Food for thought

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165 miljoen kinderen zijn wereldwijd chronisch ondervoed. Dit zorgt niet alleen voor kind dat sterft als gevolg van ondervoeding, elke 15 seconden, het heeft ook als gevolg dat kinderen daar de rest van hun leven onder lijden. Het is een groot probleem maar er zijn ook grote kansen om dit probleem aan te pakken

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Food for thought

  1. 1. food for thoughtTackling child malnutrition to unlockpotential and boost prosperity
  2. 2. Malnourished childrenscore 7% lower in mathstests and are 19% less likely tobe able to read aged 838% of children from the leastdeveloped countries have had theirgrowth stunted by malnutritionWell nourished children are13% more likely to be inthe correct grade at school,boosting lifelong skillsBetter childhood nutrition couldcut stunting by 1/3 and reduce healthissues, from diarrhoea and pneumoniato deaf-mutismThe poorest 40% are 2.8 timesmore likely to suffer the long-termeffects of malnutrition than therichest 10%Poor health and education limitjob prospects. Childhoodmalnutrition cuts futureearnings by at least 20%In total, current childhoodmalnutrition could cost the globaleconomy $125bn when today’schildren grow upGood health and jobsbreak the cycle of povertyand ensure that every childgets a chance to thriveBy improving health andeducation, good nutrition leadsto a more skilful anddynamic workforceFixing malnutrition now could bringeconomic benefits over 100times as large as the costs ofinterventionsTHE PROBLEM OPPORTUNITYHEALTHEQUALITYJOBSEDUCATION$100+13%ECONOMY165 million children globally are chronically malnourished.This not only causes the death of one child every 15 seconds but locks in lifelongproblems for millions more. It’s a huge problem – but also a huge opportunity.food for thoughtSources: UNICEF, 2013, Improving Child Nutrition: The achievable imperative for global progress; Save the Children, 2013, Food for Thought
  3. 3. food for thoughtTackling child malnutrition to unlockpotential and boost prosperity
  4. 4. Save the Children works in more than 120 countries.We save children’s lives. We fight for their rights.We help them fulfil their potential.Published bySave the Children1 St John’s LaneLondon EC1M 4ARUK+44 (0)20 7012 6400savethechildren.org.ukFirst published 2013© The Save the Children Fund 2013The Save the Children Fund is a charity registered in England and Wales (213890)and Scotland (SC039570). Registered Company No. 178159This publication is copyright, but may be reproduced by any method without fee orprior permission for teaching purposes, but not for resale. For copying in any othercircumstances, prior written permission must be obtained from the publisher, and afee may be payable.Cover photo: Shamsia, age one, and her mother, Lantana, from Niger (Photo:Jonathan Hyams/Save the Children)Typeset by Grasshopper Design CompanyPrinted by Page Bros LtdAcknowledgementsThis report was written by Liam Crosby, Daphne Jayasinghe and David McNair,all from Save the Children. Other colleagues from across Save the Childrenwere involved in the development of the concept, and provided useful inputinto earlier drafts.We are grateful to Paul Dornan and Maria Ogando Portela at the Universityof Oxford for their excellent analysis. Without implication, we thank LawrenceHaddad, Julie Ruel-Bergeron, Hannah Theobald and Katie Alcock for theirinsightful comments on a previous draft.
  5. 5. contentsExecutive summary iv1 Early nutrition, cognitive development and education 1 Direct effects of malnutrition on brain development 2 The impact of malnutrition on children’s learning experiences 32 The economic impact of malnutrition 7 Malnutrition and economic outcomes in later life 7 Malnutrition and economic growth 83 Interventions that make a difference 124 Conclusion and recommendations 15Appendix 1 17Appendix 2 19Endnotes 20
  6. 6. ivIn the past two decades, the world hasachieved huge progress for children. Between1990 and 2011, the numbers of childrendying under the age of five fell faster thanever before – from 12 million to 6.9 million.Since 1999 the number of children in primaryschool has gone up by over 40 million.However, malnutrition threatens to underminethese impressive advances. In spite of the reductionin children dying, the global crisis of child mortalityremains unsolved – 19,000 children continue to dieeach day from preventable causes. Meanwhile, a globalcrisis in education means 130 million children are inschool but failing to learn even the basics.1They are leftwithout the core skills and abilities they need to fulfiltheir potential and to lead fulfilling, productive lives.Child malnutrition is a key factor underlying boththese crises. Malnutrition is an underlying cause of2.3 million children’s deaths a year, and for millionsmore children contributes to failures in cognitiveand educational development. As a result, the lifechances of millions of children around the world aredevastated. The potential cost to the global economyruns to billions of dollars.In the past two decades, progress in tacklingmalnutrition has been pitifully slow while advancesin tackling many other issues highlighted by theMillennium Development Goals (MDGs) have beenfar faster. Save the Children’s Child DevelopmentIndex has shown overall progress on the educationcomponent was 32% and on the health component23% (from the mid-1990s to the late 2000s),compared with an improvement in the nutritioncomponent of only 13%.2But in June 2013 global leaders have a historicopportunity to make a major breakthrough in thefight against hunger. By taking decisive action to tacklethe malnutrition crises head on, they can end thedeaths of millions of children a year as a result ofmalnutrition and prevent the many millions more livesbeing devastated by its effects.In this report we demonstrate how investment innutrition is not only the right thing to do, it is adown-payment on future prosperity. The evidencewe present shows that preventing malnutrition ofchildren and women in the crucial 1,000-day window– from the start of a woman’s pregnancy until herchild’s second birthday – could greatly increasechildren’s ability to learn and to earn.New findings on theimpact of malnutritionon children’s learningThe long-term consequences of child malnutrition forhealth and resilience to disease are well established.But this report presents new evidence, commissionedby Save the Children, which for the first time identifiesthe impact of malnutrition on educational outcomesacross a range of countries.TheYoung Lives study follows 3,000 children in fourcountries throughout their childhood. At key pointsin their lives, the children are interviewed and testedto determine their educational abilities, confidence,hopes and aspirations.New analysis of the survey shows that children whoare malnourished at the start of life are severelydisadvantaged in their ability to learn.Compared with non-stunted children, stuntedchildren:• score 7% lower on maths tests• are 19% less likely to be able to read asimple sentence aged 8, and 12% less likelyto be able to write a simple sentence• are 13% less likely to be in the appropriategrade for their age at school. 3These impacts remain after controlling children’sbackgrounds, including where they grew up and wentto school.Executive summary
  7. 7. ExecutivesummaryvMalnutrition andchildren’s learningThe impact of malnutrition on children’s learningis not simply that they are tired and unable toconcentrate in class because they have not eatenenough on a given day. Malnutrition in the first1,000 days – from the start of a woman’s pregnancyuntil her child’s second birthday – has a devastatingimpact on children’s future potential. It restricts theircognitive development, means they are more likelyto be sick and miss out on school, and reduces theirability to learn.4This 1,000-day window is a critical time for structuralbrain development. Good maternal nutrition isessential: pregnant or breastfeeding mothers whocan’t access the right nutrients are more likely to havechildren with compromised brain development andwho suffer from poor cognitive performance.5Andonce the child is born, nutrition continues to play akey role in ensuring the brain develops properly.6But the effects of malnutrition on a child’s cognitivedevelopment and education go beyond the biologyof the brain. A child’s nutritional status can impacton the experiences and stimulation that childrenreceive. Parents sometimes treat a malnourished boyor girl differently because they are small, and this childis also more likely to miss school and key learningopportunities due to illness.7The impact is not just on academic achievement.Malnutrition is associated with children having lowerself-esteem, self-confidence and career aspirations.Malnourished children not only face direct damageto their bodies and minds, but are less confident tolearn and aspire to change the situation they wereborn into.Investing in nutrition – acrucial down-payment onfuture prosperityIn the longer term, malnutrition can have a bigimpact on earnings when children reach adulthood.The effects of malnutrition on physical stature,the ability to do physical work, and on cognitivedevelopment, can lock children into poverty andentrench inequalities.Children who are malnourished go on toearn 20% less as adults than the children whoare well nourished.8But there is some evidencethat the difference could be even larger – one studyhas estimated this earning deficit for malnourishedchildren at 66%.9This in turn means that malnutrition can act as a bigbarrier to economic growth. Estimates suggest thatin low- and middle-income countries, the impactof malnutrition could decrease GDP by between2% and 11%. This is partly a result of its impacts oneducational development – as well as on physicalproductivity and health.10This report presents new estimates of malnutrition’seffect on GDP. By extrapolating a 20% reductionin earnings to a global level, this report shows thattoday’s malnutrition could cost the global economyas much as $125 billion when today’s children reachworking age in 2030.11why it’s crucial weact now – The potential‘demographic dividend’Investments in the potential of future generationsare more important than ever before. With mortalityrates falling rapidly but fertility rates declining at alower rate, developing countries will experience anincrease in the size of their working-age populationin the next few decades. Many countries will havetwo people of working age for every dependent. Thispresents them with a critical window of opportunityto boost economic development, known as the‘demographic dividend’.The IMF has predicted that seven of the ten fastest-growing economies in the next five years will be inAfrica.12Meanwhile, economists have identified the‘Next 11’ countries – those that have the potentialfor stellar economic growth in the next decade.13A common theme in each of these countries is thepotential provided by their demographic structures.14But to capitalise on the demographic dividend,developing countries must invest now in the healthand skills of their future workforce. Investments madenow in proven nutrition interventions could increaseopportunities for millions of children to become morehealthy and productive members of society. The next
