So we have a nutrition crisis that is killing people in every country. Now what?

This is the first of a three part series with an audacious goal – to lay out a set of global priorities, investments, and organizations with the greatest capacity to reduce nutrition-related deaths and accelerate achievement of the Sustainable Development Goals (SDGs). The analysis is based on data from the Global Burden of Disease (GBD). This is Part I.

Part I: Setting Priorities

Bravo to the EAT-Lancet Commission for catapulting the global nutrition crisis to center stage as one of a handful of our most critical global challenges.

The Commission’s work crests a wave that has been building since the first Nutrition for Growth Summit in 2013. In the years since there have been four Global Nutrition Reports, 194 governments have adopted the most ambitious set of nutrition-related national goals, and the UN General Assembly has proclaimed 2016 to 2025, the “Decade of Action on Nutrition”.

Over the same period, there have been a plethora of nutrition initiatives, including the Scaling Up Nutrition (SUN) movement and business network, the Power of Nutrition Fund, and Food Reform for Sustainability and Health (FReSH), to name a few. A leading business alliance (USCIB) and NGO (GAIN) have even joined forces to produce “Principles of Engagement” to encourage the public and private sectors to work together to address one of the greatest barriers to progress – the reticence of governments, businesses, UN agencies, and NGOs to work with, rather than against, each other on nutrition.

But what now? How to take all of this activity and turn it into real action that reduces nutrition-related deaths and disability?

Here is an answer in three exhibits:

Exhibit A uses GBD data to reveal the top 10 causes of nutrition-related deaths in the world. It also shows which causes are rising in influence and which are declining. This gives us the nutrition issues where immediate action can have the greatest impact on human health.

Exhibit B identifies the largest populations at greatest risk of nutrition-related death, by age and gender. This tells us which populations to target.

Exhibit C lists the countries where nutrition-related deaths are concentrated. This tells us which governments and non-state actors need to be fully engaged.

Together, these three exhibits help us to prioritize issues, populations, and actors so that investments have the greatest possible impact on the global nutrition crisis and the achievement of the SDGs.

Exhibit A: What causes nutrition-related deaths?

Nutrition-related deaths are divided into three categories by the GBD: (1) diet, (2) maternal and child malnutrition, and (3) nutritional deficiencies. The first two are classified as “risks” of death, while the last is a direct “cause” of death. In 2017, the GBD estimated that dietary risks contributed to 10.9 million deaths, maternal and child malnutrition to 3.2 million deaths, and nutritional deficiencies directly caused 270,000 deaths.

Among dietary risks, diets high in sodium, and low in whole grains, fruit, nuts/seeds, and vegetables caused the most deaths, while short gestation (preterm birth), low birth weight, child wasting, underweight, and Vitamin A deficiency caused the most maternal and child malnutrition-related deaths. The overwhelming majority of deaths from nutritional deficiencies were caused by protein-energy malnutrition (Chart A1).

Diet-related deaths have also risen sharply compared to deaths from child and maternal malnutrition and nutritional deficiencies. Between 1990 and 2017, diet-related deaths rose by a massive 42%, compared to declines of 57% for maternal and child malnutrition-related deaths and 52% for deaths caused by nutritional deficiencies (Chart A2).

The sharpest increases in nutrition-related deaths were from diets high in red meat (93%), low in milk (87%), low in calcium (78%), low in fiber (47%), and low in nuts/seeds (46%), while the steepest declines were for zinc deficiency (-80%), child stunting (-78%), Vitamin A deficiency (-76%), child underweight (-72%), and suboptimal breastfeeding (-69%) (Chart A3).

Exhibit B: Which populations are especially vulnerable to nutrition-related deaths?

The vast majority (91%) of the 10.9 million diet-related deaths occur among adults aged over 50 years. In contrast, the vast majority (95%) of the 3.2 million child and malnutrition-related deaths occur among children under five years. Deaths from nutritional deficiencies are more evenly spread across the life-cycle, with 52% occurring among children under 14 years and 34% among adults aged over 50 years (Chart B1).

