RESUMEN
BACKGROUND: Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. OBJECTIVES: We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016. METHODS: Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru. RESULTS: The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation. CONCLUSIONS: Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.
Asunto(s)
Trastornos del Crecimiento/epidemiología , Desarrollo Infantil , Preescolar , Escolaridad , Femenino , Trastornos del Crecimiento/economía , Trastornos del Crecimiento/fisiopatología , Trastornos del Crecimiento/prevención & control , Humanos , Lactante , Masculino , Perú/epidemiología , Pobreza , Prevalencia , Población Rural/estadística & datos numéricos , Factores Socioeconómicos , Población Urbana/estadística & datos numéricosRESUMEN
BACKGROUND: Childhood stunting is the most common manifestation of chronic malnutrition. A growing body of literature indicates that stunting can have negative repercussions on physical and cognitive development. There are increasing concerns that low- and middle-income countries (LMICs) are particularly susceptible to adverse consequences of stunting on economic development. The aim of this review is to synthesize current evidence on interventions and policies that have had success in reducing stunting and explore the impact of successes on economic indicators. METHODS: This review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were searched through MEDLINE via PubMed and Ovid, Cochrane Library, Web of Science and ProQuest. Only articles that addressed the effects of nutrition and cash-based interventions and/or policies on stunting and reported effects on childhood mortality and/or human capital indicators were included. Two reviewers independently abstracted data and assessed quality. RESULTS: Seventeen studies from Africa (47%), South America (41%), and South Asia (12%) met the eligibility criteria: 8 cohort studies, 4 case studies, 4 Randomized Control Trials (RCTs) and 1 quasi-trial. Three types of interventions/policies were evaluated: multisectoral policies, nutritional supplementations and cash-based interventions (CCT). Overall, 76% of the included studies were successful in reducing stunting and 65% of interventions/policies reported successes on stunting reductions and economic successes. Five of the 11 successful studies reported on nutritional supplementation, 4 reported on multisectoral policies, and 2 reported on CCT interventions. Average Annual Rate of Reduction (AARR) was calculated to assess the impact of multisectoral policies on childhood mortality. AARR for under 5 mortality ranged from 5.2 to 6.2% and all countries aligned with the global target of 4.4% AARR. Quality assessment yielded positive results, with the biggest concerns being attrition bias for cohort studies, blinding for trials and generalizability of results for case studies. CONCLUSIONS: Evidence suggests that investment in fighting chronic malnutrition through multisectoral policies, multi-year nutritional supplementation (protein or multiple micronutrient supplementation) and possibly CCTs can have a long-term impact on economic development of LMICs. More evidence is needed to inform practices in non-represented regions while prioritizing standardization of economic indicators in the literature.
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Países en Desarrollo , Desarrollo Económico , Asistencia Alimentaria/economía , Trastornos del Crecimiento/prevención & control , Desnutrición , Estado Nutricional , Políticas , África , Asia , Niño , Países en Desarrollo/economía , Dieta , Suplementos Dietéticos , Trastornos del Crecimiento/economía , Trastornos del Crecimiento/etiología , Humanos , Desnutrición/complicaciones , Desnutrición/dietoterapia , Desnutrición/economía , Pobreza , América del SurRESUMEN
OBJECTIVES: We assessed associations between child stunting, recovery, and faltering with schooling and human capital skills in a native Amazonian society of horticulturalists-foragers (Tsimane'). METHODS: We used cross-sectional data (2008) from 1262 children aged 6 to 16 years in 53 villages to assess contemporaneous associations between three height categories: stunted (height-for-age Z score, HAZ<-2), moderately stunted (-2 ≤ HAZ≤-1), and nonstunted (HAZ>-1), and three categories of human capital: completed grades of schooling, test-based academic skills (math, reading, writing), and local plant knowledge. We used annual longitudinal data (2002-2010) from all children (n = 853) in 13 villages to estimate the association between changes in height categories between the first and last years of measure and schooling and academic skills. RESULTS: Stunting was associated with 0.4 fewer completed grades of schooling (â¼24% less) and with 13-15% lower probability of showing any writing or math skills. Moderate stunting was associated with â¼20% lower scores in local plant knowledge and 9% lower probability of showing writing skills, but was not associated with schooling or math and writing skills. Compared with nonstunted children, children who became stunted had 18-21% and 15-21% lower probabilities of showing math and writing skills, and stunted children had 0.4 fewer completed grades of schooling. Stunted children who recovered showed human capital outcomes that were indistinguishable from nonstunted children. CONCLUSIONS: The results confirm adverse associations between child stunting and human capital skills. Predictors of growth recovery and faltering can affect human capital outcomes, even in a remote, economically self-sufficient society.
