Researchers Challenge WHO Recommendations by Reversing Stunting in Children

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More than 20% of the world's children under the age of five have a low height in relation to their age due to undernutrition or malnutrition, i.e. they are stunted. Though childhood stunting does not present an acute danger like famine, children with stunted growth are subject to chronically impaired childhood development.

Typically, they end up being a few centimeters shorter than their natural predisposition. But this is just the visible manifestation. A symptom of the body trying to save where it costs least to do so. The development of a child's muscles and organs, as well as their mental development, are also impacted.

Facts about the research

  • 750 children aged 1-5 from eastern Uganda were included in the study and followed for three months by health professionals who, e.g. measured and weighed them.
  • All the children were moderately to severely stunted due to malnutrition
  • The children were randomly divided into five groups:

(1-2) Two groups received supplements with milk protein. One of them also received a mixture of lactose and minerals, known as whey permeate
(3-4) Two groups were given supplements with soy protein. One of these was also given the lactose-mineral mixture.
(5) The last group was a control group and did not receive food supplements.

  • The children continued to be fed at home. However, the supplement accounted for up to half of their energy and protein requirements and their entire requirement for vitamins and minerals.
  • Control group families received laundry soap and all participants had transport costs covered and were given food at the clinic as a compensation for their participation.

"The body is already deficient, meaning that their bones and muscles are not getting the nutrients, especially minerals and proteins, required for optimal growth. It affects the health and physical abilities of these children throughout their lives," explains Benedikte Grenov of the University of Copenhagen's Department of Nutrition, Exercise and Sports.

Grenov is one of the lead authors of a new UCPH study conducted in collaboration with researchers at Makerere University in Uganda. The study challenges the way health authorities around the world - with the World Health Organization (WHO) at the forefront - have framed the treatment of childhood stunting.

A longstanding consensus has been that nutrient supplements are unable to stimulate growth after the age of two. As a result, initiatives aiming to use supplements for prevention of stunting at present are focused on providing small amounts to vulnerable children under two years of age, and even these projects are few and far between. The fear has been that energy-dense supplements instead could increase the risk of obesity and health problems associated with being overweight.

Such thinking is wrong according to the new study, in which researchers provided 750 stunted children in Uganda with nutrient supplements over a three-month period.

"In fact, our research demonstrates that if children with stunted growth are not treated, things go wrong. But if they are, impaired development can be reversed, even in children older than two. We managed to achieve this with the children who participated in our study. And this could mean that the children's living conditions as adults will improve, so that they become healthier, stronger and have a reduced risk of lifestyle diseases," says Benedikte Grenov, who stresses:

"Therefore, we hope that these results can help shift the thinking with regards to the treatment of stunting, and in doing so, change the recommendations."

The children where followed by health proffesionals at health centres set up in eastern Uganda. Photo: Jack I. Lewis, University of Copenhagen.

Plant protein as good as dairy

One aspect of the study was to investigate whether milk-based supplements are particularly well-suited to help improve the lives of the many stunted children around the world.

Small energy-dense sachets

The nutrient supplement used in the study was a lipid-based mixture of blended peanuts with added milk or soy protein, a vitamin and mineral mix and carbohydrate used as a sweetener. The texture is like marzipan and it has a sweet, peanut butter-like taste.

The mixture is delivered in small sachets that do not require mixing, to avoid contamination, and which the children can eat straight from the package.

While the results clearly demonstrate that milk-based supplements are beneficial for the healthy growth of children, the cheaper and more climate-friendly, plant-based alternative works just as well.

"We had actually expected to see a difference, because milk contains better quality protein and certain micronutrients that have been linked to growth-promotion. But the difference we see is so minimal, that scientifically, it makes no sense to talk about it." The big difference, according to the researcher, was between children who received a supplement and those who received nothing at all:

"This has the positive consequence that nutrient supplements can be produced at a lower cost and in a more climate-friendly manner. And even though the plant protein we used was a special type that requires specific production facilities, plant proteins generally have the advantage that they are easier to produce locally, in places where the problem is greatest."

A very wide-ranging problem

The control group continued to grow poorly

Children in the control group did not receive supplements and thereby remained in the same situation, which is normal for most stunted children.

They continued their unfortunate development and became more and more stunted. They also experienced unhealthy growth in fat mass rather than in fat-free mass - muscles and organs.

Overall, development in both their height and body composition was negative, unlike the children who received supplements. Those who received supplements grew taller and added lean mass without gaining additional fat.

These benefits can prove important to a solution strategy. With roughly 150 million stunted children under the age of five worldwide, any initiative to help them all can be insurmountable, both economically and practically.

Benedikte Grenov acknowledges that because the problem is so widespread, treating all children is practically impossible. But you could, for example, begin by offering treatment to those with severe stunting.

"The good news is that all of the children, including those with severe stunting, were able to reverse the negative trend and begin growing fat-free mass - which means muscles and organs - when provided with the supplement. These children have delayed development and typically also lower IQs in the long run. So, if supplements can be used for them first, we will have come a long way," says Grenov, who continues:

"That could be one way to go. Another could be, more generally, to look at whether regular family diets could be improved with an advanced multi-micronutrient "vitamin-"pill and easier access to high-quality protein. Indeed, it is this mixture that is so critical for optimal child growth."

About the study:

Funded by Arla Food for Health

Arla Food for Health is a joint research partnership between the University of Copenhagen, Aarhus University, Arla Foods and Arla Foods Ingredients. It was formed in 2015 and has since funded a range of independent research projects.

Arla Foods contributes 10 million Danish kroner (EUR 1.3 mio) annually, which the partnership can use to finance new research projects.

Arla Food for Health and other funders did not have influence on the analysis and interpretation of data, on the writing of the report, or on the decision to submit the paper for publication.

The contributing researchers:

Joseph Mbabazi, Hannah Pesu, Rolland Mutumba, , Jack I. Lewis, Mette F. Olsen, Kim F. Michaelsen, Christian Mølgaard, Henrik Friis, Benedikte Grenov, from Department of Nutrition, Exercise and Sports at the University of Copenhagen.

Joseph Mbabazi and Rolland Mutumba along with Nicolette Nabukeera-Barungi, Ezekiel Mupere are also affiliated with Makarere University, Uganda.

Other contributors are:

Suzanne Filteau from the London School of Hygiene and Tropical Medicine, UK
Jonathan C. Wells from UCL Great Ormond Street Institute of Child Health, UK
André Briend from Tampere University and Tampere University Hospital, Finland
and Christian Ritz from the University of Southern Denmark.

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