Influence of enhanced nutrition and psychosocial stimulation in early childhood on cognitive functioning and psychological well-being in Guatemalan adults

Rationale

Early-life nutrition interventions in low and middle-income countries have demonstrated long-term benefits on cognitive skills, however, their influence on socioemotional outcomes has not been fully explored. Moreover, the mediating processes through which nutrition intervention effects operate and are maintained over time are understudied.

Methods

We followed-up a cohort of Guatemalan adults who participated as children in a community randomized food-supplementation trial. We examined associations of exposure to nutritional supplementation from conception to age 2 years with executive function (measured using three sub-tests of the NIH Toolbox Cognition Battery) and psychological well-being (measured using two sub-scales of the NIH Toolbox Emotion Battery) at ages 40–57 years (n = 1268). We used structural equation modeling to investigate the mediating role of psychosocial stimulation (measured in childhood using parent reports and ratings of home environments), cognitive ability (measured at ages 26–42 years using standardized tests), and executive function on the association of early-life exposure to nutritional supplementation with adult psychological well-being (n = 1640).

Results

We found positive but inconsistent associations of nutritional supplementation in childhood with executive function and psychological well-being in adulthood. Psychosocial stimulation, cognitive ability, and executive function did not mediate the association of early-life nutritional supplementation with adult psychological well-being. We found strong and positive associations of psychosocial stimulation in childhood with cognitive ability, executive function, and psychological well-being in adulthood. Moreover, we observed no interaction of exposure to nutritional supplementation and psychosocial stimulation in childhood with cognitive and psychological well-being outcomes in adulthood.

Conclusion

Our findings suggest that childhood nutrition interventions have long-lasting effects on cognitive ability and psychological well-being outcomes.

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We assess the influence of early-life nutrition on neurodevelopmental outcomes.

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We use a theoretical approach to examine mediators of the association.

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We found no mediators of the association of early-life nutrition with adult psychological well-being.

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Psychosocial stimulation is strongly associated with neurodevelopmental outcomes.

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Improved child nutrition is positively associated with adult psychological well-being.

Health and Nutrition Status of the Caregiver: Effect on Caregiving Capacity

The importance of child care in ensuring optimal child survival, growth, and development is increasingly recognized. Unfortunately, poor health and nutrition status of the caregivers likely limit their agility to provide adequate care in many countries. Direct evidence for this has been shown in Egypt, where poor dietary intake, low haemoglobin levels, and low vitamin B6 status of the mothers were related to less time spent on care, less response to infants’ vocalization, less vocalization to infants, and greater utilization of older siblings as caregivers. In Kenya, lower maternal caloric intake was associated with less physical contact with their toddlers. Indirect evidence can be inferred from a review of illnesses affecting women globally in the light of the physical and mental demands of adequate caregiving. For this purpose, ill health of women is evaluated from both epidemiological and anthropological perspectives.

Psychosocial Aspects of Care and Nutrition

The quality of psychosocial care provided the young child is reflected in the caregiver's responsiveness, warmth and affection, involvement with the child, and encouragement of autonomy and exploration. First, research was examined linking the quality of psychosocial care to a child's development of mental abilities, and to his or her growth and nutrition status. There is considerable correlational evidence and some experimental evidence for this linkage. Second, the barriers to adequate psychosocial care were explored, including maternal beliefs and confidence, stress and depression, social support, and autonomy and control of resources. Third, a number of strategies to enhance psychosocial care as a mechanism for increasing the child's nutrition status are described, at the level of the child, the caregiver, the child-caregiver relationship, and the community. All of the work was interpreted in terms of an interactive or transactional model of child development.

Birth seasons and heights among girls and boys below 12 years of age: lasting effects and catch-up growth among native Amazonians in Bolivia

BACKGROUND

Seasons affect many social, economic, and biological outcomes, particularly in low-resource settings, and some studies suggest that birth season affects child growth.

AIM

To study a predictor of stunting that has received limited attention: birth season.

SUBJECTS AND METHODS

This study uses cross-sectional data collected during 2008 in a low-resource society of horticulturists-foragers in the Bolivian Amazon, Tsimane'. It estimates the associations between birth months and height-for-age Z-scores (HAZ) for 562 girls and 546 boys separately, from birth until age 11 years or pre-puberty, which in this society occurs ∼13-14 years.

