition and economic

growth at the national level, and conclude with a

discussion of the implication of these findings for

countries with high stunting prevalence in the context

of Sustainable Development Goals (SDGs) post-2015.

Methods

We conducted a literature search for published studies

up to July 2015 which examined whether childhood

stunting was associated with economic outcomes in

later life. We used the Pubmed and Econlit databases

to search for keywords in abstracts and titles related

to the following economic outcomes; wages,

income, salary, pay, earnings, productivity, capital,

resources, work, employment, industry, hours worked,

occupation, labour, sector, job, socioeconomic,

savings, economic, returns, make ends meet, welfare,

poverty; and the following measures of childhood

undernutrition; stunting, child development, growth

retardation, growth trajectory, linear growth, linear

growth retardation, growth faltering, growth failure,

early life growth failure, child undernutrition, child

malnutrition, child nutrition.

Findings for stunting in early childhood and economic outcomes in adulthood

There are two long term follow ups to nutrition

intervention studies. The first, the Institute of Nutrition

of Central America and Panama (INCAP) study (Engle &

Fernandez, 2010; Stein et al., 2008), allocated nutritional

supplements to pregnant women and infants in two

Guatemalan villages in the late 1960s and 1970s.

While not a pure randomized design, two nearby

comparison villages did not receive the supplements.

Studies which follow the INCAP children into adulthood

find positive effects of nutritional supplementation in

early childhood on economic outcomes in adulthood,

including increased productive capacity, wages, and

expenditure, and lower probability of living in poverty

8 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

(Haas et al., 1995; Haas et al., 1996; Hoddinott et al.,

2005; Martorell et al., 2010b). Intention to treat analysis

(ITT) found that men who received the supplements

as children had, on average, a 46% increase in wages

(Hoddinott et al., 2008). The association was not found

to be statistically significant for women. An instrumental

variables analysis found that a one standard deviation

(SD) increase in HAZ at age 2 years was associated with

a subsequent 21% increase in household per capita

expenditure and a 10 percentage point decrease in the

probability of reporting living in poverty at ages 25-42

years (Hoddinott et al., 2013b). A second intervention

study in Jamaica in the mid-1980s randomly allocated

undernourished children to a nutrition supplementation

intervention, psycho-social stimulation, combined

nutrition and stimulation, and a control group (Gertler et

al., 2014). These children were subsequently interviewed

in 2007-2008 at age 22 years. Those who benefited

from stimulation or combined nutrition and stimulation

interventions as children were found to have 25%

increased earnings relative to the control group.

Prospective analyses evaluate the association between

measured height in childhood and economic measured

outcomes in adulthood. Many of these analyses are

based on cohort studies in the UK, Brazil, and the

Philippines (Adair et al., 2011; Elliott & Shepherd, 2006;

Power & Elliott, 2006; Victora & Barros, 2006). Only

one study in Barbados (1967-1972) includes a matched

control group and has followed a cohort of children

who were hospitalized because of undernutrition

during the first year of life and a matched cohort of

children who did not experience undernutrition (Galler

et al., 2012). Children who experienced undernutrition

as children were found to be lower on social position

and standard of living indices in adulthood. An early

study in India found that HAZ at age 5 years was

associated with lower work capacity at age 14-17 years

(Satyanarayana et al., 1978; Satyanarayana et al., 1979).

In the Philippines, better HAZ at age 2 years was found

to be associated with an increase in the probability

of being engaged in formal work at age 20-22 years,

both in men and women (Carba et al., 2009). Research

from US and UK cohort studies has found that height

at various stages in childhood and adolescence is

positively related to work status, wages, and measures

of socioeconomic status in later life (Case et al., 2005;

Case & Paxson, 2008; Montgomery et al., 1996; Persico

et al., 2004; Sargent & Blanchflower, 1994). In a cohort

of men born in Helsinki, Finland, between 1934 and

1944, length in the first year of life was associated with

subsequent earnings (Barker et al., 2005). A review of

three cohort studies in LMICs found that HAZ at age 2

years was associated with an 8% increase in income in

Brazil and Guatemala, and a 21% increase in household

assets in India (Victora et al., 2008).

Cost benefit analysis of childhood nutrition interventions

A number of publications focus on the cost-benefit

analysis of interventions aiming to reduce child

stunting and estimate the economic impact of stunting

reduction. A micronutrient supplementation and

early childhood stimulation program in Nicaragua

was found to have a cost-benefit ratio of 1.5 (Boo et

al., 2014). An intervention in Indonesia was found to

have a cost-benefit ratio of 2.08 based on productivity

enhancements from reduced undernutrition, earnings

from deaths averted, and household savings from

health care costs avoided (Qureshy et al., 2013). In a

review of cost-benefit ratios of nutrition interventions,

estimates ranged from 3.5:1 to 42.7:1 per child, with a

median of 17.9:1 (Hoddinott et al., 2013a).

A similar methodology has been used to estimate the

aggregate burden of stunting at a national level and

worldwide. Productivity gains due to reductions in child

stunting in China over the period 1991 to 2001 were

estimated at US$ 12 billion in 2001 (Ross et al., 2003)

while the productivity-related costs of stunting in Peru

were estimated at 2.2% of gross domestic product

(GDP) (Alcázar et al., 2013). The cost of undernutrition

in Cambodia has been estimated at more than US$

400 million annually, or approximately 2.5% of yearly

GDP, of which 57% is a result of undernutrition in early

childhood (Bagriansky et al., 2014). Based on a model

originally developed for Latin America (Fernández &

Martínez, 2007), the Cost of Hunger in Africa (COHA)

study aims to provide economic estimates of the costs

of malnutrition in 13 countries. A recent report on

Malawi indicated that the costs associated with stunting

were of the order of 10% of GDP per year (African Union

Commission/World Food, 2015). The annual GDP loss

due to undernutrition has been estimated to be up to

12% in LMICs (Horton & Steckel, 2011).

Stunting and economic growth

Individual level estimates of the costs of stunting do

not take into account the potential spillover effects on

aggregate capital formation, labour markets, savings

and investment behavior, and other factors that make

up the determinants of economic growth. Relevant

pathways, summarized in Figure 1, include increases

in morbidity, mortality and health expenditure, and

reductions in human capital investment (for example,

education), physical capital investment, and labour

supply. Productivity may suffer because of ill health or

9

reduced work capacity in adulthood, and reductions

in human capital and technological progress (due to

lower cognitive development or levels of educational

attainment and infrastructure). Other channels include

the impact of undernutrition on chronic disease, which

would involve the diversion of productive savings,

which boost investment, towards unproductive

treatment costs (Bloom et al., 2014). While the

available evidence indicates a strong association

between economic growth and proxies for nutritional

status in childhood (Arora, 2001; Chakraborty et al.,

2010; Dalgaard & Strulik, 2015; María-Dolores &

Martínez-Carrión, 2011; Piper, 2014; Weil, 2007), it is

hard to quantify the causal magnitude of these effects.

One recent paper finds that each centimetre increase

in height at the population level is expected to raise

income per capita by 6% (Akachi & Canning, 2015).

There are numerous pathways through which poverty,

and therefore income per capita, are expected to

impact the nutritional status of children. For example,

capacity to purchase food, raising both the quantity

and the quality of food and nutrient intake by women

and young children. In addition, net nutritional intake is

also likely to increase because of reductions in the risk

of infection and poor health (Shekar et al., 2006). At

the national level, education, infrastructure and health

services are all positively associated with GDP. However,

economic growth may not necessarily translate into

improvements in household income due to unequal

sharing of growth gains and lack of access to public

and private services (Haddad, 2015; Lawrence et al.,

2015). The impact of a 10% increase in GDP per capita

in the short-run is generally estimated to be in the range

of 0-2 percentage point absolute decrease in stunting

prevalence (Bershteyn et al., 2015; Harttgen et al., 2013;

Headey, 2013; Heltberg, 2009; Ruel et al., 2013; Smith

& Haddad, 2002; Vollmer et al., 2014; Webb & Block,

2012), although some estimates, particularly those

which focus on long run changes in national income,

are found to be larger (Haddad et al., 2003; Ruel et al.,

2013; Smith & Haddad, 2002). In contrast, a recent

analysis of Indian states found that economic growth

was not associated with reductions in stunting or other

measures of undernutrition (Subramanyam et al., 2011).

One paper examined whether the timing of economic

growth is important for attained height and found that

economic growth in the first year of life and puberty

were most associated with the adult height of women in

sub-Saharan Africa (Moradi, 2010).

Conclusion

Welcome progress has seen stunting fall from 50% in

1970 to 30% in 2010 in LMICs. However, the prevalence

of stunting remains high in some regions, and is

currently at 38% in South Asia and 37% in sub-Saharan

Africa. Assessing the wage premium associated with

adult height, we find that the median return to a 1

centimetre increase in stature is associated with a

4% increase in wages for men and a 6% increase in

wages for women in our preferred set of studies which

have attempted to address unobserved confounding

and measurement error. In contrast, the evidence on

the impact of economic growth on stunting is mixed.

Further evidence needs to inform how best to prioritize

effective and cost effective interventions to reduce

stunting in the most adversely affected areas.

Trends and inequalities in child stunting in South Asia

Introduction

Recognizing the importance of early child nutrition,

much global attention has focused on averting child

undernutrition through the Millennium Development

Goals, the Scaling Up Nutrition (SUN) movement, and

the SDGs, which endorse the World Health Assembly’s

target of reducing the number of stunted children

aged 0-59 months by 40% by 2025 (UN, 2015b). A

key recommendation from these initiatives is the need

for better quality data, information and analyses to

understand who is most vulnerable to stunting (Black

et al., 2013). Following on this recommendation,

Section 3 seeks to provide a comprehensive

assessment of the patterns in child stunting in South

Asia with particular attention to temporal trends and

variations in the prevalence of stunting among different

socioeconomic groups.

There is substantial evidence that child stunting follows

a socioeconomic gradient (Akhtar, 2015; Di Cesare et

al., 2015; Gaiha & Kulkarni, 2005; Kanjilal et al., 2010;

Kumar & Kumari, 2014; Kumar et al., 2014; Menon,

2012). In this section, we look at the patterning of child

stunting along three domains of deprivation: 1) children’s

access to food, represented by dietary diversity; 2) social,

represented by maternal educational attainment; and 3)

economic, represented by household wealth. Together,

these three domains represent three levels of the

determinants of child nutrition – child-level, mother-level,

and household-level – in UNICEF’s conceptual model of

nutrition (UNICEF, 2013). While much work considers

the second two aspects of deprivation (Gaiha & Kulkarni,

2005; Kumar & Kumari, 2014; Kumar et al., 2014), to our

knowledge, only a few studies consider all three domains

of deprivation in South Asia (Di Cesare et al., 2015;

10 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

Kanjilal et al., 2010). We focus on children ages 6-23

months as the first two years of life are critical for linear

growth and growth faltering (Victora et al., 2010), and

the existing population surveys assess dietary diversity

in children aged 6-23 months, after the initial six-month

exclusive breastfeeding period. We identify patterns in

the prevalence of stunting by children’s dietary diversity,

mother’s education, and household wealth and examine

temporal changes in the prevalence of stunting in groups

defined by these social and economic dimensions of

deprivation. Furthermore, we consider both absolute

and relative changes in the prevalence of stunting by

categories of deprivation to understand inequalities in the

prevalence of child stunting more comprehensively.

