Undernutrition, Poor Feeding Practices, and Low Coverage of Key Nutrition Interventions
OBJECTIVE: To estimate the global burden of malnutrition and highlight data on child feeding practices and coverage of key nutrition interventions.
METHODS: Linear mixed-effects modeling was used to estimate prevalence rates and numbers of underweight and stunted children according to United Nations region from 1990 to 2010 by using surveys from 147 countries. Indicators of infant and young child feeding practices and intervention coverage were calculated from Demographic and Health Survey data from 46 developing countries between 2002 and 2008.
RESULTS: In 2010, globally, an estimated 27% (171 million) of children younger than 5 years were stunted and 16% (104 million) were underweight. Africa and Asia have more severe burdens of undernutrition, but the problem persists in some Latin American countries. Few children in the developing world benefit from optimal breastfeeding and complementary feeding practices. Fewer than half of infants were put to the breast within 1 hour of birth, and 36% of infants younger than 6 months were exclusively breastfed. Fewer than one-third of 6- to 23-month-old children met the minimum criteria for dietary diversity, and only ∼50% received the minimum number of meals. Although effective health-sector–based interventions for tackling childhood undernutrition are known, intervention-coverage data are available for only a small proportion of them and reveal mostly low coverage.
CONCLUSIONS: Undernutrition continues to be high and progress toward reaching Millennium Development Goal 1 has been slow. Previously unrecognized extremely poor breastfeeding and complementary feeding practices and lack of comprehensive data on intervention coverage require urgent action to improve child nutrition.
WHAT'S KNOWN ON THIS SUBJECT:
Despite significant improvements in the past 3 decades, childhood undernutrition in developing countries continues to be a serious and persistent public health problem. Stagnation in Africa coupled with population growth has resulted in increasing numbers of affected children.
WHAT THIS STUDY ADDS:
Children in developing countries are poorly fed: only 36% of infants younger than 6 months were exclusively breasted, and fewer than one-third of 6- to 23-month-old children met the minimum criteria for dietary diversity. Coverage data are lacking on key nutrition interventions.
Adequate nutrition is essential for achieving Millennium Development Goal (MDG) 1, which is to eradicate extreme poverty and hunger, as well as MDGs 4 and 5, which are to reduce child mortality and improve maternal health. The links between early childhood nutrition and child mortality are well documented.1 However, the importance of nutrition goes beyond survival and includes improved cognitive development and other short-term and long-term health benefits.2,3 Child nutrition, particularly length/height for age, is a powerful measure of population-level well-being.4 In 2008, the Lancet series on maternal and child undernutrition drew renewed attention to the magnitude of mortality and the global burden of disease associated with poor nutrition.5 Maternal and child undernutrition are associated directly or indirectly with more than one-third of the 8.1 million deaths that occur among children younger than 5 years annually.6 The Lancet series systematically identified a set of 13 health-sector–based direct interventions to improve infant and young child nutrition.7 However, little is known about the proportion of children who receive them and where the information gaps are most severe.
Although appropriate breastfeeding and complementary feeding practices are critical for child growth and development,8 limited knowledge about the type, scale, and distribution of these practices has impeded action. To fill this gap, the World Health Organization (WHO) and their partners have initiated a process to identify new reliable and valid indicators to assess infant and young child feeding practices.9,–,12 The work was facilitated by the guiding principles for feeding of breastfed and nonbreastfed children aged 6 to 24 months13,14 and in 2008 resulted in consensus and publication of 8 core and 7 optional indicators.10
We present here new data on levels and trends of underweight and stunting in children younger than 5 years as of 2010 that are based on a much larger and more recent set of national nutritional surveys than used previously,5 and we assessed progress toward achieving MDG 1 according to United Nations (UN) region. We also present data that illustrate the new infant and young child feeding indicators, which highlight critical dimensions of both breastfeeding and complementary feeding practices and available coverage data of the nutrition interventions recommended in the Lancet series.7 We discuss our findings in the context of new initiatives and policy and programmatic opportunities to tackle the unfinished agenda of eradicating childhood undernutrition.
