2014 Global Hunger Index: The challenge of hidden hunger

Abstract

With one more year before the 2015 deadline for achieving the Millennium Development Goals, the 2014 Global Hunger Index report offers a multifaceted overview of global hunger that brings new insights to the global debate on where to focus efforts in the fight against hunger and malnutrition. The state of hunger in developing countries as a group has improved since 1990, falling by 39 percent, according to the 2014 GHI. Despite progress made, the level of hunger in the world is still “serious,” with 805 million people continuing to go hungry, according to estimates by the Food and Agriculture Organization of the United Nations. The global average obscures dramatic differences across regions and countries. Regionally, the highest GHI scores—and therefore the highest hunger levels—are in Africa south of the Sahara and South Asia, which have also experienced the greatest absolute improvements since 2005. South Asia saw the steepest absolute decline in GHI scores since 1990. Progress in addressing child underweight was the main factor behind the improved GHI score for the region since 1990.

Full text

–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
GLOBAL HUNGER INDEX
THE CHALLENGE OF HIDDEN HUNGER
2014

GLOBAL HUNGER INDEX
THE CHALLENGE OF HIDDEN HUNGER
2014
International Food Policy Research Institute:
Klaus von Grebmer, Amy Saltzman, Ekin Birol,
Doris Wiesmann, Nilam Prasai, Sandra Yin,
Yisehac Yohannes, Purnima Menon
Concern Worldwide:
Jennifer Thompson
Welthungerhilfe:
Andrea Sonntag
Bonn / Washington, D.C. / Dublin
October 2014
Chapters 01, 02, 03, and 05 of this report were
peer reviewed. Chapter 04 is based on evidence
from project work.

2 Name des Teilbereich | Chapter 1 | 2014 Global Hunger Index
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Everyone has the right to adequate food in a quantity and quality sufficient
to satisfy their dietary needs. One of the key challenges going forward is to
shine a light on food quality, to address hidden hunger.

2014 Global Hunger Index | Foreword 3
For decades, the global political and development agenda has failed to
put the spotlight on hunger and undernutrition. While recent years have
seen more ambition and action, the tragedy of hunger persists for
805 million hungry people today. This suffering—which for many is
part of everyday life—cannot be allowed to continue. As the contours
of the post-2015 development agenda emerge, the international
community must work to ensure that food and nutrition security is at
the heart of the new development framework. It is possible to success-
fully end poverty, but only if we successfully fight hunger.
This is the ninth year in which the International Food Policy
Research Institute (IFPRI) has calculated the Global Hunger Index (GHI),
analyzing and recording the state of hunger worldwide, highlighting the
countries and regions where action is most needed.
The 2014 GHI shows
that progress has been made in reducing the proportion of hungry peo-
ple in the world. Despite progress, levels of hunger remain “alarming”
or “extremely alarming” in 16 countries. This year’s report focuses on a
critical aspect of hunger that is often overlooked: hidden hunger. Also
known as micronutrient deficiency, hidden hunger affects more than an
estimated 2 billion people globally. The repercussions of these vitamin
and mineral deficiencies can be both serious and long-lasting.
FOREWORD
Effects of hidden hunger include child and maternal death, physi-
cal disabilities, weakened immune systems, and compromised
intellects. Where hidden hunger has taken root, it not only prevents
people from surviving and thriving as productive members of soci-
ety, it also holds countries back in a cycle of poor nutrition, poor
health, lost productivity, persistent poverty, and reduced economic
growth. This demonstrates why not only the right to food, but also
access to the right type of food at the right time, is important for
both individual well-being and countries as a whole.
In this report, Concern Worldwide and Welthungerhilfe pro-
vide important on-the-ground perspectives, describing what their
organizations are doing in order to alleviate hidden hunger and
sustainably promote food and nutrition security. Based on these expe-
riences and the research findings of IFPRI, this report proposes pol-
icy recommendations to help reduce the prevalence of vitamin and
mineral deficiencies.
Now is the time for the global community to mobilize to end
hidden hunger. We hope that this report will not only generate discus-
sion but also serve as a catalyst for more concerted efforts to overcome
hunger and reduce nutrition insecurity around the world.
Dr. Shenggen Fan
Director General
International Food Policy
Research Institute
Dominic MacSorley
Chief Executive
Concern Worldwide
Dr. Wolfgang Jamann
Secretary General and
Chairperson
Welthungerhilfe

4 Contents | 2014 Global Hunger Index
CONTENTS
SUMMARY 5
CHAPTER
01 The Concept of the Global Hunger Index 6
02 Global, Regional, and National Trends 10
03 Addressing the Challenge of Hidden Hunger 20
04 Integrated Approaches toward Improved Nutrition Outcomes 28
05 Policy Recommendations 36
APPENDIXES
A Data Sources and Calculation of the 1990, 1995, 2000, 2005, and 2014 Global Hunger Index Scores 40
B Data Underlying the Calculation of the 1990, 1995, 2000, 2005, and 2014 Global Hunger Index Scores 41
C Country Trends for the 1990, 1995, 2000, 2005, and 2014 Global Hunger Index Scores 43
BIBLIOGRAPHY 47
PARTNERS 51
CHAPTER 01 CHAPTER 02 CHAPTER 03 CHAPTER 04 CHAPTER 05

2014 Global Hunger Index | Summary 5
With one more year before the 2015 deadline for achieving the Mil-
lennium Development Goals, the 2014 Global Hunger Index report
offers a multifaceted overview of global hunger that brings new
insights to the global debate on where to focus efforts in the fight
against hunger and malnutrition.
The state of hunger in developing countries as a group has
improved since 1990, falling by 39 percent, according to the 2014 GHI.
Despite progress made, the level of hunger in the world is still “seri-
ous,” with 805 million people continuing to go hungry, according to esti-
mates by the Food and Agriculture Organization of the United Nations.
The global average obscures dramatic differences across regions
and countries. Regionally, the highest GHI scores—and therefore the
highest hunger levels—are in Africa south of the Sahara and South Asia,
which have also experienced the greatest absolute improvements since
2005. South Asia saw the steepest absolute decline in GHI scores since
1990. Progress in addressing child underweight was the main factor
behind the improved GHI score for the region since 1990.
From the 1990 GHI to the 2014 GHI, 26 countries reduced
their scores by 50 percent or more. In terms of absolute progress, com-
paring the 1990 GHI and the 2014 GHI, Angola, Bangladesh, Cambodia,
Chad, Ghana, Malawi, Niger, Rwanda, Thailand, and Vietnam saw the
biggest improvements in scores.
Levels of hunger are “extremely alarming” or “alarming” in 16
countries, with Burundi and Eritrea both classified as “extremely alarm-
ing,” according to the 2014 GHI. Most of the countries with “alarming”
GHI scores are in Africa south of the Sahara. Unlike many other coun-
tries south of the Sahara, where hunger has been decreasing, Swazi-
land is an exception. It suffered the biggest increase in a GHI score
between the 1990 GHI and the 2014 GHI. Reliable data for the Dem-
ocratic Republic of the Congo and Somalia, however, are sorely lacking.
One form of hunger that is often ignored or overshadowed by
hunger related to energy deficits is hidden hunger—also called micronu-
trient deficiency—which affects some 2 billion people around the world.
This shortage in essential vitamins and minerals can have long-term, irre-
versible health effects as well as socioeconomic consequences that can
erode a person’s well-being and development. By affecting people’s pro-
ductivity, it can also take a toll on countries’ economies.
SUMMARY
Hidden hunger can coexist with adequate or even excessive con-
sumption of dietary energy from macronutrients, such as fats and
carbohydrates, and therefore also with overweight /obesity in one
person or community.
Poor diet, disease, impaired absorption, and increased micro-
nutrient needs during certain life stages, such as pregnancy, lactation,
and infancy, are among the causes of hidden hunger, which may “invis-
ibly” affect the health and development of a population.
Possible solutions to hidden hunger include food-based
approaches: dietary diversification, which might involve growing more
diverse crops in a home garden; fortification of commercial foods; and
biofortification, in which food crops are bred with increased micronu-
trient content. Food-based measures will require long-term, sustained,
and coordinated efforts to make a lasting difference. In the short term,
vitamin and mineral supplements can help vulnerable populations com-
bat hidden hunger.
Along with these solutions that address the low content or den-
sity of vitamins and minerals in food, behavioral change communica-
tion is critical to educate people about health services, sanitation and
hygiene, and caring practices, as well as the need for greater empow-
erment of women at all levels.
To eliminate hidden hunger, governments must demonstrate
political commitment by making fighting it a priority. Governments and
multilateral institutions need to invest in and develop human and finan-
cial resources, increase coordination, and ensure transparent monitor-
ing and evaluation to build capacity on nutrition.
Governments must also create a regulatory environment that
values good nutrition. This could involve creating incentives for pri-
vate sector companies to develop more nutritious seeds or foods.
Transparent accountability systems are needed in order to ensure
that investments contribute to public health, while standardized data col-
lection on micronutrient deficiencies can build the evidence base on the
efficacy and cost effectiveness of food-based solutions.
These and other recommendations set out in this report are
some of the steps needed to eliminate hidden hunger. Ending hunger
in all its forms is possible. It must now become a reality.

6 Name des Teilbereich | Chapter 1 | 2014 Global Hunger Index
01
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
It is unacceptable that 162 million young children
are still suffering from chronic undernutrition.
United Nations, Millennium Development Goals Report, 2014

BOX 1.1 CONCEPTS OF HUNGER
The words that refer to different concepts of hunger can be con-
fusing. Hunger is usually understood to refer to the distress
associated with lack of food. The Food and Agriculture Organi-
zation of the United Nations (FAO) defines food deprivation, or
undernourishment, as the consumption of fewer than about
1,800 kilocalories a day—the minimum that most people
require to live a healthy and productive life.*
Undernutrition goes beyond calories and signifies deficiencies
in any or all of the following: energy, protein, or essential vita-
mins and minerals. Undernutrition is the result of inadequate
intake of food—in terms of either quantity or quality—poor uti-
lization of nutrients due to infections or other illnesses, or a
combination of these factors. These in turn are caused by a
range of factors including household food insecurity; inade-
quate maternal health or childcare practices; or inadequate
access to health services, safe water, and sanitation.
Malnutrition refers more broadly to both undernutrition (prob-
lems of deficiencies) and overnutrition (problems of unbalanced
diets, such as consuming too many calories in relation to
requirements with or without low intake of micronutrient-rich
foods). In this report, “hunger” refers to the index based on the
three component indicators described on this page.
* FAO considers the composition of a population by age and sex to calculate its average
minimum energy requirement for an individual engaged in low physical activity, which
varies by country (from about 1,650 to more than 2,000 kilocalories per person per
day for developing countries in 2011–2013 according to FAO 2014). The country’s
average minimum energy requirement for low physical activity is used to estimate
undernourishment (FAO, IFAD, and WFP 2014). In 2012, FAO started computing the
average minimum energy requirement for an individual engaged in normal physical
activity and using this higher threshold to estimate the prevalence of food inadequacy
for each country. This indicator is a less conservative measure of food deficiency in the
population than the undernourishment indicator (FAO 2014).
2014 Global Hunger Index | Chapter 01 | The Concept of the Global Hunger Index 7
The Global Hunger Index (GHI) is a tool designed to comprehensively
measure and track hunger globally and by region and country.1 It high-
lights successes and failures in hunger reduction and provides insights
into the drivers of hunger and nutrition insecurity. Calculated each year
by the International Food Policy Research Institute (IFPRI), the GHI is
designed to raise awareness and understanding of regional and coun-
try differences. It is hoped that the report will trigger action to reduce
hunger around the world.
A number of different indicators can be used to measure
hunger (Box 1.1). To reflect the multidimensional nature of hunger, the
THE CONCEPT OF THE
GLOBAL HUNGER INDEX
1 For background information on the concept, see Wiesmann (2004) and Wiesmann, von Braun,
and Feldbrügge (2000).
2 According to recent estimates, undernutrition is responsible for 45 percent of deaths of children
younger than five years old (Black et al. 2013).
3
For a multidimensional measure of poverty, see the index developed by the Oxford Poverty
and Human Development Initiative for the United Nations Development Programme (Alkire and
Santos 2010).
4 FAO stopped publishing country-level estimates of undernourishment for the Democratic Repub-
lic of the Congo and Myanmar in 2011 (FAO, IFAD, and WFP 2011). According to past GHI reports,
the GHI score of the Democratic Republic of the Congo was in the “extremely alarming” category
with the highest levels of hunger. For South Sudan, which became independent in 2011, and pres-
ent-day Sudan, separate undernourishment estimates are not yet available from FAO (FAO 2014).
Therefore GHI scores calculated for former Sudan refer to the population of both countries.
GHI combines three equally weighted indicators into one index:
1. Undernourishment: the proportion of undernourished people as a
percentage of the population (reflecting the share of the population
with insufficient caloric intake);
2. Child underweight: the proportion of children under the age of five
who are underweight (that is, have low weight for their age, reflect-
ing wasting, stunted growth, or both), which is one indicator of child
undernutrition; and
3. Child mortality: the mortality rate of children under the age of five
(partially reflecting the fatal synergy of inadequate food intake and
unhealthy environments).2
This multidimensional approach to measuring hunger offers several
advantages. It reflects the nutrition situation not only of the popu-
lation as a whole, but also of children—for whom a lack of dietary
energy, protein, or micronutrients (that is, essential vitamins and
minerals) leads to a high risk of illness, poor physical and cognitive
development, or death. It also combines independently measured
indicators to reduce the effects of random measurement errors.3
The 2014 GHI has been calculated for 120 countries for
which data on the three component indicators are available and
where measuring hunger is considered most relevant (Box 1.2). The
index excludes some higher-income countries because the prevalence
of hunger there is very low.
The GHI is only as current as the data for its three component
indicators. This year’s GHI reflects the most recent country-level data
available for the three component indicators spanning the period of
2009 to 2013. It is thus a snapshot not of the present, but of the
recent past. For some countries, such as Afghanistan, the Democrat-
ic Republic of Congo, Georgia, Myanmar, Papua New Guinea, and
Somalia, lack of data on undernourishment prevents the calculation
of GHI scores.4
The scores are based on source data that are continually
revised by the United Nations (UN) agencies that compile them, and