Methods

We used cross-sectional data from 15 DHS, collected in

Bangladesh, India, Nepal, and Pakistan between 1991

and 2014. The final analytic sample comprised 55,459

children aged 6 to 23 months. In the dietary diversity

analyses for India and Pakistan, only 13,570 children

from the latest survey were included due to lower data

availability and/or quality in the previous surveys.

Linear growth was measured as length in younger

children (6-23 months) using Shorr measuring boards,

which are adjustable to the nearest millimetre (WHO,

2006). Measurements were standardized into HAZ

using WHO age- and sex-specific child growth

standards. Children who were two SD or more below

median HAZ score were classified as stunted.

We considered three domains of deprivation as key

explanatory variables: child dietary diversity, mother’s

education, and household wealth. Dietary diversity

was measured using a score (Corsi et al., 2016; WHO,

2008; WHO, 2010) ranging from 0 to 7, based on the

number of food groups a child was fed during the 24

hours preceding the survey. The seven food groups

are: 1) grains, roots and tubers; 2) legumes and nuts;

3) dairy products (milk, yogurt, cheese); 4) flesh foods

(meat, fish, poultry and liver/organ meats); 5) eggs; 6)

vitamin-A rich fruits and vegetables; 7) other foods and

vegetables. Dietary diversity scores were categorized

in three groups - low, medium, and high - depending

of the level of dietary diversity and using the following

cut-offs from the dietary diversity score: 0-1, 2-3, and

4-7, respectively. Children 6-23 months old with a

dietary-diversity score between 4 and 7 were classified

as meeting the minimum dietary diversity (WHO,

2010). Mother’s education was stratified in 3 levels:

no education, primary, and secondary and higher.

Wealth quintiles were provided by the DHS (Rutstein &

Johnson, 2004).

We estimated the weighted prevalence of stunting over

time and by children’s dietary diversity group, mother’s

Stunting

Morbidity

Human CapitalInvestment

LabourSupply/Productivity

Economic Growth

Physical CapitalInvestment

MortalityHealth

Expenditure

Figure 1. Summary of the pathways linking stunting to economic growth

Adapted from Bloom et al. (2014)

11

education level, and household wealth quintile. We

estimated the percentage change in the prevalence

of stunting between the earliest and latest estimates

from each country within each group. We also

estimated Average Annual Rate of Reduction (AARR),

which is annualized change in stunting prevalence

for each subgroup, to account for differences in time

intervals between the earliest and latest surveys within

countries. Absolute and relative differences were

calculated between the two categories in dichotomous

social groups, and between the lowest and highest

categories in categorical groups, for both the earliest

and latest survey years in every country. Standard

design-based confidence limits were approximated

using the logit transformation procedure, which

guarantees that the endpoints of the estimated

proportion lie between 0 and 1. Adjusted models were

also estimated using logistic regression to assess

associations between stunting and different degrees

of deprivation, controlling for age, sex, birth order,

and place of residency. We accounted for the cluster

design of the survey in our analyses.

Results

Country-specific analyses

Approximately half of children were stunted at baseline

in all countries. From the 1990s, when the earliest DHS

surveys were administered, to the most recent survey,

which took place between 2006-2014, all countries

experienced reductions in stunting prevalence with the

largest declines recorded by Bangladesh and Nepal,

where stunting prevalence declined annually by 2.9

AARR and 4.1 AARR respectively compared to 1.3

AARR in India and 0.6 AARR in Pakistan. At 43.5%

(95% CI 42.3-44.8) and 39.7% (95% CI 35.4-44.2), India

and Pakistan had the highest prevalence of stunting

in the most recent DHS survey (2006 and 2013

respectively).

Trends in stunting by dietary diversity

In general, the prevalence of stunting was on average

higher among children whose dietary diversity was

poorer in both the earliest and latest surveys, where

data were available, yet this trend was significant

only for India (Figure 2). In Bangladesh and Nepal, a

marked decrease in the prevalence of stunting was

observed among the most deprived group between the

earliest and most recent surveys, both experiencing a

similar percent annual decline: the AARR was 3.4 in

Bangladesh and 3.3 in Nepal. A similar reduction was

also observed among the medium dietary diversity

group in Nepal, with a 3.6 AARR.

Gradients in stunting by mother’s education

The prevalence of child stunting was lower among

more educated mothers (Figure 3). Stunting

prevalences among children whose mothers’ had

secondary education or higher were 27.2% (95% CI

24.4-30.1), 32.3% (95% CI 30.7-34.0), 16.4% (95%

CI 11.4-22.9), and 25.4% (95% CI 18.9-33.2) in the

most recent surveys in Bangladesh, India, Nepal, and

Pakistan respectively. In comparison, about 40-50%

of children whose mothers were uneducated were

stunted in the most recent surveys. All sub-groups

experienced declines in stunting prevalence in all

countries; however, there was some country variability.

In Bangladesh, children of mothers with no education

and primary education experienced similar declines

– around a 1.9-2.1 AARR in stunting while children

of mothers with secondary and more education

experienced no significant decline in stunting.

Meanwhile, in India and Nepal, the greatest reductions

in stunting occurred among children with mothers who

had secondary or more education although significant

reductions were also recorded among children whose

mothers had no education. In Pakistan, no significant

annual reductions were observed in any education

group. The education gradient in stunting was

preserved in all four countries despite changes over

time among education groups.

Patterning in stunting by household wealth

In both the earliest and latest surveys, the prevalence

of stunting was significantly higher among children

from poorer households, with half to nearly two thirds

of children in the lowest two quintiles being stunted

(Figure 4). Stunting rates declined in all quintiles in

all countries; however, reductions were not uniformly

distributed. In all four countries the largest reductions

in the prevalence of stunting occurred in the richest

quintiles while the poorest quintiles recorded the

smallest declines. In the richest quintile, the prevalence

of stunting prevalence declined by 2.6, 2.7, 7.0, and

0.8 AARRs in Bangladesh, India, Nepal and Pakistan,

respectively. In comparison, in the poorest quintile, the

prevalence of stunting declined by 2.4, 0.5, 2.1, and -0.5

AARRs for the same order of countries. Absolute and

relative differences between the poorest and richest

quintiles increased in all four countries with the largest

increases in Nepal and Pakistan.

Association of stunting with different domains of deprivation

After controlling for child age, sex, birth order, and

place of residence, results from fully-adjusted models,

using pooled data from the latest survey years, revealed

12 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

Lowest

Second

Highest

Lowest

Second

Highest

Lowest

Second

Highest

Lowest

Second

Highest

Ban

gla

des

hIn

dia

Nep

alP

akis

tan

10 20 30 40 50 60 70

Stunting prevalence (%)

Earliest Most recent

Figure 2. Prevalence of stunting (95% confidence intervals) by dietary diversity score groups (limited data for

India and Pakistan*)

Figure 3. Prevalence of stunting (95% confidence intervals) by mother’s education*

* Data from Pakistan (2013), Nepal (1996; 2011), India (2006), Bangladesh (1997, but data for the highest dietary diversity group not available; 2011).

* Data from Pakistan (1991; 2013), Nepal (1996; 2011), India (1993; 2006), Bangladesh (1997; 2011).

Earliest Most recent

0 10 20 30 40 50 60 70 80

None

Primary

Secondary or Higher

Secondary or Higher

None

Primary

None

Primary

Secondary or Higher

None

Primary

Secondary or Higher

Ban

gla

des

hIn

dia

Nep

alP

akis

tan

Stunting prevalence (%)

13

significant associations between stunting and children’s

dietary diversity, mother’s education, and household

wealth quintile. The odds of stunting was significantly

higher for children in the most deprived groups; for

instance, a higher odds of stunting was observed for

children in the group with the lowest dietary diversity

compared to children in the group with the highest

dietary diversity (odds ratio (OR)=1.47, 95% confidence

interval (CI) 1.28-1.69); for children of uneducated

mothers compared to children of the most educated

mothers (OR=1.51, 95% CI 1.34-1.69); and for children

in the poorest wealth quintile compared to children

in the richest wealth quintile (OR=3.01, 95% CI 2.48-

3.64). In an extended model using the pooled sample,

we included interactions between dietary diversity and

levels of mother’s education, and found significant

interactions (p-value <0.05) between these two domains

of deprivation. We conducted the same interaction

tests in subsamples of the poorest and richest children

in separate models; however, we found no evidence of

multiplicative effects of maternal education and dietary

diversity among either the poorest or richest children.

In country-specific models, we observed mixed results.

In India, the odds of stunting was significantly higher

among children from the most deprived groups in

terms of child’s dietary diversity, maternal education,

and household wealth. In Bangladesh, the odds of

stunting was significantly higher across wealth quintiles

groups, but not by children’s level of dietary diversity

and maternal education. No significant differences were

observed in any domain in Nepal. Lastly, in Pakistan the

odds of stunting was significantly higher for wealthier

and more educated groups, but not by dietary diversity

group. Differences in the findings from pooled models

and the country-specific models can be attributed to

the influence of the data from India, which is the most

populous country in the pooled analyses. Indeed, the

findings from the India-specific model are similar to the

pooled analyses.

Conclusion

Our analysis of the prevalence and trends in child

stunting in South Asia had three key findings. First,

all countries had high stunting prevalence with nearly

Figure 4. Prevalence of stunting (95% confidence intervals) by household wealth quintile*

* Data from Pakistan (1991; 2013), Nepal (1996; 2011), India (1993; 2006), Bangladesh (1997; 2011).

0 10 20 30 40 50 60 70 80

Poorest

Second

Third

Fourth

Richest

Poorest

Second

Third

Fourth

Richest

Poorest

Second

Third

Fourth

Richest

Poorest

Second

Third

Fourth

Richest

Ban

gla

des

hIn

dia

Nep

alP

akis

tan

Stunting prevalence (%)

Earliest Most recent

14 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

half of the children suffering from stunted growth at

baseline. Stunting declined in all four countries with

greater reductions in Bangladesh and Nepal. Second,

in all four countries, the prevalence of stunting was

greater among children who had poor diets, who had

mothers with low educational attainment, or who lived

in poor households. Pooled, adjusted models showed

higher rates of stunting in children who experienced

all three dimensions of deprivation. However, country-

specific models showed varying relationships between

domains of deprivation and stunting. Third, the largest

declines in stunting were recorded in higher wealth

quintiles while the lower wealth quintiles recorded the

smallest declines in stunting. Disparities in stunting

rates were largely preserved over time, and in some

cases worsened between children from poorer vs.

richer households and between children whose

mothers had low vs. high educational attainment.

Future efforts to avert child stunting should target

groups that are most vulnerable.

Drivers of child stunting in South Asia

Introduction

The conceptual models for child undernutrition

describe immediate, underlying and basic

determinants of undernutrition at the individual,

household, environmental, socioeconomic, structural

and cultural domains, and support the need for multi-

factorial interventions (Bhutta et al., 2008; Black et al.,

2013; UNICEF, 2013). Nutrition-specific interventions

that address the immediate and underlying

determinants of fetal and child nutrition are less likely

to be effective in sustainably reducing undernutrition

unless the household, social and structural

determinants of maternal and child nutrition, including

household poverty, access to health services,

health environment, women’s education and social

exclusion, are also addressed (Black et al., 2013;

Bryce et al., 2008; Ruel et al., 2013).