Cross-sectional data on the prevalence of underweight and stunting were obtained from national nutrition surveys in the WHO Global Database on Child Growth and Malnutrition.15 Underweight is the selected indicator for monitoring MDG 1. However, we also report on levels and trends of stunting (or low length/age or height for age), because stunting reflects the accumulated consequences of poor growth16; in some countries, its trends differ from trends in underweight, which leads to a different interpretation of progress.17 Respective statistics for wasting are also presented.
Nationally representative surveys from 147 countries with data on underweight (608 surveys) and stunting (576 surveys) were available for the analysis from the WHO Global Database on Child Growth and Malnutrition (www.who.int/nutgrowthdb/en). All surveys included boys and girls, and age groups ranged from birth to 5 years; only 37 of 608 surveys (6%) did not cover the whole period. Underweight, stunting, and wasting were defined as the proportion of children who were at less than −2 SDs of the weight-for-age, length/height-for-age, and weight-for-length medians in the WHO child growth standards, respectively. Linear mixed-effects modeling was used to estimate prevalence rates and numbers of affected children according to region from 1990 to 2010. This methodology, used in previous trend analyses,5,18 is described in detail elsewhere.19 In brief, a single linear mixed-effect model was considered for each group of subregions that belonged to the same region. The model includes interactions between time and subregions and allows for random intercept and slopes among countries. The fitting was performed on the logistic transform (“logit”) of the prevalence. To account for the different country populations by using corresponding survey year, we conducted weighted analyses. For the regional level, prevalence estimates were derived by using the sum of the estimated numbers affected in the subregions divided by the total population of children younger than 5 years in that region. Thus, this overall regional estimate is the weighted average of the subregion prevalence estimates. Analyses were performed by using SAS 9 (SAS Institute, Inc, Cary, NC). Countries were grouped into regions and subregions following the UN classification system.20 The number of affected children younger than 5 years in 2010 was estimated by using the 2008 edition of World Population Prospects.21
We applied recently published indicators of infant and young child feeding practices10,–,12 to data from Demographic and Health Surveys (DHSs) in 46 developing countries between 2002 and 2008. We aggregated the data to report on median prevalence for countries grouped according to UN region. The data represent 82%, 58%, and 22% of the population of children younger than 5 years in Africa, Asia, and Latin America and the Caribbean, respectively. The core list of practices, defined in Supplemental Table 4, includes new indicators for dietary diversity (a proxy for adequate micronutrient density of foods and liquids other than breast milk), feeding frequency (a proxy for adequate energy intake from complementary foods), and minimum acceptable diet for children aged 6 to 23 months (a composite indicator). Results for the latter 2 indicators could only be calculated for breastfed children.
The only adjustments made in the calculation of the dietary-diversity indicator are as follows. Children who consumed items such as Papilla (Ministry of Health, Lima, Peru) or Bienestarina (Ministry of Health, Bogota, Colombia) received a point for 2 food groups (dairy products and grains, roots, and tubers), because Papilla and Bienestarina include both milk powder and grains. Eggs were included in the poultry food group in the 2007 Bangladeshi DHS, the 2007 Indonesian DHS, and the DHSs conducted between 2002 and 2005. Therefore, children who were reported to have eaten poultry also received a point for eggs in these surveys. To examine population-based coverage of core nutrition interventions, we identified that such data are mainly available for micronutrient interventions and undertook new analyses by using DHS data from 46 countries (2003–2009) to examine intervention coverage (ie, the percentage of mothers aged 15–49 years who received any iron tablets or syrup during pregnancy for the most recent birth and the percentage who received iron tablets/syrup for ≥90 days; and the percentage of households with salt tested for iodine levels that contain ≥15 ppm). We also analyzed DHS data from 12 countries (2005–2008) to examine the percentage of mothers who reported that their child received zinc for treatment during diarrhea. For vitamin A supplementation, we used the most recent data reported by the Countdown to 2015 report,22 which focused on 68 countries with a high burden of maternal and child mortality.
