Children concurrently wasted and stunted: A meta- analysis of prevalence data of children 6-59 months from 84 countries

Location: Global

What we know: Wasting and stunting are often present in the same geographical populations and can exist concurrently in the same children, increasing risk of mortality; the burden of concurrence is currently not known.

What this article adds: This study provides the first multiple country estimates of the prevalence and burden of children aged 6-59 months concurrently wasted and stunted using data from Demographic and Health Surveys (DHS) and Multi- indicator Cluster Surveys (MICS). In this study the pooled prevalence of children concurrently wasted and stunted in 84 countries was found to be 3.0%, 95% CI [2.97, 3.06], varying from 0% in Montenegro to 8.0%, 95% CI [7.2, 8.9], in Niger. Nine countries had a concurrence prevalence >5%, the suggested threshold for concern and intensification of identification and treatment efforts. Prevalence of concurrence was highest in the 12 to 24 month age group 4.2%, 95% CI [4.1, 4.3], and significantly higher among boys 3.54%, 95% CI [3.47, 3.61] compared to girls; 2.46%, 95% CI [2.41, 2.52] and higher in fragile and conflice- affected states 3.6%, 95% CI [3.5, 3.6], compared to stable countries 2.24%, 95% CI [2.18, 2.30]. Results indicate a need to systematically report on this condition within country and global monitoring systems.

The pooled 84 country prevalence estimate for children 6–59 months of age experiencing either wasting or stunting was found to be 38.9%, 95% CI [38.7, 39.0]. This means that only 61.1%, 95% CI [61.0, 61.3], of children in the 84 countries escape both conditions.

The estimated prevalences from this analysis were calculated to correspond to nearly 6 million children concurrently wasted and stunted in the 84 countries. The authors note that given the transitory nature of wasting in particular, where a child can experience several episodes of wasting during a set period, using cross-sectional data insufficiently estimated the actual prevalence (Garenne et al., 2009). This means that the above is likely to be an underestimate of the true burden of children experiencing these two deficits concurrently. See figure 1. For a graphical representation of the results by country.

Reducing the prevalence of children who are wasted and stunted are global priorities. Wasting and stunting are often present in the same geographical populations (Victora, 1992) and it is recognised that children can be stunted and wasted at the same time, ‘concurrently wasted and stunted’ (IFPRI 2015). Though the relationship between these manifestations of undernutrition at the level of the individual child and the mechanisms leading to this state of “concurrence” are poorly understood (Angood et al 2016), evidence suggests that children with both deficits are at a greatly elevated risk of mortality (McDonald et al., 2013).

This paper highlights the issue that despite the above, there are no global estimates of the prevalence and burden of concurrence (UNICEF et al., 2016). It is in fact rarely reported, though the data required to estimate concurrence is readily available in national surveys (Saaka & Galaa, 2016). The authors note that reporting on global figures for the prevalence of different nutritional deficits separately, underestimates the true proportion of the global population affected by nutritional deficits as a whole and, ignores this critical proportion of children affected by multiple deficits who may require additional nutritional support.

The analysis presented in the paper aims to address this gap by providing the first multiple country estimates of the prevelance and burden of children aged 6-59 months concurrently wasted and stunted using data from Demographic and Health Surveys (DHS) and Multi- indicator Cluster Surveys (MICS). The aim was to approach a global estimate though sufficiently recent data (last 10yrs) was available for just 84 countries. For countries with more than one dataset available the most recent dataset was chosen. Country- specific estimates were calculated and pooled using the random- effects meta- analysis to yield the 84 country estimates (Hamza, Reitsma & Stijnen, 2008). Burden by country was calculated using country population figured from the global joint estimates database (UNICEF et al., 2016). The analysis also explored age, sex, regional, and contextual differences, and estimated of the proportion of the children affected by either of these conditions (wasted or stunted).

The pooled prevelance of children concurrently wasted and stunted in the 84 countries was found to be 3.0%, 95% CI [2.97, 3.06]. The prevalence of concurrence varied across countries from 0% in Montenegro to 8.0%, 95% CI [7.2, 8.9], in Niger. Nine countries had a concurrence prevelance greater than 5%. Six from sub- Saharan Africa (Niger, Burundi, Djibouti, Chad, Sudan and South Sudan) and three from Asia (Timor- Leste, Yemen, and India). The authors note that a country prevalence of >5% severe wasting would warrant concern and intensification of efforts to identify and treat children. Though concurrence is associated with similair mortality risks, its prevelance is not monitored, and cases are not routinely identified, therefor, no specific action can be taken.

The estimated prevalences from this analysis were calculared to correspon to nearly 6 million children concurrently wasted and stunted in the 84 countries. The authors note that given the transitory nature of wasting in particular, where a child can experience several episodes of wasting during a set period, using cross- sectinoal data insufficiently estimates the actual prevelance (Garenne et al., 2009). This means that the above is likely to be an underestimate of the true burden of children experienceing these two deficits concurrently. See figure 1. For a graphical representation of the results by country.

Prevalence of concurrence was found to be highest in the 12- to 24- month age group 2.4%, 95% CI [4.1, 4.3], and was significantly higher among boys 3.54%, 95% CI [3.47, 3.61], compared to girls; 2.46%, 95% CI [2.41, 2.52]. Fragile and conflict- affected states reported significantly higher concurrence 3.6%, 95% CI [3.5, 3.6], than those defined as stable 2.24%, 95% CI [2.18, 2.30]. The authors note that these patterns mirrir higher prevelances of wasting and stunting when analysed seperately. Particularly in the case of the pattern of heightened nutritional vulnerability of boys, the sata suggests that further investigation is needed.

The pooled 84 country prevalence estimate for children 6-59 months of age experiencing either wasting or stunting was found to be 38.9%, 95% CI [38.7, 39.0]. This means that only 61.1%, 95% CI [61.0, 61.3], of children in the 84 countries escape both conditions. The authors note that this is a very stark metric for understanding the extent of undernutrition in these countried and refer to country disaggregated data from this analysis that was reported in the Global Nutrition Report 2016, in which it can be seen that in a number of countries (Benin, Djibouti, Yemen, Niger, Chad, Guinea- Bissau, Ethiopia, Congo DRC, Burundi and Somalia, India, Pakistan, and Loas) over half the population of children is suffering from one of these deficits (IFPRI, 2016).

Given the high risk of mortality associated with concurrence, the authors conclude that the levels of prevalence and burden reported in their analysis, indicate that there is a need to systematically report on this condition within country and global monitoring systems and, for researchers programmers and policy makers to prioritise investigation into the extent to which these children are being reached through existing programmes.

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