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Children concurrently wasted and stunted: A meta-analysis of prevalence data of children 6–59 months from 84 countries

Summary of research

By Tanya Khara, Martha Mwangome, Moses Ngari and Carmel Dolan

Tanya Khara and Carmel Dolan are ENN Technical Directors. They coordinate the ENN Wasting-Stunting (WaSt) Project and the WaSt Technical Interest Group.

Martha Mwangome is a Post-Doctoral Research Scientist at the KEMRI/Wellcome Trust Research Programme in Kenya and is actively involved in the ENN led WaSt Project.

Mosese Ngari is a PhD student and biostatistician at the KEMRI/Wellcome Trust Research Programme in Kenya offering statistical and data management support to child nutritional studies.

The full research study is available open access in 'Maternal and Child Nutrition' here. 

Reducing the prevalence of children who are wasted and stunted are global priorities. Wasting and stunting are often present in the same geographical populations (Victora, 1992) and it is recognised that children can be stunted and wasted at the same time, ‘concurrently wasted and stunted’ (IFPRI, 2015). Though the relationship between these manifestations of undernutrition at the level of the individual child and the mechanisms leading to this state of “concurrence” are poorly understood (Angood et al, 2016), evidence suggests that children with both deficits are at a greatly elevated risk of mortality (McDonald et al, 2013).

This paper highlights the issue that despite the above, there are no global estimates of the prevalence and burden of concurrence (UNICEF et al, 2016). It is in fact rarely reported, though the data required to estimate concurrence is readily available in national surveys (Saaka & Galaa, 2016). The authors note that reporting on global figures for the prevalence of different nutritional deficits separately, underestimates the true proportion of the global population affected by nutritional deficits as a whole and, ignores this critical proportion of children affected by multiple deficits who may require additional nutritional support.

The analysis presented in the paper aims to address this gap by providing the first multiple country estimates of the prevalence and burden of children aged 6–59 months concurrently wasted and stunted using data from Demographic and Health Surveys (DHS) and Multi?indicator Cluster Surveys (MICS). The aim was to approach a global estimate though sufficiently recent data (last 10yrs) was available for just 84 countries. For countries with more than one dataset available the most recent dataset was chosen. Country-specific estimates were calculated and pooled using the random-effects meta-analysis to yield the 84 country estimates (Hamza, Reitsma, & Stijnen, 2008). Burden by country was calculated using country population figures from the global joint estimates database (UNICEF et al, 2016). The analysis also explored age, sex, regional, and contextual differences, and estimated of the proportion of children affected by either of these conditions (wasted or stunted).

The pooled prevalence of children concurrently wasted and stunted in the 84 countries was found to be 3.0%, 95% CI [2.97, 3.06]. The prevalence of concurrence varied across countries from 0% in Montenegro to 8.0%, 95% CI [7.2, 8.9], in Niger. Nine countries had a concurrence prevalence greater than 5%. Six from sub-Saharan Africa (Niger, Burundi, Djibouti, Chad, Sudan, and South Sudan) and three from Asia (Timor-Leste, Yemen, and India). The authors note that a country prevalence of >5% severe wasting would warrant concern and intensification of efforts to identify and treat children. Though concurrence is associated with similar mortality risks, its prevalence is not monitored, and cases are not routinely identified, therefore, no specific action can be taken.

The estimated prevalences from this analysis were calculated to correspond to nearly 6 million children concurrently wasted and stunted in the 84 countries. The authors note that given the transitory nature of wasting in particular, where a child can experience several episodes of wasting during a set period, using cross-sectional data insufficiently estimates the actual prevalence (Garenne et al, 2009). This means that the above is likely to be an underestimate of the true burden of children experiencing these two deficits concurrently. See figure 1. For a graphical representation of the results by country.

Prevalence of concurrence was found to be highest in the 12 to 24 month age group 4.2%, 95% CI [4.1, 4.3], and was significantly higher among boys 3.54%, 95% CI [3.47, 3.61], compared to girls; 2.46%, 95% CI [2.41, 2.52]. Fragile and conflict-affected states reported significantly higher concurrence 3.6%, 95% CI [3.5, 3.6], than those defined as stable 2.24%, 95% CI [2.18, 2.30]. The authors note that these patterns mirror higher prevalences of wasting and stunting when analysed separately. Particularly in the case of the pattern of heightened nutritional vulnerability of boys, the data suggests that further investigation is needed.