  8. 8. foodforthoughtvigeneration of children in developing countries couldfuel improved innovation, prosperity and job creation.But if we fail to make that investment theconsequences could be catastrophic. Not only wouldthat leave a future public health disaster – with a hugeburden placed on health systems by a generation ofpeople left more susceptible to disease by malnutrition– but also an economic crisis. If countries are not ableto take advantage of the opportunities presented bydemographic changes, then in 50–60 years’ time theywill be left with a large cohort of elderly dependentswithout having generated the resources to carefor them.Malnutrition: perpetuatinginequalitiesWe believe that every child should have the sameopportunities in life. But the harsh reality is that,even by the age of two years, millions of children’slife chances have already been undermined bymalnutrition. As this report highlights, malnutritionis both a cause and a driver of poverty – lockingwhole communities into a cycle of deprivation andentrenching inequalities across generations.In developing countries, children born to the poorest40% of families are 2.8 times more likely to bemalnourished than those in the richest 10% – and arelikely to go on to earn less than their better-off andbetter-nourished peers.15New evidence presented inthis report shows that the gap in the prevalence ofstunting between the poorest 40% compared with thewealthiest 10% actually increased in many parts of theworld between the 1990s and 2000s.2013: a historic opportunityto tackle malnutritionThe scale of the challenge is huge. UN figuressuggest that in 2012, 47% of children under five insouthern Asia and 39% of under-fives in sub-SaharanAfrica were stunted – too short for their age dueto poor nutrition – and their potential severelydamaged.16The burden of stunting in some countriesis particularly devastating. In Nigeria, 10.9 millionchildren under five are stunted while in India, thefigure is 61.4 million.17But the challenge is not insurmountable. And weknow what needs to be done. Investing now in apackage of proven nutrition interventions, alongwith policy changes to address underlying causesof malnutrition, would help millions of children todevelop into healthy and productive members ofsociety. It is obvious that making these changes is theright thing to do. But it is also the smart thing to do.But nutrition remains chronically underfunded. In thepast three years, donors spend an average of 0.37% oftotal overseas development assistance on nutrition.This situation must change.The Scaling Up Nutrition (SUN) movementencourages countries with a high burden ofmalnutrition to make ambitious political and financialcommitments to address malnutrition. This is crucialbecause malnutrition has no political champion andoften falls through the cracks of responsibility betweenministries of health and agriculture. Sixteen countrieswith a high burden of malnutrition have producedcosted plans to address the malnutrition challenge –which are ready to be funded and implemented.On 8 June 2013 the UK and Brazilian governmentswill host the first-ever nutrition pledging conference.It is a tremendous opportunity for the internationalcommunity and national governments to make aserious commitment to addressing malnutrition bycoming forward with concrete plans that include astunting target and strong financial commitments.Donors and developing country governmentsmust seize this historic opportunity and makethe commitments needed to tackle malnutrition.They should:1 Support and finance national plans toscale up nutrition. Announce commitmentsto develop, and provide technical and financialsupport to, the implementation of evidence-based,costed nutrition plans at the country level, inSUN-member and other high-burden countries.2 Declare and meet interim impact targetsby 2016 as part of the global goal to alleviate theburden of malnutrition in children by 2025. Thesemust include stunting reduction targets, be alignedwith the World Health Assembly nutrition targetsand be based on country needs.18
  9. 9. Executivesummaryvii3 Enhance nutrition-sensitivity of agricultureinitiatives so food-based approaches cancontribute more to improving nutritionalstatus.– Reform the New Alliance for Food Securityand Nutrition and include accountabilitymechanisms with detailed public plans toachieve maternal and child nutrition impacts.– Adapt the Global Agriculture and FoodSecurity Program (GAFSP) to incentivisenutrition-sensitive approaches to agriculture.4 Ensure nutrition is a core part of theG8 Accountability Report. Continue andenhance the nutrition chapter from the 2012Accountability Report. Move towards comparabletracking of nutrition funding, outcomes andimpacts with a mechanism for published annualupdates on progress.Furthermore, programme developers for early yearssupport should:5 Recognise the importance of nutrition forcognitive and educational development, andensure that nutrition is integrated as a keycomponent of early years’ programming,including in early childhood care and developmentprogrammes.6 Integrate stimulation interventions intoearly years’ programmes, in order to mitigate theimpacts of malnutrition on children’s cognitivedevelopment.
  10. 10. Since Adina’s father died three years ago,she and her family have struggled to get by.Adina says she often goes hungry.Even as a baby, Adina missed out on vitalnutrition. Her mother, Wagaye, says shewasn’t able to breastfeed Adina becauseshe became pregnant again soon afterAdina was born.Now ten years old, Adina finds learningdifficult at school and had to repeather class last year. “I try to do well atschool but I find it hard to understandwhat the teacher tells me,” she explains. Wagaye feels Adina’s difficulties at schoolare partly a result of missing out on ahealthy diet. “I know better nutrition isimportant to doing well at school,”she says.That view is backed up by Adina’s teacher,who says Adina is one of the children inher class who struggles. “I try to supportthose in my class who aren’t performingwell,” she says. “I take them to a separateclass after school and go over things theydon’t understand.“Some of my students look much tooyoung for their age,” she adds. “They’rephysically smaller. I can tell that, from whenthey were babies, they haven’t been gettingnutritious food.You can still see that asthey get older.”Hungry for lifephoto:amertilemma/SAVETHECHILDRENviii
  11. 11. 1The 1,000 days from the start of a woman’spregnancy until her child’s second birthdayare a critical time for brain growth. Duringthis period, malnutrition affects the structuraland functional development of the brain,directly affecting cognitive development. Italso has an indirect impact, affecting the wayschildren learn and their ability to interact andengage with the world.This chapter explores the ways that malnutritionaffects children’s brain development and reviewsevidence linking these detrimental effects withpoor cognitive abilities or educational outcomes.New analysis is presented showing that malnourishedchildren are more likely to fall behind at school andto fail on key tests of literacy and numeracy.Good nutrition is essential for pregnant women,breastfeeding mothers and young children, especiallybefore their second birthday. Key nutrients are vital tobrain functioning and growth, including while a foetusis in the womb and during the early months afterbirth when the brain grows rapidly.Children’s cognitive abilities and achievement ofappropriate development milestones depend on acombination of factors, including appropriate nutrition,good health, a caregiver’s attention and opportunitiesto interact with the environment.20Evidence suggeststhat programmes that address stimulation andnutrition together result in greater improvements inchild development than those that focus on one ofthese factors in isolation.21direct effects of Malnutritionon brain developmentProtein and energyBrain growth and neurodevelopment begin in thewomb. During this period of rapid growth, proteinand energy (from carbohydrates and fat) are critical.A lack of these nutrients can have extremely damagingeffects: studies show a higher prevalence of brainabnormalities at two years of age among childrenaffected by foetal undernutrition.22Studies of youngchildren with protein–energy malnutrition show brainatrophy – a shrinking of brain cells due to a lack ofnutrients,23as shown in figure 2.Insufficient calories continue to affect children’s braindevelopment in the first months after birth – a time ofrapid neurodevelopment, including the establishmentof the parts of the brain crucial for memory (thehippocampal-prefrontal connections,24and the densityof dentrites that connect nerve impulses to the nervecell body in the hippocampus).25Micronutrients for brain growthKey micronutrients are crucial for neural developmentearly on in life. The neural tube begins to form16 days after conception and within seven monthsresembles the adult brain. While brain developmentprocesses are complex and cannot be fully exploredhere, the evidence suggests key micronutrients arecrucial to the health of children and mothers.The presence of iron in the brain is critical formyelination, the process by which a layer of fat1 Early Nutrition, Cognitive Development and Education
  12. 12. foodforthought2Figure 2  Images of the basal ganglia of a malnourished child before and aftertreatment for the management of acute malnutritionSource: El-Sherif et al (2012) Cranial Magnetic Resonance Imaging (MIR) Changes in Severely Malnourished Children before and after Treatment.26The image on the far leftshows the bottom part ofthe brain of a 10-month-old child suffering fromsevere protein energymalnutrition. Cerebralatrophy, the shrinking ofneurons due to lack ofnutrients, can be seen asthe white areas shrinkaway from the skull andblood vessels.The imageon the near left shows thesame brain after 90 daysof treatment, from whichthe problem can be seento be resolved.Figure 1 The Developmental Course of Human Brain DevelopmentSource: Thomson, Nelson (2001) Developmental Science and the Media.19This figure shows that the rapid period of brain development occurs within the 1,000-day window between the start of awoman’s pregnancy and her child’s second birthday. Months Months Years DecadesConceptionAgeBirth DeathExperience-dependent synapse formationNeurogenesis in the hippocampusReceptive language area/speech production (angulargyrus/Broca’s area)Synaptogenesis(-3 months to 15–18 years?):Seeing/hearing (visual cortex/auditory cortex)Higher cognitive functions(prefrontal cortex)Myelination (-2 months to 5–10 years)Neurulation(18–24 prenatal days)Cell migration(6–24 prenatalweeks)Prefrontalcortex -9 -8 -7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 30 40 50 60 70Adult levels of synapses
  13. 13. 1 EarlyNutrition,CognitiveDevelopmentandEducation3accumulates around neurons – brain cells designed tocarry electrical signals. Myelination enables nerve cellsto transmit information faster and allows for morecomplex brain processes. Iron deficiency prior tothree years of age is likely to result in profound andpossibly permanent myelin changes.27Iron also facilitates the production ofneurotransmitters – the chemicals that passmessages between neurons – and it is involved inthe function of neuro-receptors, which receive theneurotransmitters’ messages.28Growing evidencesuggests that maternal iron deficiency in pregnancyreduces foetal iron stores, perhaps well into thefirst year of life.29This leads to greater riskof impairments in future mental and physicaldevelopment.Iron deficiency is a strong risk factor for bothshort-term and long-term cognitive, motor andsocio-emotional impairment.30Furthermore,longitudinal studies consistently indicate thatchildren who are anaemic during infancy have poorercognition, lower school achievement and are morelikely to have behaviour problems in later childhood– an effect that could occur as a result of directbiological processes or as a result of the impact ofanaemia on children’s learning experiences.31Iron deficiency is widespread. Almost half of childrenin low- and middle-income countries – 47% of under-fives – are affected by anaemia,32and half of thesecases are due to iron deficiency.33According to theWorld Health Organization (WHO), 42% of pregnantwomen – 56 million women – suffer from anaemia.34Iodine deficiency is thought to be the world’s singlegreatest cause of preventable mental retardation. In2007, WHO estimated that nearly 2 billion peoplehad insufficient iodine intake, one-third of themchildren of school age.35Iodine is critical to the production of thyroidhormones, which are essential for the developmentof the central nervous system. Severe iodinedeficiency before and during pregnancy can lead tounderproduction of thyroid hormones in the motherand cretinism in the child.36Cretinism is characterisedby mental retardation, deaf-mutism, partial deafness,facial deformities and severely stunted growth. It canlead on average to a loss of 10–15 IQ points.37Evenin the absence of overt cretinism, chronic iodinedeficiency can affect intelligence38and mild