A Review of The Evidence Linking Child Stunting

International Journal of Epidemiology, 2017, 1171–1191
doi: 10.1093/ije/dyx017
Advance Access Publication Date: 30 March 2017
Original article
Social and Economic Determinants
A review of the evidence linking child stunting

to economic outcomes
Mark E McGovern,1,2 Aditi Krishna,3,4 Victor M Aguayo,5 and
Downloaded from https://academic.oup.com/ije/article/46/4/1171/3095890 by guest on 12 October 2023

SV Subramanian3,4*
1
CHaRMS: Centre for Health Research at the Management School, Queen’s University Belfast, 2UKCRC
Centre of Excellence for Public Health (Northern Ireland), 3Harvard Center for Population and
Development Studies, 4Department of Social and Behavioral Sciences Harvard T.H. Chan School of
Public Health and 5United Nations Children’s Fund (UNICEF), Nutrition Section, Programme Division,
New York
*Corresponding author. Harvard Center for Population and Development Studies, 9 Bow Street, Cambridge 02138, MA,
USA. E-mail: [email protected]
Accepted 17 January 2017
Abstract
Background: To understand the full impact of stunting in childhood it is important to con-
sider the long-run effects of undernutrition on the outcomes of adults who were affected
in early life. Focusing on the costs of stunting provides a means of evaluating the eco-
nomic case for investing in childhood nutrition.
Methods: We review the literature on the association between stunting and undernutri-
tion in childhood and economic outcomes in adulthood. At the national level, we also
evaluate the evidence linking stunting to economic growth. Throughout, we consider
randomized controlled trials (RCTs), quasi-experimental approaches and observational
studies.
Results: Long-run evaluations of two randomized nutrition interventions indicate sub-
stantial returns to the programmes (a 25% and 46% increase in wages for those affected
as children, respectively). Cost-benefit analyses of nutrition interventions using cali-
brated return estimates report a median return of 17.9:1 per child. Assessing the wage
premium associated with adult height, we find that a 1-cm increase in stature is associ-
ated with a 4% increase in wages for men and a 6% increase in wages for women in our
preferred set of studies which attempt to address unobserved confounding and measure-
ment error. In contrast, the evidence on the association between economic growth and
stunting is mixed.
Conclusions: Countries with high rates of stunting, such as those in South Asia and sub-
Saharan Africa, should scale up policies and programmes aiming to reduce child under-
nutrition as cost-beneficial investments that expand the economic opportunities of their
children, better allowing them and their countries to reach their full potential. However,
economic growth as a policy will only be effective at reducing the prevalence of stunting
when increases in national income are directed at improving the diets of children,
C The Author 2017. Published by Oxford University Press on behalf of the International Epidemiological Association
V 1171
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1172 International Journal of Epidemiology, 2017, Vol. 46, No. 4
addressing gender inequalities and strengthening the status of women, improving sani-
tation and reducing poverty and inequities.
Key words: Stunting, productivity, economic growth, early childhood investment
Key Messages
• Undernutrition in childhood, primarily as measured by stunting or height-for-age, is consistently linked to worse eco-
nomic outcomes as an adult

• Although lower than results from the two existing nutrition intervention studies which track affected children across
the life course, quasi-experimental estimates of the impact of height on wages are substantial, the median being 4%

per CM for men and 6% for women
• Cost benefit analyses of childhood nutrition interventions typically find them to be cost beneficial or highly cost beneficial
• At the country-level, there is little evidence that short-run increases in GDP can achieve meaningful reductions stunt-
ing prevalence, if increases in national income are not directed at improving the diets of children, addressing gender
inequalities and strengthening the status of women, improving sanitation and reducing poverty and social inequities
• Few studies examine the impact of undernutrition on economic growth, but spillover effects of health on labor mar-
kets and capital accumulation may be substantial

• Countries facing high stunting prevalence, such as those in South Asia and sub-Saharan Africa, should consider
resources used to improve childhood nutrition as cost-beneficial investments in the wellbeing of their populations
and their economies
Introduction there remain areas where the evidence is sparse. In particu-

There is growing interest in the long-run impact of child- lar, whereas there is an evidence base linking stunting to
hood conditions among both researchers and policy mak- short-run outcomes in childhood such as cognition and edu-
ers, in part because there is mounting evidence that early cational attainment, evidence on the long-run effects is
life environments impact on a variety of later life outcomes, more limited. For example, cost-benefit analyses of nutri-
including health, nutrition, cognition and mortality. In low- tion interventions and reviews of potential wage losses
and middle-income countries, the role of childhood growth associated with early life undernutrition tend to rely on cali-
restriction and stunting has been attracting particular atten- brated estimates of returns to schooling, and the fact that
tion1 which is likely a reflection of the fact that indicators children who are stunted have lower levels of educational
of progress to address child undernutrition were included in attainment, rather than measures of the direct association
the Millennium Development Goals;2 their inclusion in the between stunting and adult outcomes.5
post-2015 Sustainable Development Goals; and the sub- It is important for policy makers to have accurate infor-
optimal progress in many countries at achieving improve- mation on the long-run economic benefits associated with
ments in child nutrition.3 For example in South Asia, rates investments in child nutrition, particularly in contexts in
of childhood stunting remain at 38% despite rapid eco- which government resources are scarce or there is a high
nomic growth in some countries such as India.4 Advocacy opportunity cost of funds due to attractive investment op-
for inclusion of child nutrition targets in the Sustainable tions in other domains such as education and infrastruc-
Development Goals appeals to an emerging understanding ture. If high-quality evidence demonstrates economic
of the consequences of failure to address early life undernu- returns to reducing child stunting, this will make it easier
trition and the consequent impact of restriction of growth to compare returns on investment with these alternatives
and developmental potential on both individuals and soci- on the basis of formal cost-benefit analyses.6
ety as a whole. Incorporating markers of child nutrition The aim of this paper is to address this knowledge gap
into the new round of global development goals could by providing a comprehensive review of the evidence on the
prove beneficial in lowering stunting prevalence, not least long-run economic impact of child undernutrition, mostly
by presenting an opportunity to build commitments to ad- as measured by the direct association between stunting and
dressing this issue as part of a global policy platform.1 later life outcomes. There are other overview papers dealing
However, despite the policy focus on reducing stunting, with child undernutrition, but they either do not focus on
International Journal of Epidemiology, 2017, Vol. 46, No. 4 1173
long-run economic outcomes, or else focus on a subset of welfare, poverty; and the following measures of childhood
the literature. In contrast, we provide a comprehensive re- undernutrition: stunting, child development, growth re-
view of intervention studies that track cohorts of individu- tardation, growth trajectory, linear growth, linear growth
als who received nutritional supplements in early childhood retardation, growth faltering, growth failure, early life
into adulthood, but also cover prospective cohorts where growth failure, child undernutrition, child malnutrition,
we have data on the same individuals across the life course child nutrition. Search terms are shown in Box 1.
(some of whom may have been stunted, but where there Combinations and variations of these keywords were
was no randomized intervention), papers which adopt a also included in the search using the wildcard operator,
quasi-experimental approach relying on natural experi- and we supplemented the search using the references of the
ments (which affected nutritional intake in childhood) and
observational cross-sectional data where we are able to
measure the association between adult height and adult BOX 1. Search criteria

