the response of child nutrition to changes in income.pdf

8/11/2019 The Response of Child Nutrition to Changes in Income.pdf

1/18

The Response of Child Nutrition to Changes in Income:

Linking Biology with Economics*

Harold Aldermany

y World Bank 1818 H St., Washington, DC 20433, USA. e-mail: [email protected]

Abstract

It is regularly pointed out that despite impressive economic growth India has the largest

number of malnourished children in the world. It also has the largest number of people with

diabetes despite moderate levels of obesity. These two observations may in fact be linked;

poverty breeds malnutrition in children and chronic diseases in adults. This article reviews

evidence on the critical role of early nutrition both for long-term health and also for reducing

the intergenerational transmission of poverty. (JEL codes: I12, I14, O15)

Keywords: nutrition, child development

1 Introduction

There is likely little doubt on the validity of either the proposition that

income growth reduces malnutrition or that reducing malnutrition

promotes income growth. How much emphasis is placed on the latter,

however, depends, in part, on the expectations on the magnitude of theformer. In particular, if there is a sharp gradient of nutritional status as

one moves away from poverty then a different set of programs might be

prioritized than ifas evidence in Haddad et al. (2003)impliesincome

growth even when evenly distributed over a population has a relatively

modest, albeit significantly positive, impact on undernutrition rates.

Because it is comparatively easy to derive quasi-reduced form estimates

of the association of child malnutrition and current household income this

relationship can be used to both guide development priorities as well as

address pragmatic operational questions such as how much transfer is

needed to effect a meaningful change in health-seeking behavior

(Fernald et al. 2008). This article therefore begins with a discussion of

two observations on the relation of income and income growth to nutri-

tional status. One observation is on the magnitude of the association of

income and nutrition and the other focuses on evidence on the timing of

income. The next section explores new evidence on how these economic

paths may relate to aspects of physical growth again choosing to highlight

two particular features: (i) the timing of critical periods of growth and (ii)

some recent studies that potentially have a bearing on why obesity and

* Paper prepared for CESifo workshop on Malnutrition in South Asia Venice InternationalUniversity, San Servolo, Venice 2021 July 2011.

The Author 2012. Published by Oxford University Presson behalf of Ifo Institute, Munich. All rights reserved.For permissions, please email: [email protected] 256

CESifo Economic Studies, Vol. 58, 2/2012, 256273 doi:10.1093/cesifo/ifs012Advance Access publication 2 May 2012

byguestonSeptember

27,2013

http://cesifo.oxfordjo

urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom

byguestonSeptember

27,2013


urnals.org/

Downloadedfrom
http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/http://cesifo.oxfordjournals.org/


2/18

malnutrition are often observed in the same households, never mind the

same communities. The final section links these themes.

2 Some observation on the path from income growth to child

growth

A. The global evidence that income growth is not a sufficient condition for

the rapid reduction of malnutrition

On average, country-level rates of undernutritiondefined as low weights

for agedecline at roughly 50% of the rate that gross national products

(GNP) per capita increase. This cross country evidence differs little from

results generally derived from household surveys at the individual level(Haddad et al. 2003). Likewise, anemiadefined as hemoglobin levels

below 10.9 g/dldeclines at roughly 25% of the rate of income growth

(Alderman and Linnemayr 2009).

The majority of studies reporting such evidences are based on

cross-sectional surveys and, as always, there are challenges to the causal

interpretation of these associations. However, since anthropometric

surveys are increasingly available, one main issue for deriving such esti-

mates at the individual level for any population or subpopulation strati-

fied by classifications such as gender or age is the source of expenditure orincome data. Many data sets with information on anthropometric meas-

urements or on anemia such as Demographic and Health Surveys [DHS]

lack income or expenditure information.Filmer and Pritchett (2001)have,

however, shown that asset indices can be conveniently used to map the

relationship of economic status and nutrition. This techniquenow

widely employedalso addresses the fact that a graphic or regressional

analysis of the association of an outcome with one that is measured with

substantial error (as are expenditures and income) is biased towards zero

in proportion to the measurement error. The construction of an assetindex sweeps out most measurement error and thus reduces this bias

appreciably.

Alternatively, a measure of income or expenditures that is predicted

from assets also has this appreciable advantage over directly reported

income. This treatment for errors in variables is closely related to the

use of instrumental variables to address the simultaneity or endogenity

of income, although the issue of exclusion restrictions does not necessarily

arise when considering errors in variable bias. In any case, the mismeas-

urement of income or expenditures is plausibly the dominant issue relative

to the lagged endogeneity of assets. That is, the former is known to be

appreciable while the latter is unknown. While very young children do not

directly contribute to asset accumulation, other possible sources of bias

CESifo Economic Studies, 58, 2/2012 257

Response of Child Nutrition to Changes in Income


3/18

may reflect either the impact of a childs illness on parents ability toacquire assets or the correlation of unobserved preferences for savings

over current consumption and health seeking behavior.1

An asset index provides only an ordinal proxy for income or wealth.

