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The Challenge of Hunger and Malnutrition

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The Challenge of Hunger and Malnutrition Challenge Paper The Challenge of Hunger and Malnutrition Sue Horton, Harold Alderman, Juan A. Rivera This paper was produced for the Copenhagen Consensus 2008 project. The fi nal version of this paper can be found in the book, ‘Global Crises, Global Solutions: Second Edition’, edited by Bjørn Lomborg (Cambridge University Press, 2009) copenhagen consensus 2008 malnutrition and hunger Challenge Paper Copenhagen Consensus 2008 Challenge Paper Hunger and Malnutrition Sue Horton, Harold Alderman and Juan A. Rivera Draft, May 11 2008 Sue Horton Vice-President Academic, Wilfrid Laurier University Waterloo On N2L 3C5, Canada [email protected] Harold Alderman Social Protection Advisor – Africa Region World Bank, 1818 H Street NW Washington DC, USA [email protected] Juan A. Rivera Director, Center for Research in Nutrition and Health National Institute of Public Health, Mexico [email protected] 1 copenhagen consensus 2008 malnutrition and hunger Challenge Paper Despite significant reductions in income poverty in recent years, undernutrition remains widespread. Recent estimates published in the Lancet (Black et al 2008) suggest that “maternal and child undernutrition is the underlying cause of 3.5 million deaths, 35% of the disease burden in children younger than 5 years, and 11% of total global DALY’s” (Disability-Adjusted Life Years). Undernutrition can be indicated both by anthropometric indices (underweight, stunting and wasting) and with missing micronutrients in poor quality diets. Undernutrition in turn has negative effects on income and on economic growth. Undernutrition leads to increased mortality and morbidity which lead to loss of economic output and increased spending on health. Poor nutrition means that individuals are less productive (both due to physical and mental impairment), and that children benefit less from education. The previous 2004 Copenhagen Consensus paper on the topic discusses these mechanisms in detail (Behrman, Alderman and Hoddinott, 2004, hereafter BAH 2004). Reducing undernutrition is one of the Millennium Goals (Goal 1 aims to eradicate extreme poverty and hunger), and is also a key factor underpinning several others. Achieving goals in primary education, reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases all depend crucially on nutrition. There are cost-effective interventions for improving nutrition. Section I below discusses the challenge in more detail, section II describes selected priority solutions, section III undertakes more detailed economic analysis of these solutions, and the fourth and final section discusses the implications of the analysis. This chapter builds on and updates previous detailed analysis from the 2004 Copenhagen Consensus (BAH 2004), and focuses on pushing the analysis for some solutions further than was possible at that time, adding analysis of some additional solutions, and incorporating what is new from the extensive research literature on nutrition interventions. 1. The Challenge Available data tend to highlight nutritional deficiencies in the under-five population, where consequences are very obvious (high mortality, losses in cognitive development) – but obviously nutritional deficiencies are also important in the other 88% of the developing world’s population. Nutrition in the under-fives depends critically on nutrition of their mothers during pregnancy and lactation. Black et al. (2008) summarize the most up-to-date data on nutritional status. The data they use include anthropometric measurements expressed relative to expected body measurements in healthy populations, and estimates of micronutrient deficiencies based on serum determinations and food intake. The FAO provides regular updates on world hunger, in the World Food and State of Food Security in the World Reports (hunger is measured by data on aggregate food availability and patterns of distribution). 2 copenhagen consensus 2008 malnutrition and hunger Challenge Paper South Asia alone accounts for almost half of the world’s population of stunted children less than five (73.8 of the 177.7 million), and 10.3 of the 19.3 million severely wasted children. Africa accounts for another 56.9 million of the stunted and 5.6 million of the severely wasted (Black et al., 2008). (Stunted is defined as more than 2 standard deviations below the population standard for height-for-age, and severely wasted is more than 3 standard deviations below the standard for weight-for-height.) Underweight is declining in most regions, although only in a couple of regions (East Asia/Pacific, and Latin America/Caribbean) has it declined at a rate fast enough to meet the Millennium goals. Underweight is increasing in two