77216 Nutrition GLANCE Afghanistan at a The Costs of Undernutrition Annually, Afghanistan loses over US$235 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 concep- Scaling up core micronutrient interventions would tion and age two are at high risk for impaired cogni- cost less than US$17 million per year. tive development, which adversely affects the indi- (See Technical Notes for more information.) vidual’s learning ability, the efficiency of the coun- try’s investments in education and skills develop- Key Actions to Address Malnutrition: ment and national productivity and development. Increase the valuation of nutrition as central to national • The economic costs of undernutrition include development by developing and implementing a multi- direct costs such as the increased burden on the sectoral strategy to address both the short routes to health care system, and indirect costs of lost pro- nutrition improvement and the underlying causes. ductivity. Improve infant and young child nutrition, focusing on • Childhood anemia alone is associated with a improving early and exclusive breastfeeding during the Country Context 2.5% drop in adult wages.5 first 6 months and appropriate complementary feeding HDI ranking: 181st out of 182 from 6 to 24 months. countries1 Where Does Afghanistan Stand? Ensure good nutrition for women during pregnancy to • 59% of children under the age of five are stunted, improve birth outcomes and protect the health of the Life expectancy: 44 years2 33% are underweight, and 9% are wasted.2 mother. Lifetime risk of maternal death: • Afghanistan has achieved high rates of vitamin A supplementation: 96% of children 6–59 months of Develop the capacity of Afghanistan to deliver nutrition 1 in 82 services in the country. age receive the recommended two doses of vita- Under-five mortality rate: min A approximately six months apart.2 Full cov- 257 per 1,000 live births2 erage can decrease the risk of mortality by 23%.6 Global ranking of stunting • National policy on zinc supplementation for the underweight and reduce low birth weight to im- treatment of diarrhea has been enacted7. Zinc prove outcomes for future generations of children. prevalence: Highest out of 136 countries2 supplementation during diarrheal episodes can reduce morbidity by more than 40%.8 Most of the irreversible damage due to malnutrition in Afghanistan happens As shown in Figure 1, the overall prevalence during gestation and in the first 24 Technical Notes of stunting and underweight have decreased over the past two decades and the country is currently months of life9 Stunting is low height for age. on track towards meeting MDG 1c (halving 1990 As seen in Figure 2, Afghanistan performs poorly rates of child underweight by 2015).9 Nevertheless, relative to countries in the same region and income Underweight is low weight for age. much remains to be done to accelerate reductions in Wasting is low weight for height. Figure 2  Afghanistan has Higher Rates of Stunting Current stunting, underweight, and wasting Figure 1  Afghanistan is On Track Toward Meeting than its Neighbors and Income Peers estimates are based on comparison of the MDG 1 most recent survey data with the WHO 70 Prevalence of Stunting Among Child Growth Standards, released in 2006. 60 60 Afghanistan Prevalence Among Children They are not directly comparable to the Children Under 5 (%) 50 50 Nepal India Bhutan trend data shown in Figure 1, which are Bangladesh 40 Myanmar Pakistan Under 5 (%) calculated according to the previously-used 40 Liberia Maldives NCHS/WHO reference population. 30 30 20 20 Sri Lanka Low birth weight is a birth weight less than 2500g. 10 10 0 The methodology for calculating nationwide 0 0 1000 2000 3000 4000 1997 2000 2004 costs of vitamin and mineral deficiencies, GNI per capita (US$2008) Stunting Underweight 2015 MDG Underweight Target and interventions included in the cost Source: Stunting rates were obtained from the WHO Global Database on Child of scaling up, can be found at: Source: WHO Global Database on Child Growth and Malnutrition (figures Growth and Malnutrition (figures based on WHO child growth standards). GNI www.worldbank.org/nutrition/profiles based on the NCHS/WHO reference population). data were obtained from the World Bank’s World Development Indicators. Solutions to Primary Causes of Undernutrition afghanistan Poor Infant Feeding Practices High Disease Burden Limited Access to Nutritious Food • Qualitative field studies have found that exclusive • 1 in 3 child deaths are due to pneumonia; close to 1 • Close to 1 in 4 households is food insecure.12 breastfeeding (no liquids or solids but breast milk) in 4 child deaths are due to diarrhea.9 • Achieving food security means ensuring quality and for infants under six months is extremely rare.10 • Only 22% of the population has access to clean continuity of food access, in addition to quantity, for • During the important transition period to a mix of water.2 all