RESULTS

Children born during the rainy season (February-May) were shorter, while children born during the end of the dry season and the start of the rainy season (August-November) were taller, both compared with their age-sex peers born during the rest of the year. The correlations of birth season with HAZ were stronger for boys than for girls. Controlling for birth season, there is some evidence of eventual partial catch-up growth, with the HAZ of girls or boys worsening until ∼ age 4-5 years, but improving thereafter. By age 6 years, many girls and boys had ceased to be stunted, irrespective of birth season.

CONCLUSION

The results suggest that redressing stunting will require attention to conditions in utero, infancy and late childhood.

A Path Analysis of Nutrition, Stimulation, and Child Development Among Young Children in Bihar, India

Nutrition plays an important role in the development of a child, particularly in low‐ and middle‐income countries where malnutrition is often widespread. The relation between diet, hemoglobin, nutritional status, motor development, stimulation and mental development was examined in a cross‐sectional sample of 1,079 children 12–18 months of age living in rural Bihar, India. Path analysis revealed associations between (a) length‐for‐age z‐scores and motor development, standardized β (β) = .285, p < .001, and (b) motor and all mental development outcomes (language: β = .422; personal‐social: β = .490; memory: β = .139; and executive function: β = .072, all p < .001). Additionally, stimulation was significantly associated with language scores and hemoglobin concentration with memory. These findings inform interventions aimed at improving child development in Northern India.

Associations of maternal nutrition during pregnancy and post-partum with maternal cognition and caregiving

Pregnant and post-partum women require increased nutrient intake and optimal cognition, which depends on adequate nutrition, to enable reasoning and learning for caregiving. We aimed to assess (a) differences in maternal cognition and caregiving between women in Malawi who received different nutritional supplements, (b) 14 effect modifiers, and (c) associations of cognition and caregiving with biomarkers of iron, Vitamin A, B-vitamin, and fatty acid status. In a randomized controlled trial (n = 869), pregnant women daily received either multiple micronutrients (MMN), 20 g/day lipid-based nutrient supplements (LNS), or a control iron/folic acid (IFA) tablet. After delivery, supplementation continued in the MMN and LNS arms, and the IFA control group received placebo until 6 months post-partum, when cognition (n = 712), caregiving behaviour (n = 669), and biomarkers of nutritional status (n = 283) were assessed. In the full group, only one difference was significant: the IFA arm scored 0.22 SD (95% CI [0.01, 0.39], p = .03) higher than the LNS arm in mental rotation. Among subgroups of women with baseline low hemoglobin, poor iron status, or malaria, those who received LNS scored 0.4 to 0.7 SD higher than the IFA arm in verbal fluency. Breastmilk docosahexaenoic acid and Vitamin B12 concentrations were positively associated with verbal fluency and digit span forward (adjusting for covariates ps < .05). In this population in Malawi, maternal supplementation with MMN or LNS did not positively affect maternal cognition or caregiving. Maternal docosahexaenoic acid and B12 status may be important for post-partum attention and executive function.

Child stunting is associated with weaker human capital among native Amazonians

OBJECTIVES

We assessed associations between child stunting, recovery, and faltering with schooling and human capital skills in a native Amazonian society of horticulturalists-foragers (Tsimane').

METHODS

We used cross-sectional data (2008) from 1262 children aged 6 to 16 years in 53 villages to assess contemporaneous associations between three height categories: stunted (height-for-age Z score, HAZ<-2), moderately stunted (-2 ≤ HAZ≤-1), and nonstunted (HAZ>-1), and three categories of human capital: completed grades of schooling, test-based academic skills (math, reading, writing), and local plant knowledge. We used annual longitudinal data (2002-2010) from all children (n = 853) in 13 villages to estimate the association between changes in height categories between the first and last years of measure and schooling and academic skills.

RESULTS

Stunting was associated with 0.4 fewer completed grades of schooling (∼24% less) and with 13-15% lower probability of showing any writing or math skills. Moderate stunting was associated with ∼20% lower scores in local plant knowledge and 9% lower probability of showing writing skills, but was not associated with schooling or math and writing skills. Compared with nonstunted children, children who became stunted had 18-21% and 15-21% lower probabilities of showing math and writing skills, and stunted children had 0.4 fewer completed grades of schooling. Stunted children who recovered showed human capital outcomes that were indistinguishable from nonstunted children.

CONCLUSIONS

The results confirm adverse associations between child stunting and human capital skills. Predictors of growth recovery and faltering can affect human capital outcomes, even in a remote, economically self-sufficient society.

