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Journal of the American College of Nutrition
ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: https://www.tandfonline.com/loi/uacn20
Current Status of Malnutrition and Stunting in
Pakistani Children: What Needs to Be Done?
Amanat Ali
To cite this article: Amanat Ali (2021) Current Status of Malnutrition and Stunting in Pakistani
Children: What Needs to Be Done?, Journal of the American College of Nutrition, 40:2, 180-192,
DOI: 10.1080/07315724.2020.1750504
To link to this article: https://doi.org/10.1080/07315724.2020.1750504
Published online: 10 Apr 2020.
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Current Status of Malnutrition and Stunting in Pakistani Children: What Needs
to Be Done?
Amanat Ali
School of Engineering, University of Guelph, Guelph, Ontario, Canada
ABSTRACT
Malnutrition is one of the greatest health challenges that affects about 2 billion people globally.
Multiple factors including poverty, food insecurity, maternal health and nutritional status, mother’s
age at marriage and educational status, low birthweight or small for gestational age (SGA), prema-
ture births, suboptimal breastfeeding practices, unhealthy dietary and lifestyle patterns, health and
immunization status of children, socioeconomic status of family, environmental and household
conditions, together with cultural practices and myths, play vital role in affecting the growth of
children at early age. Although child stunting has declined in Pakistan, the reduction rate is only
0.5%, which is very low. This may be due to ineffective or inappropriate intervention programs as
they are mostly addressing only one issue at a time and don’t use the multi-sector approach to
address numerous determinants of stunting. It is therefore important to initiate cost-effective
multi-tiered intervention approaches to be implemented at pre-conception, pregnancy and early
postpartum stages to prevent the problems of malnutrition and stunting in Pakistani children. This
review discusses the etiology of child malnutrition and stunting in Pakistan, role of various deter-
minants of stunting and what type of intervention strategies and approaches should be developed
and implemented to deal with these problems.
KEY TEACHING POINTS
1. Malnutrition is one of the greatest global health challenges.
2. Poverty, food insecurity, socioeconomic status, unhealthy dietary patterns, maternal health
and nutritional status, low birthweight, suboptimal breast feeding, environmental conditions,
cultural practices and myths, are the main factors for child malnutrition and stunting
in Pakistan.
3. The slow reduction rate in child stunting may be due to inappropriate intervention programs.
4. Cost-effective multi-tiered intervention approaches must be implemented at pre-conception,
pregnancy and early postpartum stages to prevent child malnutrition and stunting
in Pakistan.
5. A holistic approach comprising nutrition and WASH interventions, together with strategies to
improve the socioeconomic status be developed and implemented to resolve this dilemma.
ARTICLE HISTORY
Received 18 February 2020
Accepted 29 March 2020
KEYWORDS
Children; malnutrition;
stunting; determi-
nants; Pakistan
Introduction
Malnutrition is one of the greatest health challenges that
affects around 2 billion people globally [1]. Malnutrition
comprises both under-nutrition and over-nutrition or exem-
plifies any deficiency, excess or imbalance in energy and/or
nutrients intakes [2,3]. Undernutrition entails underweight,
stunting, wasting, and includes deficiencies or insufficiencies
of micronutrients. Whereas, overweight, obesity and diet-
related non-communicable diseases are linked with over-
nutrition. Child growth and development is seen as a crucial
marker of nutritional and health conditions of communities.
Stunting in children is therefore perceived as the main risk
factor for unsatisfactory physical and mental development in
children under 5 years of age, with far-reaching impacts on
affected individuals and society. According to the recent
estimates of UNICEF/WHO/World Bank Group, around
151 million children under 5 years are stunted, over 50 mil-
lion are wasted and nearly 17 million are severely wasted,
globally[4,5]. Child malnutrition and stunting in South Asia,
East and West Africa remains a major unresolved global
health issue. South Asian countries have the highest number
(around 57.9 million) of stunted children. Stunting is linked
to several health and productivity threats and is associated
with increased risk of morbidity and mortality in children.
Stunted children start late in school, show poor learning and
intellectual abilities, have low intelligent quotient (IQ),
repeat classes in school and are less likely to graduate within
the normal time period. Stunted children do not attain their
maximum genetic capacity at later stage of life and therefore
impose great burden on human resources in terms of low
CONTACT Amanat Ali amanat@uoguelph.ca; amanata@gmail.com School of Engineering, University of Guelph, Albert A. Thornbrough Building, 50 Stone
Road East, Guelph, ON N1G 2W1, Canada.
ß2020 American College of Nutrition
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
2021, VOL. 40, NO. 2, 180–192
https://doi.org/10.1080/07315724.2020.1750504
economic productivity. Childhood malnutrition and mis-
treatment are also linked with mental health complications,
which may persist with maturity. Malnourished children or
those with higher scores of childhood maltreatment, or chil-
dren exposed to both adversities showed higher levels of
paranoid, schizoid, avoidant, and dependent personality dis-
order (PD) scores [6]. However, the socioeconomic condi-
tions during early age may also be important in terms of
youth cognition and intellectual development [7].
Malnutrition and stunting during childhood have long-term
impacts on the economic outcomes in later life. Stunted
children have been shown to be less productive and earn
around 20% less as adults [8]. According to some estimates
the economic losses in Pakistan, due to poor early childhood
growth and development due to malnutrition, are US $7.6
billion annually [9]. Investments made in developing appro-
priate nutrition interventions programs are therefore worth
for future prosperity and success of any country including
Pakistan [10].
Although Asia has experienced an overall reduction from
38% to 23% in stunting from 2000 to 2017, it is still consid-
ered as the highest rate [11]. According to 2018-Global
Nutrition Report, India (46.6 million), Nigeria (13.9 million)
and Pakistan (10.7 million) have the largest number of
stunted children in the world, respectively [5]. The World
Committee on Food Security has identified that malnutrition
in all its forms (including hunger, under-nutrition, micronu-
trient deficiencies, overweight and obesity), is a critical chal-
lenge for both the developing and developed countries.
Hunger can be characterized in many ways and may com-
prise individual sensations and household behavioral
responses, food scarcity and national food balance sheets
[1]. The food balance sheet approach is used to measure the
food availability in a country. Supply of an adequate and
balance diet is required to end hunger and malnutrition.
The cost-effective availability of food in a country can
greatly contribute to reduction in malnutrition and stunting
among its population and should therefore be considered
while devising relevant interventions and policies to reduce
stunting and malnutrition [9]. Pakistan is currently facing a
complex crisis of malnutrition affecting the population in all
age groups, particularly infants, children, adolescents, and
pregnant and breast-feeding women. Based on the
Worldometer of the United Nations data, Pakistan has cur-
rently an estimated population of around 219.1 million,
which may go up to >260 million by the year 2030 [12].
The magnitude of malnutrition in Pakistan has deteriorated
over the past few decades, particularly with respect to pro-
tein and micronutrient deficiencies [13,14]. Depending upon
the socioeconomic inequalities, large disparities exit in child
malnutrition and stunting in different areas of the country.
Only a few published studies provide some limited informa-
tion. These studies mostly evaluated the nutritional status of
children in certain local areas and not at national level.
There is also some variability in reported data on the preva-
lence of malnutrition and stunting in Pakistani children. We
therefore searched various popular databases such as
PubMed, JSTOR, Google Scholar, Scholars Portal Journals,
Web of Science, AGRICOLA, AGRIS etc. to collect and
evaluate the data on malnutrition and stunting. In addition
to this, data from specific reports of Food and Agriculture
Organization (FAO), World Health Organization (WHO),
World Food Program (WFP), The United Nations
Children’s Fund (UNICEF), National Nutrition Surveys,
Pakistan Economic Survey, Global Alliance for Improved
Nutrition (GAIN), Global Nutrition Reports, etc., was also
collected and assessed. The information was reviewed and
appraised thoroughly for their relevance to etiology of mal-
nutrition and stunting in Pakistani children. The present
review discusses the etiology of child malnutrition, and
stunting in Pakistan, role of various determinants and what
type of intervention strategies should be developed and
implemented to deal with these problems.
Etiology of childhood stunting
Stunting in children occurs due to continuous inadequate
daily intake of energy and nutrients that do not meet their
recommended requirements. Stunting is characterized as an
insufficient linear growth i.e., shortness in stature or height
for age. It is assessed by comparing the height for age of
children with a reference population of well-nourished and
healthy children i.e., Zscore equal to or lower than 2.
Stunting has also been defined as either excesses or imbalan-
ces in a person’s intake of energy or nutrients that is associ-
ated with impaired physical and psychological growth and
development [15]. In addition to this, repeated infections
and inadequate psychosocial stimulation may also add to
stunting. Together with genetic factors, the suboptimal fetal
nutrition can lead to impaired brain development, which is
suggested to program the risk of developing chronic diseases
at a later stage of life [16]. Globally, the term “small for ges-
tational age”(SGA) is linked to stunting [17], followed by
other factors such as poor nutrition, sanitation and diarrhea
in children [18,19]. The women of reproductive age as well
as during pregnancy have specific nutritional needs and
should maintain a healthy lifestyle for better birth outcomes
[20]. If the nutrient needs of pregnant mothers are not met
adequately, they may not be able to provide the required
nutrients to fetus during gestation. Poor nutritional status
in-utero is a major concern in Pakistan as it may block the
future growth and development of newborns and may raise
the risk of chronic diseases in adulthood [21]. Almost over a
quarter of all births in Pakistan are attributed to the prob-
lems of poor fetal growth and SGA births. Meeting the
nutritional needs of teenage girls as well as of young women
at the reproductive age, well ahead of pregnancy, may not
only improve the birth outcomes but can also assist to lessen
the rate of infant and child stunting with long lasting results
for building healthy generations. To prevent stunting in chil-
dren, it is therefore important that appropriate measures be
taken during this stage. By controlling and eradicating these
crucial risks, the rate of childhood stunting in developing
countries may well be prevented.