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Desarrollo del Adolescente , Desarrollo Infantil , Trastornos del Crecimiento/economía , Indígenas Sudamericanos/estadística & datos numéricos , Adolescente , Bolivia/epidemiología , Niño , Estudios Transversales , Femenino , Trastornos del Crecimiento/epidemiología , Humanos , MasculinoRESUMEN
BACKGROUND: Stunting prevalence in children less than 5 years has remained stagnated in Peru from 1992 to 2007, with a rapid reduction thereafter. We aimed to assess the role of different predictors on stunting reduction over time and across departments, from 2000 to 2012. METHODS: We used various secondary data sources to describe time trends of stunting and of possible predictors that included distal to proximal determinants. We determined a ranking of departments by annual change of stunting and of different predictors. To account for variation over time and across departments, we used an ecological hierarchical approach based on a multilevel mixed-effects regression model, considering stunting as the outcome. Our unit of analysis was one department-year. RESULTS: Stunting followed a decreasing trend in all departments, with differing slopes. The reduction pace was higher from 2007-2008 onwards. The departments with the highest annual stunting reduction were Cusco (-2.31%), Amazonas (-1.57%), Puno (-1.54%), Huanuco (-1.52%), and Ancash (-1.44). Those with the lowest reduction were Ica (-0.67%), Ucayali (-0.64%), Tumbes (-0.45%), Lima (-0.37%), and Tacna (-0.31%). Amazon and Andean departments, with the highest baseline poverty rates and concentrating the highest rural populations, showed the highest stunting reduction. In the multilevel analysis, when accounting for confounding, social determinants seemed to be the most important factors influencing annual stunting reduction, with significant variation between departments. CONCLUSIONS: Stunting reduction may be explained by the adoption of anti-poverty policies and sustained implementation of equitable crosscutting interventions, with focus on poorest areas. Inclusion of quality indicators for reproductive, maternal, neonatal and child health interventions may enable further analyses to show the influence of these factors. After a long stagnation period, Peru reduced dramatically its national and departmental stunting prevalence, thanks to a combination of social determinants and crosscutting factors. This experience offers useful lessons to other countries trying to improve their children's nutrition.
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Desarrollo Económico , Trastornos del Crecimiento/prevención & control , Política de Salud , Pobreza/prevención & control , Salud Rural , Determinantes Sociales de la Salud , Preescolar , Femenino , Trastornos del Crecimiento/economía , Trastornos del Crecimiento/epidemiología , Disparidades en el Estado de Salud , Humanos , Lactante , Recién Nacido , Masculino , Modelos Estadísticos , Perú/epidemiología , Prevalencia , Factores ProtectoresRESUMEN
The status of undernourishment in children under the age of five in Mexico is open to debate. Linked to poverty, underweight and stunting, the rates of undernourishment are reported to be diminishing, although poverty remains an incessant problem. This study was done to determine whether there is an association between public expenditure and underweight and stunting distribution in Mexico based on data from the 2006 health and population census and from macroeconomic, social, and demographic variables. We used principal component analysis to reduce the number of variables and analyze their behavior. Multiple regressions showed that underweight and stunting are significantly associated with the marginalization index, support from the Sistema Nacional para el Desarrollo Integral de la Familia (DIF) supplies and breakfast program, the gross domestic product per capita, and expenditure from the Opportunities program. Further, public expenditure aimed to combat undernourishment is inadequately oriented to address the needs of the poor.
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Trastornos de la Nutrición del Niño/economía , Asistencia Alimentaria/economía , Trastornos del Crecimiento/economía , Delgadez/economía , Trastornos de la Nutrición del Niño/epidemiología , Preescolar , Escolaridad , Financiación Gubernamental , Asistencia Alimentaria/normas , Trastornos del Crecimiento/epidemiología , Humanos , Lactante , México/epidemiología , Estado Nutricional , Pobreza , Análisis de Regresión , Delgadez/epidemiologíaRESUMEN
OBJECTIVE: To determine the incidence of pathology during routine screening of healthy short children, testing adherence to a consensus statement on the diagnosis and treatment of children with idiopathic short stature, and the cost per identified diagnosis resulting from comprehensive screening. STUDY DESIGN: Retrospective chart review of 1373 consecutive short stature referrals evaluated at the Cincinnati Children's Hospital Medical Center Pediatric Endocrinology Clinic between 2008 and 2011. We identified 235 patients with a height of <3rd percentile, negative history and review of systems, and normal physical examination. Outcome measures were incidence of pathology detection, diagnostic group characteristics, clinicians' adherence to testing guidelines, and screening costs. ANOVA and χ(2) were used to analyze the data. RESULTS: Nearly 99% of patients were diagnosed as possible variants of normal growth: 23% with familial short stature, 41% with constitutional delay of growth and maturation, and 36% with idiopathic short stature. The incidence of newly diagnosed pathology was 1.3%: 1 patient with biopsy-proved celiac disease, 1 with unconfirmed celiac disease, and 1 with potential insulin-like growth factor I receptor defect. On average, each patient had 64.3% of the recommended tests for age and sex; 2.1% of patients had all of the recommended testing. The total screening tests costs were $315321, yielding $105107 per new diagnosis entertained. CONCLUSIONS: Healthy short children do not warrant nondirected, comprehensive screening. Future guidelines for evaluating short stature should include patient-specific testing.
