All diet-related NCD targets are globally off course and at alarming levels, with projected probabilities of meeting any of the targets being close to zero. Mean global sodium intake for adults (aged 25+ years) is estimated at 5.6g/day, slightly higher in men (5.8g/day) than women (5.3g/day). Globally, 1.13 billion (22.1%) adults (18+ years) have raised blood pressure, more men (597.4 million, 24.1%) than women (529.2 million, 20.1%). A staggering 677.6 million (13.1%) adults (18+ years) are obese worldwide, with more women being obese (393.5 million, 15.1%) than men (284.1 million, 11.1%). Diabetes affects 422.1 million (8.5%) adults (18+ years), with slightly more men living with diabetes (217.8 million, 9.0%) than women (204.4 million, 7.9%).

Overall, malnutrition persists at unacceptably high levels on a global scale. Despite some improvements in exclusive breastfeeding, progress overall is far too slow to meet the 2025 global nutrition targets. Intensified efforts and actions are needed to reach each of those targets.

Beyond these nutrition indicators with global targets, the Global Nutrition Report also tracks several IYCF, adolescent and adult indicators (Figure 2.2). Infant and young child feeding practices remain poor. Fewer than half (44.4%) of all newborns are put to the breast within the first hour of birth (known as early initiation), while only 42.2% of infants under 6 months of age are exclusively breasted. Around two-thirds (69.7%) of children aged 12–15 months and less than half (43.9%) of children aged 20–23 months are breastfed. When it comes to solid food, only 69.5% of infants aged 6–8 months eat any solid food at all. Of children aged 6–23 months, only roughly half (53.1%) get the recommended minimum number of meals, with fewer than one in three children (29.3%) receiving the minimum diet diversity. This means that fewer than one in five (18.9%) eat a minimum acceptable diet. The latest sex-disaggregated global data on child and adolescent (5–19 years) and adult (18+ years) anthropometrics shows that far more children and adolescents are underweight than overweight or obese worldwide, while far more adults are overweight or obese than underweight. (We discuss this in more detail below in this chapter, under ‘Inequalities in malnutrition’).

National progress

The Global Nutrition Report also reports on country-level progress towards the 2025 global nutrition targets (Figure 2.3). Country-level progress is assessed as ‘on course’, ‘some progress’ or ‘no progress or worsening’ for MIYCN targets, and ‘on course’ or ‘off course’ for diet-related NCD targets (see Appendix 2 for details on data sources and methods used). Of the ten 2025 global nutrition targets, progress was not assessed at the country level for salt intake and raised blood pressure, due to lack of comparable projections.

Data availability and quality differ across indicators because of varying methodologies and modelling approaches. It is, therefore, possible that some countries may have made progress towards the targets that is not reflected in these analyses. For instance, data for the MIYCN indicators, excluding anaemia and low birth weight, is based on surveys that mostly cover low-income and lower-middle-income countries, thus the full picture is incomplete. Data for anaemia, low birth weight and the NCD targets is available for all countries, but based on modelled estimates, which may not accurately represent actual country-level status.

The assessment of country-level progress reveals that too few countries are ‘on course’ to meet any one of the global targets (Figure 2.3). The latest available data shows that 41 countries are ‘on course’ for childhood overweight, 40 for wasting and 31 for stunting; 33 countries are ‘on course’ for exclusive breastfeeding, and only 12 for low birth weight. Worse still, no country is ‘on course’ to reach the anaemia target, nor is any country ‘on course’ to halt the rise in adult obesity. Likewise, only a low proportion of countries are ‘on course’ to meet the diabetes target.

Across the targets, 106 countries with available data are ‘on course’ to meet at least one global nutrition target, with an additional 28 showing ‘some progress’ in at least one target. Of these 106, 56 countries are ‘on course’ to meet at least two targets; 21 countries to meet at least three, and just 8 countries to meet four targets, which is the maximum number of targets any country is on track to meet.

