Quantifying the fatal and non-fatal burden of disease associated with child growth failure, 2000–2023: a systematic analysis from the Global Burden of Disease Study 2023

Background: Child growth failure (CGF), which includes underweight, wasting, and stunting, is among the factors most strongly associated with mortality and morbidity in children younger than 5 years worldwide. Poor height and bodyweight gain arise from a variety of biological and sociodemographic factors and are associated with increased vulnerability to infectious diseases. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to estimate CGF prevalence, the risk of infectious diseases associated with CGF, and the disease mortality, morbidity, and overall burden associated with CGF. 

Methods: In this analysis we estimated the all-cause and cause-specific (diarrhoea, lower respiratory tract infections, malaria, and measles) disability-adjusted life-years (DALYs) lost and mortality associated with stunting, wasting, underweight, and CGF in aggregate. We combined the burden associated with mild, moderate, and severe forms of CGF: stunting was defined as height-for-age Z scores (HAZ) less than –1, underweight was defined as weight-for-age Z scores (WAZ) less than –1, and wasting was defined as weight-for-height Z scores (WHZ) less than –1, according to WHO Child Growth Standards. Population-level continuous distributions of HAZ, WAZ, and WHZ were estimated for 2000 to 2023 using data from surveys, literature, and individual-level study data. The risk of incidence of, and mortality due to, diarrhoea, lower respiratory infections, malaria, and measles was separately estimated in a meta-regression framework from longitudinal cohort data for Z scores less than –1. Finally, fatal outcomes associated with these diseases were estimated with vital registration, verbal autopsy, and case-fatality data, while non-fatal outcomes were estimated with surveys as well as health-care utilisation and case reporting data. The exposure prevalence and relative risk estimates were from continuous distributions, allowing for direct assessment of the attributable fractions for mild, moderate, and severe stunting, underweight, wasting, and the combined impact of child growth failure within populations. All estimates were age-specific, sex-specific, geography-specific, and year-specific. 

Findings: We estimated that, in children younger than 5 years in 2023, CGF was associated with 79·4 million (95% uncertainty interval [UI] 47·0–106) DALYs lost and 880 000 (517 000–1 170 000) deaths. This represented 17·9% (10·6–23·8) of 444 million (434–457) total under-5 DALYs and 18·8% (11·1–25·0) of all 4·67 million (4·59–4·75) under-5 deaths. Compared to stunting (33·0 million [24·1–42·2] DALYs, 373 000 [272 000–477 000] deaths) and wasting (39·2 million [23·8–53·0] DALYs, 428 000 [256 000–583 000] deaths), childhood underweight was associated with the largest share of CGF-related disease burden: 52·2 million (21·9–75·1) DALYs and 573 000 (236 000–824 000) deaths in children younger than 5 years in 2023. 

Interpretation: CGF remains a leading factor associated with death and disability in children younger than 5 years, despite global attention and focused interventions to reduce the prevalence of associated CGF indicators. Our findings underscore the need for policies, strategies, and interventions that focus on all indicators of CGF to reduce its associated health burden. 

Funding: Gates Foundation.