Empirical research on a selective set of risk factors

on child growth and development are valuable for

assessing the role of specific determinants, but do

not allow an examination of the relative importance

of multiple factors on children’s health and nutrition

outcomes (Bhutta et al., 2008). Existing studies

focused on LMICs have identified child feeding

practices, maternal nutrition, and household wealth

as key determinants of the nutritional status for pre-

school age children (Espo et al., 2002; Jones et al.,

2008; Kanjilal et al., 2010; Smith & Haddad, 2015).

These findings have important policy and programme

implications at the national level, but the relative

significance of the same set of risk factors may

substantially vary when the focus is on the outcome

of stunting, a measure of chronic undernutrition, as

opposed to general nutritional status; the first two

years of life, when most child stunting happens in

LMICs, as opposed to children under age of five;

and by different countries. In Section 4, we use

the most recent nationally representative data from

Afghanistan, Bangladesh, India, Nepal, and Pakistan

(home to over 95% of stunted children in South Asia)

to investigate the relative and joint importance of a

set of 13 correlates of stunting and severe stunting in

infants and young children aged 6-23 months old.

Methods

Data for Afghanistan (2013) come from the National

Nutrition Survey (Afghanistan, 2013) while data for

Bangladesh (2014), India (2006), Nepal (2011), and

Pakistan (2013) come from the latest DHS (Measure

DHS, 2016). Both National Nutrition Survey and DHS

are nationally representative household surveys that

collect detailed information of health and nutrition

indicators from children and their mothers, including

anthropometric measurements and demographic

characteristics. We stratified the sample and

performed separate analyses for two different model

specifications, depending on the age of children and

the risk factors that are relevant for each age group. In

the first model (Model 1 hereafter) we analyzed data

for 3,159 children aged 6-8 months. In the second

model (Model 2), we included data from 18,586

children aged 6-23 months.

Children were considered stunted if their HAZ was

below -2 SD of the median for their sex according to

the WHO Child Growth Standards. Additionally, severe

stunting was considered as a secondary outcome

for analysis of Model 2. Children were classified as

severely stunted if their HAZ was <-3 SD of the median

of the WHO Child Growth Standards (de Onis, 2006).

We considered a comprehensive set of 13 correlates

that has shown varying degree of association with

stunting in different settings (Bhutta et al., 2008;

Bhutta et al., 2013; UNICEF, 2013). Child’s timing

of the introduction of complementary foods and

minimum dietary diversity were defined closely

adhering to the UNICEF and WHO infant and young

child feeding indicators (WHO, 2008, 2010). Timely

introduction of complementary foods was defined for

infants 6-8 months old as having received solid, semi-

15

solid or soft foods the previous day of the interview.

Continued breastfeeding was defined for all children

aged 6-23 months. The definition of minimum feeding

frequency varied by age and breastfeeding status: for

breastfed children, it was defined as two times if 6-8

months, and three times for 9-23 months; for non-

breastfed, it was defined as four times for all children

6-23 months old. Based on the dietary diversity score

used in the previously published literature (Ruel &

Menon, 2002), minimum dietary diversity was defined

for children aged 6-23 months as having received

foods from four or more of the following food groups:

1) grains, roots and tubers; 2) legumes and nuts; 3)

dairy products (milk, yogurt, cheese); 4) flesh foods

(meat, fish, poultry and liver/organ meats); 5) eggs;

6) vitamin-A rich fruits and vegetables; and 7) other

fruits and vegetables.

Several maternal variables were also considered.

Mother’s education was categorized in three levels: no

schooling, primary, and secondary or higher. Mother’s

height was measured by trained field investigators and

was categorized in four groups: <145, 145-149.9, 150-

154.9, and 155+ cm. Of note, height measures below

100 cm or above 200 cm were excluded (Özaltin et al.,

2010). Mother’s BMI was calculated from the objectively

measured height and weight, and was grouped in <18.5,

18.5-25, and 25+ kg/m2. Mothers’ age at marriage

was defined dichotomously for married or cohabitating

mothers, using the age of 18 years as cutoff.

Finally, the following proxy variables for household

socioeconomic conditions were included. Child’s full

vaccination was defined as having received 8 vaccines

(measles, BCG, DPT 3, and Polio 3). Household indoor

pollution was defined as high air quality if non-solid

fuels were used for cooking and poor air quality if

solid fuels were used (Corsi et al., 2015). The source

of drinking water was defined as safe if water sources

were available in the household (piped into dwelling or

yard/plot, public tap/standpipe, tube well or borehole,

protected well or spring, rain water, and bottled water),

and unsafe otherwise. Household sanitation facility

was defined as improved if households had access to

flush to piped sewer system, septic tank, or pit latrine,

ventilated improved pit latrine, pit latrine with slab,

and composting toilet, and unimproved otherwise. We

included the household wealth index, as reported by the

NNS and DHS, which was constructed as a weighted

sum of household assets by using the first factor

resulted from a principal component analysis on those

assets as weights. The resulting wealth index was used

to construct cut offs to rank households into wealth

quintiles, based on the weighted frequency distribution

of households (Rutstein et al., 2004).

The following logistic regression models were

conducted to evaluate the association between selected

variables and stunting by pooling the data from five

countries and then for each country separately. A

different set of correlates was considered for 6-8

months old infants (Model 1) and 6-23 months old

children (Model 2) due to clinical relevance and

technical reasons. For instance, the timely introduction

of complementary foods was included only in Model

1 since data on this indicator are only obtained for

infants aged 6-8 months. On the other hand, the child’s

vaccination status was included only in Model 2 since

full vaccination data are applicable for children aged

12-23 months. For technical reasons, minimum feeding

frequency was excluded from Model 1 due to high

correlation with timely introduction of complementary

foods; and continued breastfeeding and minimum

dietary diversity were excluded from Model 1 because

of the small sample sizes and stunting cases for this

age group in country-specific models that resulted in

lack of statistical power and unstable estimation. For

Afghanistan-specific analysis, mother’s age at marriage

and child’s full vaccination were not available. For this

reason, the pooled analyses are presented for results

including and excluding Afghanistan. For Model 2,

we also estimated the fully-adjusted models for the

secondary outcome of severe stunting. Based on

these models, the relative significance of each of the

correlates was compared and ordered by magnitude. As

a sensitivity analysis, we re-estimated the fully-adjusted

models after removing type of drinking water, sanitation

facility, and indoor air quality since these assets were

considered in the estimation of DHS wealth quintiles

and may have issues of multicollinearity. All analyses

were accounted for the cluster survey design, and were

further adjusted for age and sex of the child, birth order,

and place of residency (urban/rural). The country fixed

effects was included in the pooled analysis. All statistical

tests were two-sided and p<0.05 was considered

to determine statistical significance. We used Stata

(version 13.1) for all analyses procedures.

Results

South Asia

Among 3,159 children aged 6-8 months in South Asia,

25.9% (n=696) were stunted. About two in five (37.5%)

of these 3,159 children were not fed complementary

foods indicating late initiation of complementary

feeding. Among 18,586 children aged 6-23 months,

38.8% (n=7,140) were stunted and 18.3% (n=3,362)

were severely stunted. 70.1% of the children aged 6-23

months did not meet the minimum dietary diversity

requirements. Mother’s nutrition and status varied

16 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

substantially across the countries. Overall, 2.8% of

the mothers of children aged 6-23 months had short

stature (height <145 cm), 12.4% were underweight

(BMI <18.5 kg/m2), and 82% had no formal education.

In terms of household level characteristics, 25.8% of

the children aged 6-23 months did not have access to

improved water source, 61.8% did not have access to

improved sanitation facility, and 16.1% were from the

lowest wealth quintile.

In the fully adjusted Model 1 (excluding Afghanistan),

maternal stature and timely introduction of

complementary foods were statistically significant

risk factors of stunting in children aged 6-8 months.

Children with short mothers (<145cm) had 2.93 times

higher odds of being stunted (95% CI: 1.93-4.46) than

those with taller mothers (155+ cm). Children who

had delayed introduction of complementary foods

had 1.47 times higher odds of stunting (95% CI: 1.12-

1.93) compared to their counterparts (Figure 5). When

Afghanistan was included in the pooled analysis, no

factor remained statistically significant.

For children aged 6-23 months (fully adjusted Model

2, excluding Afghanistan), the statistically significant

risk factors of stunting, ranked from the strongest

effect sizes, were: maternal short stature (OR: 3.37,

95% CI: 2.82-4.03), poorest household wealth

quintile (OR: 2.25, 95% CI: 1.72-2.94), maternal

underweight (OR: 1.59, 95% CI: 1.27-2.00), failure

to meet the minimum dietary diversity (OR: 1.48,

95% CI: 1.27-1.72), no maternal education (OR:

1.36, 95% CI: 1.18-1.56), and mother’s young age

at marriage (<18 years) (OR: 1.17, 95% CI: 1.05-

1.30) (Figure 6). When Afghanistan was included in

the pooled analysis, lack of continued breastfeeding

(OR: 2.02, 95% CI: 1.37-2.97) was also found

to be statistically significant, while maternal

underweight and young age at marriage were no

longer significant. Finally, in the pooled analysis for

severe stunting among children aged 6-23 months

(both including and excluding Afghanistan), the

statistically significant predictors were: maternal

short stature (OR: 3.15, 95% CI: 2.55-3.90), poorest

wealth quintile (OR: 3.07, 95% CI: 2.20-4.28), no

maternal education (OR: 1.48, 95% CI: 1.25-1.76),

maternal underweight (OR: 1.41, 95% CI: 1.05-

1.90), no minimum dietary diversity (OR: 1.37, 95%

CI: 1.11-1.70), not fully vaccinated (OR: 1.22, 95%

CI: 1.06-1.41), mother’s young age at marriage (OR:

1.16, 95% CI: 1.01-1.33) and no minimum feeding

frequency (OR: 1.14, 95% CI: 1.01-1.29).

Figure 5. Fully adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors staged 6-8 months

in South Asia* (pooled sample)

* Afghanistan was excluded due to quality of data

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

Od

ds

Rat

io

Shorts S

tatu

re

Poore

st HH w

ealth

Low B

MI

No Time i

nrod co

mp fo

ods

No educa

tion

not im

prove

d sanita

tion

Child m

arrig

e

Unsafe

wat

er

HH indoor p

ollutio

n

17

Afghanistan

In Afghanistan, there were 341 children aged 6-8

months and 26% of them were stunted. None of the

risk factors were found to be statistically significantly

associated with risk of stunting for children aged 6-8

months in Afghanistan. Of 3,644 children aged 6-23

months, 38.7% were stunted and 18.3% were severely

stunted. In this age group, lack of formal education for

mothers (OR: 3.01, 95% CI: 1.53-5.93), short maternal

stature (OR: 2.61, 95% CI: 1.41-4.84), poorest wealth

quintile (OR: 2.28, 95% CI: 1.48-3.50), lack of continued

breastfeeding (OR: 2.08, 95% CI: 1.35-3.21), and failure

to meet the minimum dietary diversity (OR: 1.34, 95%

CI: 1.04-1.72) were statistically significant risk factors

for stunting. Consistent results were found for severe

stunting in this age group, but dietary diversity and

maternal education were not statistically significant.

