- ➔ Globally in 2020, among children under five years of age, an estimated 149 million (22 percent) were stunted, 45 million (6.7 percent) were wasted, and 39 million (5.7 percent) were overweight. Progress was made towards 2030 targets on stunting, while childhood overweight was worsening.
- ➔ Stunted children were more likely to live in low- or lower-middle-income countries (89 percent of the global burden in 2020), reside in rural areas and have mothers with no formal education. Nearly 30 percent of countries representing each of the subregions of Northern Africa, Oceania and the Caribbean are experiencing an increase in stunting prevalence and therefore are not making progress towards the 2030 target of reducing the number of stunted children by 50 percent.
- ➔ Wasted children were more likely to live in low- or lower-middle-income countries (93 percent of the global burden) and reside in poorer households. Wasting levels continue to be above the 2030 target of less than 3 percent in numerous countries, especially those in Southern and South-eastern Asia.
- ➔ Overweight children were more likely to live in lower-middle- or upper-middle-income countries (77 percent of the global burden in 2020), reside in wealthier households and have mothers with at least a secondary school education. In terms of progress towards the 2030 target of less than 3 percent, more than half of the countries analysed in Western Africa and Southern Asia have achieved at least 75 percent progress, while overweight prevalence is increasing in the majority of countries analysed in Southern Africa, Oceania, South-eastern Asia, South America and the Caribbean.
- ➔ Globally, low birthweight decreased from 17.5 percent in 2000 to 14.6 percent in 2015, with progress made in most regions. However, data gaps are a challenge to global monitoring of this indicator, as nearly one in three newborns in the world are not weighed at birth.
- ➔ Steady progress has been made on exclusive breastfeeding, with 43.8 percent of infants under six months of age exclusively breastfed worldwide in 2020, up from 37.1 percent in 2012. Infants who are exclusively breastfed are more likely to live in low- or lower-middle-income countries (84 percent of the global number of exclusively breastfed infants in 2020), in rural areas, in poorer households, with mothers who had no formal education, and are more likely to be female. Most regions have achieved between 25 and 50 percent of the progress needed to reach the 2030 exclusive breastfeeding target of at least 70 percent.
- ➔ Globally in 2019, nearly one in three women aged 15 to 49 years (29.9 percent) were affected by anaemia, with stagnant, if not slightly reversed, progress since 2012 (28.5 percent). This translates into 571 million anaemic women worldwide, who were more likely to reside in rural settings, in poorer households and to have received no formal education. Progress towards the 2030 target for anaemia of a 30 percent reduction is worsening across the great majority of countries in almost all regions, particularly in Northern America, Europe, Australia and New Zealand, Oceania and South-eastern Asia.
- ➔ Adult obesity is on the rise in all regions, having increased worldwide from 11.8 percent in 2012 to 13.1 percent in 2016 – the last year for which data are available. Adults affected by obesity are more likely to live in upper-middle- or high-income countries (73 percent of the global burden in 2016), and the prevalence is higher among women. Women with obesity are more likely to reside in urban areas and in wealthier households. More efficient efforts are needed to reverse this trend.
- ➔ The persistence of the COVID-19 pandemic and other emergencies such as the war in Ukraine threaten progress towards ending all forms of malnutrition. The number of malnourished people, especially women and children, may further increase and impede the progress in achieving the 2030 global nutrition targets. This calls for concerted efforts to mitigate the effects on malnutrition.
Nutrition is central to the 2030 Agenda for Sustainable Development. This report assesses global and regional levels and trends for the seven global nutrition targets. These include the six nutrition targets endorsed by the WHA in 2012 to be achieved by 2025, for which extended 2030 targets22 were subsequently proposed by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). Four out of the six indicators were also selected to monitor progress towards SDG Target 2.2, namely stunting, wasting and overweight in children under 5 years of age and anaemia in women aged 15 to 49 years.23 The seventh target is to halt the rise in adult obesity, which the WHA adopted as part of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases (NCDs) in 2013.24
This edition innovates on previous reports by providing a more detailed characterization of the population groups most affected by malnutrition. The global burden of malnutrition is disaggregated by World Bank income groups. Additionally, the inequality analysis examines disparities across urban and rural residence, household wealth, maternal and women’s education, and gender. In this way, this report unmasks inequalities that exist within and between countries and sociodemographic groups. These analyses and disaggregations aim to shed light on the question: What population groups are most affected by malnutrition? This is a key aspect to inform the targeting of interventions for inequalities that seem to persist in the face of policies and programmes that are ineffective or too small for the challenge.
Progress towards the 2030 targets will be presented by looking into the summary of progress made by countries or territories, henceforth referred to as “countries”, for which estimates are available within regions and subregions up to the latest year.
The estimates of the prevalence and absolute numbers for the seven nutrition indicators presented below do not fully account for the impact of the COVID-19 pandemic due to challenges in updating the nutrition indicators. These estimates are based primarily on data collected prior to 2020, as the collection of child height and weight at household level was limited not only in 2020 but also in 2021 due to movement restrictions and physical distancing imposed to contain the spread of the pandemic. Even where nutrition data were collected during this time, evaluating the full impact is not possible for several of the outcomes. For this same reason, estimates of childhood stunting, wasting and overweight, as well as anaemia in women aged 15 to 49 years, have not been updated since the last edition of this report, as available data during this period do not provide sufficient regional and global coverage, and thus results would be misleading. Only estimates for exclusive breastfeeding were updated. However, recent data from 32 national nutrition surveys carried out since 2019, including 16 conducted between 2020 and 2021, are reflected in the descriptive analysis of the impact of inequalities on malnutrition, presented later in this section, considering urban and rural residence, household wealth, maternal education and gender.
