Public health nutrition

Female nutritional status across the life-span in sub-Saharan Africa. 1. Prevalence patterns
Female nutritional status across the life-span in sub-Saharan Africa. 2. Causes and consequences
Blood cholesterol and triglycerides in adolescent Egyptian girls: Relation to anthropometric measurements
Daily versus weekly iron supplementation: Programmatic and economic implications for Indonesia

Female nutritional status across the life-span in sub-Saharan Africa. 1. Prevalence patterns

Abstract
Introduction
Macronutrient disorders
Micronutrient deficiencies
Gender differences in malnutrition in sub-Saharan Africa
Conclusion
Acknowledgements
References
Appendix 1. Selected findings concerning information on female nutritional status in sub-Saharan Africa

Joanne Leslie, Elizabeth Ciemins, and Suzanne Bibi Essama

Joanne Leslie is with the University of California, Los Angeles, School of Public Health, Department of Community Health Sciences, and The Pacific Institute for Women’s Health, in Los Angeles, California, USA. Elizabeth Ciemins is with the Los Angeles County Department of Health Services, STD Program, in Los Angeles. Suzanne Bibi Essama is with the Tulane University School of Public Health in New Orleans, Louisiana, USA.

Abstract

This article reviews and synthesizes existing nutritional studies that provide gender-disaggregated data from sub-Saharan Africa. The analytic focus is on female nutritional status across the life-span. However, it was found that available data are biased towards preschool children and women of reproductive age. As in other economically disadvantaged parts of the world, the two most prevalent nutritional deficiencies among females in sub-Saharan Africa are iron-deficiency anaemia and protein-energy malnutrition. In comparison with other regions of the world, sub-Saharan African females seem to be nutritionally better off than females in South Asia, but as malnourished as, or more malnourished than, females elsewhere. Indirect indicators of nutritional status, such as birthweight and maternal mortality, suggest that the nutritional situation of women in Western Africa is poorer than that of women in Eastern and Southern Africa. In comparison with males in sub-Saharan Africa, however, no consistent pattern of female nutritional disadvantage was found.

Introduction

Increasingly, planners recognize that the health and nutrition needs of females differ from those of males not only because of physiological sex differences, but also because of gender differences. Culturally defined roles and opportunities differ between males and females, leading to significant differences in their knowledge of health and nutrition, their exposure to health and nutrition risks, their access to care, and the social consequences they experience as a result of poor health and nutrition. Therefore, a broad analysis of the life circumstances of girls and women in Africa, not just a narrow focus on biological aspects of nutritional status, is required in order to design interventions that will be effective in improving the nutritional situation of sub-Saharan African females [1, 2].

As in most developing countries, the nutritional status of girls and women in sub-Saharan Africa is compromised by the cumulative and synergistic effects of many risk factors. These factors include limited availability of, or access to, food resources caused by natural and human-made disasters; lack of control over inputs and resource allocation at the household level; traditional feeding practices and other customs that limit women’s consumption of certain energy- or nutrient-rich foods; the energy demands of heavy physical labour; the nutritional demands of frequent cycles of pregnancy and lactation; and a high burden of infections with limited access to preventive or curative care.

This overview of the nutritional implications of the multiple time- and energy-demanding roles of sub-Saharan African women would lead the reader to anticipate a high prevalence of malnutrition among sub-Saharan African females. As this article makes clear, girls and women in this region are, indeed, severely malnourished. However, given their limited economic resources and their physically arduous lives, it is perhaps surprising that their nutritional status is not even worse than it is.

Two caveats are worth noting at the outset. Available data on nutrition in sub-Saharan Africa are biased towards pre-school children and women of reproductive age. Thus, our analysis is limited by the scarcity of reliable data on the female population outside these age groups. In addition, only rarely are the available data nationally representative, or are there comparable data over time.

Macronutrient disorders

Protein-energy malnutrition

As part of its Second Report on the World Nutrition Situation, the United Nations Administrative Committee on Coordination/Subcommittee on Nutrition (ACC/SCN) has published the most thorough and up-to-date global review of the nutritional situation of women of reproductive age. Thus, the ACC/SCN report provides the starting point for our assessment of the nutritional status of females in sub-Saharan Africa. (The ACC/SCN database was compiled from about 340 small- and medium-scale studies of the nutritional status of women 15 to 49 years of age carried out since the late 1970s [3]).

The four anthropometric measures of nutritional status that the ACC/SCN was able to use for their regional estimates of the prevalence of protein-energy malnutrition among women were height, weight, body mass index (BMI = weight in kilograms divided by height in meters squared), and arm circumference. Adult women in sub-Saharan Africa were found to be surprisingly tall. The average height is 158 cm, only 3 cm less than the average height of 161 cm for European women, whereas the mean height of women in South America and most of Asia is only about 151 cm. Although these differences might be assumed to be attributable to differences in genetic potential, the fact that the mean height of women in China was found to be exactly the same as that of sub-Saharan African women suggests that factors other than genetic potential must be important determinants [3]. Short stature or stunting among adults is usually taken as an indicator of cumulative malnutrition during childhood and adolescence, and it is associated with a range of negative functional outcomes, including reduced work capacity and poorer reproductive outcomes [4, 5]. The cut-off point for the definition of stunting used by the ACC/SCN is 145 cm, which is quite conservative. (As is discussed in our companion paper in this issue [6], increased obstetrical risk has been associated with short stature even at heights well above 145 cm). When this cut-off point was used, fewer than 5% of women in sub-Saharan Africa were classified as stunted, compared with more than 15% in Middle America and Asia (excluding China), and about 12% in South America.

The three other anthropometric measures of nutritional status used in the ACC/SCN report are all more indicative of current nutritional status. By these measures, women in sub-Saharan Africa also do fairly well in comparison with women in other regions, but the differences are not so striking as for height. Absolute weight, of course, is highly correlated with height. Using 45 kg as the cut-off point (again quite conservatively), the ACC/SCN found 20% of African women to be underweight. This is about the same percentage as in Middle America and China, more than in South America, but significantly less than in Asia (excluding China), where 45% of women in South-East Asia and a shocking 60% of women in South Asia are underweight, in large part because of stunting. The percentage of women with arm circumferences below 22.5 cm could only be calculated for sub-Saharan Africa, South Asia, and South-East Asia, and these percentages followed very closely those for weight below 45 kg. The relative position of women in sub-Saharan Africa is the worst when BMI, a measure of relative thinness, is considered. When BMI below 18.5 is used as the cut-off point, fewer than 20% of women in Middle America, South America, and China, slightly more than 20% of women in sub-Saharan Africa, and about 40% of women in South and South-East Asia are classified as excessively thin.

It is instructive to compare the regional information on child nutritional status from the Second Report on the World Nutrition Situation with the information on women’s nutritional status (although, unfortunately, the ACC/SCN does not report child nutritional status disaggregated by sex). Anthropometric indicators of child nutrition have been more routinely collected than information on adult nutritional status, so it is possible to estimate regional trends in child nutrition over the past 20 years. It is when trends in child nutrition are examined that the basis for the current concern about the nutritional situation in sub-Saharan Africa becomes clearer. In all other regions of the developing world, there was a marked decline between 1975 and 1990 in the prevalence of underweight pre-school children (defined as the percentage of children below two standard deviations from the mean weight-for-age in the age range zero to five years), ranging from a 50% decline in South America to a 10% decline in South Asia. However, the prevalence of child malnutrition in sub-Saharan Africa appears to have remained essentially unchanged. Because of the continuing rapid rates of population growth in sub-Saharan Africa, the absolute number of undernourished pre-school children increased from 18.5 million in 1975 to 28.2 million in 1990. This means that the present number of undernourished pre-school girls in sub-Saharan Africa is almost as great as the total number of undernourished pre-school children in 1975. It also appears that the relative position of children in sub-Saharan Africa is somewhat less favourable than the relative position of women when compared with other regions of the developing world. Perhaps, because of their smaller size and less mature immune systems, children have been less able than adults to withstand the particularly harsh conditions that have been endured by most sub-Saharan African countries over the last decade.

It would be speculative to try to assess the nutritional situation of women and girls in individual countries, or to compare one part of the region with another, because only aggregate regional estimates of protein-energy malnutrition in sub-Saharan Africa are available from the Second Report on the World Nutrition Situation. Although a substantial amount of research has been carried out on the nutritional situation in sub-Saharan Africa during the post-colonial period, the number, scope, and quality of the studies vary substantially from one country to another, and many otherwise excellent studies (particularly of child malnutrition) do not report sex-disaggregated results. Two approaches have been taken in this paper to begin to disaggregate the extent and diversity of the nutritional problems of females in sub-Saharan Africa.

