Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data
Open accessAbstract
Background There is little information on country trends in the complete distributions of children's anthropometric status, which are needed to assess all levels of mild to severe undernutrition. We aimed to estimate trends in the distributions of children's anthropometric status and assess progress towards the Millennium Development Goal 1 (MDG 1) target of halving the prevalence of weight-for-age Z score (WAZ) below -2 between 1990 and 2015 or reaching a prevalence of 2·3% or lower.Methods We collated population-representative data on height-for-age Z score (HAZ) and WAZ calculated with the 2006 WHO child growth standards. Our data sources were health and nutrition surveys, summary statistics from the WHO Global Database on Child Growth and Malnutrition, and summary statistics from reports of other national and international agencies. We used a Bayesian hierarchical mixture model to estimate Z-score distributions. We quantified the uncertainty of our estimates, assessed their validity, compared their performance to alternative models, and assessed sensitivity to key modelling choices.Findings In developing countries, mean HAZ improved from -1·86 (95% uncertainty interval -2·01 to -1·72) in 1985 to -1·16 (-1·29 to -1·04) in 2011; mean WAZ improved from -1·31 (-1·41 to -1·20) to -0·84 (-0·93 to -0·74). Over this period, prevalences of moderate-and-severe stunting declined from 47·2% (44·0 to 50·3) to 29·9% (27·1 to 32·9) and underweight from 30·1% (26·7 to 33·3) to 19·4% (16·5 to 22·2). The largest absolute improvements were in Asia and the largest relative reductions in prevalence in southern and tropical Latin America. Anthropometric status worsened in sub-Saharan Africa until the late 1990s and improved thereafter. In 2011, 314 (296 to 331) million children younger than 5 years were mildly, moderately, or severely stunted and 258 (240 to 274) million were mildly, moderately, or severely underweight. Developing countries as a whole have less than a 5% chance of meeting the MDG 1 target; but 61 of these 141 countries have a 50-100% chance.Interpretation Macroeconomic shocks, structural adjustment, and trade policy reforms in the 1980s and 1990s might have been responsible for worsening child nutritional status in sub-Saharan Africa. Further progress in the improvement of children's growth and nutrition needs equitable economic growth and investment in pro-poor food and primary care programmes, especially relevant in the context of the global economic crisis.Funding The Bill & Melinda Gates Foundation and the UK Medical Research Council.
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Reductions in underweight and measles (because of immunisation programmes) might have contributed to falls in deaths from diarrhoea and pneumonia.
“Reductions in underweight and measles (because of immunisation programmes) might have contributed to falls in deaths from diarrhoea and pneumonia.101”
From Global burden of childhood pneumonia and diarrhoea (2013) · cites this paper as [101]
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“Nearly half of all children under 5 years of age in South Asia are undernourished (1 – 3) .”
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MethodTzioumis, E., Kay, M. C., Bentley, M. E., & Adair, L. S. (2016) · Public Health Nutrition · doi:10.1017/s1368980016000276 · Cited by 102 · see citing works
“The trends reported here are similar to findings from country-specific analyses in LMIC and in recent global assessments of preschool children((3,5,36)).”
ResultInfection by Intestinal Parasites, Stunting and Anemia in School-Aged Children from Southern Angola
Oliveira, D., Ferreira, F. S., Atouguia, J., Fortes, F., Guerra, A., & Centeno-Lima, S. (2015) · PLoS ONE · doi:10.1371/journal.pone.0137327 · Cited by 99 · see citing works
“The height for age is an indicator of stunting, classified as mild (z-scores<-1 and -2), moderate (z-scores<-2 and -3) and severe (z-scores<-3) [16].”
BackgroundClimate change, crop production and child under nutrition in Ethiopia; a longitudinal panel study
Hagos, S., Lunde, T. M., Mariam, D. H., Woldehanna, T., & Lindtjørn, B. (2014) · BMC Public Health · doi:10.1186/1471-2458-14-884 · Cited by 95 · see citing works
“the trend is showing a decreasing pattern, the proportion of under-five stunting, underweight and wasting are still high and more efforts are needed to reach the MDG goals [11].”
BackgroundMultidimensional characterization of global food supply from 1961 to 2013
Bentham, J., Singh, G. M., Danaei, G., Green, R., Lin, J. K., Stevens, G. A., Farzadfar, F., Bennett, J. E., Di Cesare, M., Dangour, A. D., et al. (2020) · Nature Food · doi:10.1038/s43016-019-0012-2 · Cited by 91 · see citing works
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Zhang, N., Bécares, L., & Chandola, T. (2016) · PLoS ONE · doi:10.1371/journal.pone.0158119 · Cited by 92 · see citing works
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Bredenkamp, C., Buisman, L. R., & de Poel, E. V. (2014) · International Journal of Epidemiology · doi:10.1093/ije/dyu075 · Cited by 91 · see citing works
Household food insecurity and child health
Schmeer, K. K., & Piperata, B. A. (2016) · Maternal and Child Nutrition · doi:10.1111/mcn.12301 · Cited by 91 · see citing works
“lem among children in the developing world (Stevens et al. 2012).”
