Setting priorities to solve the global nutrition crisis

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 disabilities?

First, we need to know what is causing the most nutrition-related deaths. This gives us the nutrition issues where immediate action can have the greatest impact on human health. Second, we need to identify the largest populations at greatest risk of nutrition-related death, by age and gender. This tells us which populations to target. And third, we need a  list of the countries where nutrition-related deaths are concentrated. This tells us which governments and non-state actors need to be fully engaged.

This information can help us to prioritize the right issues, populations, and actors so that investments have the greatest possible impact on the global nutrition crisis and the achievement of the Sustainable Development Goals (SDGs).

What causes the most nutrition-related deaths?

Ten risks and direct causes are responsible for the majority of nutrition-related deaths according to the Global Burden of Disease (GBD). Specifically, in 2019, the GBD estimated that dietary risks contributed to 7.9 million deaths, the risks of maternal and child malnutrition contributed to 2.9 million deaths, and nutritional deficiencies directly caused 252,000 deaths.

Among dietary risks, diets high in sodium, low in whole grains, legumes, and fruits, and high in red meat contributed to the most deaths. Low birth weight, short gestation (preterm birth), child wasting, underweight, and stunting contributed to the most child and maternal malnutrition-related deaths. The overwhelming majority of deaths from nutritional deficiencies were caused by protein-energy malnutrition.

Diet-related deaths have risen sharply compared to deaths from child and maternal malnutrition and nutritional deficiencies. Between 1990 and 2019, diet-related deaths rose by a massive 47%, compared to declines of 60% for child and maternal malnutrition-related deaths and 67% for deaths caused by nutritional deficiencies.

The steepest declines in child and maternal nutrition-related deaths were from vitamin A deficiency (-89%), zinc deficiency (-84%), child stunting (-80%), discontinued breastfeeding (-76%), and child underweight (-76%).

Who is vulnerable to nutrition-related deaths?

The vast majority (92%) of the 7.9 million diet-related deaths occur among adults aged over 50. In contrast, the majority (97%) of the 2.9 million child and malnutrition-related deaths occur among children under five. Deaths from nutritional deficiencies are more evenly spread across the life-cycle, with 39% occurring among children under five and 50% among adults over 50.

Males make up 57% of diet-related deaths and 55% of child and maternal malnutrition-related deaths. In contrast, females make up 55% of deaths from nutritional deficiencies, due to the larger numbers of young girls and elderly women who die from protein-energy malnutrition. In fact, 73% of deaths from nutritional deficiencies are concentrated among women and children.

Twice as many men as women die from causes related to diets high in red meat, processed meat, and sugar-sweetened beverages, and low in whole grains. More males than females also die from short gestation, low birth weight, child stunting, sub-optimal breastfeeding, zinc deficiency, and vitamin A deficiency.

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 42,000 women, iron deficiency is a major cause of Disability Adjusted Life Years (DALYs)  for women, causing 20,000,000 DALYs in 2019.

Where are the most nutrition-related deaths?

The majority of nutrition-related deaths occur in a subset of ten countries with China, India, Pakistan, Nigeria, the USA, Russia, Indonesia, Ukraine, Bangladesh, and Brazil accounting for two-thirds of all deaths.

Across all categories, China (2 million), India (1.8 million), Pakistan (485,000), Nigeria (480,000), the USA (440,000), Russia (420,000), Indonesia (370,000), Ukraine (200,000), Bangladesh (195,000), and Brazil (190,000) have the most nutrition-related deaths.

Countries from almost every region of the world are on this list indicating the wide spread of nutrition-related deaths. However, most diet-related deaths are in middle and high-income countries while most child and malnutrition-related deaths and deaths from nutritional deficiencies are in South Asia and Sub-Saharan Africa, due to the heavy burdens in India, Pakistan, Nigeria, and other countries.

It is important to note that five countries are struggling with high numbers of nutrition-related deaths across all three categories – dietary risks, child and maternal malnutrition risks, and deaths from nutritional deficiencies – including India, China, Indonesia, Pakistan, and Bangladesh, which is a reflection of the double-burden of malnutrition in Asia.

What now?

The critical first step in reversing the global nutrition crisis is setting the right priorities. If governments, companies, and civil society actors can agree that action on the following nutrition issues in the highlighted populations and countries will have the greatest impact on reducing nutrition-related deaths and disabilities, the world will be well-positioned to tackle the crisis.

The GBD analysis suggests that prioritizing the following five nutrition issues in the highlighted populations has the greatest potential to prevent nutrition-related deaths (in order of impact):

(1) Poor Diet

Efforts to change diets should focus on sodium reduction and increases in whole grains, nuts and seeds, and vegetables and fruits in the diets of men and women over aged 50, with a special focus on older populations in China, India, Russia, USA, and Indonesia. The large gender gap in diet-related risks underscores the need for special efforts to improve men’s diets in these countries.

(2) Low Birth Weight/Short Gestation

Efforts to reduce the population of babies born with low birth weight and/or preterm should focus on young women both before and during pregnancy in India, Nigeria, Pakistan, Ethiopia, and Bangladesh. There should also be a massive effort to improve the diets of babies born with low birth weight and/or preterm in these populations, especially in the first months of life.

(3) Child Wasting

Efforts to prevent, diagnose, and treat child wasting should target children under five in India, Nigeria, Ethiopia, Pakistan, and the Democratic Republic of Congo for maximum impact.

(4) Protein-Energy Malnutrition

Unlike diet and child and maternal malnutrition which raise the risk of death, nutritional deficiencies are still a direct cause of death for an estimated 252,000 people. This is unacceptable. Efforts to eliminate deaths from protein-energy malnutrition should target women aged 15 to 49 and children under five in Nigeria, India, the Democratic Republic of Congo, Ethiopia, Madagascar, Mali, Tanzania, Chad, Angola, and Burkina Faso.

(5) Iron Deficiency

As a leading cause of disability for women of workforce age, efforts to reduce iron deficiency anemia should focus on women aged 15 to 49 and children under five in Nigeria, India, Democratic Republic of Congo, Ethiopia, Madagascar, Mali, Tanzania, Chad, Angola, and Burkina Faso, Pakistan, Indonesia, Bangladesh, and Afghanistan.

Aligning the actions of the global health agencies responsible for nutrition and the donors who support their work with these nutrition priorities in these populations and countries, is our best bet at reducing nutrition-related deaths in the world.

Updated September 2021