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The Economist: The nutrition puzzle

 
February 18, 2012
Why do so many people in poor countries eat so badly—and what can be done about it?

IN ELDORADO, one of São Paulo’s poorest and most misleadingly named favelas, some eight-year-old boys are playing football on a patch of ground once better known for drug gangs and hunger. Although they look the picture of health, they are not. After the match they gather around a sack of bananas beside the pitch.

“At school, the kids get a full meal every day,” explains Jonathan Hannay, the secretary-general of Children at Risk Foundation, a local charity. “But in the holidays they come to us without breakfast or lunch so we give them bananas. They are filling, cheap, and they stimulate the brain.” Malnutrition used to be pervasive and invisible in Eldorado. Now there is less of it and, equally important, it is no longer hidden. “It has become more visible—so people are doing something about it.”

If Eldorado’s slum children today eat better, it is partly thanks to José Graziano da Silva. He ran Brazil’s Fome Zero(zero hunger) campaign, a policy that has helped to cut hunger by more than a third in Latin America’s largest country. Now Mr Graziano wants to apply the lessons he has learned more widely: he recently took over as head of the United Nations’ Food and Agriculture Organisation (FAO). And he stands a better chance of success than his predecessors. His appointment coincides with a shift in the world’s approach to fighting hunger.

Governments around the world are paying increasing attention to nutrition. In 2010 donors, charities and companies drew up a how-to policy guide called SUN (which stands for scale up nutrition). Britain’s Department for International Development and other aid agencies are devoting more of their money to nutritional projects. The World Bank has nailed its colours to the mast with a book called “Repositioning Nutrition as Central to Development”. Save the Children, an international charity, talks about “galvanising political leadership” behind the effort. Underlying all this is a change in thinking about how best to improve nutrition, with less stress on providing extra calories and food and more on improving nutrition by supplying micro-nutrients such as iron and vitamins.

A damning record

In the 1960s and 1970s, ending hunger and malnutrition seemed relatively simple: you grew more crops. If the harvest failed, rich countries sent food aid. But the Ethiopian famine of 1984 undermined this approach. Here was a disaster of biblical proportions in a country where food was available. It was a reminder of what an Indian economist, Amartya Sen, had long taught: what really matters with food is not the overall supply, but individual access.

So in the 1990s and early 2000s the emphasis switched to helping people obtain food. This meant reducing poverty and making agricultural markets more efficient. Between 1990 and 2005 the number of people living on less than $1 a day in poor countries (at 2005 purchasing-power parity) fell by a third to 879m, or from 24.9% of the total population to 18.6%.

Yet the food-price spike of 2007-08 showed that this approach also had limitations. Prices of many staple crops doubled in a year; millions went hungry. The world remains bad at fighting hunger. Experts argue about exactly how many people are affected, but the number has probably held flat at just below 1 billion since 1990.

Even where there is enough food, people do not seem healthier. On top of 1 billion without enough calories, another 1 billion are malnourished in the sense that they lack micro-nutrients (this is often called “hidden hunger”). And a further 1 billion are malnourished in the sense that they eat too much and are obese. It is a damning record: out of the world population of 7 billion, 3 billion eat too little, too unhealthily, or too much.

Malnutrition is attracting attention now because the damage it does has only recently begun to sink in. The misery of lacking calories—bloated bellies, wasted limbs, the lethargy of famine—is easy to spot. So are the disastrous effects of obesity. By contrast, the ravages of inadequate nutrition are veiled, but no less dreadful.

More than 160m children in developing countries suffer from a lack of vitamin A; 1m die because they have weak immune systems and 500,000 go blind each year. Iron deficiency causes anaemia, which affects almost half of poor-country children and over 500m women, killing more than 60,000 of them each year in pregnancy. Iodine deficiency—easily cured by adding the stuff to salt—causes 18m babies each year to be born with mental impairments.

Malnutrition is associated with over a third of children’s deaths and is the single most important risk factor in many diseases (see chart). A third of all children in the world are underweight or stunted (too short for their age), the classic symptoms of malnourishment.

The damage malnutrition does in the first 1,000 days of life is also irreversible. According to research published in TheLancet, a medical journal, malnourished children are less likely (all things being equal) to go to school, less likely to stay there, and more likely to struggle academically. They earn less than their better-fed peers over their lifetimes, marry poorer spouses and die earlier.

Paradoxically, malnutrition can also cause obesity later in life. In the womb and during the first couple of years, the body adjusts to a poor diet by squirrelling away whatever it can as fat (an energy reserve). It never loses its acquired metabolism. This explains the astronomical obesity rates in countries that have switched from poor to middle-income status. In Mexico, for instance, obesity was almost unknown in 1980. Now 30% of Mexican adults are clinically obese and 70% are overweight. These are among the highest rates in the world, almost as bad as in America. India has an obesity epidemic in cities, as people eat more processed food and adopt more sedentary lifestyles. And with obesity will come new diseases such as diabetes and heart disease—as if India did not have enough diseases to worry about.

