The I nternational L ipid‐ B ased N utrient S upplements ( iLiNS ) P roject began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid‐based nutrient supplements ( LNS ) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6–24 months and for pregnant and lactating women, for use in studies in three countries ( B urkina F aso, G hana and M alawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient‐dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti‐nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource‐poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.
The aim of this study was to quantify the excess cases of pediatric and maternal disease, death, and costs attributable to suboptimal breastfeeding rates in the United States. Using the current literature on the associations between breastfeeding and health outcomes for nine pediatric and five maternal diseases, we created Monte Carlo simulations modeling a hypothetical cohort of U.S. women followed from age 15 to age 70 years and their children from birth to age 20 years. We examined disease outcomes using (a) 2012 breastfeeding rates and (b) assuming that 90% of infants were breastfed according to medical recommendations. We measured annual excess cases, deaths, and associated costs, in 2014 dollars, using a 2% discount rate. Annual excess deaths attributable to suboptimal breastfeeding total 3,340 (95% confidence interval [1,886 to 4,785]), 78% of which are maternal due to myocardial infarction ( n = 986), breast cancer ( n = 838), and diabetes ( n = 473). Excess pediatric deaths total 721, mostly due to Sudden Infant Death Syndrome ( n = 492) and necrotizing enterocolitis ( n = 190). Medical costs total $3.0 billion, 79% of which are maternal. Costs of premature death total $14.2 billion. The number of women needed to breastfeed as medically recommended to prevent an infant gastrointestinal infection is 0.8; acute otitis media, 3; hospitalization for lower respiratory tract infection, 95; maternal hypertension, 55; diabetes, 162; and myocardial infarction, 235. For every 597 women who optimally breastfeed, one maternal or child death is prevented. Policies to increase optimal breastfeeding could result in substantial public health gains. Breastfeeding has a larger impact on women's health than previously appreciated.
In 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target to reduce by 40% the number of stunted under‐five children by 2025. The target was based on analyses of time series data from 148 countries and national success stories in tackling undernutrition. The global target translates to a 3.9% reduction per year and implies decreasing the number of stunted children from 171 million in 2010 to about 100 million in 2025. However, at current rates of progress, there will be 127 million stunted children by 2025, that is, 27 million more than the target or a reduction of only 26%. The translation of the global target into national targets needs to consider nutrition profiles, risk factor trends, demographic changes, experience with developing and implementing nutrition policies, and health system development. This paper presents a methodology to set individual country targets, without precluding the use of others. Any method applied will be influenced by country‐specific population growth rates. A key question is what countries should do to meet the target. Nutrition interventions alone are almost certainly insufficient, hence the importance of ongoing efforts to foster nutrition‐sensitive development and encourage development of evidence‐based, multisectoral plans to address stunting at national scale, combining direct nutrition interventions with strategies concerning health, family planning, water and sanitation, and other factors that affect the risk of stunting. In addition, an accountability framework needs to be developed and surveillance systems strengthened to monitor the achievement of commitments and targets.
Inadequate feeding and care may contribute to high rates of stunting and underweight among children in rural families in India. This cluster‐randomized trial tested the hypothesis that teaching caregivers appropriate complementary feeding and strategies for how to feed and play responsively through home‐visits would increase children's dietary intake, growth and development compared with home‐visit‐complementary feeding education alone or routine care. Sixty villages in Andhra Pradesh were randomized into three groups of 20 villages with 200 mother–infant dyads in each group. The control group (CG) received routine Integrated Child Development Services (ICDS); the complementary feeding group (CFG) received the ICDS plus the World Health Organization recommendations on breastfeeding and complementary foods; and the responsive complementary feeding and play group (RCF&PG) received the same intervention as the CFG plus skills for responsive feeding and psychosocial stimulation. Both intervention groups received bi‐weekly visits by trained village women. The groups did not differ at 3 months on socioeconomic status, maternal and child nutritional indices, and maternal depression. After controlling for potential confounding factors using the mixed models approach, the 12‐month intervention to the CFG and RCF&PG significantly ( P < 0.05) increased median intakes of energy, protein, Vitamin A, calcium (CFG), iron and zinc, reduced stunting [0.19, confidence interval (CI): 0.0–0.4] in the CFG (but not RCF&PG) and increased ( P < 0.01) Bayley Mental Development scores (mean = 3.1, CI: 0.8–5.3) in the RCF&PG (but not CFG) compared with CG. Community‐based educational interventions can improve dietary intake, length (CFG) and mental development (RCF&PG) for children under 2 years in food‐secure rural Indian families.
Food frequency questionnaires ( FFQs ) are less time consuming and inexpensive instruments for collecting dietary intake when compared with 24‐ h dietary recalls or double‐labelled water; however, the validation of FFQ is important as incorrect information may lead to biased conclusions about associations. Therefore, the relative validity of the B lock K ids F ood S creener ( BKFS ) developed for use with children was examined in a convenience sample of 99 youth recruited from the P ortland, OR metropolitan area. Three 24‐ h dietary recalls served as the reference. The relative validity was analysed after natural log transformation of all variables except glycaemic index prior to correlation analysis. Daily cup equivalent totals from the BKFS and ‘servings’ from 24‐ h recalls were used to compute average daily intake of fruits, vegetables, potatoes, whole grains, legumes, meat/fish/poultry and dairy. Protein grams ( g ), total kcalories, glycaemic index (glucose reference), glycaemic load (glucose reference), total saturated fat ( g ) and added sugar ( g ) were also calculated by each instrument. The correlation between data obtained from the two instruments was corrected for the within‐subject variation in food intake reported by the 24‐ h recalls using standard nutritional assessment methodology. The de‐attenuated correlations in nutritional intake between the two dietary assessment instruments ranged from 0.526 for vegetables, to 0.878 for potatoes. The 24‐ h recall estimated higher levels of saturated fat and added sugar consumption, higher glycaemic loads and glycaemic indices; the de‐attenuatted correlations of these measures ranged from 0.478 to 0.768. Assessment of B land– A ltman plots indicated no systematic difference between the two instruments for vegetable, dairy and meat/fish/poultry fat consumption. BKFS is a useful dietary assessment instrument for the nutrients and food groups it was designed to assess in children age 10–17 years.
Emotions such as guilt and blame are frequently reported by non‐breastfeeding mothers, and fear and humiliation are experienced by breastfeeding mothers when feeding in a public context. In this paper, we present new insights into how shame‐related affects, cognitions and actions are evident within breastfeeding and non‐breastfeeding women's narratives of their experiences. As part of an evaluation study of the implementation of the UNICEF UK B aby F riendly I nitiative Community Award within two primary (community based) care trusts in N orth W est E ngland, 63 women with varied infant feeding experiences took part in either a focus group or an individual semi‐structured interview to explore their experiences, opinions and perceptions of infant feeding. Using a framework analysis approach and drawing on L azare's categories of shame, we consider how the nature of the event (infant feeding) and the vulnerability of the individual (mother) interact in the social context to create shame responses in some breastfeeding and non‐breastfeeding mothers. Three key themes illustrate how shame is experienced and internalised through ‘exposure of women's bodies and infant feeding methods’, ‘undermining and insufficient support’ and ‘perceptions of inadequate mothering’. The findings of this paper highlight how breastfeeding and non‐breastfeeding women may experience judgement and condemnation in interactions with health professionals as well as within community contexts, leading to feelings of failure, inadequacy and isolation. There is a need for strategies and support that address personal, cultural, ideological and structural constraints of infant feeding.
Low nutritional value of complementary foods is associated with high incidence of childhood growth stunting in low‐income countries. This study was done to test a hypothesis that dietary complementation with lipid‐based nutrient supplements ( LNS ) promotes linear growth and reduces the incidence of severe stunting among at‐risk infants. A total of 840 6‐month‐old healthy infants in rural M alawi were enrolled to a randomised assessor‐blinded trial. The participants received 12‐month supplementation with nothing, milk– LNS , soy– LNS , or corn–soy blend ( CSB ). Supplements provided micronutrients and approximately 280 kcal energy per day. Outcomes were incidence of severe and very severe stunting [length‐for‐age z ‐score, ( LAZ ) < −3.00 and <−3.50, respectively], and change in LAZ . The incidence of severe stunting was 11.8%, 8.2%, 9.1% and 15.5% ( P = 0.098) and that of very severe stunting 7.4%, 2.9%, 8.0% and 6.4% ( P = 0.138) in control, milk– LNS , soy– LNS and CSB groups, respectively. Between 9 and 12 months of age, the mean change in LAZ was −0.15, −0.02, −0.12 and −0.18 ( P = 0.045) for control, milk– LNS , soy– LNS and CSB groups, respectively. There was no significant between‐group difference in linear growth during other age‐intervals. Although participants who received milk– LNS had the lowest incidence of severe and very severe stunting, the differences between the groups were smaller than expected. Thus, the results do not provide conclusive evidence on a causal association between the LNS supplementation and the lower incidence of stunting. Exploratory analyses suggest that provision of milk– LNS , but not soy– LNS promotes linear growth among at‐risk infants mainly between 9 and 12 months of age.
We use a representative sample of 2561 children 0-23 months old to identify the factors most significantly associated with child stunting in the state of Maharashtra, India. We find that 22.7% of children were stunted, with one-third (7.4%) of the stunted children severely stunted. Multivariate regression analyses indicate that children born with low birthweight had a 2.5-fold higher odds of being stunted [odds ratio (OR) 2.49; 95% confidence interval (CI) 1.96-3.27]; children 6-23 months old who were not fed a minimum number of times/day had a 63% higher odds of being stunted (OR 1.63; 95% CI 1.24-2.14); and lower consumption of eggs was associated with a two-fold increased odds of stunting in children 6-23months old (OR 2.07; 95% CI 1.19-3.61); children whose mother's height was <145 cm, had two-fold higher odds of being stunted (OR 2.04; 95% CI 1.46-2.81); lastly, children of households without access to improved sanitation had 88% higher odds of being severely stunted (OR 1.88; 95% CI 1.17-3.02). Attained linear growth (height-for-age z-score) was significantly lower in children from households without access to improved sanitation, children of mothers without access to electronic media, without decision making power regarding food or whose height was <145 cm, children born with a low birthweight and children 6-23months old who were not fed dairy products, fruits and vegetables. In Maharashtra children's birthweight and feeding practices, women's nutrition and status and household sanitation and poverty are the most significant predictors of stunting and poor linear growth in children under 2 years.
The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration.
Increasing breastfeeding rates is a strategic priority in the UK and understanding the factors that promote and encourage breastfeeding is critical to achieving this. It is established that women who have strong social support from their partner are more likely to initiate and continue breastfeeding. However, little research has explored the fathers' role in breastfeeding support and more importantly, the information and guidance he may need. In the current study, 117 men whose partner had given birth in the previous 2 years and initiated breastfeeding at birth completed an open‐ended questionnaire exploring their experiences of breastfeeding, the information and support they received and their ideas for future breastfeeding education and promotion aimed at fathers and families. Overall, the findings showed that fathers were encouraging of breastfeeding and wanted to be able to support their partner. However, they often felt left out of the breastfeeding relationships and helpless to support their partner at this time. Many reported being excluded from antenatal breastfeeding education or being considered unimportant in post‐natal support. Men wanted more information about breastfeeding to be directed towards them alongside ideas about how they could practically support their partner. The importance of support mechanisms for themselves during this time was also raised. The results highlight the need for health professionals to direct support and information towards fathers as well as the mother–infant dyad and to recognise their importance in promoting and enabling breastfeeding.
Poor breastfeeding practices are widely documented in K enya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings. This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in N airobi, K enya. In‐depth interviews ( IDIs ), focus group discussions ( FGDs ) and key informant interviews ( KIIs ) were conducted with women of childbearing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs , 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV ; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro‐level policies and interventions that consider the ecological setting are needed.
Eight World Health Organization (WHO) feeding indicators (FIs) and Demographic and Health Survey data for children <24 months were used to assess the relationship of child feeding with stunting and underweight in 14 poor countries. Also assessed were the correlations of FI with country gross national income (GNI). Prevalence of underweight and stunting increased with age and ≥50% of 12–23‐month children were stunted. About 66% of babies received solids by sixth to eighth months; 91% were still breastfeeding through months 12–15. Approximately half of the children were fed with complementary foods at the recommended daily frequency, but <25% met food diversity recommendations. GNI was negatively correlated with a breastfeeding index ( P < 0.01) but not with other age‐appropriate FI. Regression modelling indicated a significant association between early initiation of breastfeeding and a reduction in risk of underweight ( P < 0.05), but a higher risk of underweight for continued breastfeeding at 12–15 months ( P < 0.001). For infants 6–8 months, consumption of solid foods was associated with significantly lower risk of both stunting and underweight ( P < 0.001), as was meeting WHO guidance for minimum acceptable diet, iron‐rich foods (IRF) and dietary diversity ( P < 0.001); desired feeding frequency was only associated with lower risk of underweight ( P < 0.05). Timely solid food introduction, dietary diversity and IRF were associated with reduced probability of underweight and stunting that was further associated with maternal education ( P < 0.001). These results identify FI associated with growth and reinforce maternal education as a variable to reduce risk of underweight and stunting in poor countries.
