A presentation by Linda Adair as part of the Childhood Risk and Resilience panel discussion at the International Symposium on Cohort and Longitudinal Studies in Developing Contexts, UNICEF Office of Research - Innocenti, Florence, Italy 13-15 October 2014

1. Relating early childhood to adult
outcomes: Evidence from the Cebu
Longitudinal Health and Nutrition Survey

2. The Cebu Longitudinal Health and
Nutrition Survey (CLHNS)
Historical Context
• Desire to develop a
multipurpose demographic
survey to assess inputs to, and
consequences of maternal and
child nutrition and health
• Early 1980s concern with
effects of infant feeding on
morbidity and growth
Why Cebu?
• Availability of population
institute with capacity to launch
large, longitudinal study
• Heterogeneity of infant feeding
in urban and rural communities
• Support of the Mayor of Cebu

3. CLHNS design was based on the Mosley
& Chen Health Determinants model
HEALTH OUTCOME
(growth, mortality)
PROXIMATE
(nutrition, infection)
UNDERLYING
(SES, environment)

4. The CLHNS population included residents of 17
urban and 16 rural barangays of Metro Cebu
Cebu Province
Metro Cebu
Philippines

5. Sample
• Baseline (1883-4) All pregnant
women in 33 randomly selected
communities invited to participate
• Data collected at 30 weeks
gestation (N=3,327), then during
multiple follow-up surveys
• 3,080 single live births form
the one year birth cohort

6. Follow-up Surveys
Year N Age
1984 3080 0
1986 2550 2
1991 2264 8.5
1994 2197 11.5
1998 2117 15.5
2002 2029 19
2005 1889 21-22
2007-08 1842 24-26

7. Multilevel data collection:
Individual, Household and Community
• Health
• Anthropometry
• Diet
• Activity
• IQ
• Schooling
• Work
• Environment
• Income, assets

8. 1998 and 2005 Biomarkers
• Blood pressure
• Fasting blood samples
– Glucose, insulin, adiponectin
– Plasma lipids
– Inflammatory/immune markers
– DNA extracted, analyzed with Metabochip

9. Socioeconomic Trends in the
Philippines
• Cebu: fastest growth area in the Philippines
• Increased GNP and per capita income
• High ownership of TVs, phones
• High rates of secondary school completion and
college education compared with most other low
income Asian countries (esp. among women)
• High degree of urbanization

10. Pregnancies occurred in context of high maternal
undernutrition
Offspring grew up in an increasingly obesogenic
environment
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
Underweight OverweightObese Obese
1984 1986 1991 1994 1998 2002 2005 2013

11. Infant and young child outcomes
At Birth
11.5% LBW (<2.5 kg)
12.9% Preterm (<37 weeks gestation)
~23% Small for Gestational Age
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Prevalence of Stunting (LAZ < -2)
Males Females
0 2 4 6 8 10 12 14 16 18 20 22 24
Age in months

12. What happens to children who
were stunted at age 2?
IQ
School Attainment
Work
Cardiovascular disease risk

13. Young adult outcomes in those stunted
vs not stunted at age 2 yr
Not stunted Stunted
Stunted as adult 0.13 0.57
Did not complete
High School 0.20 0.35
Overweight 0.14 0.06
Centrally obese 0.16 0.10
Pre/hypertensive 0.12 0.09
Prediabetes/diabetes 0.01 0.01

14. Early growth is strongly correlated with IQ,
Schooling and Work Outcomes
IQ and achievement test scores vary directly with
height-for-age Z score at age 2
55
50
45
40
-3 -2 -1 0
IQ
34
32
30
28
26
24
22
20
-3 -2 -1 0
English Math
Predicted means, adjusted for parental characteristics and SES

15. Schooling status of CLHNS young
adults at age 21 years
0 200 400 600 800 1000
males
females
males
females
Primary or less Some HS HS Grad College
Not
Enrolled
Still
Enrolled
(18%)

16. IQ and Achievement: Unlike other low income countries in
Asia and worldwide, females have higher IQ and
achievement test scores
0.3
0.25
0.2
0.15
0.1
0.05
0
-0.05
-0.1
-0.15
-0.2
-0.25
females males
IQ Cebuano Math English
SD’s

17. Deficit in attained schooling of Filipino young adults associated with
stunting at age 2 (compared to those with Z-score>-1)
Crude vs. adjusted for household wealth and maternal education
0
-0.5
-1
-1.5
-2
-2.5
-3
-3.5
Note that this association is not CAUSAL, but poor growth and poor attainment
share common underlying determinants
Girls Boys
crude adjusted
<-3 -3 to -2 -2 to -1
0
-0.5
-1
-1.5
-2
-2.5
-3
-3.5
crude adjusted
<-3 -3 to -2 -2 to -1
Years of schooling
Length Z score at age 2 (WHO standard)

18. Odds of attaining some college education for those
with mild, moderate or severe stunting at age 2
1.2
1
0.8
0.6
0.4
0.2
0
Crude Adjusted Adjusted + IQ
Mild = LAZ -1 to -2, moderate=LAZ -2 to -3 severe= <-3

19. 0
-0.5
-1
-1.5
-2
-2.5
-3
0 5 10 15 20
0
-0.5
-1
-1.5
-2
-2.5
-3
0 5 10 15 20
Height Z-scores
according to
school attainment
at age 18
Started college
Finished HS
In school, behind
Late drop out
Early drop out

