Chapter 1. Overview

This report updates the results given in the Second Report on the World Nutrition Situation, Volume I (October 1992) and Volume II (March 1993 - ACC/SCN, 1992/3). New data available at country level¹ give recent trends in prevalences of underweight children, as the main nutritional indicator, in 18 countries. These can be compared with those reported in Volume II, to give a total of 46 national trend estimates for the 1980s and 1990s (see Table 1, discussed later). Primarily, this Update Report is concerned with trends around the period 1990 to 1993. Like the previous Update Report of 1989 (ACC/SCN, 1989), it does not make assessments at regional level (the models for this are not re-estimated), but aims to look at recent short-term trends, where possible drawing implications beyond the specific countries for which data are available.

¹ Many national surveys have been assisted by the Demographic and Health Surveys (DHS) project.

Over half the underweight children in the world are in South Asia, thus estimates of trends in this region have enormous importance. New data are scarce. A surveillance system established in Bangladesh indicates improvement from 1990 to 1993 (mainly in 1992), included in Figure 1. Recent changes in the situation in India are harder to assess, as data gathered in 1991/92 are from a rather small sample - tentative results are that, of seven states assessed, three showed a deterioration, and four had no significant change. General improvement was previously estimated between 1975-79 and 1988-90. As discussed in the case study in Chapter 2, India suffered an economic slow-down in the early 1990s, and there is reason to hope that the reversal of the improving trend indicated may be temporary; there are now renewed efforts to estimate more precisely the prevalences, and these results should only be taken as an interim assessment - but they may be a warning.

More details of these estimated trends, including rates of change in percentage points per year, are shown in Table 1. This also compares the new trend estimates, highlighted in grey, with those in the Second Report (it updates Table 1.3 in the Second Report (Vol I, p.11)). The results in this table in terms of rising or falling trends are the same as those that can be seen in Figure 1. Thus it is evident that most of the estimates in Sub-Saharan Africa indicate a deteriorating situation, whereas in other countries except India the falling prevalence observed earlier has generally continued.

Previously, the observed rates of change in underweight prevalences were compared with those necessary to reach the nutrition improvement goals endorsed by the World Summit for Children (UN, 1990) and the International Conference on Nutrition (FAO/WHO, 1992) (see Second Report, Vol I, p.67; Vol II, p.5). In Table 1, the rates of prevalence change (in percentage points per year) are shown in the right hand column. Also in the right hand column (in brackets) are shown regional rates of change in prevalence, in percentage points per year for 1990-2000, required to meet the goals. Thus, for example, in Sub-Saharan Africa a prevalence change of -1.5 percentage points per year would on average be required to meet the goal of halving the prevalence by the year 2000; but most of the observed trends in this region are positive, indicating deterioration in nutritional status..

A better situation exists in other regions. In the Near East and North Africa, the signs are that the rate of improvement is around that necessary to meet the goals - although starting from a low prevalence the improvement rate required is less than elsewhere. Similar relatively encouraging conclusions can be seen in South East Asia, China, Middle America/Caribbean, and South America, with rates of improvement usually similar to those necessary to reach the goal of halving the prevalence.

Figure 1. Recent Trends in Prevalence of Underweight Children

(New results are shown as solid lines and points; dotted lines are data previously given in Figure 1.3 of Second Report, Volume II, page 5)

Sub-Saharan Africa

Near East and North Africa

South Asia

South East Asia and China

Middle America and Caribbean

South America

Note: New data are those given in Table 1, highlighted; see also notes to Table 1.

