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The Journal of Nutrition

Supplement: The Impact of Climate Change, the Economic Crisis,

and the Increase in Food Prices on Malnutrition

Impact of the Economic Crisis and Increase in

Food Prices on Child Mortality: Exploring

Nutritional Pathways13

Parul Christian*

Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

21205

Abstract

The current economic crisis and food price increase may have a widespread impact on the nutritional and health status of

populations,especially in thedeveloping world. Gains in child survival over thepast fewdecades are likelyto be threatened

and millennium development goals will be harder to achieve. Beyond starvation, which is one of the causes of death in

famine situations, there are numerous nutritional pathways by which childhood mortality can increase. These include

increases in childhood wasting and stunting, intrauterine growth restriction, and micronutrient deficiencies such as that of

vitamin A, iron, and zinc when faced with a food crisis and decreased food availability. These pathways are elucidated and

described. Although estimates of the impact of the current crisis on child mortality are yet to be made, data from previous

economic crises provide evidence of an increase in childhood mortality that we review. The current situation also

emphasizes that there are vast segments of the worlds population living in a situation of chronic food insecurity that are

likely to be disproportionately affected by an economic crisis. Nutritional and health surveillance data are urgently neededin

suchpopulations to monitorboth theimpactsof a crisis and of interventions.Addressing thenutritional needsof children and

women in response to the present crisis is urgent. But, ensuring that vulnerable populations are also targeted with known

nutritional interventions at alltimes is likelyto have a substantial impacton child mortality. J. Nutr. 140: 177S181S, 2010.

Introduction

Gains in public health over the past few decades are currentlythreatened by the global economic and food crises, with youngchildren, women, and the elderly in the developing world likelyto be disproportionately affected. Concern about the impact of

this crisis on the nutritional status of populations was expressedby WHO Director General of Health, Margaret Chan, asfollows: The world already faces an estimated 3.5 milliondeaths from malnutrition each year. Many more will die as aresult of thiscrisis (1).

The world food crisis is characterized by the price index ofmajor food commodities, including staples such as rice, corn,wheat, oil, and sugar having increased overall by 24% in 2007,with increases as high as 87% in oil, 58% in dairy, and 46% inrice (2). In the past 67 mo, marked decreases in prices of manycommodities has created hope that the food crisis is past.However, the hikes in food price may have created a complexfood insecurity situation and, although not quite the same as afamine or drought, the nutritional status and health of vastsections of the worlds population living in poverty and suffer-ing from chronic food insecurity and hunger may have beenaffected.

The impact of such a crisis situation on mortality is less wellknown or recorded, although change in diet and nutritionalstatus and increase in the number suffering from hunger mayhave been assessed. It would be well worth examining whatoccurs in a famine situation to contrast it with the likely impacton mortality in a crisis situation. A famine situation is defined innumerous ways, but a common theme of these definitions is the

1 Published in a supplement to The Journal of Nutrition. Presented at the

workshop The Impact of Climate Change, the Economic Crisis, and the

Increase in Food Prices on Malnutrition, held in Castel Gandolfo, Italy, January

25, 2009. The workshop was organized by Martin W. Bloem, United Nations

World Food Programme, Rome, Italy; Klaus Kraemer, Sight and Life, Basel,

Switzerland; and Richard D. Semba, Johns Hopkins University School of

Medicine, and with the support of an educational grant from Sight and Life,

Basel, Switzerland. Supplement contents are solely the responsibility of the

authors and do not necessarily represent the official views of the organization

that they are affiliated with. Publication costs for this supplement were defrayed

in part by the payment of page charges. This publication must therefore be

hereby marked "advertisement" in accordance with 18 USC section 1734 solely

to indicate this fact. Supplement Coordinator disclosures:Martin Bloem, Klaus

Kraemer, and Richard Semba have no relationships to disclose. Supplement

Guest Editor disclosures: A. Catharine Ross and Richard Semba have no

relationships to disclose. The opinions expressed in this publication are those of

the authors and are not attributable to the sponsors or the publisher, Editor, or

Editorial Board of The Journal of Nutrition.2 Supported by the Bill and Melinda Gates Foundation, Seattle, WA, and by NIH

grant R01 HD050254-01.3 Author disclosure: P. Christian, no conflicts of interest.

* To whom correspondence should be addressed. E-mail: [email protected].

0022-3166/08 $8.00 2010 American Society for Nutrition. 177SFirst published online November 18, 2009; doi:10.3945/jn.109.111708.