Globally, in 2010, 27% (171 million) of children younger than 5 years were estimated to be stunted, 16% (104 million) were underweight, and 9% (55.5 million) showed wasting (Fig 1). The overall prevalence of underweight is quite similar in Africa and Asia (19%) and considerably higher than in Latin America and the Caribbean (3%). The overall prevalence for stunting is higher in Africa (38%) than in Asia (28%); however, in absolute numbers of those affected, many more children are stunted in Asia compared with Africa (100 vs 60 million children). In all regions, the prevalence of stunting is much higher than underweight (eg, in Latin America stunting is 4 times more prevalent than underweight). Undernutrition is more prevalent in rural than in urban areas. There were no systematic gender-specific differences. Country-specific data disaggregated by age, gender, urban/rural area, and region are available from the WHO Global Database on Child Growth and Malnutrition (www.who.int/nutgrowthdb/en).
Trends for child underweight (1990–2010) together with calculations of current average annual changes (AACs) in prevalence (percentage points per year) based on our modeling estimates are presented in Table 1. The AAC reflects progress toward attaining MDG 1 based on a target of halving the 1990 prevalence of underweight among children younger than 5 years by the year 2015. The current AAC echoes progress between 1990 and 2010, whereas the required AAC reflects necessary rates from 2010 onward to achieve MDG 1. The estimated overall prevalence in developing countries of underweight in 2010 was 18%. Trends within UN regions and subregions reveal that in Africa, the average annual reduction was only 0.1 percentage points per year for the region as a whole, which is far below the required 1.7 percentage points per year needed in the next 5 years to achieve MDG 1. The situation was particularly grave in the southern Africa subregion, where prevalence was estimated to be increasing slightly.
In eastern, south-central, and southeastern Asia there has been steady progress in reducing the prevalence of underweight, up to the rates required to meet the target for MDG 1. However, trends in China and India substantially drive those in Asia and, indeed, in the developing world; the dramatic decrease in underweight and stunting shown in eastern Asia can be explained by the improvements experienced in China. For the overall regional estimates of Asia, underweight rates increased considerably (from 19.5% to 24.7%) when China was excluded. This result was expected, because China's underweight prevalence among children younger than 5 years was 6.8% in 2002 compared with 17.4% in 1992,23 which means that the undernutrition target for MDG 1 was achieved in China some years ago. For stunting, rates in Asia also increased considerably (from 27.6% to 32.9%) when China was excluded (data not shown). Countries in South America and Central America and the Caribbean had low prevalence of underweight, and they have generally experienced annual reductions at a rate that is appropriate or greater than that required to achieve the 2015 target. Countries that drive regional trends are those that combine high prevalence of undernutrition with large child populations; mainly China and India in Asia; the Democratic Republic of Congo, Ethiopia, Nigeria, and Sudan in Africa; and, Bolivia, Guatemala, Haiti, Honduras, and Peru in Latin America.
Although trends in the estimated prevalence of stunting among children younger than 5 years from 1990 to 2010 were generally similar to those for underweight (Table 2), stunting rates were substantially higher than underweight rates in all regions. Although they generally move in the same direction over time, the same is not so for the Latin America region, where stunting rates (13%) remained above target (reaching 30% in several Andean countries and >50% in Guatemala) despite substantial declines in the prevalence of underweight (3%). The divergence was less prominent in the Caribbean and strongest in Central American and Andean countries.
Indicators of Infant and Young Child Feeding Practices
Few infants and young children benefit from optimal breastfeeding and complementary feeding practices (Fig 2; Supplemental Table 5).12 Fewer than half of infants were put to the breast within 1 hour of birth. The prevalence of exclusive breastfeeding among infants younger than 6 months was low (36%), and the rate decreased further when data were disaggregated to include only infants aged 4 and 5 months (18%). Only ∼60% of children received age-appropriate breastfeeding (defined as the proportion of infants younger than 6 months who were exclusively breastfed and the proportion of children aged 6–23 months who continued to receive breast milk while being given complementary foods).