8 The Concept of the Global Hunger Index | Chapter 01 | 2014 Global Hunger Index
low
≤ 4.9 5.0 – 9.9 10.0 – 19.9
moderate
10
5
0
BOX 1.2 HOW GHI SCORES ARE CALCULATED
A country’s GHI score is calculated by averaging the percentage
of the population that is undernourished, the percentage of chil-
dren younger than five years of age who are underweight, and the
percentage of children who die before the age of five. This calcu-
lation results in a 100-point scale on which zero is the best score
(no hunger) and 100 the worst, although neither of these extremes
is reached in practice. A value of 100 would be reached only if the
whole population was undernourished, all children younger than
five were underweight, and all children died before their fifth birth-
day. A value of zero would mean that a country had no undernour-
ished people in the population, no children younger than five who
were underweight, and no children who died before their fifth birth-
day. The scale at the right shows the severity of hunger—from
“low” to “extremely alarming”—associated with the range of pos-
sible GHI scores.
each year’s GHI report reflects these revisions. While these revisions
result in improvements in the data, they also mean that the GHI
scores from different years’ reports are not comparable with one
another. This year’s report contains GHI scores for four other refer-
ence periods—1990, 1995, 2000, and 2005—besides the most
recent GHI.
The 1990, 1995, 2000, 2005, and 2014 GHI scores present-
ed in this report reflect the latest revised data for the three compo-
nent indicators of the GHI.5 Where original source data were not
available, the authors’ estimates for the GHI component indicators
were used, based on the most recent data available. (See Appendix A
for more detailed background information on the data sources for and
calculations of the 1990, 1995, 2000, 2005, and 2014 GHI scores.)
The three component indicators used to calculate the GHI scores in
this report draw upon data from the following sources:
1. Undernourishment: Updated data from the Food and Agriculture Orga-
nization of the United Nations (FAO) were used for the 1990, 1995,
2000, and 2005, and 2014 GHI scores. Undernourishment data for
the 2014 GHI are for 2011–2013 (FAO 2014; authors’ estimates).
2. Child underweight: The “child underweight” component indicator of
the GHI scores includes data from the joint database of the United
5 For previous GHI calculations, see von Grebmer et al. (2013, 2012, 2011, 2010, 2009, 2008);
IFPRI/Welthungerhilfe/Concern (2007); Wiesmann (2006a, b); and Wiesmann, Weingärtner, and
Schöninger (2006).

2014 Global Hunger Index | Chapter 01 | The Concept of the Global Hunger Index 9
10.0 – 19.9 20.0 – 29.9 30 ≤
serious alarming extremely alarming
4030
15 25 35
20
Nations Children’s Fund (UNICEF), the World Health Organization
(WHO), and the World Bank, and additional data from WHO's continu-
ously updated Global Database on Child Growth and Malnutrition; the
most recent Demographic and Health Survey (DHS) and Multiple Indi-
cator Cluster Survey reports; statistical tables from UNICEF; and the lat-
est national survey data for India from UNICEF India.
6
For the 2014 GHI,
data on child underweight are for the latest year for which data are avail-
able in the period 2009–2013 (UNICEF/WHO/World Bank 2013; WHO
2014b; UNICEF 2014a; MEASURE DHS 2014; India, Ministry of Wom-
en and Child Development, and UNICEF 2014; authors’ estimates).
3. Child mortalit y: Updated data from the UN Inter-agency Group for
Child Mortality Estimation were used for the 1990, 1995, 2000, 6 Data on India’s latest child underweight rate are provisional.
2005, and 2014 GHI scores. For the 2014 GHI, data on child
mortality are for 2012 (IGME 2013). Despite the existence of many
technological tools to collect and assess data almost instantaneous-
ly, time lags and data gaps persist in reporting vital statistics on hun-
ger and undernutrition, particularly on micronutrient deficiencies.
While some recent improvements have been made, more up-to-date,
reliable, and extensive country data continue to be urgently needed.
Further improvements in collecting high-quality data on hunger will
allow for a more complete and current assessment of the state of
global hunger and, in turn, more effective steps to reduce hunger.

10 Name des Teilbereich | Chapter 1 | 2014 Global Hunger Index
0202
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
Like undernutrition, micronutrient deficiency or hidden hunger
is a violation of a child’s right to a standard of living
adequate for the child’s physical and mental development.
Olivier De Schutter, former United Nations special rapporteur on the right to food, 2013

2014 Global Hunger Index | Chapter 02 | Global, Regional, and National Trends 11
GLOBAL, REGIONAL, AND NATIONAL
TRENDS
Since 1990, significant progress has been made in the fight against
hunger. The Global Hunger Index (GHI) score in 1990 was 20.6 for
the developing world.1 The 2014 GHI stands at 12.5, representing a
reduction of 39 percent (Figure 2.1). Despite this progress, the num-
ber of hungry people in the world remains unacceptably high. In 2012-
2014, about 805 million people were chronically undernourished
(FAO, IFAD, and WFP 2014).
The three GHI components (undernourishment, child under-
weight, and child mortality) each contributed differently to the overall
drop in hunger as measured by the GHI since 1990. A decline in child
underweight lowered the aggregate GHI score for the developing world
by 3.5 points, whereas changes in the share of undernourished people
in the population and the child mortality rate contributed reductions of
3.1 and 1.5 points, respectively.
Large Regional and National Differences
The period since 2005 has seen the greatest progress, with the GHI
falling by 3.4 points in the developing world. In the three five-year peri-
ods between 1990 and 2005, the reductions varied from 1.4 to 1.7
points. Undernourishment fell most rapidly between 1990 and 1995,
underweight after 2005, and progress in reducing child mortality has
gained momentum since 2000. Even with these improvements, the
2014 aggregate GHI remains “serious” and warrants continued concern.
These global averages mask dramatic differences among regions and
countries. Compared with the 1990 score, the 2014 GHI score is 28
percent lower in Africa south of the Sahara, 41 percent lower in South
Asia, and 40 percent lower in the Near East and North Africa (Figure
2.1). Progress in East and Southeast Asia and Latin America and the
Caribbean was even more remarkable, with the GHI scores falling by
54 percent and 53 percent respectively (although the 1990 score was
already relatively low in the latter region). In Eastern Europe and the
Commonwealth of Independent States, the 2014 GHI score is 51 per-
cent lower than the 1995 score.2
South Asia and Africa south of the Sahara have the highest
2014 GHI scores, at 18.1 and 18.2 respectively. In absolute terms,
1 The GHI for the developing world, also referred to as the “aggregate GHI,” includes all developing
countries for which the GHI has been calculated. It also includes Afghanistan, the Democratic Repub-
lic of the Congo, Myanmar, Papua New Guinea, and Somalia. Country GHI scores were not calculat-
ed for these countries because much of the data for them is estimated or provisional. They were incor-
porated into the 2014 developing world GHI and regional GHI scores because data on child
underweight and child mortality are available or could be estimated and because provisional esti-
mates of undernourishment were provided by FAO only for regional and global aggregation (includ-
ing provisional estimates for Georgia, which were considered in the regional GHI scores for Eastern
Europe and the Commonwealth of Independent States). The unpublished undernourishment esti-
mate for Ethiopia for 1990–1992 was also obtained from FAO and incorporated in the 1990 aggre-
gate GHI and 1990 regional GHI for Africa south of the Sahara. As noted earlier, data for some oth-
er countries are not available, and most high-income countries are excluded from the GHI calculation.
2 For Eastern Europe and the Commonwealth of Independent States, the 1995 GHI score was used
for comparison because most countries in this region became independent after 1990 and no
1990 GHI scores were calculated.
FIGURE 2.1 CONTRIBUTION OF COMPONENTS TO 1990, 1995, 2000, 2005, AND 2014 GLOBAL HUNGER INDEX SCORES, BY REGION
Note: For the 1990 GHI, data on the proportion of undernourished are for 1990–1992; data on child underweight are for the year closest to 1990 in the period 1988–1992 for which data are available;
and data on child mortality are for 1990. For the 1995 GHI, data on the proportion of undernourished are for 1994–1996; data on child underweight are for the year closest to 1995 in the
period 1993–1997 for which data are available; and data on child mortality are for 1995. For the 2000 GHI, data on the proportion of undernourished are for 1999–2001; data on child underweight are
for the year closest to 2000 in the period 1998–2002 for which data are available; and data on child mortality are for 2000. For the 2005 GHI, data on the proportion of undernourished are for
2004–2006; data on child underweight are for the year closest to 2005 in the period 2003–2007 for which data are available; and data on child mortality are for 2005. For the 2014 GHI, data on the
proportion of undernourished are for 2011–2013, data on child underweight are for the latest year in the period 2009–2013 for which data are available, and data on child mortality are for 2012.
’90 ’95 ’00 ’05 ’14
Developing
World
’90 ’95 ’00 ’05 ’14
Latin America &
the Caribbean
Under-five mortality rate
Prevalence of underweight in children
Proportion of undernourished
5
10
15
20
25
30
35
20.6
18.9
17.5
15.9
12.5
’90 ’95 ’00 ’05 ’14
Eastern Europe &
Commonwealth of
Independent States
GHI score
’90 ’95 ’00 ’05 ’14
South Asia
30.6
27.3
25.0
23.4
18.1
’90 ’95 ’00 ’05 ’14
Africa South of
the Sahara
25.4
25.5
24.4
21.8
18.2
’90 ’95 ’00 ’05 ’14
East & South-
east Asia
16.4
13.9
11.9
10.0
7.6
’90 ’95 ’00 ’05 ’14
Near East &
North Africa
8.1
7.8
6.8
5.9
4.9
9.3
8.3
6.8
5.7
4.4
5.3
5.1
3.2
2.6