Nutrition is also attracting attention because of some puzzling failures. In a few big countries, notably India and Egypt, malnutrition is much higher than either economic growth or improvements in farming would suggest it should be. India’s income per head grew more than fourfold between 1990 and 2010; yet the proportion of underweight children fell by only around a quarter. By contrast, Bangladesh is half as rich as India and its income per head rose only threefold during the same period; yet its share of underweight children dropped by a third and is now below India’s. Egypt’s agricultural value-added per person rose more than 20% in 1990-2007. Yet both malnutrition and obesity rose—an extremely unusual combination.

The good news is that better nutrition can be a stunningly good investment. Fixing micro-nutrient deficiencies is cheap. Vitamin supplements cost next to nothing and bring lifelong benefits. Every dollar spent promoting breastfeeding in hospitals yields returns of between $5-67. And every dollar spent giving pregnant women extra iron generates between $6-14. Nothing else in development policy has such high returns on investment. In 2008, as part of a project called the Copenhagen consensus, eight prize-winning economists listed the projects they thought would do most good (they had an imaginary $75 billion to spend). Half their proposed projects involved nutrition.

If malnutrition does so much damage and the actions against it are cheap and effective, why is the affliction only now being taken seriously? Some countries have successfully tackled it. Brazil cut the number of underweight people by 0.7% a year between 1986 and 1996 and reduced stunting by 1.9% a year. Bangladesh reduced both rates by 2% a year in 1994-2005.

But in many countries the problem of “hidden hunger” is hidden from victims themselves, so there is no pressure for change. If everyone in a village is undernourished, poor nutrition becomes the norm and everyone accepts it. This may also explain the reluctance of poor, ill-fed people to spend extra money on food, preferring instead to buy such things as televisions or a fancy wedding. When asked about his spending choices, an ill-fed Moroccan farmer told Abhijit Banerjee and Esther Duflo of the Poverty Action Laboratory, a think-tank: “Oh, but television is more important than food.”

Education can help change attitudes by persuading people they would benefit from a better (if more expensive) diet. But people in rich countries consume vast quantities of junk food knowing full well that it is bad for them. It is unrealistic to expect consumers in poor countries to behave differently. Hence the idea of doing good by stealth.

Just push all the buttons at once

HarvestPlus, a research group, breeds staple crops with extra nutrients and distributes the “bio-fortified” seeds. It released a vitamin A-rich cassava in Nigeria in 2011. This year it will bring vitamin A-rich maize (corn) to Zambia and iron-rich beans and pearl millet to Rwanda and India. Companies do something similar with processed foods: Kraft’s Biskuat biscuits (sold in Indonesia) have nine vitamins and six minerals added.

But education or fortified foods alone will not overcome the most intractable barrier to better nutrition, which is the sheer complexity of the task. Some problems of development are relatively straightforward. You can improve education by building schools and paying teachers. Nutrition is not like that.

In many countries nutritional standards vary according to the season. Often both the amount and quality of food drop alarmingly in the months before the main harvest. Nutrition varies also within households. Mothers eat less in bad times to leave more for their older children, which harms the suckling child. Culture adds to the problem. In rural Bangladesh an attempt to improve nutrition by educating young mothers backfired, because the family diet turns out to be determined not by mothers, but by mothers-in-law.

And nutrition can also be improved in all sorts of ways, including by better sanitation, which reduces intestinal diseases and enables people to absorb more nutrients; by investing in smallholder farming, to increase dietary variety; by vaccinating children against diseases; by educating women to breastfeed babies for longer, to improve immunity. Marie Ruel, of the International Food Policy Research Institute in Washington, DC, ticks off some of the tasks: focus on the first 1,000 days of life (including pregnancy); scale up maternal-health programmes and the teaching of good feeding practices; concentrate on the poor; measure and monitor the problem.

All this implies that a successful effort to improve nutrition has to push all the buttons at once. Brazil’s Fome Zero has 90 separate programmes run by 19 ministries. It embraces everything from a conditional cash-transfer scheme, called Bolsa Família, to irrigation projects and help for smallholders. Such an effort is hard to organise and cannot work unless politicians support it. “Malnutrition reduction needs powerful champions who know how to get things done across government, avoid gobbledygook and finish the story,” says Lawrence Haddad, director of Britain’s Institute of Development Studies.

Hence the importance of Mr Graziano, the FAO’s new boss. Interest in improving nutrition is growing; so is alarm at the failures of fighting malnutrition so far. He will not find it easy to cajole more countries into a large, broad-based effort. Governments are reluctant to change and want clear evidence. And just as the damage from malnutrition builds up over a lifetime, so better nutrition reveals its benefits only over many years, as well-fed mothers pass on good health to well-fed children.

At a recent FAO conference someone was heard to remark that “at the moment nutritionists are in a position similar to environmentalists in the 1990s.” That is depressing, because it means progress will be slow; but it is encouraging, because progress will come eventually.

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