BackgroundGashu, D., Stoecker, B. J., Bougma, K., Adish, A. A., Haki, G. D., & Marquis, G. S. (2015) · Nutrition Journal · doi:10.1186/s12937-016-0155-z · Cited by 90 · see citing works
“Sub-Saharan Africa has the second largest number of stunted and underweight children next to south Asia [2].”
BackgroundCesare, M. D., Bennett, J. E., Best, N. G., Stevens, G., Danaei, G., & Ezzati, M. (2013) · International Journal of Epidemiology · doi:10.1093/ije/dyt063 · Cited by 81 · see citing works
de Mola, C. L., Quispe, R., Valle, G. A., & Poterico, J. A. (2014) · PLoS ONE · doi:10.1371/journal.pone.0092550 · Cited by 80 · see citing works
“Children from other developing countries have shown decreasing levels of chronic malnutrition [23]; and underweight [3].”
BackgroundNovignon, J., Aboagye, E., Agyemang, O. S., & Aryeetey, G. C. (2015) · Health Economics Review · doi:10.1186/s13561-015-0072-4 · Cited by 80 · see citing works
“Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskar T. Boys are more stunted than girls in sub-Saharan Africa: a meta-analysis of 16 demographic and health surveys.”
BackgroundInfluentialRoth, D. E., Perumal, N., Mahmud, A. A., & Baqui, A. H. (2013) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2013.07.030 · Cited by 79 · see citing works
Determinants of stunting during the first 1,000 days of life in Bangladesh: A review
Islam, M. S., Ullah, A. N. Z., Mainali, S., Imam, M. A., & Hasan, I. (2020) · Food Science & Nutrition · doi:10.1002/fsn3.1795 · Cited by 77 · see citing works
“Remarkable global progress was also made in reducing the prevalence of stunting among children under five, which fell from 47% in 1985 to 21.9% in 2018 (Stevens et al., 2012; UNICEF et al., 2019).”
BackgroundInfluentialWells, J. C. K. (2016) · Cambridge University Press eBooks · doi:10.1017/cbo9780511972959 · Cited by 81 · see citing works
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“Equitable income allocation and investments in public health and education programs are also vital to promoting food security, nourishing diets and to keeping children in good health (Stevens et al., 2012).”
BackgroundLeroy, J. L., Habicht, J., de Cossío, T. G., & Ruel, M. T. (2014) · Journal of Nutrition · doi:10.3945/jn.113.188474 · Cited by 73 · see citing works
The Effect of Fertility Decline on Economic Growth in Africa: A Macrosimulation Model
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Maternal Health Literacy Is Associated with Early Childhood Nutritional Status in India
Johri, M., Subramanian, S. V., Koné, G. K., Dudeja, S., Chandra, D., Minoyan, N., Sylvestre, M., & Pahwa, S. (2016) · Journal of Nutrition · doi:10.3945/jn.115.226290 · Cited by 68 · see citing works
Davis, T., Wetzel, C., Avilan, E. H., Lopes, C. D. M., Chase, R. P., WINCH, P. J., & Perry, H. B. (2013) · Global Health Science and Practice · doi:10.9745/ghsp-d-12-00045 · Cited by 65 · see citing works
“One recent analysis found virtually no improvement in child growth based on anthropometric indicators between 1985 and 2011 in sub-Saharan Africa.(6)”
BackgroundScott, N., Delport, D., Hainsworth, S. W., Pearson, R., Morgan, C., Huang, S.-W., Akuoku, J., Piwoz, E., Shekar, M., Levin, C., et al. (2020) · BMC Medicine · doi:10.1186/s12916-020-01786-5 · Cited by 67 · see citing works
“Several analyses have shown that despite improvements in child stunting and wasting over the last two decades [4], most countries are not on track to reach the SDG 2.”
BackgroundRestrepo–Méndez, M. C., Barros, A. J. D., Black, R. E., & Victora, C. G. (2014) · Public Health Nutrition · doi:10.1017/s1368980014002924 · Cited by 63 · see citing works
“In agreement with previous analyses, stunting prevalence was found to be declining in most countries((5,15)).”