wages. After reviewing the individual-level correlates of Databases searched:
stunting, we also discuss cost-benefit analyses of nutritional
PubMed, Econlit.
interventions and the aggregate relationship between stunt-
ing and economic growth at the country level. This is rele- Key terms:
vant because there may be spillover effects of child (wages, income, salary, pay, earnings, productivity,
undernutrition on economies and society that would not be capital, resources, work, employment, industry, hours
captured by simply adding up individual-level estimates. In worked, occupation, labor, sector, job, socioeconomic,
addition, examining whether economic growth can be ex- savings, economic, returns, make ends meet, welfare,
pected to successfully reduce stunting prevalence can pro- poverty)
vide an indication as to which channels are best targeted to and
achieve childhood nutrition targets.
(stunting, child development, growth retardation,
The goal of reviewing these estimates is to support pol-
growth trajectory, linear growth, linear growth retard-
icy makers in evaluating whether nutrition programmes
ation, growth faltering, growth failure, early life growth
are an efficient use of public funds, and where programmes
failure, child undernutrition, child malnutrition, child
for reducing child stunting rank in terms of return on in-
nutrition).
vestment. We conclude the paper with a discussion on the
implications of our findings for countries facing high
prevalence of child undernutrition.
studies we located, as well as the citations of these studies
obtained from Google Scholar. We identified 29 key sum-
Methods mary papers that provided conceptual or background ma-
We conducted a literature search for studies published up terial related to research on the long-run economic effects
to July 2015 that examined whether childhood stunting or of childhood stunting or undernutrition. We also identified
other measures of undernutrition were associated with eco- 21 prospective studies (some of which were based on simi-
nomic outcomes in later life. We excluded studies that lar underlying data and some of which contained data
examined outcomes in childhood (such as education or test from more than a single country) from 14 cohort studies
scores) or other non-economic outcomes in adulthood and seven intervention studies, along with five natural ex-
(such as health or cognition). We also restricted our atten- periment papers which retrospectively tied individuals to
tion to papers that used measures or proxies of undernutri- periods of adversity argued to be related to undernutrition
tion in childhood as exposures, rather than broad measures in early life. We supplemented these prospective studies
of early life conditions such as socioeconomic status or and review papers with cross-sectional research that exam-
health. We did not include studies that only examined ex- ined the relationship between adult height and adult eco-
posures in utero, as the literature focusing on these areas nomic outcomes. We identified 10 quasi-experimental
has been covered elsewhere.7–11 We conducted our litera- instrumental variables papers in this area in which we were
ture search using the Pubmed and Econlit databases for able to extract a coefficient measuring the association be-
keywords in abstracts and titles related to the following tween a 1-cm change in height and the percentage change
economic outcomes: wages, income, salary, pay, earnings, in wages. A further 17 studies used linear regression to
productivity, capital, resources, work, employment, indus- examine the wage premium related to height but did not
try, hours worked, occupation, labour, sector, job, socioe- attempt to adjust for unobserved confounding or measure-
conomic, savings, economic, returns, make ends meet, ment error. We identified another 30 studies that provided
evidence on the relationship between adult height and measure stunting or height contemporaneously in child-
other adult economic outcomes. hood but track cohort members into adulthood, and evi-
An important methodological issue for this literature is dence from natural experiments, which retrospectively tie
how child undernutrition is measured. The papers we con- individuals to events associated with periods of undernutri-
sider can be roughly divided into three categories. In the tion in early life. Third, we provide a comprehensive as-
first set, undernutrition in early life is measured contem- sessment of the literature from cross-sectional data that
poraneously during childhood, almost always using height- documents the relationship between height in adulthood
for-age, and then, in a subsequent iteration of the study, and wages, comparing estimates from observational and
the adult outcomes of these children are observed. Low quasi-experimental approaches that are designed to correct
height-for-age is generally used to indicate failure to reach for measurement error and potential unobserved con-
growth potential due to inadequate net nutrition, and is founding. Fourth, we discuss how cost-benefit analyses of
often dichotomized into an indicator for stunting (being 2 nutrition interventions have been conducted, and provide

standard deviations or more below the reference height- an overview of these findings. Finally, we consider whether
for-age, typically the World Health Organization growth there is evidence linking the prevalence of stunting to ag-
standard).12 In the second set, we observe the adult out- gregate effects on economic growth, and whether eco-
comes of individuals for whom we do not have a direct nomic growth in turn affects child undernutrition. We
measure of early life undernutrition, but we know that conclude in the discussion section with a summary of the
some of these individuals were exposed to an event such as strength of the evidence linking childhood stunting and
a famine during their childhood. In the third set, we ob- undernutrition to adult economic outcomes, as well as a re-
serve the adult outcomes of individuals and their adult view of the implications of these findings for countries
heights. In order to emphasize the importance of taking with high rates of stunting, particularly those in South
into account how childhood undernutrition was measured, Asia.
in Tables 2, 3 and 4 we note the exposure used in
each study in column 6. In Tables 5 and 6 we note the age
at which the exposure (adult height) was measured in Findings
column 9.
Review papers
Each of these approaches to measuring exposure to
early life undernutrition has its own advantages and disad- Table 1 presents the key background papers that cover
vantages, and we return to a discussion of the measure- topics outlining the rationale for investing in nutrition in
ment issue as part of the Appendix. It is important to note, early childhood,15–25 and details of the long-term follow-up
however, that the underlying assumption behind the ap- of a cohort who received a nutrition intervention in
proach of studying the link between adult height and adult Guatemala, which has featured heavily in the literature.26
outcomes is that height or length in childhood is suffi- These papers also provide a summary of the potential path-
ciently predictive of adult height for the latter to provide ways linking stunting and undernutrition to economic out-
an adequate proxy for childhood undernutrition. This hy- comes, the interaction of nutrition programmes with other
pothesis has been assessed in prospective cohort studies childhood interventions,27 the relationship between nutri-
that follow children from birth into adulthood. In the tion, productivity and economic growth,18,28,29 economic
British 1958 National Child Development Study (NCDS) returns to other interventions targeted at child and maternal
and the 1970 British Cohort Study (BCS), healthier, better- health in low- and middle-income countries,30 global losses
nourished children were substantially more likely to go on associated with malnutrition,31 the use of height as a marker
to reach their height potential.13 Moreover, a recent review for human welfare,32–36 child growth and development,37
of data from five birth cohorts in low- and middle-income trends in the global prevalence of stunting3,38 and the effect-
countries found that the correlation coefficient relating iveness of interventions to reduce child and maternal under-
length at 12 months with adult height ranged from 0.43 to nutrition.30,39–42
0.49.14 The literature thus supports the hypothesis that,
within a given population, growth failure in childhood is
predictive of reduced attained stature in adulthood.
Evidence from intervention studies, prospective
The rest of this paper is structured as follows. First, we cohorts and natural experiments
begin by reviewing existing summary papers. Second, we We were able to locate two long-term follow-ups of inter-
present an overview of estimates of the association be- vention studies conducted in Guatemala and Jamaica. The
tween stunting and subsequent outcomes from long-run former, the Institute of Nutrition of Central America and
follow-ups of intervention studies, prospective studies that Panama (INCAP) study,43,44 allocated nutritional
Table 1. Key summary papers on the economic consequences of childhood stunting and undernutrition
Author Year Focus
Alderman 2010; 2013 Summary of pathways linking stunting to economic outcomes and associated costs of
malnutrition
Alderman et al. 2014; 2015 Integration of nutritional interventions with other childhood programmes, programme de-
sign and estimation of economic returns
Behrman et al. 1993 Evidence on nutrition and productivity
Behrman 2009 Summarizes follow-up study in Guatemala and benefit-cost analyses for early life nutri-
tional interventions
Behrman et al. 2017 Potential health and economic benefits of improving early childhood nutrition, long-term
benefits, and cost-benefit analysis
Bhutta et al. 2008; 2013 Interventions to address undernutrition and micronutrient deficiencies in women and

