The Many Facets of Malnutrition
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Fifty-seven out of 129 countries around the world are faced with very serious levels of both undernutrition and adult overweight and obesity, according to the 2016 Global Nutrition Report. Africa remains one of the regions most plagued by these varied threats of malnutrition, and the continent will need to make strong commitments to reach the goal set forth by the SDGs of ending malnutrition in all its forms by 2030.

According to the report, launched this week in Washington DC, 32 percent of children in Africa under the age of five suffered from stunting (low height for age) in 2014; 8 percent suffered from wasting (low weight for age); and 6 percent of children under five were overweight. Africa also remains one of only two regions (along with Oceania) in which child stunting is not declining. Meanwhile, the regional prevalence of overweight in adults in 2014 was 40 percent for women and 25 percent for men; in several countries (Ghana, Kenya, Mauritania, Niger, Sierra Leone, Tanzania, and Zimbabwe), the prevalence of overweight and obesity among women ages 19-49 years is nearing 50 percent in urban areas. These increasing obesity and overweight rates bring with them increased risk of non-communicable diseases such as diabetes and cardiovascular disease.  Such non-communicable diseases are now responsible for nearly 50 percent of death and disability in low- and middle-income countries around the world, according to the report.  In Kenya alone, non-communicable nutrition-related diseases now account for 27 percent of deaths among people ages 30-70 years.

Micronutrient deficiencies also present a sizeable threat in the region. In 2011, 38 percent of women of reproductive age suffered from anemia, while in 2013, 42 percent of children ages 6-59 months were deficient in vitamin A.

All of these factors place enormous pressure on African countries’ health systems, economies, and human capital. The report estimates that 11 percent of Africa’s GDP is lost every year as a result of malnutrition – more than was lost during the 2008-2010 global financial crisis. Clearly, then, malnutrition represents a serious threat to the region’s economic development, one that requires increased commitment and investment to successfully address.

The report presents several examples of African countries making such commitments. For example, Kenya has become one of the few countries in the region to design a national response plan to address its growing obesity epidemic. The National Strategy for the Prevention and Control of Non-communicable Diseases 2015–2020 aims for zero increase in obesity and diabetes among adults. Kenya’s National Nutrition Action Plan (2012-2017) also includes several specific action items to address overweight and obesity levels in the country, including: develop and disseminate comprehensive guidelines for preventing, managing, and controlling nutrition-related non-communicable disease; train service providers and create public awareness campaigns to prevent, manage, and control these diseases; scale up community screening of body mass index and waist circumference; and improve nutrition and nutrition education in schools. Kenya is also currently developing a National Action Plan for the Prevention of Childhood Obesity. While these plans represent important steps in the integration of overweight and obesity into national nutrition agendas, the report points out that increased funding for obesity programs, and for nutrition programs in general, will be needed for Kenya to meet national and global goals.

Other African countries have made progress in battling micronutrient deficiencies. The report highlights improvements in iodine levels in Ethiopia between 2005 and 2014. Low levels of iodine can result in the development of goiters; in 2005, as many as 83 percent of Ethiopian schoolchildren had iodine deficiency, according to the report. While iodized salt can go a long way toward reducing deficiencies, the use of fortified salt was low at the beginning of the study period. However, thanks to improved food supply chains, increased private sector investment, government commitment to reinstate and enforce iodization legislation, and engagement by international agencies and the civil sector, more than 95 percent of Ethiopian households had access to iodized salt in 2014.

Increased commitment and investment by the government and the international community has also increased fortification of staple foods in Burkina Faso, the report cites. The government of Burkina Faso has enacted legislation making it mandatory for cooking oil to be fortified with vitamin A and for wheat flour to be fortified with a range of nutrients including iron and folic acid; these fortified products now reach more than 84 percent of the country’s population. These efforts were supported by technical assistance from an international organization, Helen Keller International (HKI), which helped local food industries strengthen their capacity to meet the new food product standards.

In a separate program, HKI partnered with IFPRI, local government health and agricultural offices, and Burkina Faso’s National Agricultural Research Institute to conduct a rigorous evaluation of the country’s Enhanced Homestead Food Production model; this study, published in 2015, found that a well-designed program that promotes homestead production of nutrient-rich foods, along with communication strategies designed to change households’ nutrition behaviors, can positively impact maternal and child nutritional status. Burkina Faso’s experience with these various programs shows how government and international support can be key in establishing and scaling up successful micronutrient programs.

According to the report, over 30 percent of government spending in Africa is allocated to five sectors that underpin nutrition: agriculture, health, education, social protection, and water, sanitation, and hygiene. These sectors thus represent a powerful channel through which to build nutrition targets into larger development goals.  

The report calls out Ghana as one African country that is doing so very successfully. From 1988 to 2003, the country’s under-5 stunting rates declined very slowly, with prevalence remaining higher than 30 percent. Since 2008, however, the decline accelerated significantly and prevalence reached a low of 19 percent in 2014. According to the report, this impressive progress is due to a combination of political and economic development and a wide range of interventions to address undernutrition. These interventions include:

  • free and low-cost health services such as the distribution of insecticide-treated bed nets to pregnant women and children, dedicated prenatal services, the use of zinc and oral rehydration solutions for treatment of diarrhea and fever in children, and increased vaccinations for children 12-23 months of age;
  • agricultural programs focusing on rural development, irrigation, and improved crop varieties and input subsidies;
  • social protection programs such as cash grants to ultra-poor households, free maternal health coverage for poor women, and a National School Feeding Program that provides one nutrient-rich meal to schoolchildren in almost 200 districts; and
  • programs granting free basic education and encouraging the education of girls.

However, the report points out that Ghana’s work is not done. Exclusive breastfeeding rates have recently declined in the country, and the quality of diets for infants and young children still need vast improvement. In addition, reductions in stunting have not been equally distributed across the country, and financial investment from the government remains below optimal levels. Finally, the prevalence of adult overweight and obesity continues to grow, pointing to the need to include these factors in future nutrition and development programs.

 Overall, the report concludes that while African countries made some progress on various nutrition indicators, further progress will not be made without significantly increased political commitment and financial investment.  The Malabo Declaration, made in June 2014, represents some such commitment; in this declaration, signatory countries and the African Union pledged to decrease child stunting by 10 percent and child underweight by 5 percent by 2025. For these goals to be reached, governments and government ministries will need to coordinate at the national and regional levels in order collect and disseminate better nutrition-related data. 

By: Sara Gustafson, IFPRI

Photo credit:Flickr: Julien Harneis