New estimates of trends in malnutrition show some improvement worldwide, but at a substantially slower rate in the last few years than in the 1980's.1 This slowdown is cause for concern. It means that, while the end of hunger and malnutrition had been coming into sight in the distant future, this prospect is now receding again. For example, at the 1990's rate malnutrition would not be overcome in South Asia for the next 200 years. Goals from the World Summit for Children of 1990, and the International Conference on Nutrition of 1992, of halving the prevalence of malnutrition between 1990 and 2000 are becoming even less likely to be met as the decade goes on. More than ever, further action is needed.
Some of the reasons for this slowdown can be quite readily understood - as touched on in this summary - while others are less clear and need to be elucidated. This is important in order to know how to reverse the falling rate of progress. Poor economic performance in recent years has led to failure to further reduce poverty in many countries, in contrast to the 1980's, having a direct effect on nutrition. Drought in parts of Africa and Asia has also contributed.
At the same time, some important interventions for child health, notably immunization, reached nearly maximum population coverage, so that most of these benefits to nutrition have been achieved, and further progress becomes more difficult.
The proportion of children underweight provides the commonest indicator of malnutrition, and is the main one used here. Being underweight - even mildly - increases risk of death, and inhibits cognitive development in children, leading to less fit and productive adults; moreover it perpetuates the problem from one generation to the next, through malnourished women having low birth weight babies.
As can be seen in Figure 1, the underweight prevalence in South Asia (of which India is over 70% of the population) is around 50%. This is half again higher than the next region, South East Asia, where around one third (32% in 1995) of the children are underweight. Sub-Saharan Africa, in contrast, has a lower prevalence of nearly 30%. The global prevalence (for developing countries) is estimated as 29% in 1995. Translating these prevalences into numbers of children (see Table 1), we can see that over half of the world's underweight children are in South Asia: 85 million out of a global total estimated at about 160 million.
Figure 1. Trends in prevalence of underweight children, 1985-1995
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A MESSAGE In spite of economic difficulties and setbacks in many countries, major advances in nutrition have been made over the last twenty years in many countries in all regions of the world. Rates of malnutrition have fallen by a quarter, the hidden hungers from micro-nutrient deficiencies have been sharply reduced, new capacities have been established and proved themselves in preventing famine at times of natural disaster - as visibly demonstrated in Southern Africa in the early 1990s. Of course, the world still has far to go to eradicate malnutrition and all the threats to nutritional security. And at this very moment, millions of refugees and displaced persons are at risk of death from hunger in Central Africa, the result of conflict, chaos and failures of political leadership. Nevertheless, three important lessons are clear from those areas where nutritional progress has been made: · many improvements in nutrition and food security are possible at low costThe international community has much to contribute to nutritional advance in all these respects, by helping to establish and sustain national efforts of food security and nutrition improvement, in addition to providing vital support for food and emergency aid at times of disaster and conflict. The single most important lesson for accelerating progress in food security and nutrition can be summarized in three words: “Commitment is vital.” This is why we all must welcome the Declaration of the World Food Summit. Commitment to reduce malnutrition is needed at the highest political levels in all countries, backed up by leadership and support elsewhere, particularly from governors and mayors and from all involved in the care and upbringing of children. Those of us involved in the UN's work in nutrition look to the World Food Summit of 1996 to be a major step forward in the march to mobilize action and renew commitment to food security and nutritional progress. We join wholeheartedly in the call to play our part in implementing this plan of action. Hunger and malnutrition can be ended, if we are determined to succeed. Richard Jolly |
The most common pattern seen, either from repeated national surveys or from interpolation methods,2 is an improving trend in the 1980s, becoming relatively slower in the early 1990s, with some evidence for speeding up again in the last year or two. The full set of survey data is given in Table 3, at the end of this paper, showing directly estimated trends. In Sub-Saharan Africa the situation has been nearly static, on average, for the last decade. As discussed later, different patterns are seen in different countries: some like Zimbabwe and Kenya showing the more usual pattern ('90s trend worse than '80s); others such as Madagascar and Zambia the opposite way round (see Figures 2 and 3). But most of Sub-Saharan Africa is now worse off nutrition-ally than 10 years ago.
