Black, Mauren M.

Engle, Patrice L.

Gardner, Julie Meeks

Grantham-McGregor, Sally

Lozoff, Betsy

Ulkuer, Nurper

Wachs, Theodore D.

Walker, Susan P

English

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Policies to reduce undernutrition include child development The Lancet Series on Maternal and Child Undernutrition highlights the damaging eﬀ ects of undernutritionduring the ﬁ rst 2 years of life on children’s survival, health, attained schooling, and ultimately their human capital. The Series also points out that, although there are eﬀ ective nutritional interventions, the international nutrition system, comprising international and donor organisations, academia, civil society, and the private sector, is fragmented and in need of reform. Animproved nutrition system will undoubtedly improve the lives of the millions of children who are undernourished. But there would still be major gaps in the educational success and improvement of human capital of millions of children in developing countries because nutritional adequacy alone is insuﬃcient. The mechanisms underlying educational failure and adverse economic consequences operate through poor early cognitive and social development.1–3 The loss of developmental potential in the ﬁrst 5 years of life, partly caused by undernutrition, results in late entry into schooling, poor educational attainment, early drop-out, and low earning potential.   The ﬁrst 2–3  years of life are crucial for both nutrition  and child development. Rapid growth, including brain development, places high demands on nutrition. However, early brain development also requires environmental stimulation.4 Inadequate cognitive or social stimulation during these early years has lifelong negative consequences on educational performance and psychological functioning. In countries where children are adequately nourished, children without early opportunities for cognitive and social stimulation develop poorly cognitively and socially, which puts them on a trajectory toward low school attainment, early exit from education, and limited economic potential.5 Experience in Jamaica shows the synergistic eﬀ ects of integrating nutrition and stimulation.6  9–24-month-old stunted children who received weekly supplements of milk and cognitive or social stimulation at home for 2 years had higher developmental scores than those who received neither or only one intervention. Long-term follow-up showed that the children who received early cognitive or social stimulation had better cognitive, educational, and psychosocial functioning in late adolescence than those who did not. Also, there were no long-term eﬀ ects of nutritional supplementation, either alone or in combination with cognitive or social stimulation.7–9 Although the nutritional intervention may have been too little too late, the long-term eﬀ ects of the cognitive or social stimulation are consistent with evidence from middle-income and high-income coun­tries on the beneﬁ cial eﬀ ects of early intervention.3,10 The extent of undernutrition and loss of developmental potential is far reaching: in children under 5 years,                                                112 million are underweight, 178 million are stunted,and over 219 million do not reach their developmentalpotential, which places an enormous burden on thechildren, their families, and their societies. Althoughundernourished children’s health is likely to be improvedby eﬀ ective nutritional interventions, they are unlikelyto catch up to well-nourished children in cognitive orsocial development without the inclusion of early childdevelopment programmes.3 Substantial numbers ofchildren growing up in poverty also lose developmentalpotential even when their nutritional status is acceptable.Thus what is needed to promote human capital areinterventions that protect children against undernutritionand lack of cognitive or social stimulation, both of whichlead to the loss of developmental potential early in life. The Millennium Development Goals (MDG) serve as blue prints to eliminate or reduce eight of the most severe chal lenges to the world’s poorest citizens. Programmes that integrate nutrition and early child development promote better health and development, which enables children to take greater advantage of educational opportunities. Such integrated programmes not only address MDG 1 on the reduction of poverty and undernutrition, but also MDG 2 on the promotion of early education. Integration across the MDGs is a cost-eﬀective strategy to reduce the consequences of poverty. For example, the 36 countries at greatest risk for childhood undernutrition are also at greatest risk for poor child development, which makes integrated programming feasible and economical. We applaud The Lancet and the authors of the Maternal and Child Undernutrition Series for their leadership and clarity about the negative consequences of undernutrition. As the international nutrition system works toward reforms, we urge global policy makers to adopt integrated approaches that incorporate nutrition and health together with early opportunities for cognitive and social stimulation. This strategy will reduce undernutrition and enable children to achieve educational and psychological success, which will, in turn, increase equity and human capital. *Maureen M Black, Susan P Walker, Theodore D Wachs, Nurper Ulkuer, Julie Meeks Gardner, Sally Grantham-McGregor, Betsy Lozoﬀ, Patrice L Engle, Meena Cabral de Mello University of Maryland School of Medicine, Baltimore, MD 21201, USA (MMB); University of the West Indies, Kingston, Jamaica (SPW, JMG); Purdue University, West Lafayette, IN, USA (TDW); UNICEF, New York, NY, USA (NU); Institute of Child Health, University College, London, UK (SG-M); University of Michigan, Ann Arbor, MI, USA (BL); Cal Poly State University, San Luis Obispo, CA, USA (PLE); WHO, Geneva, Switzerland (MCdM) We declare that we have no conﬂ ict of interest. 1 	 Grantham-McGregor S, Cheung YB, Cueto S, for the International Child Development Steering Group. Developmental potential in the ﬁrst 5 years forchildren in developing countries. Lancet 2007; 369: 60–70. 2 	 Walker SP, Wachs TD, Gardner JM, for the International Child Development Steering Group. Child development: risk factors for adverse outcomes. Lancet2007; 369: 145–57. 3 	 Engle PL, Black MM, Behrman JR, for the International Child Development Steering Group. Strategies to avoid the loss of developmental potential inmore than 200 million children in the developing world. Lancet 2007;369: 229–42. 4 Nelson CA, de Haan M, Thomas KM. Neuroscience and cognitivedevelopment: the role of experience and the developing brain. New York:John Wiley, 2006. 5 National Institute of Child Health and Human Development Early Child CareResearch Network. Duration and developmental timing of poverty andchildren’s cognitive and social development from birth through third grade.Child Dev 2005; 76: 795–810. 6 Grantham-McGregor SM, Chang SM, Walker SP, Himes JH. Nutritionalsupplementation, psychosocial stimulation, and mental development ofstunted children: the Jamaican Study. Lancet 1991; 338: 1–5. 7 Walker SP, Chang SM, Powell CA, Simonoﬀ E, Grantham-McGregor SM. Earlychildhood stunting is associated with poor psychological functioning in lateadolescence and eﬀects are reduced by psychosocial stimulation. J Nutr 2007;137: 2464–69. 8 Walker SP, Chang SM, Powell CA, Simonoﬀ E, Grantham-McGregor SM.Eﬀects of psychosocial stimulation and dietary supplementation in earlychildhood on psychosocial functioning in late adolescence: follow-up ofrandomised controlled trial. BMJ 2006; 333: 472. 9 Walker SP, Chang SM, Powell CA, Grantham-McGregor SM. Eﬀ ects of earlychildhood psychosocial stimulation and nutritional supplementation oncognition and education in growth-stunted Jamaican children: prospectivecohort study. Lancet 2005; 366: 1804–07. 10 	Love JM. The eﬀ ectiveness of early head start for 3-year-old children and theirparents: lessons for policy and programs. Dev Psychol 2005; 41: 885–901. 

Policies to Reduce Undernutrition Include Child Development

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Policies to Reduce Undernutrition Include Child Development

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