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Review of the evidence linking protein and energy to mental development

Published online by Cambridge University Press:  02 January 2007

Sally Grantham-McGregor  and
Helen Baker-Henningham
Sally Grantham-McGregor*
Affiliation:
Centre for International Child Health, Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
Helen Baker-Henningham
Affiliation:
Department of Educational Studies, University of the West Indies, Mona, Kingston, Jamaica
*
*Corresponding author: Email sally@mcgregor22.freeserve.co.uk
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Abstract

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Objective

To examine the evidence as to whether the relationship between undernutrition and poor child development is causal.

Design

Selected studies from developing countries were discussed. Observational studies were first considered then experimental studies of preventative and remedial supplementation. The type of functions affected, the presence of sensitive periods and the role of protein and energy versus that of micronutrients were reviewed.

Results

Childhood undernutrition is generally associated with concurrent and longer term deficits in cognition, behaviour and motor skills, although the relationship is likely to be confounded by socio-economic factors. Supplementation trials have had many design problems. However, those beginning at any age from pregnancy up to 24 months have consistently had concurrent benefits suggesting a causal relationship. Supplement begun in older children had little or no effect, albeit there are too few studies to conclude with confidence. The limited evidence suggests that benefits are more likely to be sustained if supplementation begins in late pregnancy or at birth and is continued until the child is at least 24 months old.

Deficits in cognition tend to be global and there is insufficient evidence of specific deficits. There is some evidence that the first 2 years of life are most sensitive to the effects of undernutrition. Most studies have failed to separate the effects of energy and protein from those of micronutrients. One study showed that energy and/or protein affects children's development. Psychosocial stimulation has had consistent benefits on undernourished childrens' development

Conclusions

Public health nutrition programmes should include a component in which children who are at risk are targeted during the first 2 years of life with combined interventions involving nutrition, health care and early stimulation.

Keywords

UndernutritionMental development
Type
Research Article
Information
Public Health Nutrition , Volume 8 , Issue 7a , October 2005 , pp. 1191 - 1201
Copyright
Copyright © The Authors 2005