Effects of Health and Nutrition on Cognitive and Behavioural Development in Children in the First Three Years of Life: Part 1: Low Birthweight, Breastfeeding, and Protein-Energy Malnutrition

The following paper and its accompanying paper (Grantham-McGregor SM, et al. Effects of health and nutrition on cognitive and behavioural development in children in the first three years of life. Part 2: Infections and micronutrient deficiencies: iodine, iron, and zinc. Food Nutr Bull 1999;20:76–99) review the literature on the conditions that are prevalent and considered to be likely to affect child development and are therefore of public health importance. the reviews are selective, and we have generally focused on recent work, particularly in areas that remain controversial. the reviews are restricted to nutritional and health insults that are important in the first three years of life. Where possible, we have discussed the better studies. This paper considers the effects of low birthweight (focusing on small-for-gestational-age babies) and early childhood protein-energy malnutrition on mental, motor, and behavioural development. We have also included a section on breastfeeding because of its importance to child health and nutrition programmes.

Parenting in Indonesia: Inter- and intracultural differences in mothers’ interactions with their young children

The interactions between 76 lower-class Indonesian mothers and their young children were observed both at home and in a structured play setting. Maternal interactive behaviour in the play session was compared with that of Japanese, Dutch, and Surinam-Dutch mothers observed in a similar setting. The interactive behaviour of Indonesian mothers was found to be more similar to that of Dutch and Surinam-Dutch mothers than to that of Japanese mothers. Mothers’ supportive behaviour in the structured play session was significantly related to their sensitivity at home. Maternal interactive behaviour in the two settings was also significantly but differentially related to characteristics of the immediate and socioeconomic context. The results suggest that socioeconomic factors have a stronger impact on the quality of parenting than cultural factors and that the observation of mother-child interactions in different settings may tap different aspects of parenting.

Nutritional Intake and Context as Predictors of Cognition and Adaptive Behaviour of Egyptian School-age Children

Relations between nutrition, cognition, and adaptive behaviour measures were assessed for 110 Egyptian pre-adolescents (47% male), ranging in age from 7 to 10 years. Using a combination of oral recall and weighing of food portions, the level of dietary intake was obtained for 19 specific nutrients, including measures of energy (kilocalories), macronutrients (protein, fat, carbohydrates), and micronutrients (vitamins, trace minerals). Children were tested on six subscales from the Egyptian version of the WISC-R plus the Raven's coloured matrices. Based on repeated naturalistic observations we also obtained measures of the children's behaviour in the school classroom, social interactions with peers and adults, activity level, and affect. Teacher ratings of the children's classroom behaviour were also obtained. The results indicated that specific nutritional indices were significantly related to male classroom behaviour and activity level, and to female verbal ability and classroom involvement. Although a diverse group of nutrients predicted developmental outcomes, common to many of these nutrients was the fact that they were derived from intake of animal source foods. The results further indicated that relations between nutrition and children's cognition and behaviour were mediated by contextual factors, such as social class and cultural expectations about the appropriateness of given behaviours.

Nutritional deficits and behavioural development

Despite a high incidence level the study of relations between nutritional deficits and children’s behavioural development is a topic that has been relatively neglected by developmental researchers. Such neglect has implications for the generalisability of developmental theories, especially to less developed countries where the majority of the world’s children live and where nutritional deficits are more likely to occur. This paper reviews evidence on the role played by nutritional deficits in children’s development and the mechanisms underlying nutrition → development links. Future directions for collaborative research between clinical, developmental, and nutritional scientists are proposed.

Infant Nutrition and 12 and 18 Months Secure Base Behavior: An Exploratory Study

A notable omission in studies of developmental links to early nutritional deficiencies is infant attachment. In those few studies investigating associations between infant nutrition and attachment, nutrition was defined solely by physical growth, and infants had moderate-severe growth retardation. In this study, we utilized multiple markers of infant nutrition. Our sample consisted of 172 12-month-old Peruvian infants and their mothers from low-income families, with a follow-up assessment on 77 infants at 18 months. Infants were not severely malnourished, but did have micronutrient deficiencies. Anthropometry, dietary intake, and iron status were used as measures of infant nutrition. Based on infant behavior in a structured laboratory situation, Q-sort techniques were used to rate three attachment markers: infant secure base behavior, interaction quality, and negative emotionality with mother. At 12 months, infant weight was positively related to interaction quality. At 18 months, infant iron status was positively related to secure base behavior. This pattern of findings remained even after statistically controlling for family socioeconomic status and maternal education. Our findings indicate that infant nutritional status is associated with markers of infant attachment and these associations are not restricted just to severely malnourished infants.

