Improvements to wikipedia page on stunting (and environmental enteropathy)

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Re: Malnutrition’s Links to Sanitation in India - and Wikipedia pages on stunting, helminthiasis and EE

I finally got around to making some improvements to the Wikipedia page on stunted growth with regards to the causes (prompted by what Henk had said above and the edits made by Kris).

It now reads like this:
en.wikipedia.org/wiki/Stunted_growth#Causes

Causes

Most stunting happens during the 1,000-day period that spans from conception to a child's second birthday.[citation needed] Whilst malnutrition used to be seen as the main and only caase of stunting, the actual causes are more complex and inter-twined. The three main causes of stunting in South Asia, and probably in most developing countries, are poor feeding practices, poor maternal nutrition, and poor sanitation.

Feeding practices
Inadequate complementary child feeding and a general lack of vital nutrients beside pure caloric intake is one cause for stunted growth. Children need to be fed diets which meet the minimum requirements in terms of frequency and diversity.

Maternal nutrition
Poor maternal nutrition during pregnancy and breastfeeding can lead to stunted growth of their children. Women who are underweight or anemic during pregnancy, are more likely to have stunted children which perpetuates the inter-generational transmission of stunting.

Water, sanitation and hygiene practices
There is most likely a link between children's linear growth and household sanitation practices. The ingestion of high quantities of fecal bacteria by young children through putting soiled fingers or household items in the mouth leads to intestinal infections. This affect children's nutritional status by diminishing appetite, reducing nutrient absorption, and increasing nutrient losses.

The diseases recurrent diarrhoea and intestinal worm infections (helminthiasis) which are both linked to poor sanitation have been shown to contribute to child stunting. The evidence that a condition called environmental enteropathy also stunts children is not inconclusively available yet, although the link is plausible and several studies are underway on this topic.[4] Environmental enteropathy is a syndrome causing changes in the small intestine of persons and can be brought on due to lacking basic sanitary facilities and being exposed to faecal contamination on a long-term basis.[4]

Research on a global level has found that the proportion of stunting that could be attributed to five or more episodes of diarrhoea before two years of age was 25%.[5] Since diarrhoea is closely linked with water, sanitation and hygience (WASH), this is a good indicator for the connection between WASH and stunted growth. To what extent improvements in drinking water safety, toilet use and good handwashing practices contribute to reduce stunting depends on the how bad these practices were prior to interventions.


I am not yet fully satisfied with it. I would like to add the right references at the right points. The new content that I added today was inspired by what I read on this website (careful: takes a while to load):
stopstunting.org/

But I can't cite the website as a source. I know it's written somewhere in some documents but it's faster if someone who works in this field points me to the best sources to cite for which statement.

I also added two external links as follows:
Stop stunting conference website
Alive and Thrive

The second link I became aware of thanks to a posting by Hanna here .

If anyone has further feedback or feels like editing this Wikipedia article further, please tell me or go ahead. Thanks.
Dr. Elisabeth von Muench
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Re: Malnutrition’s Links to Sanitation in India - and Wikipedia pages on stunting, helminthiasis and EE

Yes we have a good review on the topic here www.ncbi.nlm.nih.gov/pubmed/24781741

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Re: Malnutrition’s Links to Sanitation in India - and Wikipedia pages on stunting, helminthiasis and EE

Dear WikiDocJames (can we call you James ;-)),

I have some more info for the Tropical Sprue lemma, but you may want to try verify this before putting it on-line.

