1. Nutrition and early learning Aryeh D Stein, PhD Emory University
Early Learning: Status and The Way Forward
New Delhi, India
September 25-27, 2013

2. Overview Why focus on early nutrition?
Does early nutrition matter for education?
How much of a difference can we make?
Recommendations

3. vision of child development
Every child is unique
Children should develop according to their potential
Adequate, nutritious food
Safe, healthy environment
High-quality cognitive stimulation
Emotional support

4. Growth and Growth failure

5. Growth and growth failure
Growth happens when (and only when) food is not limiting
An individual child’s potential for growth is unknowable
Growth failure can only be measured in terms of a reference population
Growth failure results from deficits in one or more critical nutrients
Energy-providing (fat, carbohydrate)
Substrates (protein, calcium, fat)
Metabolically-important micronutrients (iron, zinc, B vitamins)
Rate-limiting nutrient not always obvious
More of the wrong nutrient(s) will not solve the underlying cause

6. Measuring child nutrition
Establishing individual nutritional need is challenging
Nutritional status is snapshot
Height / length for age
Weight for height
Micronutrient status
But it is a lagging indicator of the balance between intake and need

7. Growth failure happens early in life…
Victora et al, Pediatrics 2010

8. Most growth failure has happened by age 24 mo
Stein et al., Am J Hum Biol 2010 (updated)

9. Patterns of growth and growth failure
Stein et al., Am J Hum Biol 2010 (updated)

10. Conclusions about growth
Growth failure happens early in life
Populations that are short by age 2 remain short as adult (but in absolute terms they do not fall much further behind)
There is some evidence of ‘catch-up’ in HAZ at a population level
This is at least in part a methodological artifact

11. Child age and brain development

12. Human brain development
Grantham-McGregor et al., Lancet 2007

13. Growth failure and human capital

14. Schooling per SD of height at 2y
Victora et al, Lancet 2008

15. And more broadly, per 1 HAZ at age 2 y…
Cognitive:
Schooling – 0.8 grades more (mean of 4.7!)
0.25 SD increase in reading comprehension
0.25 SD increase in non-verbal comprehension (Raven’s)
Marriage and fertility:
Partner 1.4 y older, 1.0 y more schooling, 1.0 cm taller
Age at first birth 0.8 y later; 0.63 fewer pregnancies; 0.43 fewer children (women)
Economics:
20.9% increase in household expenditures
10.1 pp decrease in prevalence of living in poverty
Health:
5% increase in grip strength
No association with overweight/obesity, BP, glucose
Hoddinott et al., AJCN 2013

16. Child growth and cognitive achievement at age 8y
Crookston et al., AJCN in press

17. Stunting and cognitive achievement at 8 y
Crookston et al., AJCN in press

18. Conclusions about growth and cognitive functioning and schooling
Children who experience growth faltering stay in school fewer years, perform less well on standardized tests, and have diminished life prospects
Growth recovery after early childhood associated with partial recovery of cognitive function

19. What is the role of nutrition in the association between growth patterns and cognitive outcomes?

20. Nutrition, Growth, Cognition
Cognitive achievements
Food
ECCD / Schooling

21. Do nutrition interventions make a difference?

22. INCAP nutrition trial follow-up

23. Intakes in children 15-36 mo
Intervention design
2 larger villages
2 smaller villages
Atole
Fresco
Atole
Fresco
Intakes in children mo
Atole
Fresco
Ingredients (g/180 ml)
Incaparina
13.5 -
Dry skim milk
21.6
Sugar
9.0
13.3
Flavoring agent
2.1
Nutrients per 180 ml
Energy (kcal)
163 59
Protein (g)
11.5
PROTEIN
ENERGY
INTAKE
FROM
SUPPLEMENT
INTAKE
FROM
DIET

24. Yes, for growth Severe stunting (%)
Severe stunting = HAZ <-3.0 at age 3 y
Habicht and Martorell J Nutr 2010

25. Yes, for Schooling Girls: 1.17 grades
Boys: No impact on schooling attainment
“The intervention had the effect of promoting greater equality of schooling attainment between women and men, compared to their parents, as it was more effective in the subpopulation (i.e., women) with lower previous schooling.”
Maluccio et al, Econ J, 2009

26. Yes, for intellectual capacity
Stein et al., APAM 2009

27. Yes, for Income and productivity
Wages
34% to 46% higher
Annual hours worked
222 Lower
(CI: -572 to 128)
Annual income
US$ 914 higher
(CI: -$190, $2018)
Hoddinott et al. Lancet 2008.

28. Conclusions about nutrition interventions
In at least one context, supplementation of pregnant women and young children with a nutritious complementary food made a substantial difference in the growth, schooling, cognitive functioning, and economic productivity of the children as adults.
As with all randomized trials, generalization to other contexts must be considered carefully.

29. Which nutrition interventions?
WHAT?
WHY?
WHO?

30. What? - What should be the focus?
Food
Prepared meals
Nutrient supplements
Single nutrients
Multiple micronutrients
Other factors
Animal-source foods
Dietary fats
DHA
Energy
Carbohydrates
Added sugars
Zinc
Vitamin A
Calcium
B group vitamins
Iron
Diet overall

31. WHY? - What is the objective?
Improve growth
Improve micronutrient status
Improve physiologic parameters
Immune function
Oxidative stress
Encourage participation in ECCD or schooling activities

32. WHO? - Who should be the focus?
Pregnant and lactating women
Infants (6 mo - 2 /3 y)
Preschool children (3-6 y)
Elementary school children (6-11 y)
Adolescents (12 +)
Working adults
Elderly

33. Discussion and recommendations
Nutrition for prevention has to happen early in life, the earlier the better
First 1000 days
High-quality food in sufficient quantities to meet energy needs will also meet needs for all micronutrients
Single-nutrient interventions are unlikely to have generalizable impacts
Food as a participation incentive may be a useful adjunct to a high-quality educational program
Food is not a panacea
Cognitive development requires cognitive stimulation
Good nutrition can increase the efficiency of good teaching
Macronutrient / micronutrient density
Risk for overweight/obesity

34. Rates of return to investments in human potential
Heckman, Science 2006

35. Acknowledgements Funding for research: Other:
US National Institutes of Health
Wellcome Trust
Bill and Melinda Gates Foundation
Other:
CARE-India, CARE-USA
Colleagues and study participants

36. Thank you