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* This paper was revised by the authors on August 2003
Nutrition, M
a
lnutrition
and
Economic Growth *
Harold Alderman, Jere R. Behrman and John
Hoddinott
Area of Strategic Health Development
Health Systems and Policies Unit
Health Economics Group
8. Nutrition, Malnutrition and Economic Growth
By
Harold Alderman, Jere R. Behrman and John Hoddinott*
Forthcoming in Health and Economic Growth: Findings and Policy Implications, Edited by
Guillem López-Casasnovas, Berta Rivera and Luis Currais, Cambridge, MA: MIT Press, 2004.
2 August 2003
Abstract: Malnutrition is widespread in the developing world. 12 or more million low-birth-
weight births occur per year and 180 million children are characterized as malnourished. This
chapter first assesses estimates of the extent of malnutrition in developing countries. It then
surveys micro evidence about the productivity impact of improved nutrition in developing
countries – from conception through infancy and childhood and into adolescence and adulthood.
These gains may operate through many channels – increasing cognitive development, increasing
physical stature and strength, inducing earlier school enrollment and more regular school
attendance, inducing greater schooling and learning, and increasing adult productivity – as well
as saving resources that otherwise would go towards dealing with diseases and other problems
related to malnutrition. Finally the possible gains from different nutritional policy strategies
and the policy bases for adopting such strategies are examined.
*Harold Alderman is Lead Human Development Economist in the Africa Region of the World
Bank, 1818 H Street, NW, Washington DC, 20433, USA; telephone 1 202 473 0372; e-mail
halderman@worldbank.org. Jere R. Behrman is the William R. Kenan, Jr. Professor of
Economics and Director of the Population Studies Center, McNeil 160, 3718 Locust Walk,
University of Pennsylvania, Philadelphia, PA 19104-6297, USA; telephone 1 215 898 7704, fax
1 215 898 2124, e-mail: jbehrman@econ.sas.upenn.edu. John Hoddinott is a Senior Research
Fellow, FCND, International Food Policy Research Institute (IFPRI), 2033 K Street NW,
Washington DC 20006, USA, telephone 1 202 862 5637; fax 1 202 467 4439; e-mail
J.Hoddinott@cgiar.org. Only Alderman, Behrman and Hoddinott, and not the World Bank or
IFPRI, are responsible for the contents of this chapter.
1. Introduction
Malnutrition is widespread in many developing countries. It is estimated that at
least 12 million low-birth-weight births occur per year and that around 180 million pre-
school children are malnourished. Redressing this serious health problem has long been
justified on intrinsic grounds; better nutrition has been widely seen as being of value in
its own right. Others also have emphasized the importance of health and nutrition for
productivity and economic growth. That is, the emphasis is on the instrumental, rather
than the intrinsic, value of good health and nutrition. This chapter adopts such an
approach, but differs from many of the other contributions to this book in three ways.
First, our focus is on the microeconomic rather than the macroeconomic evidence of the
links between nutritional status and representations of productivity. We perceive that the
microeconomic analysis is likely to be more informative about the possible causal effects
of nutrition on productivity because of enhanced opportunities to address estimation
problems as such endogeneity at the micro level and because aggregation problems may
obscure non-linear relationships. Second, we emphasize that these links are multiple and
heterogeneous. In particular, there are important links between health/nutrition and
cognitive development and between health/nutrition and schooling so that in adulthood,
health and nutritional status may have direct links to productivity as well as indirect links
through their effects on education. Third, we emphasize that many outcomes that reflect
nutritional status are cumulative and this has implications for the design of policies and
interventions designed to ameliorate malnutrition.
This chapter begins with a brief explanation of the causes and measurement of
malnutrition as well as estimates of the extent of malnutrition across developing
2
countries. It then surveys micro evidence about the productivity impact of improved
nutrition in developing countries – from conception through infancy and childhood and
into adolescence and adulthood. These gains may operate through many channels –
increasing cognitive development, increasing physical stature and strength, inducing
earlier school enrollment and more regular school attendance, inducing greater schooling
and learning, and increasing adult productivity – as well as saving resources that
otherwise would go towards dealing with diseases and other problems related to
malnutrition. Finally the possible gains from different nutritional policy strategies and
the policy bases for adopting such strategies are examined. Given links between
improved nutrition and greater schooling as well as directly between nutrition and higher
levels of productivity and incomes, such investments are instrumental in achieving
additional outcomes valued by individuals and the societies within which they reside.
2. Understanding malnutrition
Indicators of nutritional status are measurements of body size, body composition,
or body function that reflect single or multiple nutrient deficiencies.
1
They can be
divided into three broad groups depending on the type of information. The first group is
anthropometry, the measurement of body size and gross body composition. The second
group uses clinical examinations to detect signs and symptoms of advanced nutritional
depletion. Examples are assessments of iodine deficiency by inspection and palpitation of
enlarged thyroid glands. The third group uses laboratory methods to detect decreased
levels of nutrients in body tissues or fluids, or decreased activity of an enzyme that is
1
These are outcome indicators. In addition, measures of nutrient intake or access track some of the inputs
that condition nutritional status.
3
nutrient-dependent.
2
While malnutrition is often seen as a manifestation of some form of
deprivation, it also refers to circumstances of excess such as obesity. Table 1, adapted
from Morris (2001), describes the most common measures.