The sprue, as it is called here, is quite common among expats in Kathmandu. Probably also among Nepalese people, but they probably don't get officially diagnosed. The main clinic here in KTM that expats go to is CIWEC ( ciwec-clinic.com ), their method of diagnoses (if I remember correctly) is to give the patient a specific sugar solution and measure the absorption of the sugars from urine samples.
Marijn Zandee

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Re: Malnutrition’s Links to Sanitation in India - and Wikipedia pages on stunting, helminthiasis and EE

It is true that the current "causes" part is maybe too sanitation focused. I tried to improve it a bit, but we probably need someone more knowlegable in child feeding to come up with a properly weighted article.
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Re: ‘Stop Stunting’, which examined the linkages with child food/feeding, maternal nutrition and sanitation

Dear Henk,

Thanks for making us aware about this conference website. It is a really nice website which includes the presentations of the guest speakers as well as filmed interviews. I observed only one problem: the front page of the website takes a terribly long time to load. When I tried to load it while in Hanoi, I gave up. Even with my faster internet connection here in Germany, it took much longer than I would normally expect from a website. It's worth the wait, although perhaps you could give this feedback to the IT guys who set up this page.

I was interested in this interview with Shaun Baker, Director of Nutrition at the Bill and Melinda Gates Foundation who provided general thoughts on why stunting needs to be tackled with urgency:

vimeo.com/111600322

Watching the interviews made me realised (again) that stunting really is a grave concern as it affects the future of the population in many countries, and it is not just about shorter children but about "mal-development" - including mental capacities - and that's really serious and irreversible.

Sanitation is one of three prime causes, which was highlighted nicely on the conference website:

It is acknowledged that most stunting happens during the 1,000-day period that spans from conception to children's second birthday and that the three main causes of stunting in South Asia are poor feeding practices, poor maternal nutrition, and poor sanitation:

[...]

- Household sanitation: Growing evidence suggests that there is a link between children's linear growth and household sanitation practices. The ingestion of high quantities of fecal bacteria by young children through mouthing soiled fingers and household items leads to intestinal infections which affect children's nutritional status by diminishing appetite, reducing nutrient absorption, and increasing nutrient losses. Although the proportion of people using improved sanitation in South Asia increased by 18 percentage points between 1990 and 2011, the pace of this improvement has not kept up with population growth; as a result, the region accounts for almost two thirds of the global population practising open defecation.


Thank you also for your inputs regarding the Wikipedia article on stunted growth.

You mentioned that the section on causes could do with improvements:
en.wikipedia.org/wiki/Stunted_growth#Causes

At present it reads:

Causes [edit source | editbeta]

Whilst the principal cause for stunted growth in children used to be regarded as simply malnutrition, there is increasing agreement that lack of sanitation (open defecation) and associated diseases, such as recurrent diarrhoea, intestinal worm infections (helminthiasis) and a condition called environmental enteropathy all are important causes, too.[4] Environmental enteropathy is a syndrome causing changes in the small intestine of persons and can be brought on due to lacking basic sanitary facilities and being exposed to faecal contamination on a long-term basis.[4]

Research on a global level has found that the proportion of stunting that could be attributed to five or more episodes of diarrhoea before two years of age was 25%.[5] Since diarrhoea is closely linked with water, sanitation and hygience (WASH), this is a good indicator for the connection between WASH and stunted growth. The understanding of the complex interdependence between nutrition, stunted growth and WASH has increased in recent years.


You said:

Regarding the Wikipedia page on stunting, en.wikipedia.org/wiki/Stunted_growth, perhaps the section on ‘causes’ could better explain the ‘mix’ of causes: child food and feeding, maternal nutrition and water/sanitation/hygiene practices. Poor WASH practices result in diarhoea, intestinal worms and environmental enteric dysfunction (env enteropathy). While diarrhoea and helminths have been shown to contribute to child stunting, the evidence that env enteropathy stunts children is not inconclusively available yet, although the link is plausible. Several studies are underway on this topic.

To what extent improvements in drinking water safety, toilet use and good handwashing practices contribute to reduce stunting depends on the how bad these practices were prior to interventions.


I am going to try and improve this section in the Wikipedia article in the coming week, however if anyone beats me to it, I would not be upset either. Maybe we have people on this forum who work with capable students and interns on the topic of WASH, nutrition and stunting who could probably more easily and efficiently insert the latest content and thinking on this page than I could? It does get 100-200 views per day ( stats.grok.se/en/latest90/Stunted_growth ) so wouldn't hurt to have good content on there.

