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 Pathways
13
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 the developing world. Gains in child survival over the past fewdecades are likely to 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 deciencies 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 needed in
suchpopulations tomonitor boththeimpactsof a crisis andof interventions. Addressingthenutritional needs of childrenand
women in response to the present crisis is urgent. But, ensuring that vulnerable populations are also targeted with known
nutritional interventions at all times is likely to have a substantial impact on child mortality. J. Nutr. 140: 177S181S, 2010.
Introduction
Gains in public health over the past few decades are currently
threatened by the global economic and food crises, with young
children, women, and the elderly in the developing world likely
to be disproportionately affected. Concern about the impact of
this crisis on the nutritional status of populations was expressed
by WHO Director General of Health, Margaret Chan, as
follows: The world already faces an estimated 3.5 million
deaths from malnutrition each year. Many more will die as a
result of this crisis (1).
The world food crisis is characterized by the price index of
major 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% in
rice (2). In the past 67 mo, marked decreases in prices of many
commodities has created hope that the food crisis is past.
However, the hikes in food price may have created a complex
food insecurity situation and, although not quite the same as a
famine or drought, the nutritional status and health of vast
sections of the worlds population living in poverty and suffer-
ing from chronic food insecurity and hunger may have been
affected.
The impact of such a crisis situation on mortality is less well
known or recorded, although change in diet and nutritional
status and increase in the number suffering from hunger may
have been assessed. It would be well worth examining what
occurs in a famine situation to contrast it with the likely impact
on mortality in a crisis situation. A famine situation is dened in
numerous ways, but a common theme of these denitions 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 ofcial views of the organization
that they are afliated 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 conicts of interest.
* To whom correspondence should be addressed. E-mail: pchristi@jhsph.edu.
0022-3166/08 $8.00 2010 American Society for Nutrition. 177S
First published online November 18, 2009; doi:10.3945/jn.109.111708.

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inclusion of excessive deaths. Historically, high numbers of
deaths were reported during famines, with starvation-related
deaths 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 on
inequalities in mortality among infants and children by quintiles
of consumption using the Living Standards Measurement Study
from 9 different countries shows that the poorest quintile
suffered 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 an
economic crisis may affect health, many of which focus on
complex processes including health care spending and utiliza-
tion. Changes in relative prices combined with deteriorating
household purchasing power related to increasing unemploy-
ment and decrease in availability and quality of services
provided 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 ination in food prices may
directly or indirectly result in increases in child mortality. Figure
1 illustrates the various pathways by which nutritional de-
ciencies directly or through their interaction with infectious
disease will increase the risk of childhood mortality. A number
of the links are derived from causal evidence using data from
randomized controlled studies, whereas others are likely to be
associations derived fromprospective follow-up of children with
undernutrition or nutritional deciency. The synergistic rela-
tionship between infectious diseases and mild-to-moderate
undernutrition in causing childhood deaths suggests that an
estimated 55% of deaths in young children (,72 mo) may be
attributable to undernutrition (5). The cause-specic, popula-
tion attributable fractions were 45% for measles, 57% for
malaria, 52% for pneumonia, and 61% for diarrhea (6). Recent
estimates of deaths and burden of disease attributable to
nutritional risk factor (7) revealed wasting and stunting are
responsible for the largest disease burden, with these indicators
and intrauterine growth restriction-low birth weight contribut-
ing to 21% of deaths in children under 5 y. This indicates that
any increase or decrease in the population prevalence rates of
undernutrition is likely to affect rates of child mortality. As
discussed by Darnton-Hill and Cogill (8) and based on estimates
from the Asian economic crisis (9), it is estimated that childhood
stunting rates will increase by 37% and those for wasting will
increase by 816%, at least in East Asia and the Pacic.
Estimates from South Asia and sub-Saharan Africa are urgently
needed. It is also estimated that child mortality will increase by
315% as a result of the crisis (9).
Among micronutrient deciencies, the largest disease burden
is attributed to vitamin A and zinc deciencies at 6.5 and 4.4%,
respectively (7). Vitamin A deciency has long been known to
increase the riskof childmortality by2330%basedondata from
8randomized, controlledtrials (10). Programs of biannual dosing
of children under 5 y of age with vitamin A exist in many
developing countries. The economic crisis is likely to decrease
intakes of vitamin A-rich foods and increase the risk of vitamin A
deciency, as described by West and Bouis (11). It is also likely
that vitamin A distribution programs may receive less attention
and funding amid competing needs and resources. This may
exacerbate the impact of the crisis on child survival.
Zinc deciency is associated with an increased risk of severe
and persistent diarrhea, pneumonia, and stunting. Meta-analysis
from prevention trials of daily zinc supplementation in children
up to 48 mo of age, however, have found no overall impact on
survival [combined relative risk (RR) = 0.91; 95% CI: 0.82
1.02] (12). Whereas the impact on survival was not signicant
for 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 zinc
deciency as a result of the economic crisis and increased food
prices may inuence child health and survival.