regions (Eastern/Southern Africa; and Middle East/North Africa where three large countries are experiencing conflict): UNICEF (2006). Underweight (weight-for-age) is a less precise measure of chronic nutritional status, but trends in stunting and wasting are less readily available. Micronutrient undernutrition is generally correlated with overall undernutrition, since poverty limits both the quality as well as quantity of food in the diet. There are some exceptions, such as iodine deficiency where iodine deficiency in the soil (dependent on geographic factors) has important impacts on dietary intake, if people rely mainly on local food. • Prior to widespread salt iodization in the developing world, an estimated 633 million individuals suffered from goiter (World Health Organization, 2003): currently 31% of developing-world households still do not consume iodized salt and are therefore not protected (UNICEF 2006). The lagging countries are in sub- Saharan Africa, South Asia and Central and Eastern Europe/Commonwealth of Independent States. • UNICEF (2006) estimates that 100-140 million children (mainly in South Asia and sub-Saharan Africa) are still deficient in vitamin A, despite supplementation efforts in many countries. • An estimated 2 billion individuals worldwide suffer from iron deficiency, of whom more than half are in South Asia. Progress has been very difficult although policy efforts are intensifying considerably. Age and reproductive status is as least as importance as poverty in determining iron deficiency. • Zinc deficiency is hard to measure but tends to be correlated with iron deficiency and low animal food intake. IZINCG (2004) estimates that 20% of the world’s population is at risk for deficiency based on food intake patterns. • Concern over folate is relatively new. Although diets based on unrefined grains and beans (such as those in many rural areas of developing countries) tend to have good folate content, small studies for India and China find high incidence of birth defects, perhaps related to refined rice as the main staple. More work is needed. The very significant societal and economic consequences of undernutrition are categorized in an entire section of BAH (2004). They group the consequences into resource losses due to higher mortality and morbidity, direct links between nutrition and 3 copenhagen consensus 2008 malnutrition and hunger Challenge Paper physical productivity, and indirect effects on productivity via cognitive development and schooling, and provide an extensive literature survey. Many studies provide estimates of the billions of dollars of economic losses attributable to undernutrition, e.g. World Bank (2006), Horton (2004). Since the publication of the 2004 Copenhagen Consensus volume, there have been additional research studies extending our knowledge of the consequences of undernutrition. Some of the more significant ones are longitudinal studies providing direct documentation of the effects in later life of undernutrition in early childhood, rather than relying on inference. In inferential studies, for example, micronutrient supplementation in childhood is known to increase cognitive scores, and cognitive scores in adulthood are known to affect wages and hence productivity, hence the effect of childhood supplementation on wages can be reliably inferred. BAH (2004) relied mainly on such studies, bolstered in some cases by comparison of twins or natural experiments. The new – and relatively few - longitudinal studies link data on childhood nutrition interventions directly to wages and other outcomes for those same individuals upon reaching adulthood. These studies confirm the general reliability of the inferential studies and also offer additional insights. One important recent study tracks the consequences of an intervention supplying protein and micronutrients, originally undertaken between 1969 and 1977 in Guatemala. The individuals were re-surveyed in 2002-04, by which time the individuals were between 25 and 42 years old, and had participated in the intervention for varying numbers of years at varying ages below age seven. The results in one paper (Hoddinott et al., 2008) show that wages for men who had received supplements below age three had wage rates which were 34 to 47% higher than those of the controls, and annual incomes 14 to 28% higher. Effects for women were not significant, which the authors attribute to women’s paid labor market participation being largely restricted to low productivity activities such as agricultural processing in this region. Another paper from the same study documents that exposure to the supplement before age two was associated with increased schooling by 1.2 years for women, an increase in reading comprehension by 17% for men and women, and an increase in performance on Raven’s
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