Child stunting

In the remote, mountainous regions of Afghanistan, Pakistan and Tajikistan, up to half of children are stunted, failing to reach their proper weight and height. Poor feeding practices and low quality of food from weaning age, compounded by a high burden of illness, particularly diarrhoea, contribute to stunting and growth failure. This chronic malnutrition is often compounded by high levels of anaemia and acute malnutrition from food insecurity, a humanitarian crisis or illness.

Stunting is not only about children failing to reach their potential height. The organs and immune system of a stunted two-year-old child risk underdevelopment, making her more susceptible to illness throughout her life. She will have a reduced chance to reach her mental peak, with worsened school performance and permanently less earning power. The resulting lack of resources and, in the case of a mother, her own malnourished state while pregnant and breastfeeding, sets in motion a pattern that resonates through future generations.

Central Asia Stunting Initiative (CASI)

The Aga Khan Foundation (AKF) is working with the Aga Khan University (AKU) and Aga Khan Health Services (AKHS) to break this cycle. They are targeting the full population, an estimated 387,500 people, in 475 remote and marginalised communities within Badakhshan, Afghanistan, Gilgit-Baltistan and Chitral (GBC), Pakistan and Gorno-Badakhshan Autonomous Oblast (GBAO), Tajikistan. In a long-term, multisectoral approach, they aim to prevent as well as treat stunting and improve nutrition for the whole community.

The project team initially combined secondary evidence with its own baseline surveys, looked at malnutrition indicators like body mass index and arm circumference, and took blood samples to check iron levels. Prioritising the first 1,000 days (including pregnancy) and then children aged two to five, the team provided nutrition care and support, including micronutrients for pregnant and lactating women, built the capacity of healthcare facilities to identify and treat malnutrition, and trained healthcare staff to offer advice on nutrition and breastfeeding.

The AKDN team is working closely with governments and international partners with similar objectives.

The CASI programme coordinator, AKU graduate and health and nutrition expert Dr Aminah Jahangir, says: “The World Food Programme (WFP) and UNICEF supported us to procure equipment, nutrition commodities and micronutrients. We coordinate with them for design, progress and implementation in each country. In Tajikistan, WFP gave a certificate of appreciation to AKDN for our efforts in introducing protocols relating to acute malnutrition, and the introduction of Acha-Mum for treatment of moderate acute malnutrition. These protocols will also be scaled up in other parts of the country.

We also divide some services with partners – we provide services for moderate acute malnutrition in Tajikistan but the severe and complicated cases of acute malnutrition are treated through support by UNICEF at the stabilisation centres. In Pakistan, we introduced protocols for moderate acute malnutrition and uncomplicated cases of severe acute malnutrition in CASI geographies. We refer patients to stabilisation centres run by the World Health Organization in Pakistan and have regular meetings with them and the Department of Health to advocate for the strengthening of these centres. We have a technical working group at the provincial levels where partners share data and get input on technical protocols.

In Afghanistan, we are part of the nutrition cluster and ensure there is no duplication between our services and those of the other development partners like WFP and UNICEF. We implement a stunting prevention programme supported by WFP in some non-CASI districts of Badakhshan. We also work closely with UNICEF in Afghanistan to support the inpatient severely acute malnourished management services in three units.”

Addressing maternal malnutrition

There are several months where households have access to only one or two crops, resulting in an insufficiently diverse diet to gain essential micro and macro nutrients. In Murghab District, GBAO, 25-year-old Mavluda Fakirmamadova’s economic and geographic circumstances did not permit a varied diet. Lacking vitamins, she weighed only 39 kg, was tired and dizzy, and was unable to conceive. She was given Super Cereal, a fortified porridge, by AKF’s district CASI coordinator. In a month, she had gained weight, her health had improved and she was pleasantly surprised to find that she was pregnant. In June 2022, Jumabekova Hayotbegim was born at a good height and weight (49 cm and 3.2 kg).

Newborns

In Tajikistan, the programme works with government facilities, training and supporting them to assess the birth weight of babies within 24 hours of birth, identifying the ones with low birth weight and referring those under 1.5 kg to the newborn intensive care unit (NICU) at the Aga Khan Medical Centre, Khorog (AKMCK). Staff are starting to build capacity to provide this advanced level of treatment in government district hospitals in some areas. Extremely low-birth-weight babies from areas not covered by CASI are also being accepted.

“Those babies have a limited chance of survival if they don't get into the NICU,” says Dr Claudia Hudspeth, Global Health and Nutrition Lead, AKF. “Even if the child is from a village that's not from our programmatic area, it's a no-brainer. We're treating them.”

Ismat from Ishkashim District was born prematurely in the 26^th week of pregnancy. Weighing 800g – less than a quarter of typical newborn weight – and only 33 cm long rather than the usual 50, he spent 90 days in the NICU at AKMCK. His mother, Gulyaman, said:

“While looking at Ismat, I was always afraid and not sure that such a tiny baby would survive. I was even afraid to hold him and hug him. When I came to feed him, I always talked to him. Nevertheless, I hoped that we would overcome the challenging days together. Now he is gaining weight and I am very happy. After enduring a fight for life, we are finally home with my son.”