Bangladesh

The prevalence of stunting in Bangladesh was 16.9%

among children aged 6-8 months. For this age group,

all the risk factors for stunting (Model 1) were found

to be statistically not significant, probably due to

the small sample size. Among children aged 6-23

months, 31.9% were stunted and 10.8% were

severely stunted. The following five risk factors

were found to be statistically significant for stunting

among children aged 6-23 months (Model 2): short

maternal stature (OR: 3.42, 95% CI: 2.03-5.76),

maternal underweight (OR: 2.05, 95% CI: 1.27-3.30),

lowest wealth quintile (OR: 1.98, 95% CI: 1.08-

3.63), no education for mothers (OR: 1.78, 95% CI:

1.17-2.70), and no minimum dietary diversity (OR:

1.58, 95% CI: 1.11-2.24). For severe stunting, only

maternal stature and wealth quintile remained to be

statistically significant predictors.

India

Among the five South Asian countries considered

in this study, India had the highest prevalence of

stunting for children aged 6-8 months (25.1%) and for

those aged 6-23 months (43.5%). In the fully adjusted

model for children aged 6-8 months (Model 1), short

maternal stature (OR: 3.39, 95% CI: 2.10-5.45) and

failure to introduce complementary foods in a timely

manner (OR: 1.50, 95% CI: 1.11-2.04) were the

* Afghanistan was excluded due to quality of data

Figure 6. Fully adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors staged 6-23 months

in South Asia* (pooled sample)

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

Od

ds

Rat

io

Shorts S

tatu

re

Poore

st HH w

ealth

Low B

MI

No Min

diet

div

ersit

y

No educa

tion

Child m

arrig

e

Not Im

prove

d sanita

tion

Not fully

vacc

inat

ed

No feed

ing fr

eq

Unsafe

wat

er

HH indoor p

ollutio

n

No Bre

asfe

edin

g

18 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

only statistically significant risk factors for stunting.

Maternal underweight, household wealth, maternal

education, and other factors were not statistically

significant. These findings were consistent with

those from the pooled analysis. For children aged

6-23 months (Model 2), there were five statistically

significant risk factors for stunting: short maternal

stature (OR: 3.43, 95% CI: 2.82-4.18), lowest wealth

quintile (OR: 2.26, 95% CI: 1.67-3.05), maternal

underweight (OR: 1.56, 95% CI: 1.20-2.03), poor

dietary diversity (OR: 1.52, 95% CI: 1.26-1.82), and

mothers with no education (OR: 1.36, 95% CI: 1.17-

1.57). In addition to these risk factors, not being fully

vaccinated (OR: 1.29, 95% CI: 1.11-1.51) and failure

to meet the minimum feeding frequency (OR: 1.15,

95% CI: 1.01-1.31) were also found to statistically

significantly increase the odds of severe stunting for

children aged 6-23 months.

Nepal

In Nepal, 18.8% of the children aged 6-8 months

and 29.2% of those aged 6-23 months were stunted.

The sample size and number of stunted children

were very small in Nepal, and therefore both Models

1 and 2 could not be reliably estimated due to low

statistical power. Among 122 children aged 6-8

months, only 23 cases (18.9%) of stunting were

detected, and all the estimates associated with

stunting, except for short maternal height, were

found to be statistically not significant. Among

children aged 6-23 months, short maternal stature

(OR: 5.58, 95% CI: 2.52-12.4) and lowest wealth

quintile (OR: 5.26, 95% CI: 1.35-20.5) were found to

be statistically significant predictors of stunting, but

the associated confidence intervals were very wide,

which indicated unstable estimation. The same was

true for severe stunting among children aged 6-23

months.

Pakistan

The prevalence of stunting was 25% and 39.6%

for children aged 6-8 months and 6-23 months,

respectively, in Pakistan. Due to small number of

stunted children (n=62) aged 6-8 months, all the risk

factors for stunting were found to be statistically not

significant, expect for no maternal education (OR:

7.39, 95% CI: 1.71-31.9), but the wide confidence

interval indicated unstable estimation. For children

aged 6-23 months (Model 2), short maternal stature

(OR: 3.56, 95% CI: 1.24-10.2), child marriage (OR:

1.71, 95% CI: 1.10-2.67), unimproved drinking

water source (OR: 1.63, 95% CI: 1.00-2.68) and no

minimum feeding frequency (OR: 1.59, 95% CI:

1.05-2.42) were statistically significant risk factors

for stunting. For severe stunting, only short maternal

stature was statistically significant (OR: 4.68, 95% CI:

1.57-13.9).

Conclusion

Our findings provide evidence on the relative importance

of multiple correlates of child stunting, and enriches

the existing assessments of determinants of nutritional

status among pre-school age children in LMICs (Espo

et al., 2002; Jones et al., 2008; Kanjilal et al., 2010;

Smith & Haddad, 2015). For instance, child feeding

has been increasingly recognized as a key determinant

of child nutrition, with greater than two-thirds of

malnutrition-related deaths in children estimated to be

associated with inappropriate feeding practices (Black

et al., 2008). Young children should be introduced to

complementary foods at six months of age (WHO,

2002), and failure to do so has been shown to leave

children vulnerable to irreversible outcomes of stunting

(Gross et al., 2000; Saha et al., 2008). Almost 40% of

infants aged 6-8 months in our pooled sample were

not given complementary foods, and failure to do so

was significantly associated with increased odds of

stunting. Moreover, not meeting the minimum dietary

diversity was also found be important for stunting

among children aged 6-23 months, which is consistent

with a prior review reporting that dietary diversity was

associated with height-for-age in many LMICs (Arimond

& Ruel, 2004). In addition, maternal height, a marker

of mother’s early life nutritional and environmental

conditions that has intergenerational consequences on

nutrition and health (Özaltin et al., 2010; Subramanian

et al., 2009), was also found to be one of the strongest

predictors of child stunting and severe stunting in

South Asia. Moreover, the consistent findings on

the importance of maternal undernutrition, maternal

education and household wealth index further support

that the overall environmental and socioeconomic

conditions influence child nutrition through pathways

involving food insecurity and inadequate access to care

and dietary resources for children (Ruel et al., 2013).

Overall, our analysis found that the top five risk factors

identified for stunting and underweight for children aged

6-59 months in a recent study in India (short maternal

stature, mothers having no education, households in

lowest wealth quintile, poor dietary diversity in young

children, and maternal underweight) (Corsi et al., 2015)

are also applicable for infants and children aged 6-23

months across five South Asian countries, albeit the

notable variations in the ranking and significance of

correlates by country. An important policy implication of

our research is to further emphasize that interventions

focused on specific risk factors alone may be

19

inadequate, and that a multi-factorial framework

approach should be employed to address child

stunting in South Asia. For instance, comprehensive

strategies focused on a broader progress on maternal

and household socioeconomic factors as well as

investments in nutrition specific programs to promote

dietary diversity and appropriate complementary

feeding are needed to improve stunting rates at the

population level (Bhutta et al., 2008; Bhutta et al., 2013;

Black et al., 2008; Ruel et al., 2013).

Implications for action

Stunting in childhood has immense implications as

stunted children experience worse survival, growth,

development, and livelihoods than non-stunted

children (Black et al., 2013; Grantham-McGregor et al.,

2007), leading to significant losses of human capital

and productivity (Behrman et al., 2015; Black et al.,

2013; Grantham-McGregor et al., 2007; Horton &

Steckel, 2011). In this chapter, we provide evidence to

further support that eliminating child stunting should

be moved to the forefront of national and international

policy, programme, advocacy, and research agendas.

More specifically, we argue that renewed attention to

four main priorities is needed:

South Asian countries, which have the largest proportion and burden of stunted children globally, need to universalize evidence-based policies and programmes designed to improve the nutrition situation of young children and their mothers as a national development priority. We provide evidence that proven nutrition

investments that focus on the 1,000 days from

conception to age two years and the 10-18 years

adolescence period (i.e. the two windows of

opportunity to address stunting) are cost-beneficial.

Research evidence indicates that packages that

combine context-specific nutrition, care, and

stimulation interventions may bring about the

greatest impact (Alderman et al., 2014; Gertler et

al., 2014; Yousafzai et al., 2014). Improvements in

child linear growth and reductions in child stunting

allow young children to reach their full growth and

development potential and expand their economic

opportunities as adults, generating substantial

economic returns at the individual level (Barker

et al., 2005; Hoddinott et al., 2013b; Martorell

et al., 2010b; Victora et al., 2008). Furthermore,

because of the spillover effects of reductions in

the prevalence of stunting on labour markets and

productivity, investments targeted at reducing child

stunting bring about substantial returns to society,

including significant increases in economic growth

(Akachi & Canning, 2015; Bloom et al., 2014).

In South Asia, economic growth ‘per se’ will not address child stunting. Greater attention needs to be paid to ensure that economic growth reduces inequities and addresses the drivers of child stunting among the most vulnerable population groups. Economic

growth as a policy instrument to reduce stunting

is not enough. Greater attention needs to be

paid to addressing the social, economic, and

political drivers of child stunting, with targeted

efforts towards the populations at higher risk of

growth faltering and stunting in children. There

is increasing consensus that economic growth

will only be effective in addressing child stunting

if increases in national income are directed at

improving the diets of children, strengthening

the status of women, addressing inequities,

and reducing poverty. Therefore, the literature

has begun to emphasize the importance of the

“quality of economic growth”, or how income

gains translate in reductions in child undernutrition

(Haddad et al., 2015). The impact of intermediary

factors, such as growth in food production,

sanitation, access to health services, education,

fertility, governance, and the roll-out of program

interventions have all been highlighted (Alderman

et al., 2006; Fink et al., 2011; Headey, 2013; Smith

& Haddad, 2015; Webb & Block, 2012). Therefore,

focusing on promoting an economic growth model

that does not address these intermediary factors

among the most vulnerable populations is not

likely to be effective in addressing child stunting

(Haddad, 2015). The disproportionate burden

of stunting experienced by the most deprived

population groups in South Asia and the persistent

and worsening inequalities among socio-economic

groups is of great concern. To unleash the potential

of nutrition policies and programmes, progress is

needed in addressing persistent socio-economic

inequities (Oruamabo, 2015).

Nutrition-specific and nutrition-sensitive programmes should be implemented jointly to address the main drivers of stunted growth and development in South Asian children. Programming efforts to prevent and reduce

stunting, especially those focused on the critical

1,000 day window of opportunity, should be

guided by the multi-factorial conceptual framework

20 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

of maternal and child undernutrition (UNICEF,

2013). This framework recognizes the interaction

between the underlying and basic causes of

undernutrition in determining optimal nutrition,

growth, and development in infancy and early

childhood (Bhutta et al., 2008; Maternal & Child

Group, 2013). In our analyses, when we considered

three levels of determinants of child nutrition (child-

level, mother-level, and household-level), delayed

introduction of complementary foods, failure to

meet children’s minimum dietary diversity, mother’s

short stature, underweight, lack of education,

and early marriage, and poor household wealth

were found to be the most significant drivers of

child stunting in South Asia. Nutrition-specific

interventions, such as the protection, promotion,

and support of breastfeeding, appropriate

complementary foods and feeding, care, and

hygiene practices, adolescent girls’ and women’s

nutrition, macro and micronutrient supplementation

for vulnerable population groups, food fortification

programmes, and the prevention and treatment of

infectious diseases and severe acute malnutrition,

should be combined with nutrition-sensitive

programmes that address the more distal socio-

economic determinants of maternal and child

undernutrition to prevent stunting in the first two

years of life (Bhutta et al., 2008; Bhutta et al.,

2013; Black et al., 2008; Pinstrup-Andersen, 2013;

Ruel et al., 2013). We argue that neither approach

in isolation is adequate to address the challenge

of widespread stunted growth and development

among South Asia’s children.