20. Does faster linear growth from 2-8 yr relate differently to
attained schooling in kids who were stunted at age 2?
Stunted Not Stunted
b/ci95 b/ci95
Mother's height 0.01 0.01
-0.02,0.04 -0.04,0.05
Wealth 0.27*** 0.09
0.17,0.36 -0.00,0.18
Mother's education 0.33*** 0.34***
0.28,0.39 0.27,0.40
Child sex -1.03*** -1.09***
-1.31,-0.75 -1.47,-0.71
Faster relative weight gain 2-8 yr -0.20** 0
-0.34,-0.06 -0.21,0.20
Faster linear growth 2-8yr 0.15* 0.17
0.01,0.29 -0.04,0.37
N 1292 623

21. Stunting and young adult
employment
• Declines in Traditional, labor intensive jobs and
increases in service industry and “high tech” jobs have
increased demand for higher education
• Does nutritional history matter?
– Height requirements for jobs
• Young adult employment status categorized as:
– Not working
– Employed in informal sector
– Employed in formal sector (work >=40 hrs, have benefits
and greater than minimum wage)
• Analysis stratified by current schooling status (still in
school or not)

22. Likelihood of formal sector work
increases with childhood length Z-score
at age 2 in young adults
2
1.8
1.6
1.4
1.2
1
0.8
0.6
Formal vs.
Not Working
Males Females
+schooling Formal vs.
Informal
+schooling
2
1.8
1.6
1.4
1.2
1
0.8
0.6
Formal vs.
Not Working
+schooling Formal vs.
Informal
+schooling
Schooling is an important mediator of this relationship

23. Weight status and CVD risk factors
100%
80%
60%
40%
20%
0%
<18.5 18.5-25 25-30 >30
females males

24. In a sample where 23% of infants were born SGA,
CVD risk factors have become prevalent:
0.4
0.3
0.2
0.1
0
Levels of CVD risk factors in young adults
Males Females
BMI>25 HTN FG>110 TC>200 LDL>130 HDL<35 TG>200 CRP>3 HOMA>4.65

25. 19
18
17
16
15
14
13
12
11
0 2 4 6 8 10 12 14 16 18 20 22 24
Body Mass Index
Age in months
21.75
21.25
20.75
20.25
19.75
19.25
18.75
Adult Body Mass Index
15.8
15.3
14.8
14.3
Lean Mass Index
Infant BMI trajectories in
the first 2 years relate to
adult BMI and Lean Mass

26. Systolic Blood Pressure
4
3.5
3
2.5
2
1.5
1
0.5
0
-0.5
-1
-1.5
Cebu M
Cebu F
pooled
Weight relative to linear growth Linear growth relative to weight gain
Birth 24 m MC Adult 24 m MC Adult
* Significant sex-site heterogeneity
mm Hg

27. -0.2 -0.1 0 0.1 0.2 0.3
21
15
11
8
2
1
0.5
0
Cebu Males
Relative
Weight Gain
CRP
HOMA-IR
Adiponectin
Insulin
Glucose
TG
LDL
HDL
DBP
SPB

28. Positive deviants: do some stunted
children end up as healthy adults?
• “Healthy” adults defined as those with normal
weight (BMI>25 kg/m2), no abdominal obesity
(WHtR<0.5), normal blood pressure, normal
fasting glucose, not stunted, high school
graduates
• 22% of children stunted at age 2 were
“healthy” as adults, 45% of children not
stunted at age 2 were “healthy” adults

29. Positive Deviants
Not stunted at 2 yr Stunted at 2 yr
Unhealthy Healthy Unhealthy Healthy
N=346 N=286 N=1014 N=283
Baseline Maternal
Height 151.9 152.9 149.1 151.6*
Education (~yrs) 7.9 8.4 6.2 6.8*
Wealth Index 0.60 0.73 -0.45 -0.19
Hygiene Score 6.41 6.65 5.83 6.01*
Urbanicity Score 31.54 31.64 28.75 26.82*
Infant
%male 0.55 0.44 0.57 0.45
Birth weight (kg) 3.12 3.15 2.92 3.03
Birth Length (cm) 50.0 50.1 48.5 49.2
BW<2.5 kg 0.04 0.04 0.14 0.09
SGA 0.17 0.16 0.29 0.21
Firstborn 0.27 0.29 0.19 0.17
BF duration (months) 12.53 13.34 14.88 14.57
HAZ at age 2 1.37 1.31 -3.22 -2.77
Significant predictor of membership in this group vs stunted unhealthy (mlogit)

30. Implications
• What are the outcomes of stunted children?
– Lower IQ, lower school attainment
– Short adult stature
– Reduced likelihood of obesity and CVD risk
• Tracking of risk established in the first 2 years is
substantial, but a small proportion of stunted
children become “healthy” adults
• Promoting early linear growth and preventing
excess child to adolescent weight gain should be
strong priorities

31. Collaborations
• Carolina Population Center, University of North Carolina at Chapel Hill
• Office of Population Studies Foundation, University of San Carlos, Cebu,
Philippines
• Northwestern University, Evanston, Illinois
• Johns Hopkins University, Baltimore, Maryland
Funding
NHLBI: R01-HL 085144
NIDDK:R01-DK 078150
NICHD:R01-HD 054501
NIH, Ford Foundation, Nestle Research Foundation,
Thrasher Foundation, World Bank, Asian Development
Bank