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Despite having worse wasting level and similar stunting level, why South Asia have less under five mortality than Sub Saharan Africa?

This question was posted the Cross-cutting issues forum area and has 4 replies.

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Melaku Begashaw

Normal user

29 Jan 2019, 12:16

Some background (all WHO 2016 data, Economy data World Bank):


Based on WHO’s rank of under-five mortality African countries make the lowest 19 countries with highest under five mortality rate. Out of the 50 highest mortality ranks, 40 countries are in Africa. Under five Mortality in sub Saharan African nations is 78 deaths per 1000 live births, a 106 deaths per 1000 live births decrease since 1990, while in Asia it is 86 deaths per 1,000 live births and this is a 81 deaths decrease per 1,000 live births since 1990. Even though Sub Saharan Africa’s reduction of under five mortality is far higher than that of South Asian, the under five mortality rate in Africa is still very high by 30 deaths, and even though Africa’s population is 58% of that of South Asia, the under-five mortality is higher in Africa by 1.2 million. Note: Under-5 mortality rate is probability of dying between birth and exactly 5 years of age, expressed per 1,000 live births.

The high level of mortality in Africa will be hard to describe when we see nutrition and other as both South Asia and Sub Saharan Africa have a relatively comparable infant and young child feeding practices, in some instances Africa is far better off. For instance, Early initiation of breast feeding is more practiced in Africa than India (51% and 39%, respectively), exclusive breasting on the other hand is more in South Asia (52%) than Sub Saharan Africa (42%), introduction to solid, semi-solid, or soft foods 6-8 months is high in Africa (71%) when compared to Asia (56%), in both areas minimum acceptable diet is received with few children (11% in South Asia to 12% in SSA). On the other hand continued breast feeding up to age 2 is higher in SA (68%) than SSA (50%).

The difference in mortality rate will become bizarre when we see the levels of stunting and wasting in both locations. Stunting is almost equal in SSA (34%) and SA (36%), wasting is twice higher in South Asia (16%) than Sub Sahara Africa (8%), Vitamin A supplementation (VAS) is 66% in SA and 72% in SSA and severe wasting twice higher in South Asia (5% vs 2%), and iodine consumption is 88% in SA and 80% in SSA. Per capita income (South Asia=USD 1,729, SSA=1,486), and GDP (SA=3.3 Trillion, SSA=1.67 Trillion)

What explains this phenomenon? What did South Asia did to decrease under five mortality when compared with Africa, given the level of wasting and stunting? Are there any studies?

Another unrelated question: World Bank’s Investment Bank’s investment framework for addressing malnutrition cites ‘not enough evidence on interventions that prevent wasting’. Hence, the framework concentrates on curative interventions. It calculates investments needed to meet WHA’s target of wasting and other indicators. Question: is that true we do not have enough information on interventions to prevent wasting?

André Briend

Frequent user

30 Jan 2019, 14:50

Dear Melaku,

You raise important points which have not been adequately addressed in the literature.

a) Low levels of mortality in Asia compared to Africa

The high mortality observed in Africa can partly be explained by the high prevalence of malaria in Africa compared to South Asia. But this may be only part of the story and I suspect there is also an issue with the measure of malnutrition.

Malnutrition can be best defined a state of nutrition in which a deficiency of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome (1). Measuring malnutrition following this definition is difficult, however, and all epidemiological studies rely on measuring body size (weight-for-age), and a very rough measure of body shape, weight-for-height (WFH). This is a very imperfect approach and we should be aware of its limitations.

In the context of measuring obesity, it has proposed that Body Mass Index (BMI) which is close to WFH but easier to use in adults and to some extent reflects body shape, could be used to estimate the proportion of body fat and hence to define obesity. It has been observed for long, however, that this measure is imperfect and that the relationship between BMI and body fat is different across populations, to such an extent that using different cut-offs has been recommended to define obesity (2) (3) (4) (5) (6) (7) (8). These differences in the relationship between BMI and fatness seem related to body frame size and shape.

Curiously, the same discussion on the relevance of WFH to measure nutritional status did not take place when measuring malnutrition, although it looks likely that the relationship between body nutritional reserves (i.e fat and muscle mass) and WFH is likely to be influenced as well by size and shape of body frame. To my knowledge, there is only one study which looked at the effect of relative leg length on WFH and it found that WFH overestimates the degree of malnutrition in pastoralist populations who have relatively long length (9). On the other hand, it has been shown in Brazil that the low prevalence of wasting could also be used to a different body shape not directly related to nutritional status (10). It has been known for long as well that Indian children can have high body fat mass even when having low WFH and the term “thin fat phenotype” has been coined to describe this phenomenon (11).

