The Changing Face
of Global Malnutrition
Will Masters
Professor and Chair, Department of Food and Nutrition Policy, Tufts University
www.nutrition.tufts.edu | http://sites.tufts.edu/willmasters
AAEA session on the evolving dual burden of obesity and malnutrition:
driving forces and implications for development policy
Washington, DC – 6 August 2013
What’s behind these
headlines?
The Changing Face of Global Malnutrition
From headlines to data…
and then program evaluations,
for cash transfers or other interventions
• Malnutrition, from under- to over-consumption
• The search for just-right nutrition
• The end of scarcity?
• Global malnutrition is diverse and rapidly
changing
• Malnutrition (over or under) is a disease of poverty
• Africa fell into extreme poverty only recently and is
already recovering, but has far to go
Undernutrition has long been the world’s
leading cause of disease and disability
Percent of disability-adjusted life years lost, by risk factor (1990)
Undernutrition
Overconsumption
Source: S.S. Lim et al., “A comparative risk assessment of burden of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease
Study 2010,” The Lancet, v.380, no. 9859, 15 Dec. 2012–4 Jan. 2013, pages 2224-2260.
Globally, we are now Goldilocks,
with too much and too little,
looking for just-right nutrition
Percent of disability-adjusted life years lost, by risk factor (2010)
Overconsumption
Undernutrition
Source: S.S. Lim et al., “A comparative risk assessment of burden of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease
Study 2010,” The Lancet, v.380, no. 9859, 15 Dec. 2012–4 Jan. 2013, pages 2224-2260.
The end of food scarcity?
Did we beat Malthus?
From this...
To this?
Source: K. Fuglie and S. L. Wang, “New Evidence Points to Robust but Uneven Productivity Growth in
Global Agriculture,” Amber Waves, September 2012. Washington: Economic Research Service, USDA.
Some regions are still far from abundance
Food supply and real income by region, 1990-2010
Africa has the least
food, and is the poorest
Source: FAO, The State of Food Insecurity in the World 2012. Rome: Food and Agriculture Organization.
Today’s malnutrition may last forever
Mean height-for-age z scores relative to WHO standards, by region (1-59 months)
EURO: Armenia, Kazkhst., Kyrgyst., Moldova, Mongolia, Montenegro, Turkey (1997-2005)
EMRO: Egypt, Jordan, Morocco, Yemen (1997-2007)
PAHO: Boliv., Brazil, Colomb., Dom.Rep., Guatem., Haiti, Hondur., Nicarag., Peru (1999-2006)
WPRO: Cambodia, Mongolia (2005)
AFRO: Thirty countries (1994-2006)
SEARO: Bangladesh, India, Nepal (2004-2006)
Much of the lifelong burden of
undernutrition is experienced in infancy
Source: CG Victora, M de Onis, PC Hallal, M Blössner and R Shrimpton, “Worldwide timing of
growth faltering: revisiting implications for interventions.” Pediatrics, 125(3, Mar. 2010):e473-80.
Higher-income countries grow taller children
…and at each
income level,
children are
slightly
taller
now
Source: W.A. Masters, 2013. “Child Nutrition and Economic Development”, Nutrition in Pediatrics, 5th ed.
(chapter 44), edited by C.P. Duggan, J.B. Watkins, B. Koletzko and W.A. Walke, Shelton, CT: PMPH-USA.
…and have more overweight children too
Child overweight and real income, 1970-99 and 2000-11
30
(WHO estimates, N=520 from 146 countries)
0
10
20
…and at each
income level,
children are
slightly more
likely to be
overweight
4
6
8
10
12
Log of real income (purchasing power in 2005 US dollars
Note: Data shown are for 1970-99 (darker shading) and 2000-2011 (lighter shading), with 95% confidence intervals around linear regressions.
Sample sizes are N=244 across 115 countries for 1970-1999 and N=276 across 125 countries for 2000-2011.
Source: Author's calculation. Income data are from Penn World Table Version 7.1 (Nov. 2012), online at https://pwt.sas.upenn.edu.
Overweight estimates are from WHO, Global Health Observatory Data Repository,
downloaded 2 Aug. 2013 from http://apps.who.int/gho/data/node.main.1096.
Source: Author’s calculation.
Overall, malnutrition is a disease of poverty
All child malnutrition (stunting or overweight) and real income, 1970-99 and 2000-10
0
20
40
60
80
(WHO estimates, N=441 from 118 countries)
4
6
8
10
Log of real income (purchasing power in 2005 US dollars
Note: Data shown are for 1970-99 (darker shading) and 2000-2010 (lighter shading), with 95% confidence intervals around linear regressions.