The first 1000 days of life since conception are the most
critical one, because the child growth and development
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 181
through this stage can regulate the child’s performance dur-
ing the subsequent life [22]. Inadequate nutrition during
this phase can not only lead to stunting but can also have
serious consequences for the future life as many of the
developmental processes, particularly the developments in
brain only occur during this phase, which cannot be
reversed at a later stage. Supply of an adequate, and bal-
anced diet is therefore the most critical factor, which needs
to be addressed during the first 1000 days of a child’s life
[16]. Linear growth failure in children is linked to multiple
pathological disorders and increased risk of morbidity and
mortality. Stunted children not only suffer with poor phys-
ical growth, but may also have weakened neurodevelopmen-
tal and cognitive functions, poor educational and economic
attainments in adulthood together with elevated risk of
chronic diseases. It has been suggested that the irreversible
physical and neurocognitive damages, which accompany the
poor linear growth, pose major threats to human develop-
ment [23]. Children’s nutritional problems are deep-rooted
and are linked to their mother’s health and nutritional status
during adolescence, pregnancy and breast-feeding periods.
An adequate and balanced nutrition must therefore be
ensured for the expecting mothers. In Tanzanian children,
maternal micronutrient supplementation (MMS) during
pregnancy increased the gestational age, improved birth
weight and enhanced the intrauterine growth in infants as
evident by their 6-wk mortality rate, which was only meas-
urable in female and not in male infants [24]. In order to
reduce child stunting in Nigeria, the main emphasis has
therefore been placed on lowering poverty, boosting wom-
en’s nutrition, expanding child feeding practices and
improving hygiene and sanitary conditions. It has also been
stressed that maternal educational programs and social pro-
tection policies be introduced in rural communities [25,26].
Malnutrition and infection work synergistically and
greatly heighten the risk of childhood morbidity and mortal-
ity owing to impaired immune function. It is estimated that
almost 50% of children under 5 years of age die because of
undernutrition. Although the underlying mechanisms are
still poorly identified, the immunological transformations
have been linked with impaired gut-barrier functions, poor
release of defensive material from exocrine glands, and
weakened role of complement system of plasma protein
[27]. Undernutrition and infection work synergistically and
may lead to a potentially vicious cycle that together with ill-
ness, can lead to further deterioration of nutritional status.
As a result, an imbalance can occur in the composition of
natural gut microflora that may impair the immunological
and metabolic intestinal functions. These factors blend
together with diet leading to poor absorption of nutrients,
altering their metabolism, creating inflammation and affect
the translocation of gastrointestinal microflora [28].
Subclinical changes and inflammation occurring as a result
of environmental enteric dysfunction (EED) may be the
underlying cause of failure in child growth. Adequate nutri-
tion is therefore critical for the optimal linear growth and
development in children during the first 1000 days of life.
However, in the presence of EED-related inflammation, the
role of nutrition can be severely conceded [29].
Observational studies have consistently reported reduced
capacity for carbohydrate absorption in severely malnour-
ished children [30]. Protein and micronutrient deficiencies
also affect the inherent and innate immune response in chil-
dren [31]. Changes in the intestinal microflora can force to
faltered growth, impairment of inflammatory immune func-
tions, brain functional connectivity, and may delay the psy-
chomotor and cognitive development in children [32,33].
The underlying etiology and pathophysiology of stunting in
children is, however, still unclear and pose a great challenge
in its prevention and treatment.
Determinants of stunting in children
The key determinants of malnutrition and stunting in South
Asian countries are very much similar. They can be placed
into three main categories; (1) food insecurity and inad-
equate nutrient intake, (2) socioeconomic status and
inequalities, (3) maternal and environmental factors.
Food insecurity and inadequate nutrient intake in
child stunting
The most enduring and significant factors triggering stunt-
ing are poverty and food insecurity. Food insecurity is a
major dilemma in developing countries as it impacts nutri-
tion, growth, and development in children. In severely food
insecure households, the probabilities of becoming stunted,
underweight, or wasted are higher in children due to poor
diet diversity. Food insecurity and diet diversity should
therefore be considered while formulating the policies, pro-
grams and interventions to tackle the problem of undernu-
trition [34]. Christian and colleagues observed that food
insecurity was negatively correlated with diet diversity and
micronutrient intake in children [35]. The degree of eco-
nomic growth and development in a country can also affect
the food insecurity and ultimately the risk of child stunting
[36]. Food insecurity is a crucial factor contributing to poor
nutritional status in Pakistani children. Around two-third of
households with almost 80% of children in Pakistan don’t
have access to enough amount of healthy and nutritious
food [37]. Not only the insufficient quantity and poor qual-
ity of food but also an individual’s digestive capacity and
immune response, together with lack of healthcare and
social services, are responsible for stunting. All these factors
play important role in determining the optimal linear
growth rate in children. Low child birthweights in Pakistan
can be tied to inadequate nutrition, anemia, and micronu-
trient deficiencies in expecting mothers. Although, Pakistan
is a major producer of wheat and rice and has become a
food surplus country, yet the economic uncertainty costs
more on the nutritional disparity among children and
infants. According to Pakistan Economic Survey 2018–2019,
the overall food production in Pakistan as well as the avail-
ability of staple food items are enough to meet the dietary
needs of its population [38]. The per capita availability of
calories from major food commodities is estimated to
182 A. ALI
improve to 2530 calories in 2018–2019. The average cost of
food basket, which provides 2100 calories/day containing
60 g protein/day, is estimated to be Rs. 2259 per person per
month during 2018–2019. In general, an average Pakistani
family spends almost 51% of their monthly income on food.
The Pakistan Cost of Diet Analysis estimates that 67% of
the households in Pakistan are unable to afford a nutrition-
ally adequate diet, whereas approximately 5% are unable to
have a diet that meets even the minimum requirements for
energy [39]. Despite per capita increase in income, rise in
the production and availability of food items as well as
higher intakes of gross energy (calories from food), the cur-
rent prevalence of child stunting in Pakistan is 40.2%.
However, approximately 60% of its population is still con-
fronting the problem of food insecurity, particularly the
poor and most vulnerable population groups cannot afford
enough nutritious food [40]. To tackle these challenges,
Pakistan joined the global movement of Scaling Up
Nutrition (SUN) in 2013. Generally, the people eat wheat-
based diets with low food diversity, which may not only
cause micronutrient deficiencies but may also increase the
rate of overweight and obesity. An increase in overweight
from 18% to 29% was observed among the Pakistani popula-
tion during 1999 to 2016 [41]. However, only little is known
about the non-nutritional impacts of food insecurity, for
example its impacts on brain development and mental disor-
ders, particularly in developing countries [42]. Poor maternal
mental health has also been shown to be linked with an
increased risk of infant undernutrition. Children from moth-
ers with mental distress were under nourished and had higher
risk of illness in urban Pakistan. It has been suggested that
early diagnosis and treatment of mental illness in mothers
may help to lower the rates of child’s morbidity and mortality
[43]. Prenatal depression is a public health problem, which is
related to health, malnutrition and psychosocial well-being of
both mother and child. It has been shown that women suffer-
ing with prenatal signs of depression and living in rural areas
of Pakistan, who had fewer assets, higher household debts
and faced food insecurity, showed worse depression symp-
toms, more than in high income countries [44].
Socioeconomic status and inequalities in
child stunting
There is a convincing association between multiple indica-
tors of socioeconomic status (SES) with child stunting in
low and middle-income countries (LMIC). Social inequalities
are thought to play important role in child stunting. Kismul
et al. [45] observed that children living in rural areas of
Democratic Republic of Congo (DRC) had higher prevalence
of stunting than those living in urban areas. Stunting was
substantially greater in boys than girls, particularly in male
children coming from poor families. They suggested that to
reduce stunting, together with other nutrition interventions,
immediate attention be given to breastfeeding. Woodruff
et al. [46] observed that the possible causes of wasting,
stunting, and anemia in preschool-age children in the
Republic of Guinea, were child birthweight, child health and
nutritional status, child caring practices, mother’s nutritional
and health status, household water source and sanitary con-
ditions. The socioeconomic factors influencing the nutri-
tional status of children under the age of 5 in Nigeria were
educational level of parents, especially of mothers, health
and nutritional status of the mothers during pregnancy and
breastfeeding, immunization status of the child, rural or
urban residence and wealth status of family as well as the
current political system [25,26]. The rate of child stunting in
Indonesia is about 37%. The major determinants of stunting,
which have been identified in Indonesian children are pre-
mature birth, short length at birth, non-exclusive breastfeed-
ing (NEBF), low maternal height and educational level,
unimproved latrines, untreated drinking water, poor excess
to health care and poor household socio-economic status
[47,48]. How all these factors contribute to child stunting is
however still not clear [48].
Mushtaq et al. [49] evaluated the prevalence and socio-
demographic correlates of stunting and thinness in Pakistani
primary school children (5–12 years) in Lahore, Pakistan.