References

1Hamill, P, Drizd, T, Johnson, C, Reed, R, Roche, A. NCHS growth curves for children birth to 18 years. United States: US DHEW Pub No (PHS) 78-1650, Series II, No. 165, 1977.Google Scholar
2Schurch, B. Malnutrition and behavioural development: the nutrition variable. Journal of Nutrition 1995; 125(Suppl. 8): S2255–62.Google ScholarPubMed
3UNICEF. The State of the World's Children. Oxford: Oxford University Press, 2001.Google Scholar
4Grantham-McGregor, S, Pollitt, E, Wachs, T, Meisels, S, Scott, K. Summary of the scientific evidence on the nature and determinants of child development and their implications for programmatic interventions with young children. Food and Nutrition Bulletin 1999; 20: 4–6.CrossRefGoogle Scholar
5Wachs, T. Necessary but not sufficient. The Respective Roles of Single and Multiple Influences on Individual Development. Washington, DC: American Psychological Association, 2000.Google Scholar
6Lasky, R, Klein, R, Yarbrough, C, Engle, P, Lechtig, A, Martorell, R. The relationship between physical growth and infant behavioural development in rural Guatemala. Child Development 1981; 52: 219–26.Google ScholarPubMed
7Monckeberg, F. Malnutrition and mental capacity. Pan American Health Organization, ed. Nutrition, the Nervous System and Behaviour. Scientific Publication No. 251, Washington DC: PAHO, 1972, 48–54.Google Scholar
8Powell, C, Grantham-McGregor, S. The ecology of nutritional status and development in young children in Kingston, Jamaica. American Journal of Clinical Nutrition 1985; 41: 1322–31.CrossRefGoogle ScholarPubMed
9Sigman, M, Neumann, C, Baksh, M, Bwibo, N, McDonald, M. Relationship between nutrition and development in Kenyan toddlers. Journal of Pediatrics 1989; 115: 357–64.Google ScholarPubMed
10Clarke, N, Grantham-McGregor, S, Powell, C. Nutrition and health predictors of school failure in Jamaican children. Ecology of Food and Nutrition 1991; 26: 1–11.CrossRefGoogle Scholar
11Florencio, C, Nutrition, Health and Other Determinants of Academic Achievement and School-related Behaviour of Grades One to Six Pupils. Quezan City: University of the Phillipines, 1988.Google Scholar
12Moock, P, Leslie, J. Childhood malnutrition and schooling in the Teri region of Nepal. Journal of Development Economics 1986; 20: 33–52.CrossRefGoogle Scholar
13Sigman, M, Neumann, C, Jansen, A, Bwibo, N. Cognitive abilities of Kenyan children in relation to nutrition, family characteristics, and education. Child Development 1989; 60: 1463–74.CrossRefGoogle ScholarPubMed
14Grantham-McGregor, S. A review of studies of the effects of severe malnutrition on mental development. Journal of Nutrition 1995; 125: S2233–8.CrossRefGoogle ScholarPubMed
15Wachs, T, Moussa, W, Bishry, Z, Yunis, F, Sobhy, A, McCabe, G, Jerome, N, Gallal, O, Harrison, G, Kirksey, A. Relations between nutrition and cognitive performance in Egyptian toddlers. Intelligence 1993; 17: 151–72.CrossRefGoogle ScholarPubMed
16Sigman, M, McDonald, M, Neumann, C, Bwibo, N. Prediction of cognitive competence in Kenyan children from toddler nutrition, family characteristics and abilities. Journal of Child Psychology and Psychiatry, and Allied Disciplines 1991; 32: 307–20.CrossRefGoogle ScholarPubMed
17Grantham-McGregor, S, Stewart, M, Powell, C. Behaviour of severely malnourished children in a Jamaican hospital. Developmental Medicine and Child Neurology 1991; 33: 706–14.CrossRefGoogle Scholar
18Lester, B. Spectrum analysis of the cry sounds of well nourished and malnourished infants. Child Development 1976; 47: 237–41.CrossRefGoogle ScholarPubMed
19Lester, B. Cardiac habituation of the orienting response to an auditory signal in infants of varying nutritional status. Developmental Psychology 1975; 2: 432–42.CrossRefGoogle Scholar
20Meeks-Gardner, J, Grantham-McGregor, S, Chang, S. Activity and behavioural development in stunted and non-stunted children and response to nutritional supplementation. Child Development 1995; 66: 1785–97.CrossRefGoogle Scholar
21Chavez, A, Martinez, C. Growing Up in a Developing Community. Guatemala City: Institute of Nutrition in Central America and Panama, 1982.Google Scholar
22Graves, P. Nutrition, infant behaviour, and maternal characteristics: a pilot study in West Bengal, India. American Journal of Clinical Nutrition 1976; 29: 305–19.CrossRefGoogle ScholarPubMed
23Graves, P. Nutrition and infant behaviour: a replication study in the Katmandu Valley, Nepal. American Journal of Clinical Nutrition 1978; 31 541–51.CrossRefGoogle ScholarPubMed
