Beyond Malnutrition: The Role of Sanitation in Stunted Growth

Below are the 3 latest posts to the WASH Nutrition Library, http://blogs.washplus.org/washnutrition that is maintained by the USAID Community of Practice on WASH and Nutrition. If your organization has recent studies that we can add to the library, please let us know.

  • ​Beyond Malnutrition: The Role of Sanitation in Stunted Growth
  • Reframing Undernutrition: Faecally-Transmitted Infections and the 5 As
  • Understanding the Rapid Reduction of Undernutrition in Nepal, 2001–2011:​

Beyond Malnutrition: The Role of Sanitation in Stunted GrowthEnv Health Perspect, Nov 2014

Author: Charles W. Schmidt

An excerpt from the article: Beyond Nutrition – Nutritionists have tried dozens of approaches to prevent stunting, such as micronutrient supplements for pregnant women and children (especially growth promoters including iron, zinc, calcium, and folate); increased availability of fat-fortified commercial products such Nutributter and Plumpy’nut; a concerted push to encourage breastfeeding during the first six months of life; and efforts to improve the nutritional quality of the complementary foods babies eat while weaning.6

But Jean Humphrey, a professor of human nutrition at the Johns Hopkins Bloomberg School of Public Health, says none of these interventions has been able to eliminate stunting completely. At best, she says, they improve growth by about a third of the typical height deficit in stunted Asian and African children. “This tells us that dietary improvements are important but not sufficient,” she says. “If we really want to eliminate stunting, we need to do more.”

Meanwhile, mounting evidence has shown that poor hygiene and sanitation also constrain linear growth in children. One study found that Bangladeshi children who had access to clean drinking water, improved toilets, and facilities for handwashing with soap, for instance, had a roughly 50% improvement in HAZ scores compared with control children who didn’t.18 Similar results emerged from studies in Sudan19 and Mexico,20 yet it was unclear exactly why poor WASH would contribute to stunting and WASH improvements would help to ameliorate it.

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Reframing Undernutrition: Faecally-Transmitted Infections and the 5 As, October 2014.

Robert Chambers and Gregor von Medeazza, Institute of Development Studies.

The dominant nutrition discourse concerns access to adequate food and its quality. It now includes food security, food rights and justice, governance and agriculture. Despite many initiatives to assure food access, and growing economies, high levels of undernutrition persist in much of Asia. It is increasingly suggested that much of this ‘Asian enigma’ can now be explained by open defecation (OD) combined with population density. However, the insight that ‘shit stunts’ remains a widespread blind spot. The persistence of this blind spot can in part be explained by factors which are institutional, psychological and professional.

Reductionist focus on the diarrhoeas, which are serious, dramatic, visible and measurable, has led to the relative neglect of many other often subclinical and continuously debilitating faecally-transmitted infections (FTIs) including environmental enteropathy (EE), other intestinal infections, and parasites. These are harder to measure but together affect nutrition much more: the diarrhoeas are only the tip of the much larger sub-clinical iceberg. How OD and FTIs, poverty and undernutrition reinforce each other is illustrated in this paper by looking at the case of India, which has about 60 per cent of the OD in the world, around a third of the undernourished children, and approximately a third of the people living in poverty. Through OD, FTIs and in other ways, lack of sanitation leads to losses, which may be estimated, in the range of 1 to 7 per cent of GDP in various countries.

To reframe undernutrition for a better balance of understanding and interventions, we propose two inclusive concepts: the FTIs and the 5 As. The first two As – availability and access – are oral, about food intake, while the last three As – absorption, antibodies and allopathogens – are novel categories, anal and internal, about FTIs and what happens inside the body. These concepts have implications for research, professional teaching and training, and policy and practice. While other countries make rapid progress towards becoming open-defecation free, India remains obstinately stuck, making undernutrition in India one of the great human challenges of the twenty first century. The concepts of FTIs and the 5 As reframe more inclusively how undernutrition is perceived, described and analysed. Our hope is that this reframing will contribute however modestly to a cleaner, healthier and happier world in which all children and adults are well-nourished and can grow and live to their full potential.

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Understanding the Rapid Reduction of Undernutrition in Nepal, 2001–2011: IFPRI Discussion Paper 01384, 
October 2014.

AUTHORS: Derek D. Headey (d.headey@cgiar.org) is a senior research fellow in the Poverty, Health, and Nutrition
Division of the International Food Policy Research Institute (IFPRI), Washington, DC.

John Hoddinott is a senior research fellow in the Poverty, Health, and Nutrition Division of IFPRI,  Washington, DC.

Abstract: South Asia has long been synonymous with unusually high rates of undernutrition. In the past decade, however, Nepal has arguably achieved the fastest recorded decline in child stunting in the world and has done so in the midst of civil war and postconflict political instability. Given recent interest in reducing undernutrition–particularly the role of nutrition-sensitive policies–this paper aims to quantitatively understand this surprising success story by analyzing the 2001, 2006, and 2011 rounds of Nepal’s Demographic Health Surveys.

To do so, the authors first construct and test basic models of the intermediate determinants of child and maternal nutritional change and then decompose predicted changes in nutrition outcomes over time. They identify four broad drivers of change: asset accumulation, health and nutrition interventions, maternal educational gains, and improvements in sanitation.

Many of these changes were clearly influenced by policy decisions, including increased public investments in health and education and community-led health and sanitation campaigns. Other factors, such as rapid growth in migration-based remittances, are more a reflection of household responses to changing political and economic circumstances.

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