Overall, this means that using WFH as a proxy measure of acute malnutrition can be misleading in some populations. I suspect that the high level of malnutrition suggested by wasting levels in South Asia does not adequately reflects the nutritional situation and may lead to wrong conclusions when doing comparisons with Africa.

b) Wasting prevention

I would agree with the World Bank document arguing that wasting prevention is difficult, at least in situations where there are no major problems of food insecurity. A full literature review, beyond the scope of this forum, would be needed to support this. A recent paper by the MRC team working in the Gambia however rather convincingly supports this statement. After 40 years of implementing multiple interventions to prevent malnutrition, there was an important decline in stunting but wasting remained constant (12). Maybe the difficulty to eliminate wasting can be related to problems of body shape as discussed above.

I hope this helps

1. Lochs H, Allison SP, Meier R, Pirlich M, Kondrup J, Schneider S, van den Berghe G, Pichard C. Introductory to the ESPEN Guidelines on Enteral Nutrition: Terminology, definitions and general topics. Clin Nutr Edinb Scotl. 2006;25:180–6.
2. Deurenberg P, Deurenberg-Yap M, Guricci S. Asians are different from Caucasians and from each other in their body mass index/body fat per cent relationship. Obes Rev Off J Int Assoc Study Obes. 2002;3:141–6.
3. Deurenberg P. Universal cut-off BMI points for obesity are not appropriate. Br J Nutr. 2001;85:135–6.
4. Sinaga M, Worku M, Yemane T, Tegene E, Wakayo T, Girma T, Lindstrom D, Belachew T. Optimal cut-off for obesity and markers of metabolic syndrome for Ethiopian adults. Nutr J. 2018;17:109.
5. Deurenberg-Yap M, Schmidt G, van Staveren WA, Deurenberg P. The paradox of low body mass index and high body fat percentage among Chinese, Malays and Indians in Singapore. Int J Obes Relat Metab Disord J Int Assoc Study Obes. 2000;24:1011–7.
6. Rush EC, Freitas I, Plank LD. Body size, body composition and fat distribution: comparative analysis of European, Maori, Pacific Island and Asian Indian adults. Br J Nutr. 2009;102:632–41.
7. Martinez E, Bacallao J, Devesa M, Amador M. Relationship between frame size and fatness in children and adolescents. Am J Hum Biol Off J Hum Biol Counc. 1995;7:1–6.
8. Ortiz-Hernández L, López Olmedo NP, Genis Gómez MT, Melchor López DP, Valdés Flores J. Application of body mass index to schoolchildren of Mexico City. Ann Nutr Metab. 2008;53:205–14.
9. Myatt M, Duffield A, Seal A, Pasteur F. The effect of body shape on weight-for-height and mid-upper arm circumference based case definitions of acute malnutrition in Ethiopian children. Ann Hum Biol. 2009;36:5–20.
10. Post CL, Victora CG. The low prevalence of weight-for-height deficits in Brazilian children is related to body proportions. J Nutr. 2001;131:1290–6.
11. D’Angelo S, Yajnik CS, Kumaran K, Joglekar C, Lubree H, Crozier SR, Godfrey KM, Robinson SM, Fall CHD, Inskip HM, et al. Body size and body composition: a comparison of children in India and the UK through infancy and early childhood. J Epidemiol Community Health. 2015;69:1147–53.
12. Nabwera HM, Fulford AJ, Moore SE, Prentice AM. Growth faltering in rural Gambian children after four decades of interventions: a retrospective cohort study. Lancet Glob Health. 2017;5:e208–16.

Melaku Begashaw

Normal user

30 Jan 2019, 15:12

Thank you very much for your time and knowledge. Appreciated. Well noted. Melaku

Melaku Begashaw

Normal user

30 Jan 2019, 17:29


Under five mortality
---> in South Asia: (1990=129 deaths per 1,000 live births, 2017 =48 deaths per 1,000 live births)

--->In Sub Sahran Africa: (1990=181 deaths per 1,00 live births, 2017=78 deaths per 1,000 live births)
Source: WHO SOWC_-Statistical-Tables-2017 (the tables include many indicators like WASH, immunization, and many more for those interested)

André Briend

Frequent user

4 Feb 2019, 08:28

Dear Melaku,

I just came across this paper from Obesity Reviews which examines at length the variations of WFH and BMI across populations. This paper escaped my attention so far as the main focus is on obesity, but there are also long sections on undernutrition. Very well documented and tapping onto literature which is often ignored among specialsits of malnutrition in children. Illuminating. After reading this article, you will understand that one should be very cautious when ascribing all variations of wasting prevalence to undernutrition. The question is much more complex than that and we need as well an in-depth discussion of these issues among malnutrition specialists.

Hruschka DJ, Hadley C. How much do universal anthropometric standards bias the global monitoring of obesity and undernutrition? Obes Rev. 2016 Nov;17(11):1030-1039. doi: 10.1111/obr.12449. Epub 2016 Jul 7.

This article is in free access. I hope you will find it interesting.

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