They observed that 8% were stunted, and 10% were thin,
without any gender specificity. In both boys and girls, the
degree of stunting increased with age, whereas thinness was
only observed among boys. They identified that the major
determinants of stunting and thinness included, age, areas
with low socio-economic status (SES), lower parental educa-
tion, more siblings, crowded housing and living in smoking
environment. Children coming from poor, less educated
families, living in low-income neighborhoods and in
crowded houses with smoking environment, had increased
frequency of stunting and thinness. They suggested that
interventions addressing the poor and socially disadvantage
groups be given priority [49]. Asim and Nawaz [13]
reported that most of the studies, conducted in Pakistan to
identify the causes of child malnutrition, were cross sec-
tional and used quantitative and descriptive methods
through structured interviews, except one that used mix
method technique. They observed that the main factors
related to child malnutrition and stunting were large family
size, early marriages, high fertility rates, inadequate birth
spacing, poor breast-feeding practices and poverty. They
identified that there is an urgent need for more integrated
qualitative and quantitative studies to understand the under-
lying causes of child malnutrition and stunting in Pakistan
[13]. Khan et al. [10] observed that 44.4%, 29.4%, and 10.7%
of Pakistani children (0–59 months) were stunted, under-
weight, and wasted, respectively. Children born to mothers,
who were 18 years at marriage, lived in rural areas, and
visited antenatal clinic >3 times during pregnancy, had low
probability of becoming stunted. Mother’s educational level,
height, BMI and child’s birthweight showed strong correl-
ation with underweight in children. They concluded that
most of these factors contributing to malnutrition in
Pakistani children can be averted [10]. The socio-economic
distress in Pakistan is on the increase and is linked to
contradictory public policies implemented during the previ-
ous years in the country. It has been indicated that the
changing socioeconomic status of people in Pakistan, is going
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 183
to bring a shift in nutritional status of people from under- to
over-nutrition, with widespread burden of under nutrition
[50]. A better socioeconomic status or wealth index has how-
ever been associated with reduced child malnutrition.
Therefore, empowering women in Pakistan can help to
improve the nutritional status of children that is important
for future economic development in the country [51].
Maternal and environmental factors in
child stunting
Multiple factors including the maternal health, environmental
and household conditions, poverty, socioeconomic inequal-
ities, low birthweight, contaminated water, sanitary, and
hygiene conditions, as well as infection and diarrhea are
regarded as the important underlying causes of malnutrition
and stunting in children [52,53]. Kim et al. [54] evaluated 13
different linkages of child stunting in South Asian countries
(Bangladesh, India, Nepal, Pakistan, and Afghanistan), which
can influence the nutrient intake in children. They grouped
these risk factors into five main categories comprising (1)
maternal nutrition and infection, (2) teenage motherhood
and short birth intervals, (3) fetal growth restriction (FGR)
and preterm birth, (4) child nutrition, infection, and socioe-
conomic and environmental variations. Aguayo et al. [55]
observed that the most significant triggers of child stunting
in Maharashtra, India, were child birthweight, feeding practi-
ces, women’s nutritional status, poor sanitary conditions and
poverty. Low birthweight children and children fed only a
few times/days had 2.5-fold and 63% higher probabilities of
becoming stunted. Children born to mothers with <145 cm
height, had also 2-fold higher chances of becoming stunted.
Similarly, low feeding frequency, low consumption of eggs,
dairy products, fruits, and vegetables were related to stunting
in children. Children coming from families with poor sani-
tary facilities had 88% higher probabilities of becoming
stunted [55]. Low birth weight (LBW) is regarded as a strong
predictor of all the three indicators of undernutrition (stunt-
ing, wasting, and underweight). The frequency of stunting,
wasting, underweight, and low birth weight (LBW) in Malawi
children has been reported to be 39%, 2%, 11%, and 10%,
respectively. The factors responsible for low birth weight are
therefore important and must be addressed in all nutrition
interventions targeting to reduce the rate of stunting [2]. It
has been hypothesized that exposure to aflatoxins and myco-
toxins through contaminated foods may damage the intes-
tinal lining, suppress immune system and damage the liver
functions in both children and their mothers and may lead
to stunting in children [56]. Children living in agricultural
areas and exposed to pesticides since perinatal period,
infancy, and childhood have also been shown to have a
higher risk of developing growth disorders [57].
Water, sanitation, hygiene (WASH) and
poverty nexus
According to a recent World Bank report, the major issues
related to child stunting in Pakistan are, supply of
contaminated water, poor sanitary conditions, and poverty.
Pakistan is the 3rd largest country in the world behind India
and Indonesia, where people go to bathroom in the open.
Although the frequency of open defecation in Pakistan has
gone down from 29% to 11.5%, it is estimated that still 40
million people in Pakistan lack a decent toilet [58]. Open
defecation is associated with many health and nutritional
concerns as it can spread diseases, leads to intestinal infec-
tions and can contribute to stunting in children. Enormous
differences exist in the country with respect to clean water
supply, hygiene and sanitation. High levels of E. coli con-
tamination in water and soil samples (50–75%) has been
found at various locations in Punjab, with much worst situ-
ation in Sindh [59]. The level of contamination is higher in
more densely populated poor rural districts because of
improper sewerage disposal system and ineffective treatment
of human wastes. Untreated fecal sludge and wastewater
mixed with ground and surface water enter the irrigation
system and pollute the soil leading to the production of con-
taminated food crops for human consumption. This chain
of contamination is further magnified by different other
environmental channels. Proper removal of fecal wastes is
therefore of critical significance in reducing the bacterial
contamination of water, soil, and food. Together with social
and economic mechanisms, poor water, sanitation and
hygiene (WASH) conditions influence the child growth and
development due to persistent exposure to enteric patho-
gens. Any intervention strategy to improve the water, sanita-
tion and hygiene (WASH) conditions will certainly help to
lower the risk of non-diarrheal mortality and morbidity [60].
It has therefore been suggested that together with traditional
nutrition interventions, new improved WASH strategies be
developed and implemented, specifically to prevent the process
of stunting during the first 2 years of life [61].
Dietary, curative and behavioral improvements can only
serve at best, if the total fecal burden in the environment is
reduced. Water should be treated on priority basis and crops
should not be irrigated with untreated wastewater. Although,
Pakistan has made some progress in lowering poverty,
improving diet diversity and reducing open defecation, yet
the rate of diarrheal incidences and prevalence of stunting are
still high [10]. Removal of all types of bacterial and patho-
genic contamination from water is therefore important to
control the intestinal infections and diarrhea. E. coli is the
main cause of diarrhea, as it attaches to the internal lining of
intestine. It markedly damages the intestinal villi of young
children leading to environmental enteric dysfunction (EED),
a causal factor connecting poor sanitation to stunting.
Diarrhea triggers excessive loss of water and nutrients from
the body. Although the body’s innate protective system helps
to recoup from illness, the repeated episodes of diarrhea may
occur, which make it hard for children to digest and absorb
nutrients, even after recovering from diarrhea. The EED has
also been linked to stunting because of diminished response
to oral vaccines and compromised immune system in chil-
dren leading to potential lifelong health challenges [62,63].
EED in children has a key role in the pathophysiology of
stunting and is increasingly recognized as a major factor
184 A. ALI
underlying malnutrition, deficient immune responses, and
impaired cognitive and mental growth in children of develop-
ing countries [64,65]. Malnourished children develop a differ-
ent set of bacteria in their stomach that can cause
environmental enteric dysfunction (EED), which is now
believed to be one of the leading causes of malnutrition and
stunting in Pakistan [64]. Based on current evidence, it is
suggested that multi-sector strategies including nutrition and
WASH interventions be developed and implemented to slash
the linear growth failures in children worldwide [66].
Zambruni et al. [67] reported that stunting in Peruvian
infants occurred as a result of increase in the markers of
enterocyte turnover as well as changes in the composition of
fecal microbiota. Stunting has also been linked with increased
levels of markers of systemic inflammatory response [67].
Based on the above-mentioned data, the major determinants
of malnutrition and stunting in children in developing coun-
tries can be summarized as follows:
1. Poverty
2. Household wealth index
3. Social inequalities
4. Political system of the country and cul-
tural background
5. Unimproved latrines
6. Untreated drinking water
7. Poor excess to health care in rural areas
8. Health and immunization status of children
9. Diarrhea and infections
10. Rural, urban and geopolitical zones
11. Food systems of the country
12. Food insecurity
13. Unhealthy dietary patterns
14. Poor bioavailability of some micronutrients from foods
15. Micronutrient deficiencies
16. Maternal health
17. Mother’s age at marriage
18. Low maternal height
19. Short birth length, and premature birth
20. Low birth weight (LBW), or small for gestational
age (SGA)
21. Mother’s educational level
22. Nutritional status of pregnant and breastfeed-
ing mothers
23. Suboptimal breastfeeding practices
24. Exposure to pesticides during perinatal period, infancy,
and childhood
A snapshot of data from the national nutrition
surveys in Pakistan
The Government of Pakistan and UNICEF in 2011 reported
that almost 44% children were stunted, slightly higher male
(48%) than female (42%). About 15% had wasting and many
others had deficiency of at least one or the other micronu-
trient [68]. The linear mixed-effect model estimates on child
growth and malnutrition indicated that there has been a
gradual decrease in stunting in Pakistan from about 70% in
1977 to 38% in 2018 [69]. The 2017–2018 Pakistan
Demographic and Health Survey (2017–2018 PDHS) col-
lected data on several important health indicators and nutri-
tional status of children [21]. According to 2017–2018
PDHS, the prevalence of stunting in children declined from
45% in 2012–2013 to 38% in 2017–2018, including 17% of
severely stunted. Similarly, the percentage of wasting and
underweight children declined from 11% to 7% and 30% to
23%, respectively. Rural areas showed higher rates of child
stunting (41%) as compared to their urban counterparts
(31%). It is interesting to note that children born to unedu-
cated mothers were more likely to become stunted (57%)
than those from educated mothers (37%). The prevalence of
stunting increases with age, exceeding 48% among children
aged 24–35 months. The report indicated that stunting was
inversely related to household wealth quintile, as 57% of
children from poor families were stunted, as compared to
22% of children in the highest wealth quintile [21]. Stunting
rates vary with the geographic location in the country as the
situation in Sindh has worsened overtime. The recent adop-
tion of Accelerated Action Plan (AAP) on Stunting and
Malnutrition in Sindh presumes to reduce the child stunting
from 48% to 30% by 2021 and to 15% by 2026. The plan
intends to develop and integrate the multi-sector interven-
tions to minimize stunting [70]. Pakistan is among the
countries, who have the lowest rates of exclusive breastfeed-
ing (EBF) in South Asia [71]. Low rates of EBF can be
regarded as one of the leading causes of child stunting
dilemma in Pakistan. During the first 6 months of life,
exclusive breastfeeding (EBF) is enough to meet the nutri-
tional needs of infants. WHO has therefore included EBF in
the priority areas and has set up new global targets for EBF
at 50% to be achieved by the year 2025 and at 70% by 2030
[72]. The 2017–2018 PDHS data shows that only 48%
infants under 6 months of age are exclusively breastfed
(EBF), which is an improvement as compared to 5 years ago
(38%). The data shows that in addition to breastmilk, 8% of
young infants consume plain water, 1% consume non-milk
liquids, 23% consume other milk, and 13% consume com-
plementary foods. Around 54% of children (6–23 months)
timely get complementary food, whereas only 12% receive a
minimally acceptable adequate diet [21].
