evidence-based blog of Filippo Dibari

Perspective: What Does Stunting Really Mean? A Critical Review of the Evidence

In Under-nutrition on June 3, 2019 at 9:49 am

by Jef L LeroyEdward A Frongillo on Advance in Nutrition journal

Advances in Nutrition, Volume 10, Issue 2, March 2019, Pages 196–204,


The past decade has seen an unprecedented increase in attention to undernutrition, and drastically reducing child stunting has become a global development objective. The strong focus on linear growth retardation and stunting has enabled successful advocacy for nutrition, but with this focus has come some confusion and misunderstanding about the meaning of linear growth retardation and stunting among researchers, donors, and agencies active in nutrition.

Motivated by the belief that a sharp focus will further accelerate progress in reducing undernutrition, we critically reviewed the evidence. The global attention to stunting is based on the premise that any intervention aimed at improving linear growth will subsequently lead to improvements in the correlates of linear growth retardation and stunting.

Current evidence and understanding of mechanisms does not support this causal thinking, with 2 exceptions: linear growth retardation is a cause of difficult births and poor birth outcomes. Linear growth retardation is associated with (but does not cause) delayed child development, reduced earnings in adulthood, and chronic diseases. We thus propose distinguishing 2 distinctly different meanings of linear growth retardation and stunting.

First, the association between linear growth retardation (or stunting) and other outcomes makes it a useful marker.

Second, the causal links with difficult births and poor birth outcomes make linear growth retardation and stunting outcomes of intrinsic value.

In many cases a focus on linear growth retardation and stunting is not necessary to improve the well-being of children; in many other cases, it is not sufficient to reach that goal; and for some outcomes, promoting linear growth is not the most cost-efficient strategy.

We appeal to donors, program planners, and researchers to be specific in selecting nutrition outcomes and to target those outcomes directly.

Cost-effectiveness of community-based screening and treatment of moderate acute malnutrition in Mali

In Under-nutrition on May 6, 2019 at 3:20 pm

source: BMJ webpage

By Sheila Isanaka1, Dale A Barnhart2, Christine M McDonald3, Robert S Ackatia-Armah4, Roland Kupka5, Seydou Doumbia6, Kenneth H Brown4, Nicolas A Menzies7


Introduction Moderate acute malnutrition (MAM) causes substantial child morbidity and mortality, accounting for 4.4% of deaths and 6.0% of disability-adjusted life years (DALY) lost among children under 5 each year. There is growing consensus on the need to provide appropriate treatment of MAM, both to reduce associated morbidity and mortality and to halt its progression to severe acute malnutrition. We estimated health outcomes, costs and cost-effectiveness of four dietary supplements for MAM treatment in children 6–35 months of age in Mali.

Methods We conducted a cluster-randomised MAM treatment trial to describe nutritional outcomes of four dietary supplements for the management of MAM: ready-to-use supplementary foods (RUSF; PlumpySup); a specially formulated corn–soy blend (CSB) containing dehulled soybean flour, maize flour, dried skimmed milk, soy oil and a micronutrient pre-mix (CSB++; Super Cereal Plus); Misola, a locally produced, micronutrient-fortified, cereal–legume blend (MI); and locally milled flour (LMF), a mixture of millet, beans, oil and sugar, with a separate micronutrient powder. We used a decision tree model to estimate long-term outcomes and calculated incremental cost-effectiveness ratios (ICERs) comparing the health and economic outcomes of each strategy.

Results Compared to no MAM treatment, MAM treatment with RUSF, CSB++, MI and LMF reduced the risk of death by 15.4%, 12.7%, 11.9% and 10.3%, respectively. The ICER was US$9821 per death averted (2015 USD) and US$347 per DALY averted for RUSF compared with no MAM treatment.

Conclusion MAM treatment with RUSF is cost-effective across a wide range of willingness-to-pay thresholds.

Affiliation of the authors:

  1. Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  2. Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  3. Children’s Hospital Oakland Research Institute, Oakland, California, USA
  4. Department of Nutrition and Program in International and Community Nutrition, University of California, Davis, CA, USA
  5. United Nations Children’s Fund, Nutrition Section, New York, NY, USA
  6. Faculty of Medicine and Odontostomatology, University of Sciences, Techniques and Technology of Bamako, Bamako, Mali
  7. Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  8. Correspondence toDr Sheila Isanaka; sisanaka@hsph.harvard.edu

Do Vegetarians Get Enough Protein?

In Over-nutrition on April 13, 2019 at 6:08 am

from NutritionFacts webage

The only nutrient Americans may be more deficient in than fiber is potassium. See 98% of American Diets Potassium-Deficient. For more on how S.A.D. the Standard American Diet is, see Nation’s Diet in Crisis.

Americans eating meat-free diets average higher intakes of nearly every nutrient. See my video Nutrient-Dense Approach to Weight Management.

Isn’t animal protein higher quality protein, though? See D Greger’s videos:

For more on protein, see: Plant Protein Preferable and Prostate Cancer Survival: The A/V Ratio.

And for a few on fiber:

If you haven’t yet, you can subscribe to Dr Greger’s videos for free by clicking here.

%d bloggers like this: