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BMJ Glob Health. 2019 Jan 13;4(1):e001155. doi: 10.1136/bmjgh-2018-001155. eCollection 2019.

Path analyses of risk factors for linear growth faltering in four prospective cohorts of young children in Ghana, Malawi and Burkina Faso.

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Department of Nutrition, University of California Davis, Davis, California, USA.
Departments of Pediatrics and Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.
Department of Agricultural and Resource Economics, University of California Davis, 2135 Social Sciences and Humanities, Davis, California, USA.
Department of Psychiatry, University of Malawi College of Medicine, Blantyre, Southern Region, Malawi.
Institut de Recherche en Sciences de la Santé, Avenue de la Liberté, Burkina Faso.
Department of Public Health, University of Turku and Turku University Hospital, Finland, Turku.
Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, Rhode Island, USA.
School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi.
Department of Nutrition and Food Science, University of Ghana, Legon, Ghana.
Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, University of Tampere, Tampere, Finland.
Bill & Melinda Gates Foundation, Seattle, Washington, USA.
Department of Paediatrics, Tampere University Hospital, Tampere, Finland.
Intake, Center for Dietary Assessment, Seattle, Washington, USA.


Stunting prevalence is an indicator of a country's progress towards United Nations' Sustainable Development Goal 2, which is to end hunger and achieve improved nutrition. Accelerating progress towards reducing stunting requires a deeper understanding of the factors that contribute to linear growth faltering. We conducted path analyses of factors associated with 18-month length-for-age z-score (LAZ) in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements Project in Ghana (n=1039), Malawi (n=684 and 1504) and Burkina Faso (n=2619). In two cohorts, women were enrolled during pregnancy. In two other cohorts, infants were enrolled at 6 or 9 months. We examined the association of 42 indicators of environmental, maternal, caregiving and child factors with 18-month LAZ. Using structural equation modelling, we examined direct and indirect associations through hypothesised mediators in each cohort. Out of 42 indicators, 2 were associated with 18-month LAZ in three or four cohorts: maternal height and body mass index (BMI). Six factors were associated with 18-month LAZ in two cohorts: length for gestational age z-score (LGAZ) at birth, pregnancy duration, improved household water, child dietary diversity, diarrhoea incidence and 6-month or 9-month haemoglobin concentration. Direct associations were more prevalent than indirect associations, but 30%-62% of the associations of maternal height and BMI with 18-month LAZ were mediated by LGAZ at birth. Factors that were not associated with LAZ were maternal iron status, illness and inflammation during pregnancy, maternal stress and depression, exclusive breast feeding during 6 months post partum, feeding frequency and child fever, malaria and acute respiratory infections. These findings may help in identifying interventions to accelerate progress towards reducing stunting; however, much of the variance in linear growth status remained unaccounted for by these 42 individual-level factors, suggesting that community-level changes may be needed to achieve substantial progress.


Africa; Linear growth; childhood; path analysis; pregnancy; prospective cohort; stunting

Conflict of interest statement

Competing interests: KHB has worked as a consultant and later as employee for the Bill & Melinda Gates Foundation.

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