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What does stunting tell us?
(2023)
Stunting is commonly linked with undernutrition. Yet, already after World War I, German pediatricians questioned this link and stated that no association exists between nutrition and height. Recent analyses within different populations of Low- and middle-income countries with high rates of stunted children failed to support the assumption that stunted children have a low BMI and skinfold sickness as signs of severe caloric deficiency. So, stunting is not a synonym of malnutrition. Parental education level has a positive influence on body height in stunted populations, e.g., in India and in Indonesia. Socially disadvantaged children tend to be shorter and lighter than children from affluent families.
Humans are social mammals; they regulate growth similar to other social mammals. Also in humans, body height is strongly associated with the position within the social hierarchy, reflecting the personal and group-specific social, economic, political, and emotional environment. These non-nutritional impact factors on growth are summarized by the concept of SEPE (Social-Economic-Political-Emotional) factors. SEPE reflects on prestige, dominance-subordination, social identity, and ego motivation of individuals and social groups.
Students learn by repetition. Repetition is essential, but repetition needs questioning, and questioning the repertoire belongs to the essential tasks of student education. Guiding students to questioning was and is our prime motive to offer our International Student Summer Schools. The data were critically discussed among the students, in the twilight of Just So Stories, common knowledge, and prompted questioning of contemporary solutions. For these schools, the students bring their own data, carry their preliminary concepts, and in group discussions, they may have to challenge these concepts. Catch-up growth is known to affect long bone growth, but different opinions exist to what extent it also affects body proportions. Skeletal age and dental development are considered appropriate measures of maturation, but it appears that both system develop independently and are regulated by different mechanisms. Body weight distributions are assumed to be skewed, yet, historic data disproved this assumption. Many discussions focused on current ideas of global growth standards as a common yardstick for all populations world-wide, with new statistical tools being developed including network reconstruction and evaluation of the reconstructs to determine the confidence of graph prediction methods.
125 years ago, European infants grew differently from modern infants. We show weight gains of 20 healthy children weighed longitudinally from birth to age 1 year, published by Camerer in 1882. The data illustrate the historically prevalent concepts of infant nutrition practiced by German civil servants, lawyers, merchants, university professors, physicians, foresters and farmers. Breastfeeding by the mother was not truly appreciated in those days; children were often breastfed by wet nurses or received bottled milk. Bottle feeding mainly used diluted cow’s milk with some added carbohydrates, without evidence that appropriate amounts of oil, butter or other fatty components were added. French children from 1914 showed similar weight gain patterns suggesting similar feeding practices. The historical data suggest that energy deficient infant formula was fed regularly in the late 19th and early 20th century Europe, regardless of wealth and social class. The data question current concerns that temporarily feeding energy deficient infant formula may warrant serious anxieties regarding long-term cognitive, social and emotional behavioral development.
Background: Members of the same social group tent to have the same body height. Migrants tend to adjust in height to their host communities.
Objectives: Social-Economic-Political-Emotional (SEPE) factors influence growth. We hypothesized that Vietnamese young adult migrants in Germany (1) are taller than their parents, (2) are as tall as their German peers, and (3) are as tall as predicted by height expectation at age 13 years.
Sample: The study was conducted in 30 male and 54 female Vietnamese migrants (mean age 26.23 years. SD=4.96) in Germany in 2020.
Methods: Information on age, sex, body height, school and education, job, height and ethnicity of best friend, migration history and cultural identification, parental height and education, and recalled information on their personal height expectations at age 13 years were obtained by questionnaire. The data were analyzed by St. Nicolas House Analysis (SNHA) and multiple regression.
Results: Vietnamese young adults are taller than their parents (females 3.85cm, males 7.44cm), but do not fully attain height of their German peers. The body height is positively associated with the height of best friend (p < 0.001), the height expectation at age 13 year (p < 0.001), and father’s height (p=0.001).
Conclusion: Body height of Vietnamese migrants in Germany reflects competitive growth and strategic growth adjustments. The magnitude of this intergenerational trend supports the concept that human growth depends on SEPE factors.
Background: Physical fitness is decreased in malnourished children and adults. Poor appearance and muscular flaccidity are among the first signs of malnutrition. Malnutrition is often associated with stunting.
Objectives: We test the hypotheses that stunted children of low social strata are physically less fit than children of high social strata.
Sample: We investigated 354 school girls and 369 school boys aged 5.83 to 13.83 (mean 9.54) years from three different social strata in Kupang (West-Timor, Indonesia) in 2020.
Methods: We measured height, weight, and elbow breadth, calculated standard deviation (SDS) of height and weight according to CDC references, and the Frame index as an indicator of long-term physical fitness, and we tested physical fitness in standing long jump and hand grip strength.
Results: Children of low social strata are physically fittest. They jump longer distances, and they have higher values in the Frame index. No association exists between height SDS and physical fitness, neither in respect to standing long jump, nor to hand grip strength.
Conclusion: Stunting does not impair physical fitness in Indonesian school children. Our results support the concept that SEPE (social-economic-political-emotional) factors are involved in the regulation of human growth.
Objective:
Stunting (height-for-age < −2 SD) is one of the forms of undernutrition and is frequent among children of low- and middle-income countries. But stunting perSe is not a synonym of undernutrition. We investigated association between body height and indicators of energetic undernutrition at three critical thresholds for thinness used in public health: (1) BMI SDS < −2; (2) mid-upper arm circumference divided by height (MUAC (mm) × 10/height (cm) < 1·36) and (3) mean skinfold thickness (SF) < 7 mm and to question the reliability of thresholds as indicators of undernutrition.
Design:
Cross-sectional study; breakpoint analysis.
Setting:
Rural and urban regions of Indonesia and Guatemala – different socio-economic status (SES).
Participants:
1716 Indonesian children (6·0–13·2 years) and 3838 Guatemalan children (4·0–18·9 years) with up to 50 % stunted children.
Results:
When separating the regression of BMI, MUAC or SF, on height into distinguishable segments (breakpoint analysis), we failed to detect relevant associations between height, and BMI, MUAC or SF, even in the thinnest and shortest children. For BMI and SF, the breakpoint analysis either failed to reach statistical significance or distinguished at breakpoints above critical thresholds. For MUAC, the breakpoint analysis yielded negative associations between MUAC/h and height in thin individuals. Only in high SES Guatemalan children, SF and height appeared mildly associated with R2 = 0·017.
Conclusions:
Currently used lower thresholds of height-for-age (stunting) do not show relevant associations with anthropometric indicators of energetic undernutrition. We recommend using the catch-up growth spurt during early re-feeding instead as immediate and sensitive indicator of past undernourishment. We discuss the primacy of education and social-economic-political-emotional circumstances as responsible factors for stunting.