food for thought Tackling to unlock potential and boost prosperity food for thought 165 million children globally are chronically malnourished. This not only causes the death of one child every 15 seconds but locks in lifelong problems for millions more. It’s a huge problem – but also a huge opportunity.

THE PROBLEM OPPORTUNITY LT HEA H 38% of children from the least Better childhood could developed countries have had their cut stunting by 1/3 and reduce health issues, from diarrhoea and pneumonia growth stunted by malnutrition to deaf-mutism

+13% Malnourished children score 7% lower in maths Well nourished children are tests and are 19% less likely to 13% more likely to be in be able to read aged 8 the correct grade at school, boosting lifelong skills

EDUCATION The poorest 40% are 2.8 times more likely to suffer the long-term Good health and jobs effects of malnutrition than the break the cycle of poverty richest 10% and ensure that every child EQUALITY gets a chance to thrive

$100 Poor health and education limit By improving health and job prospects. Childhood education, good nutrition leads malnutrition cuts future to a more skilful and earnings by at least 20% dynamic workforce

JOBS

In total, current childhood malnutrition could cost the global economy $125bn when today’s Fixing malnutrition now could bring economic benefits over 100 children grow up times as large as the costs of interventions EC ONOMY

Sources: UNICEF, 2013, Improving Child Nutrition: The achievable imperative for global progress; Save the Children, 2013, Food for Thought food for thought Tackling child malnutrition to unlock potential and boost prosperity

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.

Acknowledgements This report was written by Liam Crosby, Daphne Jayasinghe and David McNair, all from Save the Children. Other colleagues from across Save the Children were involved in the development of the concept, and provided useful input into earlier drafts. We are grateful to Paul Dornan and Maria Ogando Portela at the University of Oxford for their excellent analysis. Without implication, we thank Lawrence Haddad, Julie Ruel-Bergeron, Hannah Theobald and Katie Alcock for their insightful comments on a previous draft.

Published by Save the Children 1 St John’s Lane London EC1M 4AR UK +44 (0)20 7012 6400 savethechildren.org.uk

First published 2013

© The Save the Children Fund 2013

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Cover photo: Shamsia, age one, and her , Lantana, from Niger (Photo: Jonathan Hyams/Save the Children)

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Executive summary iv

1 Early nutrition, cognitive development and education 1 Direct effects of malnutrition on brain development 2 The impact of malnutrition on children’s learning experiences 3

2 The economic impact of malnutrition 7 Malnutrition and economic outcomes in later life 7 Malnutrition and economic growth 8

3 Interventions that make a difference 12

4 Conclusion and recommendations 15

Appendix 1 17

Appendix 2 19

Endnotes 20 Executive summary

In the past two decades, the world has In this report we demonstrate how investment in achieved huge progress for children. Between nutrition is not only the right thing to do, it is a 1990 and 2011, the numbers of children down-payment on future prosperity. The evidence dying under the age of five fell faster than we present shows that preventing malnutrition of ever before – from 12 million to 6.9 million. children and women in the crucial 1,000-day window Since 1999 the number of children in primary – from the start of a woman’s pregnancy until her child’s second birthday – could greatly increase school has gone up by over 40 million. children’s ability to learn and to earn. However, malnutrition threatens to undermine these impressive advances. In spite of the reduction in children dying, the global crisis of child mortality New findings on the remains unsolved – 19,000 children continue to die impact of malnutrition each day from preventable causes. Meanwhile, a global on children’s learning crisis in education means 130 million children are in school but failing to learn even the basics.1 They are left The long-term consequences of child malnutrition for without the core skills and abilities they need to fulfil health and resilience to disease are well established. their potential and to lead fulfilling, productive lives. But this report presents new evidence, commissioned by Save the Children, which for the first time identifies Child malnutrition is a key factor underlying both the impact of malnutrition on educational outcomes these crises. Malnutrition is an underlying cause of across a range of countries. 2.3 million children’s deaths a year, and for millions more children contributes to failures in cognitive The Young Lives study follows 3,000 children in four and educational development. As a result, the life countries throughout their childhood. At key points chances of millions of children around the world are in their lives, the children are interviewed and tested devastated. The potential cost to the global economy to determine their educational abilities, confidence, runs to billions of dollars. hopes and aspirations. In the past two decades, progress in tackling New analysis of the survey shows that children who malnutrition has been pitifully slow while advances are malnourished at the start of life are severely in tackling many other issues highlighted by the disadvantaged in their ability to learn. Millennium Development Goals (MDGs) have been Compared with non-stunted children, stunted far faster. Save the Children’s children: Index has shown overall progress on the education • score 7% lower on maths tests component was 32% and on the health component • are 19% less likely to be able to read a 23% (from the mid-1990s to the late 2000s), simple sentence aged 8, and 12% less likely compared with an improvement in the nutrition to be able to write a simple sentence component of only 13%.2 • are 13% less likely to be in the appropriate But in June 2013 global leaders have a historic grade for their age at school. 3 opportunity to make a major breakthrough in the These impacts remain after controlling children’s fight against . By taking decisive action to tackle backgrounds, including where they grew up and went the malnutrition crises head on, they can end the to school. deaths of millions of children a year as a result of malnutrition and prevent the many millions more lives being devastated by its effects. iv Executive summary v

14

13 we

10 11 But there is some evidence is some evidence But there 8

9 Meanwhile, economists have identified the economists have Meanwhile, 12 A common theme in each of these countries is the structures. their demographic by potential provided Investments in the potential of future generations of future in the potential Investments With mortality before. important more than ever are but fertility rates declining at a rates falling rapidly countries will experience an developing rate, lower population in the size of their working-age increase countries will have Many decades. in the next few This dependent. every age for people of working two of opportunity them with a critical window presents as the known to boost economic development, dividend’. ‘demographic of the ten fastest- that seven The IMF has predicted years will be in economies in the next five growing Africa. why it’s crucial on to go malnourished who are Children who children less as adults than the earn 20% nourished. well are The potential – now act ’ ‘demographic dividend ‘Next 11’ countries – those that have the potential ‘Next 11’ countries – those that have in the next decade. stellar economic growth for This report presents new estimates of malnutrition’s estimates of malnutrition’s new This report presents a 20% reduction By extrapolating on GDP. effect that this report shows in earnings to a global level, could cost the global economy malnutrition today’s reach children as $125 billion when today’s as much age in 2030. working that the difference could be even larger – one study larger – one study be even could that the difference for malnourished deficit this earning has estimated at 66%. children But to capitalise on the demographic dividend, dividend, on the demographic But to capitalise in the health now invest countries must developing made Investments workforce. and skills of their future interventions nutrition could increase in proven now to become more opportunities millions of children for The next members of society. and productive healthy This in turn means that malnutrition can act as a big that malnutrition This in turn means Estimates suggest that to economic growth. barrier the impact countries, and middle-income in low- between by GDP could decrease of malnutrition of its impacts on is partlyThis a result 2% and 11%. physical as on – as well educational development and health. productivity 6 And 5 a

7

4 This 1,000-day window is a critical time for structural structural time for is a critical window This 1,000-day is Good maternal nutrition brain development. who or pregnant essential: to have likely more are access the right nutrients can’t and brain development with compromised children performance. poor cognitive from who suffer The impact is not just on academic achievement. achievement. The impact is not just on academic lower having is associated with children Malnutrition aspirations. self-confidence and career self-esteem, damage face direct not only Malnourished children less confident to but are to their bodies and minds, were to change the situation they learn and aspire born into. In the longer term, malnutrition can have a big can have malnutrition In the longer term, adulthood. reach impact on earnings when children stature, on physical of malnutrition The effects and on cognitive work, the ability to do physical and into poverty can lock children development, inequalities. entrench Investing in nutrition – on -payment down crucial future prosperity But the effects of malnutrition on a child’s cognitive cognitive on a child’s of malnutrition But the effects the biology beyond go and education development status can impact nutritional of the brain. A child’s that children on the experiences and stimulation a malnourished boy sometimes treat receive. child and this small, are because they or girl differently learning to miss school and key likely is also more opportunities due to illness. The impact of malnutrition on children’s learning on children’s of malnutrition The impact and unable to tired are that they is not simply not eaten have because they concentrate in class in the first Malnutrition day. enough on a given pregnancy the start a woman’s of – from 1,000 days – has a devastating second birthday until her child’s their It restricts potential. future impact on children’s likely more are means they development, cognitive their and reduces out on school, to be sick and miss ability to learn. and Malnutrition ’s learning children once the child is born, nutrition continues to a to play continues nutrition once the child is born, properly. the brain develops in ensuring role key vi food for thought figure is61.4million. children underfive are stuntedwhileinIndia, the devastating.is particularly InNigeria, 10.9million damaged. to poornutrition –andtheirpotentialseverely Africa were for theiragedue stunted–tooshort southern Asia and39%ofunder-fives insub-Saharan suggest thatin2012, 47%ofchildren underfive in The scaleofthechallengeishuge. UN figures to tackle 2013: ahistoric opportunity better-nourished peers. likely togo ontoearnlessthantheirbetter-off and malnourished thanthoseintherichest10%–andare 40% offamiliesare 2.8timesmore likely tobe In developing countries, children borntothe poorest entrenching inequalitiesacross generations. whole communities intoacycleofdeprivationand is bothacauseanddriver ofpoverty –locking malnutrition.As thisreporthighlights, malnutrition life chanceshave already beenunderminedby even by theageoftwo years, millionsofchildren’s inlife.opportunities Buttheharshreality isthat, We believe thatevery child shouldhave thesame inequalities Malnutrition: perpetuating for them. without having generatedtheresources tocare ofelderly dependents will beleftwithalargecohort demographic changes, thenin50–60 years’ timethey to take presented advantageoftheopportunities by – butalsoaneconomiccrisis. Ifcountriesare notable people leftmore susceptibletodiseaseby malnutrition burden placedonhealthsystemsby agenerationof that leave afuture publichealthdisaster–withahuge consequences couldbecatastrophic. Notonly would But ifwe failtomake thatinvestment the fuel improved innovation, prosperity andjobcreation. generation ofchildren indeveloping countriescould world between the1990sand2000s. wealthiest 10%actually increased inmanyofthe parts stunting between thepoorest 40%compared withthe this reportshows thatthegap intheprevalence of 16 The burden ofstuntinginsomecountries malnutrition 17