Countries affected by conflict or other forms of fragility (as discussed in Chapter 1) are at a higher risk for malnutrition. In 2016, 1.8 billion people (24% of the world’s population) were living in fragile or extremely fragile countries.^[5] This figure is projected to grow to 2.3 billion people by 2030 and 3.3 billion by 2050. In such settings, prevalence of wasting^[6] among children under 5 years of age, an acute form of malnutrition, can be used to assess the recent nutrition status of these young children, as well as the overall food and nutrition situation of the general population.^[7] A wasting prevalence of 15% or more is regarded as very high and a trigger for intervention.^[8] Tufts University carried out a study in four countries: Bangladesh and Niger (both fragile, following the classification of OECD),^[9] and Chad and South Sudan (both extremely fragile, following the same classification). This study found that, over the last decade, acute malnutrition prevalence^[10] has occasionally dipped below 15%, but has generally remained above this threshold, despite substantial humanitarian efforts.

New analysis by the Global Nutrition Report demonstrates that fragile countries (20 of 43, 46.5%) and extremely fragile countries (7 of 15, 46.7%) are disproportionally burdened by high levels of all three forms of malnutrition compared to non-fragile countries (10 of 136, 7.4%) (Figure 2.5). Likewise, a greater proportion of fragile countries (42 of 43, 97.7%) and extremely fragile countries (14 of 15, 93.3%) experience at least two forms of malnutrition at high levels compared with non-fragile countries (68 of 136, 50.0%). Of note, there are variations in the forms of malnutrition that fragile, extremely fragile and non-fragile settings mostly face. Non-fragile countries are mostly burdened by high levels of overweight (overweight alone or overlapping with other forms, 74 of 136, 54.4%), whereas fragile countries experience high levels of anaemia (41 of 43, 95.3%) and extremely fragile countries have high levels of anaemia and stunting (14 of 15, 93.3%). These findings highlight the need to understand and address drivers of fragility itself, and how these lead to unequal nutrition outcomes.

As explored in the previous report, multiple forms of malnutrition can also coexist at the individual level.^[12] The 2018 Global Nutrition Report highlighted the coexistence of stunting and wasting at the individual level, meaning that a given child can be both stunted and wasted at the same time, placing them at increased risk for deleterious nutrition deficits, impaired cognitive development and even death. Of the 111 countries with available data, 10 have prevalence above 5% of coexisting stunting and wasting in individuals, and these are concentrated in Africa (7) and Asia (3). Of those, Yemen, South Sudan and Sudan have the highest prevalence, all at 6.7%.

Stunting and overweight can also coexist in the same child at the same time. Across the 111 countries with available data, 10 countries in Africa (5) and Western Asia (5) have a prevalence of at least 5% in coexisting childhood stunting and overweight at the individual level. Syria is the only country in which this prevalence exceeds 10% (11.1%), followed by Equatorial Guinea (8.6%) and Egypt (8.1%). Understanding how different forms of malnutrition can coexist at the individual, household and country level, and across the life course, is crucial, requiring more systematically collected and granular data.

Inequalities in stunting, wasting and overweight among children under 5

Figure 2.7 presents the prevalence of stunting, wasting and overweight (including obesity) in children aged under 5 years by urban–rural location, sex, wealth and education, using the population-weighted mean of 98 countries for which there is available data across all population groups. Similarly to IYCF indicators, mostly low- and lower-middle-income countries are represented. This data suggests that absolute inequalities are more profound for stunting compared to wasting and overweight. Across all three indicators, no major differences are noted by sex, while largest inequalities are seen by wealth: stunting and wasting are more prevalent among the poorest, and overweight among the richest.

Location and education show contrasting inequalities for stunting and wasting versus overweight. Stunting and wasting prevalence is higher among children in rural areas and with less educated mothers, whereas the reverse is seen for overweight, which is higher for children in urban areas and with more educated mothers. Such wealth, location and education gaps are evident even in mostly low- and lower-middle-income settings. This perpetuates vulnerability and creates barriers to escaping poverty, posing a significant challenge to the global community and its commitment to leave no one behind and reach the zero-hunger target.

