Child malnutrition remains one of the gravest threats to children in Africa. In communities where food is scarce or unaffordable, children are often the first to suffer-and the last to recover. Malnutrition robs children of their strength, their ability to learn, and their chance to grow up healthy. It is a leading cause of child mortality in sub-Saharan Africa, and a major factor in lifelong physical and cognitive impairment. Nearly 1 in 10 children in the region dies before age 5, often from preventable conditions made deadly by malnutrition. Malnutrition weakens immune systems and increases vulnerability to diseases like pneumonia, malaria, and diarrhea.
Globally in 2022, 149 million children under 5 were estimated to be stunted (too short for age), 45 million were estimated to be wasted (too thin for height), and 37 million were overweight or living with obesity. Nearly half of deaths among children under 5 years of age are linked to undernutrition. These mostly occur in low- and middle-income countries. The developmental, economic, social and medical impacts of the global burden of malnutrition are serious and lasting, for individuals and their families, for communities and for countries.
A child being screened for malnutrition. Source: UNICEF
Malnutrition literally means “bad nutrition” and technically includes both over- and under- nutrition. The World Food Programme (WFP) defines malnutrition as “a state in which the physical function of an individual is impaired to the point where he or she can no longer maintain adequate bodily performance process such as growth, pregnancy, lactation, physical work and resisting and recovering from disease”[1].
Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause [1]. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001 [2, 3].
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Key Factors Contributing to Child Malnutrition
Several factors contribute to the widespread issue of child malnutrition in Africa. These include:
- Poverty: Poverty remains the major contributor to this ill. The vicious cycle of poverty, disease and illness aggravates this situation. Childers et al estimated that some 1.4 billion people now live in absolute poverty, 40% more than 50 years ago. Nearly one of every four human beings alive today exists only on the margins of survival, too poor to obtain the food they need to work, or adequate shelter, or minimal health care, let alone education for their children [11]. Poverty is unmistakably the driving factor in the lack of resources to purchase or otherwise procure food, but the root causes of poverty are multifaceted. Poverty, combined with other socioeconomic and political problems, create the bulk of food insecurity around the globe [10].
- Lack of Education: Lack of education especially amongst women disadvantages children, especially as far as healthy practices like breastfeeding and child healthy foods are concerned. Improving the educational status of parents, especially of mothers, on nutrition, sanitation and common disease prevention strategies should logically reduce the malnutrition related mortality and morbidity. It is said that the way to the child's stomach is through the mind of the mother. Quality of food taken, choices and quantity are all at the discretion of the mother or care giver. This problem is very crucial in Sub Saharan Africa, where access to formal education for the girl child in certain communities is still a major burning challenge. Education could help reduce excessively large family sizes that are usually seen in most regions of Sub Saharan Africa.
- Adverse Climatic Conditions: Adverse climatic conditions have also played significant roles like droughts, poor soils and deforestation. Climate change represents a major threat for the coming decades, particularly in Africa which has more climate sensitive economies than any other continent. Some regions in Africa have become drier during the last century (e.g. the Sahel) and it is projected that the continent will experience a stronger temperature increase trend than the global average [20]. Africa has often been identified as one of the most vulnerable regions to climate variability and change because of multiple stresses and low resilience, arising from endemic poverty, weak institutions, as well as recurrent droughts and associated complex emergencies and conflicts.
- Sociocultural Barriers: Sociocultural barriers are major hindrances in some communities, with female children usually being the most affected.
- Corruption and Lack of Government Investment: Corruption and lack of government interest and investment are key players that must be addressed to solve this problem. Improvement in government policy, fight against corruption, adopting a horizontal approach in implementing programmes at community level must be recognized.
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Specific Forms of Malnutrition
Kwashiorkor and marasmus are two forms of Protein Energy Malnutrition (PEM) that have been described. The distinction between the two forms of PEM is based on the presence of edema (kwashiorkor) or absence of edema (marasmus). Marasmus involves inadequate intake of protein and calories, whereas a child with kwashiorkor has fair-to-normal calorie intake with inadequate protein intake. In addition to PEM, children may be affected by micronutrient deficiencies, which also have a detrimental effect on growth and development. The most common and clinically significant micronutrient deficiencies in children and childbearing women throughout the world include deficiencies of iron, iodine, zinc, and vitamin A and are estimated to affect as many as two billion people.
The Vicious Cycle of Malnutrition and Poverty
Focusing on children under the age of five, who are the most affected by malnutrition in Sub Saharan Africa, a vicious cycle has been described to actually exist between poverty and malnutrition. In fact, the World Bank estimates that on average individuals suffering from malnutrition lose 10 per cent of their potential lifetime earnings. This has a much broader impact too; in the same report the World Bank found that countries can lose 2-3 per cent of their GDP because of under nutrition [13]. Malnutrition has in some instances been actually considered, and generally is considered as a poverty indicator. Malnutrition leads to sub optimal intellectual development. Knowing that children are the future of any society, an unproductive generation shall thus be prone to be poor, completing this poverty malnutrition chain [14]. Malnourished women usually have malnourished fetuses during pregnancy, delivered generally with low birth weights and consequently growing into physically and mentally stunted children.