In parallel to national and regional efforts to reduce child stunting, there is a need for research and programmatic evidence to better understand how to drive faster and larger declines in South Asian countries, particularly among the most vulnerable children: the youngest, poorest, and the socially excluded. Understanding what drives child stunting at the

national and subnational levels (i.e. the importance

of context), how stunting influences child growth

and development, and which domains of growth

and development are more affected require further

research. Relatedly, understanding how best to

implement and scale up programmes aiming at

improving children’s growth and development and

reducing stunting – either through information,

counselling and support on optimal child feeding

and care, through dietary diversification, nutrition

supplementation and/or fortification programs, or

through integrated child nutrition and psychosocial

stimulation programmes are key areas of further

inquiry. Recent reviews indicate that integrated

interventions have great promise (Black et al.,

2015; Christian et al., 2015; Grantham-McGregor

et al., 2014; Yousafzai & Aboud, 2014; Yousafzai

et al., 2014). However, more research is needed to

evaluate rigorously the effects of these programs,

particularly in the long-run. If these interventions

are able to address the joint etiologies of stunting

and poor child development, they may be more

effective in promoting child health and well-being.

High child stunting rates in South Asia challenge

progress towards the SDGs, notably ending poverty in

all its forms (SDG 1); promoting sustained, inclusive,

and sustainable economic growth, full productive

employment and decent work for all (SDG 8); and

reducing inequality within and among countries (SDG

10) (UN, 2015b). Indeed the SDGs explicitly note the

importance of nutrition with SDG 2 aiming to end

hunger, achieve food security and improved nutrition

and endorsing the WHA target to reduce the number

of stunted children by 40% by 2025 (UN, 2015b).

The achievement of this global target requires that

South Asian countries accelerate efforts to reduce the

prevalence of stunting in the region and contribute

to achieve the SDGs related to child survival, growth,

development, education, participation, and equity.

21

22 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

23

HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

Patrick Webb, Kassandra L Harding, and Victor M. Aguayo

Introduction

Much of the world’s burden of malnutrition is visible.

Children and adults who are wasted or obese can often

be identified without special training or equipment.

However, there are other equally important forms

of malnutrition that are less obvious to the naked

eye; namely, deficiencies of essential vitamins and

minerals. According to the World Health Organization

an estimated two billion or more people suffer

what is called micronutrient malnutrition or more

colloquially ‘hidden hunger’ (WHO, 2016). This form

of malnutrition tends to be hidden both to the person

suffering the deficiency and to the outside world until

it becomes so severe that clinical signs emerge.

The most serious deficiencies of some micronutrients,

such as vitamin A and zinc, cause death: roughly

270,000 annual deaths in children less than 5 years old

are attributed to these two micronutrient deficiencies

alone (Black et al., 2013). Yet even mild or moderate

forms of hidden malnutrition have wide-ranging

implications for human growth and development.

Deficiencies in iodine and iron, for example, contribute

to physical growth impairment in utero and early

childhood, as well as to cognitive deficits. In 2013, out

of 289 diseases and injuries contributing to the global

burden of disease, the combination of just three - iron,

iodine and vitamin A deficiencies - contributed 5% of

the world’s burden of ‘years lived with disability’ (YLD),

which is a metric of lost wellbeing associated with a

poor state of health (Global Burden of Disease Study

2013 Collaborators, 2015).

Such nutrition losses are associated with impaired

human capital. The term human capital is used to

reflect the combination of skills, knowledge, and

experience accumulated by individuals throughout the

life-course based on their physical attributes and brain

development. Growing well as an infant, learning in

24 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

school, working productively as an adult, and providing

for the next generation all contribute to the social

and economic wealth of nations. By contrast, threats

to human capital represent a drag on sustainable

development. South Asia is one of the regions of the

world carrying the highest burden of hidden malnutrition

and associated health burdens (Vos et al., 2012).

This paper presents an overview of what is empirically

known about the human and economic impacts of

various micronutrient deficiencies, and about recent

patterns and trends in micronutrient deficiencies

across South Asia. It draws on the most recent surveys

and datasets to highlight where gains have been

made and where a lack of progress continues to be of

concern. A final section lays out policy and programme

implications, calling for an urgent prioritization by

South Asia’s governments and development partners

of this largely unseen threat to future development.

Hidden malnutrition and the development of nations: a review of evidence

There are many form of micronutrient malnutrition,

but a few essential vitamins and minerals stand out

in terms of the scale of global deficiencies and for the

significance of their public health impact. Arguably the

most pernicious and widespread condition is anaemia.

Defined as a low blood haemoglobin concentration,

anaemia affects an estimated 2 billion people (WHO,

2015). An estimated 50% of cases of anaemia are due

to iron deficiency; other causes include deficiencies in

other micronutrients such as folate, riboflavin, vitamins

A or B12 and infections such as malaria, tuberculosis

or HIV/AIDS.

Iron deficiency anaemia adversely affects birth weight,

children’s cognitive and motor development, and adult

labour productivity (Stevens et al., 2013)., Almost one

in five children under the age of five years* have some

form of iron deficiency anaemia, while severe anaemia

is associated with around 90,000 deaths annually

(Stevens et al., 2013;WHO, 2014).

While delivery of supplements to pregnant women and

fortification of staple foods have been widely pursued

for decades, anaemia remains a major challenge

marked out for the “lack of progress” made in reducing

prevalence rates since the early 1990s (IFPRI, 2015).

A second major global hidden deficiency is zinc.

Assessments of national diets suggest that more than

17% of the world’s population is at risk (Black et al.,

2013). Deficiency in zinc (a serum concentration of

<60 µg/dl) is linked to poor child growth outcomes,

impaired immune function, the incidence and severity

of diarrhoeal disease, and numerous other nervous and

reproductive system problems (Wessels et al., 2012).

Indeed, an estimated 116,000 child deaths are ascribed

to zinc deficiency or to elevated risk of deficient dietary

intake of zinc each year (Black et al., 2013). Conversely,

zinc supplementation to pregnant women has been

shown to significantly reduce pre-term births in low

income countries (Mori et al., 2012).

The third micronutrient deficiency of significance is

vitamin A. Globally, one third of all children under five

years suffer vitamin A deficiency (VAD) which causes

blindness or death when associated with severe bouts

of diarrhoea or measles. An estimated 157,000 children

under five die annually due to VAD (Black et al., 2013).

Around 15% of pregnant women also experience

VAD, susceptibility being at its highest during the

third trimester due to accelerated foetal development.

Overall (across all ages), VAD is associated with over

800,000 YLD (Vos et al., 2012).

Around 30% of people suffer from iodine deficiency

disorders, which represent the fourth nutrient

deficiency of critical importance globally (Andersson

et al., 2012). Iodine deficiency in pregnant women is

responsible for birth defects, including in utero foetal

brain development and impaired cognitive potential,

while in children it impairs cognitive ability; in the most

severe cases, iodine deficiency results in the growth of

goitre, in cretinism or even in death (Vos et al., 2012).

These ‘big four’ micronutrients cause so much damage

to health, education, physical and mental growth, labour

productivity, and longevity that their hidden impacts on

the economy can be enormous. Good nutrition supports

high mental acuity and individual earnings, which in

turn support macroeconomic and societal growth.

Conversely, malnutrition impairs individual output,

which acts cumulatively as a drag on national growth.

For example, Meenakshi et al. (2010) calculated that

low vitamin A status among mothers and children

can be associated with an annual loss of 1% of gross

national product. Similarly, Horton & Ross (2003)

showed that the cumulative economic impact of

* The term “children under 5 years old” refers to children 6 to 59 months old unless otherwise specified.

25

cognitive impairment and lower labour productivity due

to iron-deficiency anaemia is on average 4% of national

income in low income countries. Indeed, children

who were iron deficient in Costa Rica during infancy

had 10% lower cognitive test scores than those who

were not deficiency, but also 26% lower test scores

at the age of 19 years; in other words, the impairment

persisted throughout their childhood (Lozoff et al.,

2006). Similarly, roughly 10% of children born to

iodine-deficient mothers are likely to suffer severe

mental retardation (Hunt, 2005). This has extraordinary

implications for countries of South Asia, where almost

a third of households do not consume adequately

iodized salt on a regular basis (UNICEF, 2014).

What is more, where there is one nutrient deficiency

there are often others. It has been estimated that

annual economic losses from low weight, poor growth,

and clusters of micronutrient deficiencies average 11%

of gross domestic product (GDP) in Asia and Africa

(IFPRI, 2016). Indeed, Madsen (2016) showed that

from 1960 through 2006, the combination of anaemia

and iodine deficiency was linked to lower intelligence

quotients (IQ), and that a 10% fall in IQ among

individuals was associated with a 1% fall in national

economic growth rates each year.

In terms of hidden malnutrition, the main drivers of

such negative economic impacts are lower learning

and productivity capabilities due to iron deficiency

anaemia, diarrhoeal episodes associated with zinc

deficiency, low immunity to diseases linked to a lack

of vitamin A, and compromised intellectual potential

due to iodine deficiency. Many individuals suffer more

than one of these deficiencies simultaneously, and

many deficiencies persist through a person’s lifespan.

Micronutrient deficiencies are also associated with the

growing global problem of overweight and obesity,

which carry high risks of non-communicable diseases

(Via, 2012). The association of obesogenic conditions

and vitamin and mineral deficiencies is underpinned

by low quality diets (Aitsi-Selmi, 2014). Monotonous,

nutrient-poor diets affect maternal health and nutrition,

but they can also lead to in utero malnutrition that has

effects on the newborn that last into adulthood and

can impact the next generation. One study in Thailand

that followed children from birth to age 9 years found

that “growth between birth and four months, whether

in length or weight, was the variable most consistently

and strongly related to IQ.” (Pongcharoen et al., 2012).

Since much of a child’s risk of malnutrition is

determined by the mother’s nutrition and health status

at conception, conditions during her pregnancy, birth

outcomes, and subsequent childcare, what women

know about nutrition, how well educated and literate

they are, and how they are able to act on knowledge

is a major determinant of hidden malnutrition and the

ability of societies and nations to interrupt the cycle of

hidden hunger.

Women’s education and hidden malnutrition: a review of evidence

Formal educational attainment and informally-obtained

knowledge held by mothers have both been shown to

be significantly linked to improved nutrition among their

children (Smith and Haddad, 1999). Cross-country time

series as well as studies using natural experiments have

confirmed that maternal education is a key determinant

of birthweight, neonatal survival, and children’s

attained height. For example, using Demographic and

Health Survey (DHS) data from 19 countries, Ruel

and Alderman (2013) showed that the risk of child

stunting was significantly lower among mothers with

primary or secondary education even after controlling

for wealth, residence, and child’s age and sex. The

same study found a significant yet smaller effect of

paternal education. Single country studies, such as one

in Bangladesh, note that as the proportion of women

with some secondary education rises (in Bangladesh

it doubled between 1994 and 2005), the prevalence

of child stunting tends to fall -- as it did in Bangladesh

from 70% to 48% over the same period (Heady, 2013).

Similarly, Cunningham et al. (2016) argue that maternal

education in Nepal was a key factor in underpinning

what they describe as “remarkable improvements” in

child undernutrition from 1996 to 2011.

