Opportunities to Protect and Enhance Nutrition

Fig. 1 Cambodia, 2005 Malnutrition by Age

0

10

20

30

40

50

60

0.49

0.99

1.99

2.99

3.99

4.99

Age (years)

Percent malnourished

Underweight

Stunted

Wasted

Opportunities to Protect and Enhance Nutrition

in the East Asia and Pacific Region

June 20, 2009

Judith S. McGuire

With assistance from Amber Willink and Eko Pambudi

7/9/2009

EXECUTIVE SUMMARYThe East Asia and Pacific region shows dramatic contrasts in nutrition. Many of the Pacific Islands have some of the highest obesity rates in the world (close to 80% among women in Tonga) while Cambodia, Laos and Timor Leste have some of the highest rates of underweight and stunting (close to or above 50%). Micronutrient deficiencies, especially anemia, persist even among the successful East Asian countries like China and Thailand. Women have high rates of anemia, excessive thinness, and short stature that are risk factors for maternal mortality, low birth-weight, and poor health. Many of the countries in the region are net food exporters and, on paper at least, have sufficient calories to feed their populations and yet the poor, isolated populations and ethnic minorities are food insecure. Major causes of child malnutrition include poverty and food insecurity, poor water and sanitation, womens status, and young child feeding practices.

The food and fuel price spikes of 2007-8 and the current financial crisis threaten food security and nutrition in East Asia and Pacific region. Most of these economies, which grew at high rates before the crisis, were particularly vulnerable because they were highly integrated into world markets, many people lived close to the poverty line, their consumption basket and diet were heavily dependent on one commodity (rice) which has a uniquely shallow market structure, and because large numbers of people were already malnourished before the crisis started. Food price inflation has been accompanied by rising unemployment in certain sectors, particularly in urban areas, which has thrown some populations into a food security crisis.

Most of the high burden countries have in place already national social and economic policies that include nutrition as a key outcome. They also have national nutrition policies and nutrition programs. The common problem appears to be reaching the community level, management and quality control, consolidating services, and building and sustaining an institutional framework that is multi-sectoral, operational, self-directed, and focused on results at the community level. There are several policy, program, and institutional success stories in the region serve as a knowledge base for other countries.

This paper concentrates on the countries of the region with the highest burden of under-nutrition, examines their policy and programmatic context, and recommends Bank engagement in nutrition through its strong portfolio on community-driven development and conditional cash transfer programs. It proposes a three-pronged strategy with opportunities for follow up engagements in five countries (Cambodia, Indonesia, Lao PDR, Philippines, Vietnam and Timor Leste); sector work in those countries that lack adequate data (Papua New Guinea and the Solomon Islands); and a regional research program on preventing and mitigating obesity and diet-related chronic diseases. It also recommends setting up a regional knowledge network which facilitates sharing knowledge, procuring in bulk regional technical assistance, and creates a community of practice in which participating countries, individuals, and institutions support each other.

Introduction

Improving nutrition is a key input to as well as outcome from development. In addition to being one of a human beings most basic needs (and, many feel, an inalienable right), good nutrition is instrumental in building human capital: it affects survival, the immune system, cognitive development and learning capacity, physical strength, capacity, and endurance, and successful reproduction. Malnourished and low birth-weight children have much higher risk of dying than normally nourished children and the survivors have reduced life chances. Low weight-for-age explains about one-third of total under-five mortality and over half of the post-neonatal portion of it. Severely and acutely malnourished children the tabloid image of malnutrition -- are extremely frail and have very high mortality. But most of the nutrition-related mortality occurs in the mildly and moderately malnourished children. Stunted, underweight and unhealthy women who get pregnant are at greater risk of passing malnutrition on to the next generation especially if those women continue their physically demanding work schedule and dont eat a good diet or get needed medical attention. Such women are also at greater risk of dying during childbirth. Data on womens nutritional status (aside from anemia) are sorely lacking but the high rates of maternal mortality, low birth-weight, and anemia suggest that womens malnutrition (both concurrent and vestiges of childhood malnutrition, like stunting) adversely affects a large number of women in the region. Child malnutrition adds up to 11% of the total global burden of disease. Stunting, severe wasting and low birth-weight account for 21% of deaths in children under 5 and burden of disease in children under 5 and an additional 11% of the disease burden is due to micronutrient deficiencies. That does not count the substantial effect of anemia and under-nutrition on learning.

The East Asia and Pacific region shows dramatic contrasts in nutrition. Many of the Pacific Islands have some of the highest obesity rates in the world (close to 80% among women in Tonga) while Cambodia, Laos and Timor Leste have some of the highest rates of underweight and stunting. Micronutrient deficiencies, especially anemia, persist even among the successful East Asian countries like China and Thailand. Most of the countries are net food exporters and, on paper at least, have sufficient calories to feed their populations. The problem is that the poor and remote families cant buy the diet they need and many factors other than food availability affect nutrition.

