The double burden of malnutrition (DBM) is conceptualized as the coexistence of undernutrition along with overweight, obesity or diet-related noncommunicable diseases (NCDs). It severely threatens populations’ health, especially in Sub-Saharan Africa (SSA), with a high prevalence of under-nutrition and a growing prevalence of diet-related NCDs. The 2017 estimate shows that 58.7 million children under five years of age were stunted (Low height for age), 13.8 million wasted (Low weight for age) and 9.7 million underweight. The overall prevalence of overweight/obesity among adults in the region was estimated to be 42%.
Health systems in Africa, as well as every health system in the world have been challenged by the “novel” coronavirus (Covid-19) infection, caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Covid-19 was everywhere, and no country has been spared. The emergence and spread of the virus led to a global crisis of unprecedented reach and proportion. While Africa appeared to suffer less from the virus than other continents in terms of absolute infections and deaths, there are concerns that the pandemic has pushed millions more into extreme poverty. Most of the benefits gained from existing research, prevention and malnutrition control programs addressing the DBM in Africa are declining, thus raising the concern about a negative interaction between Covid-19 and malnutrition in SSA. This paper aims to highlight the interactions between Covid-19 and the DBM and its global health implications. We discuss the role of the Covid-19 crisis in worsening the DBM in SSA and we propose approaches to preserve decades of progress made so far in addressing the DBM.
Impact of Covid-19 on food systems
Food systems in Sub-Saharan Africa (SSA) were already weak and fragile before Covid-19 occurred, and the region considered as being at highest food security risk, with rapidly growing population leading to a constant increase in food demand, high burden of poverty, unemployment and hunger. Moreover, the fragility of food systems in SSA is permanently deepened by conflicts, economic crises, climate extremes and variability, animal and plant pests, diseases and other natural hazards. The Covid-19 crisis has thus reinforced an already highly unfavorable context for food security. Indeed, Covid-19 and its containment measures disrupted food and agricultural supply chain, with consequences on crop production, food prices, availability and quality. Most sub-Saharan African countries adopted partial or nationwide lock-downs, borders closures, travel and transportation restrictions, school closure, workplace closure and social distancing as emergency response strategies to mitigate the spread of Covid-19.
Increasing local production implies an increased commitment of Sub-Saharan African governments and stakeholders to invest in, and support the local agricultural industry, strengthen domestic markets, and promote intra-regional trade.
Although the region has shown some degree of resilience regarding crop production, with no significant correlation between Covid-19 and changes in cereals production between 2019 and 2020, there is emerging evidence of Covid-19 impact on small farmers and specific cultures. For example, in a study on smallholder bean farmers in SSA, 20 to 35% of interviewed farmers in Eastern and Southern Africa reported challenges accessing hired labor, different types of inputs and source of financing due to the pandemic. Few case-studies conducted across Africa reported similar observations.
During the pandemic, panic buying and disruption of local and international trade and marketing activities (limited availability of agricultural inputs, higher inputs prices, extended transportation periods for food items, decrease in purchasing power, loss in crop productivity and farm income…) due to Covid-19 containment measures, led to an exacerbation of food price increase in many African countries. Moreover, these measures resulted in loss of employment and reduced household income.
Covid-19 and The Double Burden of Malnutrition
Under-nutrition
According to recent FAO (Food and Agriculture Organization) estimates, under-nutrition will still affect about 670 million people in 2030, 78 million more than in a Covid-19 free scenario. SSA like the rest of the continent experienced a striking rise in the prevalence of under-nutrition between 2019 and 2020. The International Food Security Assessment (IFSA) reports indicate that the percent of food insecure people in the SSA population increased by over 9% between 2019 and 2021 (35.3% to 44.9%) compared to an increase of about 4% (31% to 35.3%) from 2017 to 2019. Similarly, the prevalence of undernourishment in the region increased from 20.2% in 2017–2019 to 21.8% in 2018–2020. An assessment of food insecurity indicators during the pandemic in SSA has shown a profound impact in worsening several aspects of food insecurity including food accessibility, availability, utilization and stability.
Overweight/obesity
Although there is limited data proving the direct effect of Covid-19 on overweight and obesity in Sub-Saharan Africa, the pandemic is very likely to have deepened an already alarming trend of rising prevalence of overweight, obesity and other diet related Non-communicable diseases (NCDs). Evidence indicates that inflations in food prices driven by the economic repercussions of Covid-19 and its containment measures resulted in higher costs and increased unaffordability of healthy foods worldwide. Between 2019 and 2020, the cost of a healthy diet rose from 2.9% in SSA. In addition, about 894 million people could not afford a healthy diet in 2020 in the region, corresponding to a 3.1% increase between 2019 and 2020.
Addressing the double burden of malnutrition post Covid-19
It is vital to consider the persistent changes and consequences arising from Covid-19 crisis on the DBM, and learn from the lessons to improve our strategies addressing food insecurity and malnutrition.
Increase local production and reduce foreign reliance: Sufficient local production could be a key factor for food availability and stability in SSA. Increasing local production implies an increased commitment of SSA governments and stakeholders to invest in, and support the local agricultural industry, strengthen domestic markets, and promote intra-regional trade. There is an urgent need to invest not only in developing quality infrastructure, but also in optimizing agricultural production, targeting crops that offer a comparative advantage for the country. Another key strategy is to boost R&D to gain national or regional autonomy on agricultural inputs supply and food products transformation.
Reinforce national and regionally integrated nutritional surveillance: Effective surveillance systems including under-nutrition, overweight/obesity, other diet-related NCDs and micro-nutrient deficiency indicators, are necessary to improve malnutrition control and prevention programs and produce anticipated responses to future threats. Moreover, regional integration of the surveillance systems for coordinated actions could foster impact and efficiency.
Improve social security systems: SSA governments should increase their commitment in building social protection mechanisms that ensure quality, diverse, affordable and healthy food for all citizens. It is also critical to strengthen our capacity to provide local food aid in situations of crisis and emergency.
Improve nutrition services integration in health systems: A key strategic action in preventing the DBM in SSA might be to create or reinforce nutrition services that are built into healthcare services. Indeed according to FAO, Systematically integrating nutrition into health systems would ensure greater effectiveness of nutrition policies, programs and actions, including nutrition interventions, nutrition counseling and education.
Promote and enhance nutritional education: Nutritional education (NE) could substantially change the trend of the DBM. NE can be integrated in school curricula as it is the case in a few countries, reinforced by nutrition services in health facilities or disseminated through media and social media campaigns.
Solange Dabou holds a Master of science in Clinical Biochemistry from the University of Dschang and have followed a distance learning training in epidemiology and health statistics from Aix Marseille University. Dr. Ngo Valery Ngo is a Medical Doctor and a Senior Health Researcher at Nkafu Policy Institute, a think tank at the Denis & Lenora Foretia Foundation in Yaoundé, Cameroon. Regina Sinsai holds a Bachelor of Arts Degree in Psychology from the United States International University – Africa, in Nairobi and an HND in General Nursing from the Humanity Health Professional Training Center (HHPTC) in Yaoundé. Ghyslaine Bruna Djeunang Dongho, Ph. D., is the Senior Researcher in Global Health and Public Health at the Nkafu Policy Institute. Kepgang Evrard is a young research and humanitarian passionate, who holds a master’s degree in Public health and epidemiology at the University of Dschang.
Article first appeared in On Policy.
Photo by Chams Dine via Iwaria.