children
Dewey and Begum 2011 Overview of the long-run impact of stunting
Fogl 1994 The role of physiology in economic growth
Halim et al. 2015 Economic impacts of 23 reproductive, maternal, newborn and child health (RMNCH)
interventions, published in 29 empirical studies
Hoddinott et al. 2013 Functional consequences of stunting, summarizes literature around each of the links in the
life cycle, and estimates benefit-cost ratios for a plausible set of nutritional interventions
to reduce stunting
Horton and Steckel 2011 Estimates of the economic losses from malnutrition worldwide
Hübler 2016 Summarizes relationship between height and wages from an economic perspective, with
summary of recent evidence
Martorell 2005 Overview of design and findings from the Guatemala Institute of Nutrition of Central
America and Panama (INCAP) Study
Norgan 2000 Physiological perspective on the long-term economic consequences of growth retardation
in children and adolescents
Schultz 2003 Summarizes key methodological challenges associated with estimating returns to height
and human capital from an economic perspective
Steckel 1995; 2009; 2013 Overview of literature which uses height as a measure of human welfare
Strauss and Thomas 1998 Discusses our understanding of the interrelationships between health, nutrition and eco-
nomic development
Sudfeld et al. 2015 Association of child growth with child development
Stevens et al. 2012 Summary of global prevalence and trends in child stunting
UNICEF 2013 Reviews background studies, current prevalence of malnutrition across various indicators,
case studies in improving nutrition, and global initiatives
Victora et al. 2008 Associations between maternal and child undernutrition with human capital and adult
health in low-income and middle-income countries
World Bank 2006; 2007; 2010 Reviews the effectiveness of nutrition interventions and rationale for investment in early
child development
supplements to pregnant women and infants in two found that a 1 standard deviation increase in height-for-
Guatemalan villages in the late 1960s and 1970s. Two age was associated with a 21% increase in household per
nearby control villages did not receive the supplements. A capita expenditure and a 10% point decrease in the prob-
number of studies that follow the children included in the ability of reporting living in poverty at ages 25–42.49 A se-
INCAP intervention into adulthood find effects of receiv- cond intervention study was conducted in Jamaica in the
ing the nutritional supplements on economic outcomes, mid 1980s.50 A group of undernourished children were
including productive capacity, wages, expenditure and the randomly allocated to groups that included a nutrition sup-
probability of living in poverty.45–48 Studies that use inten- plementation intervention, psychosocial stimulation, com-
tion to treat analysis (ITT) find that men who received the bined nutrition and stimulation, and a control group.
supplements as children had, on average, a 46% increase These children were subsequently followed up with in
in wages.43 The association was not found to be statistic- 2007–08 at age 22. Those who received the stimulation
ally significant for women. An instrumental variables ana- and combined intervention were found to have increased
lysis using variation in height-for-age Z score at age 2 earnings by 25% relative to the control group. The associa-
years predicted by receipt of the nutritional supplement, tion between the nutritional supplement alone and wages
was not statistically significant. These two studies, papers
follow-up was significantly greater in subjects

from treated villages of both sexes (þ0.038)
Maximum oxygen consumption (VO2max) at
increased household per capita expenditure

from which are shown in Table 2, are the only two long-
(21%) and a lower probability of living in

1-SD increase in HAZ was associated with
term follow-ups to nutrition interventions that we are
Intervention increased earnings by 25%
46% increase in average wages for men

aware of.
We located five natural experiment papers which exam-
poverty (10 percentage points)

ined the long-run economic outcomes of cohorts exposed
to conditions in infancy that were likely to have resulted in
undernutrition for those affected. The benefit of this nat-
ural experiment approach is that the events of interest can
often reasonably be considered as unexpected shocks
which affect nutritional status in a way that is unrelated to
unobserved characteristics of these individuals, thereby
Result

reducing concerns about unobserved confounding. Three
of these events are the famine in China in 1959–61,51 the
war-related famine in Greece (1941–42) and the war-
Height-for-age Z (HAZ) score at
periment during gestation and
periment during gestation and

Nutritional supplementation ex-
Nutritional supplementation ex-
related food crisis in Germany (1944–48).52,53 Although

Psychosocial stimulation to
growth-stunted toddlers
the Dutch ‘Hunger Winter’ of 1944–45 also features in this

literature, we are not aware of any study that examines the
the preschool years
the preschool years
economic outcomes of survivors.54 An additional paper

considers exposure to rainfall in Indonesia in early life,
age 2 years
which is positively associated with higher crop yields, stat-

Exposure
ure, and thus likely better nutritional status, and found

Table 2. Intervention studies on the economic consequences of childhood stunting and undernutrition
that exposure was significantly associated with higher

scores on asset indices (a proxy for household wealth) for
1986–87
1969–77
1969–77
1969–77
women, but was not statistically significant for men.55

Year
Survivors of the Chinese famine in 1959–61 were found to

have lower labour supply and reductions in some measures
Cluster, randomized, inten-
Cluster, randomized, inten-
of income compared with surrounding cohorts who were

Randomized, intention to
Cluster, randomized, in-

strumental variables/
treatment on treated
not in infancy during the famine. Those in infancy during

the Greek famine of 1941–42 were found to have lower oc-
cupational status when followed up on using national cen-
tion to treat
tion to treat
sus data. In contrast, there was no evidence of adverse

economic effects of exposure to the German food crisis in
treat
Design
childhood, although this study found that those exposed in

utero were adversely affected. Kesternich et al. (2014) find
Institute of Nutrition
that having lived in a European country affected by conflict

of Central America
during World War II was associated with lower wealth in

Jamaican Study
and Panama
later life for those among the bottom two socioeconomic

status (SES) tertiles in childhood, with poor nutrition being
INCAP:
INCAP
INCAP
one potential channel for this result.56 A final study exam-

Data
ined the relationship between height and adult outcomes

using an approach based on sibling comparisons in
Guatemala
Guatemala
Guatemala
Location
Sweden, which has the benefit of allowing all observed and

Jamaica
unobserved factors constant within families to be con-

trolled for.57 This study found large returns to height in
the form of increases in wages and occupational status.58
Hodonnitt et al. 2008;
Martorell et al. 2010
Hodonnitt et al. 2005;
Hoddinott et al. 2013
Results from these studies are shown in Table 3.

Haas et al. 1995
Gertler et al. 2014
Alderman et al. (2006) use an instrumental variables ap-

Haas et al. 1996;
proach and report that drought exposure in childhood in

Zimbabwe led to height-for-age Z score 1.25 standard
Authors
deviations (SD) lower, which was estimated to be associ-

ated with a 14% reduction in lifetime earnings; however,
this figure is calculated from calibrated effects of schooling
International Socio-Economic Index of Occupational Status

Labour supply reduced by 1.7–2.1% per 0.1% excess death
Associations with income, occupational status and employ-
0.42% increase in earnings per cm increase in occupational
rainfall) in their year and location of birth live in house-

Women with 20% higher rainfall (relative to normal local
rate increase; for the 1959 cohort, the annual per capita
(ISEI), coefficient ranged between 0.296 and 1.111
holds that score 0.12 standard deviations higher on an

asset index. No statistically significant relationship for
on earnings, rather than a direct association observed in
ment status for the cohort in utero only, not for those
the data, and is therefore not included in Table 3.59
agrarian income decreased by approximately 2%

Alderman et al. (2006) conduct a similar analysis for
Tanzania.60
Evidence from prospective studies

Next we present evidence from prospective studies, which
have the benefit of measuring stunting or undernutrition in
exposed in childhood
early life rather than relying on adult height, but do not

generally deal with measurement error or unobserved con-

founding. Most of these studies use measures of childhood
height collected as part of established cohort studies in the
status
UK, Brazil and the Philippines.61–64 One study that does
men
Result
included a matched control group has followed a cohort of

children who were hospitalized for protein-energy malnu-
Rainfall exposure in
Famine exposure in
Famine exposure in
Famine exposure in
trition during the first year of life (matched to a cohort

early childhood
Swedish males en- Height at age 18
who did not experience the same) in Barbados in 1967–

early life
early life
early life
72.65 Those who experienced the undernutrition episode