Global trends
Trends in prevalence and absolute numbers for the seven nutrition indicators are summarized in Figure 11. The latest estimate for low birthweight revealed that 14.6 percent of newborns (20.5 million) were born with a low birthweight (less than 2 500 g) in 2015, a modest decrease from the 17.5 percent (22.9 million) in 2000. Infants born weighing less than 2 500 g are approximately 20 times more likely to die than those with adequate birthweight,25 and those who survive face long-term consequences, including a higher risk of stunting, diminished intelligence quotient, and increased likelihood of developing obesity and diabetes as adults.26 Updated low birthweight estimates will be released later this year (2022).
FIGURE 11Global trends in prevalence and absolute numbers indicate that overweight among children under five years of age, anaemia among women, and obesity among adults are increasing, while low birthweight, stunting among children under five years of age and exclusive breastfeeding have steadily improved since 2000
SOURCES: Data for stunting, wasting and overweight are based on UNICEF, WHO & International Bank for Reconstruction and Development/World Bank. 2021. UNICEF, WHO, World Bank Group Joint Child Malnutrition Estimates, April 2021 Edition. Cited 2 May 2022. https://data.unicef.org/topic/nutrition, www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb, https://data.worldbank.org; data for exclusive breastfeeding are based on UNICEF. 2021. Infant and Young Child Feeding: Exclusive breastfeeding. In: UNICEF Data: Monitoring the Situation of Children and Women. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding; data for anaemia are based on WHO. 2021. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.imr.PREVANEMIA?lang=en; data for adult obesity are based on WHO. 2017. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.main.A900A?lang=en; and data for low birthweight are based on UNICEF & WHO. 2019. UNICEF-WHO Low Birthweight Estimates: levels and trends 2000–2015. Geneva, Switzerland. Cited 2 May 2022. data.unicef.org/resources/low-birthweight-report-2019
Optimal breastfeeding practices, including exclusive breastfeeding for the first six months of life, are critical for child survival and the promotion of health and cognitive development. Globally, the prevalence of exclusive breastfeeding among infants under six months has risen from 37.1 percent (49.9 million) in 2012 to 43.8 percent (59.4 million) in 2020. Still, more than half of all infants under six months of age globally did not receive the protective benefits of exclusive breastfeeding. There is some concern that misconceptions around COVID-19 transmission via breastmilk may have influenced breastfeeding practices, but the full impact on trends is still unclear.27
Stunting, the condition of being too short for one’s age, is a marker for several impacts of undernutrition and is caused by a combination of nutritional and other factors that simultaneously undermines the physical and cognitive development of children and increases their risk of dying from common infections. Stunting and other forms of undernutrition early in life may also predispose children to overweight and NCDs later in life.3 Globally, the prevalence of stunting among children under five years of age has declined steadily, from an estimated 33.1 percent (201.6 million) in 2000 to 22.0 percent (149.2 million) in 2020.
Child wasting is a life-threatening condition caused by insufficient nutrient intake, poor nutrient absorption, and/or frequent or prolonged illness. Affected children are dangerously thin with weakened immunity and a higher risk of mortality.28 The prevalence of wasting among children under five years of age was 6.7 percent (45.4 million) in 2020, more than double the 2030 global target of less than 3 percent. Wasting is an acute condition that can change rapidly and is affected by seasonality in many contexts. This makes reliable trends over time challenging to present and interpret. For this reason, only the most recent available estimates are presented in this report.
Children who are overweight or obese face both immediate and potentially long-term health impacts. Immediate impacts include respiratory difficulties, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance and psychological effects.29 Long term, they have a higher risk of NCDs later in life. Overweight has been on the rise in many countries, hastened by increasingly inadequate levels of physical activity and access to highly processed foods, which tend to be high in energy, fats, free sugars and/or salt.30 Globally, the prevalence of overweight among children under five years of age increased slightly from 5.4 percent (33.3 million) in 2000 to 5.7 percent (38.9 million) in 2020. Although not statistically significant, rising trends are seen in around half of the countries worldwide. Based on this, and given the associated risks, this should be interpreted with concern.
The prevalence of anaemia among women aged 15 to 49 years, which was estimated to be 31.2 percent in 2000, signalled a slight downward trend until around 2012, but then rose again to 29.9 percent in 2019. Meanwhile, the absolute number of women with anaemia has risen steadily from 493 million in 2000 to 570.8 million in 2019, which has implications for female morbidity and mortality and can lead to adverse pregnancy and newborn outcomes.31
Globally, adult obesity nearly doubled in absolute value from 8.7 percent (343.1 million) in 2000 to 13.1 percent (675.7 million) in 2016. Updated global estimates are poised to be released before the end of 2022. However, it is not yet clear if there will be sufficient data to reflect how the COVID-19 pandemic has impacted this outcome. It is possible that movement restrictions imposed to contain the spread of the virus may have increased physical inactivity and sedentary behaviours, which together with shifting dietary practices towards unhealthy eating habits, may have resulted in increased adult body mass index (BMI) globally.32
The global burden of malnutrition varies across country income groups,33 and in some cases, over time. The burden per income group depends on the prevalence of the nutrition outcome as well as the population size of that income group; thus, both aspects are key to interpret disparities. Although the income group classification for a given country can shift over time, the analysis presented here considers the distribution of burden based on the latest classification, looking at shifts that happened across countries as per the income group they are currently classified under.