Table 1: Measures of nutritional status and their prevalence
Indicator Interpretation Most common means of reporting
Group I: Anthropometric Indicators
Prevalence of low
birthweight
An indicator of intrauterine growth
retardation resulting from short maternal
stature, poor maternal nutrition before or
during pregnancy, infection and smoking.
Percentage of children with birthweights
below 2500 grams
Prevalence of low
height-for-age
(stunting) in
preschool or school-
age children
Children’s skeletal (linear) growth
compromised due to constraints to one or
more of nutrition, health, or mother-infant
interactions. This is an indicator of chronic
nutritional deprivation.
Expressed as a z score or as the
percentage of children stunted. Z scores
are calculated by standardizing a child's
height given age and sex against an
international standard of well nourished
children. A z score of -1 indicates that
given age and sex, the child's height is one
standard deviation below the median child
in that age/sex group. Children with z
scores below –2 are classified as stunted;
with z scores below –3 are classified as
severely stunted.
Prevalence of low
weight-for-height
(wasting) in
preschool
or school-age
children
Children suffer thinness resulting from
energy deficit and/or disease-induced poor
appetite, malabsorption, or loss of
nutrients. This is an indicator of transitory
nutritional deprivation.
Expressed as a z score or as the
percentage of children wasted. Z scores
are calculated by standardizing a child's
weight given height and sex against an
international standard of well nourished
children. Children with z scores below –
2
are classified as wasted; with z scores
below –3 are classified as severely
wasted.
Prevalence of low
weight-for-age
(underweight) in
preschool
or school-age
children
This is a composite measure of child
nutritional status, reflecting both chronic
and transitory nutritional deprivation. This
is a Millennium Development Goal
indicator.
Expressed as a z score or as the
percentage of children underweight. Z
scores are calculated by standardizing a
child's weight given age and sex against
an international standard of well
nourished children. Children with z
scores below –2 are classified as
underweight; with z scores below –3 are
classified as severely underweight.
2
This section draws heavily on ACC/SCN (2000), Gibson (1990) and Morris (2001) who provide very
helpful introductions to these measures.
4
Prevalence of low
body mass index in
adults or adolescents
Adults suffer thinness as a result of
inadequate energy intake, an
uncompensated increase in physical
activity, or (severe) illness.
Expressed as Body Mass Index (BMI).
BMI is calculated by dividing weight in
kilograms by the square of height in
meters. Individuals are considered to be
chronically energy deficient if they have a
BMI below18.5, overweight if they have
a BMI greater than 25, and obese if they
have a BMI greater than 30.
Group 2 Clinical Examinations or Group 3 Laboratory Methods
Prevalence of iodine
deficiency
Iodine deficiency results from low intake
of iodine in the diet.
Expressed by clinical inspection of
enlarged thyroids or in terms of iodine
concentrations in urine (µg/L). The
benchmark for the elimination of iodine
deficiency is to have less than 20 per cent
of the population with levels below 50
µg/L
Group 3 Laboratory Methods
Prevalence of low
hemoglobin (anemia)
in preschool or
school-age children
Children suffer from anemia, either as a
result of low iron intakes or poor
absorption, or as a result of illness. Severe
protein-energy malnutrition and vitamin
B12/folate deficiency can also lead to
anemia.
Expressed as grams of hemoglobin per
liter of blood. Cutoffs to define anemia are
110 g/L for children 6-
59 months, 115 g/L
for children 5-11 years and 120 g/L for
children 12-14 years.
Prevalence of low
hemoglobin (anemia)
in nonlactating,
nonpregnant women
Women suffer from anemia as a result of
low iron intakes, poor absorption, illness,
or excessive losses of blood. Severe
protein-energy malnutrition and vitamin
B12/folate deficiency can also lead to
anemia. Anemia is rare in adult men
except in conditions of extreme iron-
deficient diets.
Expressed as grams of hemoglobin per
liter of blood. Cutoffs to define anemia are
120 g/L for nonpregnant women, 110 for
pregnant women and 130 for adult men.
Source: ACC/SCN (2000) and Morris (2001).
Nutritional status is an outcome, reflecting the purposive actions of individuals
given preferences and constraints. In behavioral models, an individual’s nutritional status
often is treated as an argument in the welfare function of individuals or the households in
which they reside (Behrman and Deolalikar 1988; Strauss and Thomas 1995). It is
assumed that welfare increases as nutritional status improves, but possibly at a
diminishing rate and, as suggested above, increases in certain measures of nutritional
5
status, such as body mass, may be associated with reductions in welfare beyond a certain
point.
In allocating resources, household decision makers take into account the extent to
which these investments will make both their children and themselves better-off in the
future as well as currently.
3
These allocations are constrained in several ways. There are
resource constraints reflecting income (itself an outcome) and time available as well as
prices faced by households. There is also a constraint arising from the production process
for health outcomes, including nutritional status. This constraint links nutrient intakes –
the physical consumption of macronutrients (calories and protein) and micronutrients
(minerals and vitamins) – as well as time devoted to the production of health and
nutrition, the individual’s genetic make-up and knowledge and skill regarding the
combination of these inputs to produce nutritional status. There are interdependencies in
the production of nutritional status and other dimensions of health; for example, malaria
limits hemoglobin formation.
