Stunting Successfully Reversed – New Research Challenges WHO’s Guidelines

A Child’s Growth Is Measured

A recent study challenges the conventional belief that nutrient supplements can’t stimulate growth after age two, demonstrating that even older stunted children can benefit from such supplements, and plant-based proteins are as effective as dairy for this purpose. The picture depicts a child’s growth being measured. Credit: Jack I Lewis, Copenhagen University.

Currently, the WHO does not advise the use of nutrient supplements for children with stunted growth. However, a recent study from the University of Copenhagen suggests that supplements can reverse stunting.

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. While not as immediately life-threatening as famine, stunting can lead to long-term detrimental effects on a child’s development.

Usually, these children do not reach their potential height, falling short by a few centimeters – a tangible sign of their bodies economizing on growth to conserve resources. However, the physical discrepancy in height is just a surface indicator. This condition also compromises the proper growth of muscles and organs, as well as hampers cognitive development, affecting their overall well-being and potential future prospects.

“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 the 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.”

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.

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

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 have 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

  • 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 compensation for their participation.

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.

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.

Reference: “Effect of milk protein and whey permeate in large quantity lipid-based nutrient supplement on linear growth and body composition among stunted children: A randomized 2 × 2 factorial trial in Uganda” by Joseph Mbabazi, Hannah Pesu, Rolland Mutumba, Suzanne Filteau, Jack I. Lewis, Jonathan C. Wells, Mette F. Olsen, André Briend, Kim F. Michaelsen, Christian Mølgaard, Christian Ritz, Nicolette Nabukeera-Barungi, Ezekiel Mupere, Henrik Friis and Benedikte Grenov, 23 May 2023, PLOS Medicine.
DOI: 10.1371/journal.pmed.1004227

The study was funded by Arla Food for Health.

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