77196 Nutrition at a GLANCE SOUTH AFRICA The Costs of Malnutrition • Over one-third of child deaths are due to under- Annually, South Africa loses over US$1.1 billion nutrition, mostly from increased severity of dis- in GDP to vitamin and mineral deficiencies.3,4 ease.2 Scaling up core micronutrient nutrition • Children who are undernourished between con- interventions would cost US$55 million per year. ception and age two are at high risk for impaired (See Technical Notes for more information) cognitive development, which adversely affects the country’s productivity and growth. Key Actions to Address Malnutrition: • South Africa is anticipated to lose a cumulative Increase exclusive breastfeeding rates and improve US$1.9 billion to chronic disease by 2015.5 young child feeding through effective education and • The economic costs of undernutrition and over- counseling services. weight include direct costs such as the increased burden on the health care system, and indirect Achieve universal salt iodization. costs of lost productivity. Address the growing burden of overweight and obesity Country Context • Childhood anemia alone is associated with a through policies that promote diverse diets and physical activity. 2.5% drop in adult wages.6 HDI ranking: 129th out of 182 Improve dietary diversity through increased market countries1 Where Does South Africa Stand? access and diversified agricultural production in rural Life expectancy: 52 years2 • 27% of children under the age of five are stunted, areas, and national food policies that align with public 12% are underweight, and 5% are wasted.2 health nutrition. Lifetime risk of maternal death: 1 in 1102 • 55% of those aged 15 and above are overweight or obese.7 Under-five mortality rate: • 15% of infants are born with a low birth weight.2 within South Africa there is likely to be variation 67 per 1,000 live births2 across geographies and socio-demographic groups. Global ranking of stunting As shown in Figure 1, undernutrition has stayed prevalence: 67th-highest out of roughly constant in South Africa since the early FIgure 2  South Africa has Higher Rates of Stunting 136 countries2 1990s. South Africa will not meet MDG 1c (halv- than Lower Income Countries in Other Regions ing 1990 rates of child underweight by 2015) with 35 business as usual.8 Prevalence of Stunting Among Botswana 30 Swaziland Namibia Technical Notes Children Under 5 (%) Angola 25 Figure 1  South Africa is not on Track Towards Meeting Bolivia South Africa Ecuador Stunting is low height for age. MDG 1 20 Sri Lanka 15 Underweight is low weight for age. 30 10 Prevalence Among Children Wasting is low weight for height. 25 5 Current stunting and wasting estimates are 20 Under 5 (%) 0 based on comparison of the most recent 0 1000 2000 3000 4000 5000 6000 7000 survey data with the WHO Child Growth 15 GNI per capita (US$2008) Standards, released in 2006. They are 10 not directly comparable to the trend data Source: Stunting rates were obtained from the WHO Global Database on Child shown in Figure 1, which are calculated 5 Growth and Malnutrition (figures based on WHO child growth standards). GNI data were obtained from the World Bank’s World Development Indicators. according to the previously-used NCHS/ 0 WHO reference population. 1994 1999 2003 Low birth weight is a birth weight less Stunting Underweight 2015 MDG Underweight Target than 2500g. The Double Burden of Undernutrition and Overweight is a body mass index (m2/kg) Source: WHO Global Database on Child Growth and Malnutrition (figures based on the NCHS/WHO reference population). Overweight of ≥ 25; obesity is a BMI of ≥ 30. While undernutrition rates have stagnated for 15 The methodology for calculating As seen in Figure 2, despite South Africa’s rela- years, South Africa has also seen an increase in nationwide costs of vitamin and mineral tively high per capita income, it has rates of child obesity in adults and children. This “double bur- deficiencies, and interventions included in stunting comparable to other lower-income coun- den� is the result of various factors. Progress in the cost of scaling up, can be found at: www.worldbank.org/nutrition/profiles tries in its region, and higher rates of stunting than improving community infrastructure and develop- lower-income countries in other regions. Further, ment of sound public health systems has been slow, Solutions to Primary Causes of Undernutrition SOUTH AFRICA Poor Infant Feeding Practices High Disease Burden Limited Access to Nutritious Food • Only 8% of infants under six months are exclu- • 16% of child deaths are due to either diarrhea or • Achieving food security means ensuring quality and sively breastfed.2 pneumonia.8 continuity of food access, in addition to quantity, for • During the important transition period to a mix of • Undernourished children have an increased risk of all household members. breast milk and solid foods between six and nine falling sick and greater severity of disease. • Dietary diversity is essential for food security. months of age, one-half of infants are not fed ap- • Undernourished children