Sample sizes are N=244 across 115 countries for 1970-1999 and N=276 across 125 countries for 2000-2011.
Source: Author's calculation. Income data are from Penn World Table Version 7.1 (Nov. 2012), online at https://pwt.sas.upenn.edu.
Overweight and stunting estimates are from WHO, Global Health Observatory Data Repository,
downloaded 2 Aug. 2013 from http://apps.who.int/gho/data/node.main.1096.
Source: Author’s calculation.
12
Higher income changes
diet quality as well as quantity
Share of calories from animal sources, total food supply and income, 1961-2009
Total calories available
rise from under 2000
to over 3500
per person/day
Animal-sourced foods rise from
about 5% to about 40% of calories
Source: W.A. Masters, 2013. “Child Nutrition and Economic Development”, Nutrition in Pediatrics, 5th ed.
(chapter 44), edited by C.P. Duggan, J.B. Watkins, B. Koletzko and W.A. Walke, Shelton, CT: PMPH-USA.
Higher income also buys sanitation and
clean water (among other things)
Access to sanitation, improved water and income, 1990-2010
Access to improved
water rises from
under 40% to 100%
of households
Access to sanitation rises from
under 5% to 100%
of households
Source: W.A. Masters, 2013. “Child Nutrition and Economic Development”, Nutrition in Pediatrics, 5th ed.
(chapter 44), edited by C.P. Duggan, J.B. Watkins, B. Koletzko and W.A. Walke, Shelton, CT: PMPH-USA.
Sanitation may be especially important
for stunting in high-density areas
India
Note: Observations are nationally representative country totals from 130 DHS surveys in 65
countries, 1990-2010, with circles are proportional to population.
Source: Dean Spears (2013), http://riceinstitute.org.
Africa has almost all of the world’s
most extreme poverty and hunger
Mali
Yemen
Nigeria
(at border
with Chad)
Ethiopia
South
Sudan
Central
African
Republic
Source: USAID Famine Early Warning Systems
Network, 3/27/2013 (http://www.fews.net)
Africa’s burden of disease is still
principally infectious, rather than NCDs
Percentage of total Disability-Adjusted Life-Years lost
attributable to non-communicable diseases (NCDs), 2010
Source: C.J.L. Murray and A.D. Lopez, Measuring the Global Burden of Disease. New
England Journal of Medicine, 369 (August, 2013):448-57.
Africa’s burden of disease is still
principally mortality, rather than disability
Percentage of total Disability-Adjusted Life-Years (DALYs)
due to years lived with disability, 2010
Source: C.J.L. Murray and A.D. Lopez, Measuring the Global Burden of Disease. New
England Journal of Medicine, 369 (August, 2013):448-57.
Undernutrition has begun to improve
in some African countries
National trends in prevalence of underweight children (0-5 years)
Selected countries with repeated national surveys
Somalia is an
exception, its
malnutrition
worsened
before the
2011 famine
Source: UN SCN. Sixth Report on the World Nutrition Situation. Released October 2010,
at http://www.unscn.org.
Undernutrition levels and trends
vary widely across Africa
National trends in prevalence of underweight children (0-5 years)
Selected countries with repeated national surveys
Conditions in the Sahel are
among the worst in Africa
Source: UN SCN. Sixth Report on the World Nutrition Situation. Released October 2010, at
http://www.unscn.org.
In Asia, where undernutrition was worst,
we’ve seen >20 years of improvement
National trends in prevalence of underweight children (0-5 years)
Selected countries with repeated national surveys
Source: UN SCN. Sixth Report on the World Nutrition Situation. Released October 2010, at
http://www.unscn.org.
Africa’s impoverishment is relatively recent
and may already be ending
Source: Calculated from World Bank (2011), PovcalNet (http://iresearch.worldbank.org/PovcalNet/), updated
11 April 2011. Estimates are based on over 700 household surveys from more than 120 countries, and refer
to per-capita expenditure at purchasing-power parity prices for 2005.
Despite the recent turnaround,
Africa is the last frontier of ultra poverty
(<$0.625/day)
Source: Author’s calculation from World Bank (2011), PovcalNet (http://iresearch.worldbank.org/PovcalNet/),
updated 11 April 2011. Estimates are based on over 700 household surveys from more than 120 countries,
and refer to per-capita expenditure at purchasing-power parity prices for 2005.
