Relating early childhood to adult outcomes: Evidence from the Cebu

Longitudinal Health and Nutrition Survey

The Cebu Longitudinal Health and Nutrition Survey (CLHNS)

Historical Context

• Desire to develop a multipurpose demographic survey to assess inputs to, and consequences of maternal and child nutrition and health

• Early 1980s concern with effects of infant feeding on morbidity and growth

Why Cebu?

• Availability of population institute with capacity to launch large, longitudinal study

• Heterogeneity of infant feeding in urban and rural communities

• Support of the Mayor of Cebu

CLHNS design was based on the Mosley

& Chen Health Determinants model

PROXIMATE

(nutrition, infection)

UNDERLYING(SES, environment)

HEALTH OUTCOME(growth, mortality)

Cebu Province

Metro Cebu

The CLHNS population included residents of 17

urban and 16 rural barangays of Metro CebuPhilippines

Sample

• Baseline (1883-4) All pregnant women in 33 randomly selected communities invited to participate

• Data collected at 30 weeks gestation (N=3,327), then during multiple follow-up surveys

• 3,080 single live births form the one year birth cohort

Follow-up Surveys

Year N Age

1984 3080 0

1986 2550 2

1991 2264 8.5

1994 2197 11.5

1998 2117 15.5

2002 2029 19

2005 1889 21-22

2007-08 1842 24-26

Multilevel data collection: Individual, Household and Community

• Health

• Anthropometry

• Diet

• Activity

• IQ

• Schooling

• Work

• Environment

• Income, assets

1998 and 2005 Biomarkers

• Blood pressure

• Fasting blood samples

– Glucose, insulin, adiponectin

– Plasma lipids

– Inflammatory/immune markers

– DNA extracted, analyzed with Metabochip

Socioeconomic Trends in the Philippines

• Cebu: fastest growth area in the Philippines

• Increased GNP and per capita income

• High ownership of TVs, phones

• High rates of secondary school completion and college education compared with most other low income Asian countries (esp. among women)

• High degree of urbanization

Pregnancies occurred in context of high maternal undernutrition

Offspring grew up in an increasingly obesogenicenvironment

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

1984 1986 1991 1994 1998 2002 2005 2013

Underweight OverweightObese Obese

At Birth11.5% LBW (<2.5 kg)

12.9% Preterm (<37 weeks gestation)

~23% Small for Gestational Age

Infant and young child outcomes

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0 2 4 6 8 10 12 14 16 18 20 22 24

Males Females

Prevalence of Stunting (LAZ < -2)

Age in months

What happens to children who were stunted at age 2?

IQSchool Attainment

WorkCardiovascular disease risk

Young adult outcomes in those stunted vs not stunted at age 2 yr

Not stunted Stunted

Stunted as adult 0.13 0.57Did not complete High School 0.20 0.35

Overweight 0.14 0.06

Centrally obese 0.16 0.10

Pre/hypertensive 0.12 0.09

Prediabetes/diabetes 0.01 0.01

Early growth is strongly correlated with IQ, Schooling and Work Outcomes

IQ and achievement test scores vary directly with height-for-age Z score at age 2

40

45

50

55

IQ

-3 -2 -1 0

20

22

24

26

28

30

32

34

English Math

-3 -2 -1 0

Predicted means, adjusted for parental characteristics and SES

Schooling status of CLHNS young

adults at age 21 years

0 200 400 600 800 1000

females

males

females

males

Primary or less Some HS HS Grad College

StillEnrolled(18%)

Not Enrolled

IQ and Achievement: Unlike other low income countries in Asia and worldwide, females have higher IQ and

achievement test scores

-0.25

-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

0.15

0.2

0.25

0.3

IQ Cebuano Math English

females males

SD’s

Deficit in attained schooling of Filipino young adults associated with stunting at age 2 (compared to those with Z-score>-1)

Crude vs. adjusted for household wealth and maternal education

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

<-3 -3 to -2 -2 to -1

crude adjusted

-3.5

-3

-2.5

-2

-1.5

-1

-0.5

0

<-3 -3 to -2 -2 to -1

crude adjusted

Year

s o

f sc

ho

olin

g

Length Z score at age 2 (WHO standard)

Girls Boys

Note that this association is not CAUSAL, but poor growth and poor attainment share common underlying determinants

Odds of attaining some college education for those with mild, moderate or severe stunting at age 2

0

0.2

0.4

0.6

0.8

1

1.2Crude Adjusted Adjusted + IQ

Mild = LAZ -1 to -2, moderate=LAZ -2 to -3 severe= <-3

-3

-2.5

-2

-1.5

-1

-0.5

0

0 5 10 15 20

-3

-2.5

-2

-1.5

-1

-0.5

0

0 5 10 15 20

Started collegeFinished HSIn school, behindLate drop outEarly drop out

Height Z-scores according to school attainment at age 18

Does faster linear growth from 2-8 yr relate differently to attained schooling in kids who were stunted at age 2?