Stunting

To quantify gaps by sociodemographics, we assessed all countries with available data for a given population group, and not just those with data for all groups. The largest inequalities are seen by wealth, followed by education and location, while stunting is only slightly higher in boys (33.5%) than girls (31.2%). Average stunting rates are estimated to be more than twice as high among children living in the poorest households (43.6%) compared with those in the richest (18.6%). The magnitude of this wealth gap varies across the 92 countries with available stunting data by wealth, with the absolute difference in prevalence being 5% or higher in 79 countries, and 10% or higher in 62 countries. This wealth gap is greatest in Guatemala (poorest 66.4%, richest 17.5%, difference 49.0%), Nigeria (poorest 62.8%, richest 18.3%, difference 44.5%) and Lao PDR (poorest 60.6%, richest 19.7%, difference 40.9%).^[15]

Stunting is also higher among children with less educated (39.2%) versus more educated (24.0%) mothers. Of 82 countries with available stunting data by maternal education, the education gap is 5% or higher in 62 countries, and 10% or higher in 40 countries. This gap is largest in Guatemala (higher 25.9%, lower 55.4%, difference 29.5%), Burundi (higher 31.3%, lower 58.6%, difference 27.3%) and Eritrea (higher 19.4%, lower 46.2%, difference 26.8%).

Of 110 countries with available stunting data by location, children living in rural areas (35.6%) have higher stunting rates than those living in urban areas (25.6%). The location gap is at least 5% in 70 countries, and at least 10% in 41. It is largest in Burundi (rural 58.8%, urban: 27.8%, difference 30.9%) and Lao PDR (rural 48.6%, urban 27.4%, difference 21.2%). Peru is a country with large location and wealth inequalities. Spotlight 2.1 shows the links between urban–rural location and wealth, and how these impact stunting in Peru.

Wasting

There are modest inequalities in wasting prevalence by wealth, with only small differences by sex, location and education. Rates are only slightly higher in boys (12.8%) than girls (11.5%), for children located in rural (12.4%) versus urban (11.4%) areas, and for children of mothers with less (12.9%) versus more (11.2%) education. For wasting, the gap was largest between children living in the poorest (14.1%) versus the richest (10.0%) households. Of 107 countries with available wasting data, the wealth gap is 5% or greater in 15 countries. It is largest in Djibouti (poorest 28.3%, richest 12.8%, difference 15.5%), South Sudan (poorest 30.1%, richest 17.4%, difference 12.8%) and Eritrea (poorest 20.3%, richest 7.8%, difference 12.5%).

Overweight

Inequalities in childhood overweight are less profound by sociodemographic characteristics. Average rates are minimally higher in boys (4.6%) than girls (4.1%). Despite the relatively similar prevalence by location, wealth and education – partly due to representation of mainly low- and lower-middle-income countries – there are some interesting patterns. Overweight is higher for children in the richest (5.7%) versus poorest (3.6%) households, in urban (4.9%) versus rural (4.0%) areas, and with more (5.0%) versus less (3.8%) educated mothers. Similar patterns are observed on a country-level basis, where the largest wealth gap is seen in Peru (rich 14.8%, poor 2.8%, difference 12.0%) and Eswatini (rich 17.5%, poor 5.8%, difference 11.7%).

Geospatial analytical frameworks can be used to assess malnutrition at subnational level, and to understand within-country inequalities (Spotlight 2.2). Drilling down to the subnational level, analysis reveals heterogeneity in levels and probability of meeting the 2025 global nutrition targets for childhood wasting, stunting and overweight. Such analyses can identify locations disproportionally affected, and inform priority-setting and targeted resource allocation at the community level.

While the latest available data provides a snapshot of existing inequalities, repeated data shows how these differences have changed over time. Stunting rates have been slowly but steadily declining, with global prevalence falling from 32.5% in 2000 to 21.9% in 2018. Wasting prevalence (measured at one point in time) is typically not analysed over time, as wasting can fluctuate rapidly over the course of a year. In contrast, prevalence of overweight in children under the age of 5 was 5.9% for 2018, with no major differences noted since 2000 (4.9%). Inequalities across nutrition indicators for children under the age of 5, as shown in Figure 2.7, were largest for stunting, particularly by wealth. Therefore, exploring how this wealth gap in stunting changes over time would provide new insights into nutrition inequalities.