While correlations between education levels and

undernutrition are robust across regions and over

time, the links between education and micronutrient

deficiencies have received less attention. Although,

maternal education is a commonly identified predictor

for risks of anaemia, serum retinol, serum zinc,

and other measures of micronutrient status among

children, few studies have explicitly considered how

maternal education interacts with micronutrient

deficiencies in the household, and vice versa. Such

links are bi-directional in that knowledge may

allow families to prevent or deal with micronutrient

deficiencies, while such deficiencies impact

individuals’ ability to obtain and act on knowledge.

As Block (2007) points out, the ability to understand

and identify micronutrient content and quality in foods

may require more knowledgeable and/or educated

consumers, thus maternal education could be an

important determinant of a child’s micronutrient status.

26 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

Figure 7. Prevalence of micronutrient deficiencies by average years of women’s schooling at the country level

(Harding et al., 2018)

a. Prevalence of vitamin A deficiency among children <5 years (2013) by women’s schooling (2010)

b. Prevalence of estimated inadequate zinc intake in the population (2005) by women’s schooling (2000)

0

Years of schooling

5 10 15

0

20

40

60

80

Prev

alen

ce o

f VA

D a

mo

ng

<5

yr (

%)

High income

Lower middle income

Low income

Upper middle income

High income

Lower middle income

Low income

Upper middle income

Pre

vale

nce

of

esti

mat

ed in

adeq

uat

e zi

nc

inta

ke (

%)

0

20

40

60

0 5 10 15

Years of schooling

27

A recent analysis using cross-country data (roughly

200 countries depending on the outcome of focus) for

the period 1990 to 2013 confirmed such relationships

(Harding et al. 2018). The number of years of women’s

schooling was significantly associated with all

micronutrient deficiencies, with the exception of iodine

(Figures 7a-c).

Importantly, when controlling for national income per

capita, women’s years of schooling was no longer

associated with child anaemia in the upper middle

income countries, but it remained a significant predictor

of child anaemia in the lower income categories,

especially in the lowest income group, while the lack

of formal education among women was not predictive

of zinc deficiency in the lower income countries, but

remained a significant predictor of zinc deficiency in

the upper income countries. Thus, in the case of child

anaemia, education appears to matter relatively more

in the context of greater poverty, whereas in the case

of zinc deficiency, measured as inadequate zinc intake,

there may be a base level of resources needed before

education can impact zinc status (i.e. in poor context,

regardless of education or knowledge, it may not be

feasible to purchase foods rich in zinc).

These findings, complemented by others, strongly

support the conclusions that i) girls’ education plays

an important role in improving nutrition across

generations; it represents a nutrition sensitive action

that all governments should act upon; ii) while

women’s anaemia and children’s vitamin A improve

along with women’s education, improvements in

zinc and child anaemia are mediated by the effects

of poverty; which means that complementary actions

(beyond) education are needed to address multiple

forms of hidden malnutrition; and iii) where poverty,

overt (not hidden) malnutrition and education of girls

all lag (as in parts of South Asia), there is an urgent

need for governments to prioritize actions to address

such problems simultaneously.

Additionally, it is important to invest in appropriate

informal knowledge acquisition (beyond schooling) by

girls and mothers relating to quality diets and nutrition.

For example, Webb and Block (2004) assessed the

impact of a mass media campaign in Central Java

that promoted population-wide understanding of

good dietary sources of vitamin A. Using seven survey

rounds involving almost 32,000 rural households,

the authors correlated with child nutrition outcomes

mothers’ responses to questions about the messages

that had formed the basis of the campaign. The

messages included information about the value of

dietary vitamin A to child health and growth, and the

importance of feeding vitamin A-rich foods to young

children. They showed that while maternal schooling

was, as expected, an important determinant of child

growth, even ‘uneducated mothers’ (i.e. mothers

lacking formal education) benefitted from well-crafted

c. Median urinary iodine excretion (UIE) of a country (µg/L) (2012) by women’s schooling (2010)

High income

Lower middle income

Low income

Upper middle income

Med

ian

uri

nar

y io

din

e ex

cret

ion

(µ

g/L

)

0

100

200

300

400

500

0 105 15

Years of schooling

28 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

nutrition information that they could act on. That is,

knowledge gained informally (rather than just the

years spent in school) offers a strong basis for mothers

to improve the diversity and quality of the food that

they provide to their children (Webb and Block,

2004). As such, it becomes all the more important for

governments to seek to equip girls and women with

the resources (informational as well as educational)

they need to be able to do all they can to tackle hidden

hunger through their own dietary choices.

Trends in hidden malnutrition in South Asia

While hidden malnutrition is still global in its reach,

its prevalence and impacts area disproportionately

concentrated in poorer regions of the world such as

South Asia. The scale of the problem facing South

Asia’s national governments and development partners

is huge. South Asia alone accounts for almost 40%

of the entire world’s YLDs attributed to anaemia

(Kassebaum et al., 2014). In 2013, roughly 2% of all

preventable child deaths in low and middle income

countries (LMICs) were attributable to vitamin A

deficiency, and South Asia has some of the highest

prevalence of vitamin A deficiency in the world:

exceeding 30% in countries like Nepal and Sri Lanka

and exceeding 60% in India (Stevens et al., 2015). At

the same time, South Asia has the highest rates of

inadequate zinc intake, at 30% compared with the

global average of 17% (Wessels et al., 2012)

This matters for South Asia’s future. Despite some

important progress made across the region in

recent years, at least in terms of economic growth,

agricultural output and exports, poverty reduction

and even in improved health, South Asia’s burden of

micronutrient deficiencies is still very large: Pakistan

has long been classified as a nation with ‘severe iodine

Figure 8. Prevalence of micronutrient deficiencies globally and in South Asia and Sub-Saharan Africa*.

0

10

Vitamin Ade�ciency

amongchildren <5

Prev

alen

ce o

f m

icro

nu

trie

nt

de�

cien

ces

(%)

Iodinede�ciency

ZincDe�ciency

Anemia amongchildren < 5

Anemia amongpregnantwomen

20

30

40

50

100

90

80

70

60

World South Asia Sub-Saharan Africa

* Vitamin A deficiency: Serum retinol <0.70 µmol/L; data from 2013 (Stevens et al., 2015); Iodine deficiency: Urine iodine excretion <100 µg/L among school aged children; South Asia includes Southeast Asia and Sub-Saharan Africa includes all of Africa; data from 2011 (Andersson et al., 2012); Zinc deficiency: Weighted average of country mean of estimated inadequate zinc intake at population level; data from 2005 (Wessells et al., 2012); Anaemia: Defined as haemoglobin <11 g/dL; data from 2011; Sub-Saharan Africa includes West and Central Africa (Stevens et al., 2013).

29

deficiency’; almost two-thirds of children under 5 in

Afghanistan suffer vitamin A deficiency and India

continues to report that around 53% of women of

reproductive age are anaemic (India, 2016), compared,

for example, with only 19% in China (IFPRI, 2016)

At the same time, improvements remain patchy

and slow. The prevalence of inadequate zinc intake

in South Asia has changed little between 1990 and

2005: Afghanistan, Nepal, and Sri Lanka, for example,

recorded less than a one percentage point change

over 15 years (Wessels et al., 2012). Between 1995

and 2011, the prevalence of anaemia among non-

pregnant women in South Asia fell only slightly from

53% to 47%, but with little change among pregnant

women (Stevens et al., 2013). Similarly, the estimated

prevalence of vitamin A deficiency among children

under 5 years of age across South Asia declined very

slowly and only slightly from 47% in 1991 to 44% in

2013 (Stevens et al., 2013). The lack of progress in

reducing these deficiencies puts most of the countries

in the region off-course in their attempt to reach global

nutrition targets set for the coming couple of decades.

The details of country-level patterns and trends

matter a lot to the design of appropriate policy and

programme responses by location. That is, since

micronutrient problems are not equally felt by all

populations in the same ways everywhere in the

region, detailed knowledge of drivers and differential

outcomes is a key to effectively-tailored action. For

example, South Asia had the highest prevalence

of anaemia in 1990, and still had the world’s 4th

highest prevalence among males in 2010, and 3rd

highest among females (Kassebaum et al., 2014).

However, important differences exist across the region.

In Afghanistan, Nepal, and Sri Lanka, anaemia is

considered to be a ‘moderate’ public health problem

for non-pregnant women, whereas it is a ‘severe’

problem in Bangladesh, Bhutan, India, and Pakistan

(Kassebaum et al., 2014; Harding et al., 2017a).

With around 50 percent of women of reproductive

age suffering some form of anaemia in the mid-2000s,

India has one of the highest prevalences of anaemia

in South Asia; further, this prevalence was largely

remained unchanged at a national level between the

late 1990s and 2006 (India 2006; Bharati et al., 2015)

(Figure 9). In recent years (2016), there has been a

substantial decreased in anaemia among women

of reproductive age in some states in India and not

others, though the prevalence remains high. For

example, the prevalence in Tripura dropped from 65%

in 2006 to 55% in 2016 and the prevalence in Sikkim

dropped remarkably from 60% to 35%. On the other

hand, the prevalence increased or did not change

in states such as Haryana, Tamil Nadu and West

Bengal (India, 2016). Anaemia rose in Afghanistan,

Figure 9. Prevalence of anaemia among women of reproductive age across time (1990 to 2012), by country [data

from Stevens et al., 2013 and Harding et al., 2017a]

Bangladesh India

Pakistan Sri Lanka

Afghanistan Bhutan

Nepal

Prev

alan

ce o

f an

emia

am

on

g n

on

-pre

gn

ant

wo

men

(%

)

20

1990 1995 2000 2005 2010

30

40

50

60

30 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

from 40% of children under 5 in 2004 to 45% in 2011

(Afghanistan, 2013), and in Pakistan, from 51% in

2001 to 62% in 2011(WHO, 2007; Pakistan, 2011). Yet,

countries like Nepal and Sri Lanka have seen declines

in anaemia among pregnant women since the 1990s.

Current rates are still too high (they remain public

health problems), but the downward trend over 20

years from 1990 to around 2010 is a bright spot to be

noted so that lessons might be learned on how this

positive trend has been achieved (Stevens et al., 2013).

Of course, even within countries there are important

differences. In India, Bangladesh and Nepal, anaemia

is more prevalent in rural than in urban populations,

whereas in Pakistan there is little difference by location.

In neighbouring Nepal, the prevalence of anaemia

among children is highest in the low-lying plains (50%),

but only slightly lower in the hills (41%) (Bhandari and

Banjara, 2015). Some Indian states such as Puducherry,

Goa, Meghalaya and Tripura have a relatively low

prevalence of anaemia in children aged 6 to 59 months

below 50%, while other states such as Haryana have an

anaemia prevalence rate exceeding 70% (India, 2016).

Trend lines also differ: Bharati et al., (2015) reported that

in India’s southern states, mean haemoglobin levels in

women of reproductive age fell from roughly 11.9 g/dL

in 1998/99 to slightly above 11.6 g/dL in 2005/2006 but

rose over the same period in the north-east (from 11.6 g/

dL to 11.8 g/dL) (Bharati et al., 2015).

Similar differences in rates across locations and

populations apply to other micronutrients as well.

In the case of zinc, about 39% of children under five

in Pakistan are deficient (Pakistan 2011), while in

Bangladesh the rate is 45% (ICDDRB et al., 2013).