Stunted Not Stunted

b/ci95 b/ci95

Mother's height 0.01 0.01

-0.02,0.04 -0.04,0.05

Wealth 0.27*** 0.09

0.17,0.36 -0.00,0.18

Mother's education 0.33*** 0.34***

0.28,0.39 0.27,0.40

Child sex -1.03*** -1.09***

-1.31,-0.75 -1.47,-0.71

Faster relative weight gain 2-8 yr -0.20** 0

-0.34,-0.06 -0.21,0.20

Faster linear growth 2-8yr 0.15* 0.17

0.01,0.29 -0.04,0.37

N 1292 623

Stunting and young adult

employment

• Declines in Traditional, labor intensive jobs and increases in service industry and “high tech” jobs have increased demand for higher education

• Does nutritional history matter?– Height requirements for jobs

• Young adult employment status categorized as:– Not working– Employed in informal sector– Employed in formal sector (work >=40 hrs, have benefits

and greater than minimum wage)• Analysis stratified by current schooling status (still in

school or not)

Likelihood of formal sector work

increases with childhood length Z-

score at age 2 in young adults

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Formal vs.Not Working

+schooling Formal vs.Informal

+schooling0.6

0.8

1

1.2

1.4

1.6

1.8

2

Formal vs.Not Working

+schooling Formal vs.Informal

+schooling

Schooling is an important mediator of this relationship

Males Females

Weight status and CVD risk factors

0%

20%

40%

60%

80%

100%

females males

<18.5 18.5-25 25-30 >30

In a sample where 23% of infants were born SGA, CVD risk factors have become prevalent:

0

0.1

0.2

0.3

0.4

BMI>25 HTN FG>110 TC>200 LDL>130 HDL<35 TG>200 CRP>3 HOMA>4.65

Males Females

Levels of CVD risk factors in young adults

11

12

13

14

15

16

17

18

19

0 2 4 6 8 10 12 14 16 18 20 22 24

Bo

dy

Mas

s In

dex

Age in months

18.75

19.25

19.75

20.25

20.75

21.25

21.75

Adult Body Mass Index

14.3

14.8

15.3

15.8

Lean Mass Index

Infant BMI trajectories in the first 2 years relate to adult BMI and Lean Mass

Systolic Blood Pressure

-1.5

-1

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

4

Cebu M

Cebu F

pooled

Weight relative to linear growth Linear growth relative to weight gain

* Significant sex-site heterogeneity

Birth 24 m MC Adult 24 m MC Adult

mm

Hg

-0.2 -0.1 0 0.1 0.2 0.3

0

0.5

1

2

8

11

15

21

CRP

HOMA-IR

Adiponectin

Insulin

Glucose

TG

LDL

HDL

DBP

SPB

Cebu MalesRelative Weight Gain

Positive deviants: do some stunted children end up as healthy adults?

• “Healthy” adults defined as those with normal weight (BMI>25 kg/m2), no abdominal obesity (WHtR<0.5), normal blood pressure, normal fasting glucose, not stunted, high school graduates

• 22% of children stunted at age 2 were “healthy” as adults, 45% of children not stunted at age 2 were “healthy” adults

Positive DeviantsNot stunted at 2 yr Stunted at 2 yr

Unhealthy Healthy Unhealthy Healthy

N=346 N=286 N=1014 N=283

Baseline Maternal

Height 151.9 152.9 149.1 151.6*

Education (~yrs) 7.9 8.4 6.2 6.8*

Wealth Index 0.60 0.73 -0.45 -0.19

Hygiene Score 6.41 6.65 5.83 6.01*

Urbanicity Score 31.54 31.64 28.75 26.82*

Infant

%male 0.55 0.44 0.57 0.45

Birth weight (kg) 3.12 3.15 2.92 3.03

Birth Length (cm) 50.0 50.1 48.5 49.2

BW<2.5 kg 0.04 0.04 0.14 0.09

SGA 0.17 0.16 0.29 0.21

Firstborn 0.27 0.29 0.19 0.17

BF duration (months) 12.53 13.34 14.88 14.57

HAZ at age 2 1.37 1.31 -3.22 -2.77

Significant predictor of membership in this group vs stunted unhealthy (mlogit)

Implications

• What are the outcomes of stunted children?– Lower IQ, lower school attainment

– Short adult stature

– Reduced likelihood of obesity and CVD risk

• Tracking of risk established in the first 2 years is substantial, but a small proportion of stunted children become “healthy” adults

• Promoting early linear growth and preventing excess child to adolescent weight gain should be strong priorities

Collaborations• Carolina Population Center, University of North Carolina at Chapel Hill

• Office of Population Studies Foundation, University of San Carlos, Cebu, Philippines

• Northwestern University, Evanston, Illinois

• Johns Hopkins University, Baltimore, Maryland

FundingNHLBI: R01-HL 085144 NIDDK:R01-DK 078150 NICHD:R01-HD 054501

NIH, Ford Foundation, Nestle Research Foundation, Thrasher Foundation, World Bank, Asian Development Bank