12 Global, Regional, and National Trends | Chapter 02 | 2014 Global Hunger Index
3 Data on India's child underweight rate in 2013–2014 are provisional.
BOX 2.1 EXPLAINING INDIA’S IMPROVED GHI SCORE
This year marks the end of a “data drought.” India determined its
first new provisional national underweight estimate in eight years.
At 30.7 percent, it points to real progress compared with the last
estimate of 43.5 percent in 2005–2006 (IIPS and Macro Interna-
tional 2007; India, Ministry of Women and Child Development, and
UNICEF, India, 2014).1
As a consequence, India no longer ranks second to last on underweight
in children, but 120th among 128 countries with data on child under-
nutrition from 2009–2013. Progress in dealing with underweight
helped India’s 2014 GHI score fall to 17.8. Its GHI score declined by
26 percent, or 6.4 points, between the 2005 GHI and the 2014 GHI,
outpacing the drop seen in other countries in South Asia in the same
time period. India now ranks 55th out of 76 countries, before Bangla-
desh and Pakistan, but still trails behind neighboring Nepal (rank 44)
and Sri Lanka (rank 39), see Table 2.1, p. 16. While no longer in the
“alarming” category, India’s hunger status is still classified as “seri-
ous,” according to the GHI.
Many factors may have contributed to the improvement. Since the last
undernutrition data became available, the Indian government rolled out
and expanded several programs that targeted a mix of direct and indi-
rect causes of undernutrition. Nutrition-specific interventions that were
scaled up after 2006 include (1) a final push to expand the Integrat-
ed Child Development Services program that aims to improve the
health, nutrition, and development of children in India and establish
1.4 million centers; and (2) the launch of the National Rural Health
Mission, a community-based outreach and facility-based health initia-
tive to deliver essential health services to rural India (Avula et al. 2013).
Indirect factors may have included the National Rural Employment
Guarantee Scheme, a rural jobs program, and reforms in several
states to the Public Distribution System, which distributes food to the
poor. Although implementation of these social sector programs has
been fairly uneven across India’s diverse states, given the scale and
budget of these programs in India, it is likely that changes have helped
improve underlying conditions for child growth in parts of India.
Efforts have also been made to create an enabling environment for
nutrition. Within the context of India’s decentralized governance
system, state governments have taken ownership of nutrition and
tried to strengthen delivery of targeted nutrition efforts. The state
of Maharashtra was the first of several to bring high- level political
and bureaucratic leadership to nutrition through a Nutrition
Mission, a program with greater flexibility and freedom than usual
(Gillespie et al. 2013). Another key element in the enabling envi-
ronment for food security and nutrition was the creation of a body
called the Commissioners to the Supreme Court on the Right to
Food Act, a group that supports independent monitoring of the
delivery of food-based programs like the Integrated Child Develop-
ment Services program and the Public Distribution System.
While India has made significant progress in reducing underweight
among children under five in the past few years, much work still
needs to be done at the national and state levels so that a great-
er share of the population will enjoy nutrition security.
1 India’s provisional underweight estimate was based on a survey conducted by India’s
Ministry of Women and Child Development with support from UNICEF in 2013–2014.
South Asia and East and Southeast Asia experienced the greatest
improvements. South Asia saw the steepest absolute decline in GHI
scores since 1990, amounting to more than 12 points. The region
reduced its GHI score by 3 points between 1990 and 1995—mainly
through a decline of almost 9 percentage points in underweight in chil-
dren—and, following a ten-year slowdown, made considerable prog-
ress again since 2005. The decrease of more than 5 points in South
Asia’s GHI score since 2005 can be largely attributed to recent suc-
cesses in the fight against child undernutrition.
According to the most recent survey data from India, where
the vast majority of South Asia’s population lives, underweight in chil-
dren fell by almost 13 percentage points between 2005–2006 and
2013–2014 (India, Ministry of Women and Child Development, and
UNICEF 2014).3 A range of programs and initiatives launched by
India’s central and state governments in the past decade seem to final-
ly have made a difference for child nutrition (Box 2.1).
Africa south of the Sahara has the highest regional GHI score,
closely followed by South Asia. The region began with a lower GHI score
than South Asia in 1990 and has since experienced less improvement
overall. Between 1990 and 1995, the GHI score for Africa south of the
Sahara increased minimally, then fell slightly until 2000, and declined
more rapidly thereafter, by more than 6 points overall. As large-scale
civil wars of the 1990s and 2000s ended, countries earlier gripped by
conflict became more politically stable. Economic growth resumed on

Canada
United States
of America
Mexico
Guatemala
El Salvador
Belize
Honduras
Jamaica
Haiti
Cuba
Dominican Rep.
Panama
Nicaragua
Costa Ric a
Colombia
Peru
Ecuador
Uruguay
Paraguay
Chile
Brazil
Bolivia
Argentina
Venezuela
Trinidad & Tobago
Suriname
Guyana
French Guiana
Zimbabwe
Zambia
Swaziland
South
Africa
Namibia
Lesotho
Botswana
Angola
Mozambique
Mauritius
Madagascar
Uganda
Tunisia
Togo
Tanzania
Somalia
Sierra Leone
Senegal
Rwanda
Nigeria
Niger
Morocco
Mauritania Mali
Malawi
Libya
Liberia
Kenya
Guinea-Biss au
Guinea
Ghana
The Gambia
Gabon
Ethiopia
Eritrea
Equatorial Guinea
Egypt
Djibouti
Côte
d'Ivoire
Congo,
Dem. Rep.
Chad Sudan*
South
Sudan*
Central African
Republic
Cameroon
Burundi
Burkina Faso
Benin
Algeria
Western Sahara
Comoros
Congo,
Rep.
Yemen Vietnam
Uzbekistan
U.A.E.
Turkmenistan
Turke y
Thailand
Tajiki sta n
Syria
Sri Lanka
Saudi Arabia
Russian Federation
Qatar
Philippines
Papua
New
Guinea
Pakistan
Oman
Nepal
Mongolia
Malaysia
Lebanon
Lao
PDR
Kyrgyz Rep.
Kuwait
S. Korea
N. Korea
Kazakhstan
Jordan
Japan
Israel Iraq Iran
Indonesia
India
Timor-Leste
Cyprus
China
Cambodia
Myanmar
Brunei
Bhutan
Bangladesh
Australia
Afghanistan
Bahrain
Ukraine
Greece
Bos. &
Herz.
Croatia
Georgia
Azerb.
Armenia
Romania
Moldova
Mace.
Bulgaria
Albania
Serb.
Mont.
Slovakia
Slov. Hungary
United
Kingdom
Sweden
Spain
Portugal
Norway
Italy
Ireland
Iceland
Greenland
Germany
France
Finland
Denmark Lithuania
Latvia
Estonia
Belarus
Poland
Czech Rep.
Austria
Switz.
Neth.
Lux.
Bel.
Solomon Islands
Fiji
Vanuatu
New Zealand
2014 Global Hunger Index | Chapter 02 | Global, Regional, and National Trends 13
Note: An increase in the GHI indicates a worsening of a country’s hunger situation. A decrease
in the GHI indicates an improvement in a country's hunger situation. GHI scores were not
calculated for countries with very small populations.
* GHI scores and the rate of progress since 1990 could only be calculated for former Sudan as
one entity, because separate undernourishment estimates for 2011–2013 and earlier were
not available for South Sudan, which became independent in 2011, and present-day Sudan.
Figure 2.2 COUNTRY PROGRESS IN REDUCING GHI SCORES
Percentage change in 2014 GHI compared with 1990 GHI
Increase
Decrease of 0.0–24.9 %
Decrease of 25.0–49.9 %
Decrease of 50% or more
Countries with 1990 and
2014 GHI of less than 5
No data
Industrialized country
4 The numbers in these first two sentences refer to the 86 countries for which (1) data for the 1990
and 2014 GHI scores are available and (2) either or both of those scores is greater than 5.
the continent, and advances in the fight against HIV and AIDS helped
reduce child mortality in the countries most affected by the epidemic.
Since 2000, mortality rates for children under the age of five have
declined in Africa south of the Sahara. A key factor behind the improved
rates seems to be the decrease in the prevalence of malaria, which
coincided with the increased use of insecticide-treated bed nets and
other antimalarial interventions (Demombynes and Trommlerová 2012).
Other factors that may have helped reduce mortality rates include high-
er immunization rates; a greater share of births in medical centers;
improved antenatal care; better access to clean water and sanitation
facilities; and increasing levels of income leading to better nutrition
and access to medical care.
The situation in the Sahel, however, remains precarious. The ris-
ing frequency and intensity of climate shocks has continued to erode the
coping capacity of vulnerable households. The trend toward increased
demand for humanitarian assistance illustrates this deterioration of resil-
ience in the region and underlines the need to rebuild resilience through
long-term efforts (UN OCHA 2014; von Grebmer et al. 2013). The secu-
rity situation in northern Mali improved due to international efforts, but
violence has increased in northern Nigeria. An exodus of people from
this region, the Central African Republic, and Darfur put more pressure
on Chad, Cameroon, and Mali to absorb refugees. Displaced populations
and their host communities face a high risk of food insecurity, malnutri-
tion, and epidemics. Substantial humanitarian assistance for the Sahel
region—including food and nutrition security interventions, protection
from violence, measures to boost households’ and communities’ coping
capacity, and support for internally displaced people and refugees—will
continue to be necessary (UN OCHA 2014).
Best and Worst Country-Level Results
From the 1990 GHI to the 2014 GHI, 26 countries reduced their scores
by 50 percent or more (Figure 2.2). Thirty-nine countries made mod-
est progress with scores that dropped by between 25.0 and 49.9
percent, and 17 countries decreased their GHI scores by less than 25
percent.
4
In Africa south of the Sahara, only one country—Ghana—is
among the 10 best performers in terms of improving its GHI score since
1990 (Figure 2.3). Kuwait’s progress in reducing hunger is due main-
ly to its unusually high score in 1990, when Iraq invaded the country:
Its GHI score fell by more than 10 points (or two-thirds) by 1995, by
3.6 points between 1995 and 2000, and by only 0.1 point after 2000
(see country trends in Appendix C).
Thailand has achieved impressive progress in reducing hun-
ger since 1990 (see Appendix C). In the past two decades, Thailand

14 Global, Regional, and National Trends | Chapter 02 | 2014 Global Hunger Index
experienced robust economic growth and reduced poverty (World
Bank 2014) despite brief setbacks related to the Asian financial
crisis. As early as the 1980s, the government showed a strong com-
mitment to fighting child undernutrition by integrating nutrition into
its National Economic and Social Development Plan and implement-
ing successful community -driven nutrition programs (Tontisirin and
Winichagoon 1999).
Another Southeast Asian country—Vietnam—also cut back its
1990 GHI by more than three-quarters. It reduced the proportion of
undernourished from 48 percent to only 8 percent, lowered underweight
in children from 41 percent to 12 percent between 1990 and 2011, and
more than halved the under-five mortality rate. While every second preg-
nant woman in Vietnam was anemic in 1995, only one in three pregnant
women still suffered from anemia six years later (World Bank 2014). GDP
per capita has more than tripled in Vietnam since 1990, and strong,
broad-based economic growth translated into a decline in the proportion
of people living on less than US$1.25 per day, from 64 percent to
17 percent between 1993 and 2008 (World Bank 2014). The country
put nutrition high on its agenda, effectively developed and carried out a
plan to prevent protein-energy malnutrition among children, achieved high
coverage of immunization and other primary healthcare services, grant-
ed targeted health subsidies to the poor, and ran successful social secu-
rity programs (von Braun, Ruel, and Gulati 2008; Huong and Nga 2013).
Ghana has substantially decreased its GHI scores since 1990.
The country reduced child underweight and child mortality by more
than 40 percent and slashed the proportion of undernourished from
44 percent in 1990–1992 to less than 5 percent in 2011–2013. Gha-
na is considered one of the most politically stable countries in Africa
south of the Sahara and has invested heavily in agriculture, rural devel-
opment, education, and health. The country boosted its vaccination
rates for common childhood diseases in the past 30 years (World Bank
2014), and the government provided farmers with information, agricul-
tural inputs, and infrastructure such as roads and storage facilities.
Because agriculture employs half the workforce in Ghana, investments
in agriculture helped to transform other sectors. The government also
launched an ambitious program to give all kindergarten and primary
school pupils a daily hot, nutritious meal made from locally produced
foods (von Grebmer et al. 2011). However, little progress has been
made in eradicating anemia among pregnant women and preschool
children (World Bank 2014).
In four countries, GHI scores have risen since 1990. Iraq is the
second-worst performer. The other three countries with negative devel-
opments—Comoros, Burundi, and Swaziland—are located in Africa
south of the Sahara (Figure 2.3). Increased hunger since 1990 in
Comoros can be attributed to prolonged conflict and political instabil-
ity. In Comoros, the GHI peaked in 2000, then declined by four points
in the following five years, but fell only slightly after 2005. Between
1990 and 2005, Burundi’s GHI score rose steadily, by almost 7 points
altogether, approaching a score of 40. Since then, hunger has fallen in
Burundi and the trend seems to have reversed (see Appendix C). With
FIGURE 2.3 GHI WINNERS AND LOSERS FROM 1990 GHI TO 2014 GHI
Note: Countries with both 1990 and 2014 GHI scores of less than 5 are excluded.
Panama -60
Saudi Arabia -62
Egypt -63
Peru -65
Venezuela -71
Mexico -71
Ghana -71
Vietnam -76
Thailand -77
Kuwait -90
Swaziland +67
Iraq +48
Comoros +28
Burundi +11
0 20 40-20
-40
-60
-80 60-100
Winners (Percentage decrease in GHI) Losers (Percentage increase in GHI)
80