Country-level analysis across 80 countries with available survey data, mostly low- or lower-middle-income countries, reveals that the median annualised decrease in stunting prevalence is larger in the poorest group (0.8%) than in the richest group (0.5%). In fact, the inequality between the poorest and richest households in stunting (wealth gap) is decreasing in 47 countries but increasing in 33 (Figure 2.10). For the 47 countries where the wealth gap is decreasing, the median annualised decrease is 0.5%, mainly due to larger decreases in the prevalence of the poorest group. Of the 33 countries where the wealth gap is increasing, the median annualised increase is 0.3%, mainly due to larger decreases in the richest group. In roughly half of fragile or extremely fragile countries, the wealth gap is increasing; in the rest it is decreasing, warranting further investigation.

Despite these general declining trends, there are noticeable differences in patterns of change at country level. A notable case is Lesotho, where stunting decreased by 30 percentage points in the richest group (2000 43.3%, 2014 13.3%, difference 30.0%), and by only half that much in the poorest group (2000: 60.7%, 2014: 45.6%, difference 15.1%) (Figure 2.11). In five of the ten countries with the largest wealth inequality in stunting, the increased gap is driven by a decrease in the richest group, coupled with an increase or stagnation in the poorest group. This applies to Benin, South Africa, and three fragile or extremely fragile countries – Burundi, Lao PDR, and Nigeria. Burundi and Nigeria are shown in Figure 2.11. Such differential patterns in the wealth gap, particularly when the poorest groups are left further behind, should be carefully considered in the design and implementation of nutrition actions. There are cases though in which comparatively greater reductions are seen in the poorest groups, such as in Peru, Ghana and Mongolia (Figure 2.11). Despite these improvements, the wealth gap is still present, disproportionally burdening the poor, and needs to be addressed.

Inequalities in childhood and adolescent underweight, overweight and obesity

Comparatively less granular data is available for children and adolescents aged 5 to 19 years. Far more boys and girls are underweight than overweight or obese worldwide (Figure 2.12). Childhood and adolescent underweight has decreased globally, from 37.0% in 2000 to 31.6% in 2016 among boys, and from 29.6% in 2000 to 25.9% in 2016 among girls. During the same period, overweight has increased from 10.3% to 19.2% among boys and 10.3% to 17.5% among girls, and obesity from 3.3% to 7.8% among boys and 2.5% to 5.6% among girls.

By sex, prevalence for each of those indicators is slightly higher in boys than in girls. This modest gap between the sexes is relatively stable over time, with signs of increase for overweight and obesity. Similar patterns are seen on a country level, yet this sex gap can also be wider, or reversed (with girls higher than boys). Latest data suggests that Lesotho has the largest sex gap in childhood and adolescent underweight (boys 32.5%, girls 14.1%, difference 18.4%), followed by Zimbabwe (boys 32.5%, girls 15.0%, difference 17.5%) and DR Congo (boys 37.8%, girls 21.9%, difference 15.9%). For overweight, the largest sex gap is seen in southern and eastern African countries, most notably Lesotho (boys 6.2%, girls 24.7%, difference 18.5%), Eswatini (boys 8.3%, girls 25.0%, difference 16.7%) and Zimbabwe (boys 6.7%, girls 22.3%, difference 15.8%). The largest gaps where overweight prevalence in boys exceeds that of girls are seen in East Asian nations, most notably China (boys 35.0%, girls 20.8%, difference 14.2%) and South Korea (boys 33.7%, girls 21.1%, difference 12.6%). The largest gaps for obesity are observed in Southeastern and East Asian nations, such as Brunei (boys 18.3%, girls 9.9%, difference 8.4%), China (boys 15.4%, girls 7.1%, difference 8.3%) and South Korea (boys 12.9%, girls 4.7%, difference 8.3%).