24Meeks-Gardner, J, Grantham-McGregor, S, Himes, J, Chang, S. Behaviour and development of stunted and non-stunted Jamaican children. Journal of Child Psychology and Psychiatry, and Allied Disciplines 1999; 40: 819–27.CrossRefGoogle Scholar
25Pollitt, E, Saco-Pollitt, C, Jahari, A, Husaini, M, Huang, J. Effects of an energy and micronutrient supplement on mental development and behaviour under natural conditions in undernourished children in Indonesia. European Journal of Clinical Nutrition 2000; 54(Suppl. 2): S80–90.Google ScholarPubMed
26Grantham-McGregor, S, Schofield, W, Haggard, D. Maternal child interaction in survivors of severe malnutrition who received psychosocial stimulation. European Journal of Clinical Nutrition 1989; 43: 45–52.Google ScholarPubMed
27Allen, L. The nutrition CRSP: what is marginal malnutrition, and does it affect human function? Nutrition Review 1993: 51: 255–67.CrossRefGoogle ScholarPubMed
28Mora, J, Clement, J, Christiansen, N, Ortiz, N, Vuori, L, Wagner, M. Nutritional supplementation, early stimulation and child development. In: Brozek, J, Schurch, B, eds. Behavioural Effects of Energy and Protein Deficits. DHEW Publication no. 79–1906. Washington DC: US Department of Health, Education and Welfare, 1979, 225–69.Google Scholar
29Lasky, R, Klein, R, Yarbrough, C, Engle, P, Lechtig, A, Martorell, R. The relationship between physical growth and infant behavioural development in rural Guatemala. Child Development 1981; 52: 219–26.CrossRefGoogle ScholarPubMed
30Powell, C, Walker, S, Himes, J, Fletcher, P, Grantham-McGregor, S. Relationships between physical growth, mental development and nutritional supplementation in stunted children: the Jamaican study. Acta Paediatrica 1995; 84: 22–9.CrossRefGoogle ScholarPubMed
31Champakam, S, Srikantia, S, Gopalan, C, Kwashiorkor and mental development. American Journal of Clinical Nutrition 1968; 21: 844–52.CrossRefGoogle ScholarPubMed
32Cravioto, J, Delcardie, E. Microenvironmental factors in severe protein calorie malnutrition. In: Scrimshaw, N, Behar, M, eds. Nutritional Agricultural Development. New York: Plenum Publishing Corporation, 25–36.Google Scholar
33Hoorweg, J, Stanfield, J. The effects of protein-energy malnutrition in early childhood on intellectual and motor abilities in later childhood and adolescence. Developmental Medicine and Child Neurology 1976; 18 330–50.CrossRefGoogle ScholarPubMed
34Galler, J, Ramsey, F, Solimano, G. The influence of early malnutrition on subsequent behavioural development. III Learning disabilities as a sequel to malnutrition. Pediatric Research 1984; 18: 309–13.CrossRefGoogle ScholarPubMed
35Galler, J, Ramsey, F, Forde, V. A follow up study of the influence of early malnutrition on subsequent development IV. Intellectual performance in adolescence. Journal of Nutrition Education and Behaviour 1986; 3: 211–22.Google Scholar
36Richardson, S, Birch, H, Hertzig, M, School performance of children who were severely malnourished in infancy. American Journal of Mental Deficiency 1979; 77: 623–32.Google Scholar
37Grantham-McGregor, S, Schofield, W, Powell, C, Development of severely malnourished children who received psychosocial stimulation: six-year follow-up. Pediatrics 1987; 79: 247–54.Google ScholarPubMed
38Nwuga, V. Effect of severe kwashiorkor on intellectual development among Nigerian children. American Journal of Clinical Nutrition 1977; 30: 1423–30.CrossRefGoogle ScholarPubMed
39Hoorweg, J. Protein-Energy Malnutrition and Intellectual Abilities: A Study of Teen-Age Ugandan Children. Mouton: S. Gravenhage Parijs, 1976.CrossRefGoogle Scholar
40Bartel, P, Griesel, R, Burnett, L, Freiman, I, Rosen, E, Geefhuysen, J. Long-term effects of kwashiorkor on psychomotor development. South African Medical Journal 1978; 53: 360–2.Google ScholarPubMed
41Birch, H, Pineiro, C, Alcalde, E, Toca, T, Cravioto, J. Relation of kwashiorkor in early childhood and intelligence at school age. Pediatric Research 1971; 5: 579–85.CrossRefGoogle Scholar
42Hertzig, M, Birch, H, Richardson, S, Tizard, J, Intellectual levels of school children severely malnourished during the first two years of life. Pediatrics 1972; 49: 814–24.Google ScholarPubMed
43McLaren, D, Yatkin, U, Kannawati, A, Sabbagh, S, Kadi, Z. The subsequent mental and physical development of rehabilitated marasmic infants. Journal of Mental Deficiency Research 1973; 7: 273–81.Google Scholar