It is important to recognize that many nutritional outcomes are the consequence of
cumulative processes that begin in utero. A number of maternal factors have been shown
to be significant determinants of intrauterine growth retardation (IUGR), the
characterization of a newborn who does not attain their growth potential. Most important
are mother’s stature (reflecting her own poor nutritional status during childhood), her
nutritional status prior to conception as measured by her weight and micro-nutrient status,
3
Implicit in this framework is the assumption that parents or other decision makers are in agreement
regarding investments in nutrition and that they are willing to pool their resources in order to undertake
these investments. Where there is disagreement on the nature and the allocation of these investments, the
ability of individual parents to impose their preferences – their bargaining power – also plays a role
(Alderman, et. al.1995; Behrman 1997; Haddad, Hoddinott and Alderman 1997).
6
and her weight gain during pregnancy. Diarrheal disease, intestinal parasites, and
respiratory infections may also lead to IUGR and where endemic (such as sub-Saharan
Africa), malaria is a major determinant. In developed countries, smoking is also a
significant contributor to IUGR. IUGR is measured as the prevalence of newborns below
the 10
th
percentile for weight given gestational age (ACC/SCN, 2000). Because
gestational age is rarely known, IUGR is often proxied by low birthweight (LBW). As of
2000, it is estimated that 11% of newborns, or 11.7 million children have low birthweight
(ACC/SCN, 2000).
4
In pre-school and school age children, nutritional status is often assessed in terms
of anthropometry. “The basic principle of anthropometry is that prolonged or severe
nutrient depletion eventually leads to retardation of linear (skeletal) growth in children
and to loss of, or failure to accumulate, muscle mass and fat in both children and adults”
(Morris, 2001, p.12). A particularly useful measure is height given age as this reflects the
cumulative impact of events affecting nutritional status that result in stunting. As of 2000,
it is estimated that one child in three under the age of five, 182 million children in all, are
stunted (ACC/SCN, 2000).
A number of factors contribute to poor anthropometric status in children. One is
low birthweight; a number of studies show a correlation between low birthweight and
subsequent stature though, in the absence of any subsequent intervention, not between
low birthweight and growth (Ashworth, Morris and Lira 1997; Hoddinott and Kinsey
2001; Li, et. al. 2003; Ruel 2001). In addition, the first two years of life pose numerous
4
Other estimates are higher. For instance. Ceesay, et al. (1997) claim that there are over 22 million LBW
children per year. Blanc and Wardlaw (2002) discuss aspects of estimates from micro data.
7
nutritional challenges to the newborn. Growth rates are highest in infancy, thus adverse
factors have a greater potential for causing retardation at this time. Younger children have
higher nutritional requirements per kilogram of body weight and are also more
susceptible to infections. They are also less able to make their needs known and are more
vulnerable to the effects of poor care practices such as the failure to introduce safe
weaning foods in adequate quantities. Evidence from numerous studies clearly indicates
that the immediate causes of growth faltering are poor diets and infection (primarily
gastrointestinal) and that these are interactive (Chen 1983; NAS 1989). For these reasons
almost all the growth retardation observed in developing countries has its origins in the
first two to three years of life (Martorell 1995).
A growing body of evidence indicates that growth lost in early years is, at best,
only partially regained during childhood and adolescence, particularly when children
remain in poor environments (Martorell, et al. 1994). For example, Martorell (1995,
1999), Martorell, Khan and Schroeder (1994) and Simondon, et. al. (1998) all find that
stature at age three is strongly correlated with attained body size at adulthood in
Guatemala and Senegal. Hoddinott and Kinsey (2001) find that children who were
initially aged 12-24 months in the aftermath of a drought in rural Zimbabwe in 1994/95
had z scores for height-for-age that are about six tenths of a standard deviation below that
of comparable children not exposed to this drought when measured at ages 60-72 months.
However, older children did not suffer such permanent consequences; this is consistent
with evidence that child development has “sensitive” periods where development is more
receptive to influence and that during such periods, some shocks may be reversible while
others are not (Bornstein 1989; Yaqub 2002). Alderman, Hoddinott and Kinsey (2002)
8
find that in rural Zimbabwe, children exposed to the civil war or to the 1982-84 droughts
were found to have lower stature compared to siblings not affected by these shocks when
remeasured in 2000. The magnitudes of these shocks are large; exposure to the 1982-84
drought reduced stature in late adolescence by 2.3 centimeters.
It is also important to recognize that “severe malnutrition in early childhood leads
to deficits in cognitive development … if the children return to poor environments”
(Grantham-McGregor, Fernald and Sethuraman 1999, p.66. See also Pollitt 1990).
Although many studies from developed countries fail to show difference in development
levels for children with low birth weights (LBW), there are few longitudinal studies from
developing counties from which to generalize (Hack 1998). More recent studies that test
the impact of low birth-weight over a wide range indicate that the relationship between
birth weight and cognitive function carries into the range of normal weights even in
developed countries (Richards, et al. 2001; Matte, et al. 2001). Even if, as Richards, et al.
observe, this association between birth weight and cognitive ability partially attenuates
over time – they followed a cohort for 43 years – the significant difference in function at
age 8 affects educational attainment.
Malnourished children are found to score poorly on tests of cognitive function,
have poorer psychomotor development and fine motor skills. They tend to have lower
activity levels, interact less frequently in their environments and fail to acquire skills at
normal rates (Grantham-McGregor, et. al. 1997, 1999; Johnston, et. al. 1987; Lasky, et.
al. 1981). Controlled experiments with animals suggests that this may occur because
malnutrition results in irreversible damage to brain development such as that associated
with the insulation of neural fibers (Yaqub 2002).