The first approach is to examine three indirect indicators related to women’s nutritional status that are available for essentially all countries in the region. Table 1 presents the daily per capita energy supply, the percentage of infants with low birthweight, and the maternal mortality rate for all countries in sub-Saharan Africa for which such data could be found. Table 1 and other tables are organized alphabetically by subregion, and then alphabetically by country within each subregion. The four sub-regions - Eastern, Middle, Southern, and Western Africa - and the countries within them follow World Health Organization (WHO) usage [7]. For table 1, two World Bank sources were consulted [8, 9], and where conflicting numbers were encountered, both are presented in table 1. In most cases the numbers were close, but in a few cases they were so different as to make one or both suspect.

Daily per capita energy supply is not specific to individual households, much less to females within those households, but countries with a daily per capita energy availability below 2,100 kcal are usually designated as food insecure and believed to be at risk of having a substantial number of food-deficient households [10]. We also know that in sub-Saharan Africa, women who live in the most food-deficient households are usually the same women who do the most physically demanding work and who give birth to and breastfeed the largest number of infants. Therefore, without the ability to estimate a specific number, it seems safe to assume that in any country with a daily per capita energy supply below 2,100 kcal, there will be a reasonably high prevalence of female malnutrition. Of the 37 countries in table 1 for which kilocalorie estimates of daily per capita energy supply in 1989 were available, 12, or about one-third, fell below 2,100 kcal.

Several studies in sub-Saharan Africa (as well as many studies from other parts of the world) have demonstrated a relationship between women’s nutritional status - both current and past - and the birthweight of their infants [11-13]. Although low birthweight can occur in the absence of maternal malnutrition, and moderately malnourished women can give birth to infants of adequate birthweight, the correlation between poor maternal nutritional status and low birthweight at the aggregate level is sufficiently strong that it is appropriate to use the percentage of low-birthweight infants as an indirect indicator of female nutritional status. In general, we would expect to find a substantial degree of malnutrition among women of reproductive age (both stunting and thinness) in countries reporting a rate of more than 10% low-birthweight infants. Twenty-five of the 37 countries in table 1 for which information was available, or approximately two-thirds, reported more than 10% low-birthweight infants in the mid-1980s.

Maternal mortality rate is also a reasonable indicator of maternal nutritional status, particularly in the absence of adequate, accessible prenatal and childbirth services. Maternal mortality is clearly a major problem in the region; Africa has 20% of the world’s births but 40% of the world’s maternal deaths [14]. Stunting is associated with a greater risk of obstructed labour, and both obstructed labour and anaemia are among the major causes of maternal mortality in sub-Saharan Africa [5]. Therefore, although the maternal mortality rate does not differentiate among the different kinds of nutritional problems that may affect girls and women, a high maternal mortality rate is strongly suggestive of a high prevalence of female malnutrition. Virtually all of the countries in table 1 had maternal mortality rates in 1980 of over 100 maternal deaths per 100,000 live births, and 13 of the 36 countries for which data were available had maternal mortality rates above 500.

Comparisons among countries and even subregions of sub-Saharan Africa based on the data in table 1 must be made quite cautiously because of missing data and some lack of comparability among the data (e.g., maternal mortality rates for some countries are based entirely on hospital data). In addition, there are some inconsistencies in data between the two sources used to compile this table. Nonetheless, with these caveats in mind, the data in table 1 do present some slightly surprising findings when the four subregions are compared. In terms of food availability, table 1 suggests that Eastern Africa and Middle Africa are the two most food-insecure parts of the region. In both subregions, more than half the countries have a daily per capita energy supply below 2,100 kcal, and for most of the remainder of the countries, per capita energy availability is only slightly above the 2,100 kcal level. The food availability situation appears to be distinctly better in Southern and Western Africa.

TABLE 1. Selected health And agricultural indicators related to female nutritional status in sub-Saharan Africa

Country	Daily per capita energy supply, 1989a	% low-birthweight babies, 1985b	Maternal mortality rate per 100,000 live births, 19806
Eastern Africa
Burundi	1,932	14/18	800
Comoros	(89%)	7	460
Ethiopia	1,667	13	360
Kenya	2,163	13/18	170 c
Madagascar	2,158	10	300
Malawi	2,139	10	250
Mauritius	2,887	9/8	99
Mozambique	1,680	15/11	479/300 d
Rwanda	1,971	17	210
Somalia	1,906	-	1,100
Uganda	2,153	10	300/500
United Republic of Tanzania	2,206	4/13	185
Zambia	2,077	14	110
Zimbabwe	2,299	15/6	90
Middle Africa
Angola	1,807	17/21	-
Cameroon	2,217	13	303
Central African Republic	2,036	15	600
Chad	1,743	11	700/1,000
Congo	2,590	12	200
Gabon	2,383	16/8	130
Zaire	1,991	16	800
Southern Africa
Botswana	2,375	8	300/200
Lesotho	2,299	10	370
Namibia	1,946	-	-
South Africa	3,122	12	550 e
Swaziland	(110%)	7	-
Western Africa
Benin	2,305	10	1,680 d
Burkina Faso	2,288	18/11	600
Cape Verde	(112%)	-	107
Côte d’Ivoire	2,577	14/15	-
Gambia	(97%)	-	1,034
Ghana	2,248	17	1,070 d
Guinea	2,132	18
Guinea-Bissau	(105%)	14	400
Liberia	2,382	-	173
Mali	2,314	17/13	-
Mauritania	2,685	10	119/1,100
Niger	2,308	20	420
Nigeria	2,312	25	1,500
Senegal	2,369	10	530 c,d
Sierra Leone	1,799	14	450
Togo	2,214	20	418

Sources: World Bank: World Development Report 1992 [8] and Better Health in Africa [9].

a. Entries in kilocalories are from the 1992 World Development Report. Those printed in bold are below 2,100 kilocalories per person per day, which a recent FAD/WHO document labels as indicative of household food insecurity based on a very low level of average food consumption [10]. For countries with populations under one million, no data were available from the World Development Report, and the estimated daily per capita energy supply in 1985 as a percentage of requirement from Better Health in Africa [9] is given. Although figures vary from country to country according to the age and sex distribution of the population, the daily per capita energy supply needs to be about 2,300 to be equivalent to 100% of average requirements.

b. Where two numbers are given, the first is from the World Development Report [8] and the second from Better Health in Africa [9]. Where only one number is given, the two sources agreed, or only one source had an entry for that indicator and country.

c. Before 1980.

d. Hospital data only.

e. Rural data only.

Unlike daily per capita energy availability, the percentage of infants born with low birthweights and maternal mortality rates are specific to females. Therefore, table 1 appears to suggest that Western and Middle Africa are the two subregions where female malnutrition is the most prevalent, despite overall better food security. A question that may warrant further investigation is whether there are any dietary or behavioural factors in Eastern Africa that contribute to protecting female nutritional status in the presence of extremely low household food availability. Alternatively, it may be that access to health care is better in Eastern and Southern Africa, thus to some extent compensating for the negative effect of food insecurity.

Table 2 shows data that measure the nutritional status of women more directly, using BMI as a measure of chronic energy deficiency. Table 2 also shows BMI data for men from the studies where they were available, but discussion of the gender differences shown in table 2 is reserved for later in this section. Although different cut-off points have been recommended, in general a BMI below 18 or 18.5 is considered excessively thin, and such a person is categorized as suffering from chronic energy deficiency. It should be noted that although 18.5 seems to be an appropriate cut-off in terms of obstetrical risk, a lower cut-off, perhaps as low as 16, is more predictive of increased morbidity risk [1].

Among the countries from Eastern Africa with BMI data available, it is clear that the situation is most severe in Ethiopia, with half the women suffering from chronic energy deficiency. Twelve percent of women in the Zimbabwe study, and probably a similar percentage in the Kenya study, would be considered malnourished. For Middle Africa, data are only available from two studies done in Zaire. Although the data are not presented in terms of percentages below a cut-off, the relatively low range of the mean BMI values (19.7 to 21.7) suggests that the percentage of women suffering from chronic energy deficiency in these Zairian populations would be lower than in Ethiopia, but higher than in Zimbabwe or Kenya. As far as Western Africa is concerned, except for Côte d’Ivoire, where the mean BMI of women is similar to that found in the Kenya study, the BMI data support the conclusion of substantial female malnutrition suggested by the indirect indicators in table 1. The data in table 2 are consistent with the estimated regional average of 21% of women in sub-Saharan Africa who have a BMI below 18.5 [3].