Exposure
years
were found to be lower on social position and standard of

living indices in adulthood. An early study in India found
Table 3. Natural experiments on the economic consequences of childhood stunting and undernutrition
that height for age at age 5 years was associated with lower
military between
1984 and 1997
work capacity in the teenage years (14–17).66,67 In the

listing for the
Philippines, length-for-age Z score at age 2 years was

Retrospective matching of 1959–61
found to be associated with an increase in the probability

of being engaged in formal work at age 20–22 for both
Year
men and women.68 Research from US and UK cohort stud-

ies have found that height at various stages in childhood
Prospective, sibling fixed
and the teenage years is positively related to work status,

wages and measures of socioeconomic status in later
cohort to event
cohort to event
cohort to event
cohort to event
life.69–73 In a cohort of men born in Helsinki, Finland, be-

tween 1934 and 1944, length in the first year of life was
effects
Design
associated with subsequent earnings.74 A review of three

cohort studies in low- and middle-income countries found
that height-for-age Z score at age 2 was associated with an
Nutrition Survey: CHNS
8% increase in income in Brazil and Guatemala (although

the latter was only significant at the 10% level), and a
Life Survey: IFLS
China Health and
Indonesia Indonesia Family
21% increase in household assets in India.23 These data

Military records
Germany Census: IPUMS
10% sample
GEIS Census
are shown in Table 4. Further notes to the studies outlined

in Tables 2, 3 and 4 are presented in Table A1 in the
Location Data
Appendix (available as Supplementary data at IJE online).

Lundborg et al. 2014 Sweden
Greece
Evidence from cross-sectional studies of adult

Chen and Zhou 2007 China
height and adult income

A difficulty with interpreting the results in the previous sec-
Stratmann 2011
tion is that it is problematic to compare the magnitude of

Yang 2009
coefficients across studies because of differences in expos-

Maccini and
Neelsen and
Jürges 2013
ure and outcome measures. In addition, there are relatively

Authors
few prospective studies that include measures of childhood

stunting or undernutrition alongside adult economic
1178
Table 4. Prospective studies on the economic consequences of childhood stunting and undernutrition
Authors Location Data Design Year Exposure Result
Galler et al. 2004 Barbados Prospective, 1967–72 Hospitalized for protein-energy Hollingshead social position index (0.62) and
matched malnutrition (PEM) during PCA standard of living index (þ0.70)
the first year of life
Satyanarayana et al. India Prospective 1960–63 Nutritional status age 5 (height Childhood malnutrition was associated with
1978; Satyanarayana for age) physical work capacity
et al. 1979
Carba et al. 2009 Philippines Cebu Longitudinal Health Prospective 1983–85 Length-for-age Z-score 40% increase in likelihood of formal work com-
and Nutrition Survey pared with not working for men, 0.2 higher
likelihood of formal vs informal work for
females
Barker et al. 2005 Finland Cohort of men born in Prospective Cohort born 1934–44 Height at any age between Each 2-cm increase in length between birth and
Helsinki birth and 12 years 1 year was associated with a 3.5% increase in
income
Case et al. 2005 England National Child Development Prospective Cohort born 1958 Height at age 16 years Increase in employment at age 33 but not at 46,
Study: NCDS increase in SES at ages 33 and 46
Case and Paxson 2008 England NCDS Prospective Cohort born 1958 Height at ages 7, 11 and 16 Height associated with income
years
Montgomery et al. 1996 England NCDS Prospective Cohort Born 1958 Height at age 16 years Odds ratio of 2.41 for being employed (bottom
vs top height quintile)
Persico et al. 2004 England NCDS Prospective Cohort born 1958 0.88% increase in wages per unit, White male
workers only
Persico et al. 2004 USA National Longitudinal Survey Prospective Men and women aged Height aged 16–23 years 0.72% increase in wages per unit, White male
of Youth: NLSY 1979 14–21 in 1979 workers only
Sargent and England NCDS Prospective Cohort born 1958 Height at ages 11, 16, 23 years 0.2% increase in wages for men per cm increase
Blanchflower 1994 in height after age 16, 0.1% for women
Victora et al. 2008 Brazil Pelotas birth cohort study Prospective Cohort born 1982 Height-for-age score age 2 8% increase in annual income for per SD
years increase
Victora et al. 2008 Guatemala INCAP Prospective 1969–77 Height-for-age score age 2 Marginally significant (P < 0.1) 8% increase in
years annual income per SD increase
Victora et al. 2008 India Cohort born in New Deli Prospective 1969–72 Height-for-age score age 2 27% increase in number of household assets
years
International Journal of Epidemiology, 2017, Vol. 46, No. 4

Table 5. Quasi-experimental estimates of the association between adult height and wages
Authors Location Data Design Year All Men Women Age N Notes
(Association) (Association) (Association) exposure
(height) and
outcome
(wages)
measured
Böckerman and Finland Older Finnish Twin Twin FE IV 1990–2004 NS 12% Varied 1284 Average yearly earnings over the period;
Vainiom€aki 2013 Cohort Study male estimate is similar but not statis-
tically significant
Elu and Price 2013a China CHNS IV 2006 10.30% 5% 7% Varied 1949 Monthly earnings
Elu and Price 2013b Tanzania Tanzanian Household IV 2004 6% 4% Unknown 427 Hourly earnings, height in inches, coeffi-
Worker Survey cients are scaled by 0.4, not clear if age
is controlled for
Gao and Smyth 2010 China China Urban Labour IV 2005 4.80% 10.80% Unknown 11512 Hourly wage; not clear if age is controlled
Survey for
Heineck 2005 Germany German Socio- IV 2003 NS NS Varied 24000 East Germany; gross monthly earnings;
Economic Hausman-Taylor IV
Panel:GSOEP
Heineck 2005 Germany GSOEP IV 2003 0.50% NS Varied 24000 West Germany; gross monthly earnings
Hoddinott et al. 2008 Guatemala INCAP Intervention 2002–04 15.80% NS 25–42 1424 Semi-elasticity estimate is taken from
Horton and Steckel (2011)
Schultz 2002 Brazil
Health and Nutrition IV 1989 8–10% 8–10% 25–54 11855
Survey
Schultz 2002 USA NLSY79 IV 1989–93 1–4% 3–6% 20–28 9257
Schultz 2003 Ivory Coast Living Standards IV 1985–89 NS NS Varied 12221 Hourly wage
Measurement
Surveys: LSMS
Schultz 2002; Schultz 2003 Ghana LSMS IV 1985–90 5.60% 7.60% Varied 10888 Hourly wage
Thomas and Strauss 1997 Brazil Estudo Nacional da IV 1974–75 1.43% Mean ¼ 36 10675 Hourly wage; men in labour market only;
Despesa Familiar: regression included log height, semi-
ENDEF elasticity is for a 1-cm increase at mean
height
Yimer and Fantaw 2011 Ethiopia Ethiopian Urban IV 2001 2% Varied 820 Gross hourly wage; implementation of IV
Household Survey: is not clearly defined
EUHS
NS, not statistically significant.