9
One such deficiency that has been studied both in laboratory and in
epidemiological studies is iodine deficiency, which adversely affects the development of
the central nervous system. A meta-analysis indicates that individuals with an iodine
deficiency had, on average, 13.5 points lower IQs than comparison groups. While
interventions have shown that provision of iodine to pregnant women can reduce this gap,
the provision of iodine to school aged children does not appear to reverse earlier damage
(Grantham-McGregor, Fernald and Sethuraman 1999b). Prevalences of iodine deficiency
are not available by age; it is estimated that altogether, globally more than 700 million
people are affected.
Adequate iron intake is also necessary for brain development. The studies
reviewed by Grantham-McGregor, Fernald and Sethuraman (1999b) do not indicate that
subsequent interventions to rectify these deficiencies reverse this damage. Given that
more than 40 per cent of children aged 0-4 in developing countries suffer from anemia
(ACC/SCN 2000) this could be a major global contributor to poor schooling outcomes.
Anemia in school aged children may also affect schooling whether or not there had been
earlier impaired brain development. Supplementation trials for school age children
consistently indicate improved cognition, although this is less regularly observed with
interventions aimed at deficient younger children.
Reduced breastfeeding – an effect of low birth weight as well as a common cause
of childhood malnutrition - is also a well-documented influence of cognitive
development, even in developed countries (Grantham-McGregor, Fernald and
10
Sethuraman 1999a). This is in keeping with the prevailing view that very young children
are most vulnerable to impaired cognitive development.
5
3. The links between malnutrition and economic productivity
We now turn to the micro evidence about the productivity impact of improved
nutrition in developing countries – from conception through infancy and childhood and
into adolescence and adulthood. These many channels through which these gains may
operate are grouped in the following way: the saving of resources that otherwise would
go towards dealing with diseases and other problems related to malnutrition; the direct
gains arising from improvements in physical stature and strength as well as improved
micronutrient status; and the indirect gains arising from the links between nutritional
status and schooling, nutritional status and cognitive development and the subsequent
links between schooling, cognitive ability and adult productivity.
a) The costs of poor nutrition
One significant cost of malnutrition is higher mortality. The probability of infant
mortality is estimated to be significantly higher for LBW than for non-LBW infants.
Conley, Strully and Bennett (2003) conclude that intra-uterine resources competition –
and, by inference, nutrition – explain a substantial portion of excess mortality of LBW
children in the United States. In their study, an additional pound at birth led to a 14%
decrease in mortality in the period between 28 days and one year for both fraternal and
5
One exception is provided by Glewwe and King (2001) who find that malnutrition in the second year of
life had a larger impact on the IQs of Philippine school children than that in earlier periods.
11
identical twins. In contrast, the risk of death in the first 28 days was elevated 27% for
each pound difference in weight for fraternal twins compared to only 11% for identical
twins, implying a large role for genetic factors. Ashworth (1998) reviews 12 data sets
including two from India and one from Guatemala, and concludes that the risk of
neonatal death for term infants 2000-2499 grams at birth is four times that for infants
2500-2999 grams and 10 times that of infants 3000-3499 grams. Relative risks of post-
neonatal mortality for LBW compared to the two respective groups were two and four
times as large. These risk ratios translate into fairly large differences in mortality rates
given the relatively high mortality rates in many developing countries. Using the data she
reports for the Indian and Guatemalan samples, Alderman and Behrman (2003) estimate
that the probability of an infant death (either neonatal or post-neonatal) drops by about
0.078 for each birth in the 2500-2999 grams range instead of in the 2000-2499 gram
range.
When the impacts of poor pre-schooler nutrition are added to the effects of low
birthweight, Pelletier, et al. (1995) venture the widely cited estimate that 56% of child
deaths in developing countries at attributable to the potentiating effects of malnutrition
(83% of this, due to the more prevalent mild to moderate malnutrition rather then the
severe cases most commonly monitored). More recently, WHO (2002) has claimed that
malnutrition contributes to 3.4 million child deaths in 2000 (60% of child deaths).
Pelletier and Frongillo (2003) have recently employed data on changes in national
12
malnutrition rates and mortality to get a differenct perspective on this association, yet one
that supports the earlier evidence on the association of mortality and malnutrition.
6
The availability of experimental evidence on the use of micronutrient supplements
provides unambiguous evidence on the relationship of mortality and vitamin intakes in
many environments including ones that show few clinical symptoms of deficiencies. The
potential to reduce child deaths by distributing vitamin A on a 6 monthly basis is
particularly dramatic; meta-analysis of field trials indicate that such provision of vitamin
A can reduce overall child mortality by 25-35% (Beaton, et al. 1993). Amongst adults,
anemia is a particular concern for the health of women of child bearing age not only
because of elevated risk of adverse birth outcomes but also because the risk of maternal
death is substantially elevated for anemic women; over a fifth of maternal deaths are
associated with anemia (Ross and Thomas 1996; Brabin, Hakimi and Pelletier 2001).
7
Beyond the issue of increased mortality, malnutrition increases the risk of
illnesses that impair the welfare of survivors. This relationship between nutrition and
both infections and chronic diseases can be traced through different parts of the life cycle.