So far, the National Nutrition Survey (NNS-2018) is the
largest country-wide survey in Pakistan that has collected
district level data from 115,500 households on the nutri-
tional and health status of children under five, adolescent
girls, women of childbearing age, including pregnant and
breastfeeding women. It has also collected data on food
security, dietary habits and breast-feeding practices, house-
hold water quality, sanitation facilities as well as the socio-
economic factors that may impact the nutrition and health
related indicators such as household income, gender
empowerment, and mother’s educational level, etc. [73]. The
findings revealed overtime changes in nutrition indicators of
the country, following the implementation of various nutri-
tion and social support programs/initiatives during the past.
According to NNS-2018, currently around 12 million chil-
dren in Pakistan are stunted with an overall prevalence rate
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 185
of stunting at 40.2%. The prevalence rate of stunting varies
with the geographical location from 32.6% in Islamabad
Capital Territory (ICT) to 48.3% in Khyber Pakhtunkhwa-
newly merged districts (KP-NMD). The average overall
annual reduction rate in stunting in the country is estimated
to be at only 0.5%, which is too slow to slash stunting in
Pakistan. The survey indicated that the prevalence of wast-
ing is on the rise, from 8.6% in 1997 to 15.1% in 2011 and
17.7% in 2018, the highest rate in Pakistan’s history. It is
more common in Sindh (23.3%) and KP-NMD (23.1%),
whereas is lower in Gilgit-Baltistan (GB) and ICT areas at
9.4% and 12.1%, respectively. The data portrays a grim pic-
ture of nutrition in Sindh, as 48% of children under the age
of five are stunted including 35% severely stunted. The inci-
dence of global acute malnutrition (GAM) in districts of
Tharparkar, Sanghar, and Qamber-Shahdadkot has been
found to be 22.7%, 16% and 13.8%, respectively. The num-
ber of overweight children under 5 years has almost doubled
since 2011 from 5% to 9.5% in 2018, the highest in KP-
NMD and Balochistan (18.7% and 16.7%, respectively), and
lowest in Sindh (5.2%) and ICT (5.8%). The number of
anemic children increased from 50.9% in 2001 to 61.9% in
2011 with a little decline in 2018 (53.7%). The frequency of
iron deficiency anemia is 28.6%, zinc deficiency is 18.6%,
and Vitamin A deficiency is 51.5%. Although undernutrition
in women of reproductive age declined from 18% in 2011 to
14% in 2018, the rate of overweight and obesity has
increased from 28% in 2011 to 37.8% in 2018. The survey
revealed that 12.7% Pakistani children develop one or other
functional disability, 1.2% in seeing, 1.5% in hearing, 2.6%
in walking, 4.5% in remembering, 8.5% in self-care and
5.6% in communication [73].
What needs to be done?
Eliminating child malnutrition is of fundamental significance
in the development of individuals and societies. To achieve
zero stunting, appropriate, and effective integrated nutrition
intervention programs are required, particularly during the
first 2 years of life. The multi-target-oriented intervention
strategies focusing on improvement in growth and
anthropometric indices should be applied. For this purpose,
supply of clean water, improved hygiene, sanitary condi-
tions, health care services, provision of an adequate and
nutritious diet and above all, the alleviation of poverty and
socioeconomic inequalities are essential. With globally
changing food environment, the people are now eating more
and more highly processed ready-made energy-dense fast
foods, which not only lack in many essential nutrients but
are also responsible for creating nutrient imbalances.
According to World Food Program, about 43% of Pakistanis
are facing the issue of food insecurity [74]. On the contrary,
it is estimated that people in Pakistan waste about 40% of
food, so there is an urgent need to address this mismanage-
ment of food resources. The World Bank Indicators revealed
that about 50% population in Pakistan lives below the pov-
erty line. The first millennium development goal (MDG) is
to reduce hunger. The Global Nutrition Targets for 2025 list
slashing the rate of child stunting as a major goal in achiev-
ing zero hunger [75]. Scaling Up Nutrition (SUN) stresses
that prevention of stunting should be projected in all future
sustainable development projects of member countries.
Suboptimal breastfeeding practices and micronutrient defi-
ciencies are believed to be the major risk factors for child
stunting and poor health status. Pakistan should not only
promote exclusive breastfeeding (EBF) but must also focus on
complementary feeding programs for children over 6 months.
Guidelines on complementary feeding practices, highlighting
their time of introduction and frequency of feeding be devel-
oped and introduced to boost their dietary impact to improve
the nutritional status of children. Suitable cheaper fortified
complementary nutritious foods, which are compatible with
local traditional recipes/dishes be developed and provided,
particularly to high-risk food insecure families.
We still have many critical limitations to understand the
physiological relationship between malnutrition, stunting,
wasting, infection, and illness. For developing nutrition
interventions, these issues are generally separated and dealt
in terms of policy, guidance, programing and financing.
Inadequate and imbalanced nutrition, in the early life of
infants and children, can have serious consequences on the
economic growth and development of nations. There are
many important questions, which still require precise
answers and clarifications, whether any intervention beyond
the first 1000 days, can have the advantage to catch-up
growth and height as well as other developmental markers
at a later stage. Also, at what time such interventions be
introduced and are there optimal formulations of ready-to-
use foods to promote optimal linear growth during and after
recovery from severe acute malnutrition [76]. According to
the Global Alliance for Improved Nutrition (GAIN), early
marriages and practices of feeding girls less than boys are
the key reasons for stunting in children. Boys are generally
given more food than girls, as a result the girls become mal-
nourished and stunted. They are not only unable to compete
with boys in many fields but also the malnourished mothers
cannot give birth to healthy babies [48].
The distinctive sociocultural, religious and demographic
circumstances in Pakistan drastically influence the health-
seeking behaviors of its population. The attitudes and tribal
practices related to maternal and infant nutrition in some
areas of Pakistan have strong influence on their dietary and
health practices. In order to fight against the traditions, cus-
toms and practices related to poor healthcare practices and
perceived behaviors, substantial endeavors are needed to
raise awareness in public, especially in women of rural areas
[77]. Culturally sensitive health improvement programs be
developed keeping in view the poverty and local customs
related to women’s decisions and practices. This may help
to boost the maternal and infant dietary practices [78]. To
improve the maternal health and nutritional status as well as
to reduce stunting in children, collaborative efforts are
required emphasizing not only at nutritional front but also
on a broad range of actions within various areas including
agriculture, environment, water, sanitation and hygiene, edu-
cation, poverty alleviation and social protection as well as
186 A. ALI
development of appropriate legislation and policies. It has
been suggested that malnutrition in Pakistan should be
viewed through a political-economy lens with overall devel-
opment outcomes [79]. Multisector strategies including both
nutrition-sensitive and nutrition-specific approaches with
strong political-will must be developed and implemented to
reduce malnutrition and child stunting in Pakistan. The gov-
ernment must understand the significance of investing today
in nutrition intervention programs, not only to slash the
issue of malnutrition and stunting but also to build a
healthy and productive nation for future. Nutrition strategies
should therefore be taken as net-investment for building
nation’s future [80].
In Pakistan, not only the poverty, food insecurity, poor
hygiene and sanitary conditions, infection and susceptibility
to diseases, maternal health, unequal gender relations,
unhealthy dietary patterns and sedentary lifestyle but also
high population growth rate, rapid urbanization, vulnerabil-
ity to safety and security situation as well as the absence of
a strong political will, further add to the complexity of
nutrition challenges. The data from a recent study suggests
that most of these factors are preventable. However, inte-
grated strategies to tackle these factors be developed in the
larger context of community based educational and nutrition
interventions [10]. Generally, the nutrition interventions tar-
get only some specific risk factors in isolation.