44Evans, D, Moodie, A, Hansen, J. Kwashiorkor and intellectual development. South African Medical Journal 1971; 45: 1413–26.Google ScholarPubMed
45Pereira, S, Sundararaj, R, Begum, A. Physical growth and neurointegrative performance of survivors of protein-energy malnutrition. British Journal of Nutrition 1979; 42: 165–71.CrossRefGoogle ScholarPubMed
46Graham, G, Adrianzen, B. Status of school of Peruvian children severely malnourished in infancy. In: Brozek, J, ed. Behaviour Effects of Energy and Protein Deficits. Washington: US Department of Health, Education and Welfare NIH. 1979 pub No. 79-1906, 185–94.Google Scholar
47Moodie, A, Bowie, M, Mann, M, Hansen, J. A prospective 15 year follow-up study of kwashiorkor patients. Part 11. Social circumstances, educational attainment and social adjustment. South African Medical Journal 1980; 58: 577–681.Google Scholar
48Martorell, R, Rivera, J, Kaplowitz, J, Pollitt, E. Long term consequences of growth retardation during early childhood. In: Hernandez, M, Argenta, J, eds. Human Growth: Basic and Clinical Aspects. Amsterdam: Elsevier, 1992, 143–9.Google Scholar
49Mendez, M, Adair, L. Severity and timing of stunting in the first two years of life affect performance on cognitive tests in late childhood. Journal of Nutrition 1999; 129: 1555–62.CrossRefGoogle ScholarPubMed
50Richardson, S. Severity of malnutrition in infancy and its relation to later intelligence. In: Brozek, J, ed. Behavioural Effects of Energy and Protein Deficits. Washington DC: National Institute of Arthritis, Metabolism, and Digestive Diseases, US Department of Health, Education and Welfare, 1979, 172–84.Google Scholar
51Walker, S, Grantham-McGregor, S, Powell, C, Chang, S. Effects of stunting in early childhood on growth, IQ and cognition at age 11–12 years and the benefits of nutritional supplementation and psychological stimulation. Journal of Pediatrics 2000; 137: 36–41.CrossRefGoogle Scholar
52Fernald, L, Grantham-McGregor, S. Stress response in school age children who have been growth retarded since early childhood. American Journal of Clinical Nutrition 1998; 68: 691–8.CrossRefGoogle ScholarPubMed
53Chang, S, Walker, S, Grantham-McGregor, S, Powell, C. Early stunting and later behaviour and school achievement. Journal of Child Psychology and Psychiatry, and Allied Disciplines 2002; 43: 775–83.Google ScholarPubMed
54Galler, J, Ramsey, F. A follow up study of the influence of early malnutrition on development: behaviour at home and at school. Journal of the American Academy of Child and Adolescent Psychiatry 1989; 28: 254–61.CrossRefGoogle ScholarPubMed
55Barrett, D, Radke-Yarrow, M, Klein, R. Chronic malnutrition and child behaviour. Effects of caloric supplementation on social and emotional functioning at school age. Developmental Psychology 1982; 18: 541–56.CrossRefGoogle Scholar
56Barrett, D, Radke-Yarrow, M, Effects of nutritional supplementation on children's responses to novel, frustrating and competitive situations. American Journal of Clinical Nutrition 1985; 42: 102– 20.Google ScholarPubMed
57Joos, S, Pollitt, E, Mueller, W, Albright, D. The Bacon Chow study: maternal nutritional supplementation and infant behavioural development. Child Development 1983; 54: 669–76.CrossRefGoogle Scholar
58Hsueh, A, Meyer, B. Maternal dietary supplementation and 5 year old Stanford Binet IQ test on the offspring in Taiwan. Federation Proceedings 1981; 40: 897.Google Scholar
59Waber, D, Vuori-Christiansen, L, Ortiz, N, Clement, J, Christiansen, N, Mora, J, Reed, R, Herrera, M. Nutritional supplementation, maternal education, and cognitive development of infants at risk of malnutrition. American Journal of Clinical Nutrition 1981; 34: 807–13.CrossRefGoogle ScholarPubMed
60Pollitt, E, Gorman, K, Engle, P, Martorell, R, Rivera, J. Early supplementary feeding and cognition. Monographs of the Society for Research in Child Development 1993; 58: 235.CrossRefGoogle ScholarPubMed
61Chavez, A, Martinez, C, Soberanes, B, Dominguez, L, Avila, A. Early Nutrition and Physical and Mental Development in Mexican Rural Adolescent Families. Washington, DC: International Center for Research on Women, 1994.Google Scholar
62Super, C, Herrera, M, Mora, J. Cognitive Outcomes of Early Nutritional Intervention in the Bogota Study. Seattle: Abstracts of the meeting of the Society for Research in Child Development, 1991.Google Scholar