15 New evidence presented in which are ready tobefundedandimplemented. costed planstoaddress themalnutrition challenge– with ahighburden ofmalnutrition have produced ministries ofhealthandagriculture. Sixteencountries often fallsthrough thecracksofresponsibility between because malnutrition hasnopoliticalchampionand commitments toaddress malnutrition. This iscrucial malnutrition tomake ambitiouspoliticalandfinancial encourages countrieswithahighburden of The ScalingUpNutrition(SUN)movement 2 1 They should: the commitmentsneededtotacklemalnutrition. andmakemust seizethishistoricopportunity Donors anddeveloping governments country stunting targetandstrong financialcommitments. coming forward with concrete plansthatincludea serious commitmenttoaddressing malnutrition by community andnationalgovernments tomake a It isatremendousfor theinternational opportunity will hostthefirst-ever nutrition pledgingconference. On 8June 2013theUKandBraziliangovernments This situationmust change. total overseas development assistanceonnutrition. past three years, donorsspendanaverage of0.37% But nutrition remains chronically underfunded. Inthe right thingtodo. thingtodo. Butitis alsothesmart society. Itisobviousthatmakingthesechangesthe develop intohealthy andproductive membersof of malnutrition, would help millionsofchildren to with policychangestoaddress underlying causes package ofproven nutrition interventions, along know whatneedstobedone. Investing now ina And weBut thechallengeisnotinsurmountable. and be based on country needs. and bebasedoncountry with the nutrition targets must includestuntingreduction targets, bealigned burden ofmalnutrition inchildren by 2025. These by oftheglobalgoal toalleviate 2016aspart the Declare andmeetinterimimpacttargets SUN-member andotherhigh-burden countries. level,costed nutrition plansatthecountry in to,support theimplementationofevidence-based, to develop, andprovide technicalandfinancial scale upnutrition.Announce commitments andfinancenationalplansto Support 18

Executive summary vii Recognise the importance of nutrition for the importanceRecognise for nutrition of and development, and educational cognitive a key is integrated as that nutrition ensure , programming years’ component of early and development childhood care including in early programmes. to mitigate the in order programmes, years’ early cognitive on children’s impacts of malnutrition development. Furthermore, programme developers for early years years early for developers programme Furthermore, support should: 5 6 interventions into stimulation Integrate Report.Accountability and Continue Reform the New Alliance for Food for Alliance the New Reform include accountability and Nutrition and detailed public plans to mechanisms with impacts. maternal and child nutrition achieve and Food Agriculture the Global Adapt to incentivise (GAFSP) Security Program to agriculture. approaches nutrition-sensitive – Enhance nutrition-sensitivity of agriculture of agriculture nutrition-sensitivity Enhance can approaches so food-based initiatives nutritional to improving more contribute status. – Ensure nutrition is a core part of the is a core nutrition Ensure G8 enhance the nutrition chapter from the 2012 from chapter enhance the nutrition comparable towards Move Accountability Report. outcomes and funding, tracking of nutrition published annual impacts with a mechanism for updates on progress. 3 4 photo : amerti lemma /SA V E THE CHILDREN Hungry for life

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 vital nutrition. Her mother, Wagaye, says she wasn’t able to breastfeed Adina because she became pregnant again soon after Adina was born. Now ten years old, Adina finds learning difficult at school and had to repeat her class last year. “I try to do well at school but I find it hard to understand what the teacher tells me,” she explains. Wagaye feels Adina’s difficulties at school are partly a result of missing out on a healthy diet. “I know better nutrition is important to doing well at school,” she says. That view is backed up by Adina’s teacher, who says Adina is one of the children in her class who struggles. “I try to support those in my class who aren’t performing well,” she says. “I take them to a separate class after school and go over things they don’t understand. “Some of my students look much too young for their age,” she adds. “They’re physically smaller. I can tell that, from when they were babies, they haven’t been getting nutritious food. You can still see that as they get older.”

viii 1 Early Nutrition, cognitive Development and Education

The 1,000 days from the start of a woman’s direct effects of Malnutrition pregnancy until her child’s second birthday on brain development are a critical time for brain growth. During this period, malnutrition affects the structural Protein and energy and functional development of the brain, Brain growth and neurodevelopment begin in the directly affecting cognitive development. It womb. During this period of rapid growth, protein also has an indirect impact, affecting the ways and energy (from carbohydrates and fat) are critical. children learn and their ability to interact and A lack of these nutrients can have extremely damaging engage with the world. effects: studies show a higher prevalence of brain abnormalities at two years of age among children This chapter explores the ways that malnutrition affected by foetal undernutrition.22 Studies of young affects children’s brain development and reviews children with protein–energy malnutrition show brain evidence linking these detrimental effects with atrophy – a shrinking of brain cells due to a lack of poor cognitive abilities or educational outcomes. nutrients,23 as shown in figure 2. New analysis is presented showing that malnourished children are more likely to fall behind at school and Insufficient calories continue to affect children’s brain to fail on key tests of literacy and numeracy. development in the first months after birth – a time of rapid neurodevelopment, including the establishment Good nutrition is essential for pregnant women, of the parts of the brain crucial for memory (the breastfeeding mothers and young children, especially hippocampal-prefrontal connections,24 and the density before their second birthday. Key nutrients are vital to of dentrites that connect nerve impulses to the nerve brain functioning and growth, including while a foetus cell body in the hippocampus).25 is in the womb and during the early months after birth when the brain grows rapidly. Micronutrients for brain growth Children’s cognitive abilities and achievement of Key micronutrients are crucial for neural development appropriate development milestones depend on a early on in life. The neural tube begins to form combination of factors, including appropriate nutrition, 16 days after conception and within seven months good health, a caregiver’s attention and opportunities resembles the adult brain. While brain development to interact with the environment. 20 Evidence suggests processes are complex and cannot be fully explored that programmes that address stimulation and here, the evidence suggests key micronutrients are nutrition together result in greater improvements in crucial to the health of children and mothers. child development than those that focus on one of The presence of iron in the brain is critical for these factors in isolation.21 myelination, the process by which a layer of fat

1 food for thought 2 9 8 7 6 5 4 3 2 1 1 3 5 7 9 01 21 3 5 7 9 10 11 12 13 14 15 16 17 18 19 20 30 40 50 60 70 9 8 7 6 5 4 3 2 10 11 12 1 9 8 7 6 5 4 3 2 1 0 -1 -2 -3 -4 -5 -6 -7 -8 -9 Months Source: El-Sherifetal(2012)Cranial MagneticResonance Imaging(MIR)Changes inSeverely Children before Malnourished andafter Treatment . Source:Thomson, Nelson(2001)Developmental ScienceandtheMedia. woman’s pregnancy andherchild’s secondbirthday. This figure shows thattherapid periodofbrain development occurswithinthe1,000-day window betweenofa thestart treatment for Figure 2 Figure 1 Conception (18–24 prenatal days) Neurulation weeks) (6–24 prenatal Cell migration The Developmental CourseofHumanBrainDevelopment Images of the management of gangliaof the basal Birth Neurogenesis inthehippocampus Experience-dependent synapse formation Myelination (-2monthsto5–10years) Months cortex Prefrontal

acute malnutrition 19 a malnourishedchildbeforeandafter Age Years (prefrontal cortex) Higher cognitive functions cortex) auditory Seeing/hearing (visualcortex/ gyrus/Broca’s area) speech production (angular Receptive language area/ (-3 monthsto15–18years?): Synaptogenesis to beresolved. the problem canbeseen of treatment, same brainafter90days on thenearleftshows the blood vessels. away from theskulland the whiteareas shrink nutrients, neurons due to lackof atrophy, theshrinkingof malnutrition. severe protein energy old childsuffering from the brainofa10-month- shows of thebottompart The image onthefarleft Adult levels ofsynapses canbeseenas Cerebral from which

The image Decades

26 Death 1 Early Nutrition, Cognitive Development and Education 3 It 40 43

47 and ensure that and ensure 44

there appears to be a relationship to be a relationship appears there 45 42 In turn, ‘experience-dependent’ processes, ‘experience-dependent’ processes, In turn, 46 of studies on the impact of results While the 41 plays an important role in brain development development in brain an important role Zinc plays of efficiency for to be essential and is thought in the hippocampus, neurons between communication and memory learning occur. where processes such as the brain responding to the development of a to the development such as the brain responding structure as the brain’s life throughout continue skill, to the stimuli and connections change in response and activities the individual experiences. of malnutrition The impact on children’s educational experiences to the biological factors discussed In addition are experiences and environment children’s above, nutrition A child’s important brain development. for interact with that they can influence the way their environment. on certain its normal for The brain relies stimuli the visual input through example, – for development of the optic nerve the development is crucial for visual cortex (the part of the brain that processes So-called ‘experience expectant’ processes images). long-term and have in life early such as these happen effects. is required during early foetal development development foetal early during is required Folate neural tube defects to prevent is also key to other biological processes that affect that affect biological processes to other is also key and RNA synthesis including DNA brain development, and carbohydrates of protein, and the metabolism fat. zinc supplementation on cognitive outcomes are outcomes are on cognitive zinc supplementation inconsistent, between and children’s cognitive and cognitive and children’s zinc deficiency between birth-weight low including among motor development, warranted. is clearly research More children. the neural tube forms properly to create the brain to create properly the neural tube forms supplementation is also folate Iron and spinal cord. mothers to and breastfeeding important pregnant for deficiency anaemia. iron prevent together to produce work Vitamin B12 and folate that deficiencies shows Research blood cells. red . in brain development in both could affect B12 is also essential to the vitamin iron, Like symptoms of Neurological process. myelination the central appear to affect vitamin B12 deficiency cases cause and in severe nervous system, brain atrophy. 34 Even Even 37

31

27 39 According to the According and mild iodine and half of these 33 38 32 Growing evidence evidence Growing Furthermore, Furthermore, 28 30 Cretinism is characterised Cretinism 36