Often the index is reported in quintiles as illustrated inTable 1or similar

aggregations. Such tables confirm that malnutrition rates are high even

among those who are not poor. For example, using the data inTable 1,

where all households in the lowest two quintiles by wealth in Pakistan to

have the characteristics of the middle quintile, poverty in the country

would be virtually eliminated, yet over 38% of the entire population ofchildren would still be malnourished.

Such an association of malnutrition and asset rankings can be used to

derive an approximation of income elasticities if the ranking of assets can be

associated with the average income of each quintile using alternative data.

Similarly, it is straightforward to construct average elasticities of income

Table 1 Nutrition and poverty: prevalence of child underweight by wealth

quintiles

Region Country Lowest 2nd 3rd 4th Highest

South Asia

Bangladesh 59 53 45 43 30

India 61 54 49 39 26

Pakistan 54 47 43 37 26

Africa

Benin 29 30 23 20 10

Burkina Faso 42 40 41 39 22

Ethiopia 49 51 51 45 37

Mozambique 31 28 26 19 9

Rwanda 27 30 28 24 14

Tanzania 25 26 22 20 12

Uganda 27 26 25 19 12

Source: Gwatkin et al., Country Reports on HNP and Poverty: Socio-economic Differences

in Health, Nutrition and Population, April 2007.

Note: Data for children


4/18

growth at an aggregate level. For example, in the 1990s, India experienced a

growth rate in GDP per capita of 5.3% whereas malnutrition declined by

1.5% (World Bank 2006). The implied average elasticity of0.28 is lower

than the rule of thumb of0.5 mentioned above and lower than that ofChina (0.67) or Bangladesh (0.73) over the same period.

Indeed, results from India on the prospects of addressing malnutrition

primarily through income growth are generally discouraging. For exam-

ple, Subramanyam et al. (2011) find that state-level economic growth in

India offers little or no explanation for reductions in malnutrition between

1992 and 2006. Since this analysis of three rounds of the National Family

Health Survey also includes family wealth among the covariates and since

there were strong gradients of the risk of underweight with poverty as well

as maternal and paternal education in this data, the result hints at the roleof state infrastructure and execution of its programs rather than private

resources. This does not completely remove the puzzle of the relatively low

response to growth, but it does help locate it.

Still, for many purposes a cardinal estimate of the impact of income

growth is required at a more disaggregated level. Even in the absence of

direct survey data on income or expenditures it is nevertheless often pos-

sible to map expenditures to the same assets that are commonly used to

construct an asset index using data from an income and expenditure

survey and then use these parameters to predict expenditures within aDHS or similar survey that has information on assets. Such an approach

was used within the context of a randomized longitudinal trial of a com-

munity nutrition program in rural Uganda. This estimate found that while

income growth will have a positive and statistically significant impact on

undernutrition, a 5% rate of per capita income growthsubstantially

larger than the average for the decade that preceded the studywould

take 33 years to reduce underweight rates by half (Alderman 2007).

As mentioned, such indications of the magnitude of improvements given

income growth can be useful in policy projections. Such a starting pointmay, however, not fully guide the design of cash transfers support programs

since there is some evidence that the source of income matters, either

through labeling effects (Kooreman 2000; Paxson and Schady 2010) or

through gender control. Ideally, to understand the path from income to

nutrition one would like to complement a reduced form approach with a

nutrition production function to gain insights on the contribution of key

inputs in overall health as well as assess how income and prices affect the

demand for these inputs. While health production functions are likely to be

more stable than reduced form estimates (Rosenzweig and Schultz 1988),

the difficulty in finding suitable identifying restrictions for input demand

remains an obstacle to their application. Randomized controlled trials have

served to derive the impact of selective inputs, particularly micronutrients,




5/18

but as is increasingly recognized it is still the exception that the heterogen-

eity of response within a population is addressed in such studies.

Additionally, the issue of substitution and complementarity of inputs is

generally not assessed in randomized trials.

B. Timing of income seems to matter

The evidence discussed above, being based on instrumented expenditures

or income and thus indirectly on assets, should reflect a measure of

permanent income. Why then, is the evidence that short-term shocks to

income have long-term consequences on nutritional outcomes so perva-

sive? In one example from this body of evidence,Alderman et al. (2006)

found that children who were 2 years old during a period of drought and

civil unrest in Zimbabwe were more malnourished than their siblings.

Moreover, this shock has a long reach; when this cohort was tracked

over two decades, the malnourished children were found to be both

shorter and had fewer grades completed than other children.