When children have completed 6 months of age they require adequate and safe complementary foods in addition to breast milk; however, fewer than one-third of children aged 6 to 23 months met the minimum criteria for dietary diversity. The exceptions were countries in Latin America and the Caribbean, where 71% of children consumed at least 4 food groups on the day before the survey. The median proportion of breastfed children who received the minimum number of meals of complementary foods was only 50%. When indicators of dietary diversity and minimum meal frequency were combined and reported as the minimum acceptable diet for breastfed children, only 21% of children aged 6 to 23 months met the minimum criteria; the low was 16% in countries of the African region. The country profile shown in Fig 3 illustrates the range of indicators that are now available for assessing infant and young child feeding practices and can be collected in population-based surveys in a standard way.12
Coverage of Health-Sector–Based Interventions
Of the 13 interventions recommended in the Lancet series on maternal and child undernutrition,7 information about coverage from the DHSs is only available for 5 of them: iron and folic acid supplementation to women during pregnancy; vitamin A supplementation for children; use of zinc supplements during treatment of diarrhea; and fortification of salt with iodine (as assessed through the presence of iodized salt in the house and listed separately for all women with a birth in 5 years preceding the survey and for children younger than 5 years) (Table 3). No other source of data provides nationally representative information for a large number of countries; thus, intervention-coverage data on the other 8 interventions are not available.
The percentage of mothers who received any iron tablets during pregnancy ranged from 52% to 75%; however, those who received them for ≥90 days was lower (range: 17%–43%) (Fig 4). The proportion of households with iodized salt was better and ranged from 47% to 77% (data not shown). Coverage of zinc supplementation among children who had diarrhea in the 2 weeks that preceded the survey and whose mothers sought treatment at a health facility was extremely low (range: 0.2%–2.4%) (data not shown). According to a recent report, vitamin A supplementation reached 81% among children younger than 5 years.24
Despite significant improvements in the past 3 decades, the rate of childhood undernutrition continues to be unacceptably high in many countries. These updated results for 2010 are in line with those published for 2005 by Black et al5 and for the period 2003–2008 by the United Nations Children's Fund.25 Although both Africa and Asia have a similar prevalence of undernourished children, Asia has the largest number affected because of its larger population size.23 However, the stagnation in Africa coupled with population growth has resulted in increasing numbers of affected children. The high prevalence of stunting compared with underweight underlines the need to better target interventions to address its direct determinants, including improving overall dietary quality and diversity, rather than focus solely on adequate energy and weight gain. It also calls for better integration of nutrition interventions with prevention and treatment of common childhood illnesses that interact synergistically with poor diet in the etiology of stunting26,27 and play an important role in early childhood growth failure.28
Our data on feeding practices provide compelling evidence that interventions for improving exclusive breastfeeding and complementary feeding must be strengthened and expanded. It is sobering to note that only 34% of infants younger than 6 months were exclusively breastfed in the 29 African countries, and this rate declined to 17% among infants aged 4 to 5 months. In addition, fewer than half of African children received the minimum meal frequency and <1 of 6 African children aged 6 to 23 months (in the 26 countries for which data are available) met the criteria for a minimum acceptable diet.
Data to determine the causes of poor feeding practices are not available, although cultural beliefs and knowledge paradigms are known to influence feeding practices.29 For breastfeeding, possible explanations might be low coverage and poor quality of counseling, and/or the lack of a supportive environment that would allow mothers to adopt the recommended practices. For complementary feeding, possible explanations are likely related to both lack of economic access to sufficient quality and quantity of foods and low coverage and poor quality of counseling as well as the lack of a supportive environment. Quality of foods is as important as quantity, and dietary diversity has been shown to be associated with micronutrient density of the diet and, therefore, the nutrient adequacy of complementary foods.30 Dietary diversity is also correlated with height-for-age z scores.31 The lack of communication strategies for reinforcing messages about recommended practices might also play a role.
