Infant and Child Stunting: The Contribution of Food and Water Insecurity
Nadia at the Shurugwi research office with local SHINE collaborators. From right to left: Batsi, Naome, Jaya, Tsitsi, Shami, Zee, Nadia. "This was during a trip to Shurugwi district to observe data collection among rural women for a study on early child development."
A “blueprint to achieve a better and more sustainable future for all”, the UN Sustainable Development Goals call for, among many things, clean water and sanitation for all (goal #6) and an end to hunger (goal #2) by 2030. African countries have also committed to implement the African Union Agenda 2063, a vision and plan to build a more prosperous Africa in 50 years. Yet natural disasters and recurrent droughts are compromising the efforts of many countries throughout the continent. In rural Zimbabwe, over 70% of children live in abject poverty and 5.5 million people are facing starvation. Economic and political instability have exacerbated a food crisis in a country where nearly 90% of infants experience malnutrition, especially stunted growth.
Improving child growth and development is essential to ensuring that all children survive, thrive and lead transformative lives irrespective of where they live1, yet stunting affects 22% (149 million) of children under the age of 5 globally2. Stunting is largely irreversible beyond 2 years of age3,4 and affects the entire life-course5 through increased mortality6, exacerbation of disease frequency, duration and severity7, reduced scholastic performance8, lower adult earnings9-11 and long-term risk of chronic diseases such as obesity and cardiovascular diseases12. It also persists across generations since women who were themselves stunted in childhood tend to have stunted children13,14, creating a near unbreakable cycle of poverty and reduced human capital.
- Student(s):
Nadia Koyratty - Faculty Mentor:
Laura Smith - Country:
Zimbabwe - Date of Travel
July 2019 - August 2019
Nadia with data managers, Tafadzwa and Wellington. "They were teaching me how to enter data in the system, how to identify and fix errors, and what the different codes meant."
The World Health Assembly has set the target of reducing stunting by 40% by 2025. However, the determinants of stunting are poorly understood15 and the effectiveness of existing programs to reduce its incidence is limited16. Even the most intensive nutrition intervention has only led to 20% stunting reduction17. UNICEF’s causal framework for child undernutrition3 suggests that stunting occurs within a complex interplay of distal and both acute and chronic environmental stressors, including food and water insecurity. For instance, inconsistent access to or lack of food or water, inadequate nutrient intake, poor physical and mental health of care-givers, unhygienic handling of food and unsafe water, are all influenced by resource insecurity and may determine the extent to which households adopt and maintain nutrition recommendations. Nevertheless, there remain important gaps in impact assessments of nutrition interventions and pathways to improved child growth as they relate to food and water insecurity.
Nadia Koyratty, PhD Candidate in the Department of Epidemiology and Environmental Health is working with local Zimbabwean partners, including the Zvitambo Institute for Maternal and Child Health Research in Harare and the Zimbabwe Ministry of Health and Child Care, to understand the impact of food and water insecurity among rural farming households. Supported by the Community for Global Health Equity and the Bill and Melinda Gates Foundation, Koyratty travelled to Zimbabwe to deepen her understanding of the complex causal framework for food and water insecurity and undernutrition – specifically how food and water insecurity affects uptake and maintenance of adequate nutrition practices and, in turn, physical growth of infants and young children under 5 years.
The Zvitambo vehicle that is used by researchers to go out in the field to meet participants.
Dr. Laura Smith, Assistant Professor of Epidemiology and Environmental Health and Community of Excellence in Global Health Equity, oversees her work. She has a long-standing partnership with collaborators in Zimbabwe and is currently Associate Director for Nutrition at Zvitambo. Dr. Smith investigates mycotoxin exposure – toxic molds that contaminate staple foods like maize and groundnuts – in pregnancy and birth outcomes and the potential link between mycotoxin exposure to gut dysfunction and stunting among children in Zimbabwe through the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial.
A water source from observed during a site visit.
Through her partnership with Zvitambo, Dr. Smith and Koyratty are developing scales to measure food and water insecurity in rural subsistence farming households in Zimbabwe. Food and water insecurity are multi-dimensional concepts consisting of i) availability (e.g. food stocks, land for crops and livestock, food aid, water volume) ii) access (market distance, resources to obtain food, distance to clean and safe water sources, affordability) iii) utilization (food quality and diversity, food and water safety, storage) and iv) supply stability (experience of social, economic or environmental shocks that make is difficult to meet food and water needs). However, current food and water (in)security metrics are incomplete and underdeveloped – they focus on the experienceof food and water insecurity, such as feelings of worry or shame. While useful in certain situations, these tools are not comprehensive enough and may underestimate the true prevalence of insecure households. Zimbabwe Holistic Household Insecurity Scales (ZHHIS), ZHHIS-FOOD and ZHHIS-WATER, will be more holistic and representative of the rural Zimbabwean household.
