77159 NUTRITION at a GLANCE EL SALVADOR The Costs of Malnutrition Annually, El Salvador loses over US$110 million • Over one-third of child deaths are due to undernu- trition, mostly from increased severity of disease.2 in GDP to vitamin and mineral deficiencies.3,4 • Children who are undernourished between con- Scaling up core micronutrient interventions would ception and age two are at high risk for impaired cost El Salvador only US$8 million per year.19 cognitive development, which adversely affects (See Technical Notes for more information) the country’s productivity and growth. • The economic costs of undernutrition and over- Key Actions to Address Malnutrition: weight include direct costs such as the increased Reduce stunting through effective growth monitoring burden on the health care system, and indirect and promotion including education and counseling costs of lost productivity of adult workers. regarding optimal infant and young child feeding. • Undernourished children who experience rapid Reduce micronutrient deficiencies through access weight gain after infancy are at higher risk for to nutritious complementary food after six months of Photo courtesy of WFP El Salvador chronic diseases such as diabetes and coronary age, supplementation, fortification of staple foods, and heart disease.10 Country Context • Childhood anemia alone is associated with a diet diversification. 2.5% drop in adult wages.6 Reduce disparities in nutritional status between HDI ranking: 106 out of 182 the poor and the rich through the adoption of countries1 policies and programs focusing on improving nutrition, Where Does El Salvador Stand? education, and income of low income families. Life expectancy: 72 years2 • 21% of children under the age of five are stunted, Lifetime risk of maternal death: 6% are underweight, and 2% are wasted.7 Address the growing burden of overweight and • 7% of infants are born with a low birth weight.2 obesity through policies that promote the adoption 1 in 3502 • 38% of children between 6–24 months are ane- of a healthy lifestyle including healthy eating and Under-five mortality rate: 17 per increased physical activity. mic.17 1,000 live births2 • 6% of children are overweight which is equal to Global ranking of stunting the prevalence of child underweight.7 prevalence: 85th out of 136 • 49% of adults are overweight or obese.8 Children in rural areas are almost twice as likely countries2 to be stunted as children in urban areas (18% vs. Disparities in Malnutrition within El Salvador 10%). Undernutrition is also linked to maternal There are striking disparities in the rates of malnu- education: almost 40% of children born to mothers with no education are stunted. Most notable is the Technical Notes trition between various subgroups in El Salvador. correlation between child stunting and household Low birth weight is a birth weight less income, as shown in Figure 2.17 than 2500g. FIGURE 1  El Salvador is in the Upper Tier for Stunting Stunting is low height for age. Rates When Compared to Countries with Similar Income FIGURE 2  Children from the Lowest Income Quintile are Levels in the Region Almost Seven Times More Stunted Than Children in the Underweight is low weight for age. 35 Richest Income Quintile Prevalence of Stunting Among Wasting is low weight for height. 30 Peru 35 Children Under 5 (%) Overweight is a body mass index (kg/m2) Ecuador Prevalence of Child Stunting (%) 25 of ≥ 25; obesity is a BMI of ≥ 30. Belize 30 20 El Salvador Nicaragua Panama 25 Current stunting, underweight, and wasting 15 Colombia estimates are based on comparison of the Uruguay 20 10 Dominican most recent survey data with the WHO Republic 15 5 Child Growth Standards, released in 2006. Jamaica Chile 10 0 This note was prepared by a World Bank 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 5 team composed of Marie Chantal Messier GNI per capita (US$2008) 0 First Second Third Fourth Fifth (LCSHH), Christine McDonald (consultant) (Poorest) (Richest) and Rafael Cortez (LCSHH). Editorial Source: Stunting rates were obtained from the 2010 WHO World Health Statistics Report.9 GNI data were obtained from the World Bank’s World support was provided by Julie Ruel- Development Indicators.4 Source: FESAL, 2008.17 Bergeron and Sonia Levere. Solutions to Primary Causes of Undernutrition EL SALVADOR Poor Infant Feeding Practices High Disease Burden Limited Access to Nutritious Foods • 67% of newborns do not receive breast milk • Undernourished children have an increased likeli- • Consuming a diverse and nutritious diet seems to within one hour of birth.10 hood of falling sick and experience greater severity be a challenge as reflected in the rates of stunting, • 69% of infants under six months of age are not of disease. anemia, and overweight. exclusively breastfed.10 • Undernourished children who fall sick are much • Dietary diversity is essential for healthy eating and • 24% of infants between six to nine months of age more likely to die from childhood illnesses than well- food security. are not fed appropriately with breast milk and nourished children. Solution: Involve all sectors concerned with nutrition solid foods during this important transition period • Children who are undernourished in the first 2 years security including education, health, agriculture, food where both breastmilk and other nutritious foods of life