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Links Between Nutrition and Cognition in Children
Maureen Black, Ph.D.
Department of Pediatrics
University of Maryland School of Medicine
RTI International
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Learning Objectives
1. Describe how timing relates to associations between nutrition and cognition in children.
2. Describe why self-regulation is relevant to infant/toddler feeding practices.
3. Describe recommendations for promoting infant/toddler nutrition.
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Environment in
Infancy/Childhood
Pregnancy
Environment
Parent’s
Health/Wellbeing
Pre-pregnancy
Timing and context (positive/negative) of early
environments shape children’s potential
Environments across the life-course
Health & Growth
Learning & Academics
Behavior & Emotions
Epigenetic Changes
Genetic Blueprint
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Fetus Late Infancy/Toddler Pubertal
Developmental Perspective
Thompson & Nelson, 2000
1000 days
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Nutrient Deficiencies
• Timing
o Sensitive Periods
• Severity
o Deprivation vs. Toxicity
• Duration
o Acute vs. Chronic
• Recovery/Protection
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Macronutrientsnecessary for growth
• Carbohydrates– Fuel, provide most calories
– Fiber - carbohydrates that body cannot digest. Pass through the intestinal tract intact and remove waste.
• Proteins– Growth, immune functioning, tissue repair
• Fats and cholesterol– Concentrated calories
– Taste
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Micronutrientsspecific functions
• Vitamins and minerals
• Not made by the body
• Poor diet quality (e.g., low fruits & vegetables, low animal source food)
• Not necessarily impact growth
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IODINE:T3/T4 -essential to neurodevelopment
• Severe ID during pregnancy may lead to cretinism
• 2013 meta analysis - 24 studies1
– IQ deficiencies of 6.9-10.2 points
• 2005 meta analysis - 37 studies in China2
– IQs deficiencies of 12.5 points
• 2018 review– Associated with ADHD– Aggravated by pregnancy and maternal hypothyroxinemia – Can impact postnatal development and plasticity of neural tissues
Iodizing salt is a powerful prevention measure
8
1Bougma et al, 2013; 2Qian et al, 2005, 3Velasco, 2018
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IRON – aids transport of oxygen to brain
• 1Christian, JAMA, 2010; 2Li et al. Pediatrics. 2009; 3Zhou et al, Am J Clin Nutr. 2006; 4Baumgartner, 2015. 5 Cusiac, 2018
• IDA in infancy and < 2 y associated with poor development
• Long-term effects of infant IDA even after tx (observational studies)
• Prenatal iron supplementation trials show mixed findings– Mixed findings related to cognitive development1-3
• Mixed findings related to Infant iron supplementation on motor and cognition4
• Maternal iron supplementation, delayed clamping or “milking” umbilical cord, and early iron supplementation improve the iron status of at-risk infants 5
• Concern about risk of morbidity and gut microbial composition and inflammation
9
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Fetus Late Infancy/Toddler Pubertal
Developmental Perspective
Thompson & Nelson, 2000
Iron: 0.27 mg/day 11 mg/day 7 mg/day
0–6 months 6-12 months 1-3 years
1000 days
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Fetus Late Infancy/Toddler Pubertal
Developmental Perspective
Thompson & Nelson, 2000
Iron: 0.27 mg/day 11 mg/day 7 mg/day
0–6 months 6-12 months 1-3 years
1000 days
TIMING
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ZINC – constituent of enzymes involved in many major metabolic pathways
• Benefits of preventing zinc deficiency in infancy and in combination with iron
• Cochrane review of zinc supplementation and mental and motor development – concluded no consistent effects
Gogia & Sachdev, Cochrane Database, 2012; Colombo, J Nutr, 2014; Black Pediatrics, 2004
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Multiple Micronutrients
• 1Christian et al. JAMA. 2010; 2Tofail et al. Am J Clin Nutr. 2008; 3Prado et al, Pediatrics. 2012; 4Li et al. Pediatrics 2009. 5McGrath et al. Pediatrics. 2006; 6Adu-Afarwuah et al. Am J Clin Nutr. 2007; 7Faber et al. Am J Clin Nutr. 2005
• Deficiencies often occur in combination1-5
– Poverty, Poor quality diet
– Limited access to diverse, nutrient rich foods
• Impact of improving one micronutrient in the context of multiple deficiencies
• Interaction/competition among micronutrients
• Timing – when to intervene
• Side effects• Short term effects of infant supplementation inconsistent – limited
evidence on long-term effects6-7
13
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Prenatal Maternal Nutrition
• Few trials examined effects on child development
• Motor development at 7 months; no effects at 18 months or 5 years (Bangladesh)
• Motor and cognitive scores at age 3.5 in children of undernourished & anemic mothers (Indonesia)
• Beneficial effect of MMN vs. vit A at 7-9 years on one test of cognition (Nepal)
(1) Haider & Bhutta, Cochrane Database, 2015; Fall et al., Food & Nutr Bull, 2009; Kawai et al., Bull WHO, 2011; Ramakrishnan et al., Paediatr Perinat Epi, 2012(2) Hamadani et al., Pediatrics, 2014; Prado et al., Pediatrics, 2012; Christian et al., JAMA, 2010 , Nguyen, 2017
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Preconception Maternal Nutrition
• Strong rationale for ensuring nutritional adequacy prior to conception
• Several trials in the field
• Controversy regarding appropriate timing and measures of child development.
