The burden of malnutrition

Christine Hancock, Co-founder of C3 Collaborating for Health, and C3 Associate and nutritionist Nathalie Vauterin, explore how poverty, dietary behaviours, and food systems impact malnutrition

Poor diet and being overweight or living with obesity increases the likelihood of developing cancer, diabetes, cardiovascular disease and poor oral health, in addition to impacting negatively upon an individual’s mental health.1

In the UK 63% of the adult population are overweight, and 27% live with obesity.2 Globally, 1.9 billion adults are overweight or obese, in contrast to 462 million underweight adults.

What is malnutrition?

The two main risk factors for global disease burden are maternal and child malnutrition – as measured by disability adjusted life years (DALYs) – a measure of overall disease burden expressed as a number of years lost due to ill health, disability or premature death.3

The term malnutrition encompasses several contrasting and opposite states that include: undernutrition (wasting, stunting, being underweight); inadequate intake of vitamins or minerals; and being overweight or living with obesity. It is low- and middle-income countries that suffer the highest rates of malnutrition on a global scale – and where rates of childhood overweight and obesity are drastically and rapidly rising.

Malnutrition and poverty – a viscous cycle

In wealthier countries, non-communicable diseases (NCDs) such as cardiovascular disease, type 2 diabetes and cancers, disproportionately affect vulnerable and disadvantaged groups4 – and it is universally acknowledged that poverty amplifies the risk of (and risks from) malnutrition.

The relationship between poverty and malnutrition is complex and involves multiple systems at play but fundamentally, malnutrition increases healthcare costs, reduces productivity, and slows economic growth – and ultimately perpetuates a cycle of poverty and ill-health.5

Furthermore, when considering health inequalities, the evidence is overwhelmingly clear that obesity or malnutrition, is a risk factor for severe COVID-19 infection and death.

A report from the Food Policy Research Institute published in March 2021 evidenced that death rates from COVID-19 have been ten-times higher in countries where more than half of the population are living with obesity.6 Indeed, tthe pandemic has laid bare food insecurity and inequalities among different world regions, rural and urban communities, rich and poor populations, and disadvantaged groups.

NCD prevention

The evidence is strongly in favour of following a healthy diet and performing physical activity to prevent developing NCDs. A multitude of randomised controlled clinical trials have evidenced that healthy dietary behaviours and physical activity are positively associated with a reduced risk and incidence of chronic long-term conditions such as cardiovascular disease, type 2 diabetes, metabolic syndrome, neurodegenerative disorders, and cancers.7

Therefore, the combination of regular physical activity and a balanced diet has a central preventive role in reducing the incidence of NCDs and subsequently reducing costs to health services – and ultimately decreasing the burden of preventable conditions on health systems globally. The Mediterranean diet – which includes whole cereals, legumes, vegetables, fruits, nuts, and olive oil, with lesser consumption of dairy, meat, and poultry – is perhaps the most frequently endorsed and recommended diet within the literature.

Dietary behaviours & food systems

The last 50 years has seen radical changes in food systems on a global scale, which has contributed to significant changes to diet, malnutrition, and the development of NCDs.

Modern and more efficient food production methods have enabled a prolific increase in the availability of cheap, high-calorie foods, which has resulted in an imbalance between healthy foods such as fresh fruits, vegetables, legumes, pulses, and nuts, and unhealthy foods that are high in salt, sugars, saturated fats, and trans fats.

The Global Burden of Disease Study 2017 estimated that in the adult population in 195 different countries, 22 per cent of total deaths and 15 per cent of DALYs are attributable to dietary risks including: the low-intake of wholegrain, fruits, nuts, vegetables, and omega-3 fatty acids; and the excessive intake of sodium.8 Globally consumption of sugar-sweetened beverages and processed and ultra-processed foods (UPFs) has increased dramatically.9 This rise in dietary consumption has negatively influenced the nutritional quality of foods that are available, affordable, and acceptable to consumers and as such present challenges to the prevention and control of NCDs as well as to undernutrition.10 And to compound matters, more than a quarter of the world’s population are now insufficiently physically active.11

Unsurprisingly, the impact of unhealthy dietary behaviours on health services and health systems globally is enormous. The impact of preventable ill health on the population threatens the long-term sustainability of the NHS in the UK. Unless urgent action is taken, it is estimated that by 2050 overweight and obesity will cost the UK’s NHS £9.7bn per year, with a societal cost of £49.9bn per year.12

Therefore, it seems more necessary than ever to address diet (and other risk factors such as physical inactivity, alcohol, and tobacco use), and crucially, to enable the whole of society to make healthy choices by making these choices easier, accessible and available to all.