Africa now has 1/8th of the world’s people,
but 2/3rds of the ultra-poor
Source: Author’s calculation from World Bank (2011), PovcalNet (http://iresearch.worldbank.org/PovcalNet/),
updated 11 April 2011. Estimates are based on over 700 household surveys from more than 120 countries,
and refer to per-capita expenditure at purchasing-power parity prices for 2005.
An underlying cause of Africa’s
impoverishment has been its child-survival
baby boom, roughly 20 years behind Asia’s
Child and elderly dependency rates by region (0-15 and 65+), 1950-2055
Africa had the world’s most
severe demographic burden
(>90 children per 100 adults)
100
90
Africa is now experiencing Asia’s
earlier ‘demographic gift’,
but more slowly
80
70
2013
60
World
SSAfrica
SoAsia
50
40
Source: Calculated from UN Population Division, World Population Projections (http://esa.un.org/unpd/wpp),
accessed 11 Aug 2012, based on UN Population Prospects: The 2010 Revision (April 2011).
A related cause of Africa’s impoverishment
is fast, sustained rural population growth
Rural population growth rates by region, 1950-2055
2.5
Africa had over 2% annual growth in
the rural population, for over 30 years!
2.0
Africa is now experiencing Asia’s
earlier slowdown in rural
population growth,
but more slowly
1.5
1.0
0.5
2013
0.0
-0.5
-1.0
-1.5
SS Africa
Rural population growth
eventually falls below zero;
land per farmer can then
expand with mechanization
World
So Asia
Source: Calculated from UN Population Division, World Population Projections (http://esa.un.org/unpd/wpp),
accessed 11 Aug 2012, based on UN Population Prospects: The 2010 Revision (April 2011).
The rural population stops growing
and farm sizes can rise when
urbanization employs all new workers
…in Africa that won’t happen
until the 2050s
Population by principal residence, 1950-2050
Billions of people
10
9
8
7
6
5
4
3
2
1
—
World
Total
Urban
Rural
2.0
(total)
1.8
1.6
1.4
1.2
2013
1.0
0.8
0.6
Worldwide, rural
0.4
population growth
has almost stopped 0.2
0.0
Sub-Saharan
Total
Africa
Urban
Rural
2013
Africa still has both
rural & urban growth
Source: Calculated from UN World Urbanization Prospects, 2011 Revision , released October 2012 at
http://esa.un.org/unpd/wup. Downloaded 18 April 2013.
Africa’s continued rising rural population is
in sharp contrast to the rest of the world
Billions of people
Population by principal residence, 1950-2050
8
7
6
5
4
3
2
1
—
2.0
World outside Africa
1.8
1.6
Total
1.4
Urban
1.2
2013
Rural
1.0
0.8
0.6
0.4
Outside Africa, the rural
population is falling sharply 0.2
0.0
Sub-Saharan Africa
Total
2013
Urban
Rural
Africa still has both
rural & urban growth
Source: Calculated from UN World Urbanization Prospects, 2011 Revision , released October 2012 at
http://esa.un.org/unpd/wup. Downloaded 18 April 2013.
Africa’s burst of rural population growth
drove a sharp fall in land per farmer
Land available per farm household (hectares)
Reprinted from Robert Eastwood, Michael Lipton and Andrew Newell (2010), “Farm Size”, chapter 65 in Prabhu
Pingali and Robert Evenson, eds., Handbook of Agricultural Economics, Volume 4, Pages 3323-3397. Elsevier.
Africa’s green revolution has just begun
USDA estimates of average cereal grain yields (mt/ha), 1960-2013
3.5
World
3.0
Southeast Asia
South Asia
2.5
Sub-Saharan Africa
2.0
1.5
1.0
2012
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
1970
1968
1966
1964
1962
1960
0.5
Source: Calculated from USDA , PS&D data (www.fas.usda.gov/psdonline), downloaded 2 Aug 2013. Results shown are each
region’s total production per harvested area in barley, corn, millet, mixed grains, oats, rice, rye, sorghum and wheat.
So the new face of global malnutrition is
diverse and rapidly changing
In poorest regions, mean WHZ falls in 1st year,
then recovers in 2nd and 3rd years
Mean weight-for-height z scores relative to WHO standards, by region (1-59 mo.)
Only in South Asia and Africa is the
average infant thin for their height;
In Africa, they are thin only in infancy;
In Asia, they remain thin.
Source: CG Victora, M de Onis, PC Hallal, M Blössner and R Shrimpton, “Worldwide timing of
growth faltering: revisiting implications for interventions.” Pediatrics, 125(3, Mar. 2010):e473-80.