"A typical Zimbabwean lunch for vegetarians. It includes sadza (thick maize flour porridge that is the staple food in Zimbabwe), greens (I think this was pumpkin leaves or collard greens) and stewed beans. Zimbabweans LOVE meat, so it's not an accurate representation of what a non-vegetarian would eat. But it was yummy!"
Koyratty and Dr. Smith plan to characterize food and water insecurity using the ZHHIS-FOOD and ZHHIS-WATER measures to understand how they affect adoption of adequate nutrition behaviours. With this data, their team can implement innovative and sustainable approaches to both nutrition-sensitive and nutrition-specific interventions to prevent growth retardation, accelerate progress on reducing child stunting, and pave the way for healthier populations. This data can also inform the work of organizations that provide aid, cash or in-kind assistance, and social support, as well as global health professionals who lead supplementation programmes, agriculture interventions and sanitation programmes.
Koyratty reflects on the kindness and generosity of her hosts. Her experience in Zimbabwe helped her to understand many of the problems facing the population. She also had opportunities to enjoy the amazing wildlife: birds of all shapes, sizes and colors in her garden during lunch, and lions, elephants, rhinos, giraffes and hippopotamus at local wildlife reserves.
- UN. Sustainable Development Goal 3. Sustainable Development Goal 3 2016; https://sustainabledevelopment.un.org/sdg3. Accessed 17 May 2020.
- FAO, IFAD, UNICEF, WFP, WHO. The State of Food Security and Nutrition in the World 2019. Safeguarding against economic slowdowns and downturns. Rome: FAO;2019.
- UNICEF. Improving Child Nutrition. The achievable imperative for global progress. New York, USA2013.
- WHO. CHILDHOOD STUNTING: Challenges and opportunities. Report of a webcast colloquium on the operational issues around setting and implementing national stunting reduction agendas. Geneva2013.
- Black MM, Walker SP, Fernald LCH, et al. Early childhood development coming of age: science through the life course. Lancet. 2017;389(10064):77-90.
- Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-451.
- Walson JL, Berkley JA. The impact of malnutrition on childhood infections. Current opinion in infectious diseases. 2018;31(3):231-236.
- Prado EL, Larson LM, Cox K, Bettencourt K, Kubes JN, Shankar AH. Do effects of early life interventions on linear growth correspond to effects on neurobehavioural development? A systematic review and meta-analysis. The Lancet Global Health. 2019;7(10):e1398-e1413.
- Bhutta ZA. Early nutrition and adult outcomes: pieces of the puzzle. The Lancet. 2013;382(9891):486-487.
- Horta BL, Victora CG, de Mola CL, et al. Associations of Linear Growth and Relative Weight Gain in Early Life with Human Capital at 30 Years of Age. J Pediatr. 2017;182:85-91 e83.
- Martorell R. Improved nutrition in the first 1000 days and adult human capital and health. Am J Hum Biol. 2017;29(2).
- Dewey KG, Begum K. Long-term consequences of stunting in early life. Matern Child Nutr. 2011;7 Suppl 3:5-18.
- Behrman JR, Calderon MC, Preston SH, Hoddinott J, Martorell R, Stein AD. Nutritional supplementation in girls influences the growth of their children: prospective study in Guatemala. The American journal of clinical nutrition. 2009;90(5):1372-1379.
- Ozaltin E, Hill K, Subramanian SV. Association of maternal stature with offspring mortality, underweight, and stunting in low- to middle-income countries. JAMA. 2010;303(15):1507-1516.
- Prendergast AJ, Humphrey JH. The stunting syndrome in developing countries. Paediatr Int Child Health. 2014;34(4):250-265.
- Bhutta ZA, Ahmed T, Black RE, et al. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371(9610):417-440.
- Humphrey JH, Mbuya MNN, Ntozini R, et al. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. Lancet Glob Health. 2019;7(1):e132-e147.
Nadia Koyratty and the Community of Excellence in Global Health Equity would like to thank collaborators at the Zvitambo Institute for Maternal and Child Health Research, in particular Mr. Robert Ntozini and Mr. Bernard Chasekwa, and Dr. Roseanne Schuster from Arizona State University, who devoted their time and attention to deepening her knowledge and understanding of complex issues like food and water insecurity and child undernutrition in rural settings.