INCAP Studies of Malnutrition and Cognitive Behavior

The Institute of Nutrition of Central America and Panama (INCAP) has made major contributions to the study of the effects of malnutrition on learning. This report summarizes work on the relationship of nutrition to children's learning and development from the 1960's through 1998. The Oriente Longitudinal Study examined the effects of two types of supplementation for mothers and young children on their growth and development (an energy-only drink compared with a protein-energy drink) using a quasi-experimental design. Both drinks were supplemented with micronutrients, and were offered daily. As a result of the research on malnutrition and mental development, researchers could conclude by 1993 that supplementary feeding of infants and young children resulted in significant increases cognitive development and school performance through adolescence. The research also suggested that the pathways that link malnutrition with later development are not only through the neurological system but also operate through changes in child behavior which affect the kinds of care children receive. Other research on learning and development showed that families understood the concept of intelligence, demonstrated the link between micronutrients and cognitive development, and documented the amount of wastage or repetition and drop-out that occurs in Guatemalan schools.

Models linking nutritional deficiencies to maternal and child mental health

The primary goal of this article was to illustrate how nutritional deficiencies can translate into adult or child mental health problems. Whereas brain development and function play an essential role in the etiology and maintenance of mental health problems, what is required are models that go beyond nutrition-brain relations and integrate the contributions of nutritionally related contextual and behavioral characteristics. Four such models are presented. The multiple risks model derives from evidence showing covariance between nutritional deficiencies and other life stressors. Given that poorly nourished adults may be less able to actively cope with stressors, nutritional deficiencies may accentuate the negative impact of stress exposure on mental health. The cross-generational model is based on evidence showing less adequate patterns of mother-child interactions when mothers are poorly nourished. Impairments in mother-child interactions increase the likelihood of child mental health problems and the risk of subsequent child nutritional deficiencies. The attachment model derives from evidence showing that poorly nourished infants may be less likely to elicit the types of maternal child-rearing patterns that translate into secure infant-mother attachments. Insecure attachments in infancy are associated with an increased risk of both short-term and long-term child mental health problems. The temperament model is based on evidence documenting that certain patterns of infant temperament are related to an increased risk of later behavioral problems. Infant nutritional deficiencies can influence the development of temperament, and certain temperament patterns can contribute to an increased risk of infant nutritional deficiencies.

Iron deficiency in infancy and mother-child interaction at 5 years

Five-year-old Costa Rican children, who had either chronic, severe iron deficiency or good iron status in infancy, were observed with their mothers during a structured interaction task in a laboratory setting and everyday interactions in their home. Child affect and behavior as well as the quality of mother-child interaction of the formerly chronic iron-deficient children (n = 40) were compared to those with good iron status in infancy (n = 102). Children who had chronic iron deficiency in infancy were more likely to display lower levels of physical activity, positive affect, and verbalization during the structured task at 5 years, despite iron therapy that corrected their iron deficiency anemia in infancy. Mother-child reciprocity during the structured task (e.g., eye contact, shared positive affect, turn taking) was more likely to be lower in the chronic iron deficiency group compared to the good iron group. Mothers of children in the chronic iron deficiency group showed less responsivity in both settings. These results show that children with chronic, severe iron deficiency in infancy continue at behavioral disadvantage relative to their peers at school entry. Sustained differences in mother-child interaction might contribute to the long-lasting behavioral and developmental alterations reported in children with chronic, severe iron deficiency in infancy.

The long-term impact of preschool health and nutrition on education

Malnutrition and infectious diseases in infancy and early childhood have an impact on the cognitive development of children in developing countries. The long-term effects of these diseases are less well understood. A number of studies relate early malnutrition, iron deficiency, and malaria infection to poor cognitive abilities in the school-age years. The long-term effect of randomized interventions in early childhood has been evaluated for nutrition supplementation and psychosocial stimulation of malnourished children and for malaria prevention in a community cohort. The evidence suggests that improving the health and nutrition of young children can improve their subsequent chances of attending school, the gender equity of education access, and performance of children once at school.

