Nutrition, Adult Cognitive Skills, and Productivity: Results and Influence of the INCAP Longitudinal Study.

This article summarizes research based on the INCAP Longitudinal Study that demonstrates the positive effects of the atole intervention on prime-age adult cognitive skills and productivities. The findings are interpreted in the context of a life-cycle stages model in which various factors and investments at each stage of life influence outcomes not only in that stage but in subsequent ones. The results point to the likely importance of improvements in adult cognitive skills due to better early-life nutrition on adult male labor market outcomes as well as on women's "home productivity" in terms of anthropometrics for the next generation. Possible mechanisms are also explored, including the impacts of early-life exposure to atole on children's height when starting school, on grades of schooling attainment, and on the extent of experience with higher-skilled jobs, as well as the impacts of improved cognitive skills on wages. Not only are investments in early-life nutrition important for immediate welfare but also they have significant productivity payoffs in adulthood.

Setting research priorities on multiple micronutrient supplementation in pregnancy.

Prenatal micronutrient deficiencies are associated with negative maternal and birth outcomes. Multiple micronutrient supplementation (MMS) during pregnancy is a cost-effective intervention to reduce these adverse outcomes. However, important knowledge gaps remain in the implementation of MMS interventions. The Child Health and Nutrition Research Initiative (CHNRI) methodology was applied to inform the direction of research and investments needed to support the implementation of MMS interventions for pregnant women in low- and middle-income countries (LMIC). Following CHNRI methodology guidelines, a group of international experts in nutrition and maternal health provided and ranked the research questions that most urgently need to be resolved for prenatal MMS interventions to be successfully implemented. Seventy-three research questions were received, analyzed, and reorganized, resulting in 35 consolidated research questions. These were scored against four criteria, yielding a priority ranking where the top 10 research options focused on strategies to increase antenatal care attendance and MMS adherence, methods needed to identify populations more likely to benefit from MMS interventions and some discovery issues (e.g., potential benefit of extending MMS through lactation). This exercise prioritized 35 discrete research questions that merit serious consideration for the potential of MMS during pregnancy to be optimized in LMIC.

Review of the evidence regarding the use of antenatal multiple micronutrient supplementation in low- and middle-income countries.

Inadequate micronutrient intakes are relatively common in low- and middle-income countries (LMICs), especially among pregnant women, who have increased micronutrient requirements. This can lead to an increase in adverse pregnancy and birth outcomes. This review presents the conclusions of a task force that set out to assess the prevalence of inadequate micronutrient intakes and adverse birth outcomes in LMICs; the data from trials comparing multiple micronutrient supplements (MMS) that contain iron and folic acid (IFA) with IFA supplements alone; the risks of reaching the upper intake levels with MMS; and the cost-effectiveness of MMS compared with IFA. Recent meta-analyses demonstrate that MMS can reduce the risks of preterm birth, low birth weight, and small for gestational age in comparison with IFA alone. An individual-participant data meta-analysis also revealed even greater benefits for anemic and underweight women and female infants. Importantly, there was no increased risk of harm for the pregnant women or their infants with MMS. These data suggest that countries with inadequate micronutrient intakes should consider supplementing pregnant women with MMS as a cost-effective method to reduce the risk of adverse birth outcomes.

Exposure to improved nutrition from conception to age 2 years and adult cardiometabolic disease risk: a modelling study.

BACKGROUND: Low-income and middle-income countries with populations that are chronically undernourished in early life are undergoing a nutrition transition and are experiencing an epidemic of cardiometabolic disease. These dual burdens are thought to be causally related; therefore, the extent to which improvements in early-life nutrition can offset adult-onset disease is important. The aim of this study was to examine whether improvement of protein-energy nutrition from conception to age 2 years can attenuate the risk of cardiometabolic disease. METHODS: We followed up a cohort of 2392 individuals born between Jan 1, 1962, and Feb 28, 1977, in four villages in Guatemala who had participated in a cluster-randomised protein-energy nutritional supplementation (Atole) trial. Of 1661 participants available for follow-up from Feb 26, 2015, to April 29, 2017, we studied 684 women and 455 men. We assessed cardiometabolic disease risk at ages 37-54 years using anthropometry, fasting and post-challenge glucose, fasting lipid concentrations, and blood pressure. We used generalised linear and logistic regression modelling to estimate the effect of Atole from conception to age 2 years (the first 1000 days) on cardiometabolic disease risk. FINDINGS: Exposure to Atole from conception to age 2 years was associated with increased fatness (body-mass index [1·29 kg/m2, 95% CI 0·08 to 2·50], body fat [1·73%, 0·20 to 3·26], and obesity [odds ratio 1·94, 1·11 to 3·40]), diastolic blood pressure (1·59 mm Hg, -0·74 to 3·92), and blood lipids (total cholesterol [10·10 mg/dL, 0·80 to 19·40] and non-HDL cholesterol [10·41 mg/dL, 1·51 to 19·31]), reduced post-challenge glucose (-5·84 mg/dL, -12·51 to 0·83), and reduced odds of diabetes (odds ratio 0·46, 0·21 to 0·97). We found stratum heterogeneity by sex in pooled models for non-HDL cholesterol (4·34 mg/dL, 95% CI -6·86 to 15·55 for women vs 19·84 mg/dL, 5·86 to 33·82 for men) and post-challenge glucose (-0·19 mg/dL, -8·63 to 8·24 for women vs -13·10 mg/dL, -23·64 to -2·56 for men). p values for interaction of sex and exposure to Atole from conception to age 2 years were 0·09 and 0·04, respectively. INTERPRETATION: Improved protein-energy nutrition from conception to the 2nd birthday reduced the odds of diabetes at ages 37-54 years; however, this protein-energy supplementation also increased the risk of obesity and several obesity-related conditions. Our findings suggest a mixed ability of protein-energy nutritional supplementation in early life to prevent adult cardiometabolic disease incidence in the context of high childhood stunting and high adult overweight and obesity. FUNDING: National Institutes of Health.

