The Difficulties in Demonstrating That Aflatoxin Reduction Improves Stunting in Developing World Regions

Aflatoxins are highly toxic secondary metabolites that contaminate dietary staples in many developing world regions, with hundreds of millions of people estimated to be chronically exposed. In this review, we summarize the evidence about AF exposure assessment and its relationship to stunting. Despite multiple attempts, this question has eluded a strong scientific conclusion due to the nature of the toxin and exposure, the disparate methods used for assessment, and the ethical difficulties of studying a toxin in low-resource settings. We highlight current challenges in defining these relationships, how this has reduced the ability to draw conclusions in this area, and approaches to overcome these to advance the field. Current reviews tend to report mixed associations, but typically lack critique of the study designs, and a limited understanding of patterns of aflatoxin exposure coupled with a probable variable threshold for effect. We highlight the potential diverse patterns of AF exposure over time and how that may influence study design to address this critical public health issue.