«WP 2012-012: January 2012 The Nutrition Challenge in Sub-Saharan Africa Jessica Fanzo PhD1 Jessica Fanzo, Bioversity International, Via dei Tre ...»
WP 2012-012: January 2012
The Nutrition Challenge in
Jessica Fanzo PhD1
Jessica Fanzo, Bioversity International, Via dei Tre Denari 472/a, 00057 Maccarese (Fiumicino), Rome, Italy.
This paper is part of a series of recent research commissioned for the African Human Development Report. The
authors include leading academics and practitioners from Africa and around the world, as well as UNDP
researchers. The findings, interpretations and conclusions are strictly those of the authors and do not necessarily represent the views of UNDP or United Nations Member States. Moreover, the data may not be consistent with that presented in the African Human Development Report.
Abstract: Sub-Saharan Africa is home to some of the most nutritionally insecure people in the world. Poor infrastructure and limited resources compounded with conflict, HIV, and poor access to health services are factors that contribute to the staggering levels of malnutrition and food insecurity on the continent. Despite these enormous challenges, some countries in Africa are making progress towards food and nutrition security and there has never been a better time to work towards improved human development that has nutrition as a goal.
Keywords: Nutrition security, stunting, micronutrient deficiencies, 1000 days JEL Classification: 1 - Health; I10 - General
1. The Food and Nutrition Security Situation in Africa: A Landscape Analysis Africa: A land of promise with great nutrition challenges The continent of Africa with its 52 countries is one with incredible opportunities in the face of many challenges. The land itself is diverse topographically, with a large representation of agroecological climates and food diversity of over 150 food crops of which 115 are indigenous  that make Africa distinctive. The population, an estimated 800 million with the youngest population bulge, has quadrupled in the last 50 years with a low life expectancy of below 50 years of age in many countries and unacceptable rates of maternal and child mortality. Furthermore, Africa has seen income disparity increase further in the last decades which directly impacts those who are food insecure and hungry.
Sub-Saharan Africa is home to some of the most nutritionally insecure people in the world.
Poor infrastructure and limited resources compounded with conflict, HIV, and poor access to health services are factors that contribute to the staggering levels of malnutrition and food insecurity on the continent. Despite these enormous challenges, some countries in Africa are making progress towards food and nutrition security and there has never been a better time to work towards improved human development that has nutrition as a goal.
The definition of food security set out at the 1996 World Food Summit stated that “food security exists when all people at all times have both physical and economic access to sufficient food to meet their dietary needs for a productive and healthy life”  . The achievement of food security depends upon four distinct but interrelated processes. The first is food availability, which refers to ensuring sufficient quantity and diversity of food is available for consumption from the farm, the marketplace or elsewhere. Second, food access refers to households having the physical and financial resources required to obtain these foods as well as not suffering limits to their access deriving from customs or traditions. Third and key to nutrition is food utilization, which implies the capacity and resources necessary to use and store food appropriately to support healthy diets. The primary factor influencing utilization is individual health status. This might include access to potable drinking water and adequate sanitation, knowledge of food preparation and the basic principles of good nutrition, and proper child care and illness management . The fourth and final process is food stability and the ability to cope with shocks and vulnerabilities both in the short term as well as in the long term.
For many years, food security was simply equated with enhancing the availability of food, and was linked to innovations in agricultural production. While food availability is clearly important to achieving food security, having the means to effectively access and utilize quality food remains central to good nutrition . The issue of access to high quality nutritious foods has become a major challenge for many individuals living in Africa. Most diets, in sub-Saharan Africa consist mainly of cereal or root staple crops, and very little in the way of animal source proteins, micronutrient rich vegetables and fruits, and quality diversity of the food basket. These foods are either not accessible because of high cost, not locally available, unequally distributed within households or are not considered household priorities when incomes are not sufficient to meet the needs of a high quality diet .
Focusing on the individual level, food utilization also takes into consideration the biological utilization of food. Biological utilization refers to the ability of the human body to take food and convert it into energy either used to undertake daily activities, or stored. Utilization requires not only an adequate diet, but also a healthy physical environment, including safe drinking water, fuel needed for cooking, adequate sanitation and hygiene, decreased burden of infectious disease, and the knowledge and understanding of proper care for oneself, for food preparation, storage and safety.
To meaningfully incorporate the nutrition elements into the concept of food security, it is important ensure “adequate protein, energy, vitamins, and minerals for all household members at all times” . But going beyond just food intake to include health and environmental factors, nutrition security is when a household has secure access to food coupled with a sanitary environment, adequate health services, and knowledgeable child care practices .
One element in establishing food and nutrition security is to ensure that households, communities and nations do not go hungry. As Figure 1 shows, hunger impacts an estimated 925 million globally  and 195 million children are stunted, with 90% of these children living in just 36 countries [15, 23]. Sub-Saharan Africa holds the second highest burden of those who suffer from hunger with 239 million peoples as food insecure after South Asia.
Figure 1: Number of People who are Hungry (FAO 2010)
In the developing world, malnutrition is the single largest killer of children under 5, trapping regions in a cycle of extreme poverty. But on the other end of the spectrum, obesity is dramatically on the rise not only in developed, industrialized countries but in low-income and transition countries, some in Africa, as well, which will have a tremendous impact on frail, overburdened health care systems and the productivity levels of the workforce.
While a number of countries globally have made substantial gains in reducing levels of those suffering from hunger and stunting, declines in children who are stunted in the African region have been marginal - from an estimated 38% in 1990 to 34% in 2008 .
