Piecing together the stunting puzzle: a framework for attributable factors of child stunting.

Reducing the burden of stunting in childhood is critical to improving health in low- and middle-income settings. However, because many aetiologies underlie linear growth failure, stunting has proved difficult to prevent and reverse. Understanding the contributions these aetiologies make to the burden of stunting can help the development of targeted, effective interventions. To begin to frame these causes, a qualitative and a quantitative framework of the primary drivers of stunting in low-resource settings were developed. Population attributable fractions (PAF) were estimated to inform the quantitative framework. According to these estimates, infectious diseases were responsible for large attributable fractions in all settings, and a combination of dietary indicators also comprised a large fraction in Africa. However, the PAF calculation was found to have several limitations, including a requirement for a binary outcome and sensitivity to confounding, which necessitate broad interpretation of the results. More robust tools to model complex causality are needed in order to understand the causal aetiology of stunting.