2014 Global Hunger Index | Chapter 02 | Global, Regional, and National Trends 15
BOX 2.2 THE GLOBAL HUNGER INDEX’S RELATIONSHIP WITH HIDDEN HUNGER
The Global Hunger Index (GHI) shows statistically significant corre-
lations with measures of hidden hunger, namely indicators of
vitamin A deficiency and anemia, and with a proxy indicator of diet
quality for children (see figure and notes).1 The strength of this cor-
relation varies from moderate to strong. It is moderate in the case of
night blindness in preschool children and pregnant women, low lev-
els of serum retinol in preschool children, and anemia in preschool
children and pregnant women (with correlation coefficients of 0.40–
0.60).2, 3 The correlation is strong for poor diet quality of comple-
mentary foods for infants and young children (correlation coefficient
>0.70).4 The GHI and its components’ lack of association with low
serum retinol levels in pregnant women may be attributed to a dearth
of data: Survey data from the World Health Organization (2009) were
available for only 17 countries with GHI scores (not shown).
The figure below shows that the GHI is more closely associated with
hidden hunger than FAO’s undernourishment indicator. The propor-
tion of undernourished seeks to capture caloric consumption in the
population, but not the micronutrient adequacy of vulnerable
groups such as children and women. Child mortality and child
underweight are the two components of the GHI that make the index
sensitive to variations in micronutrient deficiencies and children’s
dietary diversity. Child mortality correlates more highly than child
underweight with anemia in preschool children and pregnant wom-
en, night blindness, and low serum retinol in preschool children.
Child underweight is more strongly associated than child mortality
with low dietary diversity in infants and young children and night
blindness in pregnant women.
The correlation between the GHI, its components, and urinary iodine
concentration in preschool children—the most common indicator of
iodine deficiency—is weak and insignificant (correlation coefficients
<0.20, using nationally representative data on iodine deficiency for
61 countries from Andersson, Karumbunathan, and Zimmermann
2012; not shown). This is not surprising because neither the main
causes of iodine deficiency (low iodine content of soils and conse-
quently the crops grown in these soils, and lack or insufficient cov-
erage of salt iodization), nor its most serious consequences—which
include pregnancy loss, goiter, and mental retardation—are likely to
be reflected in the three indicators included in the GHI (de Benoist
et al. 2004; Andersson, Karumbunathan, and Zimmermann 2012).
1
For a definition of micronutrient deficiencies and information on the most common ones, see
Chapter 3.
2 Correlation coefficients measure the association between two variables. A value of 0 indi-
cates no association, a value of 1 perfect positive association.
3 Low serum retinol levels are one indicator of vitamin A deficiency.
4 The consumption of at least four of seven food groups is defined as the minimum dietary
diversity for infants and young children and is a proxy indicator for the micronutrient den-
sity of complementary foods (Working Group on Infant and Young Child Feeding Indicators
2006, 2007). Comparable nationally representative data for adult diet quality in develop-
ing countries are not yet available, but an indicator of minimum dietary diversity for wom-
en of reproductive age was recently developed as a proxy for micronutrient adequacy (FAO
and IRD 2014).
Notes: Spearman rank correlation coefficients can range from 0 (no association) to 1 (perfect
association). All correlations with the GHI are statistically significant at p<0.01. For the GHI
components, solid color indicates significance at p<0.05. Nationally representative survey data
were used for indicators of micronutrient deficiencies and diet diversity. The latest available
data were matched with the GHI and its components using the year of the survey and the GHI
reference periods. N indicates the number of countries for which the correlation coefficients
could be computed.
HOW THE GLOBAL HUNGER INDEX CORRELATES WITH MEASURES OF HIDDEN HUNGER
Low dietary diversity Anemia Vitamin A deficiency
Children
consuming less
than 4 food groups
Anemia,
preschool children
Night blindness,
preschool children
Anemia,
pregnant women
Low serum retinol,
preschool children
Night blindness,
pregnant women
0.8
0.6
0.4
0.2
0
Definitions an d data sources : Low dietary diversity: Proportion of children 6–23 months who
consume fewer than four out of seven food groups (grains, roots and tubers; legumes and nuts;
dairy products; flesh foods; eggs; vitamin-A rich fruits and vegetables; other fruits and vegeta-
bles) (WHO 2010; Kothari and Abderrahim 2010). Anemia: Proportion of preschool-age children
whose hemoglobin level is less than 110 grams per liter, and proportion of pregnant women whose
hemoglobin level is less than 110 grams per liter (World Bank 2014; MEASURE DHS 2014; de
Benoist et al. 2008). Vitamin A deficiency: Proportion of preschool-age children with night blind-
ness, proportion of pregnant women with night blindness, and proportion of preschool-age chil-
dren whose serum retinol level is less than 0.70 micromole per liter (WHO 2009).
N = 44 N = 82 N = 59 N = 27 N = 55 N = 40
not significant
(p≥0.05)
Global Hunger
Index
Under-five
mortality rate
Proportion of
under nourished
Prevalence of under-
weight in children

16 Global, Regional, and National Trends | Chapter 02 | 2014 Global Hunger Index
TABLE 2.1 COUNTRY GLOBAL HUNGER INDEX SCORES BY RANK, 1990 GHI, 1995 GHI, 2000 GHI, 2005 GHI, AND 2014 GHI
Rank Country 1990 1995 2000 2005 2014
1Mauritius 8.3 7.6 6.7 6.0 5.0
1Thailand 21.3 17. 3 10.2 6.7 5.0
3Albania 9.1 6.3 7.9 6.2 5.3
3Colombia 10.9 8.2 6.8 7. 0 5.3
5China 13.6 10.7 8.5 6.8 5.4
5Malaysia 9.4 7. 0 6.9 5.7 5.4
7Peru 16.1 12.4 10.6 10.0 5.7
8Syrian Arab Republic 7. 8 6.1 <5 5.1 5.9
9Honduras 14.6 13.9 11. 2 9.0 6.0
9Suriname 11.3 10.1 10.9 9.0 6.0
11 Gabon 10.0 8.6 7. 8 7. 4 6.1
12 El Salvador 10.8 8.8 7.9 6.4 6.2
13 Guyana 14.5 10.9 8 .1 7. 9 6.5
14 Dominican Republic 15.6 11.5 9.9 9.6 7. 0
15 Vietnam 31.4 25.4 1 7. 3 13.1 7. 5
16 Ghana 2 7. 2 20.2 16.1 11.3 7. 8
17 Ecuador 14.9 11. 9 12.0 10.3 7. 9
18 Paraguay 9.2 7. 4 6.8 6.3 8.8
19 Mongolia 20.3 23.1 18 .5 14.1 9.6
19 Nicaragua 24.0 19.7 15.4 11.4 9.6
21 Bolivia 18.6 16.8 14.5 13.9 9.9
22 Indonesia 20.5 17. 8 16.1 15.2 10.3
23 Moldova –7.9 9.0 7. 4 10 .8
24 Benin 22.5 20.5 18.0 15.3 11. 2
25 Mauritania 23.0 18.7 17.1 14.4 11.9
26 Cameroon 23.3 24.6 21.3 16.6 12.6
27 Iraq 8.6 11.9 12.8 11.6 12.7
28 Mali 2 7. 2 2 7. 2 24.8 20.7 13.0
29 Lesotho 13.1 15.4 14 .6 15.0 13 .1
29 Philippines 20.1 17. 5 17. 9 14.7 13.1
31 Botswana 15.6 16.5 18 .1 16.8 13.4
32 Gambia, The 18.7 20.4 15.5 15.1 13.6
32 Malawi 31.3 28.8 21.9 18.9 13.6
34 Guinea-Bissau 22.6 20.4 20.5 17. 3 13.7
35 Tog o 23.6 19.4 20.8 18.0 13.9
36 Guinea 22.0 20.9 22.4 18.0 14.3
37 Senegal 18.9 19.6 19.5 14. 3 14.4
38 Nigeria 25.9 23.0 17. 9 16.7 14.7
39 Sri Lanka 22.2 20.2 17.6 16. 8 15.1
40 Guatemala 15.6 16.0 17. 3 17. 0 15.6
40 Rwanda 30.6 35.1 30.6 24.1 15.6
42 Côte d'Ivoire 16.4 16.6 17. 6 16 .5 15 .7
43 Cambodia 32.9 30.8 28.1 20.8 16.1
44 Nepal 28.4 26.8 25.2 22.2 16.4
44 North Korea 17. 9 22.4 22.8 19. 3 16. 4
44 Tajik ist a n –21.5 22.3 18.8 16.4
47 Kenya 21.5 21.0 20.2 19.5 16.5
47 Swaziland 9.9 12.3 13.5 11.8 16.5
47 Zimbabwe 19.7 22.5 22.0 21.3 16.5
50 Liberia 24.5 28.9 25.1 20.7 16. 8
51 Namibia 21.7 22.0 18.4 16.5 16.9
52 Uganda 21.5 22.7 20.2 18.4 17. 0
53 Tanzania 23.5 26.8 26.3 20.8 17. 3
54 Angola 40.8 38.9 32.3 24.1 17. 4
55 India 31.2 26.9 25.5 24.2 1 7. 8
Rank Country 1990 1995 2000 2005 2014
56 Congo, Republic 22.6 22.7 18 .3 18.3 18.1
57 Bangladesh 36.6 34.4 24.0 19.8 19.1
57 Pakistan 26.7 23.3 2 2.1 21.0 19.1
59 Djibouti 34.1 29.4 28.5 25.6 19.5
60 Burkina Faso 27. 0 22.6 26.3 26.5 19.9
61 Lao PDR 34.5 31.4 29.4 25.0 20.1
62 Mozambique 35.2 32.3 28.2 24.8 20.5
63 Niger 36.4 36.1 31.2 26.4 21.1
64
Central African Republic
30.3 30.3 28 .1 28.9 21.5
65 Madagascar 25.3 24.9 2 7. 4 25.2 21.9
66 Sierra Leone 31.2 29.0 29.8 29.1 22.5
67 Haiti 33.6 32.9 25.3 2 7.9 23.0
68 Zambia 24.7 24.0 26.5 24.7 23.2
69 Yemen, Republic 30.1 2 7. 8 2 7. 8 28.0 23.4
70 Ethiopia –42.6 3 7. 4 30.8 24.4
71 Chad 39.7 35.4 30.0 29.8 24.9
72 Sudan/South Sudan* 30.7 25.9 26.7 24.1 26.0
73 Comoros 23.0 26.7 34.0 30.0 29.5
74 Timor-Leste –––25.7 29.8
75 Eritrea – 41.2 40.0 38.8 33.8
76 Burundi 32.0 36.9 38 .7 39.0 35.6
COUNTRIES WITH 2014 GHI SCORES LESS THAN 5
*GHI scores could only be calculated for former Sudan as one entity, because separate undernour-
ishment estimates for 2011–2013 and earlier were not available for South Sudan, which became
independent in 2011, and present-day Sudan.
– = Data not available or not presented. Some countries, such as the post-Soviet states prior to
1991, did not exist in their present borders in the given year or reference period.
Note: Ranked according to 2014 GHI scores. Countries with a 2014 GHI score of less than 5
are not included in the ranking, and differences between their scores are minimal. Countries that
have identical 2014 scores are given the same ranking (for example, Mauritius and Thailand both
rank first). The following countries could not be included because of lack of data: Afghanistan,
Bahrain, Bhutan, the Democratic Republic of the Congo, Georgia, Myanmar, Oman, Papua New
Guinea, Qatar, and Somalia.
Country ’90 ’95 ’00 ’05 ’14
Algeria 6.6 7.3 5.1 <5 <5
Argentina <5 <5 <5 <5 <5
Armenia – 10.5 9.0 <5 <5
Azerbaijan – 14.8 12.0 5.2 <5
Belarus – <5 <5 <5 <5
Bosnia & Herzegovina
– <5 <5 <5 <5
Brazil 8.8 7.7 6.5 <5 <5
Bulgaria <5 <5 <5 <5 <5
Chile <5 <5 <5 <5 <5
Costa Rica <5 <5 <5 <5 <5
Croatia – 5.4 <5 <5 <5
Cuba <5 8.4 <5 <5 <5
Egypt, Arab Rep. 7.0 6.3 5.3 <5 <5
Estonia – <5 <5 <5 <5
Fiji 6.2 5.3 <5 <5 <5
Iran, Islamic Rep. 8.5 7.3 5.8 <5 <5
Jamaica 6.1 <5 <5 <5 <5
Jordan <5 5.5 <5 <5 <5
Kazakhstan – <5 7.8 <5 <5
Kuwait 15.6 5.3 <5 <5 <5
Kyrgyz Republic – 11.2 9.0 5.4 <5
Latvia – <5 <5 <5 <5
Country ’90 ’95 ’00 ’05 ’14
Lebanon <5 <5 <5 <5 <5
Libya <5 <5 <5 <5 <5
Lithuania – <5 <5 <5 <5
Macedonia, FYR – 5.6 <5 <5 <5
Mexico 5.8 5.6 <5 <5 <5
Montenegro – – – – <5
Morocco 7.6 7.1 6 .1 6.4 <5
Panama 11.6 10.7 11.8 9.5 <5
Romania <5 <5 <5 <5 <5
Russian Fed. – <5 <5 <5 <5
Saudi Arabia 6.6 6.5 <5 <5 <5
Serbia – – – – <5
Slovak Republic – <5 <5 <5 <5
South Africa 7.5 6.4 7.4 7.8 <5
Trinidad & Tobago 6.7 7.6 6.8 6.7 <5
Tunisia <5 <5 <5 <5 <5
Turkey <5 5.0 <5 <5 <5
Turkmenistan – 10.5 9.1 6.9 <5
Ukraine – <5 <5 <5 <5
Uruguay 5.0 <5 <5 <5 <5
Uzbekistan – 7.7 8.9 6.9 <5
Venezuela, RB 7.5 7.3 6.8 5.8 <5

