Definition of terms and trends in child malnutrition from 1990 to 2015

Malnutrition is the failure of the body to get the appropriate amounts of nutrients to maintain healthy tissues and organ function. Iron deficiency is common and affects about 18.1% and 20.2% of children globally and in Africa, respectively.2 Worldwide, under-nutrition, including vitamin A and zinc deficiencies, accounts for approximately 3.1 million child deaths annually in low- and middle-income countries. Three anthropometric indices are used to define child nutritional status: weight-for-height (wasting), height-for-age (stunting) and weight-for-age (underweight). For any one of these indices, malnutrition is defined as a z score below −2.0.2 In addition, the WHO reference standards define two categories of severity: severe acute malnutrition (SAM) and moderate acute malnutrition (MAM). SAM is defined as a weight-for-height below −3.0 z scores below the median in children 6–59 months of age, and/or a mid-upper arm circumference (MUAC) <115 mm and/or the presence of bilateral pitting oedema, while MAM is defined as a weight-for-height between −3.0 and −2.0 z scores below the median, or MUAC between 115 mm and 125 mm and no oedema.6 Malnutrition occurring in childhood can have serious health implications later in life.

In developing countries worldwide, the proportion of children aged under-five with stunting decreased between 1990 and 2011 to approximately 26%, but remained high in Africa (36% in 2011) and Asia (27% in 2011). Similarly, the proportion of underweight under-fives dropped globally to 16% between 1990 and 2011.7 However, anthropometric status worsened in sub-Saharan Africa until the late 1990s but improved thereafter. In 2011, 314 million children below 5 years of age were mildly, moderately or severely stunted, and 258 million were mildly, moderately or severely underweight.8

At the other end of the spectrum, overweight malnutrition is beginning to be a public health problem, with a global estimate of 43 million (7%) overweight children under 5 years of age in 2011, a 54% increase from an estimated 28 million in 1990.2

This article focuses on the first three categories of stunting, underweight and wasting.

Child malnutrition, the MDGs and aspects of social epidemiology

MDG1 aims to eradicate extreme poverty and hunger by 2015, by halving (i) the number of people living on less than US$1.25 a day and (ii) the number people suffering from hunger. It also aims to achieve full and productive employment and decent work for all, including women and young people. Of the nine indicators, the author considers the most important to be the two addressing a reduction in the prevalence of underweight children and the proportion of the population consuming less than the minimum required dietary energy.

Available evidence indicates that the world will not achieve MDG1. Of even more significance are the uneven rates of achievement in different parts of the globe. For instance, the largest decline in the prevalence of malnutrition has been in East Asia, especially in China, while substantial improvements have been made in Latin America and the Caribbean. However, less progress was seen in South Asia, where the prevalence of underweight remains very high, while sub-Saharan Africa saw little or no change over the period 1990–2011.8 Another worrying aspect is the urban/rural disparity in the rate of reduction in most countries. Thus, children in rural communities are more malnourished than their urban counterparts. In some countries, the percentage of rural children who are underweight is over 50% higher than for urban children.9

Thus, rates of reduction in the prevalence of the various categories of child malnutrition vary among different income groups worldwide, and the projections of WHO, UNICEF and the World Bank indicate the 2015 target will not be met with the present rates of progress.8

Basic education, particularly of girls, is very important for achieving the MDGs. However, female education still lags behind that of males in some African countries. For instance, youth literacy rates for 2007–2011 for males and females, respectively, were 76% and 67% in sub-Saharan Africa, 80% and 72% in East and Southern Africa, and 73% and 61% in West and Central Africa, compared to a world average of 92% and 87%.10 Maternal mortality rates are still relatively high in African countries; the adjusted 2010 figures for sub-Saharan Africa, Eastern and Southern Africa, West and Central Africa and the world average are 500, 410, 570 and 210 per 100 000 live births, respectively.11 The picture was equally bleak a decade ago regarding the general HIV situation in Africa,12 but there is now some light at the end of the tunnel. Currently, more than 7 million people in Africa are accessing HIV treatment, and there were 33% fewer AIDS-related deaths in Africa in 2011 than in 2005, ranging from 25% less in Chad to 71% less in Botswana. Improvements in anti-retroviral therapy are a cause for optimism since HIV has slowed down advances in various areas, particularly education.13

Bridging the gaps

Attempts to bridge the gaps between the MDGs and the current position should give priority to the vital role of adequate nutrition in the first 5 years of life, particularly the critical first 3 years of rapid brain development. Unhealthy children cannot be properly educated, while uneducated children cannot be fully healthy. Well-nourished children have a better chance of surviving, of learning easily, and of growing into healthy adults. Therefore, it is vital to ensure adequate nutrition from the neonatal period, through infancy, preschool and early childhood into adolescence.

Concluding remarks

Nutritional status reflects deprivation related to living conditions. Thus a child may be malnourished not because their parents are poor, but because of other related reasons. Socioeconomic factors and particularly the educational level of the mother, access to clean water and sanitation, infant feeding practices and freedom from illness, especially diarrhoeal disease, are all important.

The eight MDGs provide a framework by which progress can be assessed. Progress measured at the global, regional and country level indicates the feasibility of the MDGs at that level. In addition, global trends are estimates and not actual values, and the method of data collection may be unreliable and challenge the very concept of the MDGs.

The deadline for the MDGs is 2015 and all, including the least developed nations, are attempting to meet this target. However, given the economic, social and political circumstances of some countries, this goal will not be achieved. Caution is therefore advised regarding premature claims by some leaders, particularly in sub-Saharan Africa, that MDGs have been met.

The overall strategy should be one of careful and meticulous short, medium and long term planning involving all development sectors with an emphasis on a bottom-up approach within a stable and disciplined polity. Progress has to be sustained and implementation rigorously monitored. The setting of deadlines, whether 2015 or 2035, should be not be emphasised to avoid hasty decisions as the finishing line is not necessarily the same for all. The most urgent need now is peace as well as good governance with equitable distribution of national and international resources. Sustained development is not possible in the midst of social chaos.23 The MDGs will be useful tools only if they are seen as multifaceted and co-ordinated rather than as narrow objectives requiring simple interventions.

The top priority should be implementation of the essential social services of basic education, PHC, nutrition, reproductive health care, water and sanitation in partnership with the developed economies.24 It is from this perspective that child nutrition has been discussed, because adequate infant nutrition guarantees optimal child growth, and only when this has been achieved for the majority will governments be able to accelerate sustained economic development.25