Optimal Nutrition for Human Development

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• Optimal Nutrition for Human Development

Reynaldo Martorell Hubert Dept. of Global Health
Rollins School of Public Health Emory
University Atlanta, Georgia
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Gestation and the first 2 years of life represent
a window of vulnerability for human development

• High nutritional requirements
• Rapid growth and development
• Greater susceptibility to infections
• Fully dependent on others for care

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Malnutrition begins in utero About 17 of
newborns in developing countries are born with
low birth weight (UNICEF, 2006)
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• Linear growth failure continues during the first
  two years
• The short stature of adults in poor countries is
  a result of early life growth failure

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Mean Z-scores for height-for-age relative to the
new WHO standards for Peru, 2000
Z
Age (months)
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Dietary Recommendation for Iron (mg/kg/day) from
high quality diets
Infant, 9 months
Adult Male
Dietary Reference Intakes. IOM, 2006.
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Percent of time ill with diarrhea INCAP
Longitudinal Study (1969-1977)

Age (months)
Martorell et al, 1975
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Neurological development in early life

• Brain development early life is dramatic and
  depends on the interaction between genes and how
  the child experiences the world.
• Nutrition, child care and stimulation in early
  life effect directly the wiring of the brain and
  this has a decisive and lasting effects on
  learning capacity, behavior and the ability to
  regulate emotions.

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Three challenges in nutrition to advance human
development

• Improve nutrition during pregnancy
• Improve rates of exclusive breastfeeding
• Improve complementary feeding behaviors and
  dietary quality

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Human milk is the ideal nourishment for infants

• WHO recommendation Exclusive breastfeeding to
  six months of age and continued breastfeeding
  into the second year
• Only one out of every three children is
  exclusively breastfed for the first six months in
  the developing world ( UNICEF, 2006)
• Benefits of breastfeeding better survival,
  less diarrhea, better growth and development,
  lower risk of obesity
• Risk can transmit HIV infection

UNICEF/C-79-10
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Meta-Analysis of controlled trials of vitamin A
supplementation and child mortality
Beaton and Martorell (Co-chairs), ACC/SCN, 1993
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The challenge of improving complementary feeding

• Early introduction of complementary foods
• Late introduction of complementary foods
• Low energy density foods
• Lack of micronutrient rich foods
• Too few meals
• Passive feeding by mother
• Withholding of foods from sick children
• Contaminated foods

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Zinc and Iron

• Where diets are plant-based and intakes of animal
  foods low, the risk of inadequate intakes of both
  zinc and iron is very high, even when energy and
  protein intakes meet recommended levels (Gibson,
  1994)

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Zinc supplementation and morbidity in children
pooled analysis of randomized controlled trials
95 C.I.
Incidence reduction
Diarrhea -18
-28 to -7
Pneumonia - 41
-59 to -27
Zinc Investigators Collaborative Group, J
Pediatr 1999 135689-97
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Prevalence of anemia in pregnant women
From data in Mason et al, 2001
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Mg of iron that need to be absorbed per day to
maintain iron balance (IOM, 2006)
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Consequences of anemia

• Reduced work capacity
• Increased maternal mortality during delivery
• Low birth weight
• Impaired cognitive development and learning
• Depression

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How do children from around the world grow when
their physical and psycho-social needs are met
during the vulnerable period of pregnancy and 0-2
y?


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The WHO Multicentre Growth Reference Study (MGRS)
uses a prescriptive approach and is therefore a
Standard

• Optimal Nutrition
• Breastfed infants
• Timely complementary feeding
• Optimal Environment
• Adequate environmental sanitation
• No maternal smoking
• Optimal Health Care
• Immunization
• Routine Paediatric care

Optimal Growth
WHO Multicentre Growth Reference Study
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Mean length from birth to 24 months for the six
MGRS sites
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What accounts for the striking similarity in the
growth of young children from around the world
who are raised in adequate environments?


