Habiba Hassan-Wassef, MD National Research Center, Cairo, Egypt 1-5 October 2018. Addis Abeba. The 8th Africa Nutritional Epidemiology Conference (ANEC VIII 2018)

1. Current strategies for stunting
reduction in the light of emerging
evidence of complexity
Habiba Hassan-Wassef, MD
National Research Center, Cairo, Egypt
e-mail: bio_egypt@hotmail.com

2. Outline
• Growth faltering and stunting in early childhood
• Importance of stunting reduction to Africa
• Emerging body of knowledge on the causes
• The need to look at the big picture of the food and
nutrition security system
• Adjusting current strategies for stunting reduction
to particular conditions of the African context
• Examples of programmes for integration of
strategies for reduction of the risk of exposure to
environmental toxins and bacterial contaminants
• Suggestions for the way forward

3. Undernutrition and stunting
in early childhood
• Stunting describes the relation of height to age. A child is
stunted when the height for age z-scores (HAZ) are less
than -2.
• Child stunting rates reflect prolonged nutritional
deprivations and are used to monitor changes in
nutritional status over time.
• Prolonged child undernutrition can lead to irreversible
health and developmental consequences such as
impaired brain development, vulnerability to infections
and increase in mortality rates, reduced educability and
productivity in adult life.

4. Stunting reduction is key for the realization
of Agenda 2063 and the goal of
Transforming Africa
“Improving the quality of life for the
people of Africa”
is an objective in the High 5 Agenda for
transforming Africa of the African
Development Bank

5. The quality of Africa’s human capital
“The greatest contributor to economic
growth is not physical infrastructure, but
brain power: what I refer to as “grey
matter infrastructure”. Stunted children
today lead to stunted economies
tomorrow.”
Quote taken from speech on nutrition by A. Adesina, President of the
African Development Bank.

6. Ever growing evidence on causal
factors for growth retardation
List includes:
• Environmental chemicals and contaminants
in nature and in the agro-food supply chain
• Mutagenic agents present in industrial
products in particular those destined for
household use
• Climate change related chemical exposure to
fungal toxins

7. Increased vulnerability of children and
pregnant mothers to environmental toxins
• Vulnerability increases in undernourished children
and increases the risk of infections *
• Studies indicate possibility of impact on fetal
development
*“Interventions targeting child undernutrition in developing
countries may be undermined by dietary exposure to
aflatoxin”, Sinead Watson, Yun Yun Gong & Michael Routledge
(2017) Critical Reviews in Food Science and Nutrition, 57:9,
1963-1975.

8. Limitations of current Stunting
reduction strategies
Scaling up of 10 proved nutrition-specific
interventions to cover 90% of stunted will
reduce stunting by 20% ONLY?? (Lancet
2013)

9. Examples of recent researches focusing on
identifying causes of growth retardation
• Postweaning Exposure to Aflatoxin Results in Impaired Child
Growth: A Longitudinal Study in Benin, West Africa, Yunyun Gong,
Assomption Hounsa, Sharif Egal, Paul C. Turner, Anne E. Sutcliffe,1 Andrew J. Hall, Kitty
Cardwell, and Christopher P. Wild.
• How immediate and significant is the outcome of training on
diversified diets, hygiene and food safety? An effort to mitigate
child undernutrition in rural Malawi, (2018) Anitha Seetha, Takuji W
Tsusaka, Timalizge W Munthali, Tinna Manani, Lizzie Kachulu, Nelson Kumwenda, Mike
Musoke and Patrick Okori
• Comparison of urinary aflatoxin M1 and aflatoxin albumin adducts
as biomarkers for assessing aflatoxin exposure in Tanzanian
children. Chen, G, Gong, YY, Kimanya, ME et al. (2018), Biomarkers, 23 (2). pp. 131-136.

10. Examples of recent researches focusing on
identifying causes of growth retardation (Contd.)
• Does aflatoxin exposure cause child stunting?
Project Spotlight : Mitigating aflatoxin
consumption for improving child growth in
Eastern Kenya (2015) Kelly jones and Vivian Hoffmann,IFPRI (ongoing
research)
• “Aflatoxin Impacts on Child Growth”, presentation by
Ahmed Kablan, PharmD, PhD. Office of Agricultural Research and Policy Bureau for
Food Security (BFS/ARP); USDA/ARS/Office of International Research
ProgramTanzania Nutrition GLEE

11. The Food Security System
A new conceptual Framework
Ecker, O. and Breisinger C.,
IFPRI Discussion Paper 01166 (2012)
• The Framework integrates the four pillars of food
security into a system approach.
• It links complex interactions of factors at the micro
and macro levels and shows how shocks and natural
disasters, as well as intervents of policy and
programme, affect the availability of food, people’s
access to it, and the resulting nutritional status of
individuals of all ages.
• It helps understand the complexity of causal factors
underlying child stunting and , in turn guides the
design of strategies to address them.