Table 1. Estimated Trends in Prevalences of Underweight Children (recent trends updating those in the Second Report are highlighted)

	Year, Prevalence
Country	Earlier		Later		Trend	Rate (pp/yr)
						(rate for goals)
Sub-Saharan Africa							(-1.5)
Ethiopia	1983	37.3	1992	46.9	Rising	+1.07
Kenya	1982	22.0	1987	17.5	Falling	-0.80
Kenya	1987	18.0	1993	22.3	Rising	+0.72
Lesotho1	1976	173	1981	13.3	Falling	-0.80
Madagascar	1984	33.0	1992	39.0	Rising	+0.75
Malawi	1981	24.0	1992	27.0	Rising	+0.27
Rwanda	1976	27.8	1985	27.5	Static	-0.03
Rwanda	1985	27.5	1992	29.2	Rising	+0.24
Senegal	1986	17.5	1992	20.1	Rising	+0.43
Tanzania	1987	33.0	1992	28.0	Falling	-1.00
Togo	1977	20.5	1988	24.4	Rising	+0.35
Zambia	1985	26.5	1991	26.8	Static	+0.05
Zambia2	1990	27.8	1992	29.0	Rising	+0.60
Zimbabwe	1984	14.0	1988	10.0	Falling	-1.00
Near East and N. Africa							(-0.6)
Egypt	1978	16.6	1988	10.0	Falling	-0.66
Egypt	1990	10.4	1992	9.4	Falling	-0.50
Morocco	1987	12.0	1992	9.0	Falling	-0.60
Tunisia	1975	20.2	1988	7.8	Falling	-0.95
South Asia							(-2.9)
Bangladesh	1981	70.1	1989	66.5	Falling	-0.45
Bangladesh3	1990	71.0	1993	67.0	Falling	-1.33
India	1977	71.0	1988/90	63.0	Falling	-0.67
India4	1988/90	63.0	1991/92	66.0	Rising	+1.00
Pakistan	1977	54.7	1990	40.4	Falling	-1.10
Sri Lanka	1980	47.5	1987	36.6	Falling	-1.56
South East Asia							(-1.6)
Indonesia	1986	51.0	1989	46.0	Falling	-1.70
Malaysia	1983	25.6	1986	21.1	Falling	-1.50
Myanmar	1982	42.0	1990	32.4	Falling	-1.20
Philippines	1982	33.2	1990	33.5	Static	+0.04
Philippines	1990	33.5	1992	33.0	Falling	-0.25
Thailand	1982	36.0	1990	13.0	Falling	-2.88
Vietnam	1987	515	1990	41.9	Falling	-3.20
China5	1987	21.7	1990	17.5	Falling	-1.40	(-1.1)
Middle America/Caribbean							(-0.8)
Costa Rica1	1978	16.0	1982	6.0	Falling	-2.50
Costa Rica	1982	6.0	1992	2.3	Falling	-0.37
El Salvador	1975	21.6	1988	15.5	Falling	-0.47
Jamaica	1978	15.0	1985	14.9	Static	-0.01
Jamaica	1985	14.9	1989	7.2	Falling	+1.93
Nicaragua	1982	10.5	1993	11.9	Rising	+0.13
Panama	1980	16.0	1992	7.0	Falling	-0.75
Trinidad/Tobago	1976	16.3	1987	5.9	Falling	-0.95
South America							(-0.4)
Bolivia	1981	14.5	1989	11.4	Falling	-0.39
Brazil	1975	18.4	1989	7.1	Falling	-0.81
Brazil (NE)	1989	12.7	1992	9.2	Falling	-1.17
Chile6	1978	2.1	1986	2.5	Static	+0.01
Colombia	1980	16.7	1989	10.1	Falling	-0.73
Peru	1984	13.4	1992	10.8	Falling	-0.33
Venezuela	1982	10.2	1987	5.9	Falling	-0.85

Note: The purpose of this table is more to give prevalence trends than levels comparable across countries. Most prevalences given are of children 0-59 months, <-2 SDs by NCHS standards. In some of the recent cases, however, this indicator was not available and could not be estimated (e.g. 0-36 month age range, <80% w/a cut-off), in which case priority was given to deriving identically-defined prevalences comparable within country across time. This has minor effects on the estimated rates, in percentage-points per year (pp/yr), which are considered generally comparable across countries.

¹ These data not included in figure 2 as too old.

² Zambia 1990-1992, rural. In figure 2, period taken as 1985-1992 and rate calculated as 0.2 pp/yr.

³ Bangladesh data for 1981/1989 from surveys, 1990/1993 from surveillance, thus levels not comparable but trends should be reliable.