2014 Global Hunger Index | Chapter 02 | Global, Regional, and National Trends 17
the transition to peace and political stability that started in 2003,
Burundi began a slow recovery from decades of economic decline. Per-
sistent food insecurity, a very high poverty rate, high inflation, and poor
education are among factors that pose challenges for the country’s
future development (FAO 2014; World Bank 2014).
In Iraq, GHI scores have increased considerably since 1990.
The country has suffered from deteriorating accessibility and quality
of basic services for decades and years of instability, ongoing violence,
large numbers of internally displaced people, and the influx of refu-
gees from Syria have added to the burden (WFP 2014a; UCDP 2013).
Hunger worsened until 2000, followed by a slight decline in GHI scores
up to 2005, and then another increase (see Appendix C). Under-five
mortality declined since 1990, but less than in most other countries
in the Near East and North Africa region. Progress in reducing child
undernutrition was also slow, although the prevalence of underweight
in children fell slightly after peaking in 2000, whereas the proportion
of undernourished in the population more than doubled since 1990
(see data table in Appendix B).5
In Swaziland, the HIV / AIDS epidemic has severely under-
mined food security along with high income inequality, high
un employment, and consecutive droughts (World Bank 2014; WFP
2014b). Swaziland’s adult HIV prevalence in 2012 was estimated at
26.5 percent—the highest in the world (UNAIDS 2013). The coun-
try’s GHI score worsened until 2000, then declined slightly until
2005, but has increased again since then (see Appendix C). Swazi-
land and several other African countries have made great strides in
preventing mother-to-child transmission of HIV, and child mortality
rates have dropped after peaking around 2003–2004 (UNAIDS 2013;
IGME 2013). However, the proportion of people who are undernour-
ished more than doubled in Swaziland since 2004–2006 (see data
table in Appendix B). Since 1990, life expectancy fell by ten years,
amounting to only 49 years in 2012, despite a slight recovery in recent
years (World Bank 2014).
Some countries achieved noteworthy absolute progress in
improving their GHI scores. Comparing the 1990 GHI and the 2014
GHI, Angola, Bangladesh, Cambodia, Chad, Ghana, Malawi, Niger,
Rwanda, Thailand, and Vietnam saw the largest improvements—with
decreases in their scores ranging between 14 and 24 points (Table
2.1). Angola and Cambodia have been recovering from devastating
conflicts: In Angola, 2002 marked the end of a 27-year civil war, and
in Cambodia, 13 years of fighting ended in 1991. Bangladesh has
experienced broad-based progress in social indicators, and its very
active nongovernmental (NGO) sector and public transfer programs
helped reduce child undernutrition among the poorest (World Bank
2014, 2005). The country is committed to regular monitoring of chil-
dren’s nutritional status and has cut back underweight in children
from a staggering 62 percent in 1990 to only 37 percent in 2011
(WHO 2014b).
Sixteen countries still have levels of hunger that are “ extremely alarm-
ing” or “alarming” in the severity map (Figure 2.4). Most of the coun-
tries with alarming GHI scores are in Africa south of the Sahara. The
only exceptions are Haiti, Laos, Timor-Leste, and Yemen. The two coun-
tries with “extremely alarming” 2014 GHI scores—Burundi and
Eritrea—are in Africa south of the Sahara.
The Democratic Republic of the Congo, with an estimated pop-
ulation of close to 70 million in 2014 (UN 2013), still appears as a gray
area on the map (Figure 2.4) because reliable data on undernourish-
ment are lacking and the level of hunger cannot be assessed. It remains
unclear if the GHI score in this country would be classified as “extreme-
ly alarming,” as in previous editions of this report, up to 2011, because
data are not available. High-quality data for the Democratic Republic
of the Congo and other likely hunger hotspots, such as Afghanistan and
Somalia, are badly needed.
In terms of the GHI components, Burundi, Comoros, and Eritrea
currently have the highest proportion of undernourished people—more
than 60 percent of the population.6 Bangladesh, Niger, Timor-Leste,
and Yemen have the highest prevalence of underweight in children
under five, amounting to more than 35 percent in each country. Ango-
la, Chad, and Sierra Leone have the highest under-five mortality rate,
ranging from 15 percent to more than 18 percent.
5
The escalation of violence in large parts of Iraq in 2014 is not yet considered in the
latest GHI, which includes data from the period 2009–2013.
6 Although the Democratic Republic of the Congo and Somalia are likely to have high proportions
of undernourished as well, they could not be included in this comparison because of a lack of
reliable data.

18 Name des Teilbereich | Chapter 1 | 2014 Global Hunger Index
Canada
United States
of America
Mexico
Guatemala
El Salvador
Belize
Honduras
Jamaica
Haiti
Cuba
Dominican Rep.
Panama
Nicaragua
Cos ta Ric a
Colombia
Peru
Ecuador
Uruguay
Paraguay
Chile
Brazil
Bolivia
Argentina
Venezuela
Trinidad & Tobago
Suriname
Guyana
French Guiana
Zimbabwe
Zambia
Swaziland
South
Africa
Namibia
Lesotho
Botswana
Angola
Mozambique
Mauritius
Madagascar
Uganda
Tunisia
Tog o
Tanzania
Somalia
Sierra Leone
Senegal
Rwanda
Nigeria
Niger
Morocco
Mauritania Mali
Malawi
Libya
Liberia
Kenya
Guinea-Bissau
Guinea
Ghana
The Gambia
Gabon
Ethiopia
Eritrea
Equatorial Guinea
Egypt
Djibouti
Côte
d'Ivoire
Congo,
Dem.
Rep.
Chad
Sudan*
South
Sudan*
Central
African
Republic
Cameroon
Burundi
Burkina Faso
Benin
Algeria
Western Sahara
Comoros
Congo,
Rep.
Yemen Vietnam
Uzbekistan
U.A.E.
Turkmenistan
Tur ke y
Thailand
Taji ki sta n
Syria
Sri Lanka
Saudi Arabia
Russian Federation
Qatar
Philippines
Papua
New
Guinea
Pakistan
Oman
Nepal
Mongolia
Malaysia
Lebanon
Lao
PDR
Kyrgyz Rep.
Kuwait
S. Korea
N. Korea
Kazakhstan
Jordan
Japan
Israel Iraq Iran
Indonesia
India
Timor-Leste
Cyprus
China
Cambodia
Myanmar
Brunei
Bhutan
Bangladesh
Australia
Afghanistan
Bahrain
Ukraine
Greece
Bos. &
Herz.
Croatia
Georgia
Azerb.
Armenia
Romania
Moldova
Mace.
Bulgaria
Albania
Serb.
Mont.
Slovakia
Slov. Hungary
United
Kingdom
Sweden
Spain
Portugal
Norway
Italy
Ireland
Iceland
Greenland
Germany
France
Finland
Denmark Lithuania
Latvia
Estonia
Belarus
Poland
Czech Rep.
Austria
Switz.
Neth.
Lux.
Bel.
Vanuatu
Solomon Islands
New Zealand
Extremely alarming 30.0 <
Alarming 20.0–29.9
Serious 10.0–19.9
Moderate 5.0–9.9
Low < 4.9
No data
Industrialized country
Figure 2.4 2014 GlObal HUNGER INDEx bY SEvERITY

2014 Global Hunger Index | Chapter 1 | Name des Teilbereich 19
Canada
United States
of America
Mexico
Guatemala
El Salvador
Belize
Honduras
Jamaica
Haiti
Cuba
Dominican Rep.
Panama
Nicaragua
Cos ta Ric a
Colombia
Peru
Ecuador
Uruguay
Paraguay
Chile
Brazil
Bolivia
Argentina
Venezuela
Trinidad & Tobago
Suriname
Guyana
French Guiana
Zimbabwe
Zambia
Swaziland
South
Africa
Namibia
Lesotho
Botswana
Angola
Mozambique
Mauritius
Madagascar
Uganda
Tunisia
Tog o
Tanzania
Somalia
Sierra Leone
Senegal
Rwanda
Nigeria
Niger
Morocco
Mauritania Mali
Malawi
Libya
Liberia
Kenya
Guinea-Bissau
Guinea
Ghana
The Gambia
Gabon
Ethiopia
Eritrea
Equatorial Guinea
Egypt
Djibouti
Côte
d'Ivoire
Congo,
Dem.
Rep.
Chad
Sudan*
South
Sudan*
Central
African
Republic
Cameroon
Burundi
Burkina Faso
Benin
Algeria
Western Sahara
Comoros
Congo,
Rep.
Yemen Vietnam
Uzbekistan
U.A.E.
Turkmenistan
Tur ke y
Thailand
Taji ki sta n
Syria
Sri Lanka
Saudi Arabia
Russian Federation
Qatar
Philippines
Papua
New
Guinea
Pakistan
Oman
Nepal
Mongolia
Malaysia
Lebanon
Lao
PDR
Kyrgyz Rep.
Kuwait
S. Korea
N. Korea
Kazakhstan
Jordan
Japan
Israel Iraq Iran
Indonesia
India
Timor-Leste
Cyprus
China
Cambodia
Myanmar
Brunei
Bhutan
Bangladesh
Australia
Afghanistan
Bahrain
Ukraine
Greece
Bos. &
Herz.
Croatia
Georgia
Azerb.
Armenia
Romania
Moldova
Mace.
Bulgaria
Albania
Serb.
Mont.
Slovakia
Slov. Hungary
United
Kingdom
Sweden
Spain
Portugal
Norway
Italy
Ireland
Iceland
Greenland
Germany
France
Finland
Denmark Lithuania
Latvia
Estonia
Belarus
Poland
Czech Rep.
Austria
Switz.
Neth.
Lux.
Bel.
Vanuatu
Solomon Islands
New Zealand
Note: For the 2014 GHI, data on the propo rtion of underno urished are for 2011–2013, data on
child underweight are fo r the latest yea r in the period 200 9–2013 for which data are a vailable,
and data on child mort ality are for 2012. GHI score s were not calculated fo r countries for which
data were not available a nd for certain co untries with ver y small populations.
* The 2014 GHI score could only be calculated for fo rmer Sudan as one entit y, because sepa -
rate undernourishm ent estimates fo r 2011–2013 were not available for S outh Sudan, which
became indepe ndent in 2011, and present-day Sudan.