1179

outcomes. An alternative approach to assessing the long- median return for men (based on 20 OLS studies) is 1%,
run economic impacts of stunting, which has less data re- and also 1% for women (based on 14 studies). For women,
quirements, is to examine the relationship between adult estimates in China, Germany and Australia are found to be
height and adult outcomes. The benefits of this approach not statistically significant.
are that data on adult height are much more widely avail- For studies that report both IV and linear regression es-
able, and it can be implemented with cross-sectional data. timates, Figure 1 demonstrates the difference between the
It is also much easier to compare results from this litera- coefficient estimates for these two approaches for men and
ture, as there are relatively more studies that examine adult women. Overall, estimates of the median return to height
wages or income as the outcome, and a continuous meas- are substantially higher for IV models, particularly for
ure of stature as the exposure. As we discuss above, the women (a 5 percentage point point difference). Further dis-
wage premium for taller individuals is often used to quan- cussion of these papers is given in the Appendix. A sum-
tify the economic impact of childhood growth restriction mary of findings from papers which examine economic

because of the association between childhood undernutri- outcomes other than wages is also presented in the appen-
tion and adult height.14 dix (available as Supplementary data at IJE online).
Nevertheless, because adult height is an imperfect proxy
for our exposure of interest, we therefore separately con-
sider the set of studies that adopt a quasi-experimental in- Cost-benefit analysis of childhood nutrition
strumental variables (IV) approach to correct for potential interventions
measurement error. Instrumental variables used in this ap- A number of papers conduct cost-benefit analyses of an
proach typically include characteristics of respondents’ intervention or package of interventions targeted at reduc-
place and time of birth,75 as well as procedures designed to ing childhood stunting or undernutrition, which requires
correct for measurement error based on observed charac- costing the economic impact. The approach typically
teristics only,76 and finally, twin differences in height and adopted in these studies can be summarized as follows.
body mass kndex (BMI).77 We provide a methodological First, the treatment effect of the programme in terms of the
discussion of the different approaches in the Appendix expected reduction in the exposure (for example, the prob-
(available as Supplementary data at IJE online). These IV ability of being stunted) is calculated. Then, the treatment
results are presented in Table 5, where we report estimates effect is multiplied by the number of affected children to
of the expected change in wages (measured in percent) obtain an estimate of the reduction in stunting prevalence
associated with a 1-cm change in adult height (known in induced by the treatment. The economic benefits of this re-
the economics literature as the semi-elasticity). duction are then usually calculated by calibrating the re-
For men, coefficient estimates range from 1% to turns to height using the existing literature. For example, if
þ10%, with no statistically significant association found the intervention increased average height by 1 cm among
in Finland, East Germany and Ivory Coast.75–85 For 100 children, and the estimated return to height is calcu-
women, coefficient estimates range from 4% in Tanzania lated at 3%, the programme is valued at 1*100*3%*aver-
and Ivory Coast to þ12% in Finland, with non-significant age wages, potentially with some correction for
estimates observed in Germany and Ivory Coast. The discounting and estimates of labour supply across the life
Tanzanian and Ivory Coast estimates for women are not- course. Additional benefits can be included, for example
able outliers as they are negative. One study gave results the return to improvements in test scores,5 or reductions in
for a combined sample (a 2% return in Ethiopia). Mean direct costs such as lower treatment costs for illness associ-
rates of return associated with an additional centimetre of ated with improvements in health status. Some studies also
height are 5% for men in 12 studies and 6% for women in include the value of lives saved as a result of these
11 studies. Assuming non-significant estimates are equal to interventions.
zero lowers the mean return to 3% for men but does not Using this approach, a micronutrient supplementation
affect the estimate for women. Median rates of return to a and early childhood stimulation programme in Nicaragua
centimetre of height are 4% for men and 6% for women. was found to have a cost-benefit ratio of 1.5. Benefits for
Corresponding linear regression estimates from studies programme participants were calibrated using estimates
that only implement ordinary least squares (OLS) models from the literature on the returns to test scores which were
are presented in Table 6.13,58,70,72,73,79,82,86–97 Using this estimated to be affected by the programme.98 In an ana-
approach, coefficient estimates are almost all less than a lysis of a stunting intervention in Indonesia, the pro-
percentage point. Exceptions are men in one study in gramme was found to have a cost-benefit ratio of 2.08 on
China (3%), men and women in Indonesia (8% and 13%, the basis of productivity enhancements from reduced
respectively) and men in Mexico (2%). Here the mean and undernutrition, earnings from deaths averted, and
Table 6. Linear regression estimates of the association between adult height and wages
Authors Location Data Design Year All Men Women Age N Notes
(height) and
outcome
(wages)
measured
Bockerman et al. 2010 Finland Health 2000 in Finland OLS 2000–01 0.67% 0.40% Mean ¼ 44 2506 Hourly earnings, which the authors calculate
as annual wage divided first by 52, and
then by the individual’s self-reported num-
ber of weekly working hours.
Case and Paxson 2008; England NCDS OLS 1991 0.65% 0.43% 33 5833 Average hourly earnings; height was meas-
Case and Paxson 2010 ured in inches, coefficient is scaled by 0.4
Case and Paxson 2008; England NCDS OLS 2000 0.63% 0.50% 42 5833 Average hourly earnings; height was meas-
Case and Paxson 2010 ured in inches, coefficient is scaled by 0.4
Case and Paxson 2010 England British Cohort Study: BCS OLS 2000 0.30% 0.28% 30 5424 Average hourly earnings; height was meas-
ured in inches, coefficient is scaled by 0.4
Case and Paxson 2010 USA Panel Study of Income OLS 1988–97 0.38% 0.18% 25–55 31996 Average hourly earnings; height was meas-
Dynamics: PSID ured in inches, coefficient is scaled by 0.4

Case and Paxson 2010 USA Health and Retirement OLS 1992–2004 0.70% 0.68% 55–74 27606 Average hourly earnings; height was meas-
Study: HRS ured in inches, coefficient is scaled by 0.4
Case et al. 2009 England British Household Panel OLS 1997–2005 0.40% 0.20% 21–60 42666 Average hourly earnings; height was meas-
Survey: BHPS ured in inches, coefficient is scaled by 0.4
Haddad and Bouis 1991 Philippines OLS 1984–85 0.7% – Varied 390 Real daily wage, rural agricultural work;
0.8% Hausman-Taylor IV applied to variables
other than height
Heineck 2008 England BHPS OLS 2004 0.60% 1.40% 21–50 4650 Results without education
Hübler 2009 Germany GSOEP OLS 1985–2004 0.25% NS 22–55 36754 Association was found to be non-linear
Kortt and Leight 2010 Australia Household, Income and OLS 2006–07 0.22% 0.28% NS 25–54 6822 Hourly wages
Labour Dynamics in
Australia: HILDA
Lindqvist 2012 Sweden Longitudinal INdividual OLS 2006 0.33% Varied 13414 Annual wages; men born between 1965 and
DAta for Sweden: 1974
LINDA
Lundborg et al. 2014 Sweden Swedish males enlisting Sibling FE 2003 0.42% 28–32 450000 Annual earnings; height measured at 18
for the military between years; height associations are non-linear
1984 and 1997
Persico et al. 2004 USA NLSY79 OLS 1996 0.70% 35 1577 Annual income; height was measured in
inches, coefficient is scaled by 0.4
Persico et al. 2004 England NCDS OLS 1991 0.88% 33 1772 Income period varies; height was measured in
inches, coefficient is scaled by 0.4
1181
(continued)

household savings from diarrhoea costs avoided.6 In a re-
Women only; adjusted for selection into the

view of cost-benefit ratios of nutrition interventions, esti-
mates ranged from 3.5:1 to 42.7:1 per child, with a median
of 17.9:1.22,99
12537 Height at age 16; hourly earnings

A similar methodology has been used to estimate the ag-
Men only; hourly earnings

gregate burden of stunting worldwide. Instead of consider-
full time labour market

ing a particular intervention, these studies calculate the
cost savings associated with reducing stunting prevalence
Annual earnings
92248 Hourly earnings
to zero in a country. Then, wage returns for each stunted

child, under the hypothetical scenario that every currently
stunted child was no longer stunted, are aggregated. An
Notes
early example of a study which attempts to quantify the

national costs associated with stunting is that of Ross et al.
1179
9306
2510
3860
N
(2003), who examine the impact of undernutrition on eco-

nomic productivity in China.100 Using estimates of the im-
(height) and
measured
pact of stunting on productivity from the literature, they

outcome
(wages)
Varied
Varied
20–65
25–65
conclude that productivity gains due to reductions in child
45þ
Age
23
stunting over the period 1991 to 2001 were worth US$12

billion (Yuan 101 billion) in 2001. Conducting a similar
analysis, Alcazar et al. (2012) found that productivity-
Women
0.30%
0.10%
13%
related costs of stunting in Peru were also large [2.2% of