⁴ Data from: Karnataka, Maharashtra, Gujarat, Kerala, Tamil Nadu, Andhra Pradesh, and Orissa.

⁵ 1987, nine provinces; 1990, seven provinces. Five provinces have data for both years; in these, the prevalence trend (weighted average by sample size) was -1.1 pp/yr.

⁶ Not included in figure 2 as both prevalences approximately equivalent to NCHS prevalences

An important determinant of at least part of nutrition trends is likely to be the economic growth rate. In the Second Report (Vol. I, p.9), underweight prevalences were compared with per capita GNP levels, showing a steep (non-linear) slope at low GNP values; one of the models used (Vol II, p.111) showed significant associations with GNP (and GNP-squared). Prevalence changes versus GNP changes were also illustrated for these earlier data (pre-1990, Second Report, Vol II, p.3). The present prevalence trend data have been further examined in relation to economic growth. Comparing rates change of GDP per caput with rates of change in prevalence shows a moderately close fit - see Figure 2, discussed in more detail below. A first use of this relationship is to get some idea as to how generalizable prevalence data are, using the known GDP growth rates.

The question of how typical are the recent estimates is particularly important for Sub-Saharan Africa. Here there are eight recent national estimates available, but these only cover a minority of the population (in contrast, for example, to the data coverage in Asia). One approach is to compare these eight national GDP rates of change with the regional average. This is shown in Table 2. The average GDP changes for the eight countries was negative recently - probably the best comparison period is 1985-1992, when the rate was -0.2%. For Sub-Saharan Africa overall, the change during this period was -0.8%. Thus these countries were slightly better off, if anything, than the average for Sub-Saharan Africa in 1985-92. The overall conclusion would be that the nutrition situation in Sub-Saharan Africa probably deteriorated somewhat more, rather than less, than indicated from the eight countries with available data.

A further question is whether the trend in the early 1990s (1990-92) was worse than that in the late 1980s. Nutritional trends in Sub-Saharan Africa were estimated to be static in 1985-90 (Second Report, Table 1.2, p. 10), and as discussed above prevalences are thought likely to have increased in 1990-92. This is in line with the reduction in GDP growth in the region, from -0.4% per year in 1985-90, to -1.9% in 1990-92, as shown in Table 2. The nutritional trend probably worsened in the early 1990s in Sub-Saharan Africa.

The situation in South Asia depends on average largely on India, for which there are direct estimates for certain states indicating possible increasing prevalences. On the other hand in other areas of the world the underweight trends available for the early 1990s were generally similar to those in the late 1980s (as can be seen roughly from Table 1). In most regions the GDP growth rate improved after 1990 (except Sub-Saharan Africa, see Table 2). The conclusion from Tables 1 and 2 is that nutritional improvement outside Sub-Saharan Africa and possibly India probably continued into the early 1990s.

The comparison of underweight prevalences changes with GDP per capita annual growth rates, shown in Figure 2, has some important further implications, which can only be touched on here. The prevalence rate data are the same as those given in Table 1; a negative (i.e. reduced) prevalence means improvement. It is expected that rapid economic growth would be associated with improving nutrition, and this is observed - certainly for such countries as Thailand and Vietnam in the 1980s (points 28 and 29 in Figure 2), and also for those growing well but less fast such as Indonesia (23) and China (30). Other countries with positive economic growth rates generally show nutritional improvement - with considerable variation - but the relationship becomes more diffuse for country-periods around and below zero growth. In fact, the fit to these data is non-linear, with no significant slope around or below zero growth, then accelerating with increasing positive growth (see Model 1 in Figure 2). Interestingly, prevalence probably still decreases somewhat (about -0.3 pp/year) at zero growth.

Such results are consistent with earlier observations (e.g. Update Report, 1989, p.16) of an underlying long-term tendency to improvement - associated with such factors as increasing education and falling fertility - disturbed by shorter-term crises, which may be economic, political, environmental, or a combination of these. However, there is perhaps more pessimism now than before concerning what the real long-term nutritional trend is in Sub-Saharan Africa.