35 risk to greater This leads 29 Iron also facilitates the production of also facilitates the production Iron chemicals that pass – the neurotransmitters in – and it is involved neurons messages between the which receive the function of neuro-receptors, messages. neurotransmitters’ World Health Organization (WHO), 42% of pregnant 42% of pregnant Health Organization (WHO), World anaemia. from – suffer – 56 million women women is widespread. Almost half of children of children Almost half is widespread. deficiency Iron countries – 47% of under- and middle-income in low- by anaemia, affected – are fives Iron deficiency is a strong risk factor for both risk factor is a strong deficiency Iron motor and short-term and long-term cognitive, socio-emotional impairment. of impairments in future mental and physical mental and physical of impairments in future development. by mental retardation, deaf-mutism, partial deafness, partial deafness, deaf-mutism, mental retardation, by It can stunted growth. and severely facial deformities to a loss of 10–15 IQ points. lead on average in the absence of overt cretinism, chronic iodine chronic cretinism, in the absence of overt intelligence deficiency can affect deficiency can reduce motor skills. deficiency can deficiency is thought to be the world’s single world’s is thought to be the In mental retardation. cause of preventable greatest 2 billion people WHO estimated that nearly 2007, of them one-third had insufficient iodine intake, of school age.children accumulates around neurons – brain cells designed to – brain cells neurons around accumulates nerve enables cells Myelination carry signals. electrical more for and allows faster information to transmit prior to deficiency Iron brain processes. complex and profound in to result of age is likely years three changes. permanent myelin possibly suggests that maternal iron deficiency in pregnancy deficiency in pregnancy iron suggests that maternal into the well perhaps stores, iron foetal reduces year of life. first Iodine is critical to the production of thyroid of thyroid Iodine is critical to the production the development essential for which are hormones, iodine Severe of the central nervous system. can lead to and during pregnancy deficiency before hormones in the mother of thyroid underproduction in the child. and cretinism longitudinal studies consistently indicate that longitudinal studies consistently poorer infancy have anaemic during who are children more and are school achievement lower cognition, in later childhood problems behaviour to have likely of direct that could occur as a result – an effect impact of of the or as a result biological processes learning experiences. anaemia on children’s cases are due to iron deficiency. due to iron cases are 4 food for thought development, thiscanbe reinforced by parents focusing Once children getbehind intheircognitive their surroundings. thatmayof lethargy affect theirabilitytoexplore mothers’ suffer from severe anaemiashow symptoms that they receive. For example, infantswhose influencing children’s experiences andthestimulation Malnutrition canaffect cognitive development by one ofthesefactorsinisolation. in childdevelopment thataddress thaninterventions and nutrition togetherresult ingreater improvements thataddresssuggests thatinterventions stimulation impacts ofpsychosocialstimulation. Infact, research effects ofmalnutrition cannotbeisolatedfrom the pathways are complexandinterrelated, andthedirect and braindevelopment canbeseeninfigure 3. These Some ofthepathways thatmightinfluencecognitive Source: Dewey ElizabethPradoandKathryn (2012) Adapted from Levitsky &Barnes(1972)andPollitt (1993) children’s cognitive development. actually are; thelower level ofstimulus canaffect age (asaresult ofmalnutrition) asyounger thanthey that adultsmay treat children who are smallfor their children’s cognitive, motor Figure 3 Nutritional status Potential mechanismsfor 49 There isevidence tosuggest 48 Physical activity Physical growth Illness and socio-emotional development the effectofnutrientdeficiencyon affectionate andspentlesstimetalkingtothem. less likely toreward theirchildren’s successes, were less from othermotherstowards theirchildren –they were mothers ofmalnourishedchildren behaved differently stronger potential. their attentiontowards thosechildren whoshow effects ofmalnutrition. environment thatcanshelterthenfrom theworst their development, thankstoaprotective partly who are stuntedtendtobelessdisadvantagedin of disadvantage. Children from better-off families Malnutrition canbecompoundedby otherforms increased frequency ofillness. for example, to learnthrough missingopportunities lower levels of stimulus asaresult ofpoorhealth– Children whoare malnourishedmay alsoreceive result theeffects of malnutrition go unabated. less abletoapply these mitigatingstrategies. children growing upinpoorer environments may be miss fewer days ofschool. Bycontrast, malnourished may have betteraccesstohealthcare andsohave to Caregiver behaviour, interaction withthe Brain development Level ofchild environment and function –child interaction 50 A studyinMexicofound that

52 For example, thesechildren and socio-emotional Cognitive, motor development 53 As a As 51 1 Early Nutrition, Cognitive Development and Education 5 These 61 62 continued overleaf were And they

was associated with higher school was associated with 60 . Children who resit grades are in turn also are grades who resit Children . 8 self-esteem and educational aspirations. Being less aspirations. and educational self-esteem malnourished New analysis commissioned by Save the Children the Children Save by commissioned analysis New 1) shows Appendix and (see table 1 overleaf background children’s for controlling after that, of their family, as the wealth characteristics (such who up in) children grew they and the community on average scored five stunted at age were later. years on a maths test three 7% worse to in maths score This is an equivalent reduction and represents the child being 3.4 months younger, a serious setback on their learning. even of literacy are The impacts on measures stunted at age who were Children stronger. a to read to be able 19% less likely were five ‘The or dogs’ ‘I like simple sentence such as later. years sun is hot’ three aspiration, self-efficacy and self-esteem. aspiration, impacts on the ways in which children feel and think feel in which children impacts on the ways with linked to be closely likely are about themselves life. outcomes in later labour market to write such a to be able 12.5% less likely equivalent to these are terms, In relative sentence. the child being 5.7 months or 7.4 months younger, respectively. or writing reading for finds that malnutrition the research Importantly, chances of being in the correct children’s affects other for their age. grade for After controlling was associated being stunted at age five factors, to be in the correct with being 13% less likely reached when children grade (or above) age school earlier – a particular to leave likely more already children many in settings where problem inadequate amounts of schooling. receive these impacts are Appendix 1 shows, As table 2 in being countries, the four constant across reasonably indicators. of the four three larger in India for

54 In addition In addition 59 57 on malnutrition of chronic the impact ietnam found Vietnam found A large landmark study A large landmark 55 Estimates based on five Estimates based on five 56 isolates nutrition This analysis 58 to the effects associated with poverty, stunting at associated with poverty, to the effects self-efficacy, was associated with reduced eight years negative effects on child cognitive development development on child cognitive effects negative wealth other factors such as for after controlling education. and parental A study analysing data from data from A study analysing Previous analysis of the Young Lives data reinforces data reinforces Lives Young of the analysis Previous and malnutrition life early the links between Stunting at around later development. children’s cognitive of age is associated with lower one year Peru and Vietnam. in at age five scores from other factors that are relevant to cognitive to cognitive relevant other factors that are from (such as school quality and educational development and looks at the association of wealth) and parental and educational with cognitive stunting at age five outcomes at age eight. in Guatemala estimated that being stunted at in Guatemala estimated to on with going age 36 months is associated grades of schooling 3.6 fewer on average receive and not stunted, who are with children compared reading of worse on scores scoring significantly and vocabulary tests. But most existing estimates of the impact of But most existing estimates of the outcomes stunting on educational and cognitive to one country restricted or one study sample. are the impact of stunting on cognitive estimate To countries, across and educational development of analysis new commissioned the Children Save which study, Lives Young the international study The development. children’s investigates covering consists of a large longitudinal sample India, continents – Ethiopia, countries in three four Vietnam. and Peru A number of studies have aimed to measure the the to measure aimed of studies have A number – particularly of stunting – of malnutrition effect educational and socio-emotional on cognitive, in adult life. both at school age and development, different cohort studies suggest that children who cohort studies suggest that children different to fail likely more 16% were stunted at age two are a grade than non-stunted children. of New estimates outcomes ve and educational cogniti 6 food for thought See Appendix 1for more detailfrom theanalysis. T cognitive andeducational outcomescontinued New estimates of IMPACT able 1 Being incorrect gradefor age Made amistake withwritingasimplesentence Made amistake withreading asimplesentence Maths score (29-questiontest) Indicator associated the impact ofchronic malnutritionon with stuntingat (8.1 percentage pointsdifference) Be 13%lesslikely tobeinthecorrect gradefor age (5.1 percentage pointsdifference) Be 12.5%more likely tomake amistake (5.9 percentage pointsdifference) Be 19%more likely tomake amistake Score 7%(0.98points)lesswell a stuntedchildwould beexpected to After controlling for background characteristics, age 5onchildoutcomesat age 8

2 the economic impact of malnutrition

The benefits of good nutrition do not stop 10% lower lifetime earnings,63 while numerous studies with improved educational outcomes. By that model the impact of malnutrition in the first improving cognitive abilities, health, physical two–five years of life place this figure at 20%.64 strength and stature, good nutrition in the The 2008 Lancet series reviewed cohort studies from early years can lead to greater wages in Brazil, Guatemala, India, the Philippines and South adulthood and hence promote the economic Africa that all followed children into adulthood, and development of a whole country. This chapter concluded that stunting is associated with reduced presents evidence that stunted children earn earnings in later life. 65 This review found that as much as 20% less than their counterparts, less severe stunting in Brazil and Guatemala was and uses this to estimate that today’s associated with higher adult incomes among both malnutrition could potentially cost the men and women.66 Models using evidence from across global economy $125 billion when children these longitudinal studies, combined with evidence born now reach working age. on the relationship between education and earnings taken from 51 countries, have estimated that children The next few decades will see key emerging who are stunted at age five earn 22% less than their economies, as well as several low-income countries in non-stunted counterparts. sub-Saharan Africa, experience demographic changes Children from the families living in the most that provide important opportunities for economic extreme poverty often suffer the highest rates of growth. But to benefit from these potential dividends, malnutrition.67 Therefore, being malnourished often they must invest now in the health and education of goes hand-in-hand with several other barriers that their future workforce. Governments and donors must undermine children’s development, making it difficult invest in the nutrition of these children if they are to to distinguish between the impacts of malnutrition ensure strong economic growth in years to come. and other closely correlated forms of deprivation. The interrelation between improved nutrition In Guatemala, a landmark randomised controlled trial and economic growth is of great importance for (RCT) – the best way of removing the effects other human and economic development. It is a two-way factors from research findings – tried to isolate the relationship. On the one hand, inclusive economic effects of malnutrition and found that providing boys growth can contribute towards reductions in the with a nutritional supplement (which was available prevalence of malnutrition. On the other hand, as this twice daily and contained extra protein and energy) section will show, reductions in malnutrition can have during the first two years of life raised incomes by a transformative effect on the economic potential of 46% when they were revisited during adulthood.68 individuals and whole societies. Data from the same study has been used to estimate that individuals who were not stunted in early Malnutrition and economic childhood were much more likely – by 28 percentage points – to work in higher-paying skilled labour or outcomes in later life white-collar work and earned as much as 66% more as adults – a much higher figure than others have Through its impact both on children’s cognitive estimated and one which may be specific to the development and on their physical health and Guatemalan context.69 development, malnutrition can have significant effects on an individual’s economic well-being in later life. The World Bank suggests that malnutrition results in

