• Mayya Husseini, Momodou K Darboe, Sophie E Moore, Helen M Nabwera, and Andrew M Prentice.
• MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Atlantic Boulevard, Fajara, Banjul, The Gambia.
• Bmc Med. 2018 Nov 1; 16 (1): 199199.

BackgroundChildhood malnutrition remains highly prevalent in low-income countries, and a 40% reduction in under-5 year stunting is WHO's top Global Target 2025. Disappointingly, meta-analyses of intensive nutrition interventions reveal that they generally have low efficacy at improving growth. Unhygienic environments also contribute to growth failure, but large WASH Benefits and SHINE trials of improved water, sanitation and hygiene (WASH) recently reported no benefits to child growth.MethodsTo explore the thresholds of socio-economic status (SES) and living standards associated with malnutrition, we exploited a natural experiment in which the location of our research centre within a remote rural village created a wide diversity of wealth, education and housing conditions within the same ecological setting and with free health services to all. A composite SES score was generated by grading occupation, education, income, water and sanitation, and housing and families were allocated to 5 groups (SES1 = highest). SES ranged from very poor subsistence-farming villagers to post graduate staff with overseas training. Nutritional status at 24 m was obtained from clinic records for 230 children and expressed relative to WHO Growth Standards.ResultsHeight-for-age (HAZ) and weight-for-age (WAZ) Z-scores were strongly predicted by SES group. HAZ varied from - 0.67 to - 2.23 (P < 0.001) and WAZ varied from - 0.90 to - 1.64 (P < 0.001), from SES1 to SES5, respectively. Weight-for-height (WHZ) showed no gradient. Children in SES1 showed greater dispersion so were further divided in a post hoc analysis. Children resident in Western housing on the research compound (SES1A) had HAZ = + 0.68 and WAZ = + 0.36. The residual gradient between those in SES1B and SES5 spanned only 0.65 Z-score for HAZ (- 1.58 to - 2.23) and was not significant for WAZ or WHZ.ConclusionsThe large difference in growth between children in SES1A living in Western-type housing and SES1B children living in the village, and the very shallow gradient between SES1B and SES5, implies a very high SES threshold before stunting and underweight will be eliminated. This may help to explain the lack of efficacy of the recent WASH interventions and points to the need for what is termed 'Transformative WASH'. Good quality housing, with piped water into the home, may be key to eliminating malnutrition.

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