Considering the use of ‘stunting’ as an indicator in nutrition projects
This is a summary of the following report: USAID Advancing Nutrition (2020) Stunting: Considerations for use as an indicator in nutrition projects. Arlington, VA: USAID Advancing Nutrition. Available at: https://www.advancingnutrition.org/resources/stunting-considerations-use-indicator-nutrition-projects
Background
Over the past decade, many national and donor-funded programmes have prioritised a reduction in stunting (low height-for-age) as their primary objective. However, improvements in linear growth are difficult to achieve over the short term in many contexts and often require long-term multi-sector investment to address various social, political and economic determinants. This has led to the apparent ‘failure’ of programmes despite their numerous other benefits for nutrition and human development. Based on literature from low- and middle-income countries published since 2013, this report discusses the use of stunting as an indicator and proposes the identification of a broader set of indicators to monitor and evaluate the United State Agency for International Development (USAID) (and other) nutrition programmes.
Interpreting stunting as an indicator
Stunting is an attractive indicator of programme performance since the data is relatively easy to collect and interpret. However, evidence suggests that stunting has been misused as an indicator of programme success for the following reasons:
- Stunting is not equivalent to undernutrition. Stunting is often erroneously equated with chronic undernutrition, resulting in a focus on addressing stunting through improved dietary practices. In reality, stunting is a marker of a deficient environment in which a number of potential factors, including diet, caregiving, frequency and severity of illness and the use of health services, limit child growth and development. Thus, multiple and multi-sector interventions that address all causes, such as environmental and social determinants, are needed to improve the long-term outcomes for children.
- Stunting is a statistical measure, not a clinical condition. The cut-off used to define stunting (-2 standard deviations from the median of a reference population) is often interpreted as a threshold for healthy growth when, in fact, the risks associated with stunting increase across a continuum. Thus, depending on the context, many children who are not classified as stunted may not be achieving their full growth potential while some children who are classified as stunted may not be in poor health.
- Not all nutrition interventions should be expected to reduce the prevalence of stunting. Decades of research show that some nutrition interventions have little effect on linear growth. At the same time, non-health-sector interventions such as poverty alleviation and education have substantially contributed to declines in stunting prevalence, especially for girls. Thus, nutrition interventions and single interventions are unlikely to reduce stunting. Further, reductions in stunting require time to show impact and this restricts its relevance as an indicator of short-term (e.g., five-year) programmatic success.
- Stunting does not capture the many important benefits of nutrition programmes. Assessing only stunting fails to reflect the many other positive effects of improved nutrition for biological, cognitive and behavioural outcomes.
Use of stunting within USAID programmes
Despite its limitations as an indicator of programme performance, stunting prevalence remains a useful population measure that reflects overall living conditions and welfare. It is also useful to compare progress within the same population over time and to identify sub-groups of vulnerable children within a population who may benefit from nutrition programmes.
Selecting indicators for USAID activities
Overall, this report highlighted that, rather than relying on stunting to measure success, nutrition programmes should measure a broader set of lower-level indicators that can be more directly attributed to programme activities. Indicator selection should be informed by a logic model that reflects the full pathway between interventions and results, incorporating a range of nutrition, health and development outcomes.