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Food and health

Stunting is not a synonym of malnutrition

A Correction to this article was published on 21 October 2019

This article has been updated

Abstract

Background

WHO documents characterize stunting as, “…impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation.” The equation of stunting with malnutrition is common. This contrasts with historic and modern observations indicating that growth in height is largely independent of the extent and nature of the diet.

Subjects

We measured 1716 Indonesian children, aged 6.0–13.2 years, from urban Kupang/West-Timor and rural Soe/West-Timor, urban Ubud/Bali, and rural Marbau/North Sumatra. We clinically assessed signs of malnutrition and skin infections.

Results

There was no relevant correlation between nutritional status (indicated by skinfold thickness) and height SDS (hSDS). In total 53% of boys, and 46% girls in rural Soe were stunted, with no meaningful association between mean of triceps and subscapular skinfolds (x̅SF) and height. Skinfold thickness was close to German values. Shortest and tallest children did not differ relevantly in skinfold thickness. The same applied for the association between hSDS and mid-upper-arm circumference (MUAC) using linear mixed effects models with both fixed and random effects. In total 35.6% boys and 29.2% girls in urban Ubud were overweight; 21.4% boys and 12.4% girls obese, but with mean hSDS = −0.3, still short. Relevant associations between hSDS and x̅SF and MUAC were only found among the overweight urban children confirming that growth is accelerated in overweight and obese children. There were no visible clinical signs of malnutrition or chronic infection in the stunted children.

Conclusion

The present data seriously question the concept of stunting as prima facie evidence of malnutrition and chronic infection.

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Acknowledgements

We gratefully acknowledge significant support by the local authorities, and in particular, by Octavianus NE, Jelalu ES, Lubis M, Arto KS, Siregar C, Rahayu S, Nasution A, Andreas ST, Harahap MA, Sihotang RD, Winny, Suryawan WB, Prayoga AW, Satria E, Paramita ADP, Febriyanti KD, Mahaputri AS, Dhyna AD, Pratama GA, Trisnia A, Purnama IA, and Wisudarma GA, from the Medical Faculty Nusa Cendana University, Kupang-East Nusa Tenggara, Indonesia; from the School of Medicine, University of Sumatera Utara, Medan, Sumatera Utara, Indonesia; and from Regional General Hospital Wangaya Denpasar.

Funding

There was no funding for data collection, analysis, or interpretation of the data; there was no funding for trial design; subject recruitment; there was partial funding of travel expenses by the Indonesian Pediatric Society, managed by Pulungan A. The corresponding author MH has full access to all the data in the study and had final responsibility for the decision to submit for publication.

Author contributions

Study design: CS, MH, BB, literature search: CS, MH, BB, measurements: Indonesia—CS, MH, and the Indonesian co-authors: DSL, FT; CPMVP, MI, LFI, NKM, MKEP, AVH, AT, SA, MGM, FRD, RRKR, SYT, PVK, BJM, RN, RP, IKR, ASL, PA, and AAIP equally contributed to the measurements of the children. Local organization of the study: MJ, JB, and AP; data analysis: CS, MH, and BB; data interpretation: CS, MH, and BB; writing: CS, MH, and BB; figures: BB, CS.

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Correspondence to M. Hermanussen.

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Scheffler, C., Hermanussen, M., Bogin, B. et al. Stunting is not a synonym of malnutrition. Eur J Clin Nutr 74, 377–386 (2020). https://doi.org/10.1038/s41430-019-0439-4

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