20 Name des Teilbereich | Chapter 1 | 2014 Global Hunger Index
03
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
The ‘hidden hunger’ due to micronutrient deficiency does
not produce hunger as we know it. You might not feel it in the belly,
but it strikes at the core of your health and vitality.
Kul C. Gautam, former deputy executive director of UNICEF

2014 Global Hunger Index | Chapter 03 | Addressing the Challenge of Hidden Hunger 21
Hidden hunger, also known as micronutrient deficiencies, afflicts
more than 2 billion individuals, or one in three people, globally (FAO
2013). Its effects can be devastating, leading to mental impairment,
poor health, low productivity, and even death. Its adverse effects on
child health and survival are particularly acute, especially within the
first 1,000 days of a child’s life, from conception to the age of two,
resulting in serious physical and cognitive consequences. Even mild
to moderate deficiencies can affect a person’s well-being and devel-
opment. In addition to affecting human health, hidden hunger can
curtail socioeconomic development, particularly in low- and middle-
income countries.
A Different Kind of Hunger
Hidden hunger is a form of undernutrition that occurs when intake
and absorption of vitamins and minerals (such as zinc, iodine, and
iron) are too low to sustain good health and development (Box 3.1).
Factors that contribute to micronutrient deficiencies include poor diet,
increased micronutrient needs during certain life stages, such as
pregnancy and lactation, and health problems such as diseases, infec-
tions, or parasites.
While clinical signs of hidden hunger, such as night blindness
due to vitamin A deficiency and goiter from inadequate iodine intake,
become visible once deficiencies become severe, the health and devel-
ADDRESSING THE CHALLENGE
OF HIDDEN HUNGER
opment of a much larger share of the population is affected by less
obvious “invisible” effects. That is why micronutrient deficiencies are
often referred to as hidden hunger.
The Global Hidden Hunger Crisis
More than 2 billion people worldwide suffer from hidden hunger, more
than double the 805 million people who do not have enough calories
to eat (FAO, IFAD, and WFP 2014). Much of Africa south of the Saha-
ra and the South Asian subcontinent are hotspots where the preva-
lence of hidden hunger is high (Figure 3.1). The rates are relatively
low in Latin America and the Caribbean where diets rely less on
single staples and are more affected by widespread deployment of
micronutrient interventions, nutrition education, and basic health ser-
vices (Weisstaub and Araya 2008). Although a larger proportion of
the burden of hidden hunger is found in the developing world, micro-
nutrient deficiency, particularly iron and iodine deficiency, is also
widespread in the developed world (Figures 3.1 and 3.2).
The nature of the malnutrition burden facing the world is
increasingly complex. Developing countries are moving from tradition-
al diets based on minimally processed foods to highly processed, ener-
gy-dense, micronutrient-poor foods and drinks, which lead to obesity
and diet-related chronic diseases. With this nutrition transition, many
developing countries face a phenomenon known as the “triple burden”
of malnutrition—undernourishment, micronutrient deficiencies, and
obesity (Pinstrup-Andersen 2007). In higher income, more urbanized
countries, hidden hunger can coexist with overweight/obesity when a
person consumes too much dietary energy from macronutrients such
as fats and carbohydrates (Guralnik et al. 2004). While it may seem
paradoxical, an obese child can suffer from hidden hunger.
Micronutrient deficiencies cause an estimated 1.1 million of
the 3.1 million child deaths that occur each year as a result of under-
nutrition (Black et al. 2013; Black et al. 2008). Vitamin A and zinc
deficiencies adversely affect child health and survival by weakening the
immune system. Lack of zinc impairs growth and can lead to stunting
in children. Iodine and iron deficits prevent children from reaching
their physical and intellectual potential (Allen 2001).
Women and children have greater needs for micronutrients
(Darnton-Hill et al. 2005). The nutritional status of women around
the time of conception and during pregnancy has long-term effects
for fetal growth and development. Nearly 18 million babies are born
with brain damage due to iodine deficiency each year. Severe anemia
contributes to the death of 50,000 women in childbirth each year. In
addition, iron deficiency saps the energy of 40 percent of women in
the developing world (UNSCN 2005; Micronutrient Initiative 2014).
Interventions to fight hidden hunger and improve nutrition outcomes
generally focus on women, infants, and young children. By targeting
BOX 3.1 DEFINITIONS
>
Hunger: distress related to lack of food
>
Malnutrition: an abnormal physiological condition, typically
due to eating the wrong amount and/or kinds of foods;
encompasses undernutrition and overnutrition
>
Undernutrition: deficiencies in energy, protein, and/or
micronutrients
>
Micronutrient deficiency (also known as hidden hunger): a form
of undernutrition that occurs when intake or absorption of vita-
mins and minerals is too low to sustain good health and devel-
opment in children and normal physical and mental function
in adults. Causes include poor diet, disease, or increased
micronutrient needs not met during pregnancy and lactation
>
Undernourishment: chronic calorie deficiency, with consump-
tion of less than 1,800 kilocalories a day, the minimum most
people need to live a healthy, productive life
>
Overnutrition: excess intake of energy or micronutrients
Sources: FAO (2013); and von Grebmer et al. (2013).

22 Addressing the Challenge of Hidden Hunger | Chapter 03 | 2014 Global Hunger Index
FIGURE 3.1 PERCENTAGE OF POPULATION WITH SELECTED MICRONUTRIENT DEFICIENCIES
Global Oceania Europe Asia Americas Africa
65
60
55
50
45
40
35
30
25
20
15
10
5
0
these populations, interventions achieve high rates of return by
improving health, nutritional status, and cognition later in life (Hod-
dinott et al. 2013).
The most commonly recognized micronutrient deficiencies
across all ages, in order of prevalence, are caused by a lack of iodine,
iron, and zinc (Table 3.1, p. 24). Less common, but significant from
a public health standpoint, is vitamin A deficiency, with an estimat-
ed 190 million preschool children and 19 million pregnant women
affected (WHO 2009). Low intakes of other essential micronutrients,
such as calcium, vitamin D, and B vitamins, such as folate are also
common (Allen et al. 2006). Although pregnant women, children,
and adolescents are often cited as populations affected the most by
hidden hunger, it impairs the health of people throughout the life
cycle (Figure 3.3, p. 24).
It is difficult to describe the magnitude of deficits for most
micronutrients. For many micronutrient deficits, prevalence data are
scarce. Scientists have not reached a consensus on standard recom-
mended intakes for many of the 19 micronutrients that directly
influence physical and mental development and the immune system
(Biesalski 2013). Furthermore, for many micronutrients, the relation-
ship between intake and utilization is not well understood.
Obtaining accurate data is a challenge. Time lags, data gaps, and lack
of disaggregation are common problems. Often proxies for common
examples of hidden hunger are imperfect. For example, anemia is used
as a proxy for iron deficiency, although only half of all anemia is caused
by iron deficiency (de Benoist et al. 2008). Typical physical measure-
ments of hunger, such as stunting (low height for one’s age), wasting
(low weight for one’s height), and underweight, may capture micronu-
trient deficiencies in affected populations, but are inadequate proxies,
because the deficiencies are seldom the only factors involved. Exact
measurements via blood samples, and also by specific diagnoses, such
as night blindness, beriberi, and scurvy, are more reliable ways to deter-
mine micronutrient deficiencies. Many important micronutrients lack
prevalence data, because related biomarkers have not yet been identi-
fied for a nutrient deficit. As long as these gaps in data persist, it will
be difficult to describe the full contours of hidden hunger.
Causes of Vitamin and Mineral Deficiencies
Poor diet is a common source of hidden hunger. Diets based mostly on
staple crops, such as maize, wheat, rice, and cassava, which provide
a large share of energy but relatively low amounts of essential vitamins
and minerals, frequently result in hidden hunger. What people eat
Vitamin A deficiency
Children < age 5
Pregnant women
Iron deficiency anemia
Preschool-age children
Pregnant women
Iodine deficiency
Population
Source: Black et al. (2013).

Canada
United States
of America
Mexico
Guatemala
El Salvador
Belize
Honduras
Jamaica
Haiti
Cuba
Dominican Rep.
Panama
Nicaragua
Costa Ric a
Colombia
Peru
Ecuador
Uruguay
Paraguay
Chile
Brazil
Bolivia
Argentina
Venezuela
Trinidad & Tobago
Suriname
Guyana
French Guiana
Zimbabwe
Zambia
Swaziland
South
Africa
Namibia
Lesotho
Botswana
Angola
Mozambique
Mauritius
Madagascar
Uganda
Tunisia
Togo
Tanzania
Somalia
Sierra Leone
Senegal
Rwanda
Nigeria
Niger
Morocco
Mauritania Mali
Malawi
Libya
Liberia
Kenya
Guinea-Biss au
Guinea
Ghana
The Gambia
Gabon
Ethiopia
Eritrea
Equatorial Guinea
Egypt
Djibouti
Côte
d'Ivoire
Congo,
Dem. Rep.
Chad Sudan*
South
Sudan*
Central African
Republic
Cameroon
Burundi
Burkina Faso
Benin
Algeria
Western Sahara
Comoros
Congo,
Rep.
Yemen Vietnam
Uzbekistan
U.A.E.
Turkmenistan
Turke y
Thailand
Tajiki sta n
Syria
Sri Lanka
Saudi Arabia
Russian Federation
Qatar
Philippines
Papua
New
Guinea
Pakistan
Oman
Nepal
Mongolia
Malaysia
Lebanon
Lao
PDR
Kyrgyz Rep.
Kuwait
S. Korea
N. Korea
Kazakhstan
Jordan
Japan
Israel Iraq Iran
Indonesia
India
Timor-Leste
Cyprus
China
Cambodia
Myanmar
Brunei
Bhutan
Bangladesh
Australia
Afghanistan
Bahrain
Ukraine
Greece
Bos. &
Herz.
Croatia
Georgia
Azerb.
Armenia
Romania
Moldova
Mace.
Bulgaria
Albania
Serb.
*
Mont.
*
Slovakia
Slov. Hungary
United
Kingdom
Sweden
Spain
Portugal
Norway
Italy
Ireland
Iceland
Greenland
Germany
France
Finland
Denmark Lithuania
Latvia
Estonia
Belarus
Poland
Czech Rep.
Austria
Switz.
Neth.
Lux.
Bel.
Solomon Islands
Fiji
Vanuatu
New Zealand
2014 Global Hunger Index | Chapter 03 | Addressing the Challenge of Hidden Hunger 23
Figure 3.2 PREvalENCE Of aNEmIa amONG PRESCHOOl-aGE CHIlDREN, 1993–2005
Severe 40.0% ≤
Moderate 20.0–39.9%
Mild 5.0–19.9%
Normal < 5.0%
No data
Source: de Benoist et al. (2008).
Note: Anemia is not an exact proxy for iron deficiency, because it has many causes. Globally, about
half of all anemia is caused by iron deficiency.
* The color category for South Sudan and Sudan is based on data from 1994 and 1995, before
2011, when South Sudan became independent. The color for Serbia and Montenegro is based on
data from 2000, when they were one entity, long before 2006 when they split into two countries.
depends on many factors, including relative prices (Box 3.2, p. 25) and
preferences shaped by culture; peer pressure; and geographical, envi-
ronmental, and seasonal factors. Victims of hidden hunger may not
understand the importance of a balanced, nutritious diet. Nor may they
be able to afford or access a wide range of nutritious foods such as ani-
mal-source foods (meat, eggs, fish, and dairy), fruits, or vegetables,
especially in developing countries. In nonemergency situations, pover-
ty is a major factor that limits access to adequate nutritious foods.
When food prices rise, consumers tend to continue to eat staple foods
while cutting their intake of nonstaple foods that tend to be richer in
micronutrients (Bouis, Eozenou, and Rahman 2011).
Another source of micronutrient deficiencies is impaired
absorption or use of nutrients. Absorption may be impaired by infec-
tion or a parasite that can also lead to the loss of or increased need for
many micronutrients. Infections and parasites can spread easily in
unhealthy environments with poor water, sanitation, and hygiene con-
ditions. Unsafe food handling and feeding practices can further exac-
erbate nutrient losses.
Diet also affects absorption. Fat-soluble vitamins such as vita-
min A are best absorbed when consumed with dietary fat, while con-
sumption of some compounds such as tannins or phytates can inhibit
iron absorption. Alcohol consumption can interfere with the absorption
of micronutrients.
The Economic Toll
Vitamin and mineral deficiencies impose a significant burden on the
affected persons and societies, both in terms of health costs and neg-
ative impacts in lost human capital and reduced economic productiv-
ity. Hidden hunger impairs physical growth and learning, limits produc-
tivity, and ultimately perpetuates poverty (Figure 3.4, p. 26) in a
continuous cycle. Countries where a large share of the population is
affected by vitamin and mineral deficiencies cannot realize their eco-
nomic potential (Stein 2013; Stein and Qaim 2007). Poor people dis-
proportionately suffer from micronutrient deficiencies, and bear the
long-term negative effects that constrain socioeconomic development
(Darnton-Hill et al. 2005).
The economic costs of all forms of micronutrient deficiency can
be considerable, cutting gross domestic product by 0.7–2 percent in
most developing countries (Micronutrient Initiative and UNICEF 2004).
For example, it is estimated that India sustains a 1 percent loss in GDP
and Afghanistan a 2.3 percent loss. Global losses in economic produc-
tivity due to macronutrient and micronutrient deficiencies reach more
than 2 to 3 percent of GDP (World Bank 2006) at a global cost of
US$1.4 to 2.1 trillion per year (FAO 2013).
On the other hand, the return on investment in nutrition can
be high. Copenhagen Consensus Expert Panels consistently find nutri-
tion interventions cost-effective (Copenhagen Consensus 2004,