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A Geographically Explicit Genetic Model of
Woldwide Human-Settlement History ( Hua Liu et
al, Am.J.Hum.Genet. 79230-237, 2006)

• Recent common origin from East Africa (56,000
  years ago)
• Humans are very homogenous compared to other
  primates (migration out of Africa from a small
  founding population of 1000 individuals)
• Success in replacing other hominids probably due
  to language and a more complex culture, outcomes
  of the human pattern of growth and development

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Repositioning nutrition as central to development
(World Bank, 2006)

• Nutrition is not only a matter of welfare or
  human rights
• Nutrition is an economic investment an engine of
  economic growth

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What happens when nutrition is improved during
the Window of Vulnerabilty/Opportunity ?
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INCAP longitudinal study , 1969-77

• Community-randomized supplementation trial
• Two villages received Atole, a nutritious
  supplement made from Incaparina, milk and sugar,
  and two received Fresco, a less nutritive drink

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Impact on total nutrient intakes and on growth

• Total diets of young children from Atole
  villages were greater by 9 g of protein, 100
  kcal/day and in micronutrients when compared to
  diets of children from Fresco villages
• Length was increased by 3 cm but only in the
  first three years of life

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Nutrition, human capital and economic
productivity (2002-04)
Emory
INCAP
Univ. of Penn.
IFPRI
Funded by Fogarty International Center, NIH and
NSF
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Human Capital Study 2002-04 age 32 years

• Original sample 2393
• Possible sample 1856,
• Achieved 1560 (84 )

Subjects living in Guatemala in 2002. 272
died, mostly in early childhood, 163 left the
country 102 were lost to follow up.
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Human Capital measures

• Schooling
• Intelligence
• (Raven test)
• Reading
• ability (Inter- American
• Reading test)

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Econometric analysis of exposure to improved
nutrition from 0-3 years of age on education
(n1469)

• Schooling Effects found in women only
• -- Improved by 1.2 years
• Cognition Effects found in men and women
• Improved Raven scores by 8
• Reading Effects found in men and women
• Improved scores by 17

Maluccio, Hoddinott, Behrman, Martorell,
Quisumbing Stein. The impact of a nutrition
experiment in childhood on education in
Guatemalan adults. The Economic Journal, under
review Raven Progressive Matrices
Inter-American Reading Series
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Economics and Household Composition 2002-04 Human
Capital Study

• History of occupation and employment
• Annual household expenditure of
• Food
• Goods and services
• Productivity and income of individuals
• Salaried
• Non-salaried
• Wealth and Assets

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Exposure to improved nutrition ( atole) and
income

• Exposure to improved nutrition before, but not
  after 3 years, improved incomes in men but not
  women
• Wages increased by 34 to 47 for various
  definitions of the window of exposure from 0-3 y.
• Exposure from 0-2 years had the greatest impact
• - Wages were increased by US 0.69 (CI
  0.18,1.19)
• - Annual incomes were increased by US 914 (
  CI -190, 2018)

Nutrition in early childhood and income of
Guatemalan adults A follow-up, more than
twenty-five years later, of a community-randomized
supplementation trial (J Hoddinott, J Behrman,
J Maluccio R Flores and R Martorell), The Lancet
, under review)
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Stunting ( low lenght for age ) vs underweight
(low weight for age) as indicators of human
development
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Distribution in reference population
-1 S.D.
-2 S.D.
Standard Deviations
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Millennium development goal of eradicating
hunger reducing 1990 levels of underweight by
50 by 2015

Source Estimates from de Onis and Blossner 2003.
WHO.
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Prevalence of anthropometric indicators in
children lt5y using NCHS/WHO 1978 and WHO 2006
curves for Peru ( DHS, 2000)

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• Conclusions (1)
• P 2y window of opportunity
• Healthy young children from around the world
  have similar growth patterns

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• Conclusions (2)
• Nutrition interventions during early life are
  drivers of long-term economic growth
• Underweight is a poor measure of human
  development length/height is the preferred
  indicator