Shocks need not even be of a magnitude commonly deemed droughts to

have an impact on child nutrition.Maccini and Yang (2009)look at rain-

fall in Indonesia and find girls born in years of low rainfall achieved

smaller adult heights and also have less schooling than those born in

years with normal rainfall. The study notes that the impact of a shortfall

of rain in a year immediately prior to birth does not have a similar mea-

sureable impact on nutrition. Recent research using the Indian National

Family and Health Survey and an international database of natural dis-

asters is in keeping with this result (Datar et al. 2011). This study finds that

small to moderate disasters reduce child growth as well as lead to

increased morbidity, with the impact being greater for girls. The study

also found that children who were post weaning were most vulnerable.

The timing of nutritional shocks is not only found when comparing

across years. Birth outcomes reflect intra-year patterns as well.Lokshin

and Radyakin (2012) find that Indian children born in the monsoonmonths have lower anthropometric scores than children born in the

post-monsoon period. This holds for both girls and boys and the results

vary little between the ordinary least squares estimates and the family

fixed effects estimates (on a much smaller sample).2 Wealth and education

mitigate these seasonal patterns without eliminating them, whereas rainfall

at the time of a childs birth has little impact. Lokshin and Radyakin,

however, cannot determine at what age this pattern kicks in, although it is

clearly prior to the age of 3 years.

2 AsAlderman et al. (2011)point out, selective survival is unlikely to influence anthropo-metric patterns at the level of mortality in South Asia.

260 CESifo Economic Studies, 58, 2/2012

H. Alderman


6/18

Studies of the timings of nutritional insults, however, seldom distinguish

the impact of prices from that of liquidity. Changes in relative prices,

whether for food or for child care, can plausibly account for a share of

either seasonal or inter-year weather-related patterns of malnutrition. Butfood prices cannot be the entire story since similar patterns of increased

mortality in light of financial shocks have been regularly noted. For exam-

ple,Baird et al. (2011)confirmed that macroeconomic shocks, defined as

deviation from trends in 59 developing countries were associated with

increased infant mortality particularly for girls. However, shocks that

occurred during gestation did not seem to affect mortality. These results

are in keeping with those for India based on family fixed effects estima-

tions (Bhalotra 2010). Again, this study finds that income shocks increase

mortality, particularly of girls. It also notes that shocks in utero have asmaller (marginally significant) impact relative to those in the neonatal

period while post-neonatal shocks do not affect mortality. When

rainfallthe impact of which is presumed to be additional to any

income effect and thus may be considered a proxy for disease environ-

mentwas included the aggregate shock decreased but not substantially.

Health care expenditures andgiven the measured increased labor of

mothers in times of distresschild care were found to decrease in times

of aggregate income shocks. Finally, Bhalotra finds that the aggregate

shocks affect children of uneducated and younger mothers more thanthey affect others.

In the absence of evidence on massive selection bias, it is reasonable to

assume that nutrition results move in a similar manner as these income

and mortality patterns particularly if they are driven by health seeking

and child care. Note, however, that these results are observed after any

government, non-governmental organization, or family responses to the

crises. Even if a public safety net cannot gear up expenditures and cannot

refine its targeting rapidly enough to address an aggregate shock, it is a

bit of a puzzle why families are unable to buffer their expenditures usingtheir own and community resources. This is especially true for seasonal

patterns; Paxson (1993) notes that seasonality in Thailand is mainly an

issue of prices and not total expenditures. Indeed, while the phenomenon

of seasonality of consumption is widespread, it is hard to explain in

terms of intertemporal utility theory. Even income fluctuations between

years are often protected by household savings and other measures to

self insure or to co-insure within a community. However, repeated or

presumablylong-term shocks may have different impact (Alderman

1996). As there are clear mechanisms to transfer income, but few to

transfer time available for child care, it remains important to determine

the manner by which these income shocks transmit to the health of

children.




7/18

3 Two features of child growth particularly relevant for

economic inquiry

A. Timing matters from a biological standpointThe literature on human development often refers to critical and sensitive

periods after which it is either impossible or at least difficult (and expen-

sive) to offset a lost opportunity for physical and cognitive development.

Given the obvious importance of understanding the timing of interven-

tions, the temporal sensitivity of undernutrition risks has been the focus of

a range of studies.Alderman et al. (2006), for example, identify impacts on

the assumption that children under 2 years are more vulnerable than

slightly older ones. Likewise, Maccini and Yang (2009) interpret their

results as implying the weather shocks they study have an effect duringthe critical period of weaning rather than the prenatal period. The limited

period of vulnerability is consistent with extensive epidemiological

evidence that shows most growth faltering occurs in the first 18 months

of life (Victora et al. 2010).3 This reflects both the risk of diarrheal disease,

especially for children who are not exclusively breastfed until 6 months, as

well as the overall deceleration of growth in infancy. Based on the lower

bound of the average change across the 5th, 50th, and 95th percentiles in

the new growth curves published by World Health Organization, a child

can be expected to grow 24 cm in year 1 and only 12 cm in year 2 and lessin its third year.