Looking further at potential inequalities by country income (Figure 2.13), prevalence of childhood and adolescent underweight is on average up to three times higher in low- and lower-middle-income countries compared with upper-middle- and high-income countries. The reverse is seen for childhood and adolescent overweight, where prevalence is up to four times higher in upper-middle- and high-income countries than in lower-middle- or low-income ones. Likewise for obesity, there are up to four-fold differences between high- and upper-middle-income countries versus lower-middle- and low-income countries. This data, coupled with the rising prevalence of child and adolescent overweight and obesity, suggests that high- and upper-middle-income countries are disproportionally burdened.

Inequalities in adult nutrition indicators

Underweight, overweight and obesity

Our world has substantially transitioned over the past four decades,^[24] from one in which adult underweight prevalence was more than double than that of obesity, to one in which more adults are obese than underweight, both globally and in all regions except parts of sub-Saharan Africa and Asia. The rising global burdens of overweight and obesity, both in adults and in children and adolescents, cannot be ignored. We need more concentrated efforts and actions to slow down and stop the worldwide rise in obesity. Targeting poor diets through effective and cost-effective approaches should be a top priority for governments, policymakers, clinicians, the food system, the health system, and public–private partnerships in the 21st century to reverse the global obesity epidemic.

Far more men and women are overweight or obese than underweight, and women are generally affected more than men (Figure 2.14). Looking at trends since 2000, male underweight has decreased from 11.1% in 2000 to 8.6% in 2016 and female underweight has decreased from 11.5% to 9.4% in the same period. In contrast, overweight (including obesity) has increased from 31.7% (609.8 million) to 39.2% (1.02 billion) in women, and in men from 29.7% (560.0 million) to 38.5% (984.6 million). Obesity in men has risen from 6.7% (124.7 million) to 11.1% (284.1 million), and in women from 10.6% (201.8 million) to 15.1% (393.5 million). These time-trends align with what is observed in adolescents (Figure 2.12).

There are similar sex differences on a country-level basis, although this sex gap can widen even further, or reverse (with men higher than women). For underweight, women generally have a higher prevalence than men but, at the country level, the reverse sex gap can be as high as 7.4% in Lesotho (women 4.5%, men 11.9%), 6.5% in Equatorial Guinea (women 10.1%, men 16.6%), 6.2% in Zimbabwe (women 4.9%, men 11.1%). The largest sex gap where women have higher prevalence than men is in Japan (women 6.8%, men 3.9%). For overweight, the largest sex differences are seen in southern and eastern African countries: 32.5% in Lesotho (women 53.7%, men 21.1%), 30.6% in Zimbabwe (women 52.8%, men 22.2%) and 30.4% in Eswatini (women 52.6%, men 22.2%). Large sex gaps in obesity are found in countries in the same regions, most notably South Africa (women 39.6%, men 15.4%, difference 24.2%), Lesotho (women 26.7%, men 4.6%, difference 22.0%), Botswana (women 29.3%, men 8.1%, difference 21.2%), Eswatini (women 26.2%, men 5.4%, difference 20.8%) and Zimbabwe (women 25.3%, men 4.7%, difference 20.5%).

Underweight remains prevalent in the world’s poorest regions, especially in South Asia.^[25] The highest underweight prevalence is seen in low- and lower-middle-income nations, up to ten times higher than in high- and upper-middle-income countries (Figure 2.13). As for adolescents, the reverse is seen for adult overweight, where prevalence can be up to three times higher in high- and upper-middle-income than lower-middle- and low-income countries. Obesity prevalence in adults can be up to five times higher in high- and upper-middle-income than in lower-middle- and low-income countries.