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Estatura , Trastornos del Crecimiento/diagnóstico , Trastornos del Crecimiento/economía , Pediatría/economía , Adolescente , Algoritmos , Biopsia , Niño , Preescolar , Medicina Basada en la Evidencia , Femenino , Costos de la Atención en Salud , Humanos , Lactante , Masculino , Pediatría/métodos , Estudios RetrospectivosRESUMEN
OBJECTIVE: To examine socio-economic inequalities in malnutrition among Colombian children and adolescents, and to assess the contribution of individual-, household- and community-level factors to those inequalities. DESIGN: Cross-sectional data were used from two sources: 2005 Colombian Demographic and Health Survey and 2005 Colombian census. Malnutrition outcomes included stunting and overweight. Multilevel Poisson models were used to estimate the association between individual, household and contextual characteristics and malnutrition. Changes in prevalence ratios of the poorest quintile (v. richest) were compared to assess the contribution of different characteristics to inequalities in malnutrition. SETTING: Population-based, representative of Colombia. SUBJECTS: Children and adolescents <18 years of age (n 30 779) from the Colombian Demographic and Health Survey. RESULTS: Children and adolescents living in the poorest households were close to five times more likely to be stunted, while those from the richest households were 1.32.8 times more likely than their poorest counterparts to be overweight. Care practices and household characteristics, particularly mother's education, explained over one-third of socio-economic inequalities in stunting. The proportion explained by access to services was not negligible (between 6% and 14 %). Access to sanitation was significantly associated with a lower prevalence of stunting for all age groups. Between 14% and 32% of socio-economic disparities in overweight were explained by maternal and household characteristics. Mother's overweight was positively associated with overweight of the child. CONCLUSION: Socio-economic inequalities in stunting and overweight coexist among children and adolescents in Colombia. Malnutrition inequalities are largely explained by household characteristics, suggesting the need for targeted interventions.
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Composición Familiar , Trastornos del Crecimiento , Disparidades en el Estado de Salud , Desnutrición , Sobrepeso , Pobreza , Características de la Residencia , Adolescente , Adulto , Estatura , Niño , Preescolar , Colombia , Escolaridad , Femenino , Trastornos del Crecimiento/economía , Disparidades en Atención de Salud , Humanos , Lactante , Masculino , Desnutrición/economía , Persona de Mediana Edad , Madres , Sobrepeso/economía , Saneamiento , Factores Socioeconómicos , Adulto JovenRESUMEN
OBJECTIVE: To evaluate the relationship between community well-being based on an index of marginalization and growth status of indigenous rural school children in Oaxaca. METHODS: Heights and weights of a cross-sectional sample of 11,454 children, 6-14 years, from schools for indigenous rural children (escuelas albergue) in 158 municipios in Oaxaca were measured in 2007. Tertiles of an index of marginalization were used to classify the 158 municipios into three categories of community well-being: lowest (highest marginalization), low, and moderate (lowest marginalization). Multivariate analysis of covariance, controlling for age, relative isolation and population size, was used to compare body size of children by category of community well-being. Contributions of marginalization, isolation and population size to variation in body size were estimated with sex-specific linear regression. RESULTS: Children from municipios lowest in well-being were shorter and lighter than children from municipios low and moderate in well-being. Marginalization and relative isolation accounted for 23% (boys) and 21% (girls) of the variance in height and for 21% of the variance in weight of girls. Marginalization was the predictor of weight in boys (23%). CONCLUSION: Community well-being was reflected in the growth status of rural indigenous school children. Compromised growth status was consistent with poor health and nutritional conditions that were and are characteristic of rural areas in the state of Oaxaca.
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Índice de Masa Corporal , Trastornos del Crecimiento/etnología , Crecimiento y Desarrollo , Indígenas Norteamericanos , Adolescente , Análisis de Varianza , Estatura , Peso Corporal , Niño , Estudios Transversales , Femenino , Trastornos del Crecimiento/economía , Trastornos del Crecimiento/epidemiología , Humanos , Masculino , México/epidemiología , Características de la Residencia , Factores Sexuales , Factores SocioeconómicosRESUMEN
OBJECTIVE: To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. METHODS: The prevalence of stunting (height-for-age z score below -2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34,409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. FINDINGS: Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. CONCLUSION: In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.