Similar critical periods of vulnerability to nutritional shocks are

observed in pregnancy. For example, one of the earliest finding of the

Dutch Famine study was that women in their third trimester of pregnancy

during the relatively brief period of severe food shortages in the winter of

1944/5 were at increased risk of low birth weight babies (Stein et al. 1975).

This risk was not noted for women who conceived later and, thus, who

entered the third trimester after the famine was relieved.

Turning such observations around, clinical and epidemiological studies

have pinpointed optimal times for intervention. For example, folate

supplementation is most likely to prevent birth defects if available

prior to conception and iodine status is also more important in early

pregnancy than after the child is born. In a study in the Gambia, Ceesay

et al. (1997) provided supplements to women in the 20 weeks prior to

expected delivery and found a six percentage points reduction in the

prevalence of low birth weight. Notably, the mean birth weight among

the intervention group increased by a larger amount in the nutritionally

poor hungry season.

3 This does not rule out catch up growth, for example, during adolescence. With increaseavailability of longitudinal data this is an area of promising research.


H. Alderman


8/18

The timing of pregnancy itself is important for the outcome of preg-

nancy in another sense as well. Birth weight is lower and mortality risk

higher when a pregnancy occurs prior to age 18a time when a woman is

still growingalthough the relative contributions to birth outcomes ofyoung women of biology, knowledge and practices for health, and

family wealth are hard to assess due to the endogeneity of reproductive

choices. But one critical period for pregnancy outcomes occurs long before

conception; the evidence on the role of maternal nutrition on the next

generation is quite strong. For example, using 109 DHS data sets from

54 countries,Ozatlin et al. (2010)found a negative association of risk of

child mortality and maternal height in 52 countries, with 46 of these

statistically significant. This was found for all regions including Europe

(although the risk was somewhat less in Africa) and was robust whenhousehold wealth rankings were taken into consideration. Thus, while

the association was not driven by differences in current wealth or

income it does reflect the wealth of the mothers natal family.

This indicator of the inter-generational transmission of healthand,

given other evidence, the transmission of povertyis fairly general; mater-

nal stature is almost always a significant determinant of child anthropom-

etry, even when other wealth and education variables are included in the

estimates (Black et al. 2008).4 This pattern, often obtained in cross section,

but a similar finding has also been shown in results of a randomized trialin Guatemala conducted between 1969 and 1977 (the participants of which

are still being tracked). This research found that the children of women

who received nutritional supplements in childhood had higher birth

weights as well as better anthropometric indicators of nutritional status

(Behrman et al. 2009). The precise pathway of this generational impact

could not be elucidated as the benefits of this intervention also included

higher education of the mothers who were supplemented when they were

children although a physiological contribution is consistent with the wider

literature.This particular study did not find any influence of next generations

nutrition from the participation of the father in the intervention as a

child. Often, but not universally, paternal stature also has a smaller coef-

ficient in cross-sectional estimates (Alderman 1990). Assuming that errors

in variables are not driving this (as it might if paternity was regularly

misassigned), it implies that phenotype influences the childs health in

4 The reference cited here is part of a series of articles that review the state of the art fornutrition. The reader who wants an introduction to the consensus views in the field (to thedegree that any discipline remains in consensus) might begin with this series. See also,Victora et al. (2008)andBhutta et al. (2008).




9/18

addition to genotype. As height represents the choices and conditions that

prevailed when the mother was herself a child, this is a strong indication of

the transmission of one generations wealth (among other factors) to the

health of the next.

The timing for the impact of an intervention is shown in a few published

studies. Community nutrition programs that stress changes in care giving

and health seeking behavior but which do not provide macro-nutrient

supplementation or income support generally find the initial impacts

only among the youngest children in the treatment group (Linnemayr

and Alderman 2011,Alderman 2007). This is in keeping with the import-

ance of exclusive breast feeding and diarrheal disease prevention in the

first months of a childs life.

The provision of supplementary foods for weaning age children havebeen shown to make a difference, but, again, it is important to fine tune

the age of the child for whom these supplements are provided. An analysis

of the Guatemala trial discussed above, found that the youngest children

were prone to increased diarrhea when receiving supplements but from age

6 to 36 months the supplements contributed to increased growth but at a

decreasing rate. After 36 months no impact was observed (Schroeder et al.

1995). As discussed in the next section, there is also a concern that as a

child ages past 2 years, addressing malnutrition with the same approaches

that have an impact at the start of weaning, such as with macronutrientsupplements, may not merely be ineffective, the approach may increase the

risk of chronic illness when the child is an adult.