NS
gross domestic product (GDP)].101 Bagriansky et al. (2014)

estimated the impact of undernutrition at more than
0.50%
0.20%
2.60%
7.50%
0.14%
2.30%
US$400 million annually in Cambodia, or approximately

Men
2.5% of yearly GDP, of which 57% is a result of children

being affected.102
A similar approach involves aggregating the costs accru-
0.40%
ing to the population in a country as a whole. For example,

All
add up the direct costs for affected individuals in a country,

2002, 2005
potentially using different methodologies as a sensitivity

2002–12
analysis, then divide by the total population in that country

1981
2012
2015
2006
Year
to obtain an estimate of per capita costs, which could be

Heckman
expressed as a percentage of GDP. Horton and Ross

Design
(2003) estimate the productivity costs of anaemia at

OLS,
OLS
OLS
OLS
OLS
OLS
0.57% of GDP in 10 countries,103 and Horton and Steckel

China Longitudinal Study
(2011) calculate the global economic losses associated with

Education Database:
malnutrition by aggregating losses for individual coun-

of Aging: CHARLS
Mexican Family Life
tries.31 Assuming that the impact of height on productivity

Taiwan Integrated
Survey: MxFLS
Postsecondary
is captured by the association of height with wages (earn-

ings), and that this translates into economic growth via the
TIPED
Germany GSOEP
share of wages in national income (approximately 50%),

England NCDS
Location Data
Indonesia IFLS
they consider the differential return to height at different

levels of mean height based on linear regression and esti-
Taiwan
Mexico
mates from the literature. At the country level, they obtain

China
NS, not statistically significant.
estimates of the wage return to 1 cm increase in height of

4.5% at 170 cm, 4% at 171 cm, 3.5% at 172 cm and 0.5%
Blanchflower 1994
Table 6. Continued
at 178 cm. Aggregating wage impacts, these assumed prod-

Rietveld et al. 2015
Smith et al. 2012
uctivity losses are combined with data on average height to

give estimated costs as a percentage of national income in
Sargent and
Sohn 2014
Vogl 2014
Tao 2014
each country. Results imply that the annual GDP loss due
Authors
to undernutrition is up to 12% in low- and middle-income

countries. Globally, these losses are estimated to have
10
Median Return to 1 CM Increase in Height
2 4 0 6 8

Men IV Men OLS Women IV Women OLS
Figure 1. Comparison of median estimates of the wage return to a 1-cm

increase in height from instrumental variables (IV) and linear regression
(OLS). Error bars show the interquartile range.
fallen from 12% of world GDP in 1900 to 6% in 2000.

The corresponding projections for 2050 imply that losses
will be of the order of 6%. Based on a model originally de-
veloped for Latin America,104 the Cost of Hunger in Africa
(COHA) study [http://www.costofhungerafrica.com] aims Figure 2. Summary of the pathways linking stunting to economic
to provide economic estimates of the costs of hunger in 13 growth.
countries. A recent report on Malawi from this study Adapted from Bloom et al. (2014).106
group indicates that the costs associated with stunting

spillover effects of stunting on economic growth. The po-
were of the order of 10% of GDP per year.105
Overall, there is therefore a multitude of evidence that tential for these effects can be informed by considering the
nutrition interventions are highly cost effective, and that standard approach in macroeconomic growth models
the economic burden of undernutrition on society as a where national income is defined as a function of labour,
whole is likely to be large; however, these studies crucially capital and the efficiency with which labour and capital in-
rely on estimates of the economic return to factors such as puts are combined (or technological progress).108 From this
adult height or reductions in child stunting. In practice, perspective, the pathways through which undernutrition
there does not seem to be a consensus in the literature as to could affect aggregate economic growth include increases
what return to height should be used. In addition, studies in morbidity, mortality and health expenditure and subse-
that aggregate from individual losses may be underesti- quent reductions in human capital investment (for example,
mates of the total economic impact because they do not education), physical capital investment and labour supply.
account for spillover effects on economic growth.106 Reductions in productivity because of ill health or work
capacity for any given labour supply, and reductions in
human capital and technological progress (due to lower lev-
The impact of stunting on economic growth els of educational attainment and infrastructure) are likely
Results in the previous section reflect the potential impact to negatively impact not only on individuals themselves,
of individual undernutrition on individual economic out- but also on economic growth when a substantial proportion
comes. The pathways linking stunting to individual income of a country’s population are affected by stunting. Other
have been discussed previously.15–17,22,35 However, relevant pathways include the impact of undernutrition on
individual-level estimates do not take account of effects on chronic disease, which would involve the diversion of pro-
aggregate capital formation, labour markets, savings behav- ductive savings (which boost investment) towards treat-
iour, investment behaviour and other factors which make ment costs.106 These pathways are summarized in Figure 2.
up the determinants of aggregate output. Estimating the full There is a literature in economics which examines
costs of undernutrition to society requires accounting for whether there is an effect of health on economic growth.
all of these potential effects. However, whereas height and However, there are relatively few studies that consider
wages tend to be correlated at the aggregate level,107 in the undernutrition specifically (either childhood undernutrition
literature there has been surprisingly little attention paid to or adult undernutrition) as an input in these production
function models of the aggregate economy. Some recent ex- relative terms (the association in percent). Once estimates
ceptions are Chakraborty et al. (2010), Dalgaard and are rescaled, the magnitudes of the reported coefficients
Strulik (2015) and Piper (2014).109–111 Estimating this rela- appear similar.119 Across six studies, the impact of a 10%
tionship in practice with currently available data is problem- increase in GDP per capita was found to be in the range of
atic because it is difficult to assess whether the causal a 0-2% reduction in stunting.119–125 For example,
pathway runs from nutrition to economic growth, or from Harttgan et al. (2013) find that although levels of GDP per
economic growth to nutrition. Most likely the relationship capita have increased substantially in many low- and
is bidirectional, but this makes it difficult to interpret par- middle-income countries over recent decades, levels of
ameter estimates from models that do not account for this stunting and undernutrition showed very little improve-
reverse causality, because estimates of the impact on growth ment.124 In this study, a 10% increase in GDP per capita
likely also incorporate some of the effect in the opposite dir- was associated with a 1.5–1.7% reduction in stunting,
ection, and vice versa. Recent summaries of the general lit- which is similar to estimates of approximately 2% ob-

