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As a pediatric gastroenterologist with a research focus on nutrition and stunting, our new prime minister Imran Khan’s inaugural speech caught my attention.

How heartening for me to hear the importance of child growth and development being addressed at a national level and in such detail.

Stunting is a devastating complication of undernutrition and can be defined simply as being shorter than the average height for your age according to the World Health Organization (WHO) child growth standards.

Special report: Malnutrition and stunting in Pakistan

The effects of this condition were beautifully explained by Khan, showing the stark differences between the brain image of a healthy, well-grown two-year-old and a stunted, undernourished child of the same age.

It was a graphic visual representation of the fact that nutrition not only affects your weight and height but also affects your intellectual abilities and therefore our nation’s potential success.

What stunting does

Early last year in a special Dawn supplement, Dr. Zulfiqar A. Bhutta, an international expert in child nutrition, had said that “with nearly 44 per cent of children stunted, if the government fails to reverse the situation, Pakistan is on a dangerous downward trajectory”.

Universal healthy nutrition, and therefore stunting, is also linked to all of the Sustainable Development Goals, which include incredible challenges to the world, including an end to hunger and improving nutrition for all people by 2030.

According to a WHO policy brief, stunting leads to reduced child development, and if it occurs before the age of two years it predicts poorer intelligence and school performance in later childhood and adolescence.

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It also has significant educational and economic consequences at the individual, household and community levels with implications on a country’s national GDP.

This year, the Pakistan Demographic and Health Survey has estimated that the overall rate of stunting in children under the age of five in Pakistan has decreased from 45pc in 2012-2013 to 38pc in 2017-2018.

However, in rural Sindh 61.6pc of children are stunted, the highest percentage in the country.

Thus, if we as an emerging economy want to move forward as a nation, we have to invest in our country’s future: our children.

Beyond diarrhea and malnutrition

However, while the solution seems easy enough — just provide our children with more food and good water — like many of life’s serious issues, the problem is more complex as you delve into it.

As our prime minister stated, Pakistan is among the top five countries worldwide where children under the age of five are dying because of diseases caused by drinking dirty water, namely diarrhea.

In order to tackle this shocking statistic, in the past decade many researchers around the world have worked towards reducing the burden of childhood diarrheal disease, specifically in resource-limited countries.

Related: State of healthcare in Pakistan

Their work did culminate in a reduction of diarrheal disease; however, the mortality (death) rates of children under five did not change as much as was expected.

Clearly, diarrhea is not the only problem and the WHO has estimated that nutrition-related factors contribute to almost half of all deaths among children under five worldwide.

As we have learned through similar research efforts though, providing good nutrition also does not solve the problem — and if we use stunting as a clinical indicator of undernutrition, approximately half of all Pakistani children are stunted despite several nutritional and hygiene-related interventions.

The fact that improving nutrition and diarrhea did not solve the problem led to the realisation that there must be a problem afflicting our nation’s children on a biologic level.

Major cause of stunting

It was learnt that despite adequate nutrition, hygiene and vaccination, children residing in low-resource countries, including those in Pakistan, were still stunted and also had poor responses to vaccines — which meant they were susceptible to contract preventable diseases.

It was hypothesised that there must be an underlying condition that is related to both diarrhea and stunting, which led to studying a condition of the small gut called Environmental Enteropathy (EE).

EE is a disease of the gut that primarily affects children living in resource-limited countries. It is thought to be a major cause of stunting and impairment of intellectual ability.

In light of these hypotheses, there are currently three large studies on environmental enteropathy being conducted in Pakistan, Zambia and Bangladesh.

These studies hope to discover the underlying cause of EE and to thereby design management strategies that would result in the eradication or at least help control this devastating condition.

Here are some of the few early insights that researchers have found to date:

  • Researchers in St. Louis, United States, have found that in Bangladeshi children with severe acute malnutrition there was a significant immaturity of the normal bacteria present in our gut that usually have a protective immunological effect.


  • They also found that this immaturity was also evident in less severe forms of malnutrition in children and correlated with weight and height measurements.


  • Their discoveries indicate that measuring bacterial maturity could serve as a testing strategy to identify states of malnutrition and also to study the benefit provided by interventions, such as food supplements and certain medications.


  • Other interesting work has found new insights into differentiating between common features found in EE and celiac disease.


Researchers found that while both diseases damage the gut architecture, this damage is more severe in celiac disease.

They also found that certain cell types that help our body fight infection, white blood cells called T lymphocytes, are more prominent in EE than in celiac disease.

I am extremely excited that Prime Minister Khan has highlighted tackling the problem of undernutrition in our children as a national priority and I look forward to the day when all children regardless of where they live in the world have the chance to live and develop to their full potential.

I strongly believe that Pakistan-led international partnerships, research and local empowerment are essential in working towards a healthy future for children in any country and I am proud to be part of that process in Pakistan.

Marium Naveed Khan, a recent medical graduate of the Aga Khan University and a research assistant at the University of Virginia, is a part of our research team and assisted in drafting this article.


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