The Double Burden of Malnutrition
The second problem is the co-existence of under- and over-nutrition in the same household, family or community. This double burden is extended to a double burden of disease. Therefore, as in many other developing countries, the over-nutrition-related diseases emerged before the battle against under-nutrition deficiency diseases has been won. This phenomenon can, at least partially, be explained by the effects of foetal malnutrition and the low quality of staple-food diets (sufficient energy but not enough micronutrients) in poor households. However, the relationship between household food insecurity and the overweight status of mothers and children are not only observed in developing countries.
Impact of Climate Change
Increasingly variable rainfall patterns are likely to affect the supply of fresh water. A lack of safe water can compromise hygiene and increase the risk of diarrheal disease, which kills 2.2 million people every year. In extreme cases, water scarcity leads to drought and famine. By the 2090s, climate change is likely to widen the area affected by drought, double the frequency of extreme droughts and increase their average duration six-fold [17]. According to the World Health Organization, Many of the major killers such as diarrheal diseases, malnutrition, malaria and dengue are highly climate-sensitive and are expected to worsen as the climate changes. As temperatures increase, precipitation is becoming more variable over most of Africa. For some regions, rainfall variability and unpredictability has been substantial in the past forty to fifty years. According to Boko et al, there has been an overall annual decline in rainfall observed since the end of the 1960s over Africa with some regions experiencing greater declines than others.
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Current Crisis and Food Insecurity
Across Africa, millions of families are facing a daily battle for survival. As of 2024, more than 282 million people in Africa are undernourished, according to the United Nations. That’s nearly one in five people across the continent. Today, several regions in Africa are facing emergency levels of hunger and food insecurity, driven by conflict, displacement and worsening climate conditions. Recurring droughts, floods, and other climate-related disasters are compounding the impact of armed conflict. The result: families lose crops, livestock and livelihoods-pushing them further into poverty and food insecurity. In 2024, Africa is home to 12 of the 20 hunger hotspots identified by the FAO and WFP as at highest risk of catastrophic food insecurity.
A woman and her children in a food distribution center. Source: Concern Worldwide
The Role of Social Determinants of Health (SDH)
Social determinants of health (SDH) are conditions in the lives of people that affect their health outcomes that are not specifically medical. SDH related to basic amenities and environment include basic sanitation, which is vital for preventing diarrheal diseases and enhancing overall health outcomes by ensuring access to essential hygiene facilities. Studies have found that children from households lacking basic sanitation facilities are 13% more likely to be stunted, and those without access to handwashing facilities are 27% more likely to be stunted. Improving access to safe water, sanitation, and hygiene (WaSH) facilities has been shown to have a significant impact on reducing underweight and stunting in children under age 5 across low-and middle-income countries, including in Africa. Access to basic drinking-water services is another environmental SDH linked to childhood malnutrition. Inadequate access to clean water increases the risk of waterborne diseases and infections, which impair nutrient absorption and overall health in children, contributing to malnutrition and stunted growth. Improving WaSH could prevent many of these health issues, significantly reducing childhood morbidity and mortality associated with malnutrition.
SDH related to education, access to services, and social protection are also important. Adult literacy is positively associated with improved childhood nutrition, as higher levels of education are linked to better health knowledge and practices that support child health and development. Health access and quality are important for understanding the capacity of health systems to address various health issues, including childhood malnutrition. Political instability and violence interrupt key services such as healthcare, sanitation, and food supply chains, increasing malnutrition. Children in politically unstable places are more likely to face food insecurity, limited healthcare access, and increased exposure to infectious diseases, all of which lead to greater malnutrition rates.
Statistical Analysis: Underweight and Stunting Prevalence
The frequency of underweight and stunting varied significantly throughout the 50 African countries studied (see Table 1; Figure 2). The average underweight percentage among the countries was 14.5%, ranging from 1.6 to 39.4%. Regionally, average percentages ranged from 6.7% for Northern countries to 18.3% for Eastern countries; differences in prevalence of underweight by region were statistically significant at p < 0.05. The average proportion of stunting was 26.8%, ranging from 7.3 to 56.4%. Regionally, average percentages ranged from 20.8% for Northern countries to 29.2% for Southern countries; however, differences in prevalence of stunting by region were not statistically significant.
