A distinguished economics professor may not be the first person that comes to mind as an expert on global nutrition, but John Hoddinott has spent years at the intersection of the two fields, studying the consequences of poverty, hunger, and undernutrition in developing countries.
Hoddinott, the H.E. Babcock Professor of Food and Nutrition Economics and Policy at Cornell University, has conducted research in countries around the world, including Bangladesh, Ethiopia, Guatemala, Mali, Namibia, and Zimbabwe.
As part of Cornell’s Expanding Nutrition Frontiers WebCast Series, Hoddinott joined eCornell’s Chris Wofford to discuss chronic undernutrition in developing countries and the obesity epidemic in developed countries, as well as possible solutions to both issues.
Wofford: John, thanks for joining us. Let’s begin by defining our topic. What is chronic undernutrition?
Hoddinott: One way to think about this is to think about the nutrient content of foods, here being micronutrients and macronutrients. Micronutrients are things like iron, vitamin A, plus a ton of other things, but we’re not talking about those. We are going to talk both directly and indirectly about the macronutrients, which are calories, proteins, and fats.
Wofford: So we’re talking about a deficiency in calorie intake, right? Spending more than you’re taking in.
Hoddinott: That’s exactly right. We know that if children are not consuming enough of these calories or other macronutrients, they’re not going to grow as fast as they should. We can measure that in two ways: we can look at how much they weigh relative to their height or we could look at their height relative to their age and sex.
About 15 years ago, the World Health Organization commissioned a massive study in five or six different parts of the world in communities which were relatively resource rich. These were places where kids had adequate access to food and good access to health care, water, and sanitation. The WHO basically just followed these kids as they grew for the first two years of their lives and it turns out that well-nourished, healthy kids by and large grow at the same rate everywhere in the world. That is really useful for us because it gives us a reference standard.
So when we talk about a child who’s chronically undernourished, we are saying they are undernourished in terms of their height relative to the standard.
At the moment, there are about 160 million children in the world who are chronically undernourished. Most to those children live either in Sub-Saharan Africa or parts of South Asia.
Wofford: A cynic might ask, why we should care that little kids are a bit shorter than they should be?
Hoddinott: Well, the first part of the story is that people who are short when they are very young are more likely to be short when they are adults. And how might that actually matter for them in terms of how their lives turn out? Well, to give one example, women who are very short face a greater risk of obstetric difficulties when giving birth.
On the economic side of things, economists have looked at this and for every additional percent in height you have as an adult, your wages are higher by maybe one to three percent.
But there is something else that arises that is actually much more important. Children who are chronically undernourished suffer neurological damage in terms of the way their brains form and develop. We know that’s linked to how well they do in school.
I was part of a 40-year study that followed individuals from birth in rural Guatemala in the 1960s and 1970s through the early 2000s.
We’re actually just in the process of going back to find them and re-interview them again, but what showed up in this study is that people who are malnourished when they’re young didn’t go as far in school. They got less well-paying jobs. They also do worse on the marriage market. When you talk about marriage, for most people that involves thoughts of love and romance, but I’m an economist and we think of these things differently. Marriage is like a market in which you are looking for a match. The taller you are, the better educated you are, the better you are going to do in the marriage market. You are going to get a better partner.
What we found is that people who are chronically undernourished at the age of two are more likely to be poor when they’re adults between 25 and 40. This tells us that being chronically undernourished early in life carries long term consequences.
Wofford: The obvious question here is, what can we do to avoid those long-term consequences?
Hoddinott: You might think there is a simple thing you can do, which is to just make sure there’s more food, right? The simple solution is saying, “Look, kids need to grow, so if we grow more food, kids will grow faster.” But say you’re living in a country where food production is already growing really fast. Bangladesh, for example, has gone from a country that was famine prone in the 1970s to one which is self sufficient in terms of food production. You’d think we would see the nutritional status of kids actually improving really dramatically. But there is no correlation whatsoever.
So then you say, “Okay, well maybe it’s not so much about food, but more about income.” With greater incomes, people could buy more food for their kids, receive better healthcare, that kind of stuff. But income doesn’t have a direct correlation either.
Wofford: Is the problem the quality of nutrition?
Hoddinott: Yes. There has been work done by nutritionists, particularly nutritionists at Johns Hopkins University, where they have gone around and analyzed the blood of chronically undernourished kids in Africa, particularly in Malawi. One of the things they found in those kids is that they have very low levels of essential amino acids.
Researchers have identified something called an mTOR and there’s a particular type of mTOR that signals the body to create growth. And what does an mTOR need to work? It’s essential amino acids.
So everytime someone suggests that the solution is just to produce more food and produce more calories, well, maybe it’s not just calories you need.
When you see that big increases in income aren’t having such a big effect on nutrition, you think that while people may be buying stuff they need, maybe they’re not quite buying the right stuff.
There is an experiment I’ve been working on with some colleagues I’d like to share.
Wofford: Please do.
Hoddinott: Okay, so we take a group of people and we’re going to randomly assign them to different treatment groups. Some people, and this is specifically related to mothers, get a cash transfer every month for two years. So that’s group number one.
