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The 2016 National Health and Morbidity Survey revealed that 20.7 percent of Malaysian children are stunted. The repercussions will affect the nation as a whole. Various efforts to address the issue has been introduced since, but we've not seen a decrease in prevalence. Why?
By: SAKINA MOHAMED
Illustrator: UMMUL SYUHAIDA OTHMAN
Research Analyst,
Jeffrey Cheah Institute
Dec 31, 2022 (Bernama) -- One in five Malaysian children are stunted and we’ve known this since 2016. The government has launched several efforts since then to address the problem.
So why haven’t we solved it yet?
It could be because we are treating stunting as simply a nutritional issue, said Derek Kok, a research analyst with the Jeffrey Cheah Institute on Southeast Asia at Sunway University.
He has been studying the issue of child stunting for the last five years.
“Stunting is caused by a complex set of factors. One of them is, of course, inadequate dietary intake -but that’s only partially why.
“There are so many other things to also look at – maternal health, the child’s living conditions, access to healthcare. The parents’ economic status also weigh in,” he told Bernama in an interview.
One of the biggest hints as to why stunting is not a direct marker for child undernutrition is that studies have shown large scale nutritional interventions have minimal influence on the height of the child, Kok revealed.
Instead, we need to look into the cause of stunting and go from there.
Research Analyst,
Jeffrey Cheah Institute
He has been studying the issue of child stunting for the last five years.
“Stunting is caused by a complex set of factors. One of them is, of course, inadequate dietary intake -but that’s only partially why.
“There are so many other things to also look at – maternal health, the child’s living conditions, access to healthcare. The parents’ economic status also weigh in,” he told Bernama in an interview.
One of the biggest hints as to why stunting is not a direct marker for child undernutrition is that studies have shown large scale nutritional interventions have minimal influence on the height of the child, Kok revealed.
Instead, we need to look into the cause of stunting and go from there.
Unfortunately, one the most difficult concepts to explain is the cause of stunting. This is because there is no one cause – the causes are multipronged and feed back into one another. The different influences are illustrated in the UNICEF Conceptual Framework for Undernutrition, as indicated in the chart below.
What we can glean from the chart is that both maternal and child health and nutrition are inextricably linked. They are caused by similar factors – poverty, health, sanitation, and environment.
However, almost every campaign to address child stunting seem to focus only on the child.
Furthermore, they often target children at inaccurate growth windows. An example of this is feeding programmes for schoolgoing children.
Such feeding programmes are extremely important, but rectifying stunting calls for the problem to be identified and remedied within the first 1,000 days of a child’s life. This period covers the child’s life in their mother’s womb till the age of two.
If the problem is not caught and corrected before then, a child may have to spend an entire lifetime dealing with the repercussions of stunting, which are largely irreversible. This includes impaired cognitive functions and a predisposition to chronic diseases.
The thin arrows show that the consequences of undernutrition can feed back to the underlying and basic causes of undernutrition, perpetuating the cycle of undernutrition, poverty and inequities.
This is why measures to address stunting should also include a focus on maternal health.
Initiatives like the one announced in the 2023 Budget to help prevent stunting is a step in the right direction, because it channels the aid directly to mothers.
The RM500 one-off cash assistance is for women from Bantuan Keluarga Malaysia households who give birth in 2023.
The government’s move to extend maternity leave from 60 days to 98 days is also important, as it allows mothers to breastfeed their children longer.
This encourages better care and feeding practices which helps address one of the underlying determinants of stunting.
The technical definition for stunting is that children are classified as stunted if they are two standard deviations away from the median height set by the WHO child growth standards.
“What that means is that the definition for stunting is not a biological one, but a statistical one,” says Kok.
This measurement is commonly used in laboratory tests, but there is no scientific basis for choosing it.
This causes a problem because if a child’s height falls slightly above or below the median height, it does not mean that the child is free from the consequences of stunting – which are serious.
“We can’t say that kids who fall on this side of the chart is okay, and those on the other side are stunted.
“If we do that, then we’ll miss out on the entire spectrum of children who may be suffering from the consequences related to growth failure – which isn’t technically defined as stunting but carry the same repercussions,” he said.
This is similar to only using salary as a measure of poverty. If, for example, only those earning RM1,000 and below are considered poor and eligible for aid, does that mean those earning RM1,050 are immune to the consequences of poverty?
The reason it is so important to acknowledge that stunting is a “gradual faltering” process is because it is an indicator that more than 1 in 5 Malaysian children are actually affected by it.
“It’s the tip of the iceberg. When you say gradual faltering, what you mean is that more than 21.8 percent of Malaysian children are stunted – way more,” Kok explained.
What does this mean for the country?
Countries lose, on average, 7 percent of per capita income because of stunting, according to a World Bank study by Galasso and Wagstaff. Studies further show that stunted individuals are more prone to illness and disease, ultimately adding on to the burden of the public healthcare system.
Furthermore, the consequences of stunting can span generations. Women who were stunted as children tend to also bear stunted children.
“This is because the consequences of undernutrition feeds back to the underlying and basic causes of undernutrition, thereby perpetuating an endless cycle of undernutrition, poverty and inequality,” Kok explained.
Unless the government intervenes and course-corrects these factors in time, this vicious cycle will carry on for generations.
“Stunting is a reflection of a child’s growth environment in the country at that time. It is not only a marker for a child’s wellbeing as a whole but an indicator for inequality in society.
“Often, it’s seen as the best marker for how society functions and takes care of its children,” said Kok.
When stunting is seen as a purely nutritional issue, the burden to tackle it would fall on the child’s parents. However, tackling these factors is simply beyond a parent's control.
“It emphasises too much on behavioural change, but what better nutritional choices can poorer parents make?” he questioned.
With so many other factors beyond diet contributing to the issue, the burden of responsibility needs to shift towards the community and more particularly, the government, he said.
Seeing stunting as more than just a nutritional issue also helps policymakers rope in the necessary forces to power an effective campaign.
“Successful campaigns against stunting have shown that effective policy interventions address underlying causes, are multi-sectoral in approach and focus on the critical 1,000-day window,” Kok said.
What are the underlying causes? Referring to the conceptual framework for undernutrition above, they are household food insecurity, inadequate care and feeding practices, unhealthy household environment and poor health services.
Kok has for years been advocating for child stunting to be part of a concerted national effort led by an inter-ministerial committee under the very top level of government, such as the Prime Minister’s Office.
“Peru managed to halve its stunting rates in less than a decade because the efforts came from the top, which is the nation’s president,” he said.
Malaysia currently treats stunting as a nutritional issue and as such places it under the Nutrition Division of the Ministry of Health.
“They’re doing an excellent job trying to tackle the issue but their efforts may fall short simply because of many other macro level factors beyond nutrition.
“Stunting is not an issue that can be solved solely with nutritional interventions. It requires whole-of-government multi-sectoral policy efforts that can impact the entire range of a child's growth environment, shaped by structural factors that only the state can solve.
“Structural issues require structural solutions,” Kok said.