Wessels et al. (2012) proposed that Sri Lanka had one

of the highest population-wide rates of inadequate

dietary intakes of zinc in the world at 48% in the mid-

2000s (2003-2007). But a more recent assessment

of dietary zinc deficiency using 2009 data suggests

that India tops the South Asia ranking with a risk of

inadequacy of 46% (Mark et al., 2016).

Again, there is large intra-nation variability; in a sample

of states, serum zinc deficiency (cut-off level ≤65 μg/

dL) was highest in Orissa (>51%) and Uttar Pradesh

(48.1%), but below 40% in Madhya Pradesh (39%), and

Karnataka (36%) (Akhtar, 2013). After India, the next

highest risk of inadequate dietary intake of zinc was

reported for Pakistan at over 39%, while the lowest

in the region was Nepal (less than 16%) (Mark et al.,

2016). In Bangladesh, zinc deficiency is higher in slums

(52%) and rural areas (49%) than in urban areas (30%)

(ICDDRB et al., 2013). Yet, rates do not differ between

urban and rural Pakistan (Pakistan 2011).

Where vitamin A deficiency (VAD) is concerned,

South Asia is still the region with the greatest number

of affected children; while all LMICs together have

Maldives

Prev

alan

ce o

f VA

D a

mo

ng

ch

ildre

n (

%)

0

10

1990 1995 2000 2005 2010 2015

20

30

40

50

Bangladesh India

Pakistan Sri Lanka

Afghanistan Bhutan

Nepal

Figure 10. Prevalence of vitamin A deficiency (VAD) among children 6-59 months old across time (1991 to 2013),

by country [data from Stevens et al., 2015 and Harding et al., 2017b]

31

Figure 11. Median urinary iodine excretion (µg/L) (population level) by country (Iodine Global Network 2017)

seen VAD decline from almost 40% to less than 30%

between 1991 and 2013, South Asia’s average remains

in the order of 44% (Stevens et al., 2015). Sri Lanka

and the Maldives are two positive outliers, as it appears

that these countries have made huge improvements

in the vitamin A status of its children since the early

1990s (Thompson and Amoroso, 2014) (Figure 10).

Where adult women are concerned, a relatively low

11% of women of reproductive age were vitamin

A deficient in Afghanistan in 2011/12 (Afghanistan

2013). This may in part be due to the effective roll

out of vitamin A supplementation and associated

prenatal care since the early 2000s. For example,

two-dose coverage rose in that country from only 58%

in 2000 to 95% in 2014 (UNICEF, 2015). By contrast,

the prevalence of vitamin A deficiency in women

was recently over 40% in Bangladesh and Pakistan

(Pakistan 2011; ICDDRB et al., 2013). Pregnant women

in Pakistan recorded rates around 46% (Pakistan 2011).

The average for Pakistan in 2011 masked a wide range,

running from around 16% of pregnant women in Sindh

with severe VAD (serum level <0.35 μmol/L), to almost

48% in Khyber Pakhtunkhwa, and almost all regions of

the country reporting 20% to 30% mild VAD (0.35-0.70

μmol/L) (Akhtar et al., 2013).

Finally, iodine deficiency is also unevenly distributed

across and within the region. At national level,

iodine deficiency (median UIE <100 µg/L) is not

a public health problem for any country in South

Asia (Andersson et al., 2012) (Figure 11) However,

some countries like Afghanistan (where only 20% of

households consumed adequately iodized salt) still

show rates almost double those of other parts of the

same region, such as Nepal (UNICEF 2014).

Drivers of hidden malnutrition in South Asia: a focus on anaemia

There has been little progress across South Asia

in resolving hidden malnutrition. Furthermore,

some countries have seriously high levels of

micronutrient deficiencies and others have pockets

of unusual severity. Therefore, much more needs

to be understood about the context-specific drivers

of various micronutrient deficiencies and how to

formulate interventions appropriately to accelerate

positive change. The underlying and proximate drivers

of deficiencies are numerous, and their respective

roles may vary by country context.

Take anaemia as an example. An analysis of recent

datasets suggests that the factors that are most

significantly associated with anaemia in women

of reproductive age vary by country. In Nepal and

Pakistan, there is wide variation across agro-ecological

UIE

(μ

g/L

)

Afghanistan

BangladeshBhutan

India

MaldivesNepal

Pakistan

Sri Lanka

0

50

100

150

200

250

300

Adequate iodine status: 100-299 μg/L

32 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

zones: around 40% of Nepalese women in the plains

are anaemic compared with 25% in the hills and

mountains; in Pakistan, anaemia rates range from

67% in sub-tropical Sindh to 30% in mountainous

Gilgit (Nepal 2011; Pakistan 2011).

In India and Bangladesh, household wealth is strongly

associated with the presence or absence of anaemia

in women. Balarajan et al. (2013) note that anaemia

in India is “socially patterned”, meaning that it is

higher among women from poorer households,

who also tend to have less schooling and to belong

to scheduled castes and scheduled tribes. Level of

household wealth - be it income or assets-based

- is also correlated with anaemia among children

in Pakistan, yet in Nepal, wealth is not statistically

correlated with anaemia for either women or children.

By contrast, in Nepal access to improved sanitation

facilities and to improved drinking water sources are

associated with lower anaemia rates. What is more, in

Nepal children in from homes with a de facto female

head of household were at a lower risk of anaemia.

In Pakistan, low egg consumption by women and

current breastfeeding were both linked to higher risk

of anaemia (Harding et al., 2017a).

Other factors must also be taken into account.

According to Bhutan’s National Nutrition Survey

2015, the prevalence of anaemia was lower among

pregnant women (27.3%) than among non-pregnant

women (34.9%), probably due to the iron and folate

supplementation programme during pregnancy

(Bhutan, 2015). In Sri Lanka, the prevalence of

anaemia among pregnant and non-pregnant women

was similar (both groups at roughly 25%) while in

Afghanistan it was higher among pregnant women

than among non-pregnant women (44% v. 31%

respectively) (WHO, 2015). The fact that parity was

associated with anaemia in Bangladesh (OR=11.34;

CI 95% 1.94-66.1) and India (54% anaemia prevalence

among women who have yet to give birth compared

with over 59% among mothers with five or more

children) suggests that more attention needs to be

paid to reaching women during pregnancy, but also

to improving their diets and health over the long-run

(Merrill et al., 2012; Balarajan et al., 2013).

Finally, the nutritional status of pre-pregnant adolescent

girls cannot be overlooked. Akhtar et al. (2013)

reported that 90% of adolescent girls in 16 districts of

India were iron deficient (Akhtar et al. 2013), which sets

in motion the problem of poor maternal nutrition when

adolescents become pregnant leading to compromised

birth outcomes and nutrient deficiencies in infants.

A recent comprehensive review highlights these and

other challenges pertaining to the nutrition situation of

adolescent girls in South Asia (Aguayo & Paintal, 2017).

Of course, diets vary widely across the region based

on wealth, location, culture and religion. Self-professed

religion is a household-level factor that was statistically

correlated with anaemia among women in Bangladesh,

Nepal and India. In Bangladesh, a predominately

Muslim country, being non-Muslim was associated

with a higher prevalence of anaemia compared with

being Muslim (>49% vs. 40%) (Kamruzzaman et al.,

2015), while in India, which is predominately Hindu,

being Muslim (56%) or Christian (51%) was associated

with a slightly lower risk of anaemia than being Hindu

(57%) (Balarajan et al., 2013). In Nepal, which is largely

Hindu, but also Buddhist, being of the Kirat religion

(the Rai people of eastern Nepal) was associated with

a lower prevalence of anaemia (prevalence ratio =0.61;

CI 95% 0.39-0.97) compared with being Hindu, after

controlling for other potential factors (Harding et al.,

2017). Perhaps surprisingly, Balarajan et al. (2013)

reported that having any or severe anaemia among

Indian women of reproductive age was lower among

vegetarians than non-vegetarians. If confirmed, the

latter would indicate that diet alone is not the sole

driver of anaemia in South Asia.

Education and literacy are additional important

predictors of anaemia among adult women, as noted

in the section above. In Bangladesh, women with

higher education had lower rates of anaemia (33%)

than those with secondary (38%) or no education (46%)

(Kamruzzaman et al., 2015). In India, women with ≥ 13

years of education had a lower prevalence of anaemia

than those who had none (43% vs. 60%) (Balarajan et al.,

2013), and in Pakistan, women’s literacy was associated

with a lower prevalence of anaemia (Pakistan 2011).

Iron depletion was a co-morbid condition with anaemia

in Pakistan. Indeed, roughly 27% of non-pregnant

women and 44% of children from the 2011 National

Nutrition Survey had low ferritin levels, with a higher

prevalence of low ferritin concentrations among

children in urban than in rural areas, and variation

across provinces (Pakistan 2011). In a recent survey

in rural Bangladesh, a high prevalence of anaemia

was reported (57%) where iron deficiency was absent

(Merrill et al., 2012). It was found that women exhibited

high levels of thalassemia, and that they had high iron

intake from groundwater. Similarly, a recent survey in

Nepal of pregnant women in the western district of

Banke found that women of Tharu ethnicity (who are

also known to exhibit thalassaemias) had a higher odds

ratio for anaemia than Brahmin women (OR=2.28; CI

95% 1.06-4.90) (Balarajan et al., 2011; Ghosh et al.,

33

2016). Such findings underline the importance of

understanding the local causes of anaemia to know

how to prevent and treat it.

Implications for action

South Asia’s lack of progress in resolving hidden

malnutrition over recent decades continues to hamper

the region’s attempts to accelerate development. The

median cost of iron deficiency for 10 low income

countries was found to be approximately US$ 2.32

per capita (0.57% of GDP) based on annual physical

productivity losses alone; when both physical and

cognitive losses are accounted for this increased to

US$ 16.78 lost per capita (4% of GDP) (Horton and

Ross, 2003). When one considers countries with larger

economies, such as India, the economic impact of

hidden malnutrition escalates rapidly. For example,

Stein & Qaim (2007) calculated the costs just for India,

where an estimated 9.3 million DALYs were lost to iron

deficiency anaemia, and zinc, vitamin A and iodine

deficiency in the mid-2000s, equivalent to losing no

less than 0.8% of annual GDP. Based on India’s 2007

GDP of US$ 1.2 trillion, this translates in 2014 dollars

to more than US$ 16 billion (based on 2014 GDP of

US$ 2 trillion). Such a huge figure from a single country

contributes about one-third of the estimated global cost

of malnutrition of US$ 3.5 trillion (FAO, 2013).

A significant proportion of such economic cost is due

to the effects of poor child nutrition on educational

performance and subsequent lifetime earnings. That

is, impaired child growth and intellectual development

across South Asia hinders school enrolment at an

appropriate age, causes absenteeism or early drop-out

due to ill-health and/or poor learning, and prevents

optimal learning and skills development. Thus,

there remains a lot to be done to stem the losses at

individual and national levels, and to bolster good

nutrition as an input to faster human and economic

development in the future. As the International Food

Policy Research Institute (2016) puts it, countries of

the region “…so long synonymous with the problem of

malnutrition, can become a major part of the solution.”

The solutions will have to come from a stronger more

consistent national level political and policy commitment

to urgently addressing micronutrient malnutrition

from multiple directions at once. A nutrient-by-nutrient

approach will not suffice and neither will a focus on

some but not all micronutrient problems. Similarly,

reliance on the distribution of supplements and other

targeted nutrition-specific actions by themselves will

achieve some but not all the gains required.