ResultFenta, H. M., Workie, D. L., Zike, D. T., Taye, B. W., & Swain, P. K. (2019) · Clinical Epidemiology and Global Health · doi:10.1016/j.cegh.2019.09.011 · Cited by 63 · see citing works
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Na, M., Aguayo, V. M., Arimond, M., Dahal, P., Lamichhane, B., Pokharel, R., Chitekwe, S., & Stewart, C. P. (2017) · Maternal and Child Nutrition · doi:10.1111/mcn.12564 · Cited by 59 · see citing works
“South Asia has achieved significant progress in reducing child undernutrition, with a decline in the prevalence of stunting in children under five from 56% to 36% in the past 2 decades (Stevens et al., 2012).”
BackgroundSmith Fawzi, M. C., Andrews, K. G., Fink, G., Danaei, G., McCoy, D. C., Sudfeld, C. R., Peet, E. D., Cho, J., Liu, Y., Finlay, J. E., et al. (2019) · BMJ Global Health · doi:10.1136/bmjgh-2018-001144 · Cited by 55 · see citing works
“We used estimates of the prevalence of stunting among children under 5 years of age for each country as published from the 2011 Nutrition Impact Model Study (NIMS).(8) To estimate the number and prevalence of stunting among children 2 years of age, we needed to adjust the NIMS estimates to be accurate for our age grou…”
MethodRevising the Global Multidimensional Poverty Index: Empirical Insights and Robustness
Alkire, S., Kanagaratnam, U., Nogales, R., & Suppa, N. (2022) · Review of Income and Wealth · doi:10.1111/roiw.12573 · Cited by 57 · see citing works
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“In contrast to either adults or young children aged less than 5 years (3,7), information about the dual burden of malnutrition among adolescents is limited in LMICs, where 90% of the world’s adolescents live (9).”
BackgroundVarghese, J. S., Swaminathan, S., Kurpad, A. V., & Thomas, T. S. (2019) · PLoS ONE · doi:10.1371/journal.pone.0210634 · Cited by 57 · see citing works
Practices and challenges of growth monitoring and promotion in ethiopia: a qualitative study.
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Prevalence and risk predictors of childhood stunting in Bangladesh
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“The rate of stunting among children under five decreased dramatically worldwide, from 47% in 1985 to 21.9% in 2018 [7,8].”
InfluentialRoth, D. E., Gernand, A. D., Morris, S. K., Pezzack, B., Islam, M. M., Dimitris, M. C., Shanta, S. S., Zlotkin, S. H., Willan, A. R., Ahmed, T., et al. (2015) · Trials · doi:10.1186/s13063-015-0825-8 · Cited by 55 · see citing works
“However, childhood undernutrition remains a persistent global public health problem [2], particularly in Sub-Saharan Africa and South Asia [3].”
Strategies for optimizing maternal nutrition to promote infant development
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“Approximately one-third of children under age 5 in LMICs, or about 314 million children, are currently affected by linear growth restriction or stunting [13].”
BackgroundDewey, K. G., Arnold, C. D., Wessells, K. R., Prado, E. L., Abbeddou, S., Adu‐Afarwuah, S., Ali, H., Arnold, B. F., Ashorn, P., Ashorn, U., et al. (2022) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqac232 · Cited by 51 · see citing works
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“Figures published in 2012 estimate that 314 million children younger than 5 years are stunted (chronically malnourished, with a low height-for-age) and 258 million are underweight (low weight-for-age) (Stevens et al., 2012).”
BackgroundDouble-duty solutions for the double burden of malnutrition
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Monitoring human growth and development: a continuum from the womb to the classroom
Villar, J., Papageorghiou, A. T., Pang, R., Salomon, L. J., Langer, A., Victora, C. G., Purwar, M., Chumlea, C., Qingqing, W., Scherjon, S. A., et al. (2015) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2015.07.002 · Cited by 49 · see citing works
“We are confident that, in time, the INTERGROWTH-21st standards will be incorporated into care and research(34,35) just as the WHO Child Growth Standards are used currently by pediatricians worldwide.(36) -”
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“In particular, research is needed in low- and middle-income countries (LMICs) where both linear growth faltering during infancy and vitamin D deficiency are common (8).”
BackgroundDhaded, S. M., Hambidge, K. M., Ali, S. A., Somannavar, M. S., Saleem, S., Pasha, O., Khan, U., Herekar, V., Vernekar, S. S., Yogesh Kumar, S., et al. (2020) · PLoS ONE · doi:10.1371/journal.pone.0218960 · Cited by 47 · see citing works
Impact of Poor Nutrition on the Academic Performance of Grade Seven learners: A Case of Zimbabwe
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“The most fundamental and basic four layers of the pyramid contain what Maslow called deficiency needs or d-needs, the individual does not feel anything if they are met, but feels anxious if they are not met (Snowman & Biehler 2011:79).”