iodinedeficiency can reduce motor skills.39Zinc plays an important role in brain developmentand is thought to be essential for efficiency ofcommunication between neurons in the hippocampus,where learning and memory processes occur.40Itis also key to other biological processes that affectbrain development, including DNA and RNA synthesisand the metabolism of protein, carbohydrates andfat.41While the results of studies on the impact ofzinc supplementation on cognitive outcomes areinconsistent,42there appears to be a relationshipbetween zinc deficiency and children’s cognitive andmotor development, including among low birth-weightchildren. More research is clearly warranted.43Folate is required during early foetal developmentto prevent neural tube defects44and ensure thatthe neural tube forms properly to create the brainand spinal cord. Iron folate supplementation is alsoimportant for pregnant and breastfeeding mothers toprevent iron deficiency anaemia.Vitamin B12 and folate work together to producered blood cells. Research shows that deficienciesin both could affect brain development in infants.Like iron, vitamin B12 is also essential to themyelination process. Neurological symptoms ofvitamin B12 deficiency appear to affect the centralnervous system, and in severe cases causebrain atrophy.45The impact of malnutritionon children’s educationalexperiencesIn addition to the biological factors discussedabove, children’s experiences and environment areimportant for brain development. A child’s nutritioncan influence the way that they interact withtheir environment.The brain relies on certain stimuli for its normaldevelopment – for example, visual input through theoptic nerve is crucial for the development of thevisual cortex (the part of the brain that processesimages). So-called ‘experience expectant’ processessuch as these happen early in life and have long-termeffects.46In turn,‘experience-dependent’ processes,such as the brain responding to the development of askill, continue throughout life as the brain’s structureand connections change in response to the stimuliand activities the individual experiences.47
  14. 14. foodforthought4Some of the pathways that might influence cognitiveand brain development can be seen in figure 3. Thesepathways are complex and interrelated, and the directeffects of malnutrition cannot be isolated from theimpacts of psychosocial stimulation. In fact, researchsuggests that interventions that address stimulationand nutrition together result in greater improvementsin child development than interventions that addressone of these factors in isolation.48Malnutrition can affect cognitive development byinfluencing children’s experiences and the stimulationthat they receive. For example, infants whosemothers’ suffer from severe anaemia show symptomsof lethargy that may affect their ability to exploretheir surroundings.49There is evidence to suggestthat adults may treat children who are small for theirage (as a result of malnutrition) as younger than theyactually are; the lower level of stimulus can affectchildren’s cognitive development.Once children get behind in their cognitivedevelopment, this can be reinforced by parents focusingtheir attention towards those children who showstronger potential.50A study in Mexico found thatmothers of malnourished children behaved differentlyfrom other mothers towards their children – they wereless likely to reward their children’s successes, were lessaffectionate and spent less time talking to them.51Children who are malnourished may also receivelower levels of stimulus as a result of poor health –for example, missing opportunities to learn throughincreased frequency of illness.Malnutrition can be compounded by other formsof disadvantage. Children from better-off familieswho are stunted tend to be less disadvantaged intheir development, partly thanks to a protectiveenvironment that can shelter then from the worsteffects of malnutrition.52For example, these childrenmay have better access to healthcare and so have tomiss fewer days of school. By contrast, malnourishedchildren growing up in poorer environments may beless able to apply these mitigating strategies.53As aresult the effects of malnutrition go unabated.Figure 3  Potential mechanisms for the effect of nutrient deficiency onchildren’s cognitive, motor and socio-emotional developmentSource: Elizabeth Prado and Kathryn Dewey (2012) Adapted from Levitsky & Barnes (1972) and Pollitt (1993)Level of childinteraction with theenvironmentNutritional statusPhysical growthIllnessPhysical activityCaregiver behaviour,parent–childinteractionBrain developmentand functionCognitive, motorand socio-emotionaldevelopment
  15. 15. 1 EarlyNutrition,CognitiveDevelopmentandEducation5A number of studies have aimed to measure theeffect of malnutrition – particularly of stunting –on cognitive, educational and socio-emotionaldevelopment, both at school age and in adult life.54A study analysing data fromVietnam foundnegative effects on child cognitive developmentafter controlling for other factors such as wealthand parental education.55A large landmark studyin Guatemala estimated that being stunted atage 36 months is associated with going on toreceive on average 3.6 fewer grades of schoolingcompared with children who are not stunted, andscoring significantly worse on scores of readingand vocabulary tests.56Estimates based on fivedifferent cohort studies suggest that children whoare stunted at age two were 16% more likely to faila grade than non-stunted children.57But most existing estimates of the impact ofstunting on educational and cognitive outcomesare restricted to one country or one study sample.To estimate the impact of stunting on cognitiveand educational development across countries,Save the Children commissioned new analysis ofthe internationalYoung Lives study, whichinvestigates children’s development. The studyconsists of a large longitudinal sample coveringfour countries in three continents – Ethiopia, India,Peru and Vietnam.58This analysis isolates nutritionfrom other factors that are relevant to cognitiveand educational development (such as school qualityand parental wealth) and looks at the association ofstunting at age five with cognitive and educationaloutcomes at age eight.Previous analysis of theYoung Lives data reinforcesthe links between early life malnutrition andchildren’s later development. Stunting at aroundone year of age is associated with lower cognitivescores at age five in Peru and Vietnam.59In additionto the effects associated with poverty, stunting ateight years was associated with reduced self-efficacy,self-esteem and educational aspirations. Being lessmalnourished60was associated with higher schoolaspiration, self-efficacy and self-esteem.61Theseimpacts on the ways in which children feel and thinkabout themselves are likely to be closely linked withlabour market outcomes in later life.62New analysis commissioned by Save the Children(see table 1 overleaf and Appendix 1) showsthat, after controlling for children’s backgroundcharacteristics (such as the wealth of their family,and the community they grew up in) children whowere stunted at age five scored on average7% worse on a maths test three years later.This is an equivalent reduction in maths score tothe child being 3.4 months younger, and representsa serious setback on their learning.The impacts on measures of literacy are evenstronger. Children who were stunted at agefive were 19% less likely to be able to read asimple sentence such as ‘I like dogs’ or ‘Thesun is hot’ three years later. And they were12.5% less likely to be able to write such asentence. In relative terms, these are equivalent tothe child being 5.7 months or 7.4 months younger,for reading or writing respectively.Importantly, the research finds that malnutritionaffects children’s chances of being in the correctgrade for their age. After controlling for otherfactors, being stunted at age five was associatedwith being 13% less likely to be in the correctgrade (or above) when children reachedage 8. Children who resit grades are in turn alsomore likely to leave school earlier – a particularproblem in settings where many children alreadyreceive inadequate amounts of schooling.As table 2 in Appendix 1 shows, these impacts arereasonably constant across the four countries, beinglarger in India for three of the four indicators.New estimates of the impact of chronic malnutrition oncognitive and educational outcomescontinued overleaf
  16. 16. foodforthought6New estimates of the impact of chronic malnutrition oncognitive and educational outcomes continuedTable 1 impact associated with stunting at age 5 on child outcomes at age 8See Appendix 1 for more detail from the analysis.Indicator After controlling for background characteristics, a stunted child would be expected toMaths score (29-question test) Score 7% (0.98 points) less wellMade a mistake with reading a simple sentence Be 19% more likely to make a mistake (5.9 percentage points difference)Made a mistake with writing a simple sentence Be 12.5% more likely to make a mistake (5.1 percentage points difference)Being in correct grade for age Be 13% less likely to be in the correct grade for age (8.1 percentage points difference)
  17. 17. 7The benefits of good nutrition do not stopwith improved educational outcomes. Byimproving cognitive abilities, health, physicalstrength and stature, good nutrition in theearly years can lead to greater wages inadulthood and hence promote the economicdevelopment of a whole country. This chapterpresents evidence that stunted children earnas much as 20% less than their counterparts,and uses this to estimate that today’smalnutrition could potentially cost theglobal economy $125 billion when childrenborn now reach working age.The next few decades will see key emergingeconomies, as well as several low-income countries insub-Saharan Africa, experience demographic changesthat provide important opportunities for economicgrowth. But to benefit from these potential dividends,they must invest now in the health and education oftheir future workforce. Governments and donors mustinvest in the nutrition of these children if they are toensure strong economic growth in years to come.The interrelation between improved nutritionand economic growth is of great importance forhuman and economic development. It is a two-wayrelationship. On the one hand, inclusive economicgrowth can contribute towards reductions in theprevalence of malnutrition. On the other hand, as thissection will show, reductions in malnutrition can havea transformative effect on the economic potential ofindividuals and whole societies.Malnutrition and economicoutcomes in later lifeThrough its impact both on children’s cognitivedevelopment and on their physical health anddevelopment, malnutrition can have significant effectson an individual’s economic well-being in later life.The World Bank suggests that malnutrition results in10% lower lifetime earnings,63while numerous studiesthat model the impact of malnutrition in the firsttwo–five years of life place this figure at 20%.64The 2008 Lancet series reviewed cohort studies fromBrazil, Guatemala, India, the Philippines and SouthAfrica that all followed children into adulthood, andconcluded that stunting is associated with reducedearnings in later life.65This review found thatless severe stunting in Brazil and Guatemala wasassociated with higher adult incomes among bothmen and women.66Models using evidence from acrossthese longitudinal studies, combined with evidenceon the relationship between education and earningstaken from 51 countries, have estimated that childrenwho are stunted at age five earn 22% less than theirnon-stunted counterparts.Children from the families living in the mostextreme poverty often suffer the highest rates ofmalnutrition.67Therefore, being malnourished oftengoes hand-in-hand with several other barriers thatundermine children’s development, making it difficultto distinguish between the impacts of malnutritionand other closely correlated forms of deprivation.In Guatemala, a landmark randomised controlled trial(RCT) – the best way of removing the effects otherfactors from research findings – tried to isolate theeffects of malnutrition and found that providing boyswith a nutritional supplement (which was availabletwice daily and contained extra protein and energy)during the first two years of life raised incomes by46% when they were revisited during adulthood.68Data from the same study has been used to estimatethat individuals who were not stunted in earlychildhood were much more likely – by 28 percentagepoints – to work in higher-paying skilled labour orwhite-collar work and earned as much as 66% moreas adults – a much higher figure than others haveestimated and one which may be specific to theGuatemalan context.692 the economic impact of malnutrition