Randomized control trials demonstrate that nutrition-sensitive social protection interventions increase the use of multiple-micronutrient powders and iron supplements in rural pre-school Bangladeshi children.

OBJECTIVE: To examine the impact of a nutrition-sensitive social protection intervention on mothers' knowledge of Fe deficiency, awareness of multiple-micronutrient powders (MMP) and the consumption of MMP and other Fe supplements by their children aged 6-59 months. DESIGN: Two randomized controlled trials with treatment arms including cash transfers, food transfers, cash and food transfers, cash and nutrition behaviour change communication (BCC), and food and nutrition BCC were implemented over two years. Both included a control group that received no transfer or BCC. Transfer recipients were mothers living in poor households with at least one child aged less than 2 years at baseline. Probit models were used to analyse endline data. SETTING: Rural areas in north-west and south Bangladesh. SUBJECTS: Mothers (n 4840) and children 6-59 months (n 4840). RESULTS: A transfer accompanied by nutrition BCC increased the share of mothers with knowledge of Fe deficiency (11·9 and 9·2 percentage points for North and South, respectively, P≤0·01), maternal awareness of MMP (29·0 and 22·2 percentage points, P≤0·01), the likelihood that their children 6-59 months had ever consumed MMP (32 and 11·9 percentage points, P≤0·01), consumed MMP in the preceding week (16·9 and 3·9 percentage points, P≤0·01) and consumed either MMP or an Fe supplement in the preceding week (22·3 and 7·1 percentage points, P≤0·01). Improvements were statistically significant relative to groups that received a transfer only. CONCLUSIONS: Nutrition-sensitive social protection (transfers with BCC added) may be a promising way to advance progress on micronutrient deficiencies.

The investment case for folic acid fortification in developing countries.

There is compelling evidence that neural tube defects can be prevented through mandatory folic acid fortification. Why, then, is an investment case needed? At the core of the answer to this question is the notion that governments and individuals have limited resources for which there are many competing claims. An investment case compares the costs and benefits of folic acid fortification relative to alternative life-saving investments and informs estimates of the financing required for implementation. Our best estimate is that the cost per death averted through mandatory folic acid fortification is $957 and the cost per disability-adjusted life year is $14.90. Both compare favorably to recommended life-saving interventions, such as the rotavirus vaccine and insecticide-treated bed nets. Thus, there is a strong economic argument for mandatory folic acid fortification. Further improvements to these estimates will require better data on the costs of implementing fortification and on the costs of improving compliance where regulations are already in place.

Nutritional supplementation in girls influences the growth of their children: prospective study in Guatemala.

BACKGROUND: Better early childhood nutrition improves schooling, adult health, skills, and wages, but there is little evidence regarding its effect on the next generation. OBJECTIVE: We assessed whether nutritional supplementation in children aged <7 to 15 y affected their children's nutritional status 29-38 y later. DESIGN: We studied 791 children 0-12 y who were offspring of 401 Guatemalan women who had participated as children in a nutritional supplementation trial in which 2 villages were randomly assigned to receive a nutritious supplement (atole) and 2 were assigned to receive a less-nutritious supplement (fresco). We compared anthropometric indicators between the offspring of mothers exposed to atole and the offspring of mothers exposed to fresco. RESULTS: Compared with the offspring of women exposed to fresco, the offspring of women exposed to atole had a 116-g (95% CI: 17, 215 g) higher birth weight, were 1.3-cm (0.4, 2.2 cm) taller, had a 0.6-cm (0.4, 0.9 cm) greater head circumference, had a 0.26 (0.09, 0.43) greater height-for-age z score, and had a 0.20 (0.02, 0.39) greater weight-for-age z score. The association for height differed by offspring sex. Sons of women exposed to atole were 2.0-cm (95% CI: 1.0, 3.1 cm) taller than the sons of women exposed to fresco. Supplementation was not associated with 6 other offspring anthropometric indicators that reflect measures of adiposity. Supplementation in boys did not affect their children's anthropometric measures. CONCLUSION: Nutritional supplementation in girls is associated with substantial increases in their offsprings' (more for sons) birth weight, height, head circumference, height-for-age z score, and weight-for-age z score.

Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults.

BACKGROUND: Substantial, but indirect, evidence suggests that improving nutrition in early childhood in developing countries is a long-term economic investment. We investigated the direct effect of a nutrition intervention in early childhood on adult economic productivity. METHODS: We obtained economic data from 1424 Guatemalan individuals (aged 25-42 years) between 2002 and 2004. They accounted for 60% of the 2392 children (aged 0-7 years) who had been enrolled in a nutrition intervention study during 1969-77. In this initial study, two villages were randomly assigned a nutritious supplement (atole) for all children and two villages a less nutritious one (fresco). We estimated annual income, hours worked, and average hourly wages from all economic activities. We used linear regression models, adjusting for potentially confounding factors, to assess the relation between economic variables and exposure to atole or fresco at specific ages between birth and 7 years. FINDINGS: Exposure to atole before, but not after, age 3 years was associated with higher hourly wages, but only for men. For exposure to atole from 0 to 2 years, the increase was US$0.67 per hour (95% CI 0.16-1.17), which meant a 46% increase in average wages. There was a non-significant tendency for hours worked to be reduced and for annual incomes to be greater for those exposed to atole from 0 to 2 years. INTERPRETATION: Improving nutrition in early childhood led to substantial increases in wage rates for men, which suggests that investments in early childhood nutrition can be long-term drivers of economic growth.