erature on health at the macro and micro levels are tained in Heltberg (2009).122 Ruel et al. (2013) reported
provided elsewhere.112–114 There is a small number of stud- that a 10% increase in GDP per capita was associated with
ies that examine the relationship between adult stature spe- a reduction in stunting prevalence of around 6 percentage
cifically and economic growth. Weil (2007) incorporates points.123 However, their study focused on the long-run
height alongside other health measures into an augmented impacts, as opposed to the other papers which considered
production function, and finds that health differences more short-term associations with GDP.
worldwide account for a relatively small proportion of dif- There are a number of additional studies, most of which
ferences in GDP (around 10% of the variance in log GDP report similar results to the above. Smith and Haddad
per worker).115 Adopting an empirical approach with a co- (2015) estimate that a 10% increase in GDP per capita is
integrating model to account for reverse causality, Arora associated with a 1.7% reduction in stunting.1 Their esti-
examines whether changes in health, including adult stature, mates of the long-run impact of GDP per capita are larger,
contributed to growth among a group of 10 industrialized at around 6%, and comparable to their earlier estimates in
countries over the course of the past century, and finds that Smith and Haddad (2002) and Haddad et al. (2003),126,127
health contributed between 30% and 40% to the economic where increases in national income over the 25-year period
growth rates over this period.116 Also in a co-integration from 1970 to 1995 were found to have led to roughly half
analysis, Marıa-Dolores and Martınez-Carri on find a bidir- of the total reduction in the developing-country prevalence
ectional relationship between height and economic growth of child undernutrition over the period. In contrast, a re-
among Spanish regions in the period 1850–1958.117 The cent analysis which adopted a multilevel approach in
evidence demonstrates a strong association between eco- Indian states, found that economic growth was not associ-
nomic growth and health, but because of the difficulties ated with reductions in stunting or other measures of
associated with testing theoretical models of how economic undernutrition.128 As far as we are aware, only one paper
growth is produced, it is currently difficult to quantify the has examined whether the timing of economic growth is
magnitude of these effects. However, one recent example of important for height, and found that economic growth in
a paper uses an instrumental variables approach in an effort puberty and in the first year of life were most associated
to overcome the problems associated with reverse causality, with the adult height of women in sub-Saharan Africa.129
and finds that each centimeter increase in average popula- Although the magnitude of the relationship between
tion height is expected to raise income per capita by 6%.118 GDP per capita and stunting continues to be
This estimate would imply that the magnitude of the return debated,130,131 there appears to be some agreement that
to increases in height at the national level is substantial. economic growth alone is unlikely to be able to achieve
substantial reductions in the prevalence of stunting, and
that any effects are too small to rely on national income
The impact of economic growth on stunting alone for achieving large reductions in child undernutri-
Some papers in the literature have found that economic tion, at least in the short run.1 The fact that some coun-
growth is associated with a reduction in the prevalence of tries, such as Sri Lanka, or regions within countries, such
child stunting, but the magnitude of the relationship has as Kerala in India, have lower prevalence of stunting than
generally been found to be small. Interpretation of esti- their incomes would suggest places emphasis on other fac-
mates can be complicated by the fact that some studies re- tors such as the local policy environment and the role of
port the impact of GDP per capita on stunting prevalence public health nutrition programmes. A recent paper sug-
in absolute terms (the association in percentage points), gests that differences in stunting prevalence across Indian
whereas others report the impact on stunting prevalence in states is less due to differences in inputs and more likely
due to differences in the predictive power of these inputs that outcome measures are different (for example, hourly
for undernutrition.132 Moreover, a series of countries have wages versus income), different methodologies are em-
been able to achieve rapid improvements in child nutri- ployed and different control variables are used across the
tional status.121 Recent reports from the United Nations studies. Age and period effects are also likely to be import-
Children’s Fund (UNICEF) and the International Food ant but are not always accounted for. A methodological
Policy Research Institute contain a series of case studies on drawback of almost all the studies we reviewed is that very
successful reductions in stunting prevalence in the best per- few adjust for the decision on whether to participate in the
forming countries.38,133,134 labour market, and only consider the earnings of those
Therefore, it seems that other more direct interventions who are employed. It could be that those who are not cur-
will be required to achieve global targets for reductions in rently employed would have lower earnings if they entered
stunting and undernutrition among children. The literature the labour market, and those outside the labour market
has begun to emphasize that the quality of economic may also be the most likely to be of lower height. An ex-

growth is likely to be important for how income gains ception is a study of female graduates in Taiwan.84 From
translate into reductions in child undernutrition.135 The that perspective, the results presented here may be under-
impact of intermediary factors on stunting, such as sanita- estimates. The studies we report on also use a variety of
tion, governance, the roll-out of nutrition programmes, different exposures to measure the impact of child under-
growth in food production and infrastructure, access to nutrition, and it is important to bear in mind that the re-
health services and infrastructure, governance, education sults are therefore not always directly comparable.
and fertility have all been investigated previ- Intervention and prospective analyses tend to rely on meas-
ously.1,121,125,136,137 Focusing on promoting economic uring childhood undernutrition using height-for-age,
growth that raises the income of the least well off, and im- which is understandable given that this approach provides
proves the quality and equity of these intermediary inputs, objectively measured information which is feasible to col-
is thus likely to be the most effective way of ensuring that lect in a variety of contexts, including household surveys.
economic growth leads to reductions in the prevalence of Whereas stunting can be used to identify growth and nutri-
child stunting.138 tional deficiencies, along with cumulative undernutrition,
these measures also have their disadvantages (for example,
they may capture other aspects of early life conditions
Discussion including disease environment and genetic growth poten-
tial, and have a lesser capacity to capture marginally inad-
Summary of the evidence linking childhood
equate diets or short-run episodes).12 Cross-sectional
stunting and undernutrition to economic
analyses rely on proxying childhood nutritional status with
outcomes
adult height, which also has its limitations. It is difficult to
The evidence reviewed in this paper supports the hypoth- assess the extent to which these issues affect our conclu-
esis that children affected by stunting or undernutrition are sions, without further data from prospective studies which
negatively affected in terms of a variety of economic out- credibly address measurement error, unobserved con-
comes, including productivity, occupational status and founding, and selection into the labour market. An assess-
wages. The magnitude of the relationship between stunting ment of publication bias in the literature would also be
and wages is larger in intervention studies (two nutrition beneficial. It is important to bear in mind that we do not
programmes were associated with a 25% and a 46% in- have the same kind of evidence that would be provided by
crease in adult wages for affected children, respectively) multiple RCTs conducted in a variety of different contexts,
than quasi-experimental studies (where we find that each and therefore we have tried to summarize the weight of the
centimetre increase in adult height is associated with an in- available evidence across a range of studies from different
crease in wages of 4% for men and 6% for women), which methodologies and of varying quality. One question is how
is in turn larger than that found in observational data to reconcile that results from the two experimental studies
(where the corresponding wage estimate is 1% for men are substantially higher than median quasi-experimental
and women). estimates. It is likely that there are at least two pathways
A theme in this review is that there is a great deal of het- linking stunting to adult outcomes, including a pure stature
erogeneity in terms of coefficient estimates, across both effect, and the effect of lost growth potential encompassing
countries and genders, although estimates in low- and cognitive impacts of undernutrition. Unlike most quasi-
middle-income countries do appear larger on average than experimental studies, long-run follow up of nutrition inter-
those from high-income countries such as the UK and the ventions can isolate the latter, which we would expect to
USA. This heterogeneity is likely to partly reflect the fact be larger. It remains to be seen whether the magnitude
found in the two existing studies is observed in subsequent short run. A focus on the quality of economic growth,
trials, but nevertheless, even if we focus solely on the lower intermediary inputs including sanitation, education, qual-
quasi-experimental median estimates, the evidence from ity of diets and access to basic health services,143 and a
different sources is still generally consistent with the combination of poverty reduction and direct nutrition
hypothesis of substantial economic returns to nutrition in interventions, are likely to be most effective at achieving
early childhood. large reductions in stunting.127
Stature in adulthood is also linked to other economic
outcomes, including occupational status, and other meas-
ures of socioeconomic position. Studies which examine po-
Implications for countries with high stunting
tential mechanisms indicate that there is a direct
prevalence in the context of Sustainable
association of stature with productivity and fatigue.139,140
Development Goals post 2015
An alternative set of studies which examine more short-run There has been some progress in reducing child stunting