  18. 18. foodforthought8Multiple pathways linking nutritionand economic outcomesPart of the impact of malnutrition on earningsmay be because of the effect on children’s physicaldevelopment. Several studies have confirmed thecorrelation between adult height and wages – forexample, a large cross-sectional study in Brazil foundthat a 1% increase in adults’ height was associatedwith a 2.4% increase in earnings.70It is likely that physical size itself (and thereforeits nutrition determinants) is a direct predictorof earnings in contexts where physical strengthis necessary, such as agriculture or other manuallabour.71Similarly, malnutrition can affect earningssimply by reducing people’s physical ability to spendtime at work, eg, due to illness.But in a world where jobs increasingly requirecognitive skills and educational qualifications, theimpacts of cognitive development and educationaloutcomes is another important pathway by whichmalnutrition can reduce wages. Poor cognitive andeducational development is linked to lower wagerates, as evidence from many countries includingKenya, Tanzania, Ghana and Pakistan shows.72, 73There is a clear association between education levels,and individuals’ subsequent earnings.74, 75But critically,the latest evidence suggests that it is actual learningand the acquisition of skills that matter most, not justthe number of years spent in school.76This is anotherreason why early childhood development, enhancedby good nutrition, is so critical – children need tostart school ready to learn, rather than struggling tounderstand what the teacher is trying to teach them.Given the importance of cognitive and educationaloutcomes on wages, this is likely to be a keypathway that links nutrition to later economic well-being.77Many of the studies that have looked ateconomic impacts of malnutrition also highlight theassociation with education – for example, the RCTin Guatemala found that boys who received thenutrient supplement had, on average, 1.2 extra yearsof schooling, and boys and girls given the supplementwent on to achieve significantly higher readingcomprehension and intelligence scores as adults.78In fact, nutrition’s relationships with cognitive andeducational development may be the most importantpathway in terms of its impacts on wages. Researchhas shown that the economic impacts of malnutritionare larger for those working in more skilled jobsthan for those in manual jobs.A study showed thatamong those working for wages or operating smallbusinesses as adults, those who had received anintervention to improve nutrition as children workedon average five extra hours per week, and earned 20%more than those who didn’t.79These impacts weremuch larger than increases seen for farm workers.Malnutrition andeconomic growthNutrition is not only important for increasingindividuals’ economic outcomes; it is essential forwhole societies’ economic development. This occurspartly as a result of the link between malnutritionand lower productivity, as this report has highlighted,with reduced earnings at the individual level leadingto knock-on effects on national-level economicgrowth.80Malnutrition also affects national economiesby increasing healthcare costs, as people who weremalnourished as children are more likely to fall illto diseases.Laying the foundations forthe demographic dividendDemographic changes occurring around the worldmean that investments in children’s future potentialare more important than ever. Europe and NorthAmerica are entering a period of population ageing,with increasingly large retired populations that needsupporting. But other areas of the world will, in thecoming decades, experience growth in the size oftheir workforce that will present an opportunity forsignificant economic growth.Many developing countries will, in the coming decades,have as many as two workers for every pre- or post-working-age person – a ratio that allows for improvedeconomic growth, provided the workforce is healthyand educated, and jobs are available for them.81It isestimated that similar demographic changes accountfor one-third of the economic growth that east Asiantiger economies experienced from 1965–1990.82Figure 4 shows the progress of various continentsin the world through this process of demographicchange. The populations of Asia and Latin Americacurrently have a very favourable worker:dependentratio. The proportion of India’s population thatis of working age is set to continue to increase.Over the next five decades, Africa will continue tosee an increase in the proportion of working-age
  19. 19. 2 theEconomicimpactofmalnutrition9people, creating an opportunity for the continentto experience strong growth, provided the rightinvestments in people and jobs are made.Failure to ensure good nutrition and human capitalduring these periods could prevent developingcountries from experiencing sustained economicgrowth.83It could even lead to BRIC countries(Brazil, Russia, India and China) and some developingcountries becoming stuck in the ‘middle-income trap’– whereby their growth may plateau after reachingmiddle-income levels.84A brake on inclusive economic growthMany studies have attempted to estimate the cost tonational economies of various forms of malnutrition.As mentioned above, malnutrition acts both byreducing economic productivity and by increasing thecosts of healthcare. While econometric methodologiesrequire various assumptions to be made regardingthe strengths of association between malnutrition andeconomic costs, the findings are stark.In seven countries in Central America, the WorldFood Programme (WFP) has estimated that theeconomic costs of children under age five beingunderweight could be between 1.7% and 10.6%of GDP (average 6.6%).86Estimates of the cost ofiron-deficiency to national economies are around4.5% of GDP in ten developing countries, rangingfrom 2% in Honduras to 7.9% in Bangladesh,87andsimilar impacts to national economies have beenestimated for iodine deficiency and underweight.88These different deficiencies overlap, with many of thesame people affected by different types of deficiencies,which makes modelling the total economic impact ofmalnutrition very difficult. Nevertheless, what is clearis that malnutrition can act as a brake on countries’economic growth.In India it has been estimated that the economic costof micronutrient malnutrition amounts to between0.8% and 2.5% of GDP,89equivalent to $15–46bn,while in China, micronutrient malnutrition alonecould cost between 0.2 and 0.4% of GDP,90equivalentto $15–29bn.In 2012 the Copenhagen Consensus panel of Nobellaureates estimated the economic benefits of investingin a comprehensive package of direct nutritioninterventions, such as vitamin A supplementationor the promotion of breastfeeding,91and found thatFigure 4 The worker:dependent ratio of several continents, plus IndiaFigure constructed by Save the Children using data from UN (2010).85AfricaAsiaLACEuropeIndiaNumberofpeopleaged15–64foreachpersonagedunder14orover652.22.01.81.61.41.21.02070206020502040203020202010200019901980197019601950
  20. 20. foodforthought10these benefits in terms of increased wages couldbe anywhere between 15 and 138 times larger thanthe costs.Many of these studies combine the impacts ofmalnutrition through various pathways, includingcognitive and physical impacts of malnutrition aswell as the additional costs such as those due toincreased healthcare burden. Nevertheless, it is clearthat reduced cognitive development is an importantpathway by which nutrition affects national economies.In its 2007 study based in seven Latin Americancountries, the WFP estimated that as much as 46% ofthe overall cost of malnutrition on GDP was due toimpacts on productivity via reduced education.92Theeffect of malnutrition on national economies is likelyto become even more significant as countries developlarger skills sectors and as non-farm sectors becomeincreasingly important.93Save the Children has undertaken new analysis toestimate the potential costs to the global economyof the reduced potential that results from childrenbeing malnourished. We used a similar methodologyto that of the Copenhagen Consensus panel of Nobellaureates, who in 2012 estimated the economicbenefits of investing in a comprehensive package ofdirect nutrition interventions. The methodology forthis analysis and the various assumptions included areshown in Appendix 2.The results of this analysis suggest that by the timetoday’s stunted children reach working age, theincome differences associated with their malnutritioncould cost the global economy $125bn per year.In fact, the impacts of malnutrition on GDP could beeven larger than a straightforward accumulation ofindividual impacts: the reduced cognitive skills thatare associated with malnutrition could have broadereffects on GDP. Research suggests, for example, thatmore foreign direct investment goes to countries withworkforces that have greater human capital, and thatthis relationship has been getting stronger over time.94Similarly, recent evidence suggests that the impact ofcognitive development on national economies may belarger than the impact on individual wages – partlyas a result of improving economic activities suchas savings.95Finally, the evidence discussed above,that impacts may be larger in skilled sectors thantraditional ones, such as agriculture, suggests that ascountries move away from agrarian economies andinto more skilled jobs, the impact of malnutrition onincomes may become even starker.Malnutrition – perpetuating inequalitiesPoverty is itself a key driver of malnutrition. Butmalnutrition also perpetuates poverty – by reducingthe potential of individuals to lift themselves outof poverty.The poorest are worst affected by malnutrition.Save the Children analysis of DHS datasets shows thataround the world, children in the poorest 40% withinany country are on average 2.8 times more likely tobe stunted than those in the richest 10%.96Theseinequalities are most extreme in Nicaragua, wherebeing born into the poorest 40% means a child is10.6 times more likely to be stunted than in therichest decile, followed closely by Peru (9.2 times)and Jordan (7.9 times).Given the resultant impacts of malnutrition on futureearning potential, a vicious cycle is created – wherethe poorest are at greatest risk of facing permanentdamage to their future learning and earning potential.The next generation is then more likely to be stunted– both through transmission from the mother duringpregnancy,97and as a result of the poverty in whichfamilies live. Malnutrition’s unequal social prevalencetherefore acts as a barrier to inclusive growth and thereduction of inequalities.A recent study using theYoung Lives dataset inAndra Pradesh, India, has suggested that if nutritionalinequalities were tackled in such a way that low-castechildren gained the same average nutritional statusas their upper caste counterparts, this would closeexisting caste cognitive differentials by 25%.98Yet, inequalities in nutritional status between wealthgroups are large and have remained stubbornly highover recent years. Figure 5 shows how the ratio ofstunting between the top 10% and the bottom 40%actually increased in sub-Saharan Africa and in southand south-east Asia between the 1990s and 2000s.While development assistance is increasingly focusedon promoting growth, such growth must be inclusiveand must deliver improvements to the economicand social well-being of the poorest in society. Giventhe social distribution of malnutrition, investmentsto tackle it are an important way to tackle povertyand its transmission, and to encourage children’sdevelopment as empowered and productive membersof society.