The distribution of the global burden for the seven nutrition indicators by income group are presented in Figure 12. For each indicator, the distribution in 2012 and in the year for which the most recent data are available are presented to show changes over time.
FIGURE 12Low- and lower-middle-income countries bear the greatest burden of stunting, wasting, low birthweight, and anaemia cases while upper-middle- and high-income countries have the greatest burden of obesity cases
SOURCES: Data for stunting, wasting and overweight are based on UNICEF, WHO & International Bank for Reconstruction and Development/World Bank. 2021. UNICEF, WHO, World Bank Group Joint Child Malnutrition Estimates, April 2021 Edition. Cited 2 May 2022. https://data.unicef.org/topic/nutrition, www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb, https://data.worldbank.org; data for exclusive breastfeeding are based on UNICEF. 2021. Infant and Young Child Feeding: Exclusive breastfeeding. In: UNICEF Data: Monitoring the Situation of Children and Women. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding; data for anaemia are based on WHO. 2021. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.imr.PREVANEMIA?lang=en; data for adult obesity are based on WHO. 2017. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.main.A900A?lang=en; and data for low birthweight are based on UNICEF & WHO. 2019. UNICEF-WHO Low Birthweight Estimates: levels and trends 2000–2015. Geneva, Switzerland. Cited 2 May 2022. data.unicef.org/resources/low-birthweight-report-2019
LICs and LMICs together carried the brunt of the low birthweight burden among newborns both in 2012 and in 2015 (83 percent of the global burden in 2020). Overall, the distribution of the burden remained similar between the two years.
Globally, most exclusively breastfed infants lived in LICs or LMICs, with the combined portion of the global number increasing from 78 percent in 2012 to 84 percent in 2020. However, there were insufficient data to examine the portion of exclusively breastfed infants in HICs, and therefore this group is not represented in Figure 12 for this indicator.
Part of the burden of stunting among children under five years of age shifted from LMICs to LICs between 2012 and 2020; namely, from 21 percent to 24 percent in the latter. Overall, stunted children are more likely to reside in LICs or LMICs.
LICs and LMICs bear the greatest burden of wasting among children under five years of age, totalling 93 percent of children affected by wasting globally.
The distribution across income groups of the burden of overweight among children under five years of age remained unchanged between 2012 and 2020, with a similar number of overweight children residing in LMICs and upper-middle-income countries (UMICs).
There were no significant shifts in the distribution of the global burden of anaemia among women aged 15 to 49 years between 2012 and 2019 across income groups. In 2019, 74 percent of women suffering from anaemia resided in LICs or LMICs, while one in five resided in UMICs.
The distribution of the global burden of obesity among adults across country income groups remained largely unchanged between 2012 and 2016, with the largest proportion (73 percent) residing in UMICs and HICs.
This analysis highlights that LICs and LMICs combined bear the greatest burden of low birthweight newborns, stunted and wasted children, and women with anaemia, keeping in mind the fact that these countries are home to a greater proportion of the global population.
Potential impacts of current crises on global nutrition
Global trends will likely be affected by recent and ongoing crises, especially those with global implications. Although the effects of the COVID-19 pandemic on malnutrition are not fully revealed yet, either due to data sparsity or the long-term impact for some of the nutritional outcomes, negative impacts on various forms of malnutrition are expected at the global level. More recently, the war in Ukraine has the potential to impact malnutrition on a global scale.34
Despite uncertainty around the impact of COVID-19 on global nutrition, there have been some simulation exercises based on different scenarios to evaluate the impact of the pandemic on child malnutrition using a limited set of covariates and estimates based on historical data.35 The 2021 edition of this report provided some projections based on these simulations for child stunting and wasting.15 It showed that between 11.2 and 16.3 million more children under five years of age in LICs and MICs may be affected by wasting from 2020 to 2022 as a consequence of the COVID-19 pandemic, compared to a scenario in which the pandemic had not occurred. For child stunting, it was predicted that between 3.4 and 4.5 million more children may be stunted in 2022 due to the impacts of the COVID-19 pandemic.
More recently, a comprehensive analytical framework36 was developed by the UNICEF-USAID-WHO Agile Core Team for Nutrition Monitoring (ACT-NM) which focuses on public-health pathways linking the pandemic to nutrition outcomes related to the six nutrition targets endorsed by the WHA. The framework is built around five categories of factors relevant to the intersection of the COVID-19 pandemic and nutrition: i) enabling determinants, ii) underlying determinants, iii) immediate determinants, iv) outcomes and v) impact. Each category of determinant has an overall theme with various subcategories. Enabling determinants include subcategories for governance, resource and sociocultural context; underlying determinants include subcategories for food, health, social protection, education, water and sanitation, while immediate determinants include ten subcategories of behavioural and nutritional status. The framework’s left-to-right axis enables users to identify, explore and assess numerous context-specific public-health pathways and consider inequalities at all levels.
