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The relative importance of pre- and postnatal determinants of stunting.: Data mining approaches to the Maternal and Infant Nutrition Interventions in Matlab (MINIMat) cohort, Bangladesh
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH). (Global barnhälsa och nutrition)
Linköping Universitet.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH), International Child Health and Nutrition.
Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK, .
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Background The WHO has set a goal to reduce the prevalence of stunted child growth by 40% by the year 2025. To reach this goal, it is imperative to establish the relative importance of risk factors for stunting to deliver the appropriate interventions. Currently, most interventions take place in late infancy and early childhood. This study aimed to identify the most critical pre- and postnatal determinants of linear growth 0–24 months and the risk factors for stunting at two years, and to identify subgroups with different growth trajectories and levels of stunting at two years.

Method and Findings Conditional inference-tree-based methods were applied to the extensive Maternal and Infant Nutrition Interventions in Matlab (MINIMat) trial database with 309 variables of 2,723 children: their parents and living conditions, including socioeconomic, nutritional and other biological characteristics of the parents; maternal exposure to violence; household food security; breast- and complementary-feeding; and measurement of morbidity of the mothers during pregnancy and repeatedly of their children up to 24 months of age. Child anthropometry was measured monthly from birth to 12 months, thereafter quarterly to 24 months. Birth length and weight were the most critical factors for linear growth 0–24 months and stunting at two years, followed by maternal anthropometry and parental education. Conditions after birth, such as feeding practices and morbidity, were less strongly associated with linear growth trajectories and stunting at two years.

Interpretation The results of this study, together with findings from recent reviews, motivate a change in policy and practice, emphasizing the benefit of interventions before conception and during pregnancy to reach a substantial reduction in stunting.

Keywords [en]
Stunting, nutrition, undernutrition, pre and postnatal interventions, data mining, decision tree, risk factors
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
URN: urn:nbn:se:uu:diva-347522OAI: oai:DiVA.org:uu-347522DiVA, id: diva2:1194858
Available from: 2018-04-04 Created: 2018-04-04 Last updated: 2018-04-04
In thesis
1. Stunted growth in children from fetal life to adolescence: Risk factors, consequences and entry points for prevention - Cohort studies in rural Bangladesh
Open this publication in new window or tab >>Stunted growth in children from fetal life to adolescence: Risk factors, consequences and entry points for prevention - Cohort studies in rural Bangladesh
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Stunted growth affects one in four children under the age of five years and comes with great costs for the child and society. With an increased understanding of the long-term consequences of chronic undernutrition the reduction of stunted growth has become an important priority on the global health agenda. WHO has adopted a resolution to reduce stunting by 40% by the year 2025 and to reduce stunting is one of the targets under the Sustainable Development Goals.

The aim of this thesis was to study linear growth trajectories, risk factors and consequences of stunting and recovery of stunting from fetal life to adolescence in a rural Bangladeshi setting and to assess the cost-effectiveness of a prenatal nutrition intervention for under-five survival and stunting.

A birth cohort of children of women participating in the Maternal and Infant Nutrition Interventions trial (MINIMat), a randomized prenatal food and multiple micronutrient (MMS) trial, was followed from birth to adolescence. Information about socioeconomic and nutritional characteristics of the mother and father was collected, and frequent anthropometry assessments of the child were done at birth, in infancy, and during childhood and adolescence. At puberty, pubertal stages according to Tanner, age at menarche and start of the pubertal growth spurt in boys were assessed. Calculations were made regarding the cost-effectiveness of prenatal food and micronutrient intervention related to the disability adjusted life years (DALYs) lost by death and stunting.

At birth, the children were on average short compared the WHO growth reference and more than half of the children were Small-for-Gestational-Age. Linear growth faltered dramatically up to 2 years, after which height-for-age Z-score increased up to adolescence. The prevalence of stunting was highest at 2 years (50%) and thereafter decreasing to 25% in adolescence. Birth size, maternal anthropometry and parental education were the most influential factors for linear growth up to and stunting at 2 years. Conditions after birth, such as feeding practices and morbidity, were less important. At 10 years, children born to short mothers (<147.5 cm), mothers with no education, or those conceived in the pre-monsoon season had an increased probability to be stunted. The median age at menarche was 13.0 years. Children that were stunted in infancy and childhood had later pubertal development as compared to non-stunted children. Children that recovered from stunting had a similar timing of puberty as their peers who had never been stunted. Supplementation with combined early prenatal food and multiple micronutrients was highly cost-effective in averting DALYs from under-five deaths and stunting.

The results from this thesis support the conclusion that a lifecycle approach is needed for the prevention of stunting. The gaps between current knowledge, policy and practice needs to be closed, with more emphasis given to prenatal interventions.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. p. 73
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1453
Keywords
stunting, linear growth, child health, undernutrition, Bangladesh, cost-effectiveness, data mining, puberty, prenatal interventions, global health
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medical Science
Identifiers
urn:nbn:se:uu:diva-347524 (URN)978-91-513-0305-5 (ISBN)
Public defence
2018-05-25, Gustavianum, Akademigatan 3, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2018-05-03 Created: 2018-04-04 Last updated: 2018-05-03

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Svefors, PernillaEkström, Eva-CharlotteEkholm Selling, Katarina

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