63McKay, H, Sinisterra, L, McKay, A, Gomez, H, Lloreda, P. Improving cognitive ability in chronically deprived children. Science 1978; 200: 270–8.CrossRefGoogle ScholarPubMed
64Husaini, M, Karyadi, L, Husaini, Y, Sandjaja, , Karyadi, D, Pollitt, E. Developmental effects of short-term supplementary feeding in nutritionally-at-risk Indonesian infants. American Journal of Clinical Nutrition 1991; 54: 799–804.CrossRefGoogle ScholarPubMed
65Grantham McGregor, S, Powell, C, Walker, S, Himes, J, Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study. Lancet 1991; 338: 1–5.CrossRefGoogle ScholarPubMed
66Pollitt, E, Watkins, W, Husaini, M. Three-month nutritional supplementation in Indonesian infants and toddlers benefits memory function 8 y later. American Journal of Clinical Nutrition 1997; 66: 1357–63.Google ScholarPubMed
67Grantham-McGregor, S, Walker, S, Chang, S, Powell, C. Effects of early childhood supplementation with and without stimulation on later development in stunted Jamaican children. American Journal of Clinical Nutrition 1997; 66: 247–53.CrossRefGoogle ScholarPubMed
68Pollitt, E, Oh, S. Early supplementary feeding, child development and health policy. Food and Nutrition Bulletin 1994; 15: 208–14.CrossRefGoogle Scholar
69Klein, R. Malnutrition and human behaviour: a backward glance at an ongoing longitudinal study. In: Levitsky, D, ed. Malnutrition, Environment and Behaviour. Ithaca: Cornell University Press, 1979, 219–37.Google Scholar
70Grantham-McGregor, S, Walker, S, Chang, S. Nutritional deficiencies and later behavioural development. Proceedings of the Nutrition Society 2000; 59 1–8.CrossRefGoogle ScholarPubMed
71Drewett, R, Wolke, D, Asefa, M, Kaba, M, Tessema, F. Malnutrition and mental development: Is there a sensitive period? A nested case-control study. Journal of Child Psychology and Psychiatry, and Allied Disciplines 2001; 42: 181–7.CrossRefGoogle Scholar
72Grantham-McGregor, S, Powell, C, Walker, S, Chang, S, Fletcher, P. The long term follow-up of severely malnourished children who participated in an intervention programme. Child Development 1994; 65: 428–39.CrossRefGoogle Scholar
73McKay, A, McKay, H. Primary school progress after preschool experience: troublesome issues in the conduct of follow-up research and findings from Cali, Colombia Study. In: King, K, Meyers, R, eds. Preventing School Failure: The Relationship Between Preschool and Primary Education. Ottawa: International Development Research Center, 1983, 32–42.Google Scholar
74Rutishauser, I, Whitehead, R. Energy intake and expenditure in 1–3 year old Ugandan children living in a rural environment. British Journal of Nutrition 1972; 28: 145–52.CrossRefGoogle Scholar
75Torun, B. Energy costs of various physical activities in healthy children. In: Schurch, B, Scrimshaw, N, eds. Activity, Energy Expenditure and Energy Requirements of Infants and Children. Lausanne: IDECG, Nestle, 1990, 139–83.Google Scholar
76Spurr, G, Reina, J. Patterns of daily energy expenditure in normal and marginally undernourished school-aged Columbian children. European Journal of Clinical Nutrition 1988; 42: 819–34.Google Scholar
77Torun, B, Viteri, F. Energy requirements of preschool children and effects of varying energy intakes on protein metabolism. In: Torun, B, Young, V, Rand, W, eds. Food and Nutrition Bulletin. Protein energy requirements of developing countries: evaluation of new data. 1982; 5(suppl.): 229–41.Google Scholar
78Viteri, F, Torun, B. Nutrition, physical activity and growth. In: Ritzen, M, Peria, A, Hall, K, Larsson, A, Zetterberg, A, Zettersrom, R, eds. The Biology of Normal Human Growth. New York: Raven press, 1981; 265–73.Google Scholar
79Jahari, A, Saco-Pollitt, C, Husaini, M, Pollitt, E. Effects of an energy and micronutrient supplement on motor development and motor activity in undernourished children in Indonesia. European Journal of Clinical Nutrition 2000; 54: S60–8.CrossRefGoogle ScholarPubMed
80Levitsky, D. Malnutrition and hunger to learn. In: Levitsky, D, ed. Malnutrition, Environment and Behaviour. Ithaca, NY: Cornell University Press, 1979, 161–79.Google Scholar
81Levitsky, D, Strupp, B. Malnutrition and the brain: changing concepts, changing concerns. Journal of Nutrition 1995; 125: 2245S–54S.CrossRefGoogle ScholarPubMed
82Walker, S, Powell, C, Grantham-McGregor, S, Himes, J, Chang, S. Nutritional supplementation, psychosocial stimulation and growth of stunted children: the Jamaican study. American Journal of Clinical Nutrition 1991; 54: 642–8.CrossRefGoogle ScholarPubMed