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inclusion of excessive deaths. Historically, high numbers ofdeaths were reported during famines, with starvation-relateddeaths being common. The impact on mortality under circum-stances of increased food insecurity has been less well elucidated,although we know that socioeconomic inequalities in mortality,especially child mortality, do exist. Analysis of survey data oninequalities in mortality among infants and children by quintilesof consumption using the Living Standards Measurement Studyfrom 9 different countries shows that the poorest quintilesuffered higher infant and under-5 mortality rates than other

quintiles (3).Numerous frameworks such as the one proposed by Waters

et al. (4) exist for analyzing pathways through which aneconomic crisis may affect health, many of which focus oncomplex processes including health care spending and utiliza-tion. Changes in relative prices combined with deterioratinghousehold purchasing power related to increasing unemploy-ment and decrease in availability and quality of servicesprovided all occur simultaneously to affect health and nutri-tional status and, in turn, survival (4).

Exploring nutritional pathways

This paper focuses on exploration of nutritional pathways by

which an economic crisis and inflation in food prices maydirectly or indirectly result in increases in child mortality. Figure1 illustrates the various pathways by which nutritional defi-ciencies directly or through their interaction with infectiousdisease will increase the risk of childhood mortality. A numberof the links are derived from causal evidence using data fromrandomized controlled studies, whereas others are likely to beassociations derived from prospective follow-up of children withundernutrition or nutritional deficiency. The synergistic rela-tionship between infectious diseases and mild-to-moderateundernutrition in causing childhood deaths suggests that anestimated 55% of deaths in young children (,72 mo) may beattributable to undernutrition (5). The cause-specific, popula-

tion attributable fractions were 45% for measles, 57% formalaria, 52% for pneumonia, and 61% for diarrhea (6). Recentestimates of deaths and burden of disease attributable tonutritional risk factor (7) revealed wasting and stunting areresponsible for the largest disease burden, with these indicatorsand intrauterine growth restriction-low birth weight contribut-ing to 21% of deaths in children under 5 y. This indicates thatany increase or decrease in the population prevalence rates of

undernutrition is likely to affect rates of child mortality. Asdiscussed by Darnton-Hill and Cogill (8) and based on estimatesfrom the Asian economic crisis (9), it is estimated that childhoodstunting rates will increase by 37% and those for wasting willincrease by 816%, at least in East Asia and the Pacific.Estimates from South Asia and sub-Saharan Africa are urgentlyneeded. It is also estimated that child mortality will increase by315% as a result of the crisis (9).

Among micronutrient deficiencies, the largest disease burdenis attributed to vitamin A and zinc deficiencies at 6.5 and 4.4%,

respectively (7). Vitamin A deficiency has long been known toincrease therisk of child mortalityby 2330%basedon data from8 randomized,controlledtrials (10).Programs of biannual dosingof children under 5 y of age with vitamin A exist in manydeveloping countries. The economic crisis is likely to decreaseintakes of vitamin A-rich foodsand increase the risk of vitamin Adeficiency, as described by West and Bouis (11). It is also likelythat vitamin A distribution programs may receive less attentionand funding amid competing needs and resources. This mayexacerbate the impact of the crisis on child survival.

Zinc deficiency is associated with an increased risk of severeand persistent diarrhea, pneumonia, and stunting. Meta-analysisfrom prevention trials of daily zinc supplementation in children

up to 48 mo of age, however, have found no overall impact onsurvival [combined relative risk (RR) = 0.91; 95% CI: 0.821.02] (12). Whereas the impact on survival was not significantfor infants (RR = 1.04; 95% CI: 0.90, 1.21), there was an 18%reduction in mortality among those .12 mo old (RR = 0.82;95% CI: 0.70, 0.96). Thus, it is plausible that an increase in zincdeficiency as a result of the economic crisis and increased foodprices may influence child health and survival.

Kramer (13) showed more than 2 decades ago that maternalnutritional factors may account for.50% of the etiology of lowbirth weight in developing countries. Maternal nutritionalfactors such as low BMI, stunting, poor weight gain duringpregnancy, and micronutrient deficiency result in poor fetal

growth and decreased gestational duration. Adequate energyintake and weight gain are critical during pregnancy. Balancedenergy protein supplementation in pregnancy based on random-ized controlled trials was shown to reduce fetal growthrestriction by 32% (2644%) (14). In a prospective observa-tional study carried out in a rural area of Maharashtra thatexamined the association between maternal diet during preg-nancy and birth outcomes, energy, protein, or carbohydrate

FIGURE 1 Nutritional pathways by which the

economic crisis and increase in food prices may

affect child mortality.