It seems reasonably clear from the information presented in tables 1, 2, and 4 (discussed in more detail in the next section) that the problem of protein-energy deficiency is of considerable magnitude among females in sub-Saharan Africa, with somewhere in the range of 5% to 10% of girls suffering from acute protein-energy malnutrition, and 20% to 40% suffering from chronic protein-energy malnutrition. Among adult women, from 1% to 6% may suffer from severe chronic energy deficiency (chronic energy deficiency based on low BMI), and from 10% to 40% may suffer from mild to moderate chronic energy deficiency. In acute famine situations, of course, the proportion of females suffering from acute protein-energy malnutrition will be much higher.

Obesity

Although inadequate energy intake is certainly the major macronutritional problem among females in sub-Saharan Africa, it is important to assess the prevalence of excess energy intake or obesity as well. Obesity is known to substantially increase the risk of many chronic diseases, and with the decline in the rates of many infectious diseases and increasing life expectancy, a rapid increase in the prevalence of non-communicable diseases can be expected in the near future in sub-Saharan Africa [24]. The prevalence of obesity is a question that has received little attention from researchers concerned with nutrition in sub-Saharan Africa, so relevant data are extremely limited. One of the few studies to examine simultaneously the prevalence of chronic energy deficiency and obesity in the same population groups was a comparative study of adult nutritional status in India, Ethiopia, and Zimbabwe [16]. In the Ethiopian population, there was a high prevalence of chronic energy deficiency (BMI was less than 18.5 in 58% of women and less than 16 in 6%) and essentially no obesity, defined as BMI greater than 25. In contrast, in the Zimbabwean population, 12% of women had a BMI below 18.5 (of whom only 1% were below 16) and 17% were defined as obese, with 2.5% having a BMI over 30. It is clear that a high prevalence of chronic energy deficiency is correlated with a low prevalence of obesity and vice versa, but also that moderate prevalences of both can be found in the same population.

TABLE 2. Body mass index (BMI) of non-pregnant, non-lactating women and of men in selected sub-Saharan African countries

Country	BMI		Comments
	Women	Men
Eastern Africa
Ethiopia [15]	19.5	18.42 a	Significant seasonal variation; lowest BMI in Mar-Apr.
Ethiopia [16]	58% < 18.5 BMI (42% BMI 18.5-24.9)	50% < 18.5 BMI (51% BMI 18.5-24.9)	0.7% of women and no men were classified as obese (BMI ³ 25.0).
Kenya [1]	22.08	-
Tanzania [17]	29.5%< 20 BMI (61.2% BMI 20-25)	-	9.3% of women were classified as obese (BMI ³ 25.0).
Zimbabwe [16]	12% < 18.5 BMI (71% BMI 18.5-24.9)	15% < 18.5 BMI (80% BMI 18.5-24.9)	17.4% of women and 5.6% of men were classified as obese (BMI ³ 25.0).
Middle Africa
Zaire [18]	Lese: 21.7 Efe: 20.2	Lese: 21.6 Efe: 20.2	Significant seasonal variation in weight loss Dec-Jun.
Zaire [19]	Tembo: 19.7 Ntomba: 21.1 Highland: 21.35	-
Western Africa
Benin b [20]	11.5% < 18.0 BMI (67.4% BMI 18.0-23.0)	-	22% of women had BMI >23.0; significant seasonal variation in rural areas; lower BMI in May-Jun.
Côte d’Ivoire [21]	22.50	22.23
Gambia [1]	20.6	-
Ghana [1]	20.38	19.39
Ghana [22]	18.8% < 18.6 BMI (60.6% BMI 18.6-23.8)	40.1% < 19.9 BMI (54.8% BMI 19.9-25.0)	20.6% of women had BMI >23.8; 5% of men had BMI >25.0.
Guinea c	20.52	-	23.5% of women had BMI <18.6; 9.7% had BMI >23.8.
Mali [23]	20.8	20.0	11.9% of women and 12.4% of men were malnourished (BMI <18).

a. BMI of men was significantly lower than that of women.
b. All women in sample were lactating.
c. Personal communication, NB Mock and MK Konde, 1991.

Region	Pregnant women		Non-pregnant women		All women
	%	Number (000s)	%	Number (000s)	%	Number (000s)
Eastern Africa	47	3,380	41	13,540	42	16,920
Middle Africa	54	1,290	43	5,330	45	6,620
Southern Africa	35	380	30	2,500	30	2,880
Western Africa	56	4,170	47	15,120	48	19,290

Source: ref. 7, table 2 (p. 10).

Micronutrient deficiencies

Iron-deficiency, anaemia

Iron-deficiency anaemia is the most common nutritional deficiency in the world, and given that it particularly affects pre-school children and women of reproductive age, it is undoubtedly the most wide spread nutritional problem affecting girls and women in sub-Saharan Africa. It is generally accepted that about half the anaemia worldwide is due to iron deficiency, and there is emerging evidence that low iron stores, even in the absence of anaemia, can have negative functional consequences [3,7]. Therefore, the prevalence of iron-deficiency anaemia can be taken as a minimum estimate of the problems of both anaemia and iron deficiency.

Other important causes of anaemia, in addition to diets that are deficient in iron, folate, or vitamin B12, are haemolysis due to malaria and haemorrhage due to hookworm or schistosomiasis. In many African countries, genetic diseases, such as sickle-cell anaemia, and human immunodeficiency virus (HIV) infection can also lead to severe anaemia.

A publication prepared jointly by the Maternal Health and Safe Motherhood Programme and the Nutrition Programme of WHO gives the most recent estimates of the prevalence of nutritional anaemias in women in the world based on studies carried out since 1970 [7]. Table 3 presents data for the four sub-Saharan African subregions on the number and percentage of women with haemoglobin levels below normal, most of which is attributable to iron deficiency. The cut-offs used by WHO were less than 120 g/L haemoglobin for non-pregnant adult women and less than 110 g/L for pregnant women; almost all studies in the review by WHO included only women of reproductive age.

The relative nutritional situation of women by subregion in terms of nutritional anaemia is quite similar to the situation presented in table 1. Table 3 suggests that although women in Western Africa have the highest prevalence of nutritional anaemia, the prevalences in Western Africa, Middle Africa, and Eastern Africa are quite similar, while women in Southern Africa are definitely less anaemic. The better situation of women in Southern Africa has been attributed by some to the widespread use of iron cooking pots in this region [7].

One disturbing finding of the Second Report on the World Nutrition Situation is the apparent increase in iron deficiency in sub-Saharan Africa and many other regions of the developing world except for the Near East, North Africa, and South America. Although the ACC/SCN cautions that estimates of the trends over time in the prevalence of anaemia should be considered quite tentative, their data suggest that the prevalence of anaemia among non-pregnant adult women of reproductive age in sub-Saharan Africa was around 37% from the mid-1970s to the mid-1980s, and had increased to about 46% by the late 1980s. Given the population increase over this time, an unavoidable conclusion is that the absolute number of anaemic women in sub-Saharan Africa has probably increased quite dramatically in the past decade. Part of the reason for the increase in iron-deficiency anaemia is that the iron density in the diet appears to be decreasing rather than increasing in sub-Saharan Africa and in most other parts of the developing world. Although dietary iron density in sub-Saharan Africa appears relatively good compared with other parts of the developing world (7 to 8 mg per 1,000 kcal), the percentage of dietary iron from animal sources is lower than for any region except South Asia, and the general bioavailability of the dietary iron must be quite low.

Anaemia during pregnancy is widely recognized as one of the major health and nutritional problems among pregnant women in sub-Saharan Africa [5]. Factors that contribute to the high incidence of anaemia among pregnant women in the region include poor dietary practices during pregnancy due to sociocultural food taboos, infection, malabsorption, malaria, and increased foetal demand. A case-control study of 122 pregnant anaemic women in Nigeria [25] found that women were aware that they were at high risk for anaemia, but their traditional preventive practices against anaemia proved ineffective.

Iodine-deficiency disorders

Iodine-deficiency disorders exist in most regions of the world, although usually in pockets, rather than throughout a country. Iodine-deficient environments are those in which iodine, which is normally supplied from soil and water, has been leached from the topsoil by rain, flooding, glaciation, or snow. These environments tend to be either mountainous inland regions or floodplains. Iodine deficiency is less strongly correlated with food insecurity than are protein-energy malnutrition and iron-deficiency anaemia. It is rare to encounter iodine deficiencies in populations living near the sea or where the soil has adequate iodine, regardless of how impoverished or subject to seasonal food shortages they may be.