and who put on weight rapidly later in child- industry, and others, to ensure that diverse, nutritious are needed. hood and in adolescence are at high risk of chronic diets are available and accessible to households of all Solution: Support women and their families to diseases related to nutrition.11 income levels. Food policies and regulations should learn and practice optimal breast feeding and intro- Solution: Prevent and treat childhood stunting, over- promote access to a variety of nutritious foods to pre- duce nutritious complementary foods when children weight and diseases or infections. Promote healthy vent stunting, micronutrient deficiencies and obesity. are six months of age, while still breastfeeding. eating and physical activity. References Vitamin and Mineral Deficiencies Cause FIGURE 3  Vitamin A and Iron Deficiency Contribute to Lost Lives and Diminished Productivity 1. UNDP. 2009. Human Development Report. 2. UNICEF. 2011. State of the World’s Children. Hidden Hunger 3. UNICEF and the Micronutrient Initiative. 2004. Although they may not be visible to the naked eye, 30 Vitamin and mineral deficiency: a global progress micronutrient deficiencies are widespread in El Sal- 25 report. vador, as shown in Figure 3. Prevalence (%) 4. World Bank. 2009. World Development Indicators 20 (Database). 15 5. Abegunde D et al. 2007. The Burden and Costs of • Iron: In the last 10 years, the prevalence of ane- Chronic Diseases in Low-Income and Middle-Income 10 Countries. The Lancet 370:1929–38. mia has increased more than 20% and has almost 6. Horton .S and Ross J. The Economics of Iron doubled in rural areas. Current rates of anemia 5 Deficiency. Food Policy. 2003;28:517–5. 7. Lutter CK, Chaarro CM. 2008. Malnutrition in among preschool children and pregnant women 0 Preschool Children Pregnant Women infants and young children in Latin America and the are 27% and 21%,15 respectively. Iron-folic acid Vitamin A Deficiency Anemia Caribbean: Achieving the Millennium Development supplementation of pregnant women, deworm- Source: 1995–2005 data from the WHO Global Database on Child Growth and Goals. PAHO: Washington DC. Malnutrition.12 8. WHO. 2005. Global Database on BMI. ing, multiple micronutrient supplementation of 9. WHO. 2010. World Health Statistics Report. WHO: infants and young children, and fortification of health system to absorb the increased costs of treat- Geneva. 10. UNICEF. 2009. Tracking Progress on Child and staple foods are effective strategies to improve the ment of diet-related diseases and will also affect the Maternal Nutrition. iron status of these vulnerable groups. productivity of the workforce. 11. Victora CG, et al. Maternal and Child Undernutrition: • Vitamin A: 14% of preschool aged children are Consequences for Adult Health and Human Capital. deficient in vitamin A.14 The Lancet 2008; 371:340–57. 12. WHO. 2009. Global Database on Child Malnutrition World Bank Nutrition-Related Activities in (Database) 13. FAO. 2009. The state of food insecurity in the world: The Double Burden of Undernutrition and El Salvador The World Bank is currently supporting the US$80 Economic crises – impacts and lessons learned. 14. WHO. 2009. Global prevalence of vitamin A Overweight million Public Health Care System Strengthening deficiency in populations at risk 1995–2005. WHO While undernutrition persists, El Salvador has project. This project seeks to expand coverage and Global Database on Vitamin A Deficiency. seen an exponential increase in rates of overweight 15. WHO. 2008. Worldwide Prevalence of Anemia quality of priority health care services including nu- 1993–2005: WHO Global Database on Anemia. and obesity, notably amongst children and women. trition, improve equity for access and utilization; and 16. Horton S. et al. 2009 Scaling Up Nutrition: What The prevalence of overweight among children un- strengthen the Government’s stewardship capacity to will it cost? 17. Republica de El Salvador, C. A. 2009. Encuesta der 5 has increased by 50% in the last 10 years.17 manage public health functions. Nacional de Salud Familiar FESAL-2008, Informe Furthermore, 80% of women over 40 years old are More information about nutrition activities in Final. overweight.17 Children born to obese mothers are the Latin America Region can be found at: www. 18. Chu et al. Association between obesity during pregnancy and increased use of health care. N Engl twice as likely to be obese and to develop type 2 worldbank.org/lacnutrition. J Med. 2008 Apr 3; 358(14):1444–53. diabetes later in life.18 19. The methodology for calculating nationwide costs of This “double burden of malnutrition� can be at- vitamin and mineral deficiencies, and interventions tributed to rapid urbanization and the adoption of Addressing undernutrition is cost included in the cost of scaling up, can be found at: www.worldbank.org/nutrition/profiles diets high in refined carbohydrates and fats, com- effective: Costs of core micronutrient bined with a more sedentary lifestyle. This nutrition interventions are as low as transition, if not curbed now, will result in high hu- US$0.05–8.46 per person annually. THE WORLD BANK man and economic costs to the Salvadoran society. Returns on investment are as high as Produced with support from the Japan Trust Fund It will have adverse impacts on the ability of the 6–30 times the cost.16 for Scaling Up Nutrition