Two country case studies attempt to illustrate potential context-specific pathways of the impact of the pandemic on child malnutrition, specifically in Chad for wasting and Peru for overweight (Box 4). Although data to provide evidence of this impact is very limited, the exercise is useful to explore the different pathways through which the COVID-19 pandemic can impact nutrition.
BOX 4COVID-19 case study: country examples of the impact of the pandemic on child wasting and overweight through context-specific pathways
Based on the ACT-NM comprehensive analytical framework, the case studies below trace potential pathways connecting multiple determinants and factors that may impact wasting and overweight among children under five years of age. However, interpretations of potential impact should be made with caution due to information gaps resulting from the stringency measures implemented by countries to control the pandemic.
A PATHWAY TO CHILDHOOD WASTING – AN EXAMPLE
Chad* began implementing COVID-19 measures in March of 2020, with its strictest in place from April to May 2020 (Stringency Index [SI] = 88.9**). In May and June 2020, 58 percent of communities reported a deterioration in their ability to meet basic needs – 11 percent of households reported a loss of income, and 13 percent of households were unable to perform farming activities due to COVID-19 measures.37 Meanwhile, the increased prices of major food items impacted 68.7 percent of households, and many relied on coping strategies including reduced food consumption (35 percent), reliance on savings (22 percent), the sale of assets (13.8 percent), or reliance on less preferred foods (10.8 percent).37,38 An estimated 2.4 million people had insufficient food consumption in early November 2020.39 Among infants under six months of age, exclusive breastfeeding rates declined from the already very low 16.4 percent (2020) to 11.4 percent (2021), possibly influenced by the fear of mother-to-child transmission of SARSCoV-2.40 Many households were unable to access necessary medical treatment in 2020 due to lack of money, fear of transmission, and the lack of available health workers.37,40 Wasting treatment programmes were scaled up in late 2020 with a 10–24 percent increase in admissions observed from the first quarter of 2020 to the first quarter of 2021, likely mitigating a higher impact on child wasting in Chad.41 Nevertheless, wasting among children under five years of age at national level appeared to be on a downward trend from 13.5 (95% confidence interval [CI]; 12.6–14.5) percent in 2018 to 12.0 (95% CI; 11.3–12.7) percent in 2019 to 9.5 (95% CI; 8.9–10.1) percent in 2020 before reversing and increasing slightly to 10.2 (95% CI; 9.5–10.8) percent in 2021.42 The observed dip in wasting in 2020 was likely influenced by efforts to mitigate the COVID-19 impact as well as the fact that the data collection period was outside of the lean season (unlike the other surveys). However, the observed reversal of the downward trend in 2021 may indicate the degradation of the nutrition-related environment.
A PATHWAY TO CHILDHOOD OVERWEIGHT – AN EXAMPLE
Peru implemented some of the strictest COVID-19 measures in Latin America with the most stringent from May to October 2020 (SI = 96.3). These were not substantially eased until December 2020 (SI = 59.3). The measures led to an increase in online food purchases and delivery services of pre-packaged foods as well as greater exposure to the marketing of highly processed foods. This shifted consumption patterns, notably towards an increased reliance on unhealthy diets, often containing processed foods high in energy, fat, free sugars and salt. This negatively affected the quantity, quality and diversity of diets in Peru. At the same time, the stringent measures may have contributed to reduced physical activity and increased sedentary lifestyle practices including excessive time spent viewing mobile phone, computer and television screens. Nationally, overweight among children under five years of age increased from 8.1 (95% CI; 7.6–8.6) percent in 2019 to 10.6 (95% CI; 9.8–11.5) percent in 2020.42
- * In 2020, Chad was classified as a LIFDC by the World Bank, but the COVID-19 pandemic worsened the situation as evidenced by the INSEED and World Bank National Socio-Economic Impacts of COVID-19 studies at the household level. ** Stringency index (SI) from the Oxford Coronavirus Government Response Tracker (OxCGRT). The stringency index is a composite measure based on the mean score of nine response indicators (i.e. school closures, workplace closures, cancellation of public events, restrictions on public gatherings, closures of public transport, stay-at-home requirements, public information campaigns, restrictions on internal movements, and international travel controls) rescaled to a value from 0 to 100 (100 = strictest).
The ongoing war in Ukraine risks increasing the number of malnourished people, especially women and children globally. This conflict is intrinsically related to the impact on the global food supply and hunger as mentioned in Section 2.1 (Box 3). A recent article published in Nature aims to raise awareness about these potential risks and makes a global call for urgent action.34 A summary of this work is presented in Box 5.
BOX 5The war in Ukraine threatens to increase the number of malnourished people, especially women and children globally
The Russian Federation and Ukraine are among the most important producers of key agricultural products and inputs (fertilizers and crude oil). The bearings of the war in Ukraine are uncertain, but its threat to global food security is quickly surfacing. The number of malnourished people, especially women and children, is poised to increase steeply if concerted efforts are not made to mitigate the conflict’s effects on malnutrition. A recent comment published in Nature outlines potential risks and also includes a list of urgent actions to mitigate its impact.34 They are described below.