Later in life, obesity rates are rising
everywhere
Note: AFR=Africa, AMR=Americas, SEAR=SE Asia, EUR=Europe, EMR=Eastern Medit., WPR=Western Pacific
Source: WHO, World Health Statistics 2012.
The end of food scarcity?
Did we beat Malthus?
FAO estimates and projections of undernourished people worldwide, 1990–2015
Source: Shenggen Fan (2013), IFPRI Global Food Policy Report, chapter 1. Old FAO estimates are from
The State of Food Insecurity in the World (Rome, various years); new estimates are from FAO, The State of
Food Insecurity in the World 2012; author’s projections are based on data from FAO and the United Nations..
U.S. aid for agriculture has just begun to
recover after being sharply cut in 1980-99
Total 35
(all sectors)
30
After Asia’s
green
revolution,
20 years of
complacency
about
agriculture
US foreign aid commitments by sector, 1967-2011
(ODA, millions of 2011 USD)
Total (all sectors, left axis)
Health (includes nutrition)
Agriculture (incl. forestry, fishing)
3.5 and
Health
agriculture
3.0
25
2.5
20
2.0
15
1.5
10
1.0
5
0.5
0
0.0
In the 2000s, donors (re)discovered health …and then agriculture
Source: Author's calculations from OECD (2013), Official Bilateral Commitments by Sector,
updated 15 April 2013 (http://stats.oecd.org/qwids).
Global aid trends have been similar
to the U.S. trends, magnified times four
All DAC donors' foreign aid commitments by sector, 1967-2011
(ODA, millions of 2011 USD)
Total 140
(all sectors)
120
100
After Asia’s
green
revolution,
20 years of
complacency
about
agriculture
80
60
Total (all
sectors, left
axis)
Health
(includes
nutrition)
Agriculture
(incl. forestry,
fishing)
14
Health
and
agriculture
12
10
8
6
40
4
20
2
0
0
In the 2000s, donors (re)discovered health …and then agriculture
Source: Author's calculations from OECD (2013), Official Bilateral Commitments by Sector,
updated 15 April 2013 (http://stats.oecd.org/qwids).
The wake-up of external aid for agriculture
has been led by the Gates Foundation
Top 15 donors’ foreign aid commitments to African agriculture, 2005-2008
Rank
2005
1
IDA
2
AfDF
3
Denmark
4
United States
5
IFAD
6
Germany
7
Belgium
8
EU Institutions
9
Japan
10
United Kingdom
11
Canada
12
Netherlands
13
France
14
15
2006
300.72 IDA
152.04 AfDF
2007
538.88 United States
226.81 IDA
2008
463.07 IDA
399.16 BMGF
114.98 France
102.30 EU Institutions
141.80 BMGF
114.79 France
391.77 United States
342.42 EU Institutions
80.72 BMGF
66.88 IFAD
99.03 AfDF
87.50 EU Institutions
235.65 Canada
186.30 IFAD
66.43 United States
65.75 Japan
84.78 IFAD
66.12 Japan
122.76 France
73.36 Germany
58.42 Sweden
45.06 Germany
60.58 Korea
54.31 Germany
56.63 Belgium
56.33 Japan
43.48 Belgium
36.19 Norway
53.48 Belgium
50.34 Canada
53.20 Ireland
41.40 Norway
BMGF
32.14 United Kingdom
24.80 Ireland
30.70 Norway
22.56 Denmark
40.64 Italy
31.46 Denmark
Norway
20.80 Netherlands
19.01 Ireland
24.79 Spain
867.01
367.23
323.58
181.73
155.20
129.49
95.13
87.25
77.42
75.13
41.81
35.39
32.36
29.17
19.31
Note: Exact amounts for BMGF have been obscured because methodology differs from that used by the DAC.
Source: P. Pingali, G. Traxler and T. Nguyen (2011), “Changing Trends in the Demand and Supply of Aid for
Agriculture Development and the Quest for Coordination.” Annual Meetings of the AAEA, July 24–26, 2011.
Many African governments are now
focusing more on agriculture
Slide is courtesy of Prabhu Pingali, Greg Traxler and Tuu-Van Nguyen (2011), “Changing Trends in the Demand
and Supply of Aid for Agriculture Development and the Quest for Coordination,” at the AAEA, July 24–26, 2011.
Africa’s green revolution arrived late,
roughly 20 years behind Asia’s
Source: Reprinted from W.A. Masters, “Paying for Prosperity: How and Why to Invest in Agricultural Research and
Development in Africa” (2005), Journal of International Affairs, 58(2): 35-64.