Greetings,
Elisabeth
Dr. Elisabeth von Muench
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Re: ‘Stop Stunting’, which examined the linkages with child food/feeding, maternal nutrition and sanitation

Dear all

UNICEF ROSA held a regional conference in 2014 on ‘Stop Stunting’, which examined the linkages with child food/feeding, maternal nutrition and sanitation. The main presentations are available here: stopstunting.org/


Regarding the Wikipedia page on stunting, en.wikipedia.org/wiki/Stunted_growth , perhaps the section on ‘causes’ could better explain the ‘mix’ of causes: child food and feeding, maternal nutrition and water/sanitation/hygiene practices. Poor WASH practices result in diarhoea, intestinal worms and environmental enteric dysfunction (env enteropathy). While diarrhoea and helminths have been shown to contribute to child stunting, the evidence that env enteropathy stunts children is not inconclusively available yet, although the link is plausible. Several studies are underway on this topic.

To what extent improvements in drinking water safety, toilet use and good handwashing practices contribute to reduce stunting depends on the how bad these practices were prior to interventions.

Hope this helps!

Best regards

Henk


Hendrik van Norden
Regional Adviser (Sanitation & Hygiene)
UNICEF Regional Office for South Asia (ROSA)
Kathmandu, Nepal
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Re: Article in NY Times: Researchers Gather in India to Discuss Malnutrition’s Links to Sanitation - and Wikipedia pages on stunting and EE

The 2012 Government of India publication (Children in India, A Statistical Appraisal, Social Statistics Division, Central Statistics Office, Ministry of statistics and Programme Implementation), 10 MB – attached - gives the following anthropometric indices for assessing the physical development of
children:

• Height-for-age - inadequate Height-for-age indicate stunting
• Weight-for-height - inadequate weight-for-height indicate wasting
• Weight-for-age - inadequate weight-for-age indicate underweight

Table 4.1 captioned, Malnourishment in children below 5 year (%), (surprisingly, there are no page numbers!), shows that 24.3% of children are stunted and 23.7% are severely stunted.

F H Mughal
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Re: Article in NY Times: Researchers Gather in India to Discuss Malnutrition’s Links to Sanitation - and Wikipedia pages on stunting and EE

Started to add some stuff to the talk page ( en.wikipedia.org/wiki/Talk:Environmental_enteropathy )

This article (from 1972!) argues that they are two different conditions/diseases: ajcn.nutrition.org/content/25/10/1047?re...egid=ajcn;25/10/1047
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Re: Article in NY Times: Researchers Gather in India to Discuss Malnutrition’s Links to Sanitation - and Wikipedia pages on stunting and EE

Two are not the same but likely closely related.

I have started EE and changed the sprue artcile

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Re: Article in NY Times: Researchers Gather in India to Discuss Malnutrition’s Links to Sanitation - and Wikipedia pages on stunting and EE

Excellent! Never heard of the term "tropical sprue" before! The Wikipedia article starts with:

Tropical sprue, also known as "environmental enteropathy",[1]


So the two are actually the same? Then all we need is a redirect from "environmental enteropathy" and from "tropical enteropathy" to "tropical sprue" - if indeed that is the correct term to use according to the WHO classification on diseases?

I am not at all an expert on this but I have the feeling that there might be a desire to replace the adjective "tropical" with "environmental" because it may not just be confined to the tropics?

Help from medical people needed...!