Children with low birth weights – reflecting a range of causes, not all of which are due to
dietary deficiencies – stay longer in hospitals in circumstances where births occur in such
6
These associations do not, however, control for changes in infrastructure or income that may both affect
mortality directly as well as influence nutrition nor can they indicate a counterfactual of the impact of
improved nutrition on expected mortality. Guilkey and Riphahn (1998) use longitudinal data of Filipino
children with controls for the endogeneity of nutrition and other health care choices. Their simulations
indicate that children with two months without weight gain in the first year of life (about 10 percent of their
sample) would have the risk of mortality elevated by 50%. Similarly, the scenarios show that if a mother is
unable or unwilling to adopt standard recommendations on breastfeeding the hazard of child mortality
increases markedly. Care has to be taken, however, in interpreting the last association as causal because
mothers may be less likely to be able to breastfeed infants who are at high risk.
7
As with associations of child mortality and nutrition, it is difficult to prove causality with these
associations. Randomized controlled trials to substantiate the observational data would need to be large
given the risk of maternal mortality and are generally considered unethical.
13
settings and have higher risks of subsequent hospitalization (Vitoria, et al. 1999). In
addition, they use outpatient services more frequently than do normal children. For
young children, in general, malnutrition leads to a vicious cycle with impaired immunity
leading to infection with attendant loss of appetite and catabolism and, thus, an increased
likelihood of additional malnutrition.
Increased morbidity has direct resource costs in terms of health care services as
well as lost employment or schooling for the caregivers. The magnitudes of these costs
differ according to the medical system, markets, and policies of a country. In developed
countries the additional costs for the survivors can be substantial. Lightwood, Phibbs,
and Glanz (1999) calculate the excess direct medical costs due to low birth weight in the
United States attributed to one cause - maternal smoking - to be $263 M in 1995. For
example, 75% of the $5.5-6 billion of excess costs due to LBW in the United States
estimated by Lewit, et al. (1995) is due to the costs of health care in infancy. A further
10% of these costs are attributed to higher requirements for special education as well as
increased grade repetition. Such requirements for special education or for social services
are substantial in developed countries (Petrou, et al. 2001). While these costs may be far
less in low-income countries where, for example, the majority of births occur outside a
clinical setting, these lower medical costs associated with LBW come at the expense of
higher mortality. In the absence of an educational system that can recognize and
accommodate the individual needs of students, however, these costs are not incurred
during childhood but rather in the form of reduced productivity in adulthood.
Undernutrition, particularly fetal undernutrition at critical periods, may result in
permanent changes in body structure and metabolism. Even if there are not subsequent
14
nutritional insults, these changes can lead to increased probabilities of chronic non-
infectious diseases later in life. The hypothesis that fetal malnutrition has far ranging
consequences for adult health is bolstered by studies that track low birth weight infants
into their adult years and document increased susceptibility to coronary heart disease,
non-insulin dependent diabetes, high blood pressure, obstructive lung disease, high blood
cholesterol and renal damage (Barker 1998). For example, while the various studies on
the impact of the Dutch famine indicate few long-term consequences on young adults,
more recent evidence shows that children whose mothers were starved in early pregnancy
have higher rates of obesity and of heart disease as adults (Roseboom, et al. 2001). In
contrast, children of mothers deprived in later pregnancy – the group most likely to be of
low birth weight – had a greater risk of diabetes (Ravelli 1998).
The evidence for the fetal origins hypothesis is still being assessed. The fact that
some consequences may not be observed until the affected individuals reached middle
age is an important consideration for interpreting the range of evidence being assembled.
There are few panels that follow cohorts this far and extrapolation from shorter panels or
from less affluent cohorts with different life histories is currently necessary, albeit
uncertain. In addition, there are at least two other explanations for the association
between LBW and adult diseases. LBW may be an indicator of poor socioeconomic
status. Low SES may have a causal impact on adult disease probabilities via other
variables such as poor nutrition later in life or higher rates of smoking. If so, LBW may
only be a correlate and not a causal variable. A different possibility is that LBW may be
due to a genetic predisposition to insulin resistance. This would tend to account for a
higher pre-disposition for adult diabetes and coronary heart diseases that reflects genetics
15
rather than aspects of the uterine environment that may be influenced by medical and
nutritional interventions.
8
Finally, even if there are the effects proposed in the fetal
orgins hypothesis, due to there long lag, the present discounted value of improvements
due to prenatal interventions to offset them is not likely to be very large (Alderman and
Behrman 2003; also see the end of Section 3).
In addition to the consequences of undernutrition, it is well known that poor diets
can contribute heart disease, stroke and diabetes. Evidence that obesity as well as
diseases commonly associated with over consumption are occurring among low income
population, often side by side with under-nutrition has added to the challenge of
addressing nutritional deficiencies (Doak, et al. 2000).
Lastly, malnutrition may have long-term consequences through the
intergenerational transmission of poor nutrition and anthropometric status. Recall that
there is considerable epidemiological evidence that stature by age three is strongly
correlated with attained body size at adulthood. Taller women experience fewer
complications during childbirth, typically have children with higher birthweights and
experience lower risks of child and maternal mortality (Ramakrishnan, et al. 1999; World
Bank 1993). However Behrman and Rosenzweig (2003) find that intergenerational birth
weight effects are primarily genetic, not due to better nutrition in the womb.
b) Direct links between nutrition and productivity
8
There is an additional aspect of the hypothesis of subsequent costs stemming from biological adaptation
to deprivation in utero that has a bearing on the estimation of the consequences of LBW. The implications
of the hypothesis will be different if the consequences are a direct result of the deprivation compared to the
possibility that they only manifest themselves if the deprivation is followed by relative abundance (Lucas,
Fewtrell and Cole 1999, Cameron 2001). High rates of diabetes among Native Americans or Ethiopian
immigrants to Israel, for example, seem to be an indirect effect of removal from an environment for which
certain genes may once have been adaptive.