Our data show a paucity of information on nutrition-intervention coverage. When data exist, they reveal a large gap between the current situation and the goal of reaching all women and young children. The low coverage of zinc supplementation for treatment of diarrhea might be explained in part by the limited availability of zinc supplements for children on the global market until recently, which has hampered implementation of national policies.32 However, the rate of iron supplementation is also relatively low, and our data reveal that coverage of nutrition interventions that require a functioning health system with broad population coverage tends to be poor compared with vitamin A supplementation, which can be delivered vertically through child health and immunization campaigns. To guide policy and program action, there needs to be better data collection on coverage of the nutrition interventions recommended in The Lancet to get a clearer picture of problems in delivery, where they are most severe, and possible remedies.
Low coverage might also be a result of the gap between the identification of core interventions (what to do) and a set of easy-to-use tools that show how the interventions can be effectively implemented. Front-line health workers likely have little working knowledge of nutrition, and the skills and health system supports to facilitate counseling might be lacking; this possibility needs to be studied and, if confirmed, remedied.
Data from the Integrated Management of Childhood Illness (IMCI) Multi-country Evaluation revealed a large number of missed opportunities to improve breastfeeding and complementary feeding practices through individual counseling at health visits.33 Training and supportive supervision can improve coverage; after IMCI training, health workers were much more likely to counsel caregivers on infant and young child feeding during sick and well-child visits, and improvements in feeding practices were reported in various studies.33,34
There is a need to strengthen policy frameworks to create favorable environments for good nutrition practices and create synergies with other sectors. The WHO Global Strategy for Infant and Young Child Feeding has formulated specific targets toward this end, such as giving effect to the International Code of Marketing of Breast-milk Substitutes and enacting legislation to protect the breastfeeding rights of women.8 However, uptake has been slow. Among the 68 countries that account for >95% of maternal and child deaths, only 22 have adopted national legislation covering all provisions of the code and only 1 ratified the International Labour Organization Maternity Protection Convention 183.24
Evidence is accumulating to show that interventions in other sectors such as agriculture and social protection that incorporate nutrition can have powerful effects on child nutrition.35,–,37 The framework for Scaling-Up Nutrition (SUN) lays out a process for catalyzing and coordinating progress in nutrition at national and global levels.38 Endorsed by >100 organizations, this multistakeholder process aims to mobilize actors across sectors to engage within country-led initiatives linked with external support. Member states have requested the WHO to develop a comprehensive implementation plan on maternal, infant, and young child nutrition as a critical component of a global multisectoral nutrition framework, which adds urgency to the quest for intensified action.6 These new developments hold great promise for improvements in nutrition and accelerated progress toward meeting MDG 1.
The magnitude of undernutrition and slow progress toward reaching MDG 1, previously unrecognized extremely poor breastfeeding and complementary feeding practices, and lack of comprehensive data on intervention coverage are serious issues. It is well understood how to mainstream nutrition into primary health care,39 and new opportunities for integrating nutrition with agriculture and intersec toral strategies exist. These opportunities, coupled with new and better tools for measuring progress and guiding program actions, clearly presents the opportunity for a more strategic approach to improving child nutrition and should not be missed.
We thank Noureddine Abderrahimat (ICF Macro) for contributions to the analysis of DHS data and Eunyong Chung (USAID), Francesco Branca, and José Martines (WHO) for valuable advice and support during the preparation of the manuscript.
- Accepted August 31, 2011.
- Address correspondence to Chessa K. Lutter, PhD, Pan American Health Organization, 525 23rd St NW, Washington, DC 20037-2895. E-mail:
Drs Lutter and Daelmans prepared the outline for the article; Drs Daelmans, Lutter, deOnis, and Ruel and Ms Kothari wrote the first draft; Ms Blössner and Drs Borghi and deOnis performed the analysis of anthropometric data; Ms Kothari conducted the analysis of indicators of feeding practices; and Ms Arimond and Drs Deitchler and Dewey contributed substantially to all drafts.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- MDG —
- Millennium Development Goal
- WHO —
- World Health Organization
- UN —
- United Nations
- DHS —
- Demographic and Health Survey
- AAC —
- average annual change
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- Copyright © 2011 by the American Academy of Pediatrics