Group number two consists of households where we’re going to give those mothers a food basket that consists of cereal and a lot of calorie-based food.
Then we’re going to have a third group that will get the cash transfer but they’ll also get nutrition counseling on what their kids eat. Another group will get the food baskets plus the nutrition counseling and finally we’ll have a control group. This goes on for two years and we look to see what happens to the kids.
Wofford: What were your findings?
Hoddinott: The cash transfer group—and, remember, this is a significant amount of money—had a little bit of an effect on what the kids ate but no effect on their height. There was also no effect whatsoever in the food basket group. It didn’t matter what they ate, even though it was stuffed full of calories. The same was true for the group that got the food baskets and the nutrition education: no effect whatsoever.
Wofford: This isn’t looking great. What about the cash and education group?
Hoddinott: That’s where you see growth that is large enough to be meaningful. To put it in context, the prevalence of chronic undernutrition falls by seven percent over two years in the group that gets the cash and the nutrition training. That’s the equivalent of three and a half percent per year. At the moment in Bangladesh, the rate of chronic undernutrition amongst kids is falling at the rate of about one percent per year and that’s one of the fastest reductions in the world. We’re seeing results that are triple the national rate, which is already excellent by international standards. So what’s going on? Why does the cash and nutrition training make the difference? Well, they used the money to buy extra calories but because of the training they were also much more likely to buy animals or soups, milk, eggs and a little bit of fish—that kind of stuff.
Wofford: What are the next steps? What do you do with that kind of information?
Hoddinott: What it suggests is a very large shift away from worrying about the amount of calories to worrying more about their quality.
There are things that point in the direction of there being something about animal source foods that is really important for child growth. So what should we be doing about that?
You might suggest that everybody gets chickens, but for most people they’d probably either die or run off. We could give everybody a cow, but that’s also really expensive and most people are probably not that great at raising livestock. A real constraint on these animal source foods is that they’re really expensive, particularly in poor populations. If we can’t get the price of those things down, it’s very hard to increase consumption levels. We need to look at both the supply and the demand for quality food products and then think about how that is best attained.
Wofford: Speaking of animals, there is a trend here in the United States in which people are eating far less meat than they used to. There’s a focus on eating fewer processed foods and so on. There are also a lot of people worried about the environmental impacts of meat production as it relates to land and water degradation and the emission of greenhouse gases. How do you weigh the benefits of an animal-based diet against some of the drawbacks?
Hoddinott: I think the answer is not so much to think about the total level of production and consumption but to think about how it’s distributed globally. North Americans and Europeans probably consume more than they should, while we have very poor populations in developing countries that aren’t consuming enough.
Wofford: How about calorie intake, obesity rates, things along those lines?
Hoddinott: Again, I’m an economist, not a nutritionist, but I think there are a couple of really interesting and important issues, one of which is the significant health costs to the U.S. economy. Certainly the overweight and obesity problems represent a significant drain on the market economy.
Globally, the prevalence of overweight and obesity are rising dramatically. For every person in the world who is considered hungry, there are two and a half people who are overweight. What that means is that designing policies and interventions becomes much, much harder, in the sense that if you are worried about the undernutrition part, you can’t just say, “Well, I think we can actually address the undernutrition part by making calories really cheap.” That might help one part of your population, but it might be somewhat detrimental to another part. So trying to get the balance right becomes really tricky.
Wofford: You said a moment ago that there’s no silver bullet solution, but are there any shining examples of economic policy or prescriptions that you think might work in one place versus another?
Hoddinott: If you’re concerned about the hunger and nutrition part, then you want to make sure that economic growth is concentrated at the bottom. In the context of chronic undernutrition, you also want to align it with work in other areas. You’ve got the nutrition education part to encourage people, for example, to have their kids consume more diverse healthy foods. You want to work on things like improving water quality. You want to improve the sanitation infrastructure, all that stuff.
Wofford: Let me ask you this. How does everything that we’ve described here translate to your work at Cornell?
Hoddinott: I actually teach a course called The Economics of Food and Malnutrition. The philosophy of the course is that it’s open to both economists and nutritionists. The idea is that if you are an economist, we’ll teach you about the nutrition, and you’ll see how the two link together. For the nutritionists who come to the course, we’ll teach you the economics and you can see how the two link.
We start off with the big picture type statistics and we drill down to ultimately, why farmers grow what they grow, particularly in developing countries. Then we move on to talk about dimensions of undernutrition, some of the things we’ve been talking about here. We talk a little bit about acute undernutrition and micronutrient deficiencies and various ways it can be addressed. Then we round that off by talking about issues around overweight and obesity, and some of the trends and economics behind that.
And that takes us back to where we began, which is the somewhat amazing factoid about the numbers of people who are hungry on the one side and overweight or obese on the other.
Wofford: This concludes our latest Expanding Nutrition Frontiers WebCast. John, thanks for making yourself available and thanks to the audience for tuning in.
Hoddinott: Thank you.
Want to hear more? This interview is based on John Hoddinott’s live eCornell WebSeries event, Chronic Undernutrition in Developing Countries: Retrospect and Prospects. Subscribe now to gain access to a recording of this event and other Expanding Nutrition Frontiers topics.