who fall sick are much • Achieving a diverse and nutritious diet seems to be propriately with both breast milk and other foods.2 more likely to die from illness than well-nourished a problem reflected in high rates of hidden hunger, Solution: Support women and their families to children. overweight and obesity. practice optimal breastfeeding and ensure timely • Parasitic infestation diverts nutrients from the body Solution: Involve multiple sectors including agricul- and adequate complementary feeding. Breast milk and can cause blood loss and anemia. ture, education, transport, gender, the food indus- fulfills all nutritional needs of infants up to six Solution: Prevent and treat childhood infection and try, health and other sectors, to ensure that diverse, months of age, boosts their immunity, and reduces other disease. Hand-washing, deworming, zinc sup- nutritious diets are available and accessible to all exposure to infections. In high HIV settings, follow plements during and after diarrhea, and continued household members. Examine food policies and the WHO 2009 HIV and infant feeding revised principles feeding during illness are important. country regulatory system as they relate to over- and recommendations.15 weight and obesity. References thwarting efforts to reduce undernutrition; while Figure 3  High Rates of Vitamin A and Iron Deficiency 1. UNDP. 2009. Human Development Report. rapid urbanization and the adoption of Western di- Contribute to Lost Lives and Diminished Productivity 2. UNICEF. 2009. State of the World’s Children. ets high in refined carbohydrates, saturated fats and 30 3. UNICEF and the Micronutrient Initiative. 2004. sugars, combined with a more sedentary lifestyle Vitamin and mineral deficiency: a global are commonly cited as the major contributors to 25 progress report. the increase in overweight and chronic diseases.9,10 Prevalence (%) 20 4. World Bank. 2009. World Development Indicators (Database). Cultural factors, perceptions and beliefs about body 15 5. Abegunde D et al. 2007. The Burden and weight also play a significant role.9 10 Costs of Chronic Diseases in Low-Income and While nearly a third of children are undernour- Middle-Income Countries. The Lancet 370: 5 ished, the majority of adults in South Africa are 1929–38. 6. Horton S, Ross J. 2003. The Economics of Iron overweight or obese. Urban children are twice as 0 Preschool Children Pregnant Women Deficiency. Food Policy 28:517-5. likely to be overweight as rural children (20% vs. Vitamin A Deficiency Anemia 7. WHO. 2009. WHO Global InfoBase (Database). 11%).9 Poor nutrition early in life is a risk factor: 8. UNICEF. 2009. Tracking Progress on Child and low-birth weight infants and stunted children may Source: 1995–2005 data from the WHO Global Database on Child Growth and Maternal Nutrition. Malnutrition. be at greater risk of chronic diseases such as dia- 9. Kruger H.S. et al. 2005. Obesity in South Africa: Challenges for Government and Health betes and heart disease than children who start out Professionals. Public Health Nutrition 8: well-nourished.11 foods are effective strategies to improve the iron 491-500. status of these vulnerable subgroups. 10. Popkin BM. et al. 1996. Stunting is Associated • Iodine: Only 62% of households consume io- with Overweight in Children of Four Nations Vitamin and Mineral Deficiencies Cause dized salt, and over 410,000 infants remain un- that are Undergoing the Nutrition Transition. J Hidden Hunger protected from iodine deficiency disorders.8 Nutr 126:3009–16. 11. Victora CG et al. 2008. Maternal and Child Although they may not be visible to the naked eye, Undernutrition: Consequences for Adult Health vitamin and mineral deficiencies impact well-being and Human Capital. The Lancet 371: 340–57. and are prevalent in South Africa, as indicated in Addressing undernutrition is cost 12. WHO. 2009. Global Prevalence of Vitamin A Figure 3. effective: Costs of core micronutrient Deficiency in Populations at Risk 1995-2005. WHO Global Database on Vitamin A Deficiency. interventions are as low as • Vitamin A: 17% of preschool aged children and 13. WHO. 2008. Worldwide Prevalence of Anemia US$0.05–3.60 per person annually. 1993-2005: WHO Global Database on Anemia. 19% of pregnant women are deficient in vitamin 14. Horton S. et al. 2009 Scaling Up Nutrition: A.12 Supplementation of young children and di- Returns on investment are as high as What will it cost? etary diversification can eliminate this deficiency. 8–30 times the costs.14 15. WHO. 2009. HIV and infant feeding: Revised principles and recommendations -- Rapid • Iron: Current rates of anemia among preschool advice. aged children and pregnant women are 24% and 22%, respectively.13 Iron-folic acid supplementa- World Bank Nutrition Related Activities in tion of pregnant women, deworming, provision South Africa of multiple micronutrient supplements to infants The World Bank is not currently supporting any nu- THE WORLD BANK and young children, and fortification of staple trition projects in South Africa. Produced with support from the Japan Trust Fund for Scaling Up Nutrition