16
There is considerable evidence of a direct link between nutrition and productivity.
Behrman (1993), Behrman and Deolalikar (1989), Deolalikar (1988), Foster and
Rosenzweig (1993), Glick and Sahn (1997), Haddad and Bouis (1991), Schultz (1996),
Strauss and Thomas (1998) and Thomas and Strauss (1997) all find that after controlling
for a variety of characteristics, that lower adult height – a consequence, in part, of poor
nutrition in childhood, is associated with reduced earnings as an adult. For example,
Thomas and Strauss (1997) estimate the direct impact of adult height on wages for urban
Brazil. While the elasticity varies somewhat according to gender and specification, for
both men and women who work in the market sector a 1% increase in height leads to a 2-
2.4% increase in wages or earnings.
9
While their study is particularly sophisticated in the
methodology used to account for labor selectivity and joint determination of health, this
result is similar to others reported in the literature. Indeed, height is even a significant
explanatory variable for wages in the United States (Strauss and Thomas 1998).
Nevertheless, the direct impact of height on wages is likely less than the impact of
schooling on wages over plausible ranges for each,
10
even if the indirect effect of height
on wages mediated by the relationship between height and schooling in included.
Micronutrient status also has important productivity effects. In particular, anemia
is associated with reduced productivity both in cross-sectional data and in randomized
interventions (Li, et al. 1994; Basta, Karyadi and Scrimshaw 1979). The magnitude may
depend on the nature of the task. For example, piece work may have greater incentives
9
In related, rather grim work, Margo and Steckel (1982) found that the value of an American slave fell by
roughly 1.5 percent for every reduction in height of one inch.
10
Strauss and Thomas (1998) point out that an illiterate man would need to be 30 cm taller than his literate
coworker to have the same expected wage.
17
for effort while heavy physical labor may show greater increases in productivity, though
anemia is nevertheless a factor in productive with relatively light work (Horton and Ross
2003).
c) Indirect links: nutrition, cognitive development, schooling and productivity
Poorly nourished children, as evidenced for example by low height-for-age, tend
to start school later, progress through school less rapidly, have lower schooling
attainment, and perform less well on cognitive achievement tests when older. These
associations appear to reflect significant and substantial effects in poor populations even
when statistical methods such as instrumental variables are used to control for the
behavioral determinants of pre-school malnutrition.
There are three broad means by which nutrition can affect schooling. First,
malnourished children may receive less schooling, because their caregivers seek to invest
less in their education, because schools use physical size as a rough indicator of school
readiness or because malnourished children may have higher rates of morbidity and thus
greater rates of absenteeism from school. While delayed entry, the second way by which
nutrition may influence schooling, does not necessarily lead to less completed education
– although under a prevailing model of the returns to education this would be an expected
consequence of delayed enrollment if the opportunity cost of a year of schooling
increases with age – late enrollment leads to lower expected lifetime earnings. In order to
maintain total years of schooling with delayed entry, an individual would have to enter
the work force later. As Glewwe and Jacoby (1995) illustrate, for each year of delay in
entry to primary school in Ghana a child in their study loses 3 percent of lifetime wealth.
The third pathway from malnutrition to educational outcomes is via the capacity to learn,
18
a direct consequence of the consequences of poor nutrition for cognitive development
described in Section 2. Additionally, a hungry child may be less likely to pay attention in
school and, thus, learn less even if he or she has no long-term impairment of intellectual
ability.
11
These three pathways clearly interact; a child with reduced ability to learn will
likely spend less time in school as well as learn less while in class.
Though intuitively plausible, it is difficult to ascertain or quantify the causal
pathway between nutrition and learning. Many of the observable factors that affect
nutrition, such as family assets and parental education, are also ones that affect education.
Similarly, unobservable attitudes about investment in children and in intra-family equity
influence heath provision and schooling decisions in a complex manner. Thus, while
there are many studies that document associations between nutrition and schooling (see
Pollitt 1990 and Behrman 1996 for reviews), there are far fewer studies that accurately
portray the causal impact of child health and nutrition on school performance.
Four recent studies represent the most complete efforts at distinguishing the
distinct contributory role of nutrition on education from associations. Glewwe and
Jacoby (1995) found delayed enrollments among the malnourished in their cross-
sectional study, but not difference in the total years completed. By contrast, Alderman,
Hoddinott, and Kinsey (2002) track a cohort of Zimbabweans over two decades finding
that both delayed school initiations and fewer grades completed for those children
11
A few studies have attempted to investigate the tie between hunger and classroom performance using
experimental design. Available results, however, are not conclusive regarding long term consequences,
perhaps, in part, because controlled studies are hampered by difficulties in running experiments for an
appreciable duration as well as the difficulty of encouraging parents to conform to the protocols of research
design and the inability to use a placebo. Moreover, as shown in Grantham-McGregor, Chang and Walker
(1997), while feeding children may improve attention, its impact on learning depends on the classroom
organization. On this point, also see Powell, et al. (1998).