7 8 food for thought comprehension andintelligencescores asadults. went ontoachieve significantly higher reading of schooling, andboys andgirls given thesupplement nutrient supplementhad, onaverage, 1.2extrayears in Guatemalafound thatboys whoreceived the association witheducation–for example, theRCT economic impactsofmalnutrition alsohighlightthe with a2.4%increase inearnings. that a1%increase inadults’heightwasassociated example, alargecross-sectional studyinBrazilfound correlation between adultheightandwages –for development. Several studieshave confirmedthe may bebecauseoftheeffect onchildren’s physical oftheimpactmalnutrition onearnings Part and economicoutcomes Multiple pathways linkingnutrition labour. is necessary, suchasagriculture orothermanual of earningsincontextswhere physical strength its nutrition determinants)isadirect predictor It islikely thatphysical sizeitself(andtherefore Kenya, Tanzania, GhanaandPakistanshows. rates, asevidence from many countriesincluding educational development islinked tolower wage malnutrition canreduce wages. Poor cognitive and pathwayoutcomes isanotherimportant by which impacts ofcognitive development andeducational cognitive skillsandeducationalqualifications, the But inaworld where jobsincreasingly require time atwork, eg, duetoillness. simply by reducing people’s physical abilitytospend are largerfor those working inmore skilledjobs has shown thattheeconomic impactsofmalnutrition pathway interms of itsimpactsonwages. Research educational development may bethe most important In fact, nutrition’s relationships with cognitive and and individuals’subsequentearnings. There isaclearassociationbetween educationlevels, being. pathway thatlinksnutrition tolatereconomicwell- outcomes onwages, thisislikely tobeakey Given ofcognitive theimportance andeducational toteachthem. understand whattheteacheristrying schoolreadystart tolearn, ratherthanstrugglingto by good nutrition, issocritical–children needto reason why early childhooddevelopment, enhanced the number ofyears spentinschool. and theacquisitionofskillsthatmattermost, notjust the latestevidence suggeststhatitisactuallearning 77 71 Many ofthestudiesthathave looked at Similarly, malnutrition canaffect earnings 70

74, 75 76 This isanother Butcritically, 72, 73

78

growth. to knock-oneffects onnational-level economic with reduced earningsattheindividuallevel leading and lower productivity, asthisreporthashighlighted, asaresultpartly ofthelinkbetween malnutrition whole societies’economicdevelopment. This occurs individuals’ economicoutcomes; itisessentialfor forNutrition isnotonlyincreasing important economic growth Malnutrition and see anincrease intheproportion of working-age Over thenextfive decades,Africawillcontinue to is ofworking ageisset tocontinue toincrease. ratio. The proportion ofIndia’s populationthat currently have favourable avery worker:dependent change. The populationsof Asia and Latin America in theworld through thisprocess ofdemographic Figure 4shows theprogress ofvariouscontinents and educated, andjobsare available for them. economic growth, provided theworkforce ishealthy working-age person–aratiothatallows for improved have asmany astwo workers for every pre- orpost- Many developing countrieswill, inthecoming decades, significant economicgrowth. their workforce thatwillpresentfor anopportunity coming decades, experiencegrowth inthesizeof supporting. Butotherareas oftheworld will, inthe with increasingly largeretired populations thatneed America are enteringaperiodofpopulationageing, are morethanever. important Europe andNorth mean thatinvestments inchildren’s future potential Demographic changesoccurring around theworld the demographicdividend Laying to diseases. malnourished aschildren are more likely tofallill by increasing healthcare costs, aspeoplewhowere much largerthanincreases seenfor farmworkers. more thanthosewhodidn’t. on average five extrahoursper week, andearned20% toimproveintervention nutrition aschildren worked businesses asadults, thosewhohadreceived an among thoseworking for wagesoroperatingsmall than for thoseinmanual jobs. A studyshowed that tiger economiesexperiencedfrom 1965–1990. for one-third oftheeconomicgrowth that east Asian estimated thatsimilardemographic changesaccount 80 the foundations for Malnutrition alsoaffects nationaleconomies 79 These impactswere 81 Itis 82 2 the Economic impact of malnutrition 9

88 Africa Asia LAC Europe India and 87 equivalent 90

and found that and found 2070

91 2060 Estimates of the cost of equivalent to $15–46bn, equivalent to $15–46bn,

86

89 2050

2040

2030 2020

could be between 1.7% and 10.6% 1.7% could be between underweight 6.6%). of GDP (average iron-deficiency to national economies are around around to national economies are iron-deficiency ranging countries, 4.5% of GDP in ten developing in Honduras to 7.9% in Bangladesh, 2% from These different deficiencies overlap, with many of the with many overlap, deficiencies These different types of deficiencies, different by same people affected modelling the total economic impact of which makes what is clear Nevertheless, verymalnutrition difficult. on countries’ can act as a brake is that malnutrition economic growth. In India it has been estimated that the economic cost amounts to between malnutrition of micronutrient 0.8% and 2.5% of GDP, to $15–29bn. to $15–29bn. In 2012 the Copenhagen Consensus panel of Nobel estimated the economic benefits of investing laureates nutrition package of direct in a comprehensive A supplementation such as vitamin interventions, of breastfeeding, or the promotion while in , micronutrient malnutrition alone malnutrition micronutrient while in China, 0.2 and 0.4% of GDP, could cost between similar impacts to national economies have been have similar impacts to national economies iodine deficiency and underweight. estimated for 2010

85

2000

1990

1980 1970 84

plus India , of several continents ratio :dependent worker 1960

The 1950 It could even lead to BRIC countries It could even

83 1.0 1.2 1.4 1.6 1.8 2.0 2.2

65 over or 14 under aged

person each for 15–64 aged people of Number Figure 4 (Brazil, Russia, India and China) and some developing India and China) and some developing Russia, (Brazil, trap’ ‘middle-income countries becoming stuck in the after reaching plateau may their growth – whereby levels. middle-income In seven countries in Central America, the World World the America, countries in Central In seven (WFP) has estimated that the Programme Food being under age five economic costs of children A brake on inclusive economic growth attempted to estimate the cost to studies have Many of malnutrition. national economies of various forms acts both by malnutrition As mentioned above, the increasing and by economic productivity reducing While econometric methodologies costs of healthcare. various assumptions to be made regarding require and malnutrition of association between the strengths stark. the findings are economic costs, Failure to ensure good nutrition and human capital and human capital nutrition good to ensure Failure developing during these periods could prevent experiencing sustained economic countries from growth. people, creating an opportunity the continent for creating people, the right provided growth, to experience strong made. jobs are in people and investments Figure constructed by Save the Children using data from UN (2010). using data from the Children Save constructed by Figure 10 food for thought this relationship hasbeengettingstronger over time. workforces that have greater humancapital, andthat more foreign direct investment goes tocountrieswith effects onGDP. Research suggests, for example, that are associatedwithmalnutrition couldhave broader individual impacts: thereduced cognitive skillsthat even largerthanastraightforward accumulation of In fact, theimpactsofmalnutrition onGDPcouldbe could costtheglobaleconomy $125bnperyear. income differences associatedwiththeirmalnutrition today’s stuntedchildren reach working age, the The results ofthisanalysis suggestthatby thetime shown in Appendix 2. this analysis andthevariousassumptionsincludedare direct nutrition interventions. for The methodology benefits ofinvesting inacomprehensive packageof laureates, whoin2012estimatedtheeconomic to thatoftheCopenhagenConsensuspanelNobel being malnourished. We usedasimilarmethodology of thereduced potentialthatresults from children estimate thepotentialcoststoglobaleconomy Save theChildren hasundertaken new analysis to impacts onproductivity viareduced education. the overall costofmalnutrition onGDPwasdueto countries, the WFP estimatedthatasmuch as46%of In its2007studybasedinseven Latin American pathway by which nutrition affects national economies. that reduced cognitive development isanimportant increased healthcare burden. Nevertheless, itisclear well astheadditional costssuchasthosedueto cognitive andphysical impactsofmalnutrition as malnutrition through variouspathways, including Many ofthesestudiescombinetheimpacts the costs. be anywhere between 15and138timeslargerthan these benefitsintermsofincreased wagescould incomes may becomeeven starker. into more skilledjobs, theimpactofmalnutrition on countries move away from agrarianeconomiesand traditional ones, suchasagriculture, suggests thatas that impactsmay be largerinskilledsectorsthan increasingly important. larger skillssectorsandasnon-farmbecome to becomeeven more significantascountriesdevelop effect ofmalnutrition onnationaleconomiesislikely as savings. as aresult ofimproving economicactivitiessuch larger thantheimpactonindividualwages–partly cognitive development onnationaleconomiesmay be Similarly, recent evidence suggests thattheimpactof 95 Finally, theevidence discussedabove, 93 92 The 94

pregnancy, – boththrough transmission from themotherduring The nextgenerationisthenmore likely tobestunted damage totheirfuture learningandearningpotential. the poorest are atgreatest riskoffacingpermanent earning potential, aviciouscycleiscreated –where Given theresultant impactsofmalnutrition onfuture and Jordan (7.9times). richest decile, followed closely by Peru (9.2times) 10.6 timesmore likely tobestuntedthaninthe being bornintothepoorest 40%meansachildis inequalities are mostextreme inNicaragua, where of society. development asempowered andproductive members and itstransmission, andtoencourage children’s to tackleitareway animportant totacklepoverty the socialdistributionofmalnutrition, investments and socialwell-being ofthepoorest insociety. Given and must deliver improvements totheeconomic on promoting growth, suchgrowth must beinclusive While development assistanceisincreasingly focused and south-east Asia between the1990sand2000s. actually increased insub-Saharan Africa andinsouth stunting between thetop10%andbottom40% over recent years. Figure 5shows how theratioof groups are largeandhave remained stubbornly high Yet, inequalities innutritional statusbetween wealth be stuntedthanthoseintherichest10%. areany onaverage country 2.8timesmore likely to around theworld, children inthepoorest 40%within Save theChildren analysis ofDHSdatasetsshows that The poorest are worst affected by malnutrition. of poverty. the potentialofindividualstoliftthemselves out malnutrition alsoperpetuatespoverty –by reducing Poverty isitselfakey driver ofmalnutrition. But Malnutrition –perpetuating inequalities existing castecognitive differentials by 25%. as theiruppercastecounterparts, thiswould close children gainedthesameaverage nutritional status inequalities were tackledinsuchaway thatlow-caste Andra Pradesh, India, hassuggestedthatifnutritional A recent studyusingthe Young Lives datasetin reduction ofinequalities. therefore actsasabarrier toinclusive growth andthe families live. Malnutrition’s unequalsocialprevalence 97 andasaresult ofthepoverty inwhich 96 These 98 2 the Economic impact of malnutrition 11 1990s 2000s groups wealth World