24 Addressing the Challenge of Hidden Hunger | Chapter 03 | 2014 Global Hunger Index
FIGURE 3.3 CONSEQUENCES OF MICRONUTRIENT DEFICIENCIES THROUGHOUT THE LIFE CYCLE
Source: Adapted from ACC/SCN (2000).
TABLE 3.1 SELECTED MICRONUTRIENT DEFICIENCIES AND THEIR EFFECTS
Micronutrient deficiency Effects include Number of
people affected
Iodine Brain damage in newborns, reduced mental capacity, goiter ~1.8 billion
Iron Anemia, impaired motor and cognitive development, increased risk of maternal
mortality, premature births, low birthweight, low energy ~1.6 billion
Vitamin A
Severe visual impairment, blindness, increased risk of severe illness and death
from common infections such as diarrhea and measles in preschool age children;
(in pregnant women) night blindness, increased risk of death
190 million preschool age
children; 19 million preg-
nant women
Zinc
Weakened immune system, more frequent infections, stunting
1.2 billion
Sources: Allen (2001); Andersson, Karumbunathan, and Zimmermann (2012); de Benoist et al. (2008);
Micronutrient Initiative (2009); Wessels and Brown (2012); and WHO (2009; 2014a).
Elderly
>
Increased morbidity
(including osteo-
porosis and mental
impairment)
> Higher mortality rate
Baby
> Low birth weight
> Higher mortality rate
>
Impaired mental development
Child
> Stunting
> Reduced mental capacity
> Frequent infections
>
Reduced learning
capacity
> Higher mortality rate
Adolescent
> Stunting
> Reduced mental capacity
> Fatigue
>
Increased vulnerability
to infection
Pregnant women
> Increased mortality
>
Increased perinatal
complications
Adult
> Reduced productivity
>
Poor socioeconomic status
> Malnutrition
>
Increased risk of chronic
disease

2014 Global Hunger Index | Chapter 03 | Addressing the Challenge of Hidden Hunger 25
2008, 2012). In 2008, the panel ranked supplements for children
(vitamin A and zinc), fortification (iron and iodine), and biofortifica-
tion among the top five best investments for economic development.
For example, estimates for salt iodization suggest that every dollar
invested generates up to US$81 in benefits (Hoddinott, Rosegrant,
and Torero 2012).
Solutions to Hidden Hunger
Diversifying Diets
Increasing dietary diversity is one of the most effective ways to sus-
tainably prevent hidden hunger (Thompson and Amoroso 2010). Dietary
diversity is associated with better child nutritional outcomes, even when
controlling for socioeconomic factors (Arimond and Ruel 2004). In the
long term, dietary diversification ensures a healthy diet that contains
a balanced and adequate combination of macronutrients (carbohy-
drates, fats, and protein); essential micronutrients; and other food-
based substances such as dietary fiber. A variety of cereals, legumes,
fruits, vegetables, and animal-source foods provides adequate nutri-
tion for most people, although certain populations, such as pregnant
women, may need supplements (FAO 2013). Effective ways to promote
dietary diversity involve food-based strategies, such as home garden-
ing and educating people on better infant and young child feeding
practices, food preparation, and storage/preservation methods to pre-
vent nutrient loss.
Fortifying Commercial Foods
Commercial food fortification, which adds trace amounts of micronu-
trients to staple foods or condiments during processing, helps
consumers get the recommended levels of micronutrients. A scalable,
sustainable, and cost-effective public health strategy, fortification has
been particularly successful for iodized salt: 71 percent of the world’s
population has access to iodized salt and the number of iodine-defi-
cient countries has decreased from 54 to 32 since 2003 (Andersson,
Karumbunathan, and Zimmermann 2012).
Other common examples of fortification include adding B vita-
mins, iron, and/or zinc to wheat flour and adding vitamin A to cooking
oil and sugar. Fortification may be particularly effective for urban con-
sumers, who buy commercially processed and fortified foods. It is less
likely to reach rural consumers who often have no access to commer-
cially produced foods. To reach those most in need, fortification must
be subsidized or mandatory; otherwise people may buy cheaper
nonfortified alternatives.
Fortification, however, has a number of shortcomings. People
may resist fortified foods. For example, up to 30 percent of Pakistanis
avoid iodized salt, according to the Micronutrient Initiative, due to a
mistaken belief that iodine causes infertility and rumors of a plot to
limit population growth (Leiby 2012). Consumers may also resist using
fortified foods due to cooking properties or flavor. From another per-
spective, it can be difficult to determine the appropriate level of
nutrients. Fortificants, the compounds used to fortify foods, may not
be stable and may be lost during processing or storage. In addition,
bioavailability, the degree or rate at which a substance can be absorbed,
may be limited. That said, evidence of the acceptability and efficacy
of home fortification continues to grow (Adu-Afarwuah et al. 2008;
Dewey, Yang, and Boy 2009; De-Regil et al. 2013).
Biofortification
Biofortification is a relatively new intervention that involves breeding
food crops, using conventional or transgenic methods, to increase
their micronutrient content.1 Plant breeders also improve yield and
pest resistance, as well as consumption traits, like taste and cooking
time—to match or outperform conventional varieties. To date, only
conventionally bred biofortified crops have been released and deliv-
ered to farmers. Biofortified crops that have been released so far
include vitamin A orange sweet potato, vitamin A maize, vitamin A
cassava, iron beans, iron pearl millet, zinc rice, and zinc wheat. While
biofortified crops are not available in all developing countries, biofor-
tification is expected to grow significantly in the next five years
(Saltzman et al. 2013).
BOX 3.2 EFFECTS OF THE GREEN REVOLUTION
Public research and development practice have over many years
focused on increasing productivity of staple crops in order to
reduce malnutrition. However, the intensified production of
high-yielding cereal varieties during the Green Revolution from
the 1970s to mid-1990s may have both improved and wors-
ened nutrition. The increase in total output of food staples
translated into a drop in the prices of starchy staples relative
to the prices of more micronutrient-rich nonstaple foods, such
as vegetables and pulses. While staple cereals became more
affordable, the prices of nonstaple foods in some countries
rose, making micronutrient-rich foods less attractive to poor
people (Bouis 2000; Kennedy and Bouis 1993).
1
Conventional plant breeding involves parent lines with high vitamin or mineral levels that are
crossed over several generations to produce plants with the desired nutrient and agronomic traits.
Transgenic approaches, in which genes are manipulated or new genes inserted, are advantageous
when the nutrient is not naturally found in a crop (for example, provitamin A in rice).

26 Addressing the Challenge of Hidden Hunger | Chapter 03 | 2014 Global Hunger Index
Biofortified foods could provide a steady and safe source of certain
micronutrients for people not reached by other interventions. In con-
trast to large-scale fortification, which usually reaches a greater share
of urban than rural residents, biofortification first targets rural areas
where crops are produced. Marketed surpluses of biofortified crops
may make their way into retail outlets, reaching consumers first in
rural areas, then in urban ones.
Given that biofortified staple foods cannot deliver as high a lev-
el nor as wide a range of minerals and vitamins as supplements or
industrially fortified foods can, they are not the best response to clin-
ical deficiencies. However, they can help close the micronutrient intake
gap and increase the daily intake of vitamins and minerals throughout
a person’s life (Bouis et al. 2011). While the evidence on biofortifica-
tion is not yet complete, several crops (iron beans, maize, pearl millet,
rice, sweet potato, and vitamin A cassava) show evidence of improved
micronutrient levels (Haas et al. 2005; 2011; 2013; 2014; Luna et al.
2012; Scott et al. 2012; Pompano et al. 2013; De Moura et al. 2014;
Tanumihardjo 2013; Talsma 2014; van Jaarsveld et al. 2005). Inter-
ventions delivering biofortified orange sweet potato significantly
improved vitamin A intake of mothers and young children (Hotz et al.
2012a; Hotz et al. 2012b).
Supplementation
Vitamin A supplementation is one of the most cost-effective interven-
tions for improving child survival (Tan-Torres Edejer et al. 2005).
Between 1999 and 2005, coverage increased more than fourfold,
and in 2012, estimated coverage rates were near 70 percent global-
ly (UNICEF 2014b). Programs to supplement vitamin A are often
integrated into national health policies because they are associated
with a reduced risk of all-cause mortality and a reduced incidence of
diarrhea (Imdad et al. 2010). According to UNICEF, at least 70 per-
cent of young children ages 6 to 59 months need to receive vitamin
A supplements every six months in order to achieve the desired reduc-
tions in child mortality. However, because of fluctuations in funding,
FIGURE 3.4 CYCLE OF HIDDEN HUNGER, POVERTY, AND STALLED DEVELOPMENT
Sources: Black et al. (2013); IFPRI (2014); FAO (2013); von Grebmer et al. (2010).
Note: The life cycle of malnutrition refers to how women who were poorly nourished as girls
tend to give birth to underweight babies, perpetuating the cycle of undernutrition.
Individual
> Hungry and malnourished mothers give birth
to low-birth-weight children in a life cycle
of malnutrition
> Diminished physical and mental capacity
> Compromised health
> Poor school performance
> Poverty, limited economic resources
> More than 2 billion people affected worldwide
Labor Force
> Reduced capacity for work
> No or lower paid jobs
> Lost productivity
> Lower life expectancy
> Lower lifetime earnings
National economic development
> Stalled or diminished economic
development
> Limited capacity to develop
health and education systems

2014 Global Hunger Index | Chapter 03 | Addressing the Challenge of Hidden Hunger 27
coverage varies widely from year to year in many priority countries. It
should also be noted that vitamin A supplements typically target only
vulnerable populations between six months and five years old.
Supplementation for other micronutrient deficiencies is less
common. In some countries, iron-folate supplements are prescribed
to pregnant women though coverage rates are often low and compli-
ance rates even lower. For children, home fortification with
micronutrient powders and lipid-based nutrient supplements can
include multiple micronutrients, like iron and zinc, but they are hard-
er to get into homes on a large scale than vitamin A supplements. The
learning curve can be steep. In a trial in rural China, about half of par-
ents or grandparents stopped giving children nutritional supplements
containing soybeans, iron, zinc, calcium, and vitamins because they
suspected the free supplements were unsafe or fake. They also feared
they would be charged later (Economist 2014).
Looking Ahead
A range of interventions are needed to solve the complex problem of
hidden hunger. To sustainably tackle the underlying causes will require
a multisectoral approach at the national and international levels.
National governments must take a cohesive approach to confronting
hidden hunger, otherwise it will not get the attention it deserves. Only
when all ministries, including agriculture, health, child development,
and education, and those handling regulatory affairs, form a united
front to improve food and nutrition security will governments truly have
a chance of succeeding. The Scaling Up Nutrition (SUN) Movement
offers a model for cross-sectoral collaboration, bringing people and
resources together at the national level to improve nutrition (SUN
2014). Essential components to fight hidden hunger must include:
>
Behavior-change communication that aims to improve women’s,
infants’, and young children’s utilization of health services, clean
water, good sanitation, and hygiene to protect them from diseases
that interfere with nutrient absorption;
>
Messaging that promotes best practices, such as early initiation of
exclusive breastfeeding up to 6 months followed by breastfeeding up
to 24 months with adequate and sufficient complementary food as an
economic and sustainable way to prevent hidden hunger in children;
>
Social protection that gives poor people access to nutritious food
and shields them from price spikes; and
>
A focus on empowering women by increasing access to education.
Eliminating hidden hunger will not be easy. Challenges lie ahead. But
if enough resources are allocated, the right policies developed, and
the right investments made, these challenges can be overcome (Fan
and Polman 2014). Much still needs to be done to ensure that peo-
ple around the world gain access to the nutrient-rich foods they and
their communities need to combat poor health and reach their devel-
opment potential.