relationships find that child undernutrition affects cogni- and undernutrition over recent decades, with stunting
tion and schooling. Controlling for these variables in prevalence falling from 50% in 1970 to 30% in 2010
height regressions generally attenuates coefficient esti- among low- and middle-income countries. However,
mates, supporting this interpretation, at least in low- and stunting remains high in some regions, and is currently at
middle-income countries. Health effects of stunting across 38% in South Asia and 37% in sub-Saharan Africa. The
the life cycle are also likely to be substantial, as are effects current momentum and international agreement on the
of in utero environment on health and economic outcomes. importance of reducing undernutrition among children
Separating out optimal timing of investments in infants are apparent in the inclusion of food security and nutri-
and children remains an important direction for future re- tion as one of the Sustainable Development Goals, the
search.141 Intergenerational transmission of disadvantage emergence of initiatives such as the Scaling Up Nutrition
is another pathway which we did not cover in this review (SUN) movement [http://scalingupnutrition.org/] and the
except insofar as it relates to economic outcomes, but this targets for reductions in stunting set by the World Health
is also likely to be an important consequence of child Assembly and United Nations and endorsed by the
undernutrition.19,142 Sustainable Development Goals (SDGs).38 However, fur-
Cost-benefit analyses that evaluate programmes imple- ther evidence is needed to inform how best to prioritize
menting nutrition interventions tend to find that they are effective and cost-effective interventions to reduce stunt-
cost-beneficial, some very cost-beneficial, and studies ing in the most adversely affected areas. Reviews of ef-
which aggregate costs across all affected individuals in a fective treatments for the direct causes of growth
country or set of countries find that the total costs of child restriction have identified promising interventions, includ-
stunting and undernutrition are high. Our median quasi- ing: periconceptual folic acid supplementation; maternal
experimental estimate of the return to 1 cm of height of energy, protein, calcium and micronutrient supplementa-
4% for men is similar to that used in previous cost-benefit tion; promotion of breastfeeding and appropriate comple-
analysis of 7%,6 research on economic growth of 3.5%115 mentary feeding of children; vitamin A and zinc
and global estimates of the economic burden of stunting of supplementation for children; and management of acute
0.5% to 4.5% (depending on the country).31 When a high malnutrition.41 However, to unleash the potential of nu-
proportion of a cohort within a country are affected, these trition programmes, progress is needed in addressing per-
studies may miss spillover effects on labour markets and sistent socioeconomic inequities.2 Intervention studies
technological progress and their consequent impact on eco- suggest that a combination of nutrition and stimulation
nomic growth. This is an important direction for future re- packages in early childhood may have the greatest
search, and taking account of externalities in the impact.27,50,144
interaction between undernourished individuals, cohorts Although economic growth in South Asia has been
and labour markets on economic growth, potentially using rapid, with more than a doubling of GDP over the past
a production function approach such as that taken in more four decades, levels of per capita GDP remain low. India
general studies of health and GDP,106 would be of great experienced 8% growth in GDP from 2000 to 2010, and
interest. In contrast to the impact of stunting or undernu- during the period 1981–2005 India’s poverty rate fell from
trition on economic growth, there are relatively more stud- 60% to 42%.4 Despite this being similar to China’s reduc-
ies that examine the impact of economic growth on tions in poverty, stunting fell much more rapidly in China
stunting. In this literature, even the studies that do find an than in India over the period. One potential explanation
association between economic growth and stunting agree for this is the low coverage of nutrition interventions. For
that the magnitudes involved are not large, at least in the example, only 25% of vulnerable children benefited from
feeding interventions and only 30–40% received vitamin A interventions identified in the literature and promoted
supplements.4 Uneven economic growth which does not internationally.
achieve gains spread equally across the distribution of At the national level, progress has been uneven at reduc-
households is another potential explanation for the lack of ing stunting, and South Asia and sub-Saharan Africa in
improvements observed in India following rising aggregate particular have lagged behind other regions. In India, the
income per capita.138,145 slow improvement in reducing child undernutrition stands
In a recent assessment of the underlying determinants out because of rapid economic growth. Focusing on com-
of stunting in South Asia, Smith and Haddad (2015) binations of nutrition programmes and proximal determin-
point to factors other than economic growth which are ants, such as gender equality and sanitation, may provide a
likely to be relevant for improving levels of child under- more reliable method of reducing child undernutrition
nutrition. Access to sanitation, dietary diversity of food than low quality growth that is not broad-based and bene-
supplies and gender equality have potentially high rates ficial for poorer or more vulnerable children and house-

of return because they are farthest below their desired holds. Because of likely spillover effects of reductions in
levels. In particular, only 38% in South Asia have ad- stunting prevalence on labour markets and productivity,
equate sanitation access and only 40% of the food supply investments targeted at reducing child stunting and under-
is made up of non-staples, resulting in poor diet quality nutrition are likely to have substantial returns to society in
as highlighted by the fact that fewer than 25% of young terms of increases in economic growth and human capital
children are fed diets that meet the minimum adequacy formation.
for child growth and development.1,135 Another area of
emphasis is governance and accountability, particularly
given that children are especially vulnerable to poor pub- Supplementary Data
lic services, but are not easily heard because of their lack Supplementary data are available at IJE online.
of political voice and the relative lack of attention paid to
undernutrition.4
Interventions targeting these factors are largely in the Funding
hands of states and provinces in countries such as India Financial support for this analysis was provided by UNICEF
and Pakistan, respectively. Coupled with the results pro- Regional Office for South Asia.
vided in this paper and the literature, there is therefore the Conflict of interest: None to declare. The opinions expressed in this
opportunity to view investments in child nutrition as a paper are those of the authors and do not necessarily reflect an offi-
strategy for economic growth and human capital forma- cial position of the institutions that they are affiliated with.
tion at the state and local levels. States in India and prov-
inces in Pakistan have gained increasing autonomy for Acknowledgments
administering major family and child programmes over the We are grateful to Matthias Blum, John Hoddonitt, and seminar
participants at the 2016 Workshop on Economics and Human
past three decades, with decentralization/devolution of nu-
Biology for comments and suggestions.
trition and other social welfare budgets.146
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A Review of The Evidence Linking Child Stunting

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International Journal of Epidemiology, 2017, 1171–1191

Social and Economic Determinants

A review of the evidence linking child stunting

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Key words: Stunting, productivity, economic growth, early childhood investment

nomic outcomes as an adult

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kets and capital accumulation may be substantial

Introduction there remain areas where the evidence is sparse. In particu-

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Author Year Focus

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was not statistically significant. These two studies, papers

follow-up was significantly greater in subjects

increased household per capita expenditure

(21%) and a lower probability of living in

Intervention increased earnings by 25%

46% increase in average wages for men

poverty (10 percentage points)

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periment during gestation and

Nutritional supplementation ex-

related food crisis in Germany (1944–48).52,53 Although

the Dutch ‘Hunger Winter’ of 1944–45 also features in this

the preschool years

economic outcomes of survivors.54 An additional paper

which is positively associated with higher crop yields, stat-

ure, and thus likely better nutritional status, and found

that exposure was significantly associated with higher

women, but was not statistically significant for men.55

Survivors of the Chinese famine in 1959–61 were found to

Cluster, randomized, inten-

of income compared with surrounding cohorts who were

Cluster, randomized, in-

not in infancy during the famine. Those in infancy during

sus data. In contrast, there was no evidence of adverse

childhood, although this study found that those exposed in

that having lived in a European country affected by conflict

during World War II was associated with lower wealth in

later life for those among the bottom two socioeconomic

one potential channel for this result.56 A final study exam-

ined the relationship between height and adult outcomes

Sweden, which has the benefit of allowing all observed and

unobserved factors constant within families to be con-

Hoddinott et al. 2013

Results from these studies are shown in Table 3.

Alderman et al. (2006) use an instrumental variables ap-

proach and report that drought exposure in childhood in

deviations (SD) lower, which was estimated to be associ-

this figure is calculated from calibrated effects of schooling

International Socio-Economic Index of Occupational Status

Associations with income, occupational status and employ-

0.42% increase in earnings per cm increase in occupational

rainfall) in their year and location of birth live in house-

(ISEI), coefficient ranged between 0.296 and 1.111

holds that score 0.12 standard deviations higher on an

agrarian income decreased by approximately 2%

Evidence from prospective studies