The main manifestations of iodine deficiency are goitre, impaired mental function, and increased rates of foetal wastage, stillbirths, and infant deaths. Severe mental and neurological impairment, known as cretinism, occurs among infants born to mothers who are seriously iodine deficient.

The extent of iodine-deficiency disorders is usually assessed by the prevalence of goitre in affected populations, although this understates the number of people affected by iodine-deficiency disorders, particularly if those suffering from reversible lethargy or mild mental impairment associated with iodine deficiency are included. The ACC/SCN estimates that the prevalence of goitre in Africa is about 8%. In Africa there are 39 million people with goitre, half a million with overt cretinism, and another 227 million who are estimated to be at risk for iodine-deficiency disorders [3, 26]. The ratio of those at risk for iodine-deficiency disorders to those with goitre is extremely high in Africa, reflecting, in part, the lack of control programmes, and suggesting that iodine-deficiency disorders will continue to be a serious public health problem in this region for many years to come.

Iodine-deficiency disorders are of particular concern among women for two reasons. First, the range of functional consequences of iodine deficiency is broader for women than for men, since it includes severe negative reproductive outcomes for both mothers and infants [26]. In addition to the broader range of functional consequences, the prevalence of goitre appears to be significantly higher among females than among males in virtually all studies with sex-disaggregated data [27]. In one Africa-specific study that reported sex-disaggregated data from Zaire, Thilly et al. [28] found a significantly higher prevalence of goitre among females than males at all ages from 10 years upwards. The prevalence of visible and voluminous goitres in the age range of peak prevalence (20 to 30 years) was almost 50% among females and about 20% among males.

Vitamin A deficiency

Vitamin A deficiency, as defined by eye damage (ranging from reversible night blindness through ulceration of the cornea to permanent scarring and blindness), has been identified as a widespread public health problem in at least 37 countries [3]. Each year it is estimated that between 250,000 and 500,000 pre-school-age children go blind from vitamin A deficiency, and that within months of going blind, two-thirds of these children die [3]. In addition, there is growing evidence that even children who do not necessarily have eye signs may have subclinical vitamin A deficiency that puts them at greater risk for morbidity and mortality from infectious diseases. Although all children older than six months, as well as pregnant and lactating women, are at risk for vitamin A deficiency, the peak prevalence seems to fall in the age range of two to four years [29]. The literature supports the general finding of a higher prevalence of eye damage due to vitamin A deficiency among pre-school-age boys than girls [30]. It is not well established whether adult men are similarly at greater risk compared with adult women, because few studies have been done on vitamin A deficiency among adults. However, in a small number of somewhat older country-specific studies from South Africa, Ethiopia, and Rwanda, higher deficiency rates were found among adult men than adult women [31-33].

In Africa about 7.2% of pre-school-age children (1.3 million) are estimated to have eye damage due to vitamin A deficiency, and another 7.2 million suffer from a mild to moderate deficiency [3, 30]. The proportion of the pre-school-age population affected in Africa is similar to the proportion in most other parts of the developing world. Within the sub-Saharan African region, the areas most affected are Eastern Africa, Southern Africa, and the Sahelian parts of Western Africa. Populations living where red palm oil is produced or distributed, that is, along the coastal parts of Western Africa and in some parts of Central Africa, are reasonably well protected against vitamin A deficiency.

Gender differences in malnutrition in sub-Saharan Africa

Throughout the world, differences between males and females in the prevalence of micronutrient deficiencies appear to be substantially attributable to biological differences between the sexes. The higher prevalence of iron-deficiency anaemia found among adolescent girls and adult women, for example, is due primarily to the increased iron losses associated with menstruation and the increased iron demands of pregnancy and lactation, although this biological risk can be exacerbated by female diets that are lower in animal protein or, in some cases, a higher prevalence of hookworm or malaria among females [34]. Similarly, higher prevalences of iodine-deficiency disorders among adult women and of vitamin A deficiency among pre-school-age boys (and perhaps among older males) are documented by studies carried out in many different cultural settings and appear to be primarily physiological, although the specific mechanisms are less well understood than in the case of iron-deficiency anaemia. In addition, there may be local dietary practices that enhance or reduce the biological gender differences.

In contrast, as far as macronutrient disorders are concerned, there are no underlying physiological reasons to expect differences between males and females in the prevalence of thinness or obesity. Where such a pattern does emerge, behavioural and cultural factors must provide the explanation. Although there are significant differences in the roles and opportunities of males and females in sub-Saharan Africa, no widespread pattern of gender differences in protein-energy malnutrition has emerged from studies to date [35, 36]. On the basis of recent sex-disaggregated Demographic and Health Survey data for children (see table 4), BMI data for adult men and women (see table 2), a secondary analysis of somewhat older height and weight data from Eveleth and Tanner’s Worldwide Variation in Human Growth [37] undertaken by Svedberg [36], and other country-specific studies [see, for example, refs. 22, 38, and 39], it seems clear that in contrast to the situation in South Asia, in sub-Saharan Africa there is no significant pattern of female disadvantage according to anthropometric measures of nutritional status.

In his extensive analysis of gender bias in undernutrition in sub-Saharan Africa, Svedberg actually proposed that the slight anthropometric advantage shown by girls, women, or both in many countries may suggest a historical pattern of preferential treatment of females due to the high value placed on women’s agricultural labour [36]. On the basis of a study of gender biases among the Mukogodo of Kenya, Cronk [40] suggested that favouritism towards daughters occurred as a result of lowered socio-economic status. In a case study in south-central Ethiopia, Vesti [15] found that females scored significantly better than males on weight-for age measurements, but only within the lowest income bracket. However, given that there are also a number of studies in sub-Saharan Africa that report dietary discrimination against females [see, for example, refs. 41-43], any firm conclusion of a nutritionally advantaged position of females in the region seems premature.

One particularly interesting report of gender differences in dietary intake comes from a study of child-feeding practices in Zinder, Niger. Field research conducted by CARE on traditional knowledge and practices related to child care and feeding revealed that in some villages girls were weaned one month later than boys. It was traditionally believed that an excess of breastmilk would make a child stupid, and accordingly boys were weaned earlier “so that they would be intelligent” and have a better chance of success in school [44]. Although this practice may be beneficial to girls’ nutrition in the short run, it is actually motivated by a lower value placed on education for females, which may be detrimental to female health and nutritional status in the longer run. A similar gender difference in breastfeeding patterns was reported in a study of women in Dakar, Senegal, and the surrounding area, where girls were breastfed up to 24 months and boys only to 18 months. However, no link with intelligence was made [45]. It is quite likely that the aggregate finding of little gender difference in anthropometric measures of protein-energy malnutrition in sub-Saharan Africa reflects the cumulative effect of a number of specific behaviours and practices, some of which may favour females and some of which may favour males. In specific settings or during certain seasons, significant gender differences have been reported. (See appendix 1 for further examples).

TABLE 4. Child health and nutrition status indicators by gender for selected sub-Saharan African countries (late 1980s) ^a

Country	Child mortality per 1,000 b		Height-for-age c		Weight-for-height c		Weight-for-age c		% with diarrhoea d		% taken to health facility with diarrhoea
	M	F	M	F	M	F	M	F	M	F	M	F
Eastern Africa
Burundi	101.0	113.8	48.3	47.8	6.2	5.1	37.5	39.0	17.7	17.0	12.8	11.7
Uganda	97.3	86.0	47.3	41.6	1.8	1.9	23.1	23.4	25.4	23.2	13.8	15.8
Zimbabwe	30.2	32.5	29.9	28.0	1.4	1.3	11.3	11.9	20.5	19.0	33.5	33.2
Western Africa
Ghana	78.3	79.4	30.2	29.8	9.0	6.9	30.3	31.1	27.0	26.1	40.8	45.6
Mali	166.0	174.0	23.8	24.9	12.0	9.8	30.0	32.2	35.7	133.0	68.4	68.3
Nigeria	93.7	89.1	43.4	42.7	9.8	8.3	35.8	35.7	19.4	16.4	23.6	26.8
Senegal	131.0	129.7	24.8	20.6	7.6	4.1	22.5	20.6	38.9	36.9	19.4	19.4
Togo	74.9	90.1	32.2	26.9	6.2	4.4	25.0	23.8	29.6	29.2	24.2	26.7

a. Data were kindly provided by Hill of the World sank They are assembled from Demographic and Health survey Reports and are for all sub-Saharan African countries for which data on these indicators were available.

b. Child mortality is usually considered most indicative of child nutritional status.

c. For children 3-36 months old, percentage below 2 SD.

d. Percentage of children under age five with diarrhoea during the two weeks preceding the survey.

