Module 9: Existing Indices of Hunger and Undernutrition

There is no universally accepted ‘gold standard’ measurement of malnutrition, mostly due to the fact that the problem of malnutrition encompasses many interrelated and complex factors. However, there are several indices available that use different methods to measure hunger and malnutrition, such as the United Nations Food and Agriculture Organization (FAO) index of undernutrition, the Global Hunger Index developed by the International Food Policy Research Institute, and the Action Aid’s HungerFREE Scorecard. Countries have also developed systems of monitoring the status of nutrition among populations.

Methods of Measurement

United Nations Food and Agriculture Organization (FAO) Index of Undernutrition

The nutrition index that has been most cited is the FAO measurement of undernutrition.(1) Under this framework, hunger is defined as energy deficiency caused by inadequate dietary intake. Using aggregates, the index measures hunger as the proportion of the population with per capita food energy intake below standard nutritional requirements. Thus, the index of undernutrition is a measure of food energy deprivation. The index is calculated by considering three parameters:  per capita availability of food, inequality of energy intake, and age/sex-specific nutrition requirements. Caloric intake estimates are based on data from country Food Balance Sheets, which estimate a country’s food supply over a three year period. The FAO’s most recent report estimates that 925 million people worldwide are undernourished.(2) 

While estimates have provided a helpful glance at malnourishment around the world, there has been some criticism of the FAO index as a measure of undernutrition. A review of the FAO index has expressed:

“[The index] is unsatisfactory in a number of ways. Food availability is a rather poor predictor of failure to grow, mortality and economic productivity…The index is not distribution-sensitive and an increase in food deficiency of the most deprived sector of the population would leave the index unchanged. Food availability data are averaged over a 3 year period and the effects of seasonal crises and droughts go unnoticed. There are also issues regarding the caloric cut-off point adopted by the FAO.”(3) 

Global Hunger Index (GHI)

The GHI is used to measure malnutrition across countries and was developed as a way to increase international attention to the problem of global malnutrition. The GHI incorporates the inadequate availability of food, child malnourishment, and child mortality.(4) The three indicators used to calculate the GHI for a particular country are:  the proportion of the population who are food-energy deficient as compiled by the FAO, the prevalence of children under five who are underweight as estimated by the WHO, and child under five mortality rates as compiled by UNICEF.  The GHI is a more comprehensive measure of undernutrition than the index provided by the FAO since its calculation involves three equally-weighted indicators.(5) An advantage of the GHI is that it reflects the nutritional status of children under five, a particularly vulnerable group to undernutrition. However, the GHI does not include information about micronutrient deficiencies, maternal malnutrition, or food security.

Action Aid’s HungerFREE Scorecard

The NGO Action Aid has developed an index that measures nutrition outcomes as well as a country’s political commitment to combating undernutrition. They assess four categories:  outcomes of hunger and undernutrition, the country’s legal commitment to provide their people with the right to food, investments in agriculture, and investments in social protection.(6) Countries are given a letter grade for each category. Hunger and malnutrition statistics are taken from the FAO and WHO, respectively. 

The Action Aid nutrition scorecard is an interesting and innovative way to monitor and evaluate hunger outcomes as well as some of their political determinates. This method of assessing the nutritional situation of a country provides information that is relevant to policy formation and can be used as a powerful tool for advocacy.(7) The purpose of the scorecard is to encourage governments from developed and developing countries to commit to hunger eradication. There are 29 developing countries and 22 developed countries with scorecards available. Scorecards are only made for countries where reliable data is obtainable and where HungerFREE campaigns exist, since they provide a means to collect information about government policies and programs. 

Methods of Monitoring: A Case Study

Bangladesh’s Food Security and Nutritional Surveillance Project

Bangladesh is a low-income country with a history of devastatingly high rates of child and maternal undernutrition. However, there has been a steady decline in the prevalence of childhood undernutrition in the last two decades: while the prevalence of rural children under five was just over 70% in 1990, it had declined to 33% by 2011.(8)(9) Despite this dramatic improvement, the actual number of malnourished children in this highly-populated country is still high when compared to other developing countries. The current national prevalence of childhood stunting, a measure of chronic malnutrition, is 41% and has been recorded up to 46% in some areas.(10) Malnutrition and food insecurity are among the greatest public health threats in the country. 

The government of Bangladesh has long recognized the need to improve health and economic development, and has made some efforts to do so by signing the Millennium Development Goals and by presenting its own Poverty Reduction Strategy Paper (PRSP). However, in order to monitor the country’s progress towards these goals, the government realized the need for a nationwide health and nutrition surveillance system. In 2009, the government of Bangladesh, in partnership with Helen Keller International (HKI) and BRAC’s James P. Grant School of Public Health, established the Food Security and Nutritional Surveillance Project (FSNSP) as a means to assess national maternal and child undernutrition. Funding for the project was provided by the European Union. 