Moreover, with population growth, the overall number of African children who are stunted has increased from an estimated 43 million in 1990 to 52 million in 2008 . In 2008, the ratio of those children who are underweight in rural to urban areas in sub-Saharan Africa was 1:4 . At the same time, 10% of children are overweight or obese in 8 of 45 subSaharan African countries .
The issue of hunger Malnutrition can take several forms including hunger, undernutrition, overnutrition and micronutrient deficiencies. In its common usage, hunger describes the subjective feeling of discomfort that follows a period without eating . However even temporary periods of hunger can be debilitating to longer term human growth and development . Acute hunger is when lack of food is short term but significant and is often caused by shocks, whereas chronic hunger is a constant or recurrent lack of food . Reducing levels of hunger has traditionally placed the emphasis on the quantity of food, and refers to ensuring a minimum caloric intake is met.
For the last ten years, hunger has been measured against the achievement of the Millennium Development Goal (MDG) One with a target to reduce the proportion of people who suffer from hunger by half between 1990 and 2015 , with hunger measured by two indices: as the proportion of the population who are undernourished and the prevalence of children under five who are underweight . Many countries remain far from reaching this target, and much of the progress made has been eroded by the recent global food price and economic crises in 2007-2008 and in 2011. Africa has also suffered progress as measured by these globally monitored indices.
The underweight prevalence indicator: The underweight indicator of the MDG1 is the proportion of children under five years of age falling below minus 2 standard deviations (moderate and severe) and minus 3 standard deviations (severe) from the median weightfor-age of the reference population. The underweight indicator was chosen for the MDG 1 target as it is felt to be the single best composite indicator, with the potential to capture aspects of acute and chronic undernutrition combined. As Figure 2 shows, Africa still suffers from a tremendous burden of undernutrition of 25% of children under five who are underweight as compared to other regions of the world. West and East Africa have a higher burden compared to North Africa. Although, South Asia suffers the highest burden, Africa’s burden, along with other compounding factors, will be a challenge for years to come.
Achieving sufficient progress in reaching the MDG1 indicator for underweight will be difficult for many African countries. Figure 3 shows in red and yellow colors that many African nations have made insufficient progress towards achieving the MDG1 goal as of 2009, or no progress at all as measured by the average annual rate of reduction (AARR).
AARR of underweight is based on multiple data estimates available from 1990 to 2008 with the AARR needed to achieve a 50% reduction over a twenty five-year period (1990 to 2015).
The rate of change required to achieve the goal is a constant 2.8% reduction per year for all countries . There are exceptions in sub-Saharan Africa including Angola, Botswana, Congo, Ghana, and Mozambique.
Figure 2: Percentage of Children under Five who are Underweight for Age (2003-2008)
Figure 3: Progress towards the MDG1 Underweight for Age Indicator For those countries which have “insufficient progress” in reducing child underweight rates, 38 of 129 countries, 60% are in Africa (as shown with red bars in Figure 4). Overall decline in underweight rates has decreased just 3% between 1990 and 2008 (28% to 25%) in Africa. In sub-Saharan Africa, countries with the highest underweight prevalence are Chad, Eritrea, Ethiopia, Madagascar, and Niger. Conversely, some countries as shown in Figure 3 within the region are well on track to meeting MDG1 including Angola, Botswana, Congo, Ghana, Guinea-Bissau, and Mozambique, . Although not all will be able to meet the goal in cutting hunger in half, some highlighted declines in underweight rates include Mauritania (57% to 27%), Malawi (29.9% to 21%) Ghana (27% to 9%) and Mozambique (27% to 18%) .
Figure 4: Percentage of Children under five who are Underweight in Countries Making Insufficient Progress toward the MDG1 Understanding where the “hotspots” of undernutrition are located on the continent can serve as proxies for identifying vulnerabilities and where targeted focus should be given priority. In Figure 5, the maps demonstrate where the hotspots of hunger are, as a percentage of children underweight for age, and an index that combines the proportion of children underweight and the population density of underweight children for each surveyed region. To create the index, each measure is normalized such that its new average, over all regions, is zero, and its standard deviation is 1. The two normalized values are added for each region to create the new index. The mapped classes are quintiles of the full distribution of the index . Areas in Southern Nigeria and Ethiopia are highlighted, as well as areas in Uganda and Kenya surrounded by Lake Victoria.
Proportion undernourished indicator: The second hunger indicator of the MDG1 refers to undernourishment defined as the insufficient food intake to continuously meet dietary energy requirements  with FAO further defining hunger as the consumption of less than 1600-2000 calories per day. The measure is a complex estimation of a distribution function of dietary energy consumption on a per-person basis. The mean of this distribution refers to the usual food consumption level and is estimated by the daily dietary energy supply per capita for a country derived from its food balance sheet (averaged over three years). The variance is derived on the basis of food consumption or income data from household income and expenditure surveys. The proportion of undernourished in the total population is defined as that part of the proportion lying below a minimum energy requirement after taking into account a country’s sex and age distribution, assuming the minimum acceptable body weight for given height for all sex–age groups and a light activity levels for adults  .
Although Asia still has the highest level of undernourished persons, sub-Saharan Africa has since 1990, increased its numbers of undernourished persons and the proportion of undernourished people remains highest at 30%, but progress varies widely at the country level (Figure 6). The Congo, Ghana, Mali and Nigeria had already achieved MDG 1 whereas in the Democratic Republic of the Congo, the proportion of undernourishment had increased to 165% .