South Asian trends on average depend substantially on the situation in India, which is revising the process of monitoring child malnutrition so that numbers are particularly uncertain at the moment. The present prevalence levels take account of a recent national survey, which lowered the estimates compared to previous results (from around 61% to 53%), but this represents a revised figure, not itself an improvement. Trends for South Asia shown in Figure 1, derived from model estimates, are in line with results from previous time series data in five states in India; these again showed improvement in the 80's followed by reversal in the early 90's. The overall prevalence change in the last decade was just adequate to bring down numbers of children underweight in South Asia, despite population growth.
In South East Asia the overall trend has been of rapid improvement in the 80's, and slowdown again in the 90's. While part of the slowdown is related to some faltering in economic growth, at various times in different places, this does not seem to give the full story, and careful examination of other factors is needed.
In China, while in 1990-93 rates of improvement were reduced, the average rate (to be treated with caution among one billion people) then picked up. Differential patterns of malnutrition are being reported between urban and rural areas.
Countries in Middle America and the Caribbean, South America, and Near East and North Africa have relatively low prevalences of underweight children, and less far to go to eliminate malnutrition. Yet here too accelerated progress is essential; indeed there is cause for concern to ensure that the trend does not reverse and deteriorate, for example in Middle America and the Caribbean.
Possible future scenarios for prevalences can be examined by looking at the implications of continuing the best and worst rates of change of the last ten years. Calculations (given at the end of this paper) illustrate that by the year 2010, if the best rates were re-established, the prevalences on average in most regions would be half or less of those in 1995. But the most affected regions - South Asia and Sub Saharan Africa - even in the optimistic scenario, would be far from this goal. Poverty reduction coupled with support for agricultural and rural development, for health and education, and with extensive and sustained community based programmes aimed at improving nutrition, have brought about rapid improvement in a number of countries. These have been particularly effective where they have supported and improved the status of women. Such policies could change the scenarios for much of Africa and Asia.
The regional trends in malnutrition are now briefly described in relation to certain causal factors. Conceptually, the framework of the International Conference on Nutrition, itself based on the UNICEF nutrition strategy, which identifies three underlying causes of malnutrition - inadequate household food security, inadequate caring capacity, and insufficient health services and an unhealthy environment - is used to suggest indicators, as shown in the seven regional panels which follow. The choice has also taken account of certain factors known to interact strongly with nutrition, such as female education, expenditures on health and education, and total fertility rate, as well as national income (GNP), poverty levels, and dietary energy supply.
Table 1 - Underweight children by region (0-60 months), 1985-1995
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Region |
Percent Underweight |
Numbers Underweight |
Trend (pp/yr) |
|||||||
|
1985 |
1990 |
1993 |
1995 |
1985 |
1990 |
1993 |
1995 |
1985-90 |
1990-95 |
|
|
Sub-Saharan Africa |
25.8 |
28.0 |
27.8 |
27.2 |
20.9 |
26.0 |
28.3 |
27.8 |
0.44 |
-0.16 |
|
Near East North Africa |
13.0 |
9.9 |
9.6 |
9.6 |
4.1 |
3.4 |
3.4 |
3.4 |
-0.62 |
-0.06 |
|
South Asia |
55.3 |
50.1 |
49.6 |
48.8 |
87.2 |
84.5 |
86.5 |
85.2 |
-1.04 |
-0.26 |
|
South East Asia |
39.8 |
34.2 |
33.1 |
32.4 |
22.3 |
19.8 |
19.5 |
19.1 |
-1.12 |
-0.36 |
|
China |
22.7 |
17.8 |
16.6 |
15.0 |
23.0 |
21.1 |
18.4 |
16.6 |
-0.98 |
-0.56 |
|
Middle America & Caribbean |
18.1 |
15.3 |
15.1 |
15.2 |
3.3 |
2.9 |
3.0 |
3.0 |
-0.56 |
-0.02 |
|
South America |
9.8 |
8.9 |
8.9 |
8.4 |
3.0 |
2.8 |
2.9 |
2.7 |
-0.18 |
-0.1 |
|
Total |
34.3 |
30.7 |
30.4 |
29.3 |
163.8 |
160.5 |
161.9 |
157.6 |
-0.72 |
-0.28 |
|
Total 0-4 Population |
|
|
|
|
476.6 |
523.3 |
533.5 |
537.4 |
|
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