• Preconception supplementation with IFA (not MMN) improved linear growth and fine motor development at 2 y of age compared with FA (Vietnam).
Nguyen, 2017
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Nutrition and Early Development
Sudfeld, Pediatrics, 2015; Victora, The Lancet, 2008; Stein, Pediatrcs, 2004; Hoddinott, MCN, 2013.
Stunting by age 2 associated with:
• Childhood: poor school performance • Adulthood: low human capital• Subsequent generation: similar growth
pattern, offspring benefit from maternal intervention
• Economic impact of reducing stunting
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Difference in School-Age Cognition Per Unit Increase in Length-for-age at 2 years1
1 Sudfeld, Pediatrics, 2015
Stunting by age 2 associated with lower cognitive performance
during school-age
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Long-term effects of stunting on human capital
• Linear growth in first 2 years of life more strongly associated with years of schooling than weight gain. (Adair, Lancet, 2013)
• Conditional growth: how a child deviates from expected height or weight, based on previous measures and growth of the population
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Regression coefficients for IQ & Years Schooling at Age 30 by Conditional
Length at Age 2
2,1
0,7
4
1,3
4,4
2
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
IQ SchoolingZ-score -0.99 to -0.01 Z-score 0.00 to 0.99 Z-score => 1.00
Adjusted for family income, parent ed, household index, skin color, mat smoking preg, birth wt,breastfeeding duration
Horta et al, J Peds, 2017
p < .001 p < .001
In comparison with stunting, greater conditional length at age 2 associated with higher IQ and
more years of schooling at age 30
No effects for stunting at age 4
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Developmental Skills of Children (12-72 months) of Mothers Stunted/Non-stunted as Infants (9-24 months)
9992
10196
10710598
108100
113
0
20
40
60
80
100
120
DevelopmentalQuotient
Cognition Hearing/speech Hand/eye Locomotion
Stunted Mother Non-stunted Mother
Walker et al., J Nutr, 2015Adjusted for child age, sex, birthwt, HAZ mater ed, occup, father in home, SES, HOME
p = .004 p = .025 p = .06 p = .09 p = .03Stunting prior to age 2 among mothers reduces
the cognitive performance of their
children
Two-generation impact!
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Poverty and Early Development
Black, The Lancet, 2017; Lu, Black, Richter, Lancet Global Health, 2016
Stunting and severe poverty used to estimate prevalence of children at risk of not reaching developmental potential
249 million children < age 5 years43% of world’s children
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Children Not Reaching Their Developmental Potential
Grantham-McGregor, The Lancet, 2007; Lu, Black, Richter, Lancet Global Health, 2016
Risk of not reaching developmental potential 2010249 million
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Response to Food Insecurity
• Quality: Foods decreased
Proteins (eggs and meat)
Fruits and vegetables
• Quality: Foods increased
Starches
Noodles
• Quantity: Decrease food
Burke, J Nutr Educ Behav. 2017
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Link between Nutrition and Cognition
Nutrition Cognition
Feeding Behavior
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Feeding Behavior
• Clara Davis (1928, 1939)
Infants in orphanage
Given choice of basic foods (not mixed foods)
Observed what they chose
Nurse fed
Regulated intake!
