The commitment by governments to eradicate hunger and undernutrition is not only an ethical imperative, but also a sound investment that will yield significant economic gains and major social benefits. Investment in nutrition in early life will benefit not only the present generation, but also their children as well as subsequent generations.
Data on the economic costs of undernutrition help to inform the policy decision-making process. It is important to consider the effects of undernutrition in terms of both its impact on short- and long-term outcomes. Early nutrition defines to a great extent how many people will survive infancy and what quality of life they can expect up until death. Undernutrition and infection in childhood are major determinants of a short life expectancy, while physical activity and diet have greater influence on the causes of morbidity and mortality among ageing populations. Among the leading risk factors for morbidity worldwide, high blood pressure is a major contributor to mortality in both developed and developing countries alike, while tobacco use increasingly influences morbidity in developing countries(
. Nutrient deficiences, such as Fe, I, Zn and vitamin A, still have an important effect on mortality and disability-adjusted life years among children aged under 5 years in developing countries(
While significant gains in life expectancy have been observed in many countries over the last 50 years, a loss in life expectancy has been observed in eight countries of sub-Saharan Africa and in North Korea(
. A net gain in healthy life years has been demonstrated from the beginning to the end of the twentieth century among American males by an elevation in the age of onset of some chronic conditions, including heart disease, arthritis, neoplasm and respiratory conditions of 7–10 years(
. Indeed, prevention of morbidity and mortality is demonstrated to have a direct effect on economic growth. In India, half of the recent economic growth may be accounted for by the increasing survival and prevention of disability among the adult population, leading to enhanced productivity in older age. An investment in increasing adult survival rate by 1 % in developing countries is linked to a 0·05 % increase in gross domestic product growth rate, while a similar increase of 1 % in investment:gross domestic product ratio is associated with a 0·014 % increase in growth rate(
It is now recognised that early undernutrition has consequences not only in the short term for morbidity, disability and death, but also in the long term for intellectual ability, economic productivity, reproductive performance, diabetes and CVD ()(
. The link between the timing of investment in human capital and loss of functionality after reaching adulthood has been investigated, showing that the greatest benefit can be achieved from an investment during the initial 1000 days of life (i.e. from the time before conception to the end of the second postnatal year of life) for physical and mental development. What we fail to do in that time period cannot be recovered; for example, iodine deficiency in early life may lead to a loss of 40–50 IQ points in developmental tests, which cannot be improved upon afterwards. Conversely, the present model shows that in fact the greatest investment is made in the last 1000 days of life, and the level of investment here is far greater than that made in the early years of life(
Fig. 1 Maternal and child undernutrition and its short-term and long-term consequences(,5).
Stunting is the most common form of undernutrition. At the present time, stunting affects around 178 million children, mainly in Africa and Asia, and to a lesser extent in Latin America(
. Stunting may be avoided by having an appropriate birth weight and appropriate nutrition over the first years of life; it is almost impossible to reverse stunting after the third year of life. Deviation from the norm in height at the age of 2 years is associated with differences in height at adulthood attained in the analysis of five cohorts from developing countries(
. Not only is linear growth negatively affected in the early years, but also brain and muscle growth become restricted, which is important in terms of labour productivity and work output, IQ, as well as mental development.
Many countries have targeted school feeding programmes based on low body weight rather than weight for height indices. Foods distributed in such programmes are high-energy/high-protein foods but are often not fortified with adequate micronutrients, resulting in very limited gain in weight and no gain in body length. One of the problems in providing food to undernourished children is that while weight and fat gains may be achieved, less progress is made in terms of length for age, suggesting a trend towards making children heavier and possibly promoting obesity(
. A better approach would be to target undernutrition during the prenatal period and early years of life.
The consequences of linear growth retardation are multiple. Growth retardation can lead to a higher risk of death in childhood, lower scores in developmental tests (IQ) and in school performance, with higher rates of drop outs and a decrease in lean body mass, which affects physical work capacity. Higher risks of labour complications in women and retarded fetal growth have also been observed. The latter suggests a transgenerational effect of undernutrition in which the effects are passed from the mother to the next generation. The impact of growth retardation is exemplified by a cohort of pregnant Guatemalan women identified in 1975 whose children had been followed up to the age of 35 years(
. Children who were stunted at 3 years of age ended up being 12 cm shorter than the control group in the same population. Children with severe stunting tended to have 0·6 years less schooling than the control group, so the educational achievement was also less. In adult life, the mean income of this population was 26 000 Quetzales for men and 8000 Quetzales for women, while the severely stunted population had a significantly lower income, at over 3000 Quetzales less among men and 1800 Quetzales less than average among women(
. This finding suggests that we may be spending money at the wrong time and that a greater investment should be made in early life to maximise productivity, health and wellbeing in adulthood.
The Economic Commission for Latin America and the Caribbean has conducted an evaluation of the economic costs of undernutrition, finding that the economic losses for thirteen countries across the region due to undernutrition amount to US$17 billion or 3·4 % of gross national product on average(
. Only 8 % of the losses due to undernutrition can be accounted for by poor health and reduction in school attendance at a young age, while lost productivity throughout adult life due to poor educational performance and poor linear growth accounts for as much as 92 % of the loss.
A high proportion of the NCD burden in China can be traced back to nutrition in early life(
. Stunting was associated with nearly 10 % of cases of CHD, 11 % of strokes and 34 % of type 2 diabetes among the population in 1995. For mortality, in 1995, diet-related NCD were responsible for 2·5 million deaths (or 43 % of all deaths), over 1 million cancer deaths, 1·1 million stroke deaths and 350 000 deaths due to CHD. The economic cost of diet-related NCD in China was estimated at 2·4 % of gross domestic product in 1995.
Prioritising steps to address undernutrition
In the context of limited resources and competing needs, economic impact evaluations contribute to providing valuable information that enables decisions on how to spend effectively and efficaciously, for the greatest benefit relative to money spent. Economic evaluation is a systematic and transparent framework for assessing benefits; it is used to help make decisions and does not make decisions directly. Methodological challenges and uncertainties associated with nutrition interventions to improve health of the next generation, including aspects such as affordability, equity, ethical concerns and political feasibility, need to be addressed. Evaluation of economic impact to prioritise possible steps is both desirable and an inevitable constraint. Economist members of the Copenhagen Consensus panel ranked top priorities for global health measures, taking into account the economic costs and benefits of different measures. In 2004, projects with a good rating for the ability to effect change included two measures to address undernutrition through providing micronutrients and the development of new agricultural technologies, while improving infant and child nutrition and reducing the prevalence of low birth weight were given a fair rating. In the 2008 consensus, steps to address undernutrition were given a higher priority, with five nutritional interventions appearing in the top ten health priorities, including micronutrient supplementation for children (vitamin A and Zn) and micronutrient fortification (Fe and salt iodisation), biofortification of crops, nutrition programmes at school and community-based nutrition promotion.