Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey
-
Upload
unicef-office-of-research-innocenti -
Category
Data & Analytics
-
view
825 -
download
0
Transcript of Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey
![Page 1: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/1.jpg)
Relating early childhood to adult outcomes: Evidence from the Cebu
Longitudinal Health and Nutrition Survey
![Page 2: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/2.jpg)
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
![Page 3: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/3.jpg)
CLHNS design was based on the Mosley
& Chen Health Determinants model
PROXIMATE
(nutrition, infection)
UNDERLYING(SES, environment)
HEALTH OUTCOME(growth, mortality)
![Page 4: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/4.jpg)
Cebu Province
Metro Cebu
The CLHNS population included residents of 17
urban and 16 rural barangays of Metro CebuPhilippines
![Page 5: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/5.jpg)
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
![Page 6: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/6.jpg)
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
![Page 7: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/7.jpg)
Multilevel data collection: Individual, Household and Community
• Health
• Anthropometry
• Diet
• Activity
• IQ
• Schooling
• Work
• Environment
• Income, assets
![Page 8: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/8.jpg)
1998 and 2005 Biomarkers
• Blood pressure
• Fasting blood samples
– Glucose, insulin, adiponectin
– Plasma lipids
– Inflammatory/immune markers
– DNA extracted, analyzed with Metabochip
![Page 9: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/9.jpg)
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
![Page 10: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/10.jpg)
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
![Page 11: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/11.jpg)
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
![Page 12: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/12.jpg)
What happens to children who were stunted at age 2?
IQSchool Attainment
WorkCardiovascular disease risk
![Page 13: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/13.jpg)
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
![Page 14: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/14.jpg)
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
![Page 15: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/15.jpg)
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
![Page 16: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/16.jpg)
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
![Page 17: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/17.jpg)
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
![Page 18: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/18.jpg)
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
![Page 19: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/19.jpg)
-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
![Page 20: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/20.jpg)
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
![Page 21: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/21.jpg)
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)
![Page 22: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/22.jpg)
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
![Page 23: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/23.jpg)
Weight status and CVD risk factors
0%
20%
40%
60%
80%
100%
females males
<18.5 18.5-25 25-30 >30
![Page 24: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/24.jpg)
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
![Page 25: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/25.jpg)
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
![Page 26: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/26.jpg)
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
![Page 27: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/27.jpg)
-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
![Page 28: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/28.jpg)
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
![Page 29: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/29.jpg)
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)
![Page 30: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/30.jpg)
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
![Page 31: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/31.jpg)
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
![Page 32: Relating early childhood to adult outcomes Cebu longitudinal health and nutrition survey](https://reader033.fdocuments.net/reader033/viewer/2022060205/55a11b741a28abb07f8b45ae/html5/thumbnails/32.jpg)