This does not mean that governments should remove

supplementation from the tool-kit available to

policymakers and other development practitioners

where it is cost-effective. Quite the contrary.

Supplementation with vitamin A, iron and folic acid,

and sometimes multiple micronutrients has proven

to be very cost effective in appropriate contexts.

Currently, LMICs are “doing well” on providing

vitamin A supplements to pre-school age children,

with a median population coverage of 79 percent,

and in providing iron and folic acid supplementation

to pregnant women, with a median coverage of

78 percent (IFPRI, 2016). Hoddinott et al. (2012)

estimate that the benefit:cost ratio of vitamin A

supplementation for children under five in low income

countries was 12.5, while the figure for iron and folic

acid supplementation for children aged 6 to 23 months

and mothers was double that at 24 months. In the

case of salt iodization the benefit:cost ratio was 81.

Vitamin A supplementation efforts have been ongoing

across the region for decades. High dose biannual

supplementation of children under five in Pakistan

from the 1990s has been linked to a roughly 24%

reduction in VAD as a result of effective program

administration and targeting (Siddiqi and Iqbal 2008;

Haider and Bhutta, 2011). In Sri Lanka, a vitamin A

supplementation programme has been associated with

fewer school days missed due to illness compared to

the placebo group (Mahawithanage et al., 2007).

However, with an average coverage of vitamin A

supplementation of only 62% in 2014 (largely driven by

India’s lower performance), South Asia still has one of

the lowest coverage rates globally – the world average

being 69% (UNICEF, 2016a). Even current rates of

coverage are at risk of declining in some countries as

a result of the phasing out of National Immunization

Days. Horton et al. (2008) point out that Bangladesh

relied on accessing hard-to-reach populations with

vitamin A supplements by combining routine health

services with Child Health Days that linked vitamin

A distribution with immunization. But Child Health

Days are increasingly questioned by governments

seeking places to save on health budget outlays. The

implication is that rates of supplementation coverage

cannot be guaranteed into the future where nation

mechanisms for delivery are not secure.

Iron (plus folic acid) supplementation relies on

clinic distribution or community health workers to

reach remote populations. For example, Nepal has

demonstrated the feasibility of achieving wide coverage

by empowering community health workers and by

focusing resources on antenatal and postnatal care.

34 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

In response to a 75% prevalence of anaemia among

pregnant women in 1998, the government began the

Intensification of Maternal and Neonatal Micronutrient

Program in 2004 with financial support from UNICEF

and the Micronutrient Initiative. The program targeted

antenatal care visits, iron and folic acid supplementation

and deworming medication during pregnancy using

female community health volunteers. Monitoring

indicators suggested successful implementation, and

the prevalence of anaemia among pregnant women

fell to 42% by 2006 (Pokharel et al., 2011). The rate of

anaemia among pregnant women continued to fall,

reaching 34% by 2010/11 (Nepal 2011).

However, supplementation is not enough to achieve

sustained full micronutrient nutrition to entire

populations. In addition to high supplementation

coverage where appropriate, additional actions are

needed. This requires other interventions focused on

i) additional non-supplement micronutrient delivery

mechanisms, including food fortification, biofortification

and diet diversification, ii) actions to promote the

nutrition security of infants and young children, and iii)

complementary nutrition-sensitive interventions that

will support gains in human capital development.

The non-supplement approaches to delivering

micronutrients have also been widely implemented

in the region. For example, vegetable oil and ghee

are fortified with vitamin A and D in Afghanistan

since 2014, and there have been several attempts to

implement iron fortification of wheat flour. India and

Pakistan have pursued the fortification of wheat flour

with iron, folic acid and vitamin B12, while Nepal has

also implemented mandatory wheat flour fortification

with iron and folic acid. Several countries in the region,

such as Nepal are testing the potential of point-of-use

or ‘home’ fortification; that is, the distribution of small

packets of multiple micronutrient powders mixed into

the complementary food offered to infants after 6

months of age (Ip et al., 2009; Sazawal et al., 2014).

An additional means of delivering micronutrients into

the local food matrix at the point of consumption is

through small dose lipid nutrient supplements which

are highly nutrient-dense oil-based spreads that can be

blended into an infant’s meal (Lopriore et al., 2004).

Salt iodization is another widely adopted approach to

tackling iodine deficiency. As mentioned above, the

benefit:cost ratio of salt iodization is very high at 81

(Hoddinott et al., 2012). However, policy and regulatory/

monitoring mechanisms are required to ensure that

adequate iodization is actually occurring and that

families have access to such salt. While the global

average for adequately iodized salt consumption stood

at 75% in 2014, South Asia was still lagging at 69%

(UNICEF, 2014). That said, a renewed push is underway

among governments of the region towards the universal

goal of 90% coverage. In India, for example, this

included the formation of state level coalitions, the

provision of technical support to enhance the capacity

of salt producers, and the sensitization of wholesalers

and retailers to procure only adequately iodized salt.

Recent data show that conditions are improving, with

household use of adequately iodized salt increasing

from 71% in 2009 to 78% in 2014 (Rah et al., 2015).

Actions to improve the dietary intake of essential

nutrients in early life include approaches to protect,

promote and support breastfeeding and higher quality

complementary foods and feeding practices. Exclusive

breastfeeding immediately after delivery until six months

of age provides infants with nutrients and protects

them from diseases that may lead to nutrient loss. Only

64% of infants in South Asia benefit from exclusive

breastfeeding, and 55% are not breastfed from within

the first hour of life (UNICEF, 2016b). The introduction

of solid, semi-solid or soft foods should occur at the

age of 6 months, yet half of infants (46%) receive foods

too late for optimal growth and development. Only 47%

of children aged 6-23 months are fed the minimum

number of meals a day and only 23% are eating the

minimum number of food groups, leaving the vast

majority vulnerable to micronutrient deficiencies.

All countries in South Asia recognize infant and young

child feeding as a strategic development priority and

have a range of policy and legislation support for

breastfeeding (Thow et al., 2017). However, gaps in

the design and implementation of these policies and

legislation remain, and there is need to strengthen

health system support for counselling and education

on breastfeeding, as well as workplace, community

and family support to breastfeeding mothers. There

is relatively little policy emphasis on complementary

feeding in the region (Thow et al., 2017), and greater

government leadership, prioritization and financing is

needed to address the nutrient gap in children’s diets

(UNICEF, 2016b). Progress on complementary feeding

requires actions by multiple sectors and stakeholder

groups that can collectively ensure a household has

access to affordable and nutritious food, and whether

caregivers have the skills, knowledge and other

resources to prepare frequent nutritious and safe foods.

The promotion of dietary diversification is a food-

based approach to increasing intake of micronutrients.

Diet diversification represents a large-scale but as

yet unfulfilled opportunity. While the consumption

of foods high in beta carotene by vitamin A deficient

35

consumers has been shown to have a significant

positive association with serum retinol concentrations

(Fujita et al., 2012; Webb and Kennedy, 2014), there

is limited empirical evidence of cost-effective policy or

programme interventions that succeed in sustaining

diet diversity across a range of nutrients (Thompson

and Amoroso, 2014). What is more, Mark et al. (2016)

calculated that the current food supply in most of

South Asia is not adequately composed to deliver

seven of the most important nutrients required for

sound nutrition and health. For example, India has

the lowest supply (in foods) of vitamin B-12 and

zinc, Pakistan has the lowest supply of thiamine, and

Bangladesh the lowest supply of vitamin A, riboflavin

and calcium. This does not mean that promotion

of agricultural diversity and market access for all

consumers cannot achieve such a goal, but more

needs to be done to demonstrate effective approaches

that can be adopted by governments across the region

(Sibhatu et al., 2015).

The most recent food-based approach to delivering

micronutrients is biofortification. An expert consultation

suggested in 2003 that “probably as many as 30

biologically distinct types of foods, with the emphasis

on plant foods, are required for healthy diets” (WHO

and FAO, 2003). Achieving access to a diverse diet is

not easy for poor people, and it represents a major

policy challenge for developing country governments.

Many consumers are constrained by income level

or distance to markets to eating a monotonous

nutritionally-inadequate diet. Biofortification represents

a way to ‘deliver more’ in the context of dietary

constraints. It is pursued through conventional crop

breeding techniques that are used to identify varieties

with high concentration of desired micronutrients.

Those varieties are then cross-bred with high-yielding

varieties to develop biofortified varieties that have high

levels of, for example, zinc or betacarotene, in addition

to other productivity traits desired by farmers (Global

Panel, 2015).

Rice biofortified with zinc was released to farmers

in Bangladesh in 2013 (Chowdhury, 2014). These

biofortified varieties have a zinc content that is 30%

higher than local varieties, and it matures faster than

some traditional strains (HarvestPlus, 2014). The

capacity to scale up adoption of high-zinc rice has

still to be demonstrated; but since poor consumers

in Bangladesh rely heavily on large amounts of rice

daily, such an approach could significantly improve

dietary intake of zinc. The same applies to biofortified

pearl millet, with higher iron and zinc content, which

is already being grown in Maharashtra state of India

(HarvestPlus, 2014).

It is the complementary among a set of actions that

offers the best promise for accelerated change.

Such complementarity has been underlined by FAO,

which calculated that an annual investment of US$

1.2 billion in the combination of a) micronutrient

supplementation, b) staple food fortification and c)

biofortification of staple crops, would result in “better

health, fewer deaths and increased future earnings”

valued at over US$ 15 billion per year: a 13-to-1 benefit

to cost ratio (FAO, 2013).

The second set of actions needed to complete the

work of resolving micronutrient deficiencies in South

Asia involve nutrition sensitive approaches that

support human capital formation. As noted by Ruel

et al. (2013) “nutrition-sensitive programmes can help

scale up nutrition-specific interventions and create a

stimulating environment in which young children can

grow and develop to their full potential.” This means

appropriately supporting agriculture, social safety nets,

early child development activities, water, hygiene and

sanitation (WASH) activities, health promotion and

universal education. It is critically important that all

children in South Asia gain access to the right kinds

of care, health services and diets; that agricultural

programmes and social safety nets be designed to

reach the most vulnerable and protect them effectively

from negative effects of food price and other shocks.

It is equally important that national and local policies

support women’s empowerment, literacy and formal

education.

It is also essential that policymakers should promote

poverty- and inequity-reducing economic growth.

Gross national income growth is critical to enabling

governments to make the investments in the nutrition

specific and nutrition sensitive programmes outlined

above. Yet, while economic growth does tend to reduce

most forms of malnutrition over time, the decrease

is generally far slower and less equitably distributed

than the corresponding poverty reduction might have

predicted (Ruel et al., 2013). In other words, malnutrition

in general, and hidden malnutrition in particular, “does

not take care of itself” (Webb and Block, 2004).

South Asia’s future depends on ensuring that policies

across the many sectors with responsibility for

promoting good nutrition are mutually-supportive, that

public programming is evidence-based and measurably

cost-effective, and that the benefits of accelerated

improvements in nutrition are equitably shared. Human

capital has to be preserved, protected and nurtured

as a South Asia-wide goal. For this to happen, hidden

malnutrition has also to be embraced as a South Asia-

wide problem to be resolved as a matter of urgency.

36 CHILD STUNTING, HIDDEN HUNGER AND HUMAN CAPITAL IN SOUTH ASIA

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