Although economic growth is a likely factor in nutritional improvement, the deviation from the rate expected is substantial and important. On a case-by-case basis, many of the points seen in Figure 2 to be improving faster than the average (for growth) seem plausible - e.g. Jamaica (34), Sri Lanka (22), Zimbabwe (12); similarly a number of notably deteriorating cases are well-recognized - e.g. Ethiopia (1), Madagascar (4), Rwanda (6). (Note that the data for India, 1989-92, point 20, are particularly tentative). Nonetheless, factors explaining the better-than-expected deviations should be examined systematically - for example are they related to social expenditures (health, education, etc.)? increased food security? - and preliminary observations outside the scope of this overview, indicate that this may be so.

Figure 2. Plot of Change in Underweight Prevalence by Economic Growth Rate

Country	From.	To
1. Ethiopia	1983,	1992
2. Kenya	1982,	1987
3. Kenya	1987,	1993
4. Madagascar	1984,	1992
5. Malawi	1981,	1992
6. Rwanda	1976,	1985
7. Rwanda	1985,	1992
8. Senegal	1986,	1992
9. Tanzania	1987,	1992
10. Togo	1977,	1988
11. Zambia	1984,	1992
12. Zimbabwe	1984,	1988
13. Egypt	1978,	1988
14. Egypt	1990,	1992
15. Morocco	1987,	1992
16. Tunisia	1975,	1988
17. Bangladesh	1981,	1989
18. Bangladesh	1990,	1993
19. India	1977,	1989
20. India	1989,	1992
21. Pakistan	1977,	1990
22. Srilanka	1980,	1987
23. Indonesia	1986,	1989
24. Malaysia	1983,	1986
25. Myanmar	1982,	1990
26. Philippines	1982,	1990
27. Philippines	1990,	1992
28. Thailand	1982,	1990
29. Viet Nam	1987,	1990
30. China	1987,	1990
31. CostaRica	1982,	1992
32. El Salvador	1975,	1988
33. Jamaica	1978,	1985
34. Jamaica	1985,	1989
35. Panama	1980,	1992
36. Nicaragua	1982,	1993
37. Trin/Tobago	1976,	1987
38. Bolivia	1981,	1989
39. Brazil	1975,	1989
40. Colombia	1980,	1989
41. Peru	1984,	1992
42. Venezuela	1982,	1987

Model 1

GDPR2 - (GDPRATE + 6)
PREV2 = -PREVRATE

PREV2 = 0.3547 -	0.1984 GDPR2 +	0.03148(GDPR2·GDPR2)
	(p = 0.22)	(p = 0.01)

R squared = 0.56
F = 24.9
n = 42

Model 2

PREVRATE	= -0.494 -	0.237 GDPRATE
	(p = 0.000)	(p = 0.000)

R squared =0.47
F = 35.9
n=42

Model 1 is equivalent to: PREVRATE = -0.2976 - 0.1794 GDPRATE - 0.03148 (GDPRATE·GDPRATE)

Table 2 Real GDP/caput Annual Growth Rates (%), by Region

Region1	1980-85	1985-90	1990-92	1985-92
Sub-Saharan Africa	-2.1	-0.4	-1.9	-0.8
Near East/N.Africa	-1.0	0.6	1.1	0.9
South Asia	3.5	1.6	2.5	2.1
South East Asia	1.8	4.6	4.2	4.7
Middle America/Caribbean	-1.3	-0.5	1.3	0.2
S.America	-2.0	-0.2	1.4	-0.2
China	8.5	6.0	7.9	5.9

Source: Calculated from data in: World Bank (1994). World Tables, Fall 1994 Update. Washingon, D.C. (Computer Disk)

Average for 8 countries with nutrition data up to 1992/93 in Sub-Saharan Africa: 1985-90, 1.0%; 1990-92, -3.5%; 1985-92, -0.2%.

Note: 8 countries/dates are: Ethiopia (83-92), Kenya (87-93), Madagascar (84-92), Rwanda (85-92), Senegal (86-92), Tanzania (87-92), Zambia (88-92).