(then again, we still speak of neglected tropical diseases, NTDs, see here:
en.wikipedia.org/wiki/Neglected_tropical_diseases )
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Re: Article in NY Times: Researchers Gather in India to Discuss Malnutrition’s Links to Sanitation - and Wikipedia pages on stunting and EE

We have an article on the related condition Tropical sprue en.wikipedia.org/wiki/Tropical_sprue
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Improvements to wikipedia page on stunting (and environmental enteropathy)

Dear all,

This topic of malnutrition and stunting (particularly for children in India) and sanitation is getting more and more attention which is great, and long overdue. There was an article in the New York Times yesterday about a conference that UNICEF organised in India (New York Times is so good at bringing sanitation to the front page time and time again; someone should thank the responsible editor):

Talks in India to Focus on Link Between Hygiene and Growth

www.nytimes.com/2014/11/11/world/asia/re...sanitation.html?_r=0

It is perhaps cynical to say this but if the children of wealthy families are also shown to be affected by stunting, perhaps the politicians will finally jump into action!?

Dr. S V Subramanian, a professor of population health at Harvard University, told the gathering on Monday that even many Indian children of wealthy families were affected by stunting. Even if they have toilets at home, they live near others who do not and can be infected by bacteria carried by flies and water.


This is also interesting:

Stunting leaves children with mental and physical deficits. About 40 percent of the world’s stunted children live in South Asia, perhaps because the region has relatively few toilets and a highly concentrated population.

“If we don’t end open defecation, children will have constant diarrhea,” Karin Hulshof, Unicef’s regional director for South Asia, who helped to coordinate the conference, said in an interview. “And then it doesn’t matter how much food you give the child, they will be stunted.”


There is also another study out by Charles Schmidt:

Beyond Malnutrition: The Role of Sanitation in Stunted Growth

ehp.niehs.nih.gov/122-A298/

A quote from this study:

Meanwhile, mounting evidence has shown that poor hygiene and sanitation also constrain linear growth in children. One study found that Bangladeshi children who had access to clean drinking water, improved toilets, and facilities for handwashing with soap, for instance, had a roughly 50% improvement in HAZ scores compared with control children who didn’t.18 Similar results emerged from studies in Sudan19 and Mexico,20 yet it was unclear exactly why poor WASH would contribute to stunting and WASH improvements would help to ameliorate it.


See also here for more new documents on the role of sanitation in stunted growth:
sanitationupdates.wordpress.com/2014/11/...n-in-stunted-growth/

If there is so much new attention on stunting and sanitation, then some people may look up stunting in Wikipedia. Therefore, I have recently improved and updated that page because I think it is important that it contains good information on the role that sanitation can play to reduce stunting:

en.wikipedia.org/wiki/Stunted_growth

The people who have subscribed to the SuSanA mailing list of working group 12 are aware of these efforts of mine, and several people have kindly sent me pieces of information or references that I should include in this Wikipedia article, after I sent an e-mail to the working group (thanks for that!).

The Wikpedia page on stunting is better now but is not yet complete nor perfect, and I urge anyone who knows a bit about this topic to tell me what else to add to the Wikipedia page to make it better. You could also add it yourself, of course.
However, I know the hurdle to write on Wikipedia is high, so I am happy to function as a "ghost writer" if needed. Just tell me what I should write or modify.

I have also done some edits on the much larger page on malnutrition (which also gets more views):
en.wikipedia.org/wiki/Malnutrition
(the two pages would obviously go hand in hand; I found it less daunting to start with the page on stunted growth).

I would also like to propose that we should create a new Wikipedia article on environmental enteropathy, as such a page doesn't exist yet. I don't want to tackle this on my own though, can I find any collaborators?
Just reply here or send me an e-mail if you are interested in contributing to the work for such a Wikipedia article.

Regards,
Elisabeth

P.S. For anyone who is interested about writing on Wikipedia himself or herself, I have compiled here some general information on how to write on Wikipedia, together with a listing of Wikipedia pages that I have edited or worked on so far. See attachment below. One thing to keep in mind (which I have recently been reminded of by people on Wikipedia watching the quality of the pages) is that you should write "in your own words" or at least paraphrase from articles - it is not sufficient nor allowed to simply copy & paste from articles; even quoting with inverted commas should only be used sparingly. See also the attachment for more explanations on this issue.
Dr. Elisabeth von Muench
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