Conclusion

As in other parts of the developing world, the two most prevalent nutritional deficiencies among females in sub-Saharan Africa are iron-deficiency anaemia and protein-energy malnutrition. Evidence for other micronutrient deficiencies among girls and women in the region is quite limited, but undoubtedly iodine-deficiency disorders are a major problem in many inland parts of sub-Saharan Africa, and vitamin A deficiency is probably quite prevalent in rural Sahelian communities where there are significant seasonal fluctuations in quantity and quality of the diet.

In comparison with other regions of the world, sub-Saharan African females seem to be nutritionally better off than females in South Asia, but as malnourished as, or more malnourished than, females in most other parts of the developing world. The nutritional situation of females in Western Africa seems to be poorer than in other parts of the region. In contrast with South Asia, there is no consistent pattern of a higher prevalence of protein-energy malnutrition among females than males, despite a generally higher work burden among adult women than among men in sub-Saharan Africa. However, small-scale studies from a few countries have found evidence of discrimination against or disadvantage experienced by females in breastfeeding and dietary patterns, and the lack of attention to gender differences in much of the work that has been done on the nutritional problems of sub-Saharan Africa means that no firm conclusion can be reached about the relative nutritional status of males and females. The companion article [6] explores evidence concerning the determinants and consequences of the nutritional status of girls and women in sub-Saharan Africa.

Acknowledgements

The review on which this and its companion article are based was originally undertaken as part of the work of the Institute of Medicine (IOM) Committee to Study Female Morbidity and Mortality in sub-Saharan Africa, of which the first author was a member. We would like to acknowledge the extremely useful comments and input of the other committee members (Maureen Law [Chair], Uche Amazigo, Judith Fortney, Philip L. Graitcer, Françoise F. Hamers, H. Kristian Heggenhougen, Karungari Kiragu, Walinjom F. T. Muna, Jonathan E. Myers, Benjamin O. Osuntokun, Patience W. Stephens, Judith N. Wasserheit, and Belmont E. O. Williams) and of the IOM staff who worked with the committee (folly F. Harrison, Dana Hotra, Delores Sutton, and most especially, Christopher P. Howson, Project Director).

References

1. Kennedy E, Garcia M. Effects of selected policies and programs on women’s health and nutritional status. Washington, DC: International Food Policy Research Institute, 1993.

2. Leslie J. Women’s lives and women’s health: using social science research to promote better health for women. J Wom Health 1992; 1(4): 307-18.

3. United Nations Administrative Committee on Coordination/Subcommittee on Nutrition. Second report on the world nutrition situation. Vol. I. Global and regional results. Geneva: United Nations Administrative Committee on Coordination/Subcommittee on Nutrition, 1992.

4. Buzina R. Bates CJ, van der Beek J. Brubacher G. Chandra RK, Hallberg L, Heseker J. Mertz W. Pretrazik K, Pollitt E, Pradilla A, Suboticanec K, Sandstend HH, Schalch W. Spurr GB, Westennofer J. Workshop on functional significance of mild-to-moderate malnutrition. Am J Clin Nutr 1989; 50: 172-6.

5. Royston E, Armstrong S. eds. Preventing maternal deaths. Geneva: World Health Organization, 1989.

6. Leslie J. Essama SB, Ciemins E. Female nutritional status across the life-span in sub-Saharan Africa. 2. Causes and consequences. Food Nutr Bull 1997; 18: 44-55.

7. World Health Organization. The prevalence of anaemia in women: a tabulation of available information. 2nd ed. WHO-MCH-MSM/92.2. Geneva: World Health Organization, 1992.

8. World Bank. World development report 1992: development and the environment. Washington, DC: World Bank, 1992.

9. World Bank Africa Technical Department. Better health in Africa. Washington, DC: World Bank, August 1992.

10. Food and Agriculture Organization/World Health Organization. Improving household food security. A theme paper prepared for the International Conference on Nutrition. PREPCOM/ICN/92/INF/6. Rome: Food and Agriculture Organization, 1992.

11. Harrison KA, Rossiter CE, Chong H. Relations between maternal height, fetal birthweight and cephalo-pelvic disproportion suggest that young Nigerian primi-gravidae grow during pregnancy. Br J Obstet Gynaecol 1985(suppl 5): 40-8.

12. Prentice AM, Cole TJ, Foord FA, Lamb WH, White-head RG. Increased birthweight after prenatal dietary supplementation of rural African women. Am J Clin Nutr 1987; 46: 912-25.

13. Neumann C, Bwibo NO, Sigman M. Functional implications of malnutrition: Kenya Project Final Report. Human nutrition collaborative research support program. Los Angeles, Calif, USA: University of California, Los Angeles, School of Public Health, 1992.

14. WHO says maternal mortality figures substantially underestimated. Nation’s Health, March 1996.

15. Vesti SA, Witcover J. Gender differences in levels, fluctuations and determinants of nutritional status: evidence from South Central Ethiopia. In: Kennedy E, Garcia M, eds. Effects of selected policies and programs on women’s health and nutritional status. Washington, DC: International Food Policy Research Institute, 1993: 1-33.

16. Ferro-Luzzi A, Sette S. Franklin M, James WPT. A simplified approach to assessing adult chronic energy deficiency. Eur J Clin Nutr 1992; 46: 173-86.

17. Kavishe FP. Analysis of the nutrition situation and trends in Tanzania during the 1980s. In: Review of nutrition relevant actions in Tanzania. Report for the United Nations ACC/SCN. Geneva: United Nations Administrative Committee on Coordination/Subcommittee on Nutrition, February 1992: 27-50.

18. Bailey RC, Jenike MR, Ellison PT, Bentley GR, Harrigan AM, Peacock NR. The ecology of birth seasonality among agriculturalists in Central Africa. J Biosoc Sci 1992; 24: 393-412.

19. Caraël M. Relations between birth intervals and nutrition in three central Africa populations (Zaire). In: Mosley WH, ed. Nutrition and human reproduction. New York: Plenum Press, 1978: 365-84.

20. Fakambi LK. Factors affecting the nutritional status of mothers. The food and nutrition program of the Ouando Horticulture and Nutrition Center in the People’s Republic of Benin. Washington, DC: International Center for Research on Women, June 1990.

21. Thomas D, Lavy V, Strauss J. Public policy and anthropometric outcomes in Côte d’Ivoire. Living Standards Measurement Study Working Paper No. 89. Washington DC: World Bank, 1992.

22. Alderman H. Nutritional status in Ghana and its determinants. Social dimensions of adjustment in sub-Saharan Africa. Working Paper No. 3. Washington, DC: World Bank, 1990.

23. Dettwyler KA. Nutritional status of adults in rural Mali. Am J Phys Anthropol 1992; 88: 309-21.

24. Feachem RG, Jamison DT, Bos ER. Changing patterns of disease and mortality in sub-Saharan Africa. In: Feachem RG, Jamison DT, eds. Disease and mortality in sub-Saharan Africa. New York: Oxford University Press for the World Bank, 1991: 3-27.

25. Elegbe I, Ojofeitimi EO, Elegbe IA. Traditional treatment of pregnancy and anemia in Nigeria. Trop Doct 1984; 14: 4, 175-7.

26. Hetzel BS. The prevention and control of iodine deficiency disorders. ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 3. Geneva: United Nations Administrative Committee on Coordination/Subcommittee on Nutrition, 1988.

27. Simon PA, Jamison DT, Manning MA. Gender differences in goiter prevalence: a review. Los Angeles, Calif, USA: University of California, Los Angeles, Graduate School of Education, 1990.

28. Thilly CH, Delange F. Ramioul L, Lagasse R. Luvivila K, Ermans AM. Strategy of goiter and cretinism control in Central Africa. Int J Epidemiol 1977; 6: 43-54.

29. Eastman SJ. Vitamin A deficiency and xerophthalmia: recent findings and some programme implications. In: Mandl P-E, ed. Assignment children. New York: UNICEF, 1987.

30. Levin HM, Pollitt E, Galloway R. McGuire J. Micro-nutrient deficiency disorders. In: Jamison DT, Mosley WH, Meashan A, Bobadilla JL, eds. Disease control priorities in developing countries. New York: Oxford University Press for the World Bank, 1993: 421-51.