B. The double burden of malnutrition and chronic disease

Research over the past decade has been able to narrow down the under-

standing of the periods of nutritional sensitivity and, in doing so, have

been able to make headway on understanding the biological pathways. In

doing so, recent research leads to the conclusion that separating the con-

cept of malnutrition into under- and over-nutrition is, to a fair degree, a

false dichotomy. For example, given the short duration of the Dutch

Famine and the rapid return to relative food abundance, this event has

facilitated a nuanced assessment of critical periods for pregnancy. As men-

tioned, birth weight was mainly influenced by deprivation in the third

trimester. However, that measure provides only a limited perspective on

development, while birth weight is a commonly used indicator for birth

outcomes it is only one of many aspects of fetal growth linked to

long-term health. As the children born during and immediately after the

famine enter into their middle age, it is apparent that they have increased

risk of chronic disease and some mental illnesses. For example, glucose

metabolism is impaired in adults who werein uteroat any time during the


H. Alderman


10/18

famine. However, only those adults whose mothers were in their first

trimester were found to be at increased risk of obesity and heart disease

as well as breast cancer.5 Recently it was noted that while no cognitive

impairment was found when the cohort were young adults as they age they

are showing loss of attention and cognitive ability at a greater rate than

the general population. Individuals whose mothers were deprived in their

first trimester show the greatest decline of ability (de Rooij et al. 2010).

Although the study of the Dutch Famine is the most comprehensive of

its genre, similar finding have been noted from the disastrous Chinese

Great Leap and in follow up from the Biafra famine of 19671970. In

the latter example,Hult et al. (2010)report increased risk of diabetes and

hypertension among children with fetal exposure to the famine compared

to the cohorts immediately preceding and immediately following thefamine.

While famines are extreme events, the patterns uncovered by studying

these temporally circumscribed events are also found in other analyses.

Moreover, although the findings are explained in terms of a biological

model that transcends political boundaries and, indeed, is not specific to

our species, there is a particular South Asian nuance to the assembled

data. For example, a longitudinal study of a cohort of births in South

Delhi followed up to age 32 found that those children who were thinner in

infancy (with a body mass index [BMI] less than 15) had an acceleratedincrease of BMI until adulthood. Although none were classified as obese

by age 12, those with the greatest increase in BMI by this age had impaired

glucose tolerance of diabetes by the age of 32 (Bhargava et al. 2005).

Similar results have been reported using a panel in Pune (Yajnik 2009).

While there is not a standard definition for rapid weight gain, the findings

in the Delhi and Pune studies are in parallel with a systematic global

review that found a similar association of early rapid growth in infancy

and early childhood and subsequent obesity in 13 of the 16 studies

reviewed (Monteiro and Victora 2005).Despite this global patterns there appear to be characteristics of the

population in India that lead to unique risk factors for chronic disease.

Moreover, the transition from a resource poor environment to one that is

less constrained may aggravate these risks. India has not only the largest

number of malnourished children in the world, but it also has the largest

number of people with diabetes (Ramachandran and Snehalatha 2010).

These two statistics may very well have a common origin. While the Indian

population does not have a high rate of obesity relative to the rest of the

5 Personal correspondence with T. J. Roseboom based on a presentation in Santiago ChileNovember, 2009, cited with permission.




11/18

world, or even other Asian countries, there is a tendency to accumulate

adipose tissue around the waist. This pattern is associated with elevated

risk of chronic disease. Thus, Indians have been referred to as thin but fat

(Yajnik 2009). Another risk factor for diabetes largely specific to India islow maternal intake of vitamin B-12 coupled with high folate. Finally, in

another dimension of intergenerational transmission of health, maternal

hyperglycemia, or diabetes poses an elevated risk of diabetes for the next

generation.

It is largely beyond this article to assess the contribution of these studies

to rapidly accumulating evidence on chronic disease. But before returning

to some semblance of economics, it is useful to allude to the larger picture

that is emerging from such epidemiological results. A seminal paper by

David Barker and Clive Osmond (1986)in which they traced adult illnessin England and Wales to birth weight records has led to a hypothesis of

the etiology of diseases termed the fetal origin hypothesis and a body of

research (as well as a professional association and journal) on the

development origins of health and disease.Gluckman et al. (2009) have

placed this in the context of human evolution; contemporary humans

inhabit an environment very different than that in which they evolved

leading to a mismatch of their biological programming and the conditions

in which they live.

The so-called Barker hypothesis remains controversial, though strongerthan when originally proposed. The original epidemiological results

showed an association. However, it is difficult, if not impossible, to

design an experiment that can provide a direct casual interpretation for

humans within the constraints of research ethics and the practicality of

observing outcomes that take a generation to manifest.6 Nevertheless, a

causal interpretation is strengthened when there is an underlying structural

biological model. Since Barkers and Osmonds original observations in a

range of laboratory studies using animals has explored this biology

(Harding et al. 2011), bolstering, if not necessarily proving, the causalinterpretation.

One manner in which this plays out is illustrated with adaption to stress

in the womb. The signal derived from limited nutrientsin uteroleads to an

adaptation in which the child or adult is particularly efficient at conserving

resources. However, when that individual is subsequently confronted with

a resource-rich environment, this maladapted response, or mismatch,

contributes to overnutrition and increased risk of chronic diseases. This

6 While there are a few randomized nutrition interventions in pregnancy that are beingtracked as the children mature (Fall 2009), even in these rare cases the assignment hasoccurred after the women knew they were pregnant, while laboratory studies of animalsindicate that preconception nutrition is critical.