Comprehensive strategies are therefore required not only to
improve the socioeconomic and sanitary conditions but also
to increase the nutrient intake to reduce/prevent child
undernutrition in South Asia [54]. Cost-effective interven-
tions should be implemented at pre-conception, during
pregnancy and early postpartum stages to prevent the prob-
lems of stunting and wasting in children [81]. Nutritional
interventions, generally, have the potential to decrease stunt-
ing. Children living in urban slums face much higher risk of
stunting. Developing nutrition-specific interventions to
address the low birth weight (LBW) and child stunting in
such environments should consider the complexity of such
environment in terms of biological, social and political variables
[82]. We, however, still need to study the impact of multi-
sectorial interventions with both nutrition-specific and nutrition
sensitive programs and must consider the interests of all the
stakeholders, in the fight against malnutrition and stunting.
Despite improvements in various socioeconomic indica-
tors, the crisis of malnutrition remains a big challenge in
Pakistan. Because of huge variation in social and geograph-
ical inequalities, it has been suggested that food and nutri-
tion intervention programs should be developed and
implemented keeping in view the requirements and impacts
at district-level [83]. Based on the available data, the evi-
dence-based initiatives and target oriented nutrition inter-
ventions must be developed to boost the health and
nutritional status of various population groups to tackle the
root causes of malnutrition. One of the important popula-
tion group to target is the expecting mothers, as healthy
mothers will give birth to healthy children. The data from
NNS-2018 shows that rural mothers are more undernour-
ished than their urban counterparts and therefore must be
served with more diverse nutrient-dense diets. There is a
need to develop well-designed integrated multisector nutri-
tion interventions using rational approaches in addressing
the needs of the most vulnerable groups, which are more
susceptible to stunting because of poverty [84]. Several ini-
tiatives and intervention programs were introduced in the
past to improve the nutrition, hygiene and vaccination.
Because of these, the percentage of fully immunized children
has increased from 54 to 66% over the past 5 years. Diarrhea
is still one of the major problems in infants and children,
but it may not be the only problem as several other factors
may be associated in creating chronic malnutrition.
Improving hygiene and diet are important to immediately
address the issue of malnutrition and stunting. These pro-
grams, however, couldn’t achieve the targeted reduction in
child stunting rate under five. Similarly, over the past few
years Pakistan has made some success in lessening the pov-
erty rate, which has although helped to improve the diet
diversity but not stunting per se in the country [10].
Inadequate quantities and poor quality of complementary
foods, together with inappropriate feeding practices, present
another threat to children’s health and nutritional status in
Pakistan. Appropriate feeding practices are essential for sur-
vival, growth, and development in early life. However, no
correct data is available to identify the risk factors for poor
complementary feeding practices in Pakistani children.
There is a need to develop appropriate intervention pro-
grams to promote the intake of nutrient-dense fortified
complementary foods (FCF), particularly for the most vul-
nerable children and population groups within the local cul-
tural context [85,86]. Further studies are also needed to
establish the safety and efficacy of small-quantities of lipid-
based nutrient supplements (SQ-LNSs) in reducing the child
morbidity [87]. It is suggested that nutrition intervention
programs should be developed on evidence-based research
data together with community involvement and cultural
acceptability. In addition to this, the improper cooking prac-
tices in Pakistan trigger many nutrient losses such as vita-
min C, B-vitamins, thiamin and folate as well as minerals,
iron and iodine in finally prepared food/dishes. To meet the
nutrient needs of individuals, both the quality and variety of
food should be targeted, as the diet diversity is the only way
to provide all essential nutrients. In this regard a simple
strategy could be to fortify the home-made foods/dishes
with micronutrients and protein supplements to compensate
the limiting minerals, vitamins, essential amino acids and
fatty acids. Information about the complementary feeding
practices of communities are vital as they play crucial role
in the reduction of malnutrition and stunting. The practice
of breastfeeding has declined globally, whereas the introduc-
tion of solid foods at an early age (3–4 months) is getting
more into the system. This is because of cultural influences
and poor knowledge on child feeding practices. In addition
to other determinants, these inappropriate infant and child
feeding practices are seriously affecting their linear growth
and development and require intensive efforts on healthy
feeding behavior changes [88]. Complementary feeding prac-
tices include the introduction of solid and semi-solid foods
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 187
at the age of 6 months. As the child grows, both the quantity
as well as the frequency of feeding is increased. The high
prevalence of acute and chronic malnutrition in Kenya has
been shown to be associated with sub-optimal complemen-
tary feeding practices during the early days of life of infants
and young children, as only 22% of the Kenyan children
6–23 months old met the criteria for a minimum acceptable
diet [89]. Therefore, cultural beliefs and traditional diets and
recipes must be given due consideration while designing the
complimentary foods/diets and feeding practices [90].
Nutrition intervention strategies should, therefore, not only
focus on reducing the poverty, food insecurity, and environ-
mental issues but also on improving and maintaining a sus-
tainable economic development goal within the local culture.
Micronutrient deficiencies, such as iron and iodine, can
undermine the brain development in early life and therefore
supplementation of foods during pregnancy and infancy is
crucial to protect the infants and children against cognitive
impairment [91]. Dietary modifications with appropriate
food fortification and micronutrients supplementation,
linked with nutrition-sensitive interventions, can help to
tackle the malnutrition and stunting [14,92]. The current
evidence indicates that supplementary foods can have mod-
est impact in improving the nutrient intake in food insecure
and vulnerable people. It may also help to improve the qual-
ity of life and certain health concerns. However, the evi-
dence is inconsistent and limited for mortality risk, which
may be due to methodological issues and reported short-
term outcomes [93].
To build a healthy and productive nation, long-term plan-
ning is required that should not only alleviate the problems
of malnutrition and stunting in children but must also
improve their overall productivity in later life. Children repre-
sent the future of any country. With its current large popula-
tion of stunted children, the best investment, which Pakistan
can make is, to help them in getting out of this critical period
of their development by initiating multi-tier intervention pro-
grams. It’s therefore important not only to control and min-
imize the episodes of diarrhea in children by restricting the E.
coli contamination through investments in fecal waste man-
agement systems, provision of safe drinking water and other
relatively low-cost interventions in sanitary and hygiene
aspects, but also to have modifications at dietary, lifestyle,
educational and behavioral improvement fronts. Niazi et al.
[94] after reviewing the nutritional intervention programs in
Pakistan, initiated during the past years by the governmental
and non-governmental organizations, concluded that these
programs failed to achieve their targeted objectives in terms
of nutrition outcomes as they didn’t follow an integrated
approach in tackling the fundamental aspects of malnutrition
such as illiteracy, poverty, and socioeconomic deprivation
[94]. Food has been shown to have a far greater and robust
association with height-for-age value, when linked with envir-
onmental factors including water, sanitation and hygiene. He
suggested that multisector interventions, as compared to iso-
lated ones, will be more successful in reducing the malnutri-
tion in Pakistan [95]. Zaidi et al. [70] compared the policy
trajectories on Nutrition and Early Childhood Development
(ECD) in Pakistan. They observed that both Nutrition and
ECD policies shared common capacity restraints and are con-
fronting powerful barriers for horizontal coordination raising
apprehensions for their efficient execution. It is believed that
target oriented actions for child well-being require well-
planned actions and investments to reveal opportunities in
their governance areas for furthering such measures [70].
Both the government and international stakeholders influence
the infant and young child feeding (IYCF) policy in Pakistan,
which should be further strengthened through improved mul-
tisector collaboration [96]. Based on the available data from
the two latest major surveys (PDHS-2017–2018 and NNS-
2018) in Pakistan, it is therefore imperative that new appro-
priate multi-sectorial intervention strategies be developed to
combat malnutrition and stunting in Pakistani children. The
best strategy is that all the stakeholders, including govern-
ments, international agencies, private sector and civil societies
as well as the individuals should work collectively to fight
against poverty, hunger, malnutrition and stunting.
It is well recognized that the socioeconomic conditions of
the family affect the diet diversity and subsequently the
energy and nutrients intake in children. Socio-economically
deprived children consume nutritionally poor diets contain-
ing energy-dense foods and sugar-sweetened beverages and
have less nutrient-dense fruits and vegetables in their diet.
Understanding the determinants of dietary intake in children
with socioeconomic disparities can help to develop appropri-
ate targeted intervention strategies [97]. Ethiopia set up a
national target that at least 11% of children (6–23 months
age) should meet the minimum acceptable dietary intake
standards by 2016. However, only 7% of children came up to
the mark, much lower than the targeted figure. This was
attributed to individual behavior and community incentives,
suggesting that nutrition interventions should be developed
to tailor the needs of individuals within the larger commu-
nity framework [98]. Stunting has a strong link with eco-
nomic wellbeing and every 10% increase in per capita
income will result in decline of stunting by 3.2%. Stunting is
more common in poor households in rural areas and urban
slums, where children live under unhygienic environments,
with limited access to nutritious food. Pakistan is losing 3
percent of its GDP because of stunting in children every
year. It is estimated that every rupee invested in addressing
the malnutrition will result in benefits of 16 rupees. Well-
nourished children are 33% more likely to escape poverty as
adults [8,99]. Although the percentage of stunted children in
Pakistan has declined from 45% in 2012–2013 to 38% or
40.2% in 2017–2018, the rate of decline is very low i.e., only
0.5%. If we look at the example of Peru, who has successfully
reduced child stunting by 50% in merely 7 years (2007–2014)
through various interventions [67], Pakistan can also over-
come the problem of malnutrition and stunting if appropri-
ate intervention programs and policies are implemented.