  21. 21. 2 theEconomicimpactofmalnutrition11Figure 5  Ratios in stunting rate between top 10% and bottom 40% wealth groupsSource: DHS analysis by Save the Children‘Palmaratio’ofunder-5stuntingprevalenceinpoorest40%comparedtorichest10%(population-weightedaverages)76543210WorldLatin Americaand CaribbeanSouth andSouth-east AsiaSub-SaharanAfricaNorth Africa/Westand Central Asia/Europe1990s2000s
  22. 22. 12Investing in nutrition is key to unlocking thepotential of a generation of children. Thegood news is that we know what works totackle malnutrition and its damaging effectson individuals and societies.A package of 13 proven direct nutrition interventionscould reduce the prevalence of stunting by a third, andchild mortality by a quarter. Investments in nutrition-sensitive approaches, such as child-focused socialprotection systems or empowering women farmers toincrease the nutrition-sensitivity of agriculture, couldhave even greater effects on tackling nutrition.99Forthose children who remain malnourished, interventionsto promote stimulation must be implemented.Nutrition interventions, along with key educational,health and care services, can help children’s brainsto develop and help them to learn and to earn forthe rest of their lives, and can yield gains that benefitthe wider society and economy. These includedirect nutrition interventions, such as promotingbreastfeeding, many of which are provided throughthe health system. In addition, indirect interventions– such as social protection, investments in agriculture,and ensuring access to safe water and sanitation –address nutrition’s underlying causes.There is strong evidence that points to the benefitsof nutrition interventions for children’s cognitivedevelopment.100Research into the impact of avariety of nutrition interventions, from a range ofdeveloping countries, has found a positive impact oneducational indicators, such as grades completed atschool,101maths and English scores102and intelligencequotient (IQ).103This appears to hold true across arange of robust studies.104Micronutrient supplementsA recent study in Indonesia provided multiplemicronutrient supplements to undernourished oranemic women during pregnancy and in the firstthree months after birth. The authors found that thishad significant effects on their children’s cognitivedevelopment, as measured by tests of visual andspatial abilities at age three.A study in Costa Rica of iron supplementation inchildren aged one and two years tracked the sameindividuals 18 years later and tested the impact ofmalnutrition within different socio-economic groups,in order to isolate this factor from the analysis. Scoresin cognitive tests in early childhood for those in themiddle socio-economic status group with adequateiron status were 8–9 percentage points higher thanthose who remained anaemic in early childhood. Thisdifference that was maintained up to age 19 years.105Among the lower socio-economic status group, thosewith adequate iron status scored 10 percentagepoints higher in early childhood, and this increasedto 25 points at age 19.106Iodine supplementation can lead to strong economicbenefits – partly because of the impact of iodinedeficiency on healthcare costs. Currently 31% ofdeveloping-world households still do not consumeiodized salt and are therefore not protected.107Itis estimated that, at an annual cost of $0.5 billion,universal salt iodization would save an annual$35.7 billion of potential costs attributable toiodine deficiency.108BreastfeedingBreastfeeding is the best way to give a child a healthystart in life. However, only 37% of children globally areexclusively breastfed for the first six months of life.109Breastfeeding prevents millions of deaths, protectingchildren from diseases such as pneumonia anddiarrhoea. In addition, breast milk contains nutrientssuch as fatty acids, growth factors and hormonesthat are important for brain development.110Such isthe strength of evidence, that a medical consensushas emerged regarding the importance for cognitivedevelopment of these nutrients and their provision inbreastmilk.111The stimulation effects of breastfeeding3 Interventions that make a difference
  23. 23. 3 Interventionsthatmakeadifference13are also important for cognitive development:breastfeeding can help the mother and child tobond, which can in turn enhance mother and babyinteraction, which is important for cognitive andsocio-emotional development.112A number of studies show that breastfeedingpromotion can have a positive impact on childdevelopment and educational attainment. For example,a study in clinics in Belarus found that childrenwho benefited from a breastfeeding promotionintervention had significantly higher scores onverbal and IQ tests, and higher teacher ratings forreading and writing at 6.5 years.113Similarly, a studyon the effect of breastfeeding duration on schoolachievement among Brazilian adolescent boys foundan increase in school achievement linked to anincrease in breastfeeding duration.114There are, of course, a number of factors that alsoinfluence children’s academic performance, suchas socio-economic status, household educationlevels and genetics. However, a meta-analysis ofseveral controlled studies found that breastfeedingis associated with a higher score for cognitivedevelopment compared with formula feeding. Thedifference between breastfed and formula fed childrenwas observed as early as six months and sustainedinto adolescence.115Stimulation of malnourishedchildren to improvecognitive outcomesAs chapter 1 shows, malnutrition can affectchildren’s interactions with their environment – forexample, in the way they are treated by parents andteachers. There is therefore a need for early years’programmes to simultaneously address both nutritionand stimulation in order to have the largest positiveeffects on cognitive development.In Jamaica, a study found that providing eithernutrients (in the form of milk-based supplements fortwo years) or stimulation (in the form of weekly playsessions) both improved children’s scores on tests ofcognitive development. However, it also found thatintegrating the two interventions led to significantlybetter impact than either one alone.116Indeedrecent evidence from severely underweight childrenin Bangladesh shows that if malnutrition cannot beprevented, interventions to improve stimulation maystill be able to improve cognitive scores.117It is therefore critical for children’s cognitivedevelopment that interventions aimed atmalnourished children integrate stimulation, in orderto minimise the negative effects of malnutrition oncognitive development. Indeed, there is internationalconsensus around the need for such interventions,which form the basis of WHO recommendations onthe treatment of malnutrition.118Nutrition shouldbe integrated into programmes that address earlychildhood care and development.Integrating nutrition intoeducational programmesin BangladeshDrawing on the evidence of the importance ofnutrition for early child cognitive development –as highlighted in this report – Save the Children isintegrating nutrition into our early child care anddevelopment (ECCD) programming.In Bangladesh, where 43% of children are stunted,Save the Children undertook a trial of an ECCDprogramme that integrated nutrition by providing1–2 days of training on the importance of dietarydiversity and nutritious food, as well as healthcareand stimulation.The results of this study showed that motherschanged their practices relating to dietarydiversity, with 64% of families in one of theintervention arms that received the nutritioneducation consuming at least four food groupsthe year after the intervention was made,compared with 33% of control families. Whilethe programme did not run long enough toregister effects on stunting, the increase in dietarydiversity is likely to have had a positive impact onchildren’s intake of nutrients.Stimulation scores also improved significantly.Indeed, this factor was shown to be especiallyimportant in achieving an improvement tocognitive scores. Children from families whoreceived the stimulation intervention saw a 40%improvement in their cognitive and languagedevelopment compared with children who didnot receive the intervention.
  24. 24. 14When Lakshmi was pregnant with twins, sheand her family were desperately short of food.Her husband, Srinavas, was struggling to findwork. “There were times we were hungry fordays,” he says. “I felt very sad that I couldn’tprovide for my pregnant wife.”When Lakshmi gave birth, both twins had alow birth-weight. “I used to breastfeed mychildren, but my milk wasn’t enough for bothof them,” she says. “We didn’t have enoughfood then.” One of her twin girls died at tenmonths old.Kasturi survived and is now eight. But shestruggles at school, and has already had torepeat one year. Her teacher, Chandra Kala,says, “I’ve been Kasturi’s teacher for twoyears now. Her learning’s very slow andthere’s been no major improvement.”Kasturi has an older sister, Sangeeta. Thecontrast in their stories is striking. WhenSangeeta was born, Srinavas was earningenough money for a healthy diet for the family.Sangeeta has gone on to thrive at school.“Sangeeta was one of our bright studentsin primary school,” says Chandra Kala, “andI hear a lot of good things about her fromher teachers in high school.”Atale of three sistersphoto:SAVETHECHILDRENKasturi (right) with her older sister, Sangeeta, and their father. Kasturi struggles at school, while Sangeeta has thrived.
  25. 25. 15Given the devastating human and economicimpacts of malnutrition, many economistshave consistently concluded that investingin nutrition is an excellent way to spurinclusive economic growth and is ‘centralto development’.119For example, the Copenhagen Consensus of NobelLaureates rated nutrition interventions as four ofthe eight most cost-effective interventions availablein development. Nutrition interventions are cost-effective, in particular in reducing the burden onassociated diseases on health services.120Cost–benefitratios for nutrition interventions have been found ashigh as 1:138.121Yet, despite its crucial importance and the growingconsensus that this is one of the ‘best buys’in development, the issue remains chronicallyunderfunded. Donors spent an average of only 0.37%of total aid on nutrition in the past three years.The Scaling Up Nutrition movement encouragescountries with a high burden of malnutrition tomake high level political and financial commitmentsto address malnutrition.This is crucial becausemalnutrition – which is silently crippling the futurepotential of millions of children – has no politicalchampion and often falls through the cracks ofresponsibility between ministries of health andagriculture. Sixteen high-burden countries haveproduced costed plans to address the malnutritionchallenge, and which are ready to be fundedand implemented.In the lead up to the G8 leader’s summit in June,the UK Prime Minister has agreed to host, with thegovernment of Brazil, a ‘Nutrition for Growth’ event– a once-in-a-decade opportunity to ensure high-levelpolitical and financial commitments to supportthese plans.In 2013, the international community stand at acrossroads. Investing in nutrition interventions nowas a down-payment on future prosperity will lead tohuge benefits for millions of children – and for theglobal economy. But if we fail to take advantage ofthis opportunity we will fail a generation of children– and diminish the prospects of many countries andtheir people.Save the Children calls on donors and governmentsin developing countries to seize this historicopportunity and make the commitments neededto tackle malnutrition. They should:1 Support and finance national plans toscale up nutrition. Announce commitmentsto develop, and provide technical and financialsupport to, the implementation of evidence-based,costed nutrition plans at the country level, inSUN-member and other high-burden countries.2 Declare and meet interim impact targetsby 2016 as part of the global goal to alleviate theburden of malnutrition in children by 2025. Thesemust include stunting reduction targets, be alignedwith the World Health Assembly nutrition targetsand be based on country needs.1224 Conclusion and Recommendations
  26. 26. foodforthought163 Enhance nutrition-sensitivity of agricultureinitiatives so food-based approaches cancontribute more to improving nutritionalstatus.– Reform the New Alliance for Food Securityand Nutrition and include accountabilitymechanisms with detailed public plans toachieve maternal and child nutrition impacts.– Adapt the Global Agriculture and Food SecurityProgram (GAFSP) to incentivise nutrition-sensitive approaches to agriculture.4 Ensure nutrition is a core part of the G8Accountability Report. Continue and enhancethe nutrition chapter from the 2012 AccountabilityReport. Move towards comparable tracking ofnutrition funding, outcomes and impacts witha mechanism for published annual updateson progress.Furthermore, programme developers for early yearssupport should:5 Recognise the importance of nutrition forcognitive and educational development, andensure that nutrition is integrated as a keycomponent of early years’ programming,including in early childhood care and developmentprogrammes6 Integrate stimulation interventions intoearly years’ programmes, in order to mitigate theimpacts of malnutrition on children’s cognitivedevelopment.
