Unsafe Drinking Water Is Associated with Environmental Enteric Dysfunction and Poor Growth Outcomes in Young Children in Rural Southwestern Uganda

Lauer, Jacqueline M.; Duggan, Christopher; Ausman, Lynne M.; Griffiths, Jeffrey K.; Webb, Patrick; Bashaasha, Bernard; Agaba, Edgar; Turyashemererwa, Florence; Ghosh, Shibani

doi:10.4269/ajtmh.18-0143

Cited by 15 publications

(11 citation statements)

References 35 publications

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“…This study found that within-country changes in stunting risk were associated with improvements in household access to improved sanitation facilities and improved drinking water sources and increased coverage of child immunization, which is consistent with findings from other trend analysis studies [17,18,19,20,22,25]. These findings are supported by the growing body of literature indicating that enteric dysfunction, resulting from poor environmental conditions (water, sanitation, and hygiene), is among the most important factors for the high childhood stunting burden in low-income settings [4,34,35].…”

Section: Discussionsupporting

confidence: 89%

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

et al. 2019

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Background: Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025. Methods: We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries. Results: Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers. Conclusions: The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition.

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Section: Discussionsupporting

confidence: 89%

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

et al. 2019

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“…Two studies, each using one or the other putative biomarkers of environmental enteric dysfunction, show convergent findings related to exposure to safer or less-safe household water. With respect to linear growth, the study in Timor-Leste 61 did not report on growth, and in Uganda, 62 the additional growth was not of a magnitude to alter the stunting rates in the community.…”

Section: Emerging Insightsmentioning

confidence: 96%

Vision of Research on Human Linear Growth

Solomons¹

2019

Food Nutr Bull

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The human body grows in length from conception to the maximal adult height over two decades. The shortest male population averages ∼150 cm and the tallest ∼183 cm. Nonetheless the dimensions of head and trunk are highly comparable, with the vast difference in the leg length. Stunting is a personal condition in which an individual has a standing height-for-age (HAZ) of less than two standard deviations of the standard curve median. It is associated with increased mortality, morbidity, and functional deficits. The process of losing relative stature is known as linear growth retardation, first attributed to chronic protein deficiency, then to an assortment of micronutrient deficiencies, and most recently to inflammation from unhygienic environmental conditions. Public health intervention trials responding to each of these possibilities have failed to produce true reversal responses measured in the 10s of centimeters. As to biological insights, there is no convenient way to separate weight from length growth with sonographic monitoring, but a third of infants can be born stunted. Normative growth (standard curves) competes with epigenetic adaptation (programming) as the beacon for in utero growth. Major investments into field trials allow us to discard multiple micronutrients and water/sanitation/hygiene interventions as measures to reverse established stunting. The preponderance of evidence is against catch-up growth during puberty. Future publications will be in the conceptual domain, resolving metrics, while the full range of stimuli and exposures impeding growth will be elucidated. Advances in measurement techniques in anthropometry and immunology and endocrinology will be mobilized to the literature.

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“…Although small-scale livestock production presents an opportunity for increased ASF production/consumption to halt child undernutrition in LMIC (27,28), a 2018 systematic review revealed no congruent relationship between ASF consumption and the alleviation of common undernutrition outcomes, including stunting (29). Furthermore, although many observational studies significantly associate improved family-level water, sanitation, and hygiene (WaSH) with improved child linear growth and lessened burden of environmental enteric dysfunction (EED), a key mediator of growth faltering (30)(31)(32), these significant effects did not persist in landmark randomized controlled trials (WASH-Benefits Bangladesh & Kenya, SHINE) (33)(34)(35)(36). Researchers suggested that unmeasured household risk factors could have confounded the beneficial effect of WaSH interventions, and called for a "transformative WaSH" approach to curtail fecal contamination at the household level in future research (33).…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, although many observational studies significantly associate improved family-level water, sanitation, and hygiene (WaSH) with improved child linear growth and lessened burden of environmental enteric dysfunction (EED), a key mediator of growth faltering ( 30 – 32 ), these significant effects did not persist in landmark randomized controlled trials (WASH-Benefits Bangladesh & Kenya, SHINE) ( 33 – 36 ). Researchers suggested that unmeasured household risk factors could have confounded the beneficial effect of WaSH interventions, and called for a “transformative WaSH” approach to curtail fecal contamination at the household level in future research ( 33 ).…”

Section: Introductionmentioning

confidence: 99%

Benefits and Risks of Smallholder Livestock Production on Child Nutrition in Low- and Middle-Income Countries

Chen

Mechlowitz

et al. 2021

Front. Nutr.

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Livestock production may improve nutritional outcomes of pregnant women and children by increasing household income, availability of nutrient-dense foods, and women's empowerment. Nevertheless, the relationship is complex, and the nutritional status of children may be impaired by presence of or proximity to livestock and their pathogens. In this paper, we review the benefits and risks of livestock production on child nutrition. Evidence supports the nutritional benefits of livestock farming through income, production, and women's empowerment. Increasing animal source food consumption requires a combination of efforts, including improved animal management so that herd size is adequate to meet household income needs and consumption and addressing sociocultural and gendered norms. Evidence supports the inclusion of behavior change communication strategies into livestock production interventions to facilitate the sustainability of nutritional benefits over time, particularly interventions that engage women and foster dimensions of women's empowerment. In evaluating the risks of livestock production, evidence indicates that a broad range of enteric pathogens may chronically infect the intestines of children and, in combination with dietary deficits, may cause environmental enteric dysfunction (EED), a chronic inflammation of the gut. Some of the most important pathogens associated with EED are zoonotic in nature with livestock as their main reservoir. Very few studies have aimed to understand which livestock species contribute most to colonization with these pathogens, or how to reduce transmission. Control at the point of exposure has been investigated in a few studies, but much less effort has been spent on improving animal husbandry practices, which may have additional benefits. There is an urgent need for dedicated and long-term research to understand which livestock species contribute most to exposure of young children to zoonotic enteric pathogens, to test the potential of a wide range of intervention methods, to assess their effectiveness in randomized trials, and to assure their broad adaptation and sustainability. This review highlights the benefits and risks of livestock production on child nutrition. In addition to identifying research gaps, findings support inclusion of poor gut health as an immediate determinant of child undernutrition, expanding the established UNICEF framework which includes only inadequate diet and disease.

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Unsafe Drinking Water Is Associated with Environmental Enteric Dysfunction and Poor Growth Outcomes in Young Children in Rural Southwestern Uganda

Cited by 15 publications

References 35 publications

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

Vision of Research on Human Linear Growth

Benefits and Risks of Smallholder Livestock Production on Child Nutrition in Low- and Middle-Income Countries

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