The pooled 84 country prevalence estimate for children 6–59 months of age experiencing either wasting or stunting was found to be 38.9%, 95% CI [38.7, 39.0]. This means that only 61.1%, 95% CI [61.0, 61.3], of children in the 84 countries escape both conditions. The authors note that this is a very stark metric for understanding the extent of undernutrition in these countries and refer to country disaggregated data from this analysis that was reported in the Global Nutrition Report 2016, in which it can be seen that in a number of countries (Benin, Djibouti, Yemen, Niger, Chad, Guinea-Bissau, Ethiopia, Congo DRC, Burundi and Somalia, India, Pakistan, and Laos), over half the population of children is suffering from one of these deficits (IFPRI, 2016).

Given the high risk of mortality associated with concurrence, the authors conclude that the levels of prevalence and burden reported in their analysis, indicate that there is a need to systematically report on this condition within country and global monitoring systems and, for researchers programmers and policy makers to prioritise investigation into the extent to which these children are being reached through existing programmes.

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References

Angood, C., Khara, T., Dolan, C., Berkley, J. A., & WaSt TIG. (2016). Research priorities on the relationship between wasting and stunting. PloS One , 11(5). e0153221. https://doi.org/10.1371/journal.pone.0153221

Garenne, M., Willie, D., Maire, B., Fontaine, O., Eeckels, R., Briend, A., & Van den Broeck, J. (2009). Incidence and duration of severe wasting in two African populations. Public Health Nutr, 12(11), 1974-1982. doi:10.1017/S1368980009004972

Hamza, T. H., Reitsma, J. B., & Stijnen, T. (2008). Meta-analysis of diagnostic studies: a comparison of random intercept, normal-normal, and binomial-normal bivariate summary ROC approaches. Med Decis Making, 28(5), 639-649. doi:10.1177/0272989X08323917

IFPRI. (2015). Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition & Sustainable Development. Panel 2.1 Extent of wasting and stunting in the same children. Washington, DC

IFPRI. (2016). Global Nutrition Report 2016: From Promise to Impact: Ending Malnutrition by 2030. Retrieved from Washington, DC

McDonald, C. M., Olofin, I., Flaxman, S., Fawzi, W. W., Spiegelman, D., Caulfield, L. Ezzati, M, Danaei, G., for the Nutrition Impact Model Study. (2013). The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries. Am J Clin Nutr, 97(4), 896-901. doi:10.3945/ajcn.112.047639

Saaka, M., & Galaa, S. Z. (2016). Relationships between Wasting and Stunting and Their Concurrent Occurrence in Ghanaian Preschool Children. J Nutr Metab, 2016, 4654920. doi:10.1155/2016/4654920

UNICEF, WHO, & Group, W. B. (2016). Levels and Trends in Child Malnutrition. WHO/UNICEF/World Bank Group Joint estimates. Retrieved from http://www.who.int/nutgrowthdb/jme_brochure2016.pdf?ua=1

Victora, C. G. (1992). The association between wasting and stunting: An international perspective. The Journal of Nutrition , 122(5), 1105–1110.

Funding clause:

This study is made possible by the generous support of the American people through the United States Agency for International Development (USAID) through the grant ENN AID-OFDA-G-15-00190 and through an Irish Aid Grant number 2016/RESNUT/001/ENN: the ideas, opinions and comments therein are entirely the responsibility of its author(s) and do not necessarily represent or reflect the view of USAID or the United States Government or Irish Aid policy.

Read more about ENN's Wasting and Stunting project here.

 

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Khara, T., Mwangome, M., Ngari, M. and Dolan, C. (2017). Children concurrently wasted and stunted: A meta-analysis of prevalence data of children 6–59 months from 84 countries. Field Exchange 57, February 2018. www.ennonline.net/fex/57/wastmetaanalysis