Hunger and malnutrition in the 21st century

Characterising the problem

A recent report for the World Committee on Food Security argued that “malnutrition in all its forms—not only hunger, but also micronutrient deficiencies, as well as overweight and obesity—is … a critical challenge not only in the developing but also in the developed countries. Resolving malnutrition requires a better understanding of the determinants and processes that influence diets.”1 Malnutrition ranges from extreme hunger and undernutrition to obesity (box 1).23 Furthermore, malnutrition is found in all countries, irrespective of their economic development, where people lack high quality diets.456 Thus, solutions to hunger and to all forms of malnutrition need to focus on ensuring an adequate supply of food, but equally, on the quality of diets.

Today, risk factors for ill health associated with poor quality diets are the main causes of the global burden of disease.56 Low quality diets lack key vitamins, minerals (micronutrients), and fibre or contain too many calories, saturated fats, salt, and sugar.7 In 2010, dietary risk factors combined with physical inactivity accounted for 10% of the global burden of disease (measured as disability adjusted life years, which reflect the number of years lost due to ill health, disability, or early death).8 By 2015, six of the top 11 global risk factors were related to diet, including undernutrition, high body mass index (BMI), and high cholesterol.910 Where governments have invested the economic gains derived from rising productivity in safety nets and services accessible to the poor, this has resulted in national growth.111213 However, where poverty persists, including in rich nations, hunger also persists.

Several faces of hunger

Hunger is a broad unscientific term that relates to nutrition and health outcomes in various ways. The proportion of people defined as hungry over the long term (usually termed “chronically undernourished”) fell from 18.6% globally in 1990-2002 to under 11% in 2014-16 (table 1). That was a decline of 211 million people while the world’s population increased by 2 billion.2 Big gains were made in large countries like China and in Brazil, Ethiopia, and Bangladesh (box 2). South America was particularly successful, reducing undernourishment by over 50% in 25 years.1 Such gains were made possible largely by rapid reduction of poverty, rising levels of literacy, and health improvements that reduced preventable child mortality.17

However, despite such progress the world still has unacceptably high numbers of undernourished people. Of the roughly 800 million undernourished, 780 million are in low income countries, especially in sub-Saharan Africa and South Asia.1 The continents of Africa and Asia have the greatest number of people living in extreme poverty, and it is here that extreme hunger and poverty together present the greatest risk of famine.

Famine is the most acute face of hunger. Over 70 million people died in famines during the 20th century.222324 Most deaths occurred in human induced crises, in which political mismanagement, armed conflict, and discrimination of marginalised political or ethnic groups compounded the effects of environmental shocks, such as droughts or locust invasions.25 Deaths from famine fell from the mid-1980s onwards. However, as of 2017 four countries were again struggling to cope: Somalia, Yemen, South Sudan, and Nigeria.26 In each case, instability induced by conflict, terrorism, drought and decades of failed governance have left over 20 million people facing famine, including 1.4 million children “at imminent risk of death.”27

A major cause of mortality in famines is children becoming severely wasted. Around 52 million children were wasted in 2016, of whom around 70% (36 million) resided in Asia (table 1).14 Roughly 12.6% of deaths among children under 5 are attributed to wasting worldwide.28 Although wasting has declined, progress has been slow and some countries have seen a rise, including Pakistan and India.29 Many of the drivers of wasting are often the same as for stunting—namely, low birth weight, lack of exclusive breast feeding, poor hygiene and sanitation, and infectious disease.30 While wasting is one sign of acute hunger, stunting (being too short for one’s age) represents chronic distress. Around 151 million preschool children were stunted in 2017, down from 200 million at the turn of the 20th century.14 Improvements were made in east Asia, including China (today reporting a prevalence of only 6% compared with the global mean of 23%) and Bangladesh as well as in Latin America (table 1).31 Nevertheless, South Asia and East and Central Africa all still had rates over 32% in 2017.

Coexisting forms of malnutrition related to diet

The coexistence of multiple forms of malnutrition is a global phenomenon. That is, wasting often coexists with stunting in the same geographical areas, and can be found simultaneously in children.32 For example, around 9% of children in India exhibit both conditions, while the rate in parts of Ghana is reported to be >3%.3233 Many countries with a high prevalence of stunting have made limited progress in achieving annual average rates of reduction required to meet global targets. For example, Timor Leste needs an annual reduction of around 5% to reduce stunting by 40% by 2030, but its current reduction rate is barely above zero.9 Ethiopia also needs an annual average rate of reduction of 5%, but continues to remain at 3%.