Latin America and Caribbean 40% bottom 10% and top South and South-east Asia Africa Sub-Saharan Asia/ Africa/West Europe between rate in stunting Ratios and Central North

0 1 2 3 4 5 6 7

averages) (population-weighted 10% richest to compared

40% poorest in prevalence stunting under-5 of ratio’ ‘Palma Figure 5 Source: DHS analysis by Save the Children Save by DHS analysis Source: 3 Interventions that make a difference

Investing in nutrition is key to unlocking the had significant effects on their children’s cognitive potential of a generation of children. The development, as measured by tests of visual and good news is that we know what works to spatial abilities at age three. tackle malnutrition and its damaging effects A study in Costa Rica of iron supplementation in on individuals and societies. children aged one and two years tracked the same individuals 18 years later and tested the impact of A package of 13 proven direct nutrition interventions malnutrition within different socio-economic groups, could reduce the prevalence of stunting by a third, and in order to isolate this factor from the analysis. Scores child mortality by a quarter. Investments in nutrition- in cognitive tests in early childhood for those in the sensitive approaches, such as child-focused social middle socio-economic status group with adequate protection systems or empowering women farmers to iron status were 8–9 percentage points higher than increase the nutrition-sensitivity of agriculture, could those who remained anaemic in early childhood. This have even greater effects on tackling nutrition.99 For difference that was maintained up to age 19 years.105 those children who remain malnourished, interventions Among the lower socio-economic status group, those to promote stimulation must be implemented. with adequate iron status scored 10 percentage Nutrition interventions, along with key educational, points higher in early childhood, and this increased health and care services, can help children’s brains to 25 points at age 19.106 to develop and help them to learn and to earn for Iodine supplementation can lead to strong economic the rest of their lives, and can yield gains that benefit benefits – partly because of the impact of iodine the wider society and economy. These include deficiency on healthcare costs. Currently 31% of direct nutrition interventions, such as promoting developing-world households still do not consume breastfeeding, many of which are provided through iodized salt and are therefore not protected.107 It the health system. In addition, indirect interventions is estimated that, at an annual cost of $0.5 billion, – such as social protection, investments in agriculture, universal salt iodization would save an annual and ensuring access to safe water and – $35.7 billion of potential costs attributable to address nutrition’s underlying causes. iodine deficiency.108 There is strong evidence that points to the benefits of nutrition interventions for children’s cognitive development.100 Research into the impact of a Breastfeeding variety of nutrition interventions, from a range of developing countries, has found a positive impact on Breastfeeding is the best way to give a child a healthy educational indicators, such as grades completed at start in life. However, only 37% of children globally are school,101 maths and English scores102 and intelligence exclusively breastfed for the first six months of life.109 103 quotient (IQ). This appears to hold true across a Breastfeeding prevents millions of deaths, protecting 104 range of robust studies. children from diseases such as pneumonia and diarrhoea. In addition, breast milk contains nutrients such as fatty acids, growth factors and hormones Micronutrient supplements that are important for brain development.110 Such is the strength of evidence, that a medical consensus A recent study in Indonesia provided multiple has emerged regarding the importance for cognitive micronutrient supplements to undernourished or development of these nutrients and their provision in anemic women during pregnancy and in the first breastmilk.111 The stimulation effects of breastfeeding three months after birth. The authors found that this

12 3 Interventions that make a difference 13 Nutrition should Nutrition should 118 angladesh nutrition into Integrating programmes educational in B of the importance on the evidence of Drawing – development child cognitive early for nutrition is the Children as highlighted in this report – Save and into our early integrating nutrition (ECCD) programming. development stunted, are of children 43% where In Bangladesh, undertook the Children a trial of an ECCD Save providing by that integrated nutrition programme of training on the importance of dietary1–2 days as healthcare as well food, and nutritious diversity and stimulation. that mothers of this study showed The results to dietarychanged their practices relating with 64% of families in one of the diversity, the nutrition intervention arms that received groups food education consuming at least four after the intervention was made, the year While families. with 33% of control compared did not run long enough to the programme dietary in the increase on stunting, effects register impact on had a positive to have is likely diversity of nutrients. intake children’s significantly. also improved scores Stimulation to be especially this factor was shown Indeed, to important an improvement in achieving families who from Children scores. cognitive a 40% intervention the stimulation saw received and language in their cognitive improvement who did with children compared development the intervention. not receive It is therefore critical for children’s cognitive cognitive children’s critical for It is therefore interventions that at aimed development in order stimulation, integrate children malnourished on of malnutrition effects the negative to minimise is international there Indeed, development. cognitive such interventions, for the need consensus around the basis of on which form recommendations WHO malnutrition. of the treatment be integrated into programmes that address early early that address programmes be integrated into development. and childhood care

117 Indeed 116

114 Similarly, a study Similarly, 113 112 ve impro 115 recent evidence from severely underweight children children underweight severely from evidence recent cannot be that if malnutrition in Bangladesh shows may stimulation interventions to improve prevented, scores. cognitive still be able to improve cognitive outcomes either that providing a study found In Jamaica, of milk-based supplements for (in the form nutrients play of weekly (in the form or stimulation years) two on tests of scores children’s sessions) both improved that it also found However, development. cognitive interventions led to significantly integrating the two better impact than either one alone. As chapter 1 shows, malnutrition can affect can affect malnutrition 1 shows, As chapter – for interactions with their environment children’s and parents by treated are they in the way example, years’ early a need for is therefore There teachers. both nutrition address to simultaneously programmes the largest positive to have in order and stimulation development. on cognitive effects of malnourished Stimulation children to There are, of course, a number of factors that also of factors a number of course, are, There such academic performance, influence children’s household education as socio-economic status, of a meta-analysis However, and genetics. levels that breastfeeding studies found controlled several cognitive for is associated with a higher score The feeding. with formula compared development children fed and formula breastfed between difference and sustained was observed as six months as early into adolescence. A number of studies show that breastfeeding that breastfeeding of studies show A number impact on child a positive can have promotion example, For and educational attainment. development children that Belarus found a study in clinics in promotion a breastfeeding who benefited from on higher scores intervention had significantly higher teacher ratings for and and IQ tests, verbal at 6.5 years. and writing reading are also important for cognitive development: development: important also cognitive for are to mother and child can help the breastfeeding and baby turn enhance mother which can in bond, and important which is cognitive for interaction, development. socio-emotional on the effect of breastfeeding duration on school of breastfeeding on the effect found adolescent boys among Brazilian achievement to an linked in school achievement an increase duration. in breastfeeding increase photo : SA V E THE CHILDREN

Kasturi (right) with her older sister, Sangeeta, and their father. Kasturi struggles at school, while Sangeeta has thrived.

A tale of three sisters

When Lakshmi was pregnant with twins, she repeat one year. Her teacher, Chandra Kala, and her family were desperately short of food. says, “I’ve been Kasturi’s teacher for two years now. Her learning’s very slow and Her husband, Srinavas, was struggling to find there’s been no major improvement.” work. “There were times we were hungry for days,” he says. “I felt very sad that I couldn’t Kasturi has an older sister, Sangeeta. The provide for my pregnant wife.” contrast in their stories is striking. When Sangeeta was born, Srinavas was earning When Lakshmi gave birth, both twins had a enough money for a healthy diet for the family. low birth-weight. “I used to breastfeed my Sangeeta has gone on to thrive at school. children, but my milk wasn’t enough for both of them,” she says. “We didn’t have enough “Sangeeta was one of our bright students food then.” One of her twin girls died at ten in primary school,” says Chandra Kala, “and months old. I hear a lot of good things about her from her teachers in high school.” Kasturi survived and is now eight. But she struggles at school, and has already had to

14 4 Conclusion and Recommendations

Given the devastating human and economic In the lead up to the G8 leader’s summit in June, impacts of malnutrition, many economists the UK Prime Minister has agreed to host, with the have consistently concluded that investing government of Brazil, a ‘Nutrition for Growth’ event in nutrition is an excellent way to spur – a once-in-a-decade opportunity to ensure high-level inclusive economic growth and is ‘central political and financial commitments to support to development’.119 these plans. In 2013, the international community stand at a For example, the Copenhagen Consensus of Nobel crossroads. Investing in nutrition interventions now Laureates rated nutrition interventions as four of as a down-payment on future prosperity will lead to the eight most cost-effective interventions available huge benefits for millions of children – and for the in development. Nutrition interventions are cost- global economy. But if we fail to take advantage of effective, in particular in reducing the burden on this opportunity we will fail a generation of children associated diseases on health services.120 Cost–benefit – and diminish the prospects of many countries and ratios for nutrition interventions have been found as their people. high as 1:138.121 Save the Children calls on donors and governments Yet, despite its crucial importance and the growing in developing countries to seize this historic consensus that this is one of the ‘best buys’ opportunity and make the commitments needed in development, the issue remains chronically to tackle malnutrition. They should: underfunded. Donors spent an average of only 0.37% of total aid on nutrition in the past three years. 1 Support and finance national plans to scale up nutrition. Announce commitments The Scaling Up Nutrition movement encourages to develop, and provide technical and financial countries with a high burden of malnutrition to support to, the implementation of evidence-based, make high level political and financial commitments costed nutrition plans at the country level, in to address malnutrition. This is crucial because SUN-member and other high-burden countries. malnutrition – which is silently crippling the future potential of millions of children – has no political 2 Declare and meet interim impact targets champion and often falls through the cracks of by 2016 as part of the global goal to alleviate the responsibility between ministries of health and burden of malnutrition in children by 2025. These agriculture. Sixteen high-burden countries have must include stunting reduction targets, be aligned produced costed plans to address the malnutrition with the World Health Assembly nutrition targets challenge, and which are ready to be funded and be based on country needs.122 and implemented.