H. Alderman


12/18

is occasionally referred to as a manifestation of a thrifty gene, but this is

less genetic than epigenetic. This latter concept refers to a developmental

plasticity that is not directly driven by genes, but rather a process by which

parts of the genes or gene-associated proteins are activated usually, but

not exclusively, through methylation. Thus, genes are not altered, but their

expression is.7

Gluckman and Forrester (personal communication) have used the

concept of fetal plasticity to gain insights on the question of why some

children manifest undernutrition in the form of marasmus and others with

kwashiorkor. The former emaciation is less likely to be fatal than the

mixture of edema and protein breakdown that occurs in the latter.

Gluckman and Forresters sample of Jamaican survivors of both forms

of malnutrition proved to be quite different. Whereas children who werediagnosed as marasmic were often born at low weights the other group

was not. The former group also had a tendency to consume more food

when given the opportunity. These results can be interpreted as a result of

fetal nutritional stress that led to low birth weight and an adaption to

consume resources efficiently consistent with the higher survival reported

for marasmus relative to kwashiorkor. But, if the child should survive and

live in an environment replete with resources this risk response is

mismatched with their current conditions, increasing risks of obesity.

4 Bringing it all home

The expanding understanding of biological plasticity and of the link of

undernutrition and subsequent health risk adds a when to the question of

what inputs are most critical. It poses some tricky questions for the timing

of interventions since the maxim, do no harm, is challenged when the

timing of interventions is considered. In the Indian context, recent

research indicates that given the possible negative interaction of micronu-

trients such as vitamin B-12 and folate mentioned above, both of which

are individually shown to be important, new guidelines may be needed.

More generally, program design must consider the risk that addressing

malnutrition in infants and young children may increase illnesses later in

7 Insights from epigenetics do not require interpretation in terms of evolutionary adapt-ability althoughGluckman et al. (2009) offer a range of plausible hypotheses that tie inthe concept of mismatch. To illustrate, evolutionary theory poses a tradeoff betweenfecundity and longevity. Under stress plants and animals may increase fitness by shiftingresources into early reproduction rather than growth. This may help explain the plasticityof menarche. For example, Indian girls, presumably from a low resource environment,adopted in Sweden, reached puberty earlier than Swedish girls and much earlier than girlsin India.




13/18

life. Similarly, this understanding provides a perspective to assist in antici-

pating the public health challenges that emerge in South Asia as it tran-

sitions from a low income environment.

Gluckman et al. (2009) poses basic and applied research questions

that come out of the understanding of developmental plasticity including

some questions such as what level of risk in later life disease is acceptable

and what are the social costs of less than optimal development and what

are the benefitcost ratios of early interventions. These are difficult ques-

tions and need to be addressed in an interdisciplinary manner but it is

likely that economists have a comparative advantage in approaching

them.

Almond and Currie (2011) have recently taken up the challenge, pla-

cing the fetal origins hypothesis through an economists lens.8 While theyare in part correct that economics has much to offer, many of the con-

tributions they illustrate come more from econometrics than from eco-

nomics, that is, from techniques and data useful for identifying causal

factors in free living populations more than behavioral choices under

constraints.

They do, however, present a general and useful model in which adult

human capital is produced from inputs in both the prenatal and postnatal

periods with the relative contribution reflected in the parameter.

Health AI

prenatal 1I

postnatal1=

This framework has been applied to early child development to explain

success in schooling and in wage earnings. It has the advantage of illus-

trating the potential for inputs in one period to complement the invest-

ments in another. Similarly, this model provides a tool for understanding

the manner by which a short-term income shock affects outcomes among

siblings. It also helps frame some key questions. Economists rightfully ask

the manner in which preferences for intra-household equity affect how

much will be invested in a child in a subsequent period. This has direct

applicability to postnatal investment in nutrition and child stimulation.

They also can give a perspective on how much investment may be needed

to reduce the impact of a bad draw in either period from having serious

consequences for the prospects of the next generation.

In modeling the production of health, conventionally one looks for the

demand for inputs given prices and preferences or uses a reduced form. In

either case, endowments are generally taken as endogenous. The fetal

8 The disciplines may not be as distinct as they first appear. Both economics and evolu-tionary biology are about resource scarcity; both tribes consider Malthus among theirancestors.


H. Alderman


14/18

origin hypothesis and the recognition of epigenetics move the question

back, at least to pregnancy and perhaps to the preconception period.

Practically speaking, the implies an increased focus on adolescent health

and, as Almond and Currie put it, a the need for a greater understandingof what is the cost of an ounce of prevention relative to a pound of cure

(properly discounted, of course).