  27. 27. 17Young Lives is a study of childhood poverty.Central to the study is a panel data setcollecting data on children and young peoplegrowing up in Ethiopia, India, Peru andVietnam. The study collects data on twogroups of children born in 1994/95, and2000/01. The study website123contains policyand research analysis, as well as technicaldocumentation and information on how toaccess publically archived data.The data is collected using a clustered (‘sentinel site’)approach. Specific geographic sites were selectedwithin each country with children of the right agerandomly sampled within each area. The sampledesign aimed to collect information on children in arange of circumstances within each country (ie, tobroadly reflect national differences), but oversamplespoor children (technical details and comparisonswith nationally representative sources are on thestudy website).The study has so far collected survey data in 2002,2006 and 2009. The analysis in this briefing usesinformation on the younger group of children (agedaround eight when data was last collected). In thisyounger cohort, approximately 2,000 children wereinitially sampled. Since similar questions were asked ineach country, in the multivariate analysis the samplesare pooled (using statistical techniques to control fornational differences), giving a sample of about 7,000children (having accounted for attrition and excludingchildren for whom there is relevant missing data).In this report, descriptive analysis is used to considerthe different later experiences of children basedon their status as ‘stunted’ or ‘not stunted’ at agefive. Stunting is used as a long-run indicator of childmalnutrition, and measured by children having aheight (converted to a z-score) below two standarddeviations of the median in a WHO age and sexreference population.To estimate the impacts associated with stunting, weuse multivariate regression. Regression analysis uses aset of background characteristics to explain particularoutcomes. By including multiple characteristics (ascontrols) the models estimate the contribution to theoverall outcome made by each characteristic.As a caution, these models are only as good as theobserved data they use. There may well be othernon-observed characteristics which could affectthe relationships observed. Taking account of thesenon-observables might well affect the predictionsnoted below.To allow us to pool the results we include a referenceto the cluster in which the child was born (wherethey were recorded as living in 2002, this absorbsthose differences associated with the site and countryof origin). Since pooled results might be particularlyinfluenced by one country, we also present resultsseparated by country in summary form in Table 2.Appendix 1Analysis of the Young Livesdataset
  28. 28. foodforthought18Table 2  Summary of findings from the Young Lives analysis Maths score Made a mistake Made a mistake Being in with reading a with writing a correct grade simple sentence simple sentence for agePooled sample -0.982*** 0.059*** 0.051*** -0.081***SE (0.127) (0.011) (0.010) (0.012)N 7,180 7,309 7,277 7,235Ethiopia -0.782*** 0.053** 0.041** -0.103***SE (0.169) (0.021) (0.019) (0.018)N 1,707 1,774 1,770 1,762India -1.080*** 0.101*** 0.078*** -0.091***SE (0.278) (0.024) (0.019) (0.025)N 1,886 1,890 1,872 1,850Peru -0.657** 0.033 0.031 -0.047***SE (0.269) (0.020) (0.023) (0.014)N 1,781 1,816 1,817 1,816Vietnam -1.033*** 0.026 0.034** -0.066*SE (0.245) (0.016) (0.016) (0.037)N 1,806 1,829 1,818 1,807***p<0.01, **p<0.05, *p<0.1. The definition of being in the correct grade for age, is that a child is either in, or ahead of, the school grade expected forthe age of the child at interview. To interpret these coefficients: the first column shows the impact on a test of 29 maths questions; the last threecolumns show the independent impact on the chances of making reading or writing mistakes or being in the correct grade associated with stunting.The coefficient of 0.059 (pooled sample, reading) is interpreted as increasing the chances of making a mistake by 5.9 percentage points.SE = Standard Error; N = Sample Size.
  29. 29. 19Existing estimates as to the economic impact ofmalnutrition differ by:• The type(s) of malnutrition that are focused on• The conceptual framework/pathway used as tohow malnutrition affects GDP (eg, some focus onimpacts via poorer health in adulthood, othersfocus on decreases in productivity throughreduced education)• Whether impacts are estimated at the individualor country level• The region or country from which the estimate isbased (few of them are global)• The population sub-section to which they refer(eg, some estimates refer just to women)In fact, most of the studies with reliable estimatesrefer to the individual level, with only a few aggregateestimates being produced, many of which are veryvague in their methodology: the World Bank hasstated that costs may be equivalent to 2–3% of GDP;WFP has stated this may be as high as 11% in someLatin American countries.124The World Bank’s Nutrition Strategy document:“Repositioning Nutrition as Central toDevelopment”125includes a wide-ranging review ofvarious of the different estimates of the economicimpact of malnutrition, but does not attempt tosystematise or synthesise them. It does not identifyone clear statistic as to the precise economic cost,to individuals or countries.The Copenhagen Consensus has consistently ratedactions to address malnutrition as the most cost-effective of all development interventions. The mostrecent paper on hunger and nutrition from theCopenhagen Consensus group has attempted toquantify the overall benefit:cost ratio of the completepackage of direct nutrition interventions (DNIs). Theyuse an estimated increase in income of 23.8 afterprovision of DNIs, based on the combined fact thatmalnutrition has been found to reduce productivityby 66% in one paper from IFPRI,126and that the DNIsreduce stunting by 36%.127They find benefit:costratios of between 23.6 and 138.6, depending on pre-existing differences in income levels and growth rates.We apply a similar methodology. We estimate thatstunted children earn 20% less in later life than non-stunted children. This estimate is based on a reviewof longitudinal studies of the impact of stunting oneducation outcomes, combined with estimates of theimpacts of these education outcomes on wages, whichhas estimated that stunted children earn 22% less thantheir non-stunted counterparts.128We round downto 20%, which is in line with other previous estimatesof the impact of malnutrition on wages,129but is amore conservative estimate than the 66% used bythe Copenhagen Consensus panel,130which itself wasbased on the most robust available longitudinal studyto investigate the economic impacts of stunting.131We apply these estimated losses of income, on acountry by country basis, to estimated per capitaincomes. For all countries where data is availablefrom the Euromonitor disposable income dataset,we have used this as an estimate of future earnings.Where income data is not available for countries, aproxy is created using the ratio of GNI per capita (forthe working population, from the World Bank WorldDevelopment Indicators) to disposable income forcountries at the same income classification.We thencalculate the lost earning potential for those childrenunder five years who are currently stunted.The results of this analysis suggest that by the timetoday’s stunted children reach working age, thedifference between their earnings and those of theirbetter-nourished counterparts could be equivalent to$125bn globally.Appendix 2Estimating the equivalentcost of malnutritionat a global level
  30. 30. 20Executive summary1Save the Children (2013) Ending the Hidden Exclusion: Learning and equityin education post-20152Save the Children (2012) The Child Development Index3See Appendix 1 for details.Young Lives is a longitudinal survey whichfollows 12,000 children across four countries throughout their lives. Formore details see http://www.younglives.org.uk/4Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 20125Georgieff M K, Rao R (1999) The role of nutrition in cognitivedevelopment. In: Nelson CA, Luciana M, editors. Handbook in DevelopmentalCognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-5046Georgieff M K, Nutrition and the developing brain: nutrient priorities andmeasurement, American Journal of Clinical Nutrition, February 2007, vol. 85no. 2 614S-620S7Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 20128It has been estimated that stunted children earn 22% less than theirnon-stunted counterparts, based on available longitudinal studies of theimpact of malnutrition on education, and evidence from 51 countriesof the impact of education on earnings. Grantham McGregor S (2007)Developmental potential in the first 5 years for children in developingcountries, Lancet 369(9555): 60–709Hoddinott J et al (2011) The Consequences of Early Childhood GrowthFailure over the Life Course, IFPRI Discussion Paper 01073Hoddinott J et al (2012) Copenhagen consensus challenge paper: Hungerand malnutrition10World Food Programme and UN-ECLAC (2007) The Cost of Hunger:Analysis of the social impact of child undernutrition in Latin America: CentralAmerica and the Dominican Republic11Horton S et al (2010) Scaling Up Nutrition:What will it cost?,Washington:The World Bank12The Economist, Africa’s impressive growth, 6 January 2011. Available at:http://www.economist.com/blogs/dailychart/2011/01/daily_chart13These were identified by Jim O’Neill, former Chief Economist atGoldman Sachs, and the person that predicted that economic rise of the‘BRICs’. The ‘Next 11’ countries are: Bangladesh, Egypt, Indonesia, Iran,South Korea, Mexico, Nigeria, Pakistan, the Philippines, Turkey, and Vietnam14Jim O’Neill (2010), The Growth Map: Economic opportunity in the BRICs andbeyond. NewYork: Penguin15Comparison of the poorest 40% against the richest 10% is anincreasingly accepted measure of the