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Path analyses of risk factors for linear growth faltering in four prospective cohorts of young children in Ghana, Malawi and Burkina Faso
  1. Elizabeth L Prado1,
  2. Elizabeth Yakes Jimenez2,
  3. Stephen Vosti3,
  4. Robert Stewart4,
  5. Christine P Stewart1,
  6. Jérôme Somé1,5,
  7. Anna Pulakka6,
  8. Jean Bosco Ouédraogo5,
  9. Harriet Okronipa1,
  10. Eugenia Ocansey1,
  11. Brietta Oaks1,7,
  12. Kenneth Maleta8,
  13. Anna Lartey9,
  14. Emma Kortekangas10,
  15. Sonja Y Hess1,
  16. Kenneth Brown1,11,
  17. Jaden Bendabenda8,
  18. Ulla Ashorn10,
  19. Per Ashorn10,12,
  20. Mary Arimond13,
  21. Seth Adu-Afarwuah9,
  22. Souheila Abbeddou1,
  23. Kathryn Dewey1
  1. 1 Department of Nutrition, University of California Davis, Davis, California, USA
  2. 2 Departments of Pediatrics and Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
  3. 3 Department of Agricultural and Resource Economics, University of California Davis, 2135 Social Sciences and Humanities, Davis, California, USA
  4. 4 Department of Psychiatry, University of Malawi College of Medicine, Blantyre, Southern Region, Malawi
  5. 5 Institut de Recherche en Sciences de la Santé, Avenue de la Liberté, Burkina Faso
  6. 6 Department of Public Health, University of Turku and Turku University Hospital, Finland, Turku
  7. 7 Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, Rhode Island, USA
  8. 8 School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
  9. 9 Department of Nutrition and Food Science, University of Ghana, Legon, Ghana
  10. 10 Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, University of Tampere, Tampere, Finland
  11. 11 Bill & Melinda Gates Foundation, Seattle, Washington, USA
  12. 12 Department of Paediatrics, Tampere University Hospital, Tampere, Finland
  13. 13 Intake, Center for Dietary Assessment, Seattle, Washington, USA
  1. Correspondence to Dr Elizabeth L Prado; elprado{at}


Stunting prevalence is an indicator of a country’s progress towards United Nations’ Sustainable Development Goal 2, which is to end hunger and achieve improved nutrition. Accelerating progress towards reducing stunting requires a deeper understanding of the factors that contribute to linear growth faltering. We conducted path analyses of factors associated with 18-month length-for-age z-score (LAZ) in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements Project in Ghana (n=1039), Malawi (n=684 and 1504) and Burkina Faso (n=2619). In two cohorts, women were enrolled during pregnancy. In two other cohorts, infants were enrolled at 6 or 9 months. We examined the association of 42 indicators of environmental, maternal, caregiving and child factors with 18-month LAZ. Using structural equation modelling, we examined direct and indirect associations through hypothesised mediators in each cohort. Out of 42 indicators, 2 were associated with 18-month LAZ in three or four cohorts: maternal height and body mass index (BMI). Six factors were associated with 18-month LAZ in two cohorts: length for gestational age z-score (LGAZ) at birth, pregnancy duration, improved household water, child dietary diversity, diarrhoea incidence and 6-month or 9-month haemoglobin concentration. Direct associations were more prevalent than indirect associations, but 30%–62% of the associations of maternal height and BMI with 18-month LAZ were mediated by LGAZ at birth. Factors that were not associated with LAZ were maternal iron status, illness and inflammation during pregnancy, maternal stress and depression, exclusive breast feeding during 6 months post partum, feeding frequency and child fever, malaria and acute respiratory infections. These findings may help in identifying interventions to accelerate progress towards reducing stunting; however, much of the variance in linear growth status remained unaccounted for by these 42 individual-level factors, suggesting that community-level changes may be needed to achieve substantial progress.

  • Linear growth
  • stunting
  • path analysis
  • prospective cohort
  • Africa
  • pregnancy
  • childhood

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Handling editor Sanni Yaya

  • Contributors EPL, SAV, KM, AL, KHB, UA, PA and KGD contributed to study design. EYJ, RCS, CSP, JSW, AP, JBO, HO, EO, BMO, EM, SYH, JB, MA, SAA and SA contributed to data acquisition. EP conducted data analysis and drafted the manuscript. All authors critically revised the manuscript and approved the final version.

  • Funding This publication is based on research funded in part by a grant to the University of California, Davis from the Bill & Melinda Gates Foundation (OPP49817), with additional funding from the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID) under terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360. The findings and conclusions contained within are those of the authors.

  • Competing interests KHB has worked as a consultant and later as employee for the Bill & Melinda Gates Foundation.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approval for the iLiNS-ZINC study procedures was obtained from the Institutional Review Board of the University of California Davis and the Comité d’Ethique Institutionnel du Centre Muraz, Bobo Dioulasso. The study was registered with the U.S. National Institute of Health as a clinical trial (; NCT00944281). Ethical approval for the iLiNS-DOSE and iLiNS-DYAD-M study procedures was obtained from the University of Malawi, College of Medicine Research and Ethics Committee and the Ethics Committee at Tampere University Hospital District, Finland. These studies were also registered with the U.S. National Institute of Health as a clinical trial (; NCT00945698 and NCT01239693). Ethical approval for the iLiNS-DYAD-G study procedures was obtained from the Ethics Committees at the University of California, Davis, the Ghana Health Service, and the University of Ghana Noguchi Memorial Institute for Medical Research (; NCT00970866).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data requests may be made by contacting the corresponding author, and will be available conditional on approval by the iLiNS Project steering committee.

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