The corollary of the cost of inaction to improve nutrition is
the reward to action. Figure 2.1 shows the benefit-cost ratio of scaling up nutrition-specific interventions to 90 percent coverage, in terms of their impact on stunting, in a wide range of countries with high stunting levels. The analysis is based on an assumption, in line with the level of stunting reduction modeled by Bhutta et al. (2013a), that scaling up a core package of interventions will lead to a 20 percent decrease in the rate of stunting.
The median benefit-cost ratio of achieving this 20 percent decline in the rate of stunting is approximately 16 for all 40 countries. In other words, for every dollar, rupee, birr, or peso invested, at the median, more than 16 will be returned. The me- dian ratio for the 27 African countries south of the Sahara is 13.
These benefit-cost ratios are competitive with the benefit- cost ratios generated by overall investments in health as reported in Jamison et al. (2013) and Stenberg et al. (2014).1 The estimated ratios are also higher than the median estimated benefit-cost ratio reported for large-scale irrigation investments in 11 countries in Africa south of the Sahara (You 2008), for
TABLE 2.1 THE HUMAN AND ECONOMIC COSTS OF MALNUTRITION Type of cost Mortality
Undernutrition
45% of under-five mortality is attributable to undernutrition (Black et al. 2013).
Morbidity
“Nutritional deficiencies” are responsible for over 50% of years lived with disability in children age four and under (Vos et al. 2012). Underweight is the number-one contributor to the burden of disease in Africa south of the Sahara and number four in South Asia (Lim et al. 2012).
School attainment
Improving linear growth for children under age two by 1 standard deviation adds about half a grade to school attainment (multicountry; in Adair et al. 2013).
Forgone labor market productivity Prevention of undernutrition in early childhood leads to hourly earnings that are 20% higher and wage rates that are 48% higher; individuals who are 33% more likely to escape poverty; and women who are 10% more likely to own their own business (Guatemala; Hoddinott et al. 2013). One extra cm of adult height corresponds to a 4.5% increase in wage rates (multicountry; Horton and Steckel 2011).
Percentage of national income
Undernutrition lowers GDP for Egypt by 1.9%; Ethiopia, 16.5%; Swaziland, 3.1%; and Uganda, 5.6% (African Union Commission et al. 2014). Asia and Africa lose 11% of GNP every year owing to poor nutrition (Horton and Steckel 2013).
Incremental health care costsa
Obesity leads to productivity losses from absentee- ism and presenteeism (indirect costs) equivalent to US$668–US$4,299/person/year in the US (Finkelstein et al. 2010).
Obesity lowered China’s GNP by 3.58% in 2000 and will lower it by 8.73% in 2025 (Popkin et al. 2006).
Obesity costs US$475–US$2,532/person/year in the US (Finkelstein et al. 2010).
Obesity cost 0.48% of GNP in China in 2000 and will cost 0.50% in 2025 (Popkin et al. 2006). Obesity will cost £648 million/year in the UK in 2020 (Wang et al. 2011).
Total cost estimates
Source: As noted in table. a
Obesity cost 33 billion euros/year in EU member states in 2002 (Fry and Finley 2005).
These are direct health care costs compared with the health care costs of a person with a normal body mass index (BMI). 8 GLOBAL NUTRITION REPORT 2014 Every extra 5 kg/m2 of BMI increases esophageal cancer
risk by 52%, colon cancer risk by 24%, women’s endo- metrial cancer risk by 59%, and gall bladder cancer risk by 59% (various countries; Wang et al. 2011).
a range of public investments in roads in India, Thailand, and Uganda (Fan et al. 2007), and for road investments in Bolivia and Mexico (Gonzales et al. 2007).
NUTRITION NEEDS TO BE BETTER POSITIONED IN THE SDGs
Improved nutrition status may have high economic returns, but how can it contribute to the sustainable development agenda? The current debate on the post-2015 sustainable development agenda is driven by the discussions on the Sustainable Develop- ment Goals (SDGs). Table 2.2 summarizes the contributions that improvements in nutrition status and accompanying efforts can make toward achieving the SDGs. There is also a quid pro quo in achieving the SDGs: meeting the SDGs should have lasting impacts on nutrition outcomes as well.
Despite these positive contributions, the nutrition commu- nity must not take it for granted that nutrition will be properly featured within the SDG accountability framework (Panel 2.1). We must be persuasive advocates.
Obesity
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