Conclusion
Overall the child stunting in Pakistan has declined from
45% in 2012–2013 to 38% or 40.2% in 2017–2018. However,
188 A. ALI
the reduction rate is only 0.5%, which is very low. This may
be because of ineffective or inappropriate intervention pro-
grams and policies as they have mostly been addressing only
one issue at a time and not using the multi-sectorial
approaches to address the numerous determinants of stunt-
ing. It is therefore important to initiate cost-effective multi-
tiered interventions to implement at pre-conception, preg-
nancy and early postpartum stages to prevent the problems
of malnutrition, stunting and wasting in children. It is sug-
gested that to resolve the dilemma of malnutrition and
stunting, a holistic approach comprising nutrition and
WASH interventions, together with strategies to improve the
socioeconomic status be developed and implemented. To
ensure that such interventions are timely developed, imple-
mented and sustained, require the willingness, support and
cooperation of policymakers, governmental and non-govern-
mental organizations, other stakeholders and above all the
individual efforts and support.
Acknowledgments
I would like to thank School of Engineering, University of Guelph,
Guelph, ON, Canada, for providing me the platform to complete
this work.
Disclosure statement
No potential conflict of interest was reported by the author(s).
References
1. Webb P, Stordalen GA, Singh S, Wijesinha-Bettoni R, Shetty P,
Lartey A. Hunger and malnutrition in the 21st century. BMJ.
2018;361:k2238.
2. Ntenda P. Association of low birth weight with undernutrition
in preschool-aged children in malawi. Nutr J. 2019;18(1):51. doi:
10.1186/s12937-019-0477-8.
3. WHO. Malnutrition-key facts. In: Malnutrition-key facts.
Geneva: World Health Organization; 2018.
4. United Nations Children’s Fund (UNICEF), WHO, International
Bank for Reconstruction and Development/The World Bank.
Levels and trends in child malnutrition: key findings of the 2019
edition of the joint child malnutrition estimates. In: Levels and
trends in child malnutrition: key findings of the 2019 edition of
the joint child malnutrition estimates. Geneva: World Health
Organization; 2019. License: CC BY-NC-SA 3.0 IGO; 2019.
5. Development Initiatives. 2018 global nutrition report: shining a
light to spur action on nutrition. In: 2018 global nutrition report:
shining a light to spur action on nutrition; North Quay House,
Quay Side, Temple Back, Bristol, BS1 6FL, UK. Development
Initiatives, Poverty Research Ltd; 2018.
6. Hock RS, Bryce CP, Fischer L, First MB, Fitzmaurice GM, Costa
PT, Galler JR. Childhood malnutrition and maltreatment are
linked with personality disorder symptoms in adulthood: results
from a Barbados lifespan cohort. Psychiatry Res. 2018;269:301–8.
doi:10.1016/j.psychres.2018.05.085.
7. Pearce MS, Deary IJ, Young AH, Parker L. Growth in early life
and childhood IQ at age 11 years: the Newcastle Thousand
Families Study. Int J Epidemiol. 2005;34(3):673–7. doi:10.1093/
ije/dyi038.
8. McGovern ME, Krishna A, Aguayo VM, Subramanian SV. A
review of the evidence linking child stunting to economic out-
comes. Int J Epidemiol. 2017;46(4):1171–91. doi:10.1093/ije/
dyx017.
9. World Food Program (WFP). The economic consequences of
undernutrition in Pakistan: an assessment of losses. In: The eco-
nomic consequences of undernutrition in Pakistan: an assess-
ment of losses. Islamabad, Pakistan: World Food Program
(WFP), Islamabad, Pakistan; 2017.
10. Khan S, Zaheer S, Safdar NF. Determinants of stunting, under-
weight and wasting among children <5 years of age: evidence
from 2012–2013 Pakistan demographic and health survey. BMC
Public Health. 2019;19(1):358.
11. UNICEF. Press release on global nutrition report 2018. In: Press
release on global nutrition report 2018; 2018.
12. United Nations (UN). Worldometer, Pakistan population (live).
In: Worldometer, Pakistan population (live); 2020.
13. Asim M, Nawaz Y. Child malnutrition in Pakistan: evidence
from literature. Children (Basel). 2018;5(5):60. doi:10.3390/
children5050060.
14. Bhutta ZA, Salam RA, Das JK. Meeting the challenges of micro-
nutrient malnutrition in the developing world. Br Med Bull.
2013;106(1):7–17. doi:10.1093/bmb/ldt015.
15. World Health Organization and UNICEF. Who child growth
standards and the identification of severe acute malnutrition in
infants and children. In: Who child growth standards and the
identification of severe acute malnutrition in infants and chil-
dren; Department of Nutrition Health and Development, 20
Avenue Appia, 1121 Geneva 27. Switzerland: World Health
Organization and UNICEF; 2009.
16. Moreno Villares JM, Collado MC, Larque E, Leis Trabazo R,
Saenz De Pipaon M, Moreno Aznar LA. [The first 1000 days: an
opportunity to reduce the burden of noncommunicable diseases].
Nutr Hosp. 2019;36(1):218–32.
17. Woldeamanuel BT, Tesfaye TT. Risk factors associated with
under-five stunting, wasting, and underweight based on
Ethiopian Demographic Health Survey datasets in Tigray region,
ethiopia. J Nutr Metab. 2019;2019:1–11. doi:10.1155/2019/
6967170.
18. Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC, Peet
E, Sania A, Smith Fawzi MC, Ezzati M, Fawzi WW. Risk factors
for childhood stunting in 137 developing countries: a compara-
tive risk assessment analysis at global, regional, and country lev-
els. PLoS Med. 2016;13(11):e1002164. doi:10.1371/journal.pmed.
1002164.
19. Akhtar S. Malnutrition in south asia—a critical reappraisal. Crit
Rev Food Sci Nutr. 2016;56(14):2320–30. doi:10.1080/10408398.
2013.832143.
20. Tran NT, Nguyen LT, Berde Y, Low YL, Tey SL, Huynh D.
Maternal nutritional adequacy and gestational weight gain and
their associations with birth outcomes among Vietnamese
women. BMC Pregnancy Childbirth. 2019;19(1):468. doi:10.1186/
s12884-019-2643-6.
21. National Institute of Population Studies—NIPS/Pakistan, ICF.
Pakistan demographic and health survey 2017–18. In: Pakistan
demographic and health survey 2017–18. Islamabad, Pakistan:
NIPS/Pakistan and ICF; 2019. For assistance using downloaded
citations from The DHS Program, please visit http://dhsprogram.
com/publications/Citing-DHS-Publications.cfm. The 2017–2018
Pakistan Demographic and Health Survey (2017–2018 PDHS)
was implemented by the National Institute of Population Studies
(NIPS) under the aegis of the Ministry of National Health
Services, Regulations and Coordination, Islamabad, Pakistan. ICF
provided technical assistance through The DHS Program, a pro-
ject funded by the United States Agency for International
Development (USAID) that provides support and technical
assistance in the implementation of population and health sur-
veys in countries worldwide. Support for the survey was also
provided by the Department for International Development
(DFID) and the United Nations Population Fund (UNFPA).
22. Beluska-Turkan K, Korczak R, Hartell B, Moskal K, Maukonen J,
Alexander DE, Salem N, Harkness L, Ayad W, Szaro J, et al.
Nutritional gaps and supplementation in the first 1000 days.
Nutrients. 2019;11(12):2891. doi:10.3390/nu11122891.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 189
23. de Onis M, Branca F. Childhood stunting: a global perspective.
Matern Child Nutr. 2016;12(Suppl 1):12–26. doi:10.1111/mcn.
12231.
24. Quinn MK, Smith ER, Williams PL, Urassa W, Shi J, Msamanga
G, Fawzi WW, Sudfeld CR. The effect of maternal multiple
micronutrient supplementation on female early infant mortality
is fully mediated by increased gestation duration and intrauterine
growth. J Nutr. 2019;150(2):356–63. doi:10.1093/jn/nxz246.
25. Akombi BJ, Agho KE, Hall JJ, Merom D, Astell-Burt T, Renzaho
A. Stunting and severe stunting among children under-5 years in
Nigeria: a multilevel analysis. BMC Pediatr. 2017;17(1):15. doi:
10.1186/s12887-016-0770-z.
26. Akombi BJ, Agho KE, Renzaho AM, Hall JJ, Merom DR. Trends
in socioeconomic inequalities in child undernutrition: evidence
from Nigeria Demographic and Health Survey (2003–2013).
PLoS One. 2019;14(2):e0211883. doi:10.1371/journal.pone.
0211883.
27. Rytter MJH, Kolte L, Briend A, Friis H, Christensen VB. The
immune system in children with malnutrition—a systematic
review. PLoS One. 2014;9(8):e105017. doi:10.1371/journal.pone.
0105017.
28. Walson JL, Berkley JA. The impact of malnutrition on childhood
infections. Curr Opin Infect Dis. 2018;31(3):231–6.
29. Millward DJ. Nutrition, infection and stunting: the roles of defi-
ciencies of individual nutrients and foods, and of inflammation,
as determinants of reduced linear growth of children. Nutr Res
Rev. 2017;30(1):50–72. doi:10.1017/S0954422416000238.
30. Kvissberg MA, Dalvi PS, Kerac M, Voskuijl W, Berkley JA,
Priebe MG, Bandsma R. Carbohydrate malabsorption in acutely
malnourished children and infants: a systematic review. Nutr
Rev. 2016;74(1):48–58. doi:10.1093/nutrit/nuv058.
31. Ibrahim MK, Zambruni M, Melby CL, Melby PC. Impact of
childhood malnutrition on host defense and infection. Clin
Microbiol Rev. 2017;30(4):919–71. doi:10.1128/CMR.00119-16.
32. Xie W, Jensen SKG, Wade M, Kumar S, Westerlund A, Kakon
SH, Haque R, Petri WA, Nelson CA. Growth faltering is associ-
ated with altered brain functional connectivity and cognitive out-
comes in urban Bangladeshi children exposed to early adversity.