• Self-regulation thought to guide infant hunger and
satiety
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Developmental Milestones Related to Eating
• O-6 months– normal suck/swallow– breast milk or formula only– Regulate:
• Demand – signal hunger• Turn away from breast/bottle when full
• ~6 months– Sit up, good head control– starts to touch food with fingers– Oral-motor (tongue laterality)– feed in high chair– Regulate
• Lean toward food, mouth open when hungry• Turn head when full
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Feeding Infants and Toddlers Study (FITS)Percent of Parents Reporting Feeding Problems (n=3022)
19
2529
35
4650
0
10
20
30
40
50
60
4-6 mos 7-8 mos 8-11 mos 12-14 mos 15-18 mos 19-24 mos
Percen
t
Carruth, 2004
Feeding problems often correspond with child’s desire for autonomy.
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Challenges – Toddler Feeding Problems
• Feeding Problems Common (Picky)
– 25-40%, Most resolve without major consequences
–BUT– Can undermine family relations
– Can signal GI problems (GERD, celiac, etc.)
– Can lead to nutritional deficiencies
– Can be a precursor to long lasting behavior problems
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Infant/Young Child Feeding
Age Developmental Skills Food/Beverage Feeding
Behavior
0-6 Suck/swallow Breast milk/
Formula
Breast/
Bottle
6-12 Tongue laterality, chew
Sit
Hand-mouth
Emerging autonomy
Complementary
food (texture &
nutrients)
Self/
Caregiver
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Infants (0-6)• Bottle-fed infants gain more weight than breast-fed
infants, even if the bottle contains breast milk.
• Do mothers cue from the bottle or infant?
• Cross-over trial of opaque, weighted vs. clear bottles
• Observed maternal responsivity, intake, duration
Maternal Responsivity*
Intake (mL)* Duration
Opaque 9.3 19.7 15.5
Clear 8.2 22.0 15.0
Ventura, Appetite, 2015* P < .05
Bottle-feeding mothers: risk of not responding to infant
and overfeeding
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Infants (prenatal-24 mos)
• Self-feed vs. caregiver feed
• BLISS (Baby-Led Introduction to Solids)
• Recruit 206 pregnant women (NZ)
CONTROL BLISS5 contacts (prenatal-5 mos)3 contacts (6-9 mos)
Intervention addressed exclusive breastfeeding 6 mos, iron & energy-rich complementary foods, soft foods, avoid choking, respond to infant signals
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Age Control BLISS Significance
BMI Z-score 12 0.20 0.44 ns
24 0.24 0.39 ns
BMI 12 16.9 17.3 ns
24 16.2 16.4 ns
Overweight 12 6% 15.1% ns
24 6.4% 10.3% ns
Exclusive breastfeed 17.3 weeks 21.7 weeks *
Delay solids 6 mos 18.1% 64.6% *
Adverse (choking -milk)
1 1 ns
Results: BLISS vs. Control 12 & 24 months
No difference: BMI, Overweight, Choking, Energy Intake
Exclusive breastfeed: BLISS 4 weeks longer Delay solids 6 months: BLISS 64.6%
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Age Control BLISS Significance
Fussy/picky (observe)
12 2.25 1.94 *
24 2.61 2.43
Enjoy Eating (caregiver report)
12 4.07 4.29 *
24 3.84 4.07 *
Child mealtime decisions(caregiver report)
12 3.87 4.04 *
Results: BLISS vs. Control 12 & 24 months
* P < .05
BLISS children less fussy/picky, greater eating enjoyment and
mealtime decisions.
Concern: excess intake??