15 16 food for thought 4 3 on progress. a mechanismfor publishedannual updates nutrition funding, outcomesandimpactswith Report. Move towards comparabletrackingof the nutrition chapter from the2012 Accountability Continue andenhance Accountability Report. Ensure nutrition isacoreoftheG8 part – – status. contribute more toimproving nutritional initiatives sofood-based approaches can Enhance nutrition-sensitivity ofagriculture sensitive approaches toagriculture. Program (GAFSP)toincentivisenutrition- Adapt theGlobal Agriculture andFood Security achieve maternalandchildnutrition impacts. mechanisms withdetailedpublicplansto and Nutritionincludeaccountability Reform theNew Alliance for Food Security Integratestimulationinto interventions 6 5 should: support Furthermore, programme developers for early years development. impacts ofmalnutrition onchildren’s cognitive early years’ programmes, inorder tomitigatethe programmes including inearly childhoodcare anddevelopment component ofearly years’ programming, ensure thatnutrition isintegratedasakey cognitive andeducationaldevelopment, and ofnutrition forRecognise theimportance Appendix 1 Analysis of the Young Lives dataset

Young Lives is a study of childhood poverty. In this report, descriptive analysis is used to consider Central to the study is a panel data set the different later experiences of children based collecting data on children and young people on their status as ‘stunted’ or ‘not stunted’ at age growing up in Ethiopia, India, Peru and five. Stunting is used as a long-run indicator of child Vietnam. The study collects data on two malnutrition, and measured by children having a groups of children born in 1994/95, and height (converted to a z-score) below two standard deviations of the median in a WHO age and sex 2000/01. The study website123 contains policy reference population. and research analysis, as well as technical documentation and information on how to To estimate the impacts associated with stunting, we access publically archived data. use multivariate regression. Regression analysis uses a set of background characteristics to explain particular The data is collected using a clustered (‘sentinel site’) outcomes. By including multiple characteristics (as approach. Specific geographic sites were selected controls) the models estimate the contribution to the within each country with children of the right age overall outcome made by each characteristic. randomly sampled within each area. The sample design aimed to collect information on children in a As a caution, these models are only as good as the range of circumstances within each country (ie, to observed data they use. There may well be other broadly reflect national differences), but oversamples non-observed characteristics which could affect poor children (technical details and comparisons the relationships observed. Taking account of these with nationally representative sources are on the non-observables might well affect the predictions study website). noted below. The study has so far collected survey data in 2002, To allow us to pool the results we include a reference 2006 and 2009. The analysis in this briefing uses to the cluster in which the child was born (where information on the younger group of children (aged they were recorded as living in 2002, this absorbs around eight when data was last collected). In this those differences associated with the site and country younger cohort, approximately 2,000 children were of origin). Since pooled results might be particularly initially sampled. Since similar questions were asked in influenced by one country, we also present results each country, in the multivariate analysis the samples separated by country in summary form in Table 2. are pooled (using statistical techniques to control for national differences), giving a sample of about 7,000 children (having accounted for attrition and excluding children for whom there is relevant missing data).

17 18 food for thought SE =Standard Error; N=SampleSize. The coefficientof0.059(pooledsample, reading) isinterpreted asincreasing thechancesofmakingamistake by 5.9percentage points. columns show theindependentimpactonchancesofmaking reading orwritingmistakes orbeinginthecorrect gradeassociatedwithstunting. the ageofchildatinterview. To interpret thesecoefficients: thefirstcolumnshows theimpactonatestof29mathsquestions; thelastthree T *** able 2 p<0.01, Peru N N SE SE India -1.080 N SE Ethiopia -0.782 N SE Pooled sample Vietnam -1.033 N SE ** p<0.05, Summary offindingsfrom * p<0.1. The definitionofbeinginthecorrect grade for age, isthatachildeitherin, oraheadof, theschoolgradeexpected for Maths score -0.657 (0.245) (0.169) (0.127) -0.982 (0.269) (0.278) 1,886 1,806 1,707 1,781 7,180 *** ** *** *** *** 0.033 0.059 0.053 0.026 0.101 the Y correct grade withwritinga simple sentence with reading a Made amistake oung Livesanalysis (0.024) (0.016) (0.037) (0.021) (0.019)(0.018) (0.011) (0.010)(0.012) (0.020) (0.023)(0.014) 1,890 1,8721,850 1,829 1,8181,807 1,774 1,7701,762 1,816 7,309 *** ** *** 0.041 0.078 0.051 simple sentence Made amistake (0.019) 7,277 7,235 1,817 1,816 0.031 0.034 *** ** *** ** -0.103 -0.066 -0.091 -0.081 for age Being in (0.025) -0.047 *** *** *** * *** Appendix 2 Estimating the equivalent cost of malnutrition at a global level

Existing estimates as to the economic impact of provision of DNIs, based on the combined fact that malnutrition differ by: malnutrition has been found to reduce productivity • The type(s) of malnutrition that are focused on by 66% in one paper from IFPRI,126 and that the DNIs • The conceptual framework/pathway used as to reduce stunting by 36%.127 They find benefit:cost how malnutrition affects GDP (eg, some focus on ratios of between 23.6 and 138.6, depending on pre- impacts via poorer health in adulthood, others existing differences in income levels and growth rates. focus on decreases in productivity through We apply a similar methodology. We estimate that reduced education) stunted children earn 20% less in later life than non- • Whether impacts are estimated at the individual stunted children. This estimate is based on a review or country level of longitudinal studies of the impact of stunting on • The region or country from which the estimate is education outcomes, combined with estimates of the based (few of them are global) impacts of these education outcomes on wages, which • The population sub-section to which they refer has estimated that stunted children earn 22% less than (eg, some estimates refer just to women) their non-stunted counterparts.128 We round down In fact, most of the studies with reliable estimates to 20%, which is in line with other previous estimates refer to the individual level, with only a few aggregate of the impact of malnutrition on wages,129 but is a estimates being produced, many of which are very more conservative estimate than the 66% used by vague in their methodology: the World Bank has the Copenhagen Consensus panel,130 which itself was stated that costs may be equivalent to 2–3% of GDP; based on the most robust available longitudinal study WFP has stated this may be as high as 11% in some to investigate the economic impacts of stunting.131 Latin American countries.124 We apply these estimated losses of income, on a The World Bank’s Nutrition Strategy document: country by country basis, to estimated per capita “Repositioning Nutrition as Central to incomes. For all countries where data is available Development”125 includes a wide-ranging review of from the Euromonitor disposable income dataset, various of the different estimates of the economic we have used this as an estimate of future earnings. impact of malnutrition, but does not attempt to Where income data is not available for countries, a systematise or synthesise them. It does not identify proxy is created using the ratio of GNI per capita (for one clear statistic as to the precise economic cost, the working population, from the World Bank World to individuals or countries. Development Indicators) to disposable income for countries at the same income classification. We then The Copenhagen Consensus has consistently rated calculate the lost earning potential for those children actions to address malnutrition as the most cost- under five years who are currently stunted. effective of all development interventions. The most recent paper on hunger and nutrition from the The results of this analysis suggest that by the time Copenhagen Consensus group has attempted to today’s stunted children reach working age, the quantify the overall benefit:cost ratio of the complete difference between their earnings and those of their package of direct nutrition interventions (DNIs). They better-nourished counterparts could be equivalent to use an estimated increase in income of 23.8 after $125bn globally.