28 Name des Teilbereich | Chapter 1 | 2014 Global Hunger Index
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
04
Increasing dietary diversity is one of the most
effective ways to sustainably prevent hidden hunger.
Thompson and Amoroso, 2010

2014 Global Hunger Index | Chapter 04 | Integrated Approaches toward Improved Nutrition Outcomes 29
Concern Worldwide and Welthungerhilfe share a strong commitment to
eliminating global food and nutrition insecurity. Both organizations draw
on experience and evidence from their programs in order to develop mod-
els which can address hunger in different countries and contexts around
the world. They are confronting the problem by tackling it on many fronts
with interventions that support dietary diversity and strengthen local
food systems. Empowering women, agricultural diversification, public
health interventions, and household practices to maximize micronutri-
ent intake are just some of the ways their programs are addressing under-
nutrition at the community level in developing countries.
This chapter offers insights from Concern and Welthungerhilfe’s
programs in rural Zambia, India, and Cambodia, recognizing the reality
that hunger and malnutrition primarily affect the rural poor who depend
on smallholder farming for a living (FAO 2013; Olinto et al. 2013). These
insights and examples of how people are directly affected by this work con-
vey not only the challenges of securing micronutrient-rich food, but also
what can be done to enhance a household’s food and nutrition security.
Realigning Agriculture to Improve
Nutrition (RAIN) Project in Zambia
Concern’s Realigning Agriculture to Improve Nutrition (RAIN) project
in Zambia is designed to address the problem of chronic undernutri-
tion by delivering sustainable and scalable cross-sectoral solutions to
transform the lives of the poorest and most vulnerable in Zambia.
Of a population of 13 million, more than 60 percent of Zambian
people live in rural areas and depend on agriculture for their livelihood
(Zambia 2012). In 2014, Zambia ranked 68th in the Global Hunger Index
(GHI), with a score indicating levels of hunger that are “alarming.” An
INTEGRATED APPROACHES TOWARD
IMPROVED NUTRITION OUTCOMES
estimated 45 percent of Zambian children under the age of five are stunt-
ed and suffer chronic malnutrition (UNICEF 2014b). Inadequate nutri-
ent intake is reflected in low dietary diversity scores: Only one-quarter
of the children surveyed met the minimum dietary diversity criterion of
having eaten four or more food groups the day before, according to a
baseline survey conducted in 2011 (Disha et al. 2012).
In 2010, Concern Worldwide Zambia and the International
Food Policy Research Institute (IFPRI) began collaborating on the
design of a five-year research project which aims to produce and share
evidence on how to optimize agriculture for nutrition. The project,
which began in mid-2011, has three objectives:
1. To reduce the prevalence of chronic malnutrition among young chil-
dren and improve the nutritional status of pregnant and lactating
women in Mumbwa District through targeted interventions during
the critical period from conception through the child’s second birth-
day (the first 1,000 days of life);
2. To realign and integrate activities and mechanisms within the Min-
istry of Agriculture and Livestock and the Ministry of Health, espe-
cially at the district level, to more effectively and efficiently achieve
sustainable nutritional outcomes; and
3. To use and share evidence generated at the district level to influ-
ence the local, national, and international policy agenda to prevent
child stunting.
One key aspect of the project involves exploring new ways to promote
coordination between officials in the agriculture, health, and commu-
nity development sectors. Malnutrition is a multidimensional problem
with many direct and underlying causes. Efforts to address it must
be multisectoral as increased coordination and alignment between
sectors and ministries will be vital for sustained impact on nutrition
outcomes. The changes begin at the district level in Mumbwa and cas-
cade down to the community level. In Mumbwa, a District Nutrition
Coordination Committee (DNCC) has been established to bring togeth-
er representatives from the ministries of agriculture and livestock,
health, community development, and maternal and child health as well
as representatives from civil society.
This model of coordination is considered innovative and effec-
tive in supporting collaboration among ministries. It will be replicated
across all 14 districts receiving support from the Scaling Up Nutrition
(SUN) Fund to implement the First 1,000 Most Critical Days Project.
Note: This chapter was prepared by Welthungerhilfe and Concern Worldwide, and reflects these
organizations’ views and analyses, which have not been peer-reviewed by IFPRI’s Publications
Review Committee and cannot be attributed to IFPRI. Any citation of results or statements from
this chapter should follow this format: Welthungerhilfe and Concern Worldwide. 2014. “Integrat-
ed Approaches toward Improved Nutrition Outcomes,” Ch. 4 in von Grebmer et al. (eds.) 2014
Global Hunger Index: The Challenge of Hidden Hunger. Bonn, Washington, D.C., and Dublin:
Welthungerhilfe, International Food Policy Research Institute, and Concern Worldwide.
BOX 4.1 SOME BASIC FACTS ABOUT REALIGNING AGRICULTURE
TO IMPROVE NUTRITION
>
Targets more than 4,490 households with pregnant women
and/or children below two years of age.
>
Has developed a system where community health workers
and smallholder farmers teach women’s groups.
>
Implementing partners: the Ministry of Agriculture and Live-
stock, the Ministry of Health, the Mumbwa Child Develop-
ment Agency, and IFPRI.
Note: For more information on this project, visit www.concern.net/rain

ZAMBIA
Central Province
Western
Province LUSAKA
30 Integrated Approaches toward Improved Nutrition Outcomes | Chapter 04 | 2014 Global Hunger Index
Community health volunteers and smallholder model farmers provide
continuing agriculture and nutrition training to groups of 15–20 wom-
en, who are pregnant or have children under the age of two. Training
covers agricultural practices that boost yields, including how to use
organic manure, best practices for integrated pest management, and
how to rear small livestock (Box 4.2).
A “pass-on” scheme facilitates livestock distribution. At the
start of the project, all smallholder model farmers were given a male
and a female goat. One-third of the group members received a female
goat and are passing on the goat’s first female offspring to other wom-
en in their group. Each woman also received one chicken. The milk,
eggs, and occasional meat from the animals are helping to increase
families’ micronutrient and protein intake, while the manure the ani-
mals produce can be used to improve the fertility of their vegetable
gardens’ soil. As access to water for irrigation during the dry season
is a big challenge, the project has also rehabilitated boreholes.
FOOD PROCESSING AND STORAGE. Household activities focus on improv-
ing food preparation and preservation and exploring appropriate
time- and labor-saving technologies to maximize women’s time for
childcare. In addition, each women’s group received a solar food dry-
er to preserve fruits and vegetables, increasing access to micronu-
trient-rich foods, such as cow pea leaves, pumpkin leaves, tomatoes,
and okra, throughout the year. While sun drying vegetables is a
traditional practice, solar dryers have improved the process by speed-
ing it up, reducing contamination, and minimizing micronutrient loss.
1
Mbereshi beans are rich in iron (102 ppm) and zinc (35 ppm).
Realigning Agriculture to Improve Nutrition (RAIN) Project
If you have any questions or complaints about the RAIN project,
call the Concern office at 0211 800195
We work together to grow nutrious food for our children. You can too.We work together to grow nutrious food for our children. You can too.
Tulabelekela antomwe mukulima chakulya chileta busani kumukwashi wesu. Tulabelekela antomwe mukulima chakulya chileta busani kumukwashi wesu.
Andinwe nga mwa chikozya.Andinwe nga mwa chikozya.
Source: Concern based on official maps.
Approaches within the Realigning
Agriculture to Improve Nutrition Project
Food Systems
HOMESTEAD GARDENS AND SMALL ANIMAL HUSBANDRY.
As in much of Zam-
bia, maize is the main crop grown and consumed in Mumbwa District.
Because a key focus of the project is to increase household consumption
of foods produced, agricultural activities focus mainly on homestead
gardening and small-scale animal husbandry. The project promotes
crops based on their nutritional value, including legumes (cowpeas,
groundnuts, and iron-biofortified beans); vegetables (amaranth, car-
rots, green beans, paprika, pumpkins and their leaves, rapeseed, toma-
toes); fruits (bananas, granadillas, passion fruit, watermelon); and
orange-fleshed sweet potatoes. Because the iron-rich beans mature
early, cook quickly, and taste good, they are popular with farmers. In
addition, people eat the leaves.1A RAIN poster promotes gender equality and the import ance of working together.
CONCERN’S PROGRAM AREAS IN ZAMBIA
Capital
Concern’s program areas
Concern’s RAIN project area
Mumbwa Chibombo
Kapiri Mposhi
Kabwe
Mkushi
Serenje

2014 Global Hunger Index | Chapter 04 | Integrated Approaches toward Improved Nutrition Outcomes 31
Social and Behavior Change
The RAIN project seeks to optimize food utilization, commonly under-
stood as the way the body makes the most of various nutrients in the
food (FAO 2008). Key social and behavior change (SBC) messages aim
to change both infant and young child feeding (IYCF) behaviors as well
as gender-related behaviors. Messages cover the importance of
diversifying diets, nutrition during pregnancy, early and exclusive
breastfeeding, the appropriate quantity and quality of complementary
foods, and preventive healthcare services, such as immunizations, and
antenatal care. The government curriculum and counselling cards are
used to educate women in infant and young child feeding practices,
and inform the project’s nutrition activities.
Gender issues are also part of the messaging related to agri-
cultural diversification, nutrition, and health. Women comprise more
than 40 percent of the agricultural workforce in the developing
world, and more than 50 percent in Africa (FAO 2011). However,
many interventions designed to help communities become more
food- and nutrition-secure fail to take into account their many roles,
demands on their time, and the specific constraints they face. This
project seeks to address this failure, not least by securing husbands’
support to work on improving agriculture and nutrition at the house-
hold level.
Specific gender-focused social and behavior change materi-
als communicate messages aimed at changing the behavior of
beneficiaries and the community at large by changing how they see
certain traditions and beliefs about gender roles ascribed by society.
These messages promote increased female decisionmaking and a
more equitable division of farming and childcare duties. Recognizing
the important role that men play, the program highlights the impor-
tance of engaging men and boys to support women in their produc-
tive and childcare duties. Key messages are conveyed in creative
ways, such as plays and cooking demonstrations. Different change
agents, including community health workers and agriculture exten-
sion agents, reinforce the messages.
Public Health Interventions
The project seeks to work through and build the capacity of existing
structures, while increasing overall demand for health services. Gov-
ernment staff and partners train all community health volunteers in
infant and young child feeding. In addition, health facility staff train
the trainers, leading monthly nutrition refresher classes for volunteers
on various topics including maternal health, how to conduct cooking
demonstrations, and how to address micronutrient deficiencies. The
community health volunteers also help mobilize the community for
the twice-yearly Child Health Week and other national days that pro-
mote public health.
BOX 4.2 SEEDS, LIVESTOCK, AND TRAINING LED
TO A MORE VARIED AND NUTRITIOUS DIET
Esnart Shibeleki is a single mother of five. Before joining the
Realigning Agriculture to Improve Nutrition project in 2011, she
and her family ate two meals a day and they grew two crops:
maize and cotton.
The project provided seeds for micronutrient-dense crops, such
as amaranth, tomatoes, carrots, soybeans, cow peas, and ground-
nuts. Now Esnart grows 14 kinds of crops in her garden and also
uses a solar dryer to dry her vegetables for consumption later.
“These new crops mean I can better feed my family,” she said.
“Now they can eat five times a day—three main meals and
two snacks. They drink goat milk and enjoy a more varied and
nutritious diet.”
After receiving chickens and a goat, Esnart was also able to add
some animal-source protein to her family’s diet, while the
manure from the animals improves the fertility of her garden’s
soil. In order to ensure decent crop yields, Esnart receives the
support of Elly, a smallholder model farmer who monitors her
work and checks that the crops are growing well.
Supplementation
The project supports micronutrient supplementation by promoting iron/
folic acid supplementation among pregnant women, deworming both
children and pregnant women, and giving vitamin A supplements to chil-
dren twice a year. These interventions are highlighted as part of the
social and behavior change messaging. The project’s vision is a long-
term one, which entails working with people to ensure most of their