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Malnutrition: the silent pandemic

BMJ 2020; 371 doi: (Published 01 December 2020) Cite this as: BMJ 2020;371:m4593
  1. Henry E Mark, international development consultant1,
  2. Glauce Dias da Costa, lecturer2,
  3. Claudia Pagliari, senior lecturer in primary care and ehealth3,
  4. Stefan A Unger, paediatric respiratory consultant4
  1. 1International Development Consultant, Nottingham, UK
  2. 2Department of Nutrition and Health, Federal University of Vicosa, Vicosa, Brazil
  3. 3Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
  4. 4Royal Hospital for Sick Children, Edinburgh, UK
  1. Correspondence to: S A Unger stefan.unger{at}

Healthy diets are a human right and the foundation of just, resilient societies

Public health has come to the fore in 2020 like no time in recent history, yet well before covid-19 the world was already witnessing a much quieter pandemic: malnutrition.

The number of people affected by malnutrition is startling. Globally, an estimated 149 million children are stunted (chronically undernourished) and 50 million are acutely undernourished (wasted),1 with undernutrition a direct or underlying cause in 45% of all child deaths.2 In addition, 40 million children under 5 years are overweight and 678 million adults are obese.1

Covid-19 has compounded these problems. Restrictions on movement of goods and people threaten supply chain disruption and price volatility in already fragile food systems, while reductions in household income affect people’s ability to buy food and other essential items.3 The prevalence of moderate and severe wasting could increase by 14% because of covid-19.4 Coupled with reductions in the coverage of nutrition and health services, this may result in over 128 000 additional deaths among children under 5 in 2020 alone.4

Research increasingly points to a role for nutritional status in resilience to infection and as a mediator of its effects.56 Adequate intakes of energy, macronutrients, and micronutrients are critical for immune functioning.7 Undernutrition can lead to immune dysfunction and increased susceptibility to infectious diseases. In turn, immune responses to infectious diseases enhance nutrient requirements, reduce appetite, and impede the absorption of nutrients creating and perpetuating a vicious cycle.8

Overweight and obesity and their comorbidities, including diabetes and heart disease, are known risk factors for covid-19, increasing the risk of both infection and severe complications.9 Obesity is also significantly associated with the need for critical care management in children admitted to hospital with covid-19.10 The chronic, low grade inflammation linked to obesity is known to compromise innate and adaptive immune responses, and emerging evidence suggests this is also the case for covid-19.11

Despite political platitudes that we are all in this together, the direct and indirect effects of covid-19 have disproportionally affected vulnerable groups.12

Links between socioeconomic measures of poverty and childhood undernutrition are well documented.113 Without intervention, an estimated 140 million additional people will experience extreme poverty because of covid-19.4 The number of people in low and middle income counties facing acute food insecurity is also estimated to double to 265 million by the end of 2020.4 In many high and middle income countries obesity is more prevalent among poorer people, partly because of the affordability and availability of low quality food in areas of high vulnerability.14 People on low incomes from ethnic minorities are also experiencing an unequal burden of covid-19 infections, hospital admissions, and mortality,12 highlighting and compounding existing inequalities.

Calls have been made for a new type of “herd immunity” that comes from redesigning social and economic systems to tackle the root causes of health inequities.15 Ending malnutrition in all its forms is fundamental to this approach, and critical to tackling the worlds’ biggest health challenges—from non-communicable diseases to antimicrobial resistance.16

There are no simple solutions, but we know a great deal about how to end malnutrition1718 and how to promote good nutrition during the pandemic.19 Yet underlying all forms of malnutrition are economic and social models that promote profit over social prosperity and do little to meet the needs of the most vulnerable people. Only when a healthy nutritious diet is seen as a basic right, and people are treated as citizens rather than consumers, will we truly be in a position to end malnutrition.

As an issue of social justice, tackling malnutrition will require social, political, and economic transformation. But this will follow only if we acknowledge that the current global prevalence of malnutrition is morally inexcusable and politically and economically unsustainable. We therefore support the call by 180 experts for integrated international guidelines on human rights, healthy diets, and sustainable food systemsas a critical step forward.20

The Nutrition for Growth Summit and the UN Food Systems Summit, both set to take place in 2021, are opportunities to shape a bold agenda. We urge those leading these summits to engage broadly and to create space for affected populations, young people, and civil society to lead this change.

Echoing calls to “build back better” after the pandemic, we urge governments around the world to commit to ending malnutrition in all its forms as a path to building healthy, prosperous, and more resilient societies.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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