The food and fuel price spikes of 2007-8 and the current financial crisis threaten food security and nutrition in East Asia and Pacific region. Most of these economies, which grew at high rates before the crisis, were particularly vulnerable because they are highly integrated into world markets, many people live close to the poverty line, their consumption basket and diet are heavily dependent on one commodity (rice) which has a uniquely shallow market structure, and because large numbers of people were already malnourished or close to it before the crisis started. In addition, the region suffered through multiple natural disasters (cyclones, flooding, earthquakes, and epidemics) that further compromised food security.

While the developing countries of East Asia grew at 11.4% in 2007 they are projected to grow at only 5.3% in 2009. China and Vietnams growth rates are projected to fall from 13.0 to 6.5% and 8.5 to 5.5%, respectively. In Southeast Asia (Indonesia, Malaysia, Philippines and Thailand) growth is predicted to fall from 6.2% to 0.7%, and the small economies from 6.7% to 1.6%. This means that progress on reducing poverty will slow and poverty might increase in these countries. It also means that nutrition at risk.

Food price inflation exacerbates economic distress for the poor, who spend a large proportion of their income on food. As economic growth has stagnated, food prices have risen, causing food insecurity.

Table 1. Food Consumer Price Inflation

2006

2007

Q1 2008

Cambodia

6.5

10

19.8 (1/2008)

China

2.3

12.3

21.0

Indonesia

14.7

11.4

12.4

Lao PDR

9.8

8.2

7.5

Malaysia

3.4

3.0

4.4

Mongolia

3.0

25.5

32.2

Philippines

5.5

3.3

7.0

Vietnam

8.7

11.2

26.0

Source: Brahmbhatt and Christiansen, 2008

Luckily, previous economic growth and sound fiscal policies enabled most of the affected countries in the region to take decisive steps to protect the poor from the crisis. That is not enough, however. Because nutrition is a fundamental input to human capital, these countries need to protect and improve the nutrition of their populations during and after the crises. In particular, to reduce their vulnerability to future economic shocks they need to address the long term structural nutrition problem not just the transitory effects of the crisis. Now, while the governments and donors are paying attention to the crisis, is the time to put in place or strengthen programs to prevent malnutrition.

This paper is funded by the Central Contingency Fund, which was set up to identify opportunities for the World Bank to help countries improve nutrition in this time of crisis. The purpose of this paper is to discuss the nutritional face of the East Asian economic crisis and present opportunities to scale up action against malnutrition. General information and trends are presented for the region as a whole and more detailed analysis is provided for the countries with the greatest burden of undernutrition (Cambodia, Indonesia, Lao PDR, Philippines, and Vietnam).

I. The Nature of the Problem

Child malnutrition

The East Asia and Pacific region represents the global spectrum of nutritional well-being (see Table 4). Underweight in children under five ranges from close to zero in Samoa up to 36% in Cambodia, 40% in Lao PDR and 46% in Timor Leste (WHO, 2008). Similarly, stunting ranges from less than 5% in Tonga, Singapore, Fiji and Samoa up to 45% in Cambodia, and 49% in Timor-Leste. Trend data, where available, are highly variable and nutritional indicators do not always track national income data. China has been able to reduce its malnutrition quickly as a result of rapid economic growth but Vietnam, with rapid economic growth, has experienced slow improvement (from 59.7% stunting in rural areas in 1985 to 34% in 2007 or about 1 percentage point a year, about the secular rate worldwide. The Philippines, one of the wealthier countries in the region has the second highest rate of low birth-weight (45.2%) (exceeded only by Cambodia at 64%). Anemia a major cause of cognitive deficit -- is widespread among women and preschool children. In Cambodia it affects close to two-thirds of preschool children and 80% of children under two years of age. Even in Thailand, anemia affects 25% of preschool children. Vitamin A deficiency ranges from less than 5% in Thailand and Malaysia to 61% in the Marshall Islands, 45% in Lao PDR, and 40% in the Philippines. These levels of vitamin A deficiency persist in spite of putative distribution of megadoses of vitamin A ranging from 35% of children in Timor Leste to 100% of children in DPR Korea. Iodine deficiency (measured in school children) ranges from 16% in China and Indonesia to 53% in Mongolia. Because iodine deficiency is basically a geological issue (if there is no iodine in the local soils, foods grown on those soils will not contain iodine), in the absence of mandatory iodization of salt, iodine deficiency becomes widespread. Salt iodization ranges from 12% in Cambodia to 100% in Fiji. Malnutrition is particularly severe in rural and remote areas and among ethnic minorities.

Table 2. Basic nutrition indicators for major low-middle income EAP countries

Stunting