Males make up 56% of risk-related nutrition deaths caused by diet and 54% of deaths caused by maternal and child malnutrition. In contrast, females make up 54% of deaths from nutritional deficiencies, largely due to the larger numbers of young girls and elderly women who die from protein-energy malnutrition. In fact, 80% of deaths from nutritional deficiencies are concentrated among women and children (Chart B2).

The largest gender gaps in diet-related deaths occur in the risk categories of “high red meat diet” (226%), “high processed meat diet” (98%), “high sugar drink diet” (94%), “low fruit diet” (46%), and “high sodium diet” (39%). This means that twice as many men as women die from high red meat, high processed meat, and high sugar drink diets (Chart B3).

More males than females also die from short gestation (34%), low birth weight (28%), child stunting (15%), suboptimal breastfeeding (13%), zinc deficiency (10%), and Vitamin A deficiency (12%). However, gender gaps are very small for child wasting and child underweight. The one area where the burden of nutrition-related deaths falls exclusively on females is iron deficiency. In addition to contributing to the deaths of an estimated 60,000 women, iron deficiency is the third leading cause of Disability Adjusted Life Years (DALYs) – a measure of death and disability – for women aged 15 to 49. Only the risks of unsafe sex and high body-mass index cause more DALYs for this population, according to the GBD.

Exhibit C: Which countries have the most nutrition-related deaths?

The vast majority (80%) of the 10.9 million diet-related deaths occur in 20 countries, with China, India, Russia, the USA, and Indonesia accounting for more than half of all deaths (Chart C1).

Countries from every region but Sub-Saharan Africa are on this list indicating the wide spread of diet-related deaths across most regions. In contrast, Sub-Saharan African countries dominate child and malnutrition-related deaths and deaths from nutritional deficiencies due to the heavy burdens in Nigeria, Ethiopia, the Democratic Republic of Congo, Tanzania, Chad, Madagascar, and Mali (Charts C2 and C3).

It is important to note that five countries appear on all three lists, including India, China, Indonesia, Pakistan, and Bangladesh, which is a reflection of the double-burden of malnutrition in Asia. Across all categories of nutrition-related deaths, China (3.2 million), India (2.4 million), Nigeria (949,000), Russia (550,000), Pakistan (518,000), the USA (508,000), Indonesia (477,000), Bangladesh (280,000), Ukraine (259,000), Brazil (214,000) have the most nutrition-related deaths.

What now?

Together these three exhibits shine a light onto the critical first step in reversing the global nutrition crisis – setting the right priorities. If governments, companies, and civil society actors can agree that action on the following nutrition issues, populations, and countries will have the greatest impact on reducing nutrition-related deaths and disability, the world will be on the right track.

The GBD analysis suggests that prioritizing the following five nutrition issues has the greatest potential to prevent nutrition-related deaths, in order of impact, (1) poor diet, (2), low birth weight, (3) child wasting, (4) protein-energy malnutrition, and (5) iron deficiency. It suggests that efforts to change diets should focus on sodium reduction and increases in whole grains, nuts and seeds, vegetables and fruits in the diets of men and women over aged 50, with a special focus on China, India, Russia, USA, Indonesia, Pakistan, Ukraine, Brazil, Japan, and Bangladesh. The large gender gap in diet-related risks supports special efforts to change men’s diets.

Efforts to reduce the population of babies born with low birth weight should focus on populations of young women both before and during pregnancy in India, Nigeria, Pakistan, Ethiopia, Bangladesh, DRC, China, Indonesia, Tanzania, and Afghanistan. There could also be a massive effort to improve the diets of low birth weight babies in these populations. The child wasting effort would target children under five India, Nigeria, Ethiopia, Pakistan, DRC, Chad, Madagascar, Mali, Indonesia, and Burkina Faso.

Efforts to reduce deaths from protein-energy malnutrition would target women aged 15 to 49 and children under five in Nigeria, India, DRC, Ethiopia, Madagascar, Mali, Tanzania, Chad, Angola, and Burkina Faso, while the effort to reduce iron deficiency would focus in on the same populations with the addition of Pakistan, Indonesia, Bangladesh, and Afghanistan.

These priority issues, populations, and actors are summarized in Figure A, together with specific performance targets to show how progress could be measured each year in the countdown to 2030.

Part II will describe in some detail the public-private partnerships that could drive progress to these five goals in the priority countries.