Inappropriate complementary feeding is one of the major causes of undernutrition among young children in T anzania. Prevalence of newly developed W orld H ealth O rganization complementary feeding indicators and their associated factors were determined among 2402 children aged 6–23 months in T anzania using data from the 2010 T anzania D emographic and H ealth S urvey. The survey used a multistage cluster sample of 10 300 households from the eight geographical zones in the country. The prevalence of the introduction of soft, semi‐solid or solid foods among infants aged 6–8 months was 92.3%. Of all the children aged 6–23 months, the prevalence of minimum dietary diversity, meal frequency and acceptable diet were 38.2%, 38.6% and 15.9%, respectively. Results from multivariate analyses indicated that the main risk factors for inappropriate complementary feeding practices in Tanzania include young child's age (6–11 months), lower level of paternal/maternal education, limited access to mass media, lack of post‐natal check‐ups, and poor economic status. Overall, complementary feeding practices in T anzania, as measured by dietary diversity, meal frequency and acceptable diet, are not adequately met, and there is a need for interventions to improve the nutritional status of young children in T anzania.
This paper quantifies the factors explaining long‐term improvements in child height for age z‐scores in Bangladesh (1996/1997–2011), India (1992/1993–2005/2006), Nepal (1997–2011) and Pakistan (1991–2013). We apply the same statistical techniques to data from a common data source from which we have extracted a set of common explanatory variables that capture ‘nutrition‐sensitive’ factors. Three are particularly important in explaining height for age z‐score changes over these timeframes: improvements in material well‐being; increases in female education; and improvements in sanitation. These factors have comparable associations across all four countries.
The World Health Organization and UNICEF define non‐oedematous severe acute malnutrition (SAM) either by a mid‐upper arm circumference (MUAC) less than 115 mm or by a weight‐for‐height z‐score (WHZ) less than –3. The objective of this study was to assess whether there was any benefit to identify malnourished children with a high risk of death to combine these two diagnostic criteria. Data of a longitudinal study examining the relationship between anthropometry and mortality in rural Senegal and predating the development of community‐based management of SAM were used for this study. First, the receiver operating characteristic (ROC) curves of MUAC and of WHZ to predict mortality were drawn, and then the points corresponding to WHZ less than –3 and/or MUAC less than 115 mm were positioned in relation to these curves. MUAC had the highest ROC curve, which indicates that it identifies high‐risk children better than WHZ. Both points representing WHZ less than –3 and/or MUAC less than 115 mm were below the MUAC ROC curve. It is concluded that to identify high‐risk malnourished children, there is no benefit in using both WHZ less than –3 and/or MUAC less than 115 mm, and that using MUAC alone is preferable.
Age‐appropriate complementary feeding practices are far from optimal among low‐ and middle‐income countries with available data. The evidence on the association between feeding practices and linear growth is mixed. We sought to systematically examine the association between two indictors of dietary quality—dietary diversity and animal source food (ASF) consumption (WHO, 2008)—and stunting (length‐for‐age z‐score) employing existing data from 39 Demographic and Health Surveys. Data on 74,548 children aged 6–23 months were pooled and multiple logistic regression models, adjusting for child, maternal, and household characteristics, employed to assess the association between dietary quality and stunting. Stratified models by child age and by World Bank country‐income classifications (World Bank, 2015) were also applied. Children aged 6–23 months consuming zero food groups in the previous day had a 1.345 higher odds of being stunted when compared to the reference group (≥5 food groups); those who did not consume any ASF in the previous day had a 1.436 higher odds of being stunted compared to children consuming all three types of ASF (egg, meat, and dairy). We estimated that 2,629 cases of stunting would have been averted (12.6% of those stunted) among the population studied if all children had consumed five or more food groups. Outcomes by country‐income groupings showed larger associations of diet diversity and ASF consumption for upper‐ and lower‐middle income countries compared to low‐income countries. In summary, dietary diversity and ASF consumption were associated with stunting, with associations varying by stratified groups.
This study examined whether toddlers' liking for fruit and vegetables (FV) predicts intake of FV later in childhood, how both relate to childhood adiposity and how these were moderated by factors in infancy. Children in the Gateshead Millennium Study were recruited at birth in 1999–2000. Feeding data collected in the first year were linked to data from a parental questionnaire completed for 456 children at age 2.5 years (30 m) and to anthropometry, skinfolds and bioelectrical impedance and 4‐day food diary data collected for 293 of these children at age 7 years. Aged 30 months, 50% of children were reported to like eight different vegetables and three fruits, but at 7 years, children ate a median of only 1.3 (range 0–7) portions of vegetables and 1.0 portion of fruit (0–4). Early appetite, feeding problems and food neophobia showed significant univariate associations with liking for FV aged 30 m, but the number of vegetables toddlers liked was the only independent predictor of vegetable consumption at age 7 years (odds ratio (OR) 1.28 p < 0.001). Liking for fruit aged 30 m also independently predicted fruit intake (OR = 1.31, p = 0.016), but these were also related to deprivation (OR = 2.69, p = 0.001) maternal education (OR = 1.28, p = 0.039) and female gender (OR = 1.8, p = 0.024). Children eating more FV at age 7 years had slightly lower body mass index and skinfolds. An early liking for FV predicted increased later intake, so increasing early exposure to FV could have long term beneficial consequences.
