Using height-adjusted stunting prevalence will fail disadvantaged children worldwide
Authors: Jef L Leroy, Edward A Frongillo, Elaine Borghi
Journal: The Lancet Global Health (2022)

In their Comment (February, 2022),1Subramanian SV Karlsson O Kim R Revisiting the stunting metric for monitoring and evaluating nutrition policies.Lancet Glob Health. 2022; 10: e179-e180Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar S V Subramanian and colleagues challenge the validity of using the prevalence of child stunting to monitor and evaluate nutrition policies. Their argument is based on a fundamental misunderstanding of the 2006 WHO growth standards and how to appropriately use and interpret stunting. The authors espouse a dangerous and unethical position. The growth standards were constructed to show what we should expect if children grow in an environment favourable to growth, regardless of location. Consistent with this purpose, the Multicentre Growth Reference Study selected subpopulations living in conditions that do not constrain their growth.2Onis M Enrolment and baseline characteristics in the WHO Multicentre Growth Reference Study.Acta Paediatr. 2007; 95: 7-15Crossref Google Scholar The study did not select children on the basis of maternal height as the authors suggest. Mothers being taller was the result of selecting children whose growth was not constrained, and it was not unique to India. Maternal short stature is not simply passed down to children. The intergenerational association in height is driven by genetic and epigenetic mechanisms and the persistence of the deficient environment. Due to this persistence, adjusting for maternal stature underestimates the contribution of the current deficient conditions on a child's stature; therefore, it is flawed conceptually and statistically. Furthermore, adjusting for maternal stature is unethical. Outcomes such as child development, educational attainment, and health status are also determined by parental (ie, genetic) factors and the environment that children grow in. Following Subramanian and colleagues' logic, we would adjust for parental attainment or status for these outcomes as well. What the authors propose is equivalent to having lower expectations for children who have the misfortune of growing up in disadvantaged conditions. From the perspective of children's rights, all children in the world have the same right to grow and develop without constraints imposed by an inadequate environment. Having lower expectations for these children disregards the Sustainable Development Goals' central commitment of leaving no-one behind and violates the ethical principles of beneficence (ie, the obligation to maximise benefits for children and to protect them from harm) and of distributive justice (ie, the need to treat children fairly and equitably). Stunting has proven to be a remarkably useful metric for comparing the environmental deficits that children are exposed to between populations and over time.3Leroy JL Frongillo EA Perspective: what does stunting really mean? A critical review of the evidence.Adv Nutr. 2019; 10: 196-204Crossref PubMed Scopus (120) Google Scholar, 4Frongillo EA Leroy JL Lapping K Appropriate Use of Linear Growth Measures to Assess Impact of Interventions on Child Development and Catch-Up Growth.Adv Nutr. 2019; 10: 372-379Crossref PubMed Scopus (14) Google Scholar Altering the way the prevalence of stunting is obtained and reported will create confusion. Adopting Subramanian and colleagues' method will substantially disincentivise the commitment and actions that are urgently needed to improve the inadequate living conditions of hundreds of millions of children globally. We declare no competing interests. The authors alone are responsible for the views expressed in this letter and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. Using height-adjusted stunting prevalence will fail disadvantaged children worldwide – Authors' replyWe thank Jef Leroy and colleagues for their reply to our Comment.1 We underscored that the prevalence of stunting is often used as a population-level measure for child undernutrition—regardless of how it ought to be used—and numerous national and global development goals are based on it. Short maternal stature is overwhelmingly the strongest determinant of stunting, and it has a far stronger association with stunting than does measures of current living standards.2 We reasoned that if stunting prevalence among children reflects a mix of genetic heritability,3 intergenerational insults, as well as current exposures to nutritional deficiencies and infections, it is useful to learn which part of the prevalence is specifically due to current deprivations. Full-Text PDF Open AccessRevisiting the stunting metric for monitoring and evaluating nutrition policiesGlobally, as well as in India, the prevalence of stunting is a commonly used metric to quantify undernutrition among children. Stunting prevalence is the proportion of children younger than 5 years who are too short for their age, according to the 2006 WHO growth standard, constructed from the Multi Growth Reference Study (MGRS).1 Using the MGRS standard, around 38% of children in India are stunted.2 This metric is also used by countries to monitor the effect of current policies that are in place to reduce the child undernutrition burden. Full-Text PDF Open Access