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Life Course Perspective to Child Development
Birth
Early Childhood
Childhood
Adolescence
Conception
Healthy nutrition and learning opportunities throughout life
Adulthood
Black et al., Lancet, 2017
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Life Course Perspective to Child Development
Birth
Early Childhood
Childhood
Adolescence
Conception
Healthy nutrition and learning opportunities throughout life
Adulthood
Chronic health problemsLimited economic potential
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Cost of inaction in grades and earnings lost
Grade Deficit Income Loss Children
Stunted
only 4.67 42.3% 106.5m (18.5%)
Poor only 0.71 5.8% 75.6m (13.1%)
Stunted and
poor 6.56 32.4% 67.2m (11.7%)
249.3m (43.3%)
Richter, The Lancet, 2017
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Cost of inaction in grades and earnings lost
43% of children in LMICs (249 million)
lose 26.6% of average adult income
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Life Course Perspective to Child Development: Begins 1st 1000 Days
Birth
Early Childhood
Childhood
Adolescence
Conception
Nurturing Care throughout life
Adulthood
Improve health and economic outcome
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Nutrition and Early Development
Grantham-McGregor, Pulic Health Nutr, 2005; Adair, Nestle Nutr, 2011
Rapid infant weight gain by age 2 associated with risk of noncommunicable diseases (NCDs) in adulthood.
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Nurturing Care
Nurturing care promotes early child development
Nutrition
Health care
Responsive caregiving
Protection from danger
Opportunities to explore,
learn and discover
Black, The Lancet, 2017; Black, Gove, Merseth, 2017
Each domain is necessary.
No single domain is sufficient.
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USA: Early Childcare (Abecedarian)
Campbell Science 2014
• Goal: Evaluate early enriched care on academic performance
• RandomizedChild Care Center Care as Usual
Nutrition, health care,
l learning curriculum
8 hours/day, 5 years
• Followed through early adulthood – benefits on academic performance & economics
• Age 35…..
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Control Treatment P-value Stepdown
Diastolic BP (mm Hg) 92.00 78.53 0.02
Systolic BP (mm Hg) 143.33 125.79 0.03
Hypertension (systolic bp ≥ 140 and diastolic bp ≥ 90)
0.44 0.10 0.02
Hypertension (systolic bp ≥ 140 or diastolic bp ≥ 90)
0.56 0.22 0.04
Obese (BMI > 30) 0.62 0.56 0.34
Obesity and hypertension 0.50 0.11 0.02
Metabolic syndrome (NCEP definition)
0.25 0.00 0.01
Campbell Science 2014
Age 35 years Beneficial effects on blood
pressure, metabolic syndrome
Biomedical Results Age 35: Males
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Early Weight Gain - Males
Campbell Science 2014
BMI Age 0-48 Months: MalesDifferences in weight gain
began very early in life.
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Maternal Feeding Evolution
• Cross-sectional studies• Unidirectional: Mother Child
• Bidirectional: Mother Child
• Supported by intervention trials (6)• Mothers taught to respond to infants’ hunger and
satiety cues.
• Lower z-scores, less overweight & excess wt. gain
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Responsive Caregiving
Caregiver “caring”
Consistent (predictable) routines
Provides feedback and guidance, not harsh
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Responsive FeedingBidirectional concepts
Mother offers
vegetable
Baby opens mouth
Mother feeds a bite
Baby fusses
Baby smiles, takes veggie,
eats
Mother smiles, offers
finger food
Black & Dewey, 2014
Baby whines, signals hunger
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Responsive Feeding Bidirectional concepts
Mother offers
vegetable
Baby opens mouth
Mother feeds a bite
Baby fusses
Baby cries and refuses
to eat
Mother pressures
child to eat
Black & Dewey, 2014
Baby whines, signals hunger
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Nurturing care is fostered by a supportive environment
Nurturing care:
parents &
caregivers
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Capacity
for nurturing care
Nurturing care:
parents &
caregivers
Nurturing care: fostered by a supportive environment –ecological
model
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Early Child
Development
Programs
Capacity
for nurturing care
Nurturing care:
parents &
caregivers
Nurturing care: fostered by a supportive environment –ecological
model
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Nurturing care: fostered by a supportive environment –ecological
model
National
Policies
Early Child
Development
Programs
Capacity
for nurturing care
Nurturing care:
parents &
caregivers
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Early Child Development
• Birth through age 8 years
• Pre-conception/prenatal
• Antenatal
• Infant/Toddler
• Preschool
• Early School-age
First 1000 days: conception-age 2 years
Second 1000 days: age 2-5
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Advancing Early Childhood Development: from Science to Scale
Improving Early Child Development:
Key to achieving the SDGs
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Thank You!
Funding: NICHD, Bill & Melinda Gates Foundation, Hilton Foundation
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