The FSNSP is a comprehensive surveillance system meant to monitor national health and nutrition. The project ran from July 2008 to June 2015. A main objective of the project was to institutionalize a surveillance system within a national framework, ensuring future sustainability and a consistent flow of nutrition information. Throughout the project, HKI transfered all roles and responsibilities to BRAC’s School of Public Health and the Bangladesh Bureau of Statistics (BBS) so that the system could continue beyond the project's end date. This public-private partnership was essential to the project’s success and sustainability. 

The FSNSP was an extension of HKI’s Nutritional Surveillance Project (NSP), which previously ran from 1990 to 2006 as one of the longest-running nutritional surveillance systems in the developing world.(11) The NSP has provided a plethora of information over its lifespan, serving as an invaluable tool for research, program implementation, monitoring, and evaluation. NSP information has been used as a platform to encourage investments in nutrition not only in Bangladesh but throughout the developing world. The FSNSP followed in its footsteps and continued to enlighten policy and planning in order to improve nutrition.   

The questionnaire used in the FSNSP was developed according to literature review, a meeting of stakeholders, and lessons learned from NSP questions. The questionnaire was designed to minimize answering bias, and restricted answers to a short time period preceding the interview in order to reduce errors based on poor memory. Three rounds of data collection were conducted per year, with each round followed by a period of data analysis. Data collectors conducted interviews with women in households across the country and ask them questions from a wide range of nutrition categories:  anthropometry, household food security, child health, infant feeding practices, dietary diversity, socioeconomic status, and morbidity. The questionnaire was developed to improve efficiency of intake, quality of analysis, and accuracy of prevalence and causes of undernutrition. 

The FSNSP monitored context-specific factors of undernutrition and food insecurity within Bangladesh, including natural disasters and their impact on population health, urbanization trends, and crop seasonality. Collected information helped identify high-risk groups that are especially vulnerable to undernutrition (such as poor farmers, ethnic minorities, geographically-marginalized communities, and individuals living in disaster zones) and differentiate between rural and urban undernutrition. It has been stated that the FSNSP had “the capacity to investigate complex relationships through comprehensive, population-based survey methodologies…to contribute to monitoring progress toward many of the MDG and PRSP objectives.”(12)

The FSNSP followed sampling procedures that ensured data adequately represented the country.  The project’s sampling frame consisted of seven surveillance zones: six based on the major agro-ecological areas of Bangladesh and the seventh included everything else.(13) Depending on the size of the village being sampled, every fifth or tenth house in a village was interviewed. Efforts were also made to control data quality by upholding standards in training. Data collectors received a two-week basic course, followed by a week-long refresher course prior to each round of data collection in the field. In Bangladesh, all interviews were conducted by female data collectors, since it made rural women being interviewed feel more comfortable with answering survey questions. 

The FSNSP represents an example of quality nutrition research that can be used to provide evidence-based information to key stakeholders. In particular, information from the surveys was disseminated to the government of Bangladesh, NGOs, international donors, and other development agencies to influence policy formation and nutrition interventions from the public and private sector. Relevant nutrition and food security information helps provide an annual picture of the state of nutrition in the country, such that interventions can be evaluated and improved upon for long-term success. The FSNSP produced information that can serve as a valuable tool for nutrition research, which made progress towards solving the problems of undernutrition and food insecurity.

Footnotes

(1) World Hunger. (2011). 2011 World Hunger and Poverty Facts and Statistics. 

(2) FAO (2011). The State of Food Security in the World 2011. 

(3) Masset, E. (2011). A review of hunger indices and methods to monitor country commitment to fighting hunger. Food Policy, 36: S102-108. 

(4) Wiesmann, D. (2006). A global hunger index: measurement concept, ranking of countries, and trends. International Food Policy Research Institute.

(5) Ibid.

(6) Action Aid. (2009). Who’s really fighting hunger. Action Aid’s HungerFREE Scorecard Investigates why a Billion People are Hungry.

(7) Masset, E. (2011). A review of hunger indices and methods to monitor country commitment to fighting hunger. Food Policy, 36: S102-108.  

(8) HKI (2006). Trends in child nutrition, 1990 to 2005 – declining rates at national level mask inter-regional and socioeconomic differences. Nutritional Surveillance Project Bulletin No. 19, August 2006.

(9) HKI (2011). The Food Security and Nutrition Surveillance Project Round 4: February – May 2011 Preliminary Results. Bulletin No. 7, July 2010. 

(10) Ibid.

(11) Akhter, N., & Haselow, N. (2010). Using data from a nationally representative nutrition surveillance system to assess trends and influence nutrition programs and policy. Fields Action Science Reports, 4.

(12) The Food Security and Nutrition Surveillance Project. (2009). http://sph.bracu.ac.bd/index.php/research-project/115-nutrition/366-foodsecurity.

(13) HKI (2011). The Food Security and Nutrition Surveillance Project Round 4: February – May 2011 Preliminary Results. Bulletin No. 7, July 2010.