Gluckman et al. (2009)also argued that the issue of plasticity implies

that the focus on birth weight may miss major indicators that point to later

health risks. Expanding on this theme, as progress is made on reducing

child mortality, emphasis on anthropometric indicators may be too narrow

a guide to health programs. First, while the Millennium Development

Goal indicator of weight for age has the advantage of relative ease in

monitoring, rapid weight gain after infancy may have attendant risks.Moreover, once the period of greatest risk for child mortality is passed,

neither weight nor height is the direct measure of what is most important

for public policy. As implied in Almond and Currie (2010, 2011), the

outcome of interest in the inter-period model in equation 1 is human

capital more broadly defined than physical growth alone.

More than the implication of maternal height or hyperglycemia for the

intergenerational transmission of poverty, one is concerned about a wider

range of cognitive and non-cognitive measures to address inequality. As

Naudeau et al. (2011)point out, there is a sharp wealth gradient in thesemeasures in which the gap between children from poorer households and

wealthier households widens over the same time period that is the period

of focus for most nutrition interventions. As the human capital model gets

more nuanced in terms of time indexed inputs, the range of indicators of

development should be correspondingly more nuanced as well.

References

Alderman, H. (2007), Improving Nutrition Through CommunityGrowth Promotion: Longitudinal Study of the Nutrition and Early

Child Development Program in Uganda, World Development 35,

137689.

Alderman, H. (1996), Saving and Economic Shocks In Rural Pakistan,

Journal of Development Economics 51, 34366.

Alderman, H. (1990), Nutritional Status in Ghana and its Determinants,

World Bank Social Dimensions of Adjustment in Sub-Saharan Africa

Working Paper #3.

Alderman, H., M. Lokshin and S. Radyakin (2011), Tall Claims:

Mortality Selection and the Height of Children in India, Economics

and Human Biology 9, 393406.




15/18

Alderman, H. and S. Linnemayr (2009), Anemia in Low Income

Countries is Unlikely to be Addressed by Economic Development

Without Additional Programs,Food and Nutrition Bulletin 30, 26570.

Alderman, H., J. Hoddinott and W. Kinsey (2006), Long Term

Consequences of Early Childhood Malnutrition, Oxford Economic

Papers 58, 45074.

Almond, D. and J. Currie (2010), Human Capital Development Before

Age Five, NBER Working Paper 15827.

Almond, D. and J. Currie (2011), Killing Me Softly, Journal of

Economic Perspectives 25, 125.

Baird, S., J. Friedman and N. Schady (2011), Aggregate Income Shocks

and Infant Mortality in the Developing World,Review of Economicsand Statistics 93, 84756.

Barker, D. J. and C. Osmond (1986), Infant Mortality, Childhood

Nutrition, and Ischaemic Heart Disease in England and Wales,

Lancet 1, 107781.

Behrman, J. R., M. Cecilia Calderon, S. Preston, J. Hoddinott,

R. Martorell and A. D. Stein (2009), Nutritional Supplementation

of Girls Influences the Growth of their Children: Prospective

Study in Guatemala, American Journal of Clinical Nutrition 90,

13729.

Bhalotra, S. (2010), Fatal Fluctuations? Cyclicality in Infant Mortality in

India,Journal of Development Economics 93, 719.

Bhargava, S., H. Sachdev and C. Fall, et al. (2005), Relation of Serial

Changes in Childhood Body-Mass Index to Impaired Glucose

Tolerance in Young Adulthood, New England Journal of Medicine

350, 86575.

Black, R., L. H. Allen, Z. Bhutta, L. E. Caulfield, M. de Onis, M. Ezzati,

C. Mathers and J. Rivera (2008), Maternal and Child Undernutrition:Global and Regional Exposures and Health Consequences,The Lancet

371, 118.

Bhutta, Z., T. Ahmad and R. Black, et al. (2008), What Works.

Interventions for Maternal and Child Undernutrition and Survival,

Lancet 371, 41740.

Ceesay, S. M., A. M. Prentice, T. J. Cole, R. Ford, E. Poskitt, L.

T. Weaver and R. G. Whitehead (1997), Effects on Birth Weight and

Perinatal Mortality of Maternal Dietary Supplements in Rural Gambia:

5 Year Randomised Controlled Trial, British Medical Journal 315,

78690.


H. Alderman


16/18

Datar, A., J. Liu, S. Linnemayr and C. Stecher (2011), The Impact of

Natural Disasters on Child Health and Investments in Rural India,

RAND, Mimeo.

Fall, C. (2009), Commentary: Can Improving a Mothers Diet Improve

Her Childrens Cardiovascular Health?, International Journal of

Epidemiology 38, 127128.

Fernald, L. C. H., P. J. Gertler and L. M. Neufeld (2008), The

Importance of Cash in Conditional Cash Transfer Programs for Child

Health, Growth and Development: An Analysis of Mexicos

Oportunidades,Lancet 371, 828837.

Filmer, D. and L. Pritchett (2001), Estimating Wealth Effects Without

Expenditure Dataor Tears: An Application to EducationalEnrollments in States of India,Demography 38, 11532.