household members. breast milk and solid foods between six and nine • Undernourished children who fall sick are much • Dietary diversity is essential for food security. months of age, 71% of infants are not fed ap- more likely to die from illness than well-nourished Solution: Involve multiple sectors including agricul- propriately with both breast milk and other foods.2 children. ture, education, transport, gender, the food industry, Solution: Support women and their families to • Parasitic infestation diverts nutrients from the body health and other sectors, to ensure that diverse, nutri- practice optimal breastfeeding and ensure timely and can cause blood loss and anemia. tious diets are available and accessible to all house- and adequate complementary feeding. Breast milk Solution: Prevent and treat childhood infection and hold members. fulfills all nutritional needs of infants up to six other disease. Hand-washing, deworming, zinc sup- months of age, boosts their immunity, and reduces plements during and after diarrhea, and continued exposure to infections. feeding during illness are important. References group. Countries with similar per capita incomes such and young children, and fortification of staple 1. UNDP. 2009. Human Development Report. as Liberia and Myanmar exhibit lower rates of child foods are effective strategies to improve the iron 2. UNICEF. 2009. State of the World’s Children. stunting, which demonstrate the ability to achieve status of these vulnerable subgroups. 3. UNICEF and the Micronutrient Initiative. better nutrition outcomes despite low income. • Iodine: Only 28% of households consume io- 2004. Vitamin and Mineral Deficiency: a dized salt, and close to one million infants remain Global Progress Report. 4. World Bank. 2009. World Development Vitamin and Mineral Deficiencies Cause unprotected from iodine deficiency disorders.9 Indicators (Database). Hidden Hunger 5. Horton S. and Ross J. The Economics of Iron Deficiency. Food Policy. 2003;28:517-5. Although they may not be visible to the naked eye, World Bank Nutrition-Related Activities in 6. Beaton G., et al. 1993. Effectiveness Of vitamin and mineral deficiencies impact well-being Afghanistan Vitamin A Supplementation in the Control in Afghanistan, as indicated in Figure 3. Projects: The World Bank is currently support- of Young Child Morbidity and Mortality in ing the Strengthening Health Activities for the Developing Countries. ACC/SCN State-of-the- Art Series, Nutrition Policy Paper No. 13. • Vitamin A: 65% of preschool aged children Rural Poor (SHARP) project which intends to in- 7. Micronutrient Initiative. 2009. Investing in the and 16% of pregnant women are deficient in crease the provision of health care and nutrition Future: A United Call to Action on Vitamin vitamin A.13 services to women and children in underserved and Mineral Deficiencies. • Iron: Current rates of anemia among preschool areas. Other projects such as the National Solidar- 8. Bhandari N., et al. 2008. Effectiveness of Zinc Supplementation Plus Oral Rehydration aged children and pregnant women are 38% and ity Program are also supporting activities which Salts Compared With Oral Rehydration Salts 61%, respectively.14 Iron-folic acid supplementa- improve nutrition. Alone as a Treatment for Acute Diarrhea in a tion of pregnant women, deworming, provision Primary Care Setting: A Cluster Randomized of multiple micronutrient supplements to infants Analytic Work: Several policy notes have been Trial. Pediatrics 121;e1279 e1285. 9. UNICEF. 2009. Tracking Progress on Child completed in past years including an overall health and Maternal Nutrition. sector review and an examination of food policy 10. World Bank. 2008. Afghanistan Nutrition. Figure 3  High Rates of Vitamin A and Iron Deficiency and security in the country. An assessment on the 11. Horton S. et al. 2009 Scaling Up Nutrition: Contribute to Lost Lives and Diminished Productivity current nutrition situation is scheduled to be deliv- What will it cost? 12. FAO. 2009. The State of Food Insecurity in 70 ered in 2010. This assessment was carried out with the World: Economic Crises – Impacts and 60 funding from the Japan Trust Fund for Scaling-Up Lessons Learned. Nutrition and the World Bank’s Regional Repriori- 50 Prevalence (%) 13. WHO. 2009. Global Prevalence of Vitamin A 40 tization Fund. Deficiency in Populations at Risk 1995–2005. WHO Global Database on Vitamin A 30 Deficiency. 14. WHO. 2008. Worldwide Prevalence of 20 Addressing undernutrition is cost Anemia 1993–2005: WHO Global Database 10 effective: Costs of core micronutrient on Anemia. 0 interventions are as low as Preschool Children Pregnant Women Vitamin A Deficiency Anemia US$0.05–3.60 per person annually. Source: 1995–2005 data from the WHO Global Database on Child Growth and Returns on investment are as high Malnutrition. as 8–30 times the costs.11 THE WORLD BANK Produced with support from the Japan Trust Fund for Scaling Up Nutrition