Country-level analysis from 190 countries reveals that the median annualised increase in overweight prevalence is the same in both sexes (0.07%). However, the sex gap is increasing in 120 countries and decreasing in 70 (Figure 2.15). Of the 120 countries where the gap is increasing, the median annualised increase is 0.16%, mainly due to larger increases among women. Of the 70 countries where the sex gap is decreasing, the median annualised decrease is 0.10%, mainly due to larger increases among men. This inequality is widening at a greater rate in most currently fragile and extremely fragile countries than in non-fragile countries, with a few exceptions (Iraq, North Korea, Libya, Occupied Palestinian Territory and Venezuela). Of the 120 countries where the sex gap is increasing, 39 (32.5%) are categorised as fragile and 13 (10.8%) as extremely fragile, with a median annualised increase of 0.20% and 0.18% respectively. In contrast, of the 70 countries with a decreased gap, only 4 (5.7%) are fragile and 1 (1.4%) extremely fragile. This suggests that fragile and extremely fragile settings are more heavily burdened by this sex gap in obesity.

Salt intake

High salt (sodium) intake increases systolic blood pressure, a major risk factor for cardiovascular disease and chronic kidney disease, and the leading dietary risk factor for death and illness worldwide.^[27] Given the key roles of social and environmental factors in shaping dietary habits, population-based approaches should be a crucial component of efforts to target salt intake. Effective strategies can be designed and implemented at the local level (e.g., in schools, workplaces and community settings), as well as regionally, at the state level, and at national levels, tailored according to need. Nationally representative US analysis has revealed that high salt intake is the leading dietary risk factor for stroke and heart disease, disproportionally affecting men, ethnic groups other than white and people of lower education.^[28] Global data on salt intake, or any other dietary factor, is not yet available by key sociodemographics. However, such disaggregated global data onat least 55 dietary factors will be made available by the Global Dietary Database in 2020.^[29]

We need such granular global data on what people are actually consuming to investigate drivers of dietary intakes and transitions over time, and to inform the design and implementation of specific policies to reduce diet-related health burdens and inequalities in different nations.

Globally, average sodium intake among adults (aged 25 years and over) is virtually unchanged since 2010. Men have slightly higher intake (5.8g/day) than women (5.3g/day) at a global level, with relatively larger differences seen at country level. The difference is greatest in southern and eastern European countries, such as Hungary (men 5.7g/day, women 3.9g/day, difference 1.8g/day), Czechia (men 5.6g/day, women 3.9g/day, difference 1.7g/day) and Slovenia (men 5.5g/day, women 3.9g/day, difference 1.6g/day).

Raised blood pressure

Over the past four decades, the number of people with raised blood pressure in the world has increased.^[30] Though raised blood pressure has traditionally affected high-income countries, the majority of the observed increase is due to raises in low- and middle-income countries, and driven to a great extent by the growing and ageing population. It is now most prevalent in low-income countries in South Asia and sub-Saharan Africa, while being a persistent health issue in Central and Eastern Europe.^[31]

Despite an increase in the number of people affected, the global prevalence of raised blood pressure has remained relatively unchanged with only slight decreases between 2000 and 2015 (Figure 2.16). Globally, more men (24.1%) than women (20.1%) have raised blood pressure, with largest sex gaps at the country level seen in Northern Europe, most notably in Latvia (men 36.4%, women 22.9%, difference 13.5%), Estonia (men 34.3%, women 20.9%, difference 13.4%) and Iceland (men 26.2%, women 13.0%, difference 13.2%).

Diabetes

There are tremendous health risks of overweight and obesity. The annual medical costs of treating the consequences of obesity are staggering, and are expected to reach US$1.2 trillion per year by 2025, with the US being by far the biggest spender.^[33] Diabetes is one of these consequences: presently, someone is estimated to die every eight seconds from diabetes or its complications – with projected increases over time.^[34] Of all global health expenditure, 10% is spent on diabetes (US$760 billion).^[35] Some alarming statistics from the International Diabetes Federation reveal that one in two adults with diabetes are undiagnosed, two in three people with diabetes live in urban areas, and three in four people with diabetes live in low- and middle-income countries.^[36]

Over the past four decades, diabetes prevalence in adults has increased, or, at best, remained unchanged, in every country. This increase has been faster in low- and middle-income countries than in high-income countries.^[37] The picture is similar for the past two decades (Figure 2.16). Globally, only slightly more men (9.0%) than women (7.9%) have diabetes, with similar small differences observed at the country level.

Photo: Province of British Columbia

Updates were made to this page in May 2020