¹ Regional groupings as defined in the Second Report on the World Nutrition Situation, see Vol.I, p.5, and Vol.II, pp. 102-104; the following countries were excluded because of unavailability of GDP data: Sub-Saharan Africa - Angola, Liberia, Somalia, Uganda; Near East & North Africa - Cyprus, Iraq, Jordan, Kuwait, Lebanon, Libya, Syria, United Arab Emirates, Yemen; South Asia - Afghanistan; South East Asia - Lao PDR, Kampochea or Cambodia, Vietnam; Middle America & Caribbean - Cuba.

The country case studies in Chapter 2 are intended to describe recent trends in nutrition. They provide some illustrations of important factors influencing these. Their selection was determined in part by the availability of new data to estimate trends, with particular stress on seeking new information for countries with large populations. Countries included are therefore not systematically selected as representing different situations, although they do in fact cover a range of these.

China and India were obviously important to include, having the largest populations overall, and India having the greatest numbers of underweight children. Bangladesh, with the highest national prevalence estimated in 1990, was included. Brazil was considered a priority for inclusion, due to its population size, although new data were only available for one region. Particular importance was attached to identifying national trend data in Sub-Saharan Africa, because of concern for deterioration. Eight estimates of recent trends were feasible, with important implications as discussed earlier.

The availability of nutritional data has improved to such an extent that it is increasingly feasible to assess trends, and indeed in future it will be more possible to focus selectively on countries of special concern and interest. For this report, 46 trend estimates (country-periods in 35 countries) were available; for the Second Report in 1992, 29 national trends could be assessed (Vol. I, p.11); and for the Update Report in 1989, in only around ten cases could trends be directly estimated. National data (observations at one point in time) are available now from over 100 surveys. The data, compiled by WHO, now usually include prevalences of stunting and wasting, as well as underweight (De Onis et al., 1993), and greater use of these indicators can be foreseen. A number of important publications now regularly include these indicators, such as UNICEF's State of the World's Children and Progress of Nations (e.g. UNICEF (1994 a & b)), UNDP's Human Development Report (e.g. UNDP, 1994), the World Development Report (e.g. World Bank, 1994), and Bread for the World's Annual Hunger reports (e.g. Bread for the World Institute, 1994). These estimates and publications all use the same basic data, and are generally consistent with each other.

Chapters 1 and 2 in this report aim to give a recent picture of nutritional trends, to update the more detailed analysis in the Second Report, and to bridge the gap to the Third Report on the World Nutrition Situation, due in 1995.

Chapter 3 draws attention to the nutritional situation of refugees and displaced people, particularly in Sub-Saharan Africa. This population, rapidly increasing in numbers, is the most seriously affected by malnutrition in the world. Assessment of nutritional conditions, and efforts to improve these, should surely include the worst-off groups. The section draws on information from the two-monthly reports now issued by the SCN, in close collaboration with UNHCR, WFP, and many other organizations, especially non-governmental. Although individual situations vary rapidly - with improvements (such as Mozambique) as well as disasters like in Rwanda and Sudan - the trend in numbers affects, and in severe malnutrition, is ominous. Chapter 3 introduces the topic, gives some details of specific situations in Asia and Africa, and ends by summarizing the nutrition conditions for refugees and displaced people in Sub-Saharan Africa.

References

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ACC/SCN (1992/3) Second Report on the World Nutrition Situation, Volume I, Global and Regional Results; Volume II, Country Trends, Methods and Statistics. ACC/SCN, Geneva.

Bread for the World Institute (1994) Hunger 1995: Causes of Hunger. Fifth Annual Report on the Stale of World Hunger. Bread for the World Institute, Silver Spring, MD 20910, USA.

De Onis, M., Monteiro, C., Akre, J., and Clugston, G. (1993) Worldwide Magnitude of Protein-Energy Malnutrition: An Overview from the WHO Global Database on Child Growth. WHO Bulletin 71 (6:703-712). WHO, Geneva.

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UNICEF (1994 a) The Stale of the World's Children 1994. UNICEF, New York.

UNICEF (1994 b) Progress of Nations. UNICEF, New York.

World Bank (1994) World Development Report 1994. World Bank, Washington D.C., USA.