19 endnotes

Executive summary 18 In May 2012, the World Health Assembly passed a resolution with six nutrition targets with one of them being stunting. For more details see 1 Save the Children (2013) Ending the Hidden Exclusion: Learning and equity http://thousanddays.org/wp-content/uploads/2012/05/WHO-Targets- in education post-2015 Policy-Brief.pdf 2 Save the Children (2012) The Child Development Index 3 See Appendix 1 for details. Young Lives is a longitudinal survey which 1 Early nutrition, cognitive follows 12,000 children across four countries throughout their lives. For development and education more details see http://www.younglives.org.uk/ 19 Thomson, R A and Nelson C A (2001) Developmental science and the 4 Prado E, Dewey K, Insight Nutrition and brain development in early life, media: early child development, American Psychologist, v56 n1 p5-15 Jan AT&T Technical Brief, issue 4, January 2012 2001 5 Georgieff M K, Rao R (1999) The role of nutrition in cognitive 20 Prado E, Dewey K, Insight Nutrition and brain development in early life, development. In: Nelson CA, Luciana M, editors. Handbook in Developmental AT&T Technical Brief, issue 4, January 2012 Cognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-504 21 Pelto G, Dickin K, Engle P (1999) A Critical Link: Interventions for physical 6 Georgieff M K, Nutrition and the developing brain: nutrient priorities and growth and psychological development, Geneva: World Health Organiza­tion measurement, American Journal of Clinical Nutrition, February 2007, vol. 85 no. 2 614S-620S Grantham-McGregor, S et al (1991) Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the 7 Prado E, Dewey K, Insight Nutrition and brain development in early life, Jamaican Study. , 338(8758), 1-5 AT&T Technical Brief, issue 4, January 2012 22 Georgieff M K, Rao R (1999) The role of nutrition in cognitive 8 It has been estimated that stunted children earn 22% less than their development. In: Nelson CA, Luciana M, editors. Handbook in Developmental non-stunted counterparts, based on available longitudinal studies of the Cognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-504 impact of malnutrition on education, and evidence from 51 countries of the impact of education on earnings. Grantham McGregor S (2007) 23 El-Sherif, A M et al (2012) Cranial magnetic resonance imaging (MRI) Developmental potential in the first 5 years for children in developing changes in severely malnourished children before and after treatment, Life countries, Lancet 369(9555): 60–70 Science Journal, 9(3) 9 Hoddinott J et al (2011) The Consequences of Early Childhood Growth 24 Georgieff M K, Rao R (1999) The role of nutrition in cognitive Failure over the Life Course, IFPRI Discussion Paper 01073 development. In: Nelson CA, Luciana M, editors. Handbook in Developmental Cognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-504 Hoddinott J et al (2012) Copenhagen consensus challenge paper: Hunger and malnutrition 25 Blatt G L et al (1994) Prenatal protein malnutrition effects on the serotonergic system in the hippocampal formation: an 10 World Food Programme and UN-ECLAC (2007) The Cost of Hunger: immunocytochemical, ligand binding, and neurochemical study, Brain Analysis of the social impact of child undernutrition in Latin America: Central Research Bulletin 34 (5): 507–518 America and the Dominican Republic Ranade, S C et al (2008) Different types of nutritional deficiencies affect 11 Horton S et al (2010) Scaling Up Nutrition: What will it cost?, Washington: different domains of spatial memory function checked in a radial arm The World Bank maze, Neuroscience 152 (4): 859–866 12 The Economist, Africa’s impressive growth, 6 January 2011. Available at: 26 El-Sherif, A M et al (2012) Cranial magnetic resonance imaging (MRI) http://www.economist.com/blogs/dailychart/2011/01/daily_chart changes in severely malnourished children before and after treatment, Life 13 These were identified by Jim O’Neill, former Chief Economist at Science Journal, 9(3) Goldman Sachs, and the person that predicted that economic rise of the Archives of Disease in Childhood (1987) Malnutrition, 62, 589–592 ‘BRICs’. The ‘Next 11’ countries are: Bangladesh, Egypt, Indonesia, Iran, South Korea, Mexico, Nigeria, Pakistan, the Philippines, Turkey, and Vietnam 27 Georgieff M K, Rao R (1999) The role of nutrition in cognitive development. In: Nelson CA, Luciana M, editors. Handbook in Developmental 14 Jim O’Neill (2010), The Growth Map: Economic opportunity in the BRICs and Cognitive Neuroscience, Cambridge, MA: MIT Press; 1999. p 491-504 beyond. New York: Penguin 28 Jukes, Drake and Bundy (2008) School Health, Nutrition and Education for 15 Comparison of the poorest 40% against the richest 10% is an All: Leveling the playing field. Wallingford: CAB International increasingly accepted measure of the concentration of inequalities. See Cobham A (2013) Palma vs Gini: Measuring post-2015 inequality, http:// 29 Allen L H, Anemia and iron deficiency: effects on pregnancy outcome, tinyurl.com/bq2x64e American Journal of Clinical Nutrition. May 2000, 71(5 Suppl):1280S-4S 16 UNICEF (2012) State of the World’s Children 2012, New York: The United 30 Prado E, Dewey K, Insight Nutrition and brain development in early life, Nations AT&T Technical Brief, issue 4, January 2012 17 Data on prevalence of stunting is taken from UNICEF (2012) State of 31 Grantham-McGregor S and Ani C, A review of Studies on the effect of the World’s Children 2012. 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20 endnotes 21 malnutrition of Economic impacts . Maternal and Victoria et al (2008) Maternal and Child Undernutrition 2. Hoddinott J et al (2008) Effect of a nutrition intervention during early of a nutrition J et al (2008) Effect Hoddinott J et al (2011) The Consequences of Early Childhood Growth Hoddinott Repositioning Nutrition as Central to Development: A Bank (2006) Repositioning Nutrition to Development: as Central World Long run impacts of child health Work: At Worms S et al (2011) Baird to be was found in height-for-age deviation of one standard A difference In R Semba and interventions. The economics of nutritional Horton S. The Consequences of Early Childhood Growth of Early Childhood Growth J et al (2011) The Consequences Hoddinott is an of life years gain in the first two Weight Martorell R et al (2010) the methodology. Appendix 1 for See Achievement Pre-School in Sanchez, A (2009) Early Nutrition and Cognitive in height-for- increase deviation a one-standard As indicated by to aspirations and self-efficacy: nutrition A (2011) From Singh S, Dercon and of cognitive The effects Stixrud J and Urzua S (2006) Heckman J J, This study found that an increase by a standard deviation of height-for- deviation a standard by an increase that found This study olume 45, May 2013, Pages 31–50 Cover image Pages 31–50 Cover 2013, May olume 45, 68 The Lancet in Guatemalan adults, childhood on economic productivity 69 01073 IFPRI Discussion Paper Course the Life . over Failure Hunger J et al (2012) Copenhagen consensus challenge paper: Hoddinott and Malnutrition. 2 63 The World scale action, Washington: large Bank for strategy 64 at http://www.povertyactionlab.org/publication/worms- gains, Available work-long-run-impacts-child-health-gains intervention of a nutrition during early Effect J et al (2008) Hoddinott The Lancet in Guatemalan adults, childhood on economic productivity child malnutrition , Tackling Hunger: from Free (2012) A Life the Children Save the Children Save London: food-based through micronutrients W et al (2002) Providing Demment M Journal of Nutrition, to human and national development, a key solutions: 3879S-3885S 11 133 no. 2003 vol. 1, November 65 adult health and human capital. consequences for child undernutrition: 2008DOI:10.1016/S0140-6736(07)61692-4 Published Online January 17, 66 associated with 8% higher in income in Brazil and Guatemala among men; as 25% higher income among women. and as much Maternal and child Victoria et al (2008) Maternal and Child Undernutrition 2. Published adult health and human capital. consequences for undernutrition: 2008DOI:10.1016/S0140-6736(07)61692-4 Online January 17, 67 Nutrition countries and health in developing Nutrition and Health: M Bloem, 2008 Humana Press; NJ: Totowa, 853-871). (pp. 56 01073 Discussion Paper IFPRI Course the Life , over Failure 57 five from outcomes in pooled analyses important of schooling predictor Journal of Nutrition, countries, birth and middle-income low- cohorts from 2 348-354 140 no. February 2010 vol. 58 59 Lives Young Oxford: 57, Paper Working , in Peru Children Achievement Stunting on Cognitive of Early-age D (2009) The Effect Thuc, Le Lives Young Oxford: 45, Paper Working Vietnam, in among Children 60 across comparison of difference allow deviations Standard age score. 95% of cases distribution, ‘bell shaped’, In a normal, indicators. different were Put simpler if there of the mean. deviations standard lie within two is deviation of one standard a difference height, by ranked 100 children the 50th child and the 84th child. between equivalent to the difference 61 Development World countries. in four time among children gender bias over V 62 outcomes and social behavior, abilities on labor market noncognitive 24(3), vol. Press, Chicago of University Journal of Labor Economics, July pages 411–482, 55 percent twenty of to an increase leads deviation, a standard by age score D (2009) The Effect Thuc, Le achievement. cognitive of the quantitative Vietnam, in Achievement among Children on Cognitive Stunting of Early-age Lives Young Oxford: 45, Paper Working tion and on brain deficiency and folate and folate deficiency on brain deficiency and folate 12 12 ogl T (2012) Early life health and adult circumstance in health and adult circumstance life T (2012) Early ogl V Currie J, J, Currie potential in the first S (2007) Developmental Grantham McGregor Torche F, Echevarria G. The effect of birthweight on childhood The effect G. Echevarria F, Torche Grantham-McGregor S M et al (1994) The long-term follow up of The long-term follow S M et al (1994) Grantham-McGregor Ardhvaryu and Nyshadham (2011) Endowments and investments within Ardhvaryu and investments and Nyshadham (2011) Endowments Grantham-McGregor S and Ani C A (2001) Review of studies on the A (2001) Review Ani C S and Grantham-McGregor Prado E, Dewey K, Insight Nutrition and brain development in early life, life, in early Insight Nutrition and brain development K, Dewey Prado E, Interventions physical for Engle P (1999) A Critical Link: Dickin K, G, Pelto Prado E, Dewey K, Insight Nutrition and brain development in early life, life, in early development Insight Nutrition and brain K, Dewey Prado E, Black M M, Effects of vitamin B Effects Black M M, Black M M, Effects of vitamin B Effects Black M M, Black, M M (2003) The evidence linking zinc deficiency with children’s linking zinc deficiency with children’s The evidence M M (2003) Black, Prado E, Dewey K, Insight Nutrition and brain development in early life, life, in early Insight Nutrition and brain development K, Dewey Prado E, and during pregnancy Hamadani JD et al (2002) Zinc supplementation Duke University Medical Center, ‘Zinc regulates communication between between communication ‘Zinc regulates Medical Center, University Duke Prado E, Dewey K, Insight Nutrition and brain development in early life, life, in early Nutrition and brain development Insight K, Dewey Prado E, in cognitive of nutrition The role Rao R (1999) Georgieff M K, Prado E, Dewey K, Insight Nutrition and brain development in early life, life, in early Nutrition and brain development Insight K, Dewey Prado E, on of research ‘A