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intakes were not associated with birth weight and otheranthropometric measurements despite low intakes of energythat did not change during pregnancy (15). However, afteradjusting for various confounders, consumption of green leafyvegetables, fruits, and milk was associated in a dose-responsivemanner to birth weight. Although causal inference cannot bemade from these results, lower intakes of micronutrientssupplied by green leafy vegetables, fruit, and milk related tothe increasing food prices may limit fetal growth, especially inenergy-deficient populations. In studies from Indonesia, de-

creased intake of plant foods during the Asian economic crisishas been associated with an increased under-5 mortality rate(16). Maternal iron deficiency may result in adverse birthoutcomes. Recent trials demonstrated the benefit of ironsupplementation in improving birth weight and reducing lowbirth weight (1720) and preterm (19,20).

It is also likely that all of these nutritional pathways willinteract with increased susceptibility to infection. Childrenduring the crisis will be more likely to be exposed to infectiouspathogens due to worsening of sanitation and supply of cleanwater and greater exposure to disease vectors. This will result inincreased susceptibility to disease exacerbated by undernutritionand micronutrient deficiency and increased sickness due to lack

of access to preventive interventions or deterioration in healthcare utilization. Illness followed by lower quality of health carecan lead to an increased risk of mortality (21). It has beenestimated that the economic crisis, if unaddressed, will increasechildhood stunting by 37%, wasting by 816%, maternalanemia by 1020%, and low birth weight by 510%, at least inEast Asia and the Pacific region (9).

Impact on child mortality: previous evidence

There is limited data on the estimated impact of the currenteconomic crisis on child mortality beyond the estimates for EastAsia (9), primarily due to limited systematic surveillance-typedata being available. Even the current crisis is shifting with food

prices having recently declined in the past several months. Eachdecade in the past appears to have brought an economic crisis.Previous economic crises provide estimates of the impact onincreases in infant and child mortality that can be used toestimate the impacts of the current one, with the caveat that eacheconomic crisis has its own unique aspects, causes, and man-ifestations. In fact, the estimated impact for East Asia that wasrecently derived used findings from the last Asian economic crisisof 19971998 (9).

The world economic crisis of the early 1980s provides onesuch example. This crisis resulted in declining growth rates and adecrease in living standards (22). High cost of fuel, heavy burdenof interest payments, and unfavorable terms of trade all resultedin devaluation of money, increased unemployment, and austerity

policies leading to cuts in health care and other spending inAfrica and Latin America. Food production in Africa was mostaffected and fell by 15%, further exacerbated by drought, with~150 million people suffering from food shortages and in somecases famine (22). One-half of the children in 1984 in areas ofdrought had protein energy malnutrition and 50% of infantdeaths were directly or indirectly caused by malnutrition. Atleast 5 million children were estimated to have died during1984, one-quarter more than would have died without a crisis.In Chad, Burkina Faso, and Mozambique (in 6 of 9 provinces),infant mortality rate (IMR) was above 200/1000, whereas inGhana, IMR increased from 100 to 120130/1000. In Sudan20,000 more children died every month in mid-1985. In Latin

America there is evidence from Costa Rica of severe malnutri-

tion doubling in 19811982 and of dramatic increases in IMR inBolivia between 1973 and 1983, especially due to diarrhealdisease and an increased proportion of infant deaths due tomalnutrition (22). Sharp increases in IMR in Brazil between1983 and 1984 were also accompanied by a marked rise in theprevalence of anemia among children.

In the Congo, the government undertook a structuraladjustment program in 1986 and 1991 to cope with theeconomic crisis with negative consequences on availability andconsumption of food. Using cross-sectional data collected from

a study undertaken in Brazzaville, researchers were able toquantify the negative impact of the adjustment (23). This studyshowed that rates of wasting and stunting were higher in 1991compared with 1986; whereas rates of wasting were higheramong those ,24 mo of age, stunting rates were higher amongthose . 24 mo. The proportion of mothers whose BMI was,18.5 was higher in 1991 (29%) compared with 25% in 1986.Also, low birth weight prevalence, which had decreased from18.4 to 10.2% between 1981 and 1985, increased to 18.7% by1990 (23).