BMC Med. 2019;17(1):199. doi:10.1186/s12916-019-1431-5.
33. Vonaesch P, Randremanana R, Gody J-C, Collard J-M, Giles-
Vernick T, Doria M, Vigan-Womas I, Rubbo P-A, Etienne A,
Andriatahirintsoa EJ, et al. Identifying the etiology and patho-
physiology underlying stunting and environmental enteropathy:
study protocol of the AFRIBIOTA project. BMC Pediatr. 2018;
18(1):236. doi:10.1186/s12887-018-1189-5.
34. Chandrasekhar S, Aguayo VM, Krishna V, Nair R. Household
food insecurity and children’s dietary diversity and nutrition in
India. Evidence from the comprehensive nutrition survey in
Maharashtra. Matern Child Nutr. 2017;13(Suppl 2):e12447. doi:
10.1111/mcn.12447.
35. Christian AK, Marquis GS, Colecraft EK, Lartey A, Soueida R.
Household food insecurity but not dietary diversity is associated
with children’s mean micronutrient density adequacy in rural
communities across Ghana. Nutrition. 2019;65:97–102. doi:10.
1016/j.nut.2019.03.006.
36. Moradi S, Mirzababaei A, Mohammadi H, Moosavian SP, Arab
A, Jannat B, Mirzaei K. Food insecurity and the risk of undernu-
trition complications among children and adolescents: a system-
atic review and meta-analysis. Nutrition. 2019;62:52–60. doi:10.
1016/j.nut.2018.11.029.
37. FAO, IFAD, UNICEF, and WHO. The state of food security and
nutrition in the world 2018. Building climate resilience for food
security and nutrition. In: The state of food security and nutri-
tion in the world 2018. Building climate resilience for food
security and nutrition. Rome: FAO; 2018.
38. Ministry of Finance, Government of Pakistan. Pakistan economic
survey 2018–2019. In: Pakistan economic survey 2018–2019.
Islamabad, Pakistan: Ministry of Finance, Government of
Pakistan; 2019.
39. Government of Pakistan, UNICEF, and UK Aid. Cost of the diet
analysis report in pakistan. In: Cost of the diet analysis report in
Pakistan. Islamabad, Pakistan: Government of Pakistan,
UNICEF, and UK Aid; 2018.
40. USAID. Food assistance fact sheet Pakistan. In: Food assistance
fact sheet Pakistan; 2019.
41. Global Alliance for Improved Nutrition. Annual report 2016–17.
In: Annual report 2016–17; Headquarters. Geneva, Switzerland:
Global Alliance for Improved Nutrition; 2017.
42. Weaver LJ, Hadley C. Moving beyond hunger and nutrition: a
systematic review of the evidence linking food insecurity and
mental health in developing countries. Ecol Food Nutr. 2009;
48(4):263–84. doi:10.1080/03670240903001167.
43. Rahman A, Lovel H, Bunn J, Iqbal Z, Harrington R. Mothers’
mental health and infant growth: a case–control study from
Rawalpindi, Pakistan. Child Care Health Dev. 2004;30(1):21–7.
doi:10.1111/j.1365-2214.2004.00382.x.
44. Maselko J, Bates L, Bhalotra S, Gallis JA, O’Donnell K, Sikander
S, Turner EL. Socioeconomic status indicators and common
mental disorders: evidence from a study of prenatal depression
in Pakistan. SSM—Popul Health. 2018;4:1–9. doi:10.1016/j.
ssmph.2017.10.004.
45. Kismul H, Acharya P, Mapatano MA, Hatløy A. Determinants of
childhood stunting in the Democratic Republic of Congo: further
analysis of demographic and health survey 2013–14. BMC Public
Health. 2018;18(1):74.
46. Woodruff BA, Wirth JP, Ngnie-Teta I, Beauliere JM, Mamady D,
Ayoya MA, Rohner F. Determinants of stunting, wasting, and
anemia in Guinean preschool-age children: an analysis of DHS
data from 1999, 2005, and 2012. Food Nutr Bull. 2018;39(1):
39–53. doi:10.1177/0379572117743004.
47. Utami N, Rachmalina R, Irawati A, Sari K, Rosha BC, Amaliah
N. Short birth length, low birth weight and maternal short stat-
ure are dominant risks of stunting among children aged 0–23
months: evidence from Bogor Longitudinal Study on Child
Growth and Development, Indonesia. Malay J Nutr. 2018;24:
11–23.
48. Beal T, Tumilowicz A, Sutrisna A, Izwardy D, Neufeld LM. A
review of child stunting determinants in Indonesia. Matern
Child Nutr. 2018;14(4):e12617. doi:10.1111/mcn.12617.
49. Mushtaq MU, Gull S, Khurshid U, Shahid U, Shad MA, Siddiqui
AM. Prevalence and socio-demographic correlates of stunting
and thinness among Pakistani primary school children. BMC
Public Health. 2011;11(1):790. doi:10.1186/1471-2458-11-790.
50. Janjua NZ, Iqbal R, Mahmood B. Association of socioeconomic
position with under- and overnutrition in Pakistan. Ann Epidemiol.
2011;21(12):884–91. doi:10.1016/j.annepidem.2011.08.006.
51. Shafiq A, Hussain A, Asif M, Hwang J, Jameel A, Kanwel S. The
effect of “women’s empowerment”on child nutritional status in
Pakistan. Int J Environ Res Public Health. 2019;16(22):4499. doi:
10.3390/ijerph16224499.
52. Tette EMA, Sifah EK, Nartey ET. Factors affecting malnutrition
in children and the uptake of interventions to prevent the condi-
tion. BMC Pediatr. 2015;15(1):189. doi:10.1186/s12887-015-0496-3.
53. Islam MR, Rahman MS, Rahman MM, Nomura S, de Silva A,
Lanerolle P, Jung J, Rahman MM. Reducing childhood malnutri-
tion in Bangladesh: the importance of addressing socio-economic
inequalities. Public Health Nutr. 2020;23(1):72–82. doi:10.1017/
S136898001900140X.[Mismatch]
54. Kim R, Mejia-Guevara I, Corsi DJ, Aguayo VM, Subramanian
SV. Relative importance of 13 correlates of child stunting in
South Asia: insights from nationally representative data from
Afghanistan, Bangladesh, India, Nepal, and Pakistan. Soc Sci
Med. 2017;187:144–54. doi:10.1016/j.socscimed.2017.06.017.
55. Aguayo VM, Nair R, Badgaiyan N, Krishna V. Determinants of
stunting and poor linear growth in children under 2 years of age
in India: an in-depth analysis of Maharashtra’s Comprehensive
Nutrition Survey. Matern Child Nutr. 2016;12(Suppl 1):121–40.
doi:10.1111/mcn.12259.
190 A. ALI
56. Watson S, Gong YY, Routledge M. Interventions targeting child
undernutrition in developing countries may be undermined by
dietary exposure to aflatoxin. Crit Rev Food Sci Nutr. 2015;
57(9):1963–75. doi:10.1080/10408398.2015.1040869.[Mismatch]
57. Kartin A, Subagio HW, Hadisaputro S, Kartasurya MI,
Suhartono S, Budiyono B. Pesticide exposure and stunting
among children in agricultural areas. Int J Occup Environ Med.
2019;10(1):17–29. doi:10.15171/ijoem.2019.1428.
58. WaterAid. Facts and statistics—WaterAid Pakistan. In: Facts and
statistics—WaterAid Pakistan. Islamabad, Pakistan: WaterAid
Pakistan; 2019.
59. PCRWR, Resources PCoRiW (PCRWR). Water quality status of
major cities of Pakistan 2015–16. In: Technology MoSa editor.
Water quality status of major cities of Pakistan 2015–16.
Islamabad, Pakistan: PCRWR, Ministry of Science and
Technology; 2016.
60. Gera T, Shah D, Sachdev HS. Impact of water, sanitation and
hygiene interventions on growth, non-diarrheal morbidity and
mortality in children residing in low- and middle-income coun-
tries: a systematic review. Indian Pediatr. 2018;55(5):381–93. doi:
10.1007/s13312-018-1279-3.
61. Cumming O, Cairncross S. Can water, sanitation and hygiene
help eliminate stunting? Current evidence and policy implica-
tions. Matern Child Nutr. 2016;12(Suppl 1):91–105. doi:10.1111/
mcn.12258.
62. Ngure FM, Reid BM, Humphrey JH, Mbuya MN, Pelto G,
Stoltzfus RJ. Water, sanitation, and hygiene (wash), environmen-
tal enteropathy, nutrition, and early child development: making
the links. Ann NY Acad Sci. 2014;1308(1):118–28. doi:10.1111/
nyas.12330.
63. Syed S, Yeruva S, Herrmann J, Sailer A, Sadiq K, Iqbal N, Kabir
F, Ahmed K, Qureshi S, Moore SR, et al. Environmental enter-
opathy in undernourished Pakistani children: clinical and histo-
morphometric analyses. Am J Trop Med Hyg. 2018;98(6):
1577–84. doi:10.4269/ajtmh.17-0306.
64. Iqbal NT, Syed S, Sadiq K, Khan MN, Iqbal J, Ma JZ, Umrani F,
Ahmed S, Maier EA, Denson LA, et al. Study of environmental
enteropathy and malnutrition (seem) in Pakistan: protocols for
biopsy based biomarker discovery and validation. BMC Pediatr.
2019;19(1):247. doi:10.1186/s12887-019-1564-x.