Gluckman, P., A. Beedle and M. Hanson (2009), Principles of

Evolutionary Medicine, Oxford University Press, Oxford.

Gluckman, P., M. Hanson and P. Bateson, et al. (2009), Towards a New

Development Synthesis: Adaptive Developmental Plasticity and Human

Disease,The Lancet 373, 16547.

Haddad, L., H. Alderman, S. Appleton, L. Song and Y. Yohannes (2003),

Reducing Child Malnutrition: How Far Does Income Growth Take

Us?, World Bank Economic Review 17, 10731.

Harding, J., A. L. Jaquiery, C. E. Hernandez, M. H. Oliver, J. G. Derraik

and F. H. Bloomfield (2011), Animal Studies of the Effects of Early

Nutrition on Long-term Health, Nestle Nutrition Workshop Series

Pediatric Program 68, 111.

Hult, M., P. Tornhammar, P. Ueda, C. Chima, A. K. Bonamy,

B. Ozumba and M. Norman (2010), Hypertension, Diabetes and

Overweight: Looming Legacies of the Biafran Famine,PLOS One 5,

e13582.Kooreman, P. (2000), The Labeling Effect of a Child Benefit System,

American Economic Review 90, 57183.

Linnemayr, S. and H. Alderman (2011), Almost Random: Evaluating

a Large-Scale Randomized Nutrition Program in the Presence of

Crossover,Journal of Development Economics 96, 10614.

Lokshin, M. and S. Radyakin (2012), Month of Birth and Childrens

Health in India,Journal of Human Resources 47, 147203.

Maccini, S. and D. Yang (2009), Under the Weather: Health, Schooling,

and Economic Consequences of Early-Life Rainfall,American Economic

Review 99, 100626.




17/18

Monteiro, P. and C. Victora (2005), Relation of Serial Changes in

Childhood Body-Mass Index to Impaired Glucose Tolerance in Young

Adulthood,Obesity Review 6, 14354.

Naudeau, S., S. Martinez, P. Premand and D. Filmer (2011), Cognitive

Development among Young Children in Low-Income Countries,

in H. Alderman, ed. No Small Matter: The Interaction of Poverty,

Shocks, and Human Capital Investments in Early Childhood

Development, World Bank, Washington DC, pp. 950.

Ozaltin, E., K. Hill and S. V. Subramanian (2010), Association

of Maternal Stature With Offspring Mortality, Underweight,

and Stunting in Low- to Middle-Income Countries, JAMA 303,

150716.Paxson, C. (1993), Consumption and Incomes Seasonality in Thailand,

Journal of Political Economy 101, 3972.

Paxson, C. and N. Schady (2010), Does Money Matter? The Effects of

Cash Transfers on Child Development in Rural Ecuador, Economic

Development and Cultural Change 59, 187229.

Rosenzweig, M. and P. Schultz (1988), The Stability of Household

Production Technology,Journal of Human Resources 23, 53549.

Ramachandran, A. and C. Snehalatha (2010), Rising Burden of Obesity

in Asia, Journal of Obesity 2010, e868573.

de Rooij, S., H. Wouters, J. Yonker, R. Painter and T. J. Roseboom

(2010), Prenatal Undernutrition and Cognitive Function in Late

Adulthood, Proceedings of the National Academy of Science of USA

107, 168818.

Schroeder, D., R. Martorell, J. Rivera, M. T. Ruel and J.-P. Habicht

(1995), Age Differences in the Impact of Nutritional

Supplementation on Growth,Journal of Nutrition 125, 1051S1059S.

Stein, Z., M. Susser, G. Saenger and F. Marolla (1975), Famine andHuman Development: The Dutch Hunger Winter of 19441945, Oxford

University Press, London.

Subramanyam, M., I. Kawachi, L. F. Berkman and S. V. Subramanian

(2011), Is Economic Growth Associated with Reduction in Child

Undernutrition in India?,PLoS Med8, e1000424.

Victora, C., M. de Onis, P. Curi Hallal, M. Blo ssner and R. Shrimpton

(2010), Worldwide Timing of Growth Faltering: Revisiting

Implications for Interventions,Pediatrics 125, 47380.

Victora, C. V., L. Adair, C. Fall, P. C. Hallal, R. Martorell, L. Richter

and H. S. Sachdev (2008), Maternal and Child Undernutrition:


H. Alderman


18/18

Consequences for Adult Health and Human Capital,The Lancet 371,

34057.

World Bank (2006), Indias Undernourished Children: A Call for Reform

and Action, Washington DC.

Yajnik, C. (2009), Nutrient-mediated Teratogenesis and Fuel-mediated

Teratogenesis: Two Pathways of Intrauterine Programming of

Diabetes, International Journal of Gynecology and Obstetrics 104,

S27S31.



the response of child nutrition to changes in income.pdf

Documents