Data from examination of the chronic situation of householdfood insecurity in the drought-prone areas of northern Ethiopiacan also be used to infer the impact of an economic and food

crisis on mortality, although data are limited on children. Thesedata reveal that household vulnerability to food crisis is stronglyrelated to total number of deaths (24). Increases were observedfrom 1989 to 19931994 during periods of increased droughtand famine. Interestingly, unlike in 19841985 during the GreatEthiopian famine when hunger-/starvation-related deaths weremuch higher, illness was a more commonly reported causeduring the period of 19891994. The data also revealed thatdeaths clustered among the younger age groups of 14 y andeven 59 y, suggesting that children were disproportionatelymore likely to suffer from these periods of household vulnera-bility (24). Another example is northern Sudan, which by the endof 1991 was facing a severe food crisis and despite the

international relief response had received only one-half of theamount of relief food that it requested (25). Numerous small-scale surveys carried out during this time compared withprevious surveys by the Sudan Emergency and RecoveryInformation and Surveillance Surveys indicated increases inrates of childhood malnutrition and higher than expectedmortality rates in different regions of Sudan (25). Also, a surveyin squatter settlements around Khartoum showed that IMR was240/1000 and more than double that expected (107/1000).Mortality among children 14 y of age was estimated to be 4times higher than expected at 90/1000 (25).

Impact on maternal nutritional status: previous evidence

Maternal nutritional status, especially during pregnancy, may

deteriorate in an economic crisis, leading to adverse pregnancyoutcomes such as low birth weight and preterm birth. There arescant data on surveillance of nutritional status among womenduring situations of crisis. Few examples when data werecollected are described here. During the late 1970s, increases inworld oil prices triggered a global recession that caused a debtcrisis in the Dominican Republic, which combined with struc-tural adjustments imposed by the International Monetary Fundcreated a dire economic condition (26). Following this, interna-tional economic policies resulted in a further loss of revenuefrom sugar exports, a reduction in gross domestic product, andincreased prices in the 1980s. This resulted in dramatic decreasesin government expenditures on health during this period and

despite inaccurate records and data, secular trends in IMR, low

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birth weight, preterm births, and maternal mortality ratesincreased (26) (Fig. 2).

More recently during the Asian crisis, nutrient intakes ofmacro- and micronutrients showed secular trends of decline(27), whereas a survey of households in rural Java revealedincreases in maternal wasting as well as anemia during 19971998 (28). On the other hand, wasting among children was notaffected, suggesting that the limited food was preferentially

distributed to young children, but not women, within thehousehold. Rates of anemia among children, however, increased,suggesting an impact on availability of the more expensivemicronutrient-rich foods across the board. Maternal thinness(wasting) was also shown to be an indicator of increasing foodprices and financial crisis in a Brazzaville, Congo, where surveysconducted before and after a 50% devaluation of the CFA(African Financial Community) franc revealed increases in thisindicator along with a decrease in child undernutrition andintakes of complementary foods (29). The prevalence of womenwith a low BMI (,18.5) increased from 11.3 to 15.6% from thebaseline to the follow-up survey. Besides affecting birth out-comes, the impact on maternal nutritional status can also

negatively affect child caring and feeding and preventive healthcare, and care during illness may also decline, both of which canresult in deterioration in child health and survival.

Modeling the impact of the economic crisis and increase infood prices using previous evidence of the relationship betweennutritional status and child survival is possible to do. Robustestimates of the attributable risks for mortality are available toenable modeling such impacts. For example the estimated globalburden of death and disease related to undernutrition andvitamin A and zinc deficiency can be used for this purpose (7).However, nationally representative surveillance data on indica-tors such as low birth weight, maternal and child nutritionalstatus, and micronutrient status that record the change in thesedue to the economic crisis are not available in many places. Ad

hoc survey-based data on maternal and childhood nutritionstatus are needed to estimate the magnitude of effects on childmortality. Furthermore, it is not necessary that rates of under-nutrition should increase for child mortality to increase or forthis to happen sequentially. Surveys conducted in drought-proneareas of Ethiopia by Save the Children, UK, as part of the famineearly warning system have shown that child mortality increasedprior to declines in mean weight for length below 90% of thereference, an indicator used for alerting a crisis situationrequiring intervention (30). Such surveillance data are neededin many regions of the world and beyond areas that are droughtprone.

In conclusion, the current economic and food price crisis is

likely to have a considerable impact on child mortality unless

urgent action is taken by the global health community andgovernments. Decreases in dietary intake (both due to eating lessand fewer meals) and poorer dietary quality and micronutrientcontent can result in increased morbidity and mortality inchildren. Declines in maternal nutritional status may result inpoor birth outcomes such as fetal growth restriction and pretermbirth, which are linked with infant and child mortality.Economic crises experienced in the past 23 decades provideexamples of the impact they can have on child mortality.Surveillance data can be used to estimate the impact of the

present crisis but may not be available in many settings. Thecurrent crisis needs urgent attention but should also trigger abroader response to the need of a large segment of the worldspopulation facing a situation of chronic food insecurity.

Other articles in this supplement include (3144).

Acknowledgment

The sole author had responsibility for all parts of the manuscript.

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Economic crisis and child mortality 181S

impact of the economic crisis and increase in child death.pdf

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