BackgroundRichard, S. A., McCormick, B., Murray‐Kolb, L. E., Lee, G. O., Seidman, J. C., Mahfuz, M., Ahmed, T., Guerrant, R. L., Petri, W. A., McQuade, E. T. R., et al. (2019) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqz004 · Cited by 44 · see citing works
Deen, J. L., Matos, L. D. C., Temple, B., Su, J., da Silva, J., Liberato, S., da Silva, V., Soares, A. I. F. S., Joshi, V., Moon, S., et al. (2013) · Health Research Policy and Systems · doi:10.1186/1478-4505-11-8 · Cited by 42 · see citing works
“Our findings are corroborated by a recent assessment of global trends in undernutrition [18].”
ResultRoba, K. T., O’Connor, T. P., Belachew, T., & O’Brien, N. M. (2016) · Pediatric Health Medicine and Therapeutics · doi:10.2147/phmt.s109574 · Cited by 42 · see citing works
“9% of children are stunted in developing countries.(4) More than Correspondence: Kedir Teji Roba School of Nursing and Midwifery, College of Health and Medical Science, Haramaya University, PO Box 235, Harar, Ethiopia Tel +251 94 580 9317 Fax +251 25 666 8081 Email kedir.”
Ohyver, M., Moniaga, J. V., Yunidwi, K. R., & Setiawan, M. I. (2017) · Procedia Computer Science · doi:10.1016/j.procs.2017.10.045 · Cited by 42 · see citing works
African stakeholders’ views of research options to improve nutritional status in sub-Saharan Africa
Holdsworth, M., Kruger, A., Nago, E. S., Lachat, C. K., Mamiro, P., Smit, K., Garimoi-Orach, C., Kameli, Y., Roberfroid, D., & Kolsteren, P. W. (2014) · Health Policy and Planning · doi:10.1093/heapol/czu087 · Cited by 40 · see citing works
“Overweight and obesity and related non-communicable diseases (NCDs) are increasingly becoming health problems in SSA (Morris 2010), especially in urban areas (Stevens et al. 2012b) due to changing dietary habits and sedentary lifestyles (Delpeuch et al. 2009).”
BackgroundZinc Deficiency in Latin America and the Caribbean
Cediel, G., Olivares, M., Alex Brito, O., Cori, H., & de Romaña, D. L. (2015) · Food and Nutrition Bulletin · doi:10.1177/0379572115585781 · Cited by 39 · see citing works
“Stunting data (length- or height-for-age z-score < 2 SD) were identified using the latest World Health Organization (WHO) child growth standards.(17,18) The prevalence of stunting was categorized as low (< 20%), medium (20% to 29%), high (30% to 39%), or very high ( 40%) according to the WHO classification.”
Method
- Authors
- Stevens, G. A., Finucane, M. M., Paciorek, C. J., Flaxman, S. R., White, R. A., Donner, A. J., & Ezzati, M.
- Affiliations
- World Health Organization (CH)
- Harvard University (US)
- University of California, Berkeley (US)
- Carnegie Mellon University (US)
- Imperial College London (GB)
- Corresponding author
- Ezzati, Majid
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2012-09
- Volume
- 380
- Issue
- 9844
- Pages
- 824-834
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC3443900
- OpenAlex
- W2130638487
- Cited by
- 384
- References
- 41
- Citations by year
- 2026: 9 · 2025: 7 · 2024: 23 · 2023: 19 · 2022: 21 · 2021: 20 · 2020: 36 · 2019: 28 · 2018: 40 · 2017: 22 · 2016: 43 · 2015: 29 · 2014: 40 · 2013: 36 · 2012: 11
- FWCI
- 34.05
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- Locations
- The Lancet (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Dépôt institutionnel de l'Université libre de Bruxelles (Université Libre de Bruxelles) (submittedVersion)
- Funders
- Medical Research Council (MR/K005901/1)
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Public Health and Nutrition
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Keywords
- child stunting, underweight children, child undernutrition, anthropometric status, height-for-age z-score, weight-for-age z-score, Millennium Development Goal 1, developing countries, sub-Saharan Africa, Latin America, Asia, child mortality reduction, childhood vaccination coverage
- MeSH terms
- Anthropometry, Child Nutritional Physiological Phenomena, Child, Preschool, Developing Countries, Female, Goals, Growth Disorders, Humans, Infant, Infant, Newborn, International Cooperation, Male, Thinness, Global Health, Prevalence, Malnutrition
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