Potential risks imposed by the crisis:
- Direct impacts on food security and quality of the diet through increased food prices and reduced food availability and access.
- Reduced reach of humanitarian assistance and services for prevention and treatment of acute malnutrition.
- Reallocations of nutrition budgets to other priorities.
Call to six urgent actions to safeguard access to nutrition services and safe, nutritious foods for women and children:
- Support call to minimize restrictions on global food and fertilizer trade, and disruptions to supply chains to mitigate food price crisis.
- Shield access to nutritious food for the most vulnerable with nutrition-sensitive social safety net measures.
- Mobilize needed resources for humanitarian assistance.
- Follow through on Tokyo Nutrition for Growth Summit (N4G) financing commitments to scale up nutrition services for the poor.
- Protect nutrition budgets and continue services of proven nutrition interventions for women and children.
- Invest in timely standardized nutrition data to guide policy and funding.
The effect of this crisis has the potential to be long term, affecting a generation of women and children who are already vulnerable to malnutrition – with implications for the human capital of communities and nations spanning generations.
Spotlight on inequalities
In this section, we explore six nutrition indicators through the lens of inequalities. This is an important addition, as global and regional patterns in malnutrition can mask disparities that exist within and between countries, including characteristics such as urban and rural residence, household wealth, education and gender. In an inequality analysis, these are the population groups that are most commonly analysed for comparisons between countries and regions, due to their strong associations with nutrition outcomes. The results from these analyses help to identify the most vulnerable population groups, contributing to evidence that can inform decision-making and effective action through the appropriate targeting and design of policies and programmes. Stakeholders can then tackle these important gaps between population groups so that no one is left behind.
An inequality analysis according to urban and rural residence, household wealth, education level and gender as applied to six nutrition indicators is presented using Equiplots in Figure 13. Equiplots depict mean prevalences for subpopulations within each category of the respective inequity dimension (i.e. type of residence, wealth, maternal education, gender). They allow visual interpretation of prevalence levels and distance between groups, which represents absolute inequality. The analysis was performed across United Nations regional classification based on data availability for countries within each region. Unweighted analysis was applied using the latest available data from national surveys between 2015 and 2021. The list of countries contributing to each region is presented in Annex 2C (Table A2.3). Despite the limitations regarding lack of data in many countries, as highlighted in the figure, this inequality analysis presents important information aiming to answer the question, “Who is most affected by malnutrition?”
FIGURE 13Inequality analyses using the latest available data per country (2015 to 2021) indicate that globally, stunted children under five years of age are more likely to be residing in rural settings, in poorer households, with mothers who received no formal education, and to be male while obesity among women is most common in urban settings and wealthier households
SOURCES: Data for stunting, wasting and overweight are based on UNICEF, WHO & International Bank for Reconstruction and Development/World Bank. 2021. UNICEF, WHO, World Bank Group Joint Child Malnutrition Estimates, April 2021 Edition. Cited 2 May 2022. https://data.unicef.org/topic/nutrition, www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb, https://data.worldbank.org; data for exclusive breastfeeding are based on UNICEF. 2021. Infant and Young Child Feeding: Exclusive breastfeeding. In: UNICEF Data: Monitoring the Situation of Children and Women. Cited 2 May 2022. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding; and estimates of anaemia and obesity in women were produced by the International Center for Equity in Health, Pelotas, Brazil based on DHS surveys (see https://equidade.org).
Inequality analyses for low birthweight are not presented in this section due to data limitations. Globally, a large proportion of newborns are not weighed at birth, and there are disparities across regions. In 2020, for example, more than one quarter (27.2 percent) of newborns were not weighed globally, while 61.9 percent of low birthweight data were missing in Western Africa compared to just 1.4 percent in Europe.42 Furthermore, low birthweight estimates disaggregated by background characteristics such as wealth, mother’s education and gender are not currently available in global databases. This is due to many factors, including discrepancies in the availability and quality of data among groups. For example, in LICs and MICs, in most cases, a much lower percentage of newborns in the poorest quintile are weighed at birth, and birthweight data are often recorded in multiples of 100 g and 500 g (data heaping), leading to less reliable estimates and potentially biased and misleading comparisons between these groups. Lastly, more research is needed to evaluate whether the current non-sex-specific cut-off for low birthweight (<2 500 g) will bias results for gender inequality analyses.
The proportion of infants under six months of age benefiting from exclusive breastfeeding is higher in rural areas across most regions, with the exception of Northern America, Europe, Australia and New Zealand, where the practice is more common in urban areas. It also tends to be higher among infants whose mothers were less educated, especially in Latin America and the Caribbean. Although exclusive breastfeeding was generally higher among households in lower wealth quintiles, Oceania excluding Australia and New Zealand (henceforth referred to as “Oceania”) had the highest prevalence among the second and fifth wealth quintiles. Northern America, Europe, Australia and New Zealand also lacked a clear pattern. Slightly more girls than boys were breastfed across most regions. Overall, infants under six months of age who are benefiting from exclusive breastfeeding are more likely to be residing in rural areas, in poorer households, have mothers who received no formal education and to be female (Figure 13A).