13. Hence the importance of adoption of effective
coordination and harmonization mechanisms
for implementation of a jointly conceived
policy and strategy with distribution of roles
between the partners and stakeholders as well
as the targeted community.
(Ref.: NEPAD recommendation describing coordination mechanisms)

14. Highlights of the present body of knowledge (1)
• Evidence of low efficacy of current stunting reduction
strategies is available.
• A body of research on the health and nutrition impact of
environmental toxins and food (and water) contaminants,
referred to as ‘a largely ignored public health problem’ (Wild
CP and Gong YY, 2010) continues to be produced.
• The dangerous impact on health is recognized by those
involved in reducing risk exposure in agricultural products
and the food chain (Re. AUC-PACA initiative calling for
“Engaging the Health and Nutrition Sectors in Aflatoxin
Control in Africa”.
• “The Mycotox Charter” for increasing awareness of, and
concerted action for, minimizing mycotoxin exposure world
wide, published in TOXINS (2018) does not sufficiently focus
on health concerns.

15. Highlights of the present body of knowledge (2)
• Details of routes of exposure, absorption,
distribution, metabolism and excretion in humans
and animals are becoming known.
• Rapid tests for biomarkers continue to be improved
for facilitating rapid screening of populations and
establishment of surveillance systems.
• Control measures are being applied in the food
processing industry.
• Application of hygiene and food safety control
measures to local markets remains wanting

16. Proposals to strengthen the health content of
‘The Mycotox Charter’
Some recommendations to increase the health content:
• Expansion of text on health in the commitment
section.
• Addition of texts on helping promote identification of
home grown solutions for reducing MT
exposure/contamination.
• Identification of appropriate strategies/tools for
application of public health regulation to local markets
in Low and Middle Income Countries.
• Addition of texts for spreading mycotoxin literacy and
knowledge and advocacy to policy makers and
politicians to be added where relevant in the Charter.

17. Balancing the various management
strategies for environmental toxins and
bacterial contaminants is not evident
The slow development of the economic cost of erosion of
human capital of future generations through inaction
does not carry enough weight* against
the immediate loss to national economies of loss of trade,
market access and of livelihoods
Due to contaminated agro-food products destined for
export
*(Health concerns receive less attention than economic concerns)

18. Examples of programs for integration of strategies
for management of environmental toxins (2)
• Building Africa’s Grey Matter Infrastructure initiative of
the AfDB for promoting increased investments in
nutrition.
• National food and nutrition policy and strategy plans
• The Scaling Up Nutrition national plans
• Food security and nutrition and sustainable agriculture
country plans
• Food inspection and control departments of the health
sector and of the National Food Safety Agency

19. Examples of programs for integration of strategies
for management of environmental toxins (2)
• Country plans for the UN Decade on Nutrition
• Programs promoting sustainable food systems
for healthy diets
• Programs promoting health, productivity and
food security
• Programmes addressing the quality and
safety of local formulation of complementary
foods

20. The way forward
• The health and economic burden of contamination of
food and feed by environmental toxin and bacteria can
compromise the achievement of development goals
and the aspired acceleration of Africa’s economic
growth and needs to be addressed.
• Integration of updated stunting reduction strategies in
various ongoing and future continental and national
debates, discussions, processes, and development
plans of concerned sectors can benefit all parties.
• Newly identified rapid risk exposure assessment
technologies can now be used for establishing a
surveillance system in high risk or endemic areas.

21. The way forward
• All available data needs to be carefully reviewed in
preparation for an AUC-PACA meeting of concerned
stakeholders to discuss how the current stunting
reduction strategies need to be adapted to the
particularities of the African context.
• There is need to respond to the call for comments and
modifications made by the authors of “The Mycotox
Charter”.
• Production of training modules and training of the
health teams in diagnosis, management and control of
environmental toxins and contaminants.

22. The way forward
• Continued evaluation of emerging evidence
• More research and networking among the African
research centers already engaged in stunting related
research
• Strengthen the health dimension in the work and
activities of of PACA and FARA
• Prepare for and organize a multi-stakeholder
conference - in collaboration with WHO - to adapt
stunting reduction strategies to particularities of the
African context

23. THANK YOU