concentration of inequalities. SeeCobham A (2013) Palma vs Gini: Measuring post-2015 inequality, http://tinyurl.com/bq2x64e16UNICEF (2012) State of theWorld’s Children 2012, NewYork: The UnitedNations17Data on prevalence of stunting is taken from UNICEF (2012) State oftheWorld’s Children 2012. Data on the population size, under age five, aretaken from the 2010 World Population Prospects.18In May 2012, the World Health Assembly passed a resolution with sixnutrition targets with one of them being stunting. For more details seehttp://thousanddays.org/wp-content/uploads/2012/05/WHO-Targets-Policy-Brief.pdf1  Early nutrition, cognitivedevelopment and education19Thomson, R A and Nelson C A (2001) Developmental science and themedia: early child development, American Psychologist, v56 n1 p5-15 Jan200120Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201221Pelto G, Dickin K, Engle P (1999) A Critical Link: Interventions for physicalgrowth and psychological development, Geneva:World Health Organiza­tionGrantham-McGregor, S et al (1991) Nutritional supplementation,psychosocial stimulation, and mental development of stunted children: theJamaican Study. The Lancet, 338(8758), 1-522Georgieff M K, Rao R (1999) The role of nutrition in cognitivedevelopment. In: Nelson CA, Luciana M, editors. Handbook in DevelopmentalCognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-50423El-Sherif, A M et al (2012) Cranial magnetic resonance imaging (MRI)changes in severely malnourished children before and after treatment, LifeScience Journal, 9(3)24Georgieff M K, Rao R (1999) The role of nutrition in cognitivedevelopment. In: Nelson CA, Luciana M, editors. Handbook in DevelopmentalCognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-50425Blatt G L et al (1994) Prenatal protein malnutrition effectson the serotonergic system in the hippocampal formation: animmunocytochemical, ligand binding, and neurochemical study, BrainResearch Bulletin 34 (5): 507–518Ranade, S C et al (2008) Different types of nutritional deficiencies affectdifferent domains of spatial memory function checked in a radial armmaze, Neuroscience 152 (4): 859–86626El-Sherif,A M et al (2012) Cranial magnetic resonance imaging (MRI)changes in severely malnourished children before and after treatment, LifeScience Journal, 9(3)Archives of Disease in Childhood (1987) Malnutrition, 62, 589–59227Georgieff M K, Rao R (1999) The role of nutrition in cognitivedevelopment. In: Nelson CA, Luciana M, editors. Handbook in DevelopmentalCognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-50428Jukes, Drake and Bundy (2008) School Health, Nutrition and Education forAll: Leveling the playing field.Wallingford: CAB International29Allen L H,Anemia and iron deficiency: effects on pregnancy outcome,American Journal of Clinical Nutrition. May 2000, 71(5 Suppl):1280S-4S30Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201231Grantham-McGregor S and Ani C, A review of Studies on the effect ofiron deficiency on cognitive development in children, Journal of Nutrition,February 1, 2001, vol 131, no. 2, 649S-668Sendnotes
  31. 31. endnotes2132Save the Children (2012) A Life Free From Hunger: Tackling childmalnutrition, London: Save the Children33World Health Organization (2001) Iron Deficiency Anaemia:Assessment,prevention, and control – A guide for programme managers, Geneva:WHO34Goonewardene M, Shehata M, and Hamad A (2012) Anaemia inpregnancy, Best Practice & Research Clinical Obstetetrics & Gynaecology,February 2012, 26(1):3-2435WHO cited in The Lancet (12 July 2008).‘Iodine deficiency – way to goyet’, The Lancet 372 (9633)36Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201237Bleichrodt N and Born M P (1994) ‘A meta-analysis of research oniodine and its relationship to cognitive development’, In: J B Stanbury, ed.The Damaged Brain of Iodine Deficiency, NewYork: CognizantCommunication, 195–20038Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201239Georgieff M K, Rao R (1999) The role of nutrition in cognitivedevelopment. In: Nelson CA, Luciana M, editors. Handbook in DevelopmentalCognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-50440Duke University Medical Center,‘Zinc regulates communication betweenbrain cells’, Science Daily, 21 September 2011,Web. 25 April 201341Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201242Hamadani JD et al (2002) Zinc supplementation during pregnancy andeffects on mental development and behaviour of infants: a follow-up study’,The Lancet, (360): 290–29443Black, M M (2003) The evidence linking zinc deficiency with children’scognitive and motor functioning, Journal of Nutrition, May 2003;133(5 Suppl 1): 1473S–1476S44Black M M, Effects of vitamin B12and folate deficiency on braindevelopment in children, Food Nutrition Bulletin, June 2008; 29(2 Suppl):S126–S13145Black M M, Effects of vitamin B12and folate deficiency on braindevelopment in children, Food Nutrition Bulletin, June 2008; 29(2 Suppl):S126–S13146Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201247Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 201248Pelto G, Dickin K, Engle P (1999) A Critical Link: Interventions for physicalgrowth and psychological development, Geneva:World Health Organiza­tion49Grantham-McGregor S and Ani C A (2001) Review of studies on theeffect of iron deficiency on cognitive development in children Journal ofNutrition, February 1, 2001 vol. 131 no. 2 649S-668S50Ardhvaryu and Nyshadham (2011) Endowments and investments withinthe household: Evidence from iodine supplementation in Tanzania, CentreDiscussion Paper no. 998, Economic Growth Centre51Grantham-McGregor S M et al (1994) The long-term follow up ofseverely malnourished children who participated in an interventionprogramme52Torche F, Echevarria G. The effect of birthweight on childhoodcognitive development in a middle-income country, International Journal ofEpidemiology, 2011 Aug; 40(4): 1008-1853Currie J,Vogl T (2012) Early life health and adult circumstance indeveloping countries, Princeton.Available at: http://www.princeton.edu/~tvogl/currie_vogl_AR.pdf54Grantham McGregor S (2007) Developmental potential in the first5 years for children in developing countries, The Lancet 369(9555): 60–7055This study found that an increase by a standard deviation of height-for-age score by a standard deviation, leads to an increase of twenty percentof the quantitative cognitive achievement. Le Thuc, D (2009) The Effectof Early-age Stunting on Cognitive Achievement among Children inVietnam,Working Paper 45, Oxford: Young Lives56Hoddinott J et al (2011) The Consequences of Early Childhood GrowthFailure over the Life Course, IFPRI Discussion Paper 0107357Martorell R et al (2010) Weight gain in the first two years of life is animportant predictor of schooling outcomes in pooled analyses from fivebirth cohorts from low- and middle-income countries, Journal of Nutrition,February 2010 vol. 140 no. 2 348-35458See Appendix 1 for the methodology.59Sanchez, A (2009) Early Nutrition and Cognitive Achievement in Pre-SchoolChildren in Peru, Working Paper 57, Oxford: Young LivesLe Thuc, D (2009) The Effect of Early-age Stunting on Cognitive Achievementamong Children inVietnam, Working Paper 45, Oxford: Young Lives60As indicated by a one-standard deviation increase in height-for-age score. Standard deviations allow comparison of difference acrossdifferent indicators. In a normal,‘bell shaped’, distribution, 95% of caseslie within two standard deviations of the mean. Put simpler if there were100 children ranked by height, a difference of one standard deviation isequivalent to the difference between the 50th child and the 84th child.61Dercon S, Singh A (2011) From nutrition to aspirations and self-efficacy:gender bias over time among children in four countries. World DevelopmentVolume 45, May 2013, Pages 31–50 Cover image62Heckman J J, Stixrud J and Urzua S (2006) The effects of cognitive andnoncognitive abilities on labor market outcomes and social behavior,Journal of Labor Economics, University of Chicago Press, vol. 24(3),pages 411–482, July2  Economic impacts of malnutrition63World Bank (2006) Repositioning Nutrition as Central to Development: Astrategy for large scale action, Washington: The World Bank64Baird S et al (2011) Worms At Work: Long run impacts of child healthgains, Available at http://www.povertyactionlab.org/publication/worms-work-long-run-impacts-child-health-gainsHoddinott J et al (2008) Effect of a nutrition intervention during earlychildhood on economic productivity in Guatemalan adults, The LancetSave the Children (2012) A Life Free from Hunger: Tackling child malnutrition,London: Save the ChildrenDemment M W et al (2002) Providing micronutrients through food-basedsolutions: a key to human and national development, Journal of Nutrition,November 1, 2003 vol. 133 no. 11 3879S-3885S65Victoria et al (2008) Maternal and Child Undernutrition 2. Maternal andchild undernutrition: consequences for adult health and human capital.Published Online January 17, 2008DOI:10.1016/S0140-6736(07)61692-466A difference of one standard deviation in height-for-age was found to beassociated with 8% higher in income in Brazil and Guatemala among men;and as much as 25% higher income among women.Victoria et al (2008) Maternal and Child Undernutrition 2. Maternal and childundernutrition: consequences for adult health and human capital. PublishedOnline January 17, 2008DOI:10.1016/S0140-6736(07)61692-467Horton S. The economics of nutritional interventions. In R Semba andM Bloem, Nutrition and Health: Nutrition and health in developing countries(pp. 853-871).Totowa, NJ: Humana Press; 200868Hoddinott J et al (2008) Effect of a nutrition intervention during earlychildhood on economic productivity in Guatemalan adults, The Lancet69Hoddinott J et al (2011) The Consequences of Early Childhood GrowthFailure over the Life Course. IFPRI Discussion Paper 01073Hoddinott J et al (2012) Copenhagen consensus challenge paper: Hungerand Malnutrition.
