Nutrition and COVID-19: Malnutrition is a threat-multiplier

As the authors of the 2020 Global Nutrition Report have stated, “Malnutrition is a threat-multiplier… If no action is taken, the effects of the current COVID-19 pandemic will only make it harder for vulnerable populations to protect themselves against malnutrition.”

The report shows that global and national nutrition patterns hide significant inequalities within countries, with vulnerable groups most affected. How did we get here and what can we do to prevent further deepening of inequalities in nutrition outcomes?

How does the COVID-19 pandemic hurt the most vulnerable?

We know that malnutrition increases the chances of individuals getting ill, staying ill, and dying. It weakens the immune system, increasing the body’s susceptibility to infections and setting in motion a vicious cycle. And just as those experiencing malnutrition and diet-related diseases face worse symptoms from COVID-19, this cycle of malnutrition, infection and death is exacerbated by the present pandemic.

When families face grave challenges in the forms of food price hikes, unemployment, restricted mobility and disruption to health and social services – regardless of whether they are directly affected by the virus – their nutritional intake, and therefore health, will be harmed if urgent action is not taken to address the barriers they face in accessing healthy food.

We learned many lessons from the 2008 global food price crisis, which pushed an estimated 130 to 155 million people into poverty. Studies in Bangladesh, Cambodia and Mauritania assessing the impact of the 2008 crisis suggested increases in acute malnutrition to the order of 50% among children in poverty. They also found evidence of a significant rise in stunting among children living in both urban and rural environments.

The effects of early stunting have life-long consequences not only for the individual, but for national economies as well. A child malnourished in the first 1,000 days of life has fewer neural connections in their brain. This damage is irreversible, and these children are more likely to drop out of school, and even when they are in school, they are less able to learn. How will countries compete in the growing digital global economy if much of their population is malnourished?

Source: 2020 Global Nutrition Report.

Disruption to already inequitable health and nutrition services

Poor and vulnerable populations are highly dependent on public services, particularly health and education. In the immediate term, disruption to health services can have devastating impacts. As a recent Lancet study notes, even modest disruptions in health services, with hypothetical reductions in coverage of 15% to 45% for six months, would result in a projected 10% to 45% increase in deaths of children aged under 5 every month. Within this scenario, it follows that that there would also be an 8% to 39% increase in maternal deaths every month, with increases in child wasting being the largest contributor to these estimated deaths across the 118 countries in the study.

The 2020 Global Nutrition Report states that the distribution of nutrition professionals is not equitable, even before the potential impact of the pandemic is taken into consideration: the global median is 2.3 nutrition professionals per 100,000 people, while in the Africa region the median is 0.9, with some countries having none. And disruptions to already inequitable health and nutrition services will be further compounded by the social and economic effects of COVID-19, which will likely further disadvantage the most vulnerable.

Increased vulnerability from micronutrient deficiencies and pre-existing conditions

Micronutrient deficiencies existed before COVID-19 as a form of ‘hidden hunger’, but the implications of such deficiencies have been brought to the fore in the context of the current pandemic. Iron, iodine, folate, vitamin A, and zinc deficiencies are the most widespread, with over 2 billion people affected worldwide. These deficiencies are common contributors to poor growth, intellectual impairments, perinatal complications and increased risk of morbidity and mortality. Vitamin D may play a special role in reducing the risk of respiratory tract infections, with a potential for lessening the effect of COVID-19 –although the evidence is not yet conclusive.

Emerging evidence also suggests that people with pre-existing conditions such as obesity, heart disease, and diabetes suffer more serious consequences of COVID-19. Some studies also indicate that that severely obese adults, including those aged under 60, develop more severe illness from COVID-19.

A recent World Bank study on the health and economic consequences of obesity revealed that of the 2 billion overweight or obese individuals worldwide, more than 70% live in low- and middle-income countries. Rapidly changing food systems in these countries allow cheap ultra-processed foods to reach the poor even in rural areas. This can lead to obesity as well as higher rates of child stunting. For example, a study in Nepal found lower height-for-age among high junk food consumers. Drawing on successful examples, such as in Chile and Mexico, the 2020 report calls on governments to act through taxes on unhealthy foods and subsidies for healthier foods, as well as labelling and regulations on marketing of processed foods.

With the economic shocks of COVID-19 already being felt, there is growing concern that poor households may be compelled to eat cheaper, less nutritious food that is more easily available. This would perpetuate unequal nutrition outcomes and further increase vulnerability to stunting, obesity and associated non-communicable diseases, which increase the severity of COVID-19 symptoms. The Global Nutrition Report rightly points out that poor diets are not simply a matter of personal food choices, and that we need to act decisively to change toxic food environments.

How can we support the most vulnerable in our response to COVID-19?

We propose five key areas for action across sectors to address nutrition as part of the global COVID-19 response, to lessen the impact of the current crisis and build resilience against future shocks:

1. Continue to provide critical community-based nutrition services using innovative/digital delivery systems for basic services such as promotion of breastfeeding, micronutrient supplementation, and basic primary health care including immunisations.
2. In partnership with the agriculture community, increase access to healthy and diverse food. This could include: a) National policies to dissuade trade bans on food supplies, especially for staple foods; b) Strengthening local supply chains for vegetables, fruit and other perishable foods that are subject to waste, especially in the context of lockdowns; and c) Putting in place taxation and marketing regulations on unhealthy foods such as sugar sweetened beverages and junk foods that promote obesity. This would not only prevent malnutrition but will also help provide fiscal space in developing countries at a time when budgets are severely constrained.
3. Ensure that emergency food distribution and safety net programs (including school meals) provide foods fortified with vitamins and minerals.
4. Scale up cash transfer programs, using nutritional vulnerabilities as beneficiary targeting criteria and provide adequate nutrition, health and hygiene advice using innovative solutions such as digital payments and social media messaging.
5. Roll out national communication campaigns on COVID-19, reiterating the need for social distancing while continuing to safely breastfeed infants, promoting handwashing, and emphasising the need for healthy diets, basic nutrition services such as vitamin A supplementation and immunisation.

The time to act is now, or else the effects of COVID-19 on malnutrition will be felt for generations to come. The World Bank Group is working to support countries on all these fronts, and we invite our partners to join us.

*The views and opinions expressed in this article are those of the authors alone and do not represent the official position of the Global Nutrition Report or associated individuals, institutions and organisations, unless explicitly stated.

Image credit: Sambrian Mbaabu / World Bank