Part of the reason for slow progress lies in overlapping micronutrient deficiencies. Inadequate supply of energy and protein both impair a child’s growth, but micronutrient deficiencies also have a role. It has been estimated that roughly 2 billion people, or about 29% of the world’s population, faced micronutrient deficiencies in 2010.34353637 Micronutrient deficiencies are also widely present in high income countries. For example, childhood anaemia in 2010 was 26% in the Russian Federation and in Georgia, and 16%, on average, across the European Union.38

Obesity is conventionally associated with food excess, but it is also associated with micronutrient deficiencies and even with daily hunger, as shown for Malaysia,39 Canada,40 and Iran.41 Indeed, people with obesity can be prone to deficiencies of micronutrients, such as zinc, iron, and vitamins A, C, D, and E.4243444546 Between 1990 and 2010, the prevalence of adults with a high BMI in sub-Saharan Africa tripled. At the same time, hypertension increased by 60%, and the prevalence of high blood glucose rose nearly 30%.47The prevalence of overweight and obesity among South Asian women is almost the same today as the prevalence of underweight.6 Pacific and Caribbean islands and countries in the Middle East and Central America have reached extremely high rates of adult overweight and obesity. Some have a prevalence as high as 80% (eg, Tonga, 84% for men, 88% for women).48

Many countries today face the dual burden of rising rates of female obesity with continuing high rates of maternal underweight. The latter matters because of ill effects on the mother and on the unborn child. Roughly 30% of stunting by a child’s 3rd birthday can be attributed to being born small for gestational age, which is linked to nutrition before birth and health problems of the mother.28 Not only is maternal underweight still more prevalent than overweight in rural parts of South Asia and sub-Saharan Africa but adult female underweight rose recently in Senegal, Madagascar, and Mali, mainly in urban settings.49

Thus, actions are needed in all countries around the world to deal with undernutrition, micronutrient deficiencies, and overweight and obesity simultaneously. No country is exempt. “Triple duty” investments are needed everywhere because wealth and food sufficiency will not in themselves resolve the problems of low quality of diets.

Effective actions to tackle hunger and malnutrition

In 2016, the world hit a new record by producing over 2.5 billion metric tons of cereal grains—up from 1.8 billion tons 20 years earlier.50 But hunger persists because an increased supply of food alone is neither the solution to hunger nor an answer to malnutrition. Countries that have made recent progress in reducing hunger and improving nutrition have a core set of common characteristics. Firstly, they tend to be politically stable countries that have pursued relatively equitable growth policies (not only increasing wealth for some but reducing poverty overall). Secondly, they employ targeted safety nets for the poor and invest in accessible services (education, clean water, healthcare). Thirdly, they assume responsibility for responding to shocks (economic, environmental, or due to conflict) in timely ways that mitigate human suffering.

Successful actions typically include a mix of targeted so called nutrition specific programming (aimed at preventing or resolving defined nutrition and health problems in individuals) and nutrition sensitive interventions for the whole population that deal with the underlying causes.93235Table 2 provides details of evidence based policies and programmes in a variety of sectors, which are known to reduce hunger and deal with malnutrition.32 In food and agriculture, these may include national price support interventions that increase the supply and accessibility of nutrient rich foods (often perishables, like dairy, fruits and fresh meats), coupled with technical and financial support for women farmers to produce nutrient rich vegetables in their gardens. In health, national policies to support accessible high quality services are critical to ensuring antenatal and postnatal care, particularly combined with targeted nutrition, exclusive breast feeding, and infant feeding messaging. Measures directed at underweight mothers are important for good birth outcomes, as well as varied forms of micronutrient supplementation.1 In other words, the quality of services, scale of coverage, and the singling out of nutritionally vulnerable demographic groups are all keys to success.2047

Good nutrition and eradication of hunger comes at a price, but pays for itself in the longer term. Donor funding for nutrition sensitive programmes rose between 2003 and 2015, from 11.8% to 19.4%, reaching around $19bn (£14bn, €16bn) in 2015.48 Such assistance is deemed to be effective, in that a 10% increase in overall nutrition sensitive aid delivers an estimated 1.1% “decrease in hunger” (measured as chronic undernourishment).48 The World Bank has argued that a “priority package” of evidence based nutritional interventions that could be readily scaled up would require roughly $23bn over a decade, or $5 per child.5152 The World Bank emphasises that while international donor agencies should increase spending to achieve global nutrition goals, national governments and citizens themselves need to increase spending and act appropriately. The role of individuals and families comes largely in the form of preferences and constraints.52 People make choices that shape dietary patterns and physical activity but also the uptake of healthcare services, spending on smoking and hygiene, as well as investments in schooling for their children and agricultural productivity (if farmers).

The value of such large investments to future human and economic development has long been understood in high income countries, such as Europe and the United States. European countries deploy a wide range of policies to combat residual hunger. These include promoting more diverse local food production and diversified diets, the latter “encouraged through nutrition education targeting school children and mothers of young children.”38 The United States also supports large state food provisioning through nutrition programmes aimed at women and children. For example, spending on the federal food stamp programme in 2017 reached $68bn ($126 per person).53 Similarly, spending on the Women Infants and Children programme, which targets low income families nutritionally at risk with food supplements, nutrition education, and health system referrals, reached $6.5bn in 2017.54