31. May JM, McLellan DL. The ecology of malnutrition in seven countries of Southern Africa and in Portuguese Guinea. Stud Med Geog 1971; 10: 3-414.

32. May JM, McLellan DL. The ecology of malnutrition in Eastern Africa and four countries of Western Africa. Stud Med Geog 1970; 9: 1-637.

33. May JM, McLellan DL. The ecology of malnutrition in Middle Africa. Stud Med Geog 1965; 8: 5-241.

34. Gillespie S. Kevany J. Mason J. Controlling iron deficiency. ACC/SCN State-of-the-Art Series, Nutrition Policy Discussion Paper No. 9. Geneva: World Health Organization, 1991.

35. Kennedy E, Bentley M. Women’s health and nutrition in sub-Saharan Africa: a review and case study from Kenya. In: Sorkin A, Siralgedin I, eds. Research in human capital and development: nutrition, food policy and development. Greenwich, Conn, USA: JAI Press, 1994: 243-76.

36. Svedberg P. Undernutrition in sub-Saharan Africa: Is there a gender bias? J Dev Stud 1990; 26: 469-86.

37. Eveleth PB, Tanner JM. Worldwide variation in human growth. Cambridge, UK: Cambridge University Press, 1976.

38. Thomas D. Gender differences in household resource allocations. Living Standards Measurement Study Working Paper No. 79. Washington DC: World Bank, 1991.

39. Strauss J. Households, communities, and preschool children’s nutrition outcomes: evidence from rural Côte d’Ivoire. Econ Dev Cult Change 1990; 36: 231-62.

40. Cronk L. Low socioeconomic status and female-biased parental investment: the Mukogodo example. Am Anthropol 1989; 91: 414-29.

41. Caplan P. Perceptions of gender stratification. Africa 1989; 59: 196-208.

42. Zumrawi FY. Local influences and customs on diets in Sudan village community. Ahfad J 1988; 5(2): 27-32.

43. Trueblood LW. Preface to May JM, McLellan DL, eds. The ecology of malnutrition in Eastern Africa and four countries of Western Africa. Stud Med Geog 1970; 9: vii-viii.

44. Swimmer K. Field research on traditional knowledge and practices related to child care and child feeding. Final report. The Zinder Child Health Project. Zinder, Niger: CARE International, 1990.

45. Faladé S. Women of Dakar and the surrounding urban area. In: Paulme D, ed. Women of tropical Africa. Berkeley and Los Angeles, Calif, USA: University of California Press, 1963: 217-29.

46. James WPT, Ferro-Luzzi A, Watenlow JC. Definition of chronic energy deficiency in adults. Eur J Clin Nutr 1988; 42: 969-81.

47. Gebre-Medhin M, Gobezie A. Dietary intake in the third trimester of pregnancy and birthweight of offspring among nonprivileged and privileged women. Am J Clin Nutr 1975; 28: 1322-9.

48. UNICEF. The wellbeing of children. In: Situation analysis of children and women in Kenya. Nairobi, Kenya: Central Bureau of Statistics, Ministry of Finance and Planning, 1984: sect. 4: 1-135.

49. Ferguson A. Women’s health in a marginal area of Kenya. Soc Sci Med 1986; 23: 17-29.

50. UNICEF. Third rural child nutrition survey 1982. Nairobi, Kenya: Central Bureau of Statistics. Ministry of Finance and Planning, 1993.

51. Kulin HE, Bwibo N. Mutie D, Santner SJ. The effect of chronic childhood malnutrition on pubertal growth and development. Am J Clin Nutr 1982; 36: 527-36.

52. Jansen AAJ, Kusin JA, Thiuri B. Lakhani SA, Mannetje W. Anthropometric results in pregnancy and lactation. In: Van Ginneken JK, Muller AS, eds. Maternal and child health in rural Kenya. London and Sydney: Croom Helm, 1984: 143-52.

53. Jansen AAJ, Gemert W, Thiuri B, Lakhani SA. Growth of infants of low and normal birth weight. In: Van Ginneken JK, Muller AS, eds. London and Sydney: Croom Helm 1984: 197-206.

54. Liljestrand J. Maternal morbidity in Mozambique. Uppsala, Sweden: Uppsala University, 1985.

55. Bantje HF. Female stress and birth seasonality in Tanzania. J Biosoc Sci 1988; 20: 195-202.

56. Carswell FL, Hughes AO, Palmer RI, Higginson J, Harland PS, Meakins RH. Nutritional status, globulin titers, and parasitic infections of two populations of Tanzanian school children. Am J Clin Nutr 1981; 34: 1292-9.

57. Kwofie K, Brew-Graves E, Adika GH. Malnutrition and pregnancy wastage in Zambia. Soc Sci Med 1983; 17: 539-43.

58. Tsu VD. Maternal height and age: risk factors for cephalopelvic disproportion in Zimbabwe. Int J Epidemiol 1992; 21: 941-6.

59. Fleisher K, Schuon R. Nutritional status of 6,867 primary school children in the Masvingo District. Cent Afr J Med 1988; 34(8): 185-9.

60. Chandiwana SK, Kambaza A, Mutetwa SM. A study of nutritional status, parasitic infections and haematology in a farmworker community in Zimbabwe. Cent Afr J Med 1984; 30(9): 172-5.

61. May JM, McLellan DL. The ecology of malnutrition in the French speaking countries of West Africa and Madagascar. Stud Med Geog 1968; 8: 5-241.

62. United States Agency for International Development. Cameroon national nutrition survey. Washington, DC: USAID, 1978.

63. Schoept BG. Social structure, women’s status and sex differential nutrition in the Zairian copperbelt. Urban Anthropol 1987; 16: 73-102.

64. Vis HL, Bossuyt M, Hennart P. Caral M. The health of mother and child in rural central Africa. Stud Fam Plann 1975; 6: 437-41.

65. Serdula MK, Akphane JM, Kunene PF, Gama DM, Staehling N. Peck R. Seward J. Sullivan B. Trowbridge FL. Acute and chronic undernutrition in Swaziland. J Trop Pediatr 1987; 33: 35-42.

66. Bleiberg FM, Brun TA, Goiham S. Gouba E. Duration of activities and energy expenditure of female farmers in dry and rainy seasons in Upper-Volta. Br J Nutr 1980; 43: 71-82.

67. Thomas D, Lavy V, Strauss J. Public policy and anthropometric outcomes in Côte d’Ivoire. Living Standards Measurement Study Working Paper No. 89. Washington, DC: World Bank, 1992.

68. Bates CJ, Prentice AM, Prentice A, Paul AA, White-head RG. Seasonal variations in ascorbic acid status and breast milk ascorbic acid levels in rural Gambian women in relation to dietary intake. Trans R Soc Trop Med Hyg 1982; 76: 341-7.

69. Lawrence M, Whitehead RG. Physical activity and total energy expenditure of child-bearing Gambian village women. Eur J Clin Nutr 1988; 42: 145-60.

70. Prentice AM, Whitehead RG, Roberts SB, Paul AA. Long term energy balance in child-bearing Gambian women. Am J Clin Nutr 1981; 34: 2790-99.

71. Tripp RB. Farmers and traders: some economic determinants of nutritional status in northern Ghana. J Trop Pediatr 1981; 27: 15-22.

72. Ofosu-Amaah, Neumann A. Danfa project final report: the Danfa comprehensive rural health and family planning project. Accra, Ghana, and Los Angeles, Calif, USA: University of Ghana Medical School, Korie Bu Hospital, and University of California, Los Angeles, School of Public Health, 1979.

73. Loutan L, Lamotte JM. Seasonal variations in nutrition among a group of nomadic pastoralists in Niger. Lancet 1984; 1(8383): 945-7.

74. Fleming AF. Tropical obstetrics and gynaecology. 1. Anaemia in pregnancy in tropical Africa. Trans R Soc Trop Med Hyg 1989; 83: 441-8.

75. United States Agency for International Development. Sierra Leone national nutrition survey. Washington, DC: USAID, October 1978.