65. Harper KM, Mutasa M, Prendergast AJ, Humphrey J, Manges
AR. Environmental enteric dysfunction pathways and child
stunting: a systematic review. PLoS Negl Trop Dis. 2018;12(1):
e0006205. doi:10.1371/journal.pntd.0006205.
66. Budge S, Parker AH, Hutchings PT, Garbutt C. Environmental
enteric dysfunction and child stunting. Nutr Rev. 2019;77(4):
240–53. doi:10.1093/nutrit/nuy068.
67. Zambruni M, Ochoa TJ, Somasunderam A, Cabada MM,
Morales ML, Mitreva M, Rosa BA, Acosta GJ, Vigo NI, Riveros
M, et al. Stunting is preceded by intestinal mucosal damage and
microbiome changes and is associated with systemic inflamma-
tion in a cohort of Peruvian infants. Am J Trop Med Hyg. 2019;
101(5):1009–17. doi:10.4269/ajtmh.18-0975.
68. Bhutta Z, Soofi S, Zaidi S, Habib A, Hussain M. Pakistan
national nutrition survey, 2011. In: Pakistan National Nutrition
Survey, 2011. Islamabad, Pakistan: Agha Khan University,
Government of Pakistan, UNICEF; 2011.
69. United Nations Children’s Fund (UNICEF), World Health
Organization IBfRaD, Bank. TW. Levels and trends in child mal-
nutrition: key findings of the 2019 edition of the joint child mal-
nutrition estimates. In: Levels and trends in child malnutrition:
key findings of the 2019 edition of the joint child malnutrition
estimates. Geneva: World Health Organization; 2019. Licence:
CC BY-NC-SA 3.0 IGO.; 2019.
70. Zaidi S, Bhutta Z, Hussain SS, Rasanathan K. Multisector gov-
ernance for nutrition and early childhood development: overlap-
ping agendas and differing progress in Pakistan. BMJ Glob
Health. 2018;3(Suppl 4):e000678. doi:10.1136/bmjgh-2017-000678.
71. Benedict RK, Craig HC, Torlesse H, Stoltzfus RJ. Trends and
predictors of optimal breastfeeding among children 0–23
months, South Asia: analysis of national survey data. Matern
Child Nutr. 2018;14(S4):e12698. doi:10.1111/mcn.12698.
72. WHO/UNICEF. Global nutrition targets 2025: breastfeeding pol-
icy brief (WHO/NMH/NHD/14.7). In: Global nutrition targets
2025: breastfeeding policy brief (WHO/NMH/NHD/14.7).
Geneva: World Health Organization; 2014.
73. Government of Pakistan, UNICEF. National nutrition survey
2018—key findings report: a summary of the key insights and
statistics. In: National nutrition survey 2018—key findings
report: a summary of the key insights and statistics. Islamabad,
Pakistan: Ministry of National Health Services, Government of
Pakistan; 2019.
74. World Food Programme (WFP). What the World Food
Programme is doing in Pakistan. In: What the World Food
Programme is doing in Pakistan. Islamabad, Pakistan: WFP;
2018.
75. World Health Organization (WHO). Global nutrition targets
2025: stunting policy brief. In: Global nutrition targets 2025:
stunting policy brief. WHO reference number: WHO/NMH/
NHD/143; Department of Nutrition for Health and
Development. Geneva, Switzerland: World Health Organization;
2014.
76. Angood C, Khara T, Dolan C, Berkley JA, WSTI Group.
Research priorities on the relationship between wasting and
stunting. PLoS One. 2016;11(5):e0153221. doi:10.1371/journal.
pone.0153221.
77. Anwar M, Green J, Norris P. Health-seeking behaviour in
Pakistan: a narrative review of the existing literature. Public
Health. 2012;126(6):507–17. doi:10.1016/j.puhe.2012.02.006.
78. Dykes F, Lhussier M, Bangash S, Zaman M, Lowe N. Exploring
and optimising maternal and infant nutrition in North West
Pakistan. Midwifery. 2012;28(6):831–5. doi:10.1016/j.midw.2011.
09.013.
79. Bhutta ZA, Gazdar H, Haddad L. Seeing the unseen: breaking
the logjam of undernutrition in Pakistan. IDS Bull. 2013;44(3):
1–9. doi:10.1111/1759-5436.12025.
80. Das JK, Achakzai ABK, Bhutta ZA. Stop stunting: Pakistan per-
spective on how this could be realized. Matern Child Nutr. 2016;
12(Suppl 1):253–6. doi:10.1111/mcn.12285.
81. Harding KL, Aguayo VM, Webb P. Hidden hunger in South
Asia: a review of recent trends and persistent challenges. Public
Health Nutr. 2018;21(4):785–95. doi:10.1017/S1368980017003202.
82. Goudet SM, Bogin BA, Madise NJ, Griffiths PL. Nutritional
interventions for preventing stunting in children (birth to 59
months) living in urban slums in low- and middle-income coun-
tries (LMIC). Cochrane Database Syst Rev. 2019;6:Cd011695.
83. Cesare MD, Bhatti Z, Soofi SB, Fortunato L, Ezzati M, Bhutta
ZA. Geographical and socioeconomic inequalities in women and
children’s nutritional status in Pakistan in 2011: an analysis of
data from a nationally representative survey. Lancet Glob Health.
2015;3(4):e229–e239. doi:10.1016/S2214-109X(15)70001-X.
84. Angdembe MR, Dulal BP, Bhattarai K, Karn S. Trends and pre-
dictors of inequality in childhood stunting in Nepal from 1996
to 2016. Int J Equity Health. 2019;18(1):42. doi:10.1186/s12939-
019-0944-z.
85. Na M, Aguayo VM, Arimond M, Stewart CP. Risk factors of
poor complementary feeding practices in Pakistani children aged
6–23 months: a multilevel analysis of the demographic and
health survey 2012–2013. Matern Child Nutr. 2017;13(S2):
e12463. doi:10.1111/mcn.12463.
86. Neufeld LM, Osendarp SJ, Gonzalez W. Fortification of comple-
mentary foods: a review of products and program delivery.
Nestle Nutr Inst Workshop Ser. 2017;87:115–29.
87. Adu-Afarwuah S, Young RR, Lartey A, Okronipa H, Ashorn P,
Ashorn U, Oaks BM, Dewey KG. Supplementation with small-
quantity lipid-based nutrient supplements does not increase child
morbidity in a semiurban setting in Ghana: a secondary outcome
noninferiority analysis of the international lipid-based nutrient
supplements (ILINS)–dyad randomized controlled trial. J Nutr.
2020;150(2):382–93. doi:10.1093/jn/nxz243.
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION 191
88. White JM, B
egin F, Kumapley R, Murray C, Krasevec J.
Complementary feeding practices: current global and regional
estimates. Matern Child Nutr. 2017;13(S2):e12505. doi:10.1111/
mcn.12505.
89. Ahoya B, Kavle JA, Straubinger S, Gathi CM. Accelerating pro-
gress for complementary feeding in Kenya: key government
actions and the way forward. Matern Child Nutr. 2019;15(S1):
e12723. doi:10.1111/mcn.12723.
90. Abeshu MA, Lelisa A, Geleta B. Complementary feeding: review
of recommendations, feeding practices, and adequacy of home-
made complementary food preparations in developing coun-
tries—lessons from Ethiopia. Front Nutr. 2016;3:41. doi:10.3389/
fnut.2016.00041.
91. Prado EL, Dewey KG. Nutrition and brain development in early
life. Nutr Rev. 2014;72(4):267–84. doi:10.1111/nure.12102.
92. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S,
Webb P, Lartey A, Black RE. Evidence-based interventions for
improvement of maternal and child nutrition: what can be done
and at what cost? Lancet. 2013;382(9890):452–77. doi:10.1016/
S0140-6736(13)60996-4.
93. Visser J, McLachlan MH, Maayan N, Garner P. Community-
based supplementary feeding for food insecure, vulnerable and
malnourished populations—an overview of systematic reviews.
Cochrane Database Syst Rev. 2018;11:Cd010578.
94. Niazi A, Niazi S, Baber A. Nutritional programmes in Pakistan:
a review. J Med Nutr Nutraceut. 2012;1(2):98–100. doi:10.4103/
2278-019X.101297.
95. Ali M. Multisectoral approach to nutrition in Pakistan. J Water
Sanit Hyg Dev. 2019;9(1):152–63. doi:10.2166/washdev.2018.122.
96. Mahmood H, Suleman Y, Hazir T, Akram DS, Uddin S, Dibley
MJ, Abassi S, Shakeel A, Kazmi N, Thow AM. Overview of the
infant and young child feeding policy environment in Pakistan:
Federal, Sindh and Punjab context. BMC Public Health. 2017;
17(S2):474. doi:10.1186/s12889-017-4341-5.
97. Zarnowiecki DM, Dollman J, Parletta N. Associations between
predictors of children’s dietary intake and socioeconomic pos-
ition: a systematic review of the literature. Obes Rev. 2014;15(5):
375–91.
98. Tassew AA, Tekle DY, Belachew AB, Adhena BM. Factors affect-
ing feeding 6–23 months age children according to minimum
acceptable diet in Ethiopia: a multilevel analysis of the Ethiopian
Demographic Health Survey. PLoS One. 2019;14(2):e0203098.
doi:10.1371/journal.pone.0203098.
99. Fenn B, Sangrasi GM, Puett C, Trenouth L, Pietzsch S. The
REFANI Pakistan study—a cluster randomised controlled trial of
the effectiveness and cost-effectiveness of cash-based transfer
programmes on child nutrition status: study protocol. BMC
Public Health. 2015;15(1):1044. doi:10.1186/s12889-015-2380-3.
192 A. ALI