Age‐appropriate infant and young child feeding ( IYCF ) practices are critical to child nutrition. The objective of this paper was to examine the associations between age‐appropriate IYCF practices and child nutrition outcomes in I ndia using data from ∼18 463 children of 0–23.9 months old from I ndia's National Family Health Survey, 2005–06‐3. The outcome measures were child height‐for‐age z‐score ( HAZ ), weight‐for‐age z‐score ( WAZ ), weight‐for‐height z‐score, stunting, underweight and wasting. Linear and logistic regression analyses were used, accounting for the clustered survey data. Regression models were adjusted for child, maternal, and household characteristics, and state and urban/rural residence. The analyses indicate that in I ndia suboptimal IYCF practices are associated with poor nutrition outcomes in children. Early initiation of breastfeeding and exclusive breastfeeding were not associated with any of the nutrition outcomes considered. Not consuming any solid or semi‐solid foods at 6–8.9 months was associated with being underweight ( P < 0.05). The diet diversity score and achieving minimum diet diversity (≥4 food groups) for children 6–23 months of age were most strongly and significantly associated with HAZ , WAZ , stunting and underweight ( P < 0.05). Maternal characteristics were also strongly associated with child undernutrition. In summary, poor IYCF practices, particularly poor complementary foods and feeding practices, are associated with poor child nutrition outcomes in I ndia, particularly linear growth.
The aim of the present study was to examine the relative validity of foods and nutrients calculated by a new food frequency questionnaire (FFQ) in the Norwegian Mother and Child Cohort Study (MoBa). Reference measures were a 4‐day weighed food diary (FD), a motion sensor for measuring total energy expenditure, one 24‐h urine collection for analysis of nitrogen and iodine excretion, and a venous blood specimen for analysis of plasma 25‐hydroxy‐vitamin D and serum folate. A total of 119 women participated in the validation study, and 112 completed the motion sensor registration. Overall, the level of agreement between the FFQ and the FD was satisfactory, and significant correlations were found for all major food groups and for all nutrients except vitamin E. The average correlation coefficient between the FFQ and the FD for daily intake was 0.48 for foods and 0.36 for nutrients, and on average, 68% of the participants were classified into the same or adjacent quintiles by the two methods. Estimated total energy expenditure indicated that under‐reporting of energy intake was more extensive with the FD than with the FFQ. The biological markers confirmed that the FFQ was able to distinguish between high and low intakes of nutrients, as measured by vitamin D, folate, protein and iodine. This validation study indicates that the MoBa FFQ produces reasonable valid intake estimates and is a valid tool to rank pregnant women according to low and high intakes of energy, nutrients and foods.
We analysed socio‐economic inequalities in stunting in South Asia and investigated disparities associated with factors at the individual, caregiver, and household levels (poor dietary diversity, low maternal education, and household poverty). We used time‐series analysis of data from 55,459 children ages 6–23 months from Demographic and Health Surveys in Bangladesh, India, Nepal, and Pakistan (1991–2014). Logistic regression models, adjusted for age, sex, birth order, and place of residency, examined associations between stunting and multiple types of socio‐economic disadvantage. All countries had high stunting rates. Bangladesh and Nepal recorded the largest reductions—2.9 and 4.1 percentage points per year, respectively—compared to 1.3 and 0.6 percentage points in India and Pakistan, respectively. Socio‐economic adversity was associated with increased risk of stunting, regardless of disadvantage type. Poor children with inadequate diets and with poorly educated mothers experienced greater risk of stunting. Although stunting rates declined in the most deprived groups, socio‐economic differences were largely preserved over time and in some cases worsened, namely, between wealth quintiles. The disproportionate burden of stunting experienced by the most disadvantaged children and the worsening inequalities between socio‐economic groups are of concern in countries with substantial stunting burdens. Closing the gap between best and worst performing countries, and between most and least disadvantaged groups within countries, would yield substantial improvements in stunting rates in South Asia. To do so, greater attention needs to be paid to addressing the social, economic, and political drivers of stunting with targeted efforts towards the populations experiencing the greatest disadvantage and child growth faltering.