The first 1,000 days

“In some areas low birth weight can affect up to 20 percent of babies,” Claudia says. “Children are born under 2.5 kg, and it’s very difficult to catch up when they’re born into a situation of deprivation. And so the idea is to prevent low birth weight in the first place, working with a generation to ensure that when a mum gets pregnant that she is well-nourished, to try to prevent the baby from being undernourished, but if the baby is undernourished, to tackle it really quickly so that they get back on track and stay on track.”

Baby Alim Davlatmamadov, from Midenved Village in GBAO, was not eating properly despite the availability of nutritious food and his mother’s best efforts, and was admitted to hospital with acute respiratory infection, rickets, anaemia and mild acute malnutrition. Aged eight months, he was almost a kilo underweight.

AKF offers children who are considerably underweight the ready-to-use supplementary food Acha-Mum. After starting the supplement, Alim began eating again, and drinking his homemade fruit and vegetable juices. By his first birthday, his health had returned to normal and he was gaining weight.

Adolescents

“In addition to working with children and pregnant women we are also focusing on nutrition in adolescent girls. The second decade of children's lives is the greatest chance for catch-up growth. Once they start menstruation, if they are already anaemic that will compound the anaemia, and adolescent girls also tend to get allocated less food within their household than they actually need. In many of our geographies adolescent girls eventually become mums and if well nourished, they can pass on that good nutrition to their newborn children as well as improve the nutrition of the family. It’s a triple benefit,” says Claudia.

The results

Between September 2019 and July 2022, CASI interventions reached almost 65,000 children across the three countries, of which nearly three-quarters were ages 0-4. The 147 project health facilities were given equipment to assess nutritional status in women and babies, measure birth weight and care for low-birth-weight babies. They were provided with nutritional supplements to treat malnutrition, although the stock of supplements in Afghanistan was affected by delays due to the conflict. Over 600 health facility providers and community health workers were trained on growth monitoring, counselling, stunting and acute malnutrition protocols and newborn survival and care, and 89 percent of the 170,000 men and women that CASI targeted attended nutrition training and behaviour change activities.

The programme has achieved an average annual relative reduction in stunting of between two and seven percent (anything over two percent is considered exemplary at global standard), with improvements at the individual and population levels. Not only has the prevalence of stunting decreased, but children who were not clinically stunted are now better nourished than previously.

CASI is in its fifth year. With these stunting reductions and nutrition gains continuing year on year, the team expects increasingly significant improvements in maternal and child health and development. It aims to continue deepening the impact over a generation to break the cycle of undernutrition.

AKDN is also starting to turn its attention to another heavy non-communicable disease burden in Central Asia. One of its nutrition programming objectives is to prevent obesity, caused by poor quality food and built environments that do not encourage exercise.

“It’s expensive to eat healthily, especially given the inflationary environment,” says Claudia. “There's also a loss of historical food types. In the Hunza Valley, there's an amazing history of using healthy apricot oils and soups. But those recipes were in people's great grandmothers’ repertoire, and a lot of that oral history has been lost. So we've moved to this modern food system without having the ability to counteract it with physical exercise. About a third of adults in Kyrgyzstan and Tajikistan are overweight or obese. We’re trying to do more around recreation in schools and on nutrition education. Because it’s hard to lose weight as an adult – where you can change it is in children.”

What’s next

Integrating interventions

In their paper How countries can reduce child stunting at scale: Lessons from exemplar countries, Dr Zulfiqar Bhutta of AKU et al concluded that half of stunting reduction could be attributed to non-health interventions. AKDN is able to bring together education, health screening and treatment, food supplement provision, initiatives aimed at increasing household incomes, gender equity education, agriculture and food security programming, and water and sanitation provision to address nutritional objectives. “We have everything under one roof to have a really significant impact in the geographies where we work, because we're working at scale at critical mass in a multisectoral way,” says Claudia. “It's not an easy funding environment, but we've got a proven model now that works.”

Ensuring sustainability

Aminah explains how the effects of CASI should continue beyond its long funding cycle: “There's a lot of focus on behaviour change and community mobilisation through not just education, but also the development of a diet through local recipes, and how the right diet can be made rich through whatever is available, and focusing on things like minimal meal frequency and minimal dietary diversity.

We are looking at how the nutrition commodities can be produced by AKDN itself, or as a joint venture, to make them cheaper and more accessible.

We are doing a lot of capacity building with community health promoters, with lady health workers in Pakistan, and at the health provider level, and have also trained the core people from our institutions. We have done a huge amount of training for government staff in each country to make sure that they understand and implement the protocols.

We work very closely with governments for the design of the programme and all the interventions. In Pakistan, the same design is now being replicated by the government in other districts of GBC. The whole funding is coming from the Government of Pakistan, but the people who are part of our technical group, such as Dr Zulfiqar Bhutta, Dr Sajid Sufi and Dr Atif Habib, are leading the design.”

With its focus on sustainability and capacity building, CASI has put into motion a process that should help break the cycle of malnutrition and stunting for future generations.