  32. 32. foodforthought22Hoddinott J et al (2010) The impact of malnutrition over the life course.Available at http://www.chronicpoverty.org/uploads/publication_files/hoddinott-et_al_malnutrition.pdf70Thomas D and Strauss J (1997) Health and wages: evidence on men andwomen in urban Brazil, Journal of Econometrics, 77(1):159–8571Haddad L J, Bouis H E (1991) The impact of nutritional status onagricultural productivity: wage evidence from the Philippines, Oxford Bulletinof Economics and Statistics, 53:45–68Thomas D and Strauss J (1997) Health and wages: evidence on men andwomen in urban Brazil, Journal of Econometrics, 77(1):159–8572Demment M W et al (2002) Providing micronutrients through food-based solutions: a key to human and national development, Journal ofNutrition, November 1, 2003 vol. 133 no. 11 3879S-3885S73Among a sample of the working population in Ghana, a one standard-deviation increase in maths and reading scores has been associated with a22% increase in hourly earnings in the public sector, and as much as 33% inthe private sector. Glewwe, P (1996) The relevance of standard estimatesof rates of return to schooling for education policy: a critical assessment,Journal of Development Economics 51, 267–290In Pakistan a one-standard deviation improvement in reading and mathsscores has been shown to be associated with a 10%–12% increase inwages. Alderman, H., Behrman, J R, Ross, D R, Sabot, R (1996) The returnsto endogenous human capital in Pakistan’s rural wage labour market,Oxford Bulletin of Economics and Statistics 58, 29–5574Francis, B and Iyare S (2006), Education and development in theCaribbean: a cointegration and causality approach, Economics Bulletin,15 (2), 1–1375Islam,Tariq Saiful, Md Abdul Wadud, and Qamarullah Bin Tariq Islam,(2007) Relationship between education and GDP growth: a mutivariatecausality analysis for Bangladesh, Economics Bulletin,Vol. 3, No. 35 pp. 1–776Hanushek E A,Woessmann L (2009) Do Better Schools Lead to MoreGrowth? Cognitive skills, economic outcomes, and causation, NBER WorkingPaper No. 1463377Currie J,Vogl T (2012) Early life health and adult circumstance indeveloping countries, Princeton. Available at: http://www.princeton.edu/~tvogl/currie_vogl_AR.pdf78Martorell R et al (2010) Weight gain in the first two years of life is animportant predictor of schooling outcomes in pooled analyses from fivebirth cohorts from low- and middle-income countries, Journal of Nutrition,February 2010 vol. 140 no. 2 348–35479Baird S et al (2011) Worms At Work: Long run impacts of child healthgains.Available at http://www.povertyactionlab.org/publication/worms-work-long-run-impacts-child-health-gains80Currie J,Vogl T (2012) Early life health and adult circumstance indeveloping countries, Princeton. Available at: http://www.princeton.edu/~tvogl/currie_vogl_AR.pdf81Bloom, D E., Canning D, and Sevilla, J (2003).The Demographic Dividend:New perspectives on the economic consequences of population change,Rand, Santa Monica (CA)82Gupta R, (2009) Leveraging Indian talent pool and demographics tobuild competitive advantage, Education, Knowledge and Economy: Volume 3,Issue 3, 200983COM (2013) Towards a Demographic Dividend: Invest in healthand education. Available at: http://www.prb.org/pdf13/africa-demographicdividend-investments.pdf84The Human Capital Roots of the Middle Income Trap: The case of China,http://ageconsearch.umn.edu/bitstream/131119/2/iaae%20plenary%20paper_zhang%20et%20al_final_draft_Aug12.pdf85United Nations Population Division (2010) World Population Prospects,NewYork:The United Nations86World Food Programme and UN-ECLAC (2007) The Cost of Hunger:Analysis of the social and impact of child undernutrition in Latin America:Central America and the Dominican Republic87Horton S and Ross J (2003) The economics of iron fortification, FoodPolicy 28 (2003) 51–7588S Horton (2006) The economics of food fortification, Journal of Nutrition,136:1068–107189Stein A J, Qaim M (2007) The human and economic costs of hiddenhunger, Food & Nutrition Bulletin,Volume 28, Number 2, June 200790World Bank (2006) Repositioning Nutrition as Central to Development:A Strategy for Large Scale Action. Washington: The World Bank. China’sGDP today is $7.3tn.91Bhutta et al (2008) Maternal and Child Undernutrition 3.What works?Interventions for maternal and child undernutrition and survival. Publishedonline January 17, 200892World Food Programme and UN-ECLAC (2007) The Cost of Hunger:Analysis of the social and impact of child undernutrition in Latin America:Central America and the Dominican Republic93This is especially true given that it has been found, in some cases, thatimpacts of malnutrition on wages can be larger in non-farm settingsthan in farm settings. See Baird S et al (2011) Worms At Work: Long runimpacts of child health gains. Available at http://www.povertyactionlab.org/publication/worms-work-long-run-impacts-child-health-gains94Noorbakhsh F, Paloni A andYoussef A (2001) Human capital andFDI inflows to developing countries: new empirical evidence, WorldDevelopment, 29(9), pp. 1593–161095National IQ and National Productivity:The hive mind across Asia, GarettJones George Mason University – Department of Economics June 201196This analysis is taken from Save the Children’s research database andwill be presented in a forthcoming report,‘Getting to Zero’. DHS dataare publicly available for download at www.measuredhs.com. Comparisonof the poorest 40% against the richest 10% is an increasingly acceptedmeasure of the concentration of inequalities. See Cobham A (2013) Palmavs Gini: Measuring post-2015 inequality97Both maternal undernutrition and low maternal education are related topoorer nutritional status in offspring.98Lopez Boo, F and Canon M E (2013) Cognitive skills gaps in India: can(late) nutrition ameliorate them? Young Lives Working paper. See: http://www.aae.wisc.edu/mwiedc/papers/2013/canon_maria.pdf3  Interventions that make a difference99Save the Children (2012) A Chance to Grow, London: Save the ChildrenWiggins S, Keats S, (2013) Smallholder Agriculture’s Contribution to ImprovedNutrition, London: Overseas Development Institute100Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 2012101Alderman, H. and J. Behrman. (2006) Reducing the incidence of low birthweight in low-income countries has substantial economic benefits, WorldBank Research Observer 21 (1): 25–48102Glewwe, P, Jacoby H G and King E M (2001) Early childhood nutritionand academic achievement: a longitudinal analysis, Journal of PublicEconomics,Volume 81 (Issue 3): 345–368103Kramer M S, Fombonne E, Igumnov S, et al. Effects of prolonged andexclusive breastfeeding on child behavior and maternal adjustment:evidence from a large, randomized trial, Pediatrics 2008; 121: e435-40 citedin Walker et al 2011104Sachdev, H P S, Gera T and Nestel P (2006) Effect of ironsupplementation on physical growth in children: systematic review ofrandomized controlled trials, Public Health Nutrition 9(7), 904-920105Lozoff, B, Jimenez E and Smith J B (2006) Double burden of irondeficiency in infancy and low socio-economic status: a longitudinal analysisof cognitive test scores to 19 years, Archives of Pediatrics and AdolescentMedicine, 160(11), 1108–13
  33. 33. endnotes23106Lozoff, B, Jimenez E and Smith J B (2006) Double burden of irondeficiency in infancy and low socio-economic status: a longitudinal analysisof cognitive test scores to 19 years, Archives of Pediatrics and AdolescentMedicine, 160(11), 1108–13107UNICEF (2006) Progress for Children:A report card on nutrition, UNICEF,NewYork108Horton S (2006) The economics of food fortification, Journal of Nutrition,136:1068–1071109Save the Children (2013) Superfood for Babies: Ho overcoming barriersto breastfeeding will save children’s lives, London: Save the Children110Prado E, Dewey K, Insight Nutrition and brain development in early life,AT&TTechnical Brief, issue 4, January 2012111Koletzko B, Lien E,Agostoni C, Böhles H, Campoy C, Cetin I and Uauy,R (2008) The roles of long-chain polyunsaturated fatty acids in pregnancy,lactation and infancy: review of current knowledge and consensusrecommendations, Journal of Perinatal Medicine, 36(1), 5–14112Save the Children (2013) Superfood for Babies: How overcoming barriers tobreastfeeding will save children’s lives113Kramer M S, Fombonne E, Igumnov S, et al. Effects of prolonged andexclusive breastfeeding on child behavior and maternal adjustment:evidence from a large, randomized trial. Pediatrics 2008; 121: e435-40 citedin Walker et al 2011114Victora C G, Barros F C, Horta B L, Lima R C, Breastfeeding andschool achievement in Brazilian adolescents, Acta Paediatrica, 2005 Nov;94(11):1656–60115Anderson, J W, Johnstone B M and Remley D T, Breastfeeding andcognitive development: a meta analysis, American Journal of Clinical Nutrition,1999, 70:525–535116Grantham-McGregor, S. et al (1991) Nutritional supplementation,psychosocial stimulation, and mental development of stunted children: theJamaican Study, The Lancet, 338(8758), 1–5117Nahar B, Hossain M, Hamadani J, Ahmed T, Grantham-McGregor S, andPersson L A (2012) Effects of psychosocial stimulation on improving homeenvironment and child-rearing practices: results from a community-basedtrial among severely malnourished children in Bangladesh. BMC publichealth,12(1), 622118Psychosocial aspects of malnutrition management, chapter 8 inManagement of Acute Malnutrition in Infants (MAMI) Project Report.Availableat http://www.ennonline.net/pool/files/ife/mami-chapter-8-psychosocial-considerations.pdf4  Conclusion and recommendations119World Bank (2006) Repositioning Nutrition as Central to Development: Astrategy for large scale action, Washington: The World BankHoddinott J et al (2012) Copenhagen consensus challenge paper: Hungerand Malnutrition120Gyles C L (2012) Health economics and nutrition: a review of publishedevidence, Nutrition Review, 2012 December, 70(12):693–708121World Bank (2006) Repositioning Nutrition as Central to Development:AStrategy for large scale action, Washington: The World Bank122In May 2012, the World Health Assembly passed a resolution with sixnutrition targets with one of them being stunting. For more details seehttp://thousanddays.org/wp-content/uploads/2012/05/WHO-Targets-Policy-Brief.pdfAppendix 1123www.younglives.org.ukAppendix 2124World Bank (2006) Repositioning Nutrition as Central to Development: Astrategy for large scale action, Washington: The World BankWorld Food Programme and UN-ECLAC (2007) The Cost of Hunger:Analysis of the social impact of child undernutrition in Latin America: CentralAmerica and the Dominican Republic125World Bank (2006) Repositioning Nutrition as Central to Development: Astrategy for large scale action, Washington: The World Bank126Hoddinott, J et al (2011) The consequences of early childhood growthfailure over the life course, Mimeo, International Food Policy ResearchInstitute, Washington, DC127Bhutta, Z et al (2008) What works? Interventions for maternal and childundernutrition and survival, The Lancet 371: 417–440128It has been estimated that stunted children earn 22% less than theirnon-stunted counterparts, based on available longitudinal studies of theimpact of malnutrition on education, and evidence from 51 countriesof the impact of education on earnings. Grantham McGregor S (2007)Developmental potential in the first 5 years for children in developingcountries, The Lancet 369(9555): 60–70129For example, Horton estimates that the costs of underweight couldequate to 10% of earnings (Horton S, 2008, The Economics of NutritionInterventions. Nutrition and health in developing countries. pp 859–871).The World Bank estimates the costs of malnutrition in childhood are atleast 10-15% of earnings in adulthood (World Bank (2006) RepositioningNutrition as Central to Development: A Strategy for large scale action).130Hoddinott J et al (2012) Copenhagen consensus challenge paper:Hunger and Malnutrition.131Hoddinott J et al (2010) The impact of malnutrition over the life course.Available at http://www.chronicpoverty.org/uploads/publication_files/hoddinott-et_al_malnutrition.pdf
  34. 34. coverphoto:hildrenCOVERPhoto:jonathanhyams/savethechildreneveryone.orgfood for thoughtTackling child malnutrition to unlockpotential and boost prosperityIn the past two decades, progress in tacklingmalnutrition has been pitifully slow.In this report we demonstrate how investmentin nutrition is not only the right thing to do, it isa down-payment on future prosperity.The evidence we present shows that preventingmalnutrition of children and women in thecrucial 1,000-day window – from the start ofa woman’s pregnancy until her child’s secondbirthday – could greatly increase children’sability to learn and to earn, and could boostthe prosperity of whole countries.

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