19
malnourished as children. Extrapolating beyond the drought shocks used for
identification, the study concludes that had the median pre-school child in the sample
achieved the stature of a median child in a developed country, by adolescence she would
be 4.6 centimeters taller, had completed an additional 0.7 grades of schooling as well as
started school seven months earlier.
Glewwe, Jacoby, and King (2001) track children from birth through primary
school and find that better nourished children both start school earlier and repeat fewer
grades. A 0.6 standard deviation increase in the stature of malnourished children would
increase completed schooling by nearly 12 months. The Filipino setting of this study is
one in which most children initiate school. Using longitudinal data from rural Pakistan
where school initiation is much lower, Alderman et al. (2001) find that malnutrition
decreases the probability of ever attending school, particularly for girls. An improvement
of 0.5 standard deviations in nutrition would increase school initiation by 4% for boys but
19% for girls. As the average girl (boy) in the villages studied who begins school
competes 6.3 (7.6) years of schooling, improvements in nutrition would have a
significant effect on schooling attainment.
It is relatively straightforward to infer from the impact of nutrition on years of
schooling to the productivity lost using the substantial literature on wages and schooling.
There are hundreds of studies on the impact of grades of schooling completed on wages -
- many of which are surveyed in Psacharopoulos (1994) and Rosenzweig (1995). Wages,
however, are also directly influenced by cognitive ability, as well as by the appreciable
influence of cognitive ability on schooling achieved. Poor cognitive function as a child is
associated with poorer cognitive achievement as an adult, see Martorell (1995),
20
Martorell, Rivera and Kaplowitz (1989), Haas, et al. (1996), Martorell (1999) and
Martorell, Khan and Schroeder (1994). A series of studies show that reduced cognitive
skills as an adult (conditional on grades of schooling completed) directly affect earnings.
These include Alderman, et al. (1996), Altonji and Dunn, (1996), Boissiere, Knight, and
Sabot (1985), Cawley, Heckman and Vytlacil (2001), Glewwe (1996), Lavy, Spratt and
Leboucher (1997) and Psacharopoulos and Velez. (1992).
12
It is possible to use these studies to estimate the magnitude of the productivity
costs of poor nutrition. For example, Alderman, Hoddinott and Kinsey (2002) use the
values for the returns to education and age/job experience in the Zimbabwean
manufacturing sector provided by Bigsten et al. (2000, Table 5) to infer the costs
associated with poor nutrition in Zimbabwe. The loss of 0.7 grades of schooling and the 7
month delay in starting school there translates into a 12 per cent reduction in lifetime
earnings. Such estimates are likely to be lower bounds given Fogel’s (1994) evidence that
links short stature amongst males to the early onset of chronic diseases and to premature
mortality.
Behrman and Rosenzweig (2003) take a more direct approach. They study a
sample of adult monozygotic (identical) twins in the United States and determine that
with controls for genetic and other endowments shared by such twins (which would not
be affected by programs to increase birth weight), the impact of low birth weight on
schooling or wages is far larger than it appeared without such controls (e.g., the impact
on schooling attainment is estimated to be twice as large, with a pound increase in birth
12
In addition, studies such as Behrman and Rosenzweig (2003) and Strauss (2000) that show the net impact
of LBW on earnings capture both the indirect schooling effect and the direct impact of ability as well as
any influence of stature.
21
weight increasing schooling attainment by about a third of a year). This may reflect post-
natal choices on investments (with fewer investments for children with greater birth
weight) or a negative correlation of health and ability endowments.
13
Alderman and Behrman (2003) consider the net present value of all benefits with
reducing a particular dimension of malnutrition. They consider seven benefits (reduced
infant mortality, reduced neonatal care, reduced childhood morbidity, lost productivity
due to reduced cognitive ability and learning, lost productivity due to smaller stature,
reduction of the costs of chronic illness, and inter-generational benefits due to better birth
outcomes) associated with reducing low birthweights. Given the net present value
approach, the absolute and relative benefits of these seven categories are affected by the
discount rate. Lower discount rates allow benefits that occur later in life to add more to
the total. Conversely, when discount rates are high benefits that occur in infancy
contribute a greater share of the total than they do under lower discount rates.
Nevertheless, over a wide range of assumptions about both discount rates and the
nominal value of benefits, the productivity gains from cognitive ability and schooling
contribute most to the total, despite the fact that these are assumed not to begin to accrue
until age 15. For example, at a discount rate of 5% and using the core assumption in this
study, the productivity gains from increased cognitive ability represent 41% of the total
gains ($580) per low birth weight prevented. The reduction in chronic disease was only
4%. At a 1% discount rate these two categories contribute 42 and 12 percent
respectively.
13
In a similar vein, Conley and Bennett (2000) find that family fixed effects models using siblings (not
necessarily twins) indicate a much larger negative relation between low birth weight and the probability of
completing high school than found in cross-sectional estimates.
22
Horton and Ross (2003) use a different approach to construct illustrative estimates
of the costs of iron deficiency for 10 countries. Rather than reporting in terms of the
benefits per case of anemia prevented they report the per capita costs of anemia. Their
estimate of the physical loss of productivity comes to 0.57% of GNP. Considering the
impact of anemia on schooling and cognitive development, they estimated the median for
the total costs to these economies at 4% of GNP or $16.78 per capita.
4. Potential policy interventions
On a very general level, policy interventions are warranted that increase social welfare.
Often it is convenient to consider instead two related basic policy motives – increasing
efficiency and improving distribution. The distributional goal that is most emphasized is
reducing poverty.
