Feast and famine

MAHARASHTRA, 2010. In a village 130km (80 miles) from Mumbai, the head of a nursery is weighing a child. Four years old, she is just 10kg (22lb), two-thirds of what she should be. More than half the nursery’s charges are below their proper weight (“wasted” in the jargon) or short for their age (“stunted”, a result of years of undernourishment). The children out in the fields are even worse off, the teacher says. And most of their mothers are anaemic. Yet this Indian state is not especially poor.

India has done a miserable job of improving its people’s nutrition—but so has most of the world. In 1974, Henry Kissinger, America’s secretary of state, told the first world food summit that no child would go to bed hungry within ten years. He was miles off. Figures calculated for a follow-up conference, held on November 19th in Rome, show that 162m children under five are stunted. The rate of child wasting has not budged in the past couple of years. The number of undernourished people in the world has fallen since 1990, but only by a fifth, and now stands at about 800m. That is despite real global GDP growth of 3.6% a year over the same period and a fall by half in the share of the population of developing countries living on $1.25 a day or less.

As the world’s economy has grown, the prevalence of undernourishment—eating too few calories to sustain an active life—has fallen only half as fast as poverty (see chart). But at least it has fallen. Micronutrient deficiency is not falling at all. To be healthy, people need not just calories but nutrients such as vitamins and minerals. Lack of vitamin A can cause blindness; lack of iron causes anaemia. Two billion people are thought to suffer from some micronutrient deficiency.

Obesity, meanwhile, is getting worse—and not only in the rich world. Between 2000 and 2013 the number of overweight children rose from 32m to 42m, more than two-thirds of them in low- and middle-income countries. It used to be thought that when poor countries had cut hunger, they would have some respite before obesity took off. Not so. As undernourishment has fallen, the number of people eating too many calories has risen correspondingly, meaning that many developing countries suffer all three manifestations of malnutrition—undernourishment, micronutrient deficiency and obesity—simultaneously.

According to the first Global Nutrition Report, published earlier this month by the International Food Policy Research Institute, a Washington think-tank, every country except China and South Korea has a public-health problem with at least one of child stunting, anaemia among women of reproductive age and excessive weight among adults. A paper from 2013 in the Lancet, a medical journal, found that 45% of deaths of children under five are attributable to malnutrition. Micronutrient deficiencies explain about half the disability suffered by children. And obesity cost America somewhere between $475 and $2,500 per person in 2010.

Why has the world done so poorly on nutrition compared with poverty? Partly because of people’s choices. Villagers whose neighbours are all stunted often see undernourishment as normal and will buy, say, a television or phone with any extra money, rather than better food. City-dwellers often eat a high-calorie diet which, combined with a sedentary life, leads to obesity. Childhood hunger trains the body to hoard fat, so the poorest are more prone to obesity as adults. Mexico went from widespread hunger to the world’s worst obesity rate in a generation.

It used to be thought that malnutrition could be solved by growing more food or providing dietary supplements. By and large, the quantity of food has not been a problem: most countries grow or import enough. But programmes for specific dietary deficiencies—such as giving out vitamin A supplements, or zinc treatment for diarrhoea—have been patchy. A study by UNICEF, the UN children’s body, and others reckons that only 2.6m children with severe acute malnutrition were treated in 2012. That was less than 15% of the total. The new nutrition report says that of the dozen programmes aimed at such children, most reach half or less of their target audience.

More fundamentally, better nutrition is a byproduct of half a dozen policies, many of which are not about diet at all, and each of which is essential. Dirty drinking water and bad sanitation cause gastrointestinal illnesses which prevent the body from absorbing nutrients. In most of sub-Saharan Africa, more than 30% of the population has no access to treated water or sanitation. The widespread practice of open defecation goes some way to explaining India’s dire nutritional performance.

If girls give birth very young, their babies are likely to be underweight, and to fail to thrive. Since poor girls are more likely to become young mothers, malnutrition is passed on through the generations. Educating girls helps break the cycle, since it tends to delay the age of first pregnancy. But in much of Africa and parts of South-East Asia, girls’ enrolment in secondary school lags ten percentage points or more behind boys’, though it has improved. Teaching people about nutrition also matters, which is best done by decent health systems with plenty of nurses and midwives—which few poor countries have.

Even then, something more is needed: a “nutrition-friendly” approach right across government. A policy may cut undernourishment, such as Brazil’s Bolsa Família, which pays mothers if their children attend school, where they get free meals. But if those meals are high-calorie stodge, and children are not taught about nutrition, they will become overweight, as has happened in Brazil. Educating girls is a good way to cut malnutrition—and even better if they also learn that exclusive breast-feeding is best for a baby’s first six months.

Appetite for change

But few countries think about nutrition when crafting education or welfare policies. When they do, the results can be striking. In Maharashtra, the prevalence of stunting among under-fives fell from 37% in 2005-06 to 24% in 2012. Many small improvements explained the change: economic growth and poverty reduction were slightly above the Indian average; spending on nutrition programmes doubled from a low level; female education rates rose from a high level; and implementation of some policies improved (staff vacancies in nurseries, for example, were cut from 50% to 15%).

Even more heartening, data released at the conference in Rome, though not yet in India, suggest that stunting among under-fives nationally fell from 48% in 2005-06 to 39% in 2014, meaning 13m fewer undernourished children. Perhaps India, where malnutrition is a bigger problem than anywhere else, is finally pushing the right buttons. And if it can, so can others.