Appendix 1. Selected findings concerning information on female nutritional status in sub-Saharan Africa

Country	Study description		Findings
	Year	Sample
Eastern Africa
Ethiopia [15]	1993	Four rural peasant associations in Sike Awraja, Southern Shewa Province	Females were consistently better off nutritionally than males. Seasonality variations affected both males and females, regardless of age. Household structure, marital status, and household sharing arrangements had a detrimental effect on adult female nutritional status, but had no effect on males. Higher household income levels meant higher nutritional status for women, but not for men. Timing and sources of income affected men’s nutritional status less than women’s, especially seasonally.
Ethiopia [16]	1992	1,087 study population	Mean BMI was 18.5 for women and 18.6 for men. Less than 1% of women and men were obese. 57% of women and 50% of men were classified as having CED. Average energy intake for normal women was 2,067 kcal/d. Average energy intake for women with CED was 1,979 kcal/d.
Ethiopia/Somalia [46]	1988	255 Ethiopian peasant women aged 36.1 ± 12.1 yr; 482 male Ethiopian peasants and Somalian army recruits aged 33.4 ± 13.1 yr	3% of Ethiopian women had grade III CED (BMI <16.0). 24% of 182 Ethiopian and Somalian men had grade III CED. In these same groups, 38% of the women and 63% of the men were classified as having less than a normal BMI of 18.5 (grades I and II CED). Among women particularly, subjects from the third world had a lower proportion of body fat than subjects of equivalent BMI in developed countries.
Ethiopia [32]	1970		Protein-deficiency syndromes were found in 8% of females and 2% of males. Anaemia was found in 19% of females and 6% of males. Enlargement of the thyroid gland was found in 9% of females and 2% of males. Vitamin A deficiency was found in 3% of females and 10% of males. Bitot’s spots were found in 1.8% of girls and 3.3% of boys in Addis Ababa.
Ethiopia [47]	1970	20 non-privileged (income <US$100/mo) and 10 privileged (income >US$650/mo) primigravidae	Non-privileged women consumed a diet deficient in all nutrients except iron and thiamine, with an average daily protein and energy intake less than 60% of FAO/WHO recommendations. The diet of privileged women met the recommendations for all nutrients except calcium (45% of recommendations) and vitamin A (95% of recommendations). Babies of non-privileged women had lower mean birthweights than babies of privileged women. Percentage of dietary energy from cereals was 41.2% for privileged and 65.5% for non-privileged women. Percentage of dietary energy from dairy products, meat, and fish was 22.0% for privileged women and 4.3% for non-privileged women.
Kenya [13]	1984-86	290 rural Embu households	Women progressively lowered their food intake during pregnancy, not only during times of food shortage, but also during normal years. Mean weight gain during pregnancy was only 50% of the recommended weight gain for US or UK women. Mean birth length was below normal (20th per-centile), and 16% of infants were considered intrauterine growth-retarded, indicative of maternal malnutrition.
Kenya [48]	1984		Average height of Kenyan children (girls and boys) was that of the lowest 3% in the reference population. Extent of chronic malnutrition may be partly due to cultural practices, such as serving food first to the father and other men, next to the first son and other children according to age, and last to the mother.
Kenya [49]	1983	524 households in Kibwezi	Women had a higher level of stress accompanied by ill health than men. Women were thinner and shorter than women in other regions of the district. Prevalence of chronic disability was higher among women than among men, especially women of child-bearing age.
Kenya [50]	1982	Survey 1: 1,400 rural children aged 1-4 yr Survey 2: 4,000 urban and rural children aged 6-60 mo	24% of all children were stunted (height-for-age <90% of standard); 3% were wasted (weight-for-height <80% of standard); 7% were severely malnourished (weight-for-age <60% of standard).
Kenya [51]	1982	342 privileged urban children aged 10-13 yr; 347 impoverished rural adolescents aged 10-18 yr	Rural children were nutritionally worse off than urban children by anthropometric measures. Among malnourished rural adolescents, sexual maturity was delayed by 2.1 yr in girls and 3 yr in boys compared with WHO standards.
Kenya [52]	1978-80	1,739 mothers, mean age 26.3 yr	In early pregnancy, mean weight of women was higher than standard; towards the end of pregnancy, it was slightly less. Average weight gain between 3.1 and 7.6 mo was 57.8% of the reference value for women of the same height. Mean upper arm circumference remained below 90% of the standard for non-pregnant women. At all times, mothers of LBW babies had lower values for anthropometric measurements than mothers of NBW babies.
Kenya [53]	1978-80	Children aged 0-2+ yr: 113 LBW girls, 80 LBW boys, 97 NBW girls, 62 NBW boys	Mean weights of NBW girls were persistently less than those of NBW boys. Mean weights of LBW girls were also less than those of LBW boys, but the mean ratios for boys are less than those for girls; towards the end of the first year of life the mean ratios converge. The same applies to length. Curves for weight and length of NBW and LBW children deviate from the standard at 18 wk for girls and 12 wk for boys. Weight curves for LBW children show catch-up growth during the first months of life, more pronounced in girls than in boys. Later both curves run a course below the 80% line. Mean birth length curves for LBW children follow the 90% line for boys and a slightly higher level for girls. Mean weights of both LBW and NBW boys lag slightly behind those of girls at 52 wk. There was a gradual fall in mean weight-for-height with advancing duration of pregnancy.
Malawi [32]	1970		Protein-energy malnutrition was very common among pre-school children, and a striking feature was the general lack of well-being of women, especially mothers (Dr. A. Burgess, WHO, 1964).
Mozambique [54]	1985	1,060 pregnant women (68% rural) from 10 sites	Women from the North were shorter than women from the South (average height, 152 and 159 cm, respectively). Nulliparous women who needed Caesarean section because of cephalopelvic disproportion were, on average, significantly shorter than controls; 36% of women who had Caesarean section and 9% of those who delivered vaginally were <150 cm tall. Maternal height was also significantly correlated with previous perinatal loss. Percentage of women in a site with haemoglobin levels below 90 g/L varied from 5% to 15%; 1% of all women had haemoglobin levels below 70 g/L. Main causes of anaemia were found to be iron deficiency and malaria. Low haematocrit values were associated with small upper arm circumference and low skinfold thickness, indicating that anaemia was correlated with undernutrition. Occasional cases of folic acid deficiency were found among severely anaemic women.
Rwanda [34]	1965		Prevalence of Bitot’s spots per 1,000 was 2.6 for women, 13.3 for men, 3.6 for girls, and 15.4 for boys. Goitre was more frequent among females than among males in Rwanda and Burundi.
Sudan [32]	1970		Kwashiorkor and marasmus were both common, perhaps because of the widespread custom of allowing fathers and older boys to eat first, leaving women and children to fend for themselves.
United Republic of Tanzania [55]	1988	Data obtained from routine delivery records of two towns, populations 17,000 and 40,000, registering 800 and 1,800 deliveries per year, respectively.	Births were markedly seasonal in areas with holendemic malaria, especially among older women, as a result of physical exhaustion due to food shortage, heavy work, and anemia, aggravated by a high rate of infection with malaria.
United Republic of Tanzania [55]	1985		Birthweights were higher in urban areas and higher in years of lower rainfall. Seasonal and yearly variations were in the range of 100-200 g. The magnitude of the variation is comparable to that recorded in famine conditions, so it is probably significant. The variation is affected by differences in the food supply, which can cause variations in birthweight of 50 g. Seasonal variation was primarily due to the coincidence of seasonal food shortage and heavy agricultural work.
United Republic of Tanzania [56]	1976	244 pupils, 51% male, mean age 12.5 yr	43 of 117 girls (37%) had weight-for-age between 70% and 80% of standard, and 31 (26%) had weight-for-age below 70% of standard; 31 of 121 boys (26%) had weight-for-age between 70% and 80% of standard, and 62 (51%) had weight-for-age below 70% of standard.
United Republic of Tanzania [32]	1970		In Kisarawe district, 50% of women and 27% of men had clinical signs of anaemia, which was thought to be a result more of malaria and hookworm infestation than of nutritional deficiency. In the same district, 39% of women, 20% of men, and 24% of children were infested with hookworm.
Zambia [57]	1983	Subjects from recent nutritional status and dietary surveys	Of 572 pregnant and lactating mothers examined, 95.3% had low or deficient serum albumin levels. Of the same group, 90.5% had high serum globulin levels. 12% of examined women were deficient and 10.2% had low levels of haemoglobin. Nearly 2% of the women had deficient retinal or vitamin A levels. 82% of the women had low retinal levels.