In most regions presented, the prevalence of stunting among children under five years of age is highest in rural residences, with the exception of Northern America, Europe, Australia and New Zealand. This difference is most pronounced in Africa. The highest prevalence was among households of the lowest wealth quintile. In Africa, the wealthiest quintile presents a substantially lower prevalence compared with the other four quintiles. In contrast, in Latin America and the Caribbean, the poorest quintile is lagging behind compared to the other four quintiles, which means that interventions must be targeted to this specific subgroup. Analyses by maternal education showed a clear pattern across all regions, with the prevalence of stunting being highest among children whose mothers had no formal education and lowest among children whose mothers received a secondary or higher education. Boys were more affected by stunting than girls in most regions. Overall, stunted children under five years of age are more likely to be residing in rural settings, in poorer households, with mothers who received no formal education, and to be male.
The prevalence of wasting among children under five years of age does not vary greatly based on urban or rural setting, household wealth or gender, with the exception of Oceania where children of mothers who received no formal education are more likely to be wasted. Overall, wasted children under five years of age may be more likely to be living in a poorer household and have a mother who received no formal education.
Comparisons of overweight among children under five years of age living in rural versus urban areas do not reveal a clear pattern across regions, while the wealthiest households have a higher prevalence of overweight in most regions. Children whose mothers received at least a secondary education seem to be more affected by overweight, with the exception of the more developed regions – Northern America, Europe, Australia and New Zealand – where children with mothers who received only primary education have the highest prevalence. Boys may be more affected by overweight than girls. Overall, overweight children under five years of age are more likely to be living in wealthier households and with mothers who received at least a secondary school education.
The prevalence of anaemia among women aged 15 to 49 years by place of residence varies by region. In Africa, the prevalence is higher among women in rural areas, while in Latin America and the Caribbean, it appears to be higher among women in urban areas. Lower wealth quintiles and having either no education or only up to a primary education are associated with anaemia in most regions. In Latin America and the Caribbean, however, the highest prevalence of anaemia was among women with secondary education or higher and among households in higher wealth quintiles. Overall, women suffering from anaemia are more likely to be residing in rural settings, in poorer households and to have received no formal education.
Globally, mean BMI among adults is higher in urban areas than in rural areas and higher among women than men.43 This suggests that urbanization may contribute to a rise in the prevalence of obesity globally, as the proportion of the world’s population living in urban areas is projected to increase. On the other hand, there is evidence that the obesity prevalence has increased faster in rural than in urban areas, likely due to the lack of access to healthy foods in LICs and MICs.44 Figure 13B presents results of inequality analyses of the prevalence of obesity exclusively among women due to the lack of primary data at individual level for men with same coverage, which would allow similar analysis. Of the 28 Demographic and Health Surveys (DHS) conducted since 2015 included in this analysis, only 10 surveys also collected anthropometric data for men (a men-to-women data availability ratio of approximately 1:4). Based on this analysis, more women 15–49 years of age suffer from obesity in urban than in rural settings across regions. The relationship between level of education and obesity varies greatly, with women with no formal education having the highest prevalence of obesity in Northern America, Europe, Australia and New Zealand, while in Africa, substantially more women with obesity had a secondary or higher education. In most regions, obesity was higher among women from wealthier households. Overall, women with obesity are more likely to reside in urban areas and in wealthier households.
A subanalysis was conducted using the 10 DHS surveys with data for men and women 20–49 years of age, highlighting substantial differences in the prevalence of obesity between men and women. Among the 10 countries located primarily in Africa and Asia,e the mean prevalence of obesity was 13.8 percent among women and 4.9 percent among men. The prevalence of obesity was higher for women in all countries, regardless of urban or rural setting or household wealth quintile.
Many regions and countries are increasingly facing multiple forms of malnutrition simultaneously at the population, household and individual levels,45 and this double burden of malnutrition can be associated with the inequalities described above. For example, results of one recent analysis in LMICs showed that the double burden of malnutrition at the household level (in this case, overweight mother with stunted child) was higher among richer households in the poorer countries, while in the richer countries, the risk was higher among poorer households.46 Effective double-duty actions to address these burdens will be those that are context-specific and that target those subpopulations most affected.
In summary, this spotlight on inequalities reveals that children in rural settings and poorer households are more vulnerable to stunting and wasting, while boys may be more affected by stunting. Children and adults, particularly women, in urban areas and wealthier households are at higher risk of overweight and obesity, respectively. Infants residing in rural areas, in poorer households, with mothers who received no formal education and female infants are more likely to be breastfed. Women with no formal education are more vulnerable to anaemia and their children to stunting and wasting. The aim of such analyses is to highlight how global progress is hindered by the specific challenges of different groups. Stakeholders can then identify more contextualized inequalities to redesign and target national policies and programmes aimed at reaching the most vulnerable groups. Addressing inequalities will be essential to achieving the 2030 targets.
Progress towards ending all forms of malnutrition by 2030
This section presents an assessment of the progress towards the 2030 global nutrition targets. Like the projections for hunger, estimates regarding levels of malnutrition towards the 2030 targets are characterized by a high level of uncertainty. The same approach applied in the last two editions of this report was used to assess the progress of the nutritional indicators, which is based on the rate of change observed from trends before the pandemic. Hence, this analysis does not reflect the potential effect of COVID-19 on malnutrition, which will likely affect progress assessment towards the 2030 targets, as already indicated through projection exercises in the 2021 edition of this report showing potential effects of the COVID-19 pandemic on stunting and wasting.15
Global progress
Global progress towards each of the seven nutrition 2030 targets is summarized in Figure 14. Although the 2015 prevalence of 14.6 percent among newborns suffering from low birthweight was not far from the 14.1 percent required to be on track for the 2030 target of a 30 percent reduction since the baseline of 2012, available data suffer from the limitations discussed earlier in this chapter. Improvements in low birthweight data quality and representativeness are needed to reliably assess the severity and magnitude of the problem.