Food systems must be transformed in a way to make affordable, sustainable, nutritious, and safe diets available for all. As Sir Michael Marmot and Ruth Bell stipulated “The United Nations Decade of Action on Nutrition, along with the 2030 Sustainable Development Agenda and Goals, are a once-in-a-lifetime opportunity to simultaneously and cost effectively improve diets, eliminate malnutrition, reduce death and disability from NCDs, and promote sustainable development”.13

C3 is partner in a European project aiming to reduce obesity and unemployment in disadvantaged areas in the North of France and South of England via an EU-funded project ASPIRE (Adding to Social capital and individual Potential In disadvantaged Regions).14 C3’s role in this multi-partner project is to engage with communities in disadvantaged neighbourhood often where the concentration of fast-food outlets is highest to support them in making healthier choices. C3 uses an innovative, evidence-based approach, CHESSTM, that shifts decision-making to local communities by engaging them as ‘citizen scientists’ in an investigation about their health and the built environment (e.g., the shops, restaurants and parks in their neighbourhood).15

The ASPIRE project offers communities opportunities to get involved in their local food systems by providing skills training and capacity building in  growing, selling and cooking their own food. Through multi-sector collaboration and using a whole system approach, C3 works with communities to make it easier for everyone to make healthier choices, which we know is especially difficult for those living in disadvantaged communities.

1. Public Health England (2017) Health matters: obesity and the food environment. Cited [23 July 2021]. https://www.gov.uk/government/publications/health-matters-obesity-and-the-food-environment

2. Organisation for Economic Co-operation and Development (2017) Health briefly 2017: OECD Indicators. Cited [21 July 2021] http://www.oecd.org/unitedkingdom/Health-at-a-Glance-2017-Key-Findings-UNITED-KINGDOM.pdf
3. Institute for Health Metrics and Evaluation, University of Washington. GBD compare data visualization. 2016. Cited [25 July2021] https://vizhub.healthdata.org/gbd-compare

4. World Health Organization. Noncommunicable diseases. Fact sheet. 2018. www.who.int/news-room/factsheets/detail/noncommunicable-diseases
5. World Health Organisation: Malnutrition: Key facts 09 June 2021. Cited [22 July 2021]. https://www.who.int/news-room/fact-sheets/detail/malnutrition
6. Global food policy report 2021: Transforming food systems after COVID-19 http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/134343/filename/134557.pdf

7. World Health Organization – Regional Office for Europe. European Food and Nutrition Action Plan 2015-2020. https://www.euro.who.int/__data/assets/pdf_file/0003/294474/European-Food-Nutrition-Action-Plan-20152020-en.pdf

8. Global, regional, and national incidence, prevalence and years lived with disability for 354 diseases and injuries for 195 countries and territories,1990-2017: a systemic analysis for the Global Burden of Disease study 2017. Lancet.2017.392 (10159):1789-1858

9. Branca, F., Lartey, A., Oenema, S., Aguayo, V., Stordalen, G.A., Richerdson, R., Transforming the food system to fight non-communicable diseases.BMJ.2019. 364,1296

10. World Cancer Research Fund International: Diet, nutrition, physical activity, and cancer: a global perspective. Third expert report 2018
11. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 19 million participants. Lancet global Health 2018;6: e1077-86

12. BMA: Improving the Nation’s diet: Action for a healthier future. https://www.bma.org.uk/media/2071/bma-improving-the-nation-s-diet.pdf
13. Marmot., Bell, R., Social determinants, and non-communicable diseases: Time for integrated action. 2019. 364;1251
14. Health and Europe centre website accessed 16 August 2021 https://healthandeuropecentre.nhs.uk/current-projects-2/aspire/
15. C3 health – Communities website accessed 16 August 2021 https://www.c3health.org/our-programmes/communities/

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