Maternal resources, parenting, and dietary patterns among rural African American children in single-parent families

A correlation study was designed to test the hypothesis that maternal education, perceived family resources, and the importance of family routines would be related to children's dietary patterns. Additionally, the study examined the hypothesis that dietary patterns would be associated with children's cognitive and physical abilities. The sample for this study included 159 African American single-mother families with a 6- to 9-year-old child living in rural areas, most of whom lived in poverty. Children's eating patterns were assessed using a self-report questionnaire administered to the mother in an interview format. Children's cognitive ability was measured by several subscales from the Woodcock Johnson Psycho-Educational Instrument and the Harter Perceived Competence Scale for children. For male children, the mother's higher education was related to more adequate eating patterns at home, and more perceived family resources were related to the likelihood of taking vitamin supplements. For female children, greater milk intake was positively related to cognitive outcomes, including applied problem, passage comprehension, calculation, synonym identification, antonym identification, and quantitative concept scores. Milk intake was clearly related to more optimal cognitive development. The results of this study support the literature related to the importance of nutrition for cognitive and physical abilities in children.

Child development: vulnerability and resilience

Many of the challenges facing children now are a function of changing times, including increase in urbanization, political violence, changing family forms, and in some areas decreased supplies of adequate food. This review focuses particularly on those changes in which children are the victims and which induce new threats for them, rather than on problems such as child disability or mental illness. The outcome variables of interest in this paper are dimensions of children's psychosocial development, including cognitive development, psychological adjustment and aggression, whereas the companion paper in this issue (Caldwell P., Child survival: vulnerability and resilience in adversity in the European past and the contemporary Third World, Soc. Sci. Med.) [1] focuses on physical aspects of children's development. The risks that are hurdles in the process of development of a young child begin from conception and carry on into later life. To address them all would be impossible; thus, in order to do justice to the issues at hand, we have chosen those risks that, in our view, are important in a child's psychosocial development in developing countries. This paper will thus provide a discussion of the concepts of risk and resilience, then apply these concepts to the analysis of three examples of risk faced by children today: nutritional threats (e.g. malnutrition due to decline in breastfeeding); family dynamics and types of family forms (e.g. child fostering and non-traditional families); and experiences of violence (domestic or political). In each case, the same four questions will be addressed: what are the consequences of the risk factor for children, what are the etiologies and conditions of risk, are there any children who seem to cope with the risk factor successfully and what are some of the protective factors, and what interventions or programs would help support these children?

Nutrition, maternal responsiveness and mental development of Ethiopian children

Forty children between the ages of 16 and 42 months and their mothers, living in an Ethiopian rural village, participated in the study. The objective was to determine the mental development of the children using the Bayley Scale of Mental Development, and to examine its relation to nutritional status and mother-child interaction. Forty-eight percent of the children were mildly or moderately malnourished; 7.5% severely so. The child's weight for age was significantly related to the child's scores on the Bayley scale. Mother-child interaction was assessed through a 30-60 min observation of the pair in a naturalistic setting around the home. The number of verbal, gestural and motor actions spontaneously initiated by the mother and child, as well as responses made by each to the others' behavior were recorded and coded separately. The rate of a mother's verbal responses to the child positively predicted the child's verbal score. In contrast, the mother's spontaneously initiated motor actions toward the child correlated negatively with the child's performance score. The mother's responsiveness was unrelated to the child's nutritional status, age or sex, but was best predicted by a fussing/crying child and by her expectations about the ages when specific social-cognitive abilities would be acquired by a child.

Relation of rearing environment to adaptive behavior of Egyptian toddlers

2 questions were explored: (1) Do observed relations found in Western cultures between specific psychosocial environmental factors and toddlers adaptive behavior resemble the pattern of relations found in a non-Western setting? (2) Does the specificity of relations between environment and performance found in Western cultures also operate in a non-Western culture? Subjects were 153 Egyptian toddlers, 18-30 months of age, and their caregivers. Twice a month between 18 and 30 months toddlers were observed in naturalistic interactions with their caregivers, and measures of caregiver behavior and toddler functioning were coded. Replicating previous results from Western cultures, canonical analysis indicated that caregiver vocal stimulation was positively related to indices of toddler behavioral competence, while nonverbal response to vocalization and physical contact stimulation were negatively related. The salience of sib caregivers was also noted. Particularly for the age period between 24 and 29 months, results indicated specificity of environmental action such that measures of caregiver vocal stimulation were uniquely related to measures of toddler vocalization, while caregiver response to distress was uniquely related to toddler emotionality. The present pattern of results suggests at least some degree of cross-cultural generalizability of environment-development relations and of the specificity model of environmental action.