FIGURE 14Reaching the 2030 global nutrition targets will require immense efforts. Only exclusive breastfeeding among infants under six months of age (37.1 to 43.8 percent) and stunting among children under five years of age (26.2 to 22.0 percent) have notably improved since 2012, yet even these indicators will require accelerated progress to meet the 2030 targets
SOURCES: Data for stunting, wasting and overweight are based on UNICEF, WHO & International Bank for Reconstruction and Development/World Bank. 2021. UNICEF, WHO, World Bank Group Joint Child Malnutrition Estimates, April 2021 Edition. Cited 2 May 2022. https://data.unicef.org/topic/nutrition, www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb, https://data.worldbank.org; data for exclusive breastfeeding are based on UNICEF. 2021. Infant and Young Child Feeding: Exclusive breastfeeding. In: UNICEF Data: Monitoring the Situation of Children and Women. Cited 2 May 2022. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding; data for anaemia are based on WHO. 2021. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.imr.PREVANEMIA?lang=en; data for adult obesity are based on WHO. 2017. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.main.A900A?lang=en; and data for low birthweight are based on UNICEF & WHO. 2019. UNICEF-WHO Low Birthweight Estimates: levels and trends 2000–2015. Geneva, Switzerland. Cited 2 May 2022. data.unicef.org/resources/low-birthweight-report-2019
The proportion of exclusively breastfed infants under six months of age increased from 37.1 percent in 2012 to 43.8 percent in 2020; however, this falls well below the 54.7 percent that would indicate the world was on track to achieving the 2030 target of at least 70 percent globally. Achieving this target will require investments in effective and context-specific interventions that promote the adoption and sustained implementation of exclusive breastfeeding. Enactment and enforcement of the International Code of Marketing of Breast-milk Substitutes, institutionalization of the Baby-friendly Hospital Initiative, and scaling-up of antenatal and postnatal breastfeeding counselling are critically needed.
Although stunting among children under five years of age has decreased from 26.2 percent in 2012 to 22.0 percent in 2020, it would need to have been reduced to 19.1 percent in 2020 to be on track to reach the 50 percent reduction in the number of stunted children by the 2030 target, which translates to a prevalence of 12.8 percent. Larger investments in both nutrition-specific and nutrition-sensitive actions will be required to ensure greater strides are made in stunting reduction.
The prevalence of wasting among children under five years of age was estimated to be 6.7 percent in 2020, more than double the 2030 target of less than 3 percent. This estimate signals that investments in the prevention, early detection and treatment of wasting must be increased substantially.
While the 2030 target calls for a substantial reduction in overweight among children under five years to just 3 percent, the prevalence has increased slightly from 5.6 percent in 2012 to 5.7 percent in 2020, albeit without statistical significance. A reversal in this trend will be required to achieve the 2030 target. As with obesity among all age groups, this will require increased investments into effective interventions to improve diet and nutrition as well as other lifestyle factors such as physical activity.
The prevalence of anaemia among women aged 15 to 49 years increased from 28.5 percent in 2012 to 29.9 percent in 2019. Thus, the world is moving further away from reaching the 2030 target of a 50 percent reduction in the number of women with anaemia, which would translate into a prevalence of 14.3 percent. Reversing this trend will require an integrated, multisectoral approach to determine and address all causes and risk factors of anaemia in women, including but not limited to those related to poor nutritional status, gynaecological conditions, malaria and other parasitic infections, and low socioeconomic status. Increased awareness and support are needed at the global, regional and national levels to facilitate these comprehensive approaches, in contrast with isolated interventions which may not have a sufficient impact on trends.
Adult obesity continued on the rise from 11.8 percent in 2012 to 13.1 percent in 2016. This trend will need to be reversed in order to return to the 11.8 percent prevalence of 2012, in alignment with the 2025 target to halt the rise in obesity. In addition to improved diet and nutrition, investments will be required to support public health actions that promote healthier lifestyles.
Regional progress
The progress achieved since the baseline year of 2012 up to the latest year for which estimates are available were compared with the progress required using the Average Annual Rate of Reduction (AARR)47,f for countries with sufficient data and summarized within regions they belong to (Figure 15). This level of granularity is useful to show that countries are in a different status of progress within regions, as within each region and subregion we can see the proportion of the respective countries in each category indicating progress achieved: ≥75 percent, 50–74.9 percent, 25–49.9 percent, 0–24.9 percent, or worsening.g However, regional estimates should be interpreted with caution as not all countries are included in the calculations (see Annex 2D).