Poverty and malnutrition are strongly linked empirically. Based on the available
aggregate data, Behrman and Rosenzweig (2003) report that cross-country variation in
GDP per capital in PPP terms is inversely related to the percentage of low birth weights
among all births and is consistent with almost half of the variation in the percentage of
births that are low birth weight (below 2500 grams) across countries.
14
Haddad et al.
(2003) estimate that the cross-country elasticity of child underweight rates (for children
under five years of age) with respect to per capita income for 1980-96 is –0.5. This is
virtually the same as the mean for the elasticity from 12 household data sets (though
estimates in both approaches decline somewhat in absolute value with the inclusion of
14
Their estimates suggest, however, that only a small part of this association between LBW and GDP per
capita is due to the causal effects of LBW on productivity.
23
fixed effects). Therefore successful efforts to reduce most forms of malnutrition are likely
to have incidences of benefits concentrated relatively among the poor. Thus policies that
are focused on alleviating malnutrition are likely to be pro-poor, though explicit efforts at
targeting such policies towards the poor is likely to make them more effectively attain the
poverty alleviation form of the distributional policy motive.
There also may be important efficiency reasons for policies pertaining to relieving
malnutrition. From a social perspective the private incentives to invest in nutrition may
be inadequate because there may be positive spillovers from better nutrition (e.g,, better
nourished individuals may be less susceptible to contagious diseases and less likely
therefore to spread them to others), because of imperfect information about the benefits
of better nutrition, and because of capital and insurance markets imperfections that lead
to less than socially desired levels of investments in nutrition and in other forms of
human capital. Therefore there are likely to be efficiency reasons – i.e., differentials
between private and social rates of return – for using public resources to alleviate
malnutrition. Moreover generally these efficiency reasons are stronger for poorer than
for better-off members of society – the poorer are more likely to be in environments in
which disease contagion is greater, have more imperfect information and have less access
to capital and insurance markets and less possibility of self-financing and self-insuring
investments. Thus there may be a number of “win-win” policy options that are pro-poor
and pro-efficiency.
To what extent are there actual possible pro-poor distributional gains and
efficiency gains from policies that reduce malnutrition is, of course, an empirical
24
question. The review of studies in Section 3, together with the higher prevalence of
malnutrition among poorer members of society noted above, suggests that that there are a
number of policies to alleviate malnutrition that might be warranted as part of anti-
poverty efforts. Malnutrition alleviation policies that improve education and improve
economic productivity are likely to have positive long-run benefit for individuals from
poor families.
The review of studies in Section 3, however, does not suggest much that is very
concrete about the efficiency policy motive. Though there are a priori reasons, as noted,
to think that nutrition may be inadequate from a social perspective due to inefficiencies,
the available literature provides virtually no empirical evidence on the extent of such
inefficiencies or on whether nutritional programs are likely to be very high in policy
hierarchies to address existing inefficiencies. Much of the empirical evidence focuses on
what arguably are private impacts of improved nutrition and does not address the
possibilities of differentials between the private and the social rates of returns to investing
in nutrition. However, this distinction between public and private returns is a bit blurred
in ‘second best’ situations in which there exist a number of departures from allocative
efficiency. In such situations, efficiency gains may come from reducing pre-existing
inefficiencies. For example, even if improved health is mainly a private benefit (and this
is arguable, as discussed above), if the state already invests in curative health care,
investments in nutrition that reduce these health expenditures are second best efficiency
gains. Similarly, given the resources most governments devote to the provision of
education, there is a public finance argument for investments in nutrition that improve the
efficiency of these schooling investments.
25
5. Conclusions
Malnutrition is widespread in many developing countries, with close to a billion people
estimated to be malnourished. Recent work has emphasized the importance of health and
nutrition for productivity and economic growth. This chapter adopts such an approach,
with focus on the microeconomic evidence of the direct and indirect links between
nutritional status and representations of productivity as they accumulate over the life
cycle.
We present a brief explanation of the causes and measurement of malnutrition and
of estimates of the extent of malnutrition across developing countries as preludes to our
survey of micro evidence about the productivity impact in developing countries of
improved nutrition on individuals throughout their life cycles – from conception through
infancy and childhood and into adolescence and adulthood. The available studies
suggest that some of these gains may be considerable and that may operate through many
channels – increasing cognitive development, increasing physical stature and strength,
inducing earlier school enrollment and more regular school attendance, inducing greater
schooling and learning, and increasing adult productivity – as well as saving resources
that otherwise would go towards dealing with diseases and other problems related to
malnutrition over the lifecycle.
We then examine the possible gains from different nutritional policy strategies
and the policy bases for adopting such strategies. The empirical evidence supports the
possible use of nutritional policy to attain better pro-poor distributional goals by helping
to make individuals from poor families more productive over their life cycles. The
26
available empirical evidence, however, is not very informative about the efficiency
motive for nutritional policies. There are a priori reasons to suspect that there are
possible efficiency gains from nutritional policies due to health spillovers and failures in
information, capital and insurance markets. But the available empirical evidence is
almost silent on the existence of such possibilities, whether there are important
differences between private and social rates of returns to investing in nutrition, whether
nutritional policies would be effective means of addressing any related efficiencies, and
to what extent some types of nutritional policies are likely to be “win-win” pro-poor and
pro-efficiency. Therefore there is an important research gap considering possible
efficiency reasons for particular nutritional policies
27
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