Zambia [32]	1970	48 girls, average age 14.5 yr	84.4% had signs of malnutrition, including skin rashes (48.4%), corneal vascularization (46.8%), glossitis (78%), and dental caries (50%). Anthropometric measures, particularly height, showed these girls to be behind European children of the same age groups.
Zimbabwe [58]	1992	203 women with operative deliveries due to cephalopelvic disproportion; 299 women with normal, unassisted deliveries	Maternal height <160 cm was associated with a twofold increased risk for cephalopelvic disproportion.
Zimbabwe/Ethiopia [16]	1992	4,528 individuals; 1,288 adults aged >18 yr	Adults in this population were taller and heavier than Indians. Mean BMI was 22.0 for women and 20.7 for men. BMI for women significantly exceeded that for men. 18% of women and 6% of men had different degrees of obesity (grade I). 11% of women and 14% of men were classified with CED.
Zimbabwe [59]	1983-84	6,867 primary-school children aged 6-17 yr	High prevalence of stunting (15.8%) was found for all children; boys were more affected than girls.
Zimbabwe [60]	1984	200 people of farmworker community; 40% female and 60% male, aged 4-40 yr	Percentage of wasted females was greater than the percentage of wasted males. 16.9% of females and 0.0% of males were severely malnourished; 11.9% of females and 6.6% of males were moderately malnourished; 28.9% of females and 22.0% of males were mildly malnourished.
Zimbabwe [32]	1970		56 of 71 females and 26 of 40 males had goitrous thyroid enlargement. In a survey of 2 villages (Dewe and Tendenguwo), the total village prevalence was 74%. 186 of 243 children had goitre (80% of girls and 59% of boys). In another region (Omay Tribal Trust Land), the highest prevalence of goitre (77%) occurred among adolescent girls; the prevalence for girls aged 6-12 yr was 67.9%. Among 341 patients at Harare Hospital, anaemia was noted in 13.5% of females and 26.5% of males, due to iron deficiency in 8.3% of females and 2.7% of males.
Middle Africa
Cameroon [61]	1968		More than 10% of women and slightly more than 5% of men were underweight.
Cameroon [62]	1978	900 children aged 3-59 mo	No consistent relation between sex and the prevalence of undernutrition was found.
Zaire [63]	1987	Data from various studies in Lemba village, Shaba region, 1975-78	Because of a distinctive form of matrilineal social organization, emphasizing the social value of women, the Lemba of south-eastern Shaba in Zaire maintain greater nutritional equality between women and men than do neighbouring groups with different social organizations and lower status of women.
Zaire [18]	1980-85	118 adult men and 91 adult women, both Efe (foragers) and Lese (farmers) living in tropical rain forest	Mean height of Lese men was 161.8 cm: among Efe (sometimes known as pygmies), mean height was 137.1 cm for women and 144.8 cm for men. Both groups were thin and showed substantial seasonal weight gain and loss (greater among Lese than Efe): mean BMI of Lese women ranged from 21.9 to 19.8, whereas BMI of Lese men showed a broader range from 22.3 to 19.4
Zaire [64]	1975	Several hundred reproductive-age women and their children followed at 4 Maternal and Child Health clinics in Kiva Province	Women suffered from general endemic malnutrition, causing delayed puberty (50% reached menarche at 15-16 yr), low levels of milk production (600 ml/d), and prolonged post-partum amenorrhoea (2 yr after delivery, only 1%-15% of women were menstruating). Infants were breastfed for a long time (60% were still breastfeeding at 24 mo), but supplements to breastmilk were introduced early (average age, 3 mo) because of maternal malnutrition.
Zaire [19]	1974-75	Comparison of 433 women from the equatorial forest and 316 women from the highlands (Kivu region)	Highland women (average height, 153.0 cm) were much shorter than equatorial forest women (159.0 cm). Highland women and Ntomba women of the equatorial forest had similar BMIs, but Tembo women of the equatorial forest had lower BMI (19.7). Seasonal deficiencies of protein and lipids lead to extended post-partum amenorrhoea among rural highland women: BMI of amenorrhoeic lactating women was lower than that of menstruating lactating women.
Southern Africa
Lesotho [31]	1971		On the basis of comparisons of their height with Institute of Nutrition of Central America and Panama (INCAP) standards, girls and boys were similar, with the majority being at least 1 yr growth-retarded (83% of girls and 85.7% of boys). 71.9% of girls and 74.8% of boys were classified as having grade I malnutrition or worse according to weight. Skinfold measurements revealed 66.4% of girls and 63.9% of boys were below Canadian Standards. No important differences between boys and girls of any age group were found for prevalence of goitre, an unusual finding.
South Africa [31]	1971		Of 1,116 children with kwashiorkor, 43 girls and 65 boys had xerophthalmia. Of 45,350 pregnant women, 10.1% had <10 g haemoglobin/100 ml blood, 86% had low iron levels, and 21% had low folic acid levels.
Swaziland [65]	1983-84	4,698 rural children and 772 peri-urban children aged 0-59 mo	Overall rates of chronic undernutrition were 28.7% for girls and 32.0% for boys in the rural sample, and 20.0% for girls and 25.7% for boys in the peri-urban sample. Rates of underweight children did not consistently differ by age in either sample. Overall, Swazi children appear slightly better off nutritionally than children in other African countries.
Western Africa
Burkina Faso [66]	1980	15 women aged 18-47 yr	Triceps skinfold values were more than 60% below standard value; other anthropometric measurements were normal.
Côte d’Ivoire [39]	1986	More than 500 rural children aged 6 yr or younger from national probability sample	10.5% of children were below 90% height-for-age, and 4.4% were below 80% weight-for-age. No significant gender differences in anthropometric measurements were found. Percentage of children with low weight-for-age was highest in the savanna (15%) and lowest in the rural south-eastern region (7%).
Côte d’Ivoire [67]	1987-88	1,678 males and 2,032 females	No significant difference was found between BMI of females (22.5) and males (22.2). Data suggest that women’s nutritional status is more likely than men’s to be substantially influenced by increases or decreases in household income and per capita expenditure.
Gambia [68]	1989	60 healthy adolescents aged 12-17 yr, and 60 elderly people aged 57-69 yr	Before supplementation, elderly women were more deficient in riboflavin than elderly men or adolescents; there were no differences between male and female adolescents in the prevalence of riboflavin deficiency. Riboflavin supplements were given for 5 wk during the rainy season when indicators of riboflavin deficiency increase (and mean weights decrease). Riboflavin status improved progressively and reached normal values for both age groups and sexes.
Gambia [12]	1987	197 supplemented and 182 control rural women	Before intervention, women were in positive energy balance during the dry harvest season, with pregnancy weight gain >1,200 g/mo. In the wet season, women were in negative energy balance, with pregnancy weight gain <500 g/mo. Birthweight was correlated with women’s energy balance and averaged 2,944 and 2,808 g in the dry and wet seasons, respectively. Supplementation was ineffective during the dry season but highly effective during the wet season. Girl babies were on average 189 g lighter than boy babies. Girls had a shorter mean gestation time than boys (37.8 vs 38.3 wk).
Gambia [69]	1982-85	32 pregnant women aged 20-35 yr (primiparous women excluded)	Levels of total energy expenditure ranged from a minimum of 2,300 kcal/d (1.7 x BMR) in Jan-Mar to a maximum of 2,700 kcal/d (2 x BMR) during the agricultural season (Jul-Oct). Reduction in physical activity by pregnant and early-lactating women reduced total energy expenditure by 140 ± 18 kcal/d (0.59 ± 0.08 MJ/d) between 28 wk of gestation and 4 wk post-partum.
Gambia [70]	1976-80	All pregnant women in Keneba	Pre-supplemented dietary energy intake of pregnant women varied from an average of only 1,480 kcal/d in the dry season to a minimum of 1,300 kcal/d in the wet season. In the dry season, women were in positive energy balance (satisfactory weight gain and deposition of subcutaneous fat). In the wet season, women were in marked negative energy balance because of a reduction in energy intake and high energy expenditure. Maternal protein intakes were not grossly deficient.
Gambia [70]	1978-79	196 women of child-bearing age	Levels of dietary energy intake were low; during the optimum dry season months, they were only 62% and 64% of the international recommended intake for pregnant and lactating women, respectively. Average energy intakes during the dry and wet seasons, respectively, were 1,483 and 1,417 kcal/d during pregnancy, 1,773 and 1,474 kcal/d during the 1st trimester of lactation, and 1,662 and 1,413 kcal/d during subsequent trimesters of lactation. Pregnant women gained 1.4 kg/mo body weight in the dry season and lost weight in the wet season. Lactating women gained weight in the dry season and lost weight in the wet season. Non-pregnant women lost 1.0 kg/mo in the wet season. Maternal nutritional status did not deteriorate with increasing parity. Wet season energy intakes were clearly inadequate. No maternal depletion in iron, haemoglobin, riboflavin, or vitamins A and C was noted.
Ghana [22]	1990