FIGURE 15Regional progress towards nutrition targets indicates worsening anaemia among women and overweight among children under five years of age, while many regions are making progress in the reduction of wasting and stunting among children under five years of age
SOURCES: Data for stunting, wasting and overweight are based on UNICEF, WHO & International Bank for Reconstruction and Development/World Bank. 2021. UNICEF, WHO, World Bank Group Joint Child Malnutrition Estimates, April 2021 Edition. Cited 2 May 2022. https://data.unicef.org/topic/nutrition, www.who.int/data/gho/data/themes/topics/joint-child-malnutrition-estimates-unicef-who-wb, https://data.worldbank.org; data for exclusive breastfeeding are based on UNICEF. 2021. Infant and Young Child Feeding: Exclusive breastfeeding. In: UNICEF Data: Monitoring the Situation of Children and Women. Cited 2 May 2022. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding; data for anaemia are based on WHO. 2021. Global Health Observatory (GHO). In: WHO. Geneva, Switzerland. Cited 2 May 2022. http://apps.who.int/gho/data/node.imr.PREVANEMIA?lang=en; and data for low birthweight are based on UNICEF & WHO. 2019. UNICEF-WHO Low Birthweight Estimates: levels and trends 2000–2015. Geneva, Switzerland. Cited 2 May 2022. data.unicef.org/resources/low-birthweight-report-2019
The great majority of countries across most regions have made modest progress (0–24.9 percent of the progress required) towards the goal of a 30 percent reduction in the prevalence of low birthweight by 2030 among newborns. In contrast, approximately half of countries representing Northern America, Europe, Australia and New Zealand are experiencing a worsening situation.
Notable progress has been made towards increasing the percentage of exclusively breastfed infants under six months of age. In the majority of regions, between 20 and 70 percent of countries fall into the ≥75 percent category, that is, reaching at least 75 percent of the total progress required. In contrast, the situation is worsening in Oceania excluding Australia and New Zealand, followed by South America, the Caribbean, Central Asia and Eastern Asia.
The majority of regions are making progress in the reduction of stunting among children under five years of age. Progress is notable in Central Asia, Eastern Asia, Northern America, Europe, Australia and New Zealand, and South America, where more than 50 percent of the countries included in this analysis had achieved at least 50 percent of the progress required to reach the 2030 target. However, nearly 30 percent of countries in Northern Africa, Oceania and the Caribbean are worsening, experiencing an increase in stunting prevalence.
All countries representing Northern Africa, Southern Africa, Eastern Asia, Central America, Oceania, Northern America, Europe, Australia and New Zealand have achieved at least 75 percent progress in reducing the prevalence of wasting to meet the 2030 target. However, nearly half of the countries representing Southern Asia and South-eastern Asia are experiencing a worsening situation.
Progress in lowering the prevalence of overweight to meet the 2030 target varies by region, with more than half of countries representing Western Africa and Southern Asia achieving at least 75 percent progress. In turn, overweight is notably worsening among most countries representing Southern Africa, Oceania, South-eastern Asia, South America and the Caribbean.
Progress towards the 2030 target for anaemia is worsening across the great majority of countries in almost all regions, particularly in Northern America, Europe, Australia and New Zealand, Oceania and South-eastern Asia. Meanwhile, all 9 countries representing Middle Africa in this analysis have achieved up to 25 percent of the progress required.
The progress in curbing the rise of obesity among adults is not presented in this figure, as the situation is worsening across all countries where data are available. No progress is being made.
In summary, although progress is being made in some regions, malnutrition persists in many forms across all regions and may in fact be worse than these findings suggest as the impact of the COVID-19 pandemic on nutritional outcomes is still unfolding, and the full impact is yet to be revealed. Reaching the 2030 global nutrition targets will require immense efforts to counteract severe global setbacks. Global trends in anaemia among women aged 15 to 49 years, overweight in children, and obesity among adults especially, will need to be reversed to achieve the progress needed to reach the Sustainable Development Goals (SDGs).
Two high-level events took place in 2021 for advancing the global nutrition agenda, the UN Food Systems Summit (UNFSS) and the Tokyo Nutrition for Growth (N4G) Summit. Both summits served as a catalytic global moment for agrifood systems transformation aimed at delivering healthy diets for all sustainably and inclusively.
The key outcomes of the UNFSS include national food system pathways developed by more than 100 countries, which detail a roadmap for transformative action and within which the number one priority echoed by many Member States is the need to deliver healthy diets from sustainable agrifood systems.48 This is also supported by the Coalitions of Action such as those focused on healthy diets from sustainable agrifood systems, blue foods and school meals which unite global actors and countries behind common visions.
Moreover, the N4G outcomes support this action through pledges to enhance political and financial commitments that address food, health and social protection system drivers to enable healthy diets and end malnutrition in all its forms.49 More than half of the 396 commitments made by 181 stakeholders across 78 countries address food (63 percent). The commitments recognize the need for coherent multisectoral policies, linking the food and health sectors, and for an increase in actions and investment, for agrifood systems to support the shift to dietary patterns that benefit nutrition, human health and the environment. Integrating nutrition into Universal Health Coverage (UHC) was one pillar, where country governments and multiple stakeholders committed to take actions aiming at strengthening health systems with a view to providing quality and affordable nutrition services.
Now it is important that Member States implement their nutrition-related commitments made at the United Nations Food Systems Summit and the Tokyo Nutrition for Growth Summit 2021 by intensifying their efforts and scaling up their activities as appropriate under the Nutrition Decade’s work programme.50