meta-analysis N and Born M P (1994) Bleichrodt (12 July 2008). ‘Iodine deficiency – way to go to – way ‘Iodine deficiency 2008). cited in The Lancet (12 July WHO Iron Deficiency Anaemia: Assessment, Assessment, Organization (2001) Iron Health Deficiency Anaemia: World in Anaemia A (2012) and Hamad M, Shehata M, Goonewardene A Life Free From Hunger: Tackling child Tackling Hunger: From Free A Life (2012) the Children Save , June 2008; 29(2 Suppl): 29(2 Suppl): 2008; June Nutrition Food Bulletin, in children, development S126–S131 , June 2008; 29(2 Suppl): 29(2 Suppl): 2008; June Nutrition Food Bulletin, in children, development S126–S131 54 60–70 The Lancet 369(9555): countries, in developing children for 5 years 52 53 51 who participated malnourished children in an intervention severely programme International Journal of country, in a middle-income development cognitive 1008-18 40(4): Aug; 2011 , Epidemiology 50 49 Journal of in children development deficiency on cognitive of iron effect 2 649S-668S 131 no. 2001 vol. February 1, Nutrition, Centre Tanzania, iodine supplementation in from Evidence the household: Centre Growth Economic 998, no. Discussion Paper 47 48 46 January 2012 issue 4, Technical Brief, AT&T January 2012 issue 4, Technical Brief, AT&T Health Organiza­ World Geneva: , and psychological development growth 45 44 43 41 January 2012 issue 4, Technical Brief, AT&T 42 study’, a follow-up of infants: and behaviour on mental development effects 290–294 (360): The Lancet, 2003; May Journal of Nutrition , and motor functioning, cognitive 1473S–1476S 133(5 Suppl 1): 40 , issue 4, January 2012 issue 4, Technical Brief, AT&T 39 Handbook in Developmental editors. Luciana M, Nelson CA, In: development. p 491-504 1999. MIT Press; MA: Cambridge, , Neuroscience Cognitive April 2013 25 Web. 21 September 2011, Science Daily, brain cells’, 38 36 January 2012 issue 4, Technical Brief, AT&T 37 ed. 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Central America and the DominicanRepublic Analysis ofthesocialandimpact ofchildundernutrition inLatin America: New York: The UnitedNations paper_zhang%20et%20al_final_draft_Aug12.pdf http://ageconsearch.umn.edu/bitstream/131119/2/iaae%20plenary%20 demographicdividend-investments.pdf and education.Available at: http://www.prb.org/pdf13/africa- Issue 3, 2009 build competitive advantage, Education, Knowledge andEconomy: V Rand, SantaMonica(CA) New perspectives ontheeconomicconsequencesofpopulationchange, Baird Setal(2011) Worms At Work: Longrunimpactsofchildhealth MartorellRetal(2010) Weight gaininthefirsttwo years oflife isan Currie J, Hanushek E A, Woessmann Lead toMore L(2009)DoBetterSchools Islam, Tariq Saiful, Md Wadud,Abdul andQamarullahBin Tariq Islam, Francis, BandIyare S(2006), Educationanddevelopment inthe Among asampleoftheworking populationinGhana, aonestandard- DemmentM W etal(2002)Providing micronutrients through food- Haddad LJ, BouisHE(1991) The impactofnutritional statuson Thomas DandStraussJ(1997)Healthwages: evidence onmenand World Food Programme andUN-ECLAC (2007) The CostofHunger: UnitedNationsPopulation Division(2010)World Population Prospects , The HumanCapital RootsoftheMiddle Income Trap:The caseofChina, COM(2013) Towards aDemographic Dividend: Invest inhealth GuptaR, (2009)Leveraging Indiantalentpoolanddemographics to Bloom, DE., CanningD, andSevilla,J (2003). 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China’s 90 hunger, Bulletin, Food &Nutrition 89 136:1068–1071 88 105 104 103 102 101 100 ,Nutrition London: Overseas Development Institute Wiggins S, Keats S, (2013)Smallholder Agriculture’s toImproved Contribution 99 3 www.aae.wisc.edu/mwiedc/papers/2013/canon_maria.pdf (late) nutrition amelioratethem? Young Lives Working paper. See: http:// 98 poorer nutritional statusinoffspring. 97 Horton SandRossJ(2003) Horton The economicsofiron fortification, Food This analysis istaken from Save theChildren’s research databaseand NationalIQandProductivity: The hive mindacross Asia, Garett NoorbakhshF, Paloni A and Youssef A (2001)Humancapital and This isespecially truegiven thatithasbeenfound, insomecases, that World Food Programme andUN-ECLAC (2007) The CostofHunger: Bhuttaetal(2008)MaternalandChildUndernutrition 3. What works? 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(2006)Reducingtheincidenceoflow birth PradoE, Dewey K, InsightNutritionandbraindevelopment inearly life, Inter V olume 81(Issue3): 345–368 ventions that make V olume 28, Number2,June 2007 Archives ofPediatricsand Archives Adolescent a difference Journal ofPublic endnotes 23 For example, Horton estimates that the costs of underweight could Horton estimates that the costs of underweight example, For Copenhagen consensus challenge paper: J et al (2012) Hoddinott course. the life over The impact of malnutrition J et al (2010) Hoddinott Repositioning Nutrition as Central to Development: A Nutrition to Development: Bank (2006) Repositioning as Central World with six passed a resolution Assembly Health World the 2012, In May www.younglives.org.uk A to Development: Bank (2006) Repositioning Nutrition as Central World A Repositioning Nutrition to Development: Bank (2006) as Central World childhood growth The consequences of early J et al (2011) Hoddinott, Interventions maternal and child for What works? Z et al (2008) Bhutta, earn 22% less than their It has been estimated that stunted children Gyles C L (2012) Health economics and nutrition: a review of published of published a review and nutrition: Health economics C L (2012) Gyles 129 130 131 121 122 Appendix 1 123 Appendix 2 124 125 126 127 128 120 The Economics of Nutrition 2008, equate to 10% of earnings (Horton S, pp 859–871). Nutrition countries and health in developing . Interventions. at in childhood are Bank estimates the costs of malnutrition World The Bank (2006) Repositioning least 10-15% of earnings in adulthood (World scale action). large for A Strategy Nutrition to Development: as Central Hunger and Malnutrition. at http://www.chronicpoverty.org/uploads/publication_files/ Available hoddinott-et_al_malnutrition.pdf , Washington: The World action, Washington: scale large Bank for Strategy details see more For being stunting. targets with one of them nutrition http://thousanddays.org/wp-content/uploads/2012/05/WHO-Targets- Policy-Brief.pdf The World scale action, Washington: large Bank for strategy The Cost of Hunger: (2007) and UN-ECLAC Programme Food World Central America: Analysis of the social impact of child undernutrition in Latin America and the Dominican Republic The World scale action, Washington: large Bank for strategy Research Policy International Food Mimeo, course, the life over failure DC Washington, Institute, 417–440 The Lancet 371: and survival, undernutrition longitudinal studies of the based on available non-stunted counterparts, 51 countries from evidence and on education, impact of malnutrition S (2007) Grantham McGregor of the impact of education on earnings. developing in for children years potential in the first 5 Developmental 60–70 The Lancet 369(9555): countries, evidence, Nutrition Review, 2012 December, 70(12):693–708 2012 December, Nutrition Review, evidence, BMC public 36(1), 5–14 36(1), American Journal of Clinical Nutrition , Archives of and Adolescent Archives and of Pediatrics recommendations 338(8758), 1–5 338(8758), , Journal of Perinatal Medicine The Lancet, Conclusion and Repositioning Nutrition as Central to Development: A Bank (2006) Repositioning Nutrition to Development: as Central World Psychosocial aspects of malnutrition management, chapter 8 in chapter management, Psychosocial aspects of malnutrition Nahar B, Hossain M, Hamadani J, Ahmed T, Grantham-McGregor S, and S, Grantham-McGregor Hamadani J, Ahmed T, Hossain M, Nahar B, Grantham-McGregor, S. et al (1991) Nutritional supplementation, et al (1991) Nutritional supplementation, S. Grantham-McGregor, Horton S (2006) The economics of food fortification, Journal of Nutrition, fortification, of food The economics Horton S (2006) , UNICEF, UNICEF, A report on nutrition, card Children: for Progress UNICEF (2006) Lozoff, B, of iron burden Double Smith J B (2006) E and B, Jimenez Lozoff, ictora C G, Barros F C, Horta B L, Lima R C, Breastfeeding and Breastfeeding Lima R C, Horta B L, C, F Barros Victora C G, and Breastfeeding T, D B M and Remley Johnstone W, Anderson, J Superfood for Babies: How overcoming barriers overcoming How to Babies: for (2013) Superfood the Children Save and of prolonged Effects et al. S, Igumnov E, Fombonne Kramer M S, Koletzko B, Lien E, Agostoni C, Böhles H, Campoy C, Cetin I and Uauy, Cetin I and Uauy, C, Campoy Böhles H, C, Agostoni Lien E, B, Koletzko Prado E, Dewey K, Insight Nutrition and brain development in early life, life, in early Nutrition and brain development Insight K, Dewey Prado E, Save the Children (2013) Superfood for Babies: Ho overcoming barriers barriers Ho overcoming Babies: for (2013) Superfood the Children Save 119 4 118 117 116 108 107 106 114 115 112 113 111 110 109 , Washington: The World scale action, Washington: large Bank for strategy Hunger J et al (2012) Copenhagen consensus challenge paper: Hoddinott and Malnutrition ,12(1), 622 health,12(1), Available ReportAcute Malnutrition (MAMI) Project in Infants . of Management at http://www.ennonline.net/pool/files/ife/mami-chapter-8-psychosocial- considerations.pdf Persson L A (2012) Effects of psychosocial stimulation on improving home on improving of psychosocial stimulation A (2012) Effects L Persson a community-based from results practices: and child-rearing environment in Bangladesh. malnourished children trial among severely psychosocial stimulation, and mental development of stunted children: the of stunted children: and mental development psychosocial stimulation, Jamaican Study, 136:1068–1071 , 160(11), 1108–13 160(11), Medicine, York New deficiency in infancy and low socio-economic status: a longitudinal analysis a longitudinal analysis status: socio-economic infancy and low deficiency in 19 years, to test scores of cognitive 1999, 70:525–535 1999, , 2005 Nov; 2005 Nov; , Acta Paediatrica in Brazilian adolescents, school achievement 94(11):1656–60 a meta analysis, development: cognitive breastfeeding will save children’s lives will save children’s breastfeeding and maternal adjustment: on child behavior breastfeeding exclusive e435-40 cited 121: Pediatrics 2008; randomized trial. a large, from evidence et al 2011 Walker in R (2008) The roles of long-chain polyunsaturated fatty acids in pregnancy, fatty acids in pregnancy, of long-chain polyunsaturated The roles R (2008) and consensus knowledge of current review lactation and infancy: recommendations, , issue 4, January 2012 issue 4, Technical Brief, AT&T to breastfeeding will save children’s lives, London: Save the Children Save London: lives, children’s will save to breastfeeding

cover photo: hildren COVER Photo: jonathan hyams/save the children thought

ackling child malnutrition child ackling to unlock everyone.org he evidence we present shows that preventing that preventing shows present we The evidence in the and women of children malnutrition the start of – from window crucial 1,000-day second her child’s until pregnancy a woman’s children’s increase – could greatly birthday and could boost ability to learn and to earn, of whole countries. the prosperity n this report we demonstrate how investment investment demonstrate how In this report we it is the right thing to do, is not only in nutrition prosperity. on future a down-payment n the past two decades, progress in tackling progress decades, In the past two slow. has been pitifully malnutrition potential and boost prosperitypotential T food for for food