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Among the predictor variables, access to basic services varied considerably (see Table 1; Figure 2). Averaging the proportions for each country, the average proportion of the population with access to basic sanitation services was 43.2%, ranging widely from almost no access at 9.0% to complete access at 100.0%. Differences by region were statistically significant at p < 0.05; the average percentages of access to basic sanitation services ranged from 85.7% for Northern countries to 31.6% in Western countries. The average proportion of the population practicing open defecation was 17.6%, ranging widely from almost no open defecation at 1.0% to two-thirds of the population practicing open defecation at 67.0%. The average usage of basic drinking water services stood at 71.1%, with access proportions varying from just over one-third (36.0%) to complete access (100.0%). The average literacy rate was 69.1%, ranging from about one-fourth of the population 15 and older being literate (27.3%) to nearly complete literacy (96.2%). The average HAQ Index was 46.2, ranging from lower quality at 26.5 to higher quality at 70.1. The Political Stability Score averaged-0.72 across the 50 African countries, and demonstrated substantial variation.
As the level of risk increased by quartile for basic sanitation services, prevalence of open defecation, basic drinking-water services, literacy rate, the HAQ Index, and Political Stability Score, the prevalence of underweight among children under age 5 saw a statistically significant increase (p < 0.05). The spread in the prevalence of underweight between Quartile 1 (most risk) and Quartile 4 (least risk) was 14.9 percentage points for basic sanitation services, 13.7 for basic drinking-water services, and 13.5 for HAQ Index. The risk ratio of prevalence of underweight among children under age 5 was more than twice the risk for Quartile 1 compared to Quartile 4 for all of the SDH; the risk ratio was 3.1 times greater for basic sanitation services and 2.8 times higher for basic drinking-water services.
As the level of risk increased by quartile for basic sanitation services, basic drinking-water services, literacy rate, the HAQ Index, and Political Stability Score, the prevalence of stunting saw a statistically significant increase (p < 0.05). The spread in the prevalence of stunting between Quartile 1 (most risk) and Quartile 4 (least risk) was 18.8 percentage points for basic drinking-water services, 17.4 for HAQ Index, and 16.8 for Political Stability Score. The risk ratio of prevalence of stunting among children under age 5 was at least 1.7 times greater the risk for Quartile 1 compared to Quartile 4 for all of the SDH; the risk ratio was 2.1 times greater for basic drinking-water services.
Progress Towards Global Nutrition Targets
In the Africa region, there has been modest progress towards achieving global nutrition targets. The global target for overweight among children under 5 years of age has 28 countries on course to meet it, exclusive breastfeeding among infants aged 0 to 5 months has 20 countries on course, wasting among children under 5 years of age has 19 countries on course, while stunting among children under 5 years of age has six countries on course. However, not a single country in the region is on course to meet the targets for anaemia in women of reproductive age (aged 15 to 49 years), low birth weight, diabetes among men, diabetes among women, obesity among men, and obesity among women. 26 countries in the region have insufficient data to comprehensively assess their progress towards these global targets.
The latest data shows that anaemia affects an estimated 40.4% of women of reproductive age. Some 13.7% of infants have a low weight at birth in the Africa region. The estimated average prevalence of infants aged 0 to 5 months who are exclusively breastfed is 44.4%, which is higher than the global average of 43.8%. Although it performs relatively well against other regions, Africa still experiences a malnutrition burden among children aged under 5 years. The average prevalence of overweight is 5.3% - the second lowest across all regions. The prevalence of stunting is 30.7%, which is higher than the global average of 22.0%. Conversely, the Africa region's prevalence of wasting is 6.0%, which is lower than the global average of 6.7%. The Africa region's adult population also faces a malnutrition burden: an average of 10.0% of adult (aged 18 and over) women live with diabetes, compared to 9.8% of men. Meanwhile, 20.8% of women and 9.2% of men live with obesity.
Recommendations
The results of this study highlight the importance of improving key SDH to reduce the prevalence of childhood malnutrition in Africa. The significant associations observed between the SDH examined in this study and childhood underweight and stunting prevalence highlight the need to address underlying factors in addition to efforts that directly address food access. By focusing on these critical areas, substantial improvements in nutritional outcomes can be achieved, ultimately enhancing the health and well-being of children across the continent.
- Ensuring community empowerment and participation: Empowering local communities to participate in decision-making processes regarding health interventions can lead to more effective and sustainable outcomes.
- Targeting interventions for vulnerable groups: Special attention should be given to vulnerable populations, including women, children under age 5, victims of conflict, and marginalized communities.
- Improving access to basic sanitation services: Concerted efforts should be directed toward initiatives aimed at improving access to basic sanitation facilities across the region.
- Eradicating open defecation: Investing in infrastructure development and community education programs is essential to promote proper sanitation practices and reduce the spread of infectious diseases, ultimately safeguarding children’s health and well-being.