Kramer (13) showed more than 2 decades ago that maternal
nutritional factors may account for .50%of the etiology of low
birth weight in developing countries. Maternal nutritional
factors such as low BMI, stunting, poor weight gain during
pregnancy, and micronutrient deciency result in poor fetal
growth and decreased gestational duration. Adequate energy
intake and weight gain are critical during pregnancy. Balanced
energy protein supplementation in pregnancy based on random-
ized controlled trials was shown to reduce fetal growth
restriction by 32% (2644%) (14). In a prospective observa-
tional study carried out in a rural area of Maharashtra that
examined 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.
178S Supplement
intakes were not associated with birth weight and other
anthropometric measurements despite low intakes of energy
that did not change during pregnancy (15). However, after
adjusting for various confounders, consumption of green leafy
vegetables, fruits, and milk was associated in a dose-responsive
manner to birth weight. Although causal inference cannot be
made from these results, lower intakes of micronutrients
supplied by green leafy vegetables, fruit, and milk related to
the increasing food prices may limit fetal growth, especially in
energy-decient populations. In studies from Indonesia, de-
creased intake of plant foods during the Asian economic crisis
has been associated with an increased under-5 mortality rate
(16). Maternal iron deciency may result in adverse birth
outcomes. Recent trials demonstrated the benet of iron
supplementation in improving birth weight and reducing low
birth weight (1720) and preterm (19,20).
It is also likely that all of these nutritional pathways will
interact with increased susceptibility to infection. Children
during the crisis will be more likely to be exposed to infectious
pathogens due to worsening of sanitation and supply of clean
water and greater exposure to disease vectors. This will result in
increased susceptibility to disease exacerbated by undernutrition
and micronutrient deciency and increased sickness due to lack
of access to preventive interventions or deterioration in health
care utilization. Illness followed by lower quality of health care
can lead to an increased risk of mortality (21). It has been
estimated that the economic crisis, if unaddressed, will increase
childhood stunting by 37%, wasting by 816%, maternal
anemia by 1020%, and low birth weight by 510%, at least in
East Asia and the Pacic region (9).
Impact on child mortality: previous evidence
There is limited data on the estimated impact of the current
economic crisis on child mortality beyond the estimates for East
Asia (9), primarily due to limited systematic surveillance-type
data being available. Even the current crisis is shifting with food
prices having recently declined in the past several months. Each
decade in the past appears to have brought an economic crisis.
Previous economic crises provide estimates of the impact on
increases in infant and child mortality that can be used to
estimate the impacts of the current one, with the caveat that each
economic crisis has its own unique aspects, causes, and man-
ifestations. In fact, the estimated impact for East Asia that was
recently derived used ndings fromthe last Asian economic crisis
of 19971998 (9).
The world economic crisis of the early 1980s provides one
such example. This crisis resulted in declining growth rates and a
decrease in living standards (22). High cost of fuel, heavy burden
of interest payments, and unfavorable terms of trade all resulted
in devaluation of money, increased unemployment, and austerity
policies leading to cuts in health care and other spending in
Africa and Latin America. Food production in Africa was most
affected and fell by 15%, further exacerbated by drought, with
~150 million people suffering from food shortages and in some
cases famine (22). One-half of the children in 1984 in areas of
drought had protein energy malnutrition and 50% of infant
deaths were directly or indirectly caused by malnutrition. At
least 5 million children were estimated to have died during
1984, 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 in
Ghana, IMR increased from 100 to 120130/1000. In Sudan
20,000 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 in
Bolivia between 1973 and 1983, especially due to diarrheal
disease and an increased proportion of infant deaths due to
malnutrition (22). Sharp increases in IMR in Brazil between
1983 and 1984 were also accompanied by a marked rise in the
prevalence of anemia among children.
In the Congo, the government undertook a structural
adjustment program in 1986 and 1991 to cope with the
economic crisis with negative consequences on availability and
consumption of food. Using cross-sectional data collected from
a study undertaken in Brazzaville, researchers were able to
quantify the negative impact of the adjustment (23). This study
showed that rates of wasting and stunting were higher in 1991
compared with 1986; whereas rates of wasting were higher
among those ,24 mo of age, stunting rates were higher among
those . 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 from
18.4 to 10.2% between 1981 and 1985, increased to 18.7% by
1990 (23).
Data from examination of the chronic situation of household
food insecurity in the drought-prone areas of northern Ethiopia
can also be used to infer the impact of an economic and food
crisis on mortality, although data are limited on children. These
data reveal that household vulnerability to food crisis is strongly
related to total number of deaths (24). Increases were observed
from 1989 to 19931994 during periods of increased drought
and famine. Interestingly, unlike in 19841985 during the Great
Ethiopian famine when hunger-/starvation-related deaths were
much higher, illness was a more commonly reported cause
during the period of 19891994. The data also revealed that
deaths clustered among the younger age groups of 14 y and
even 59 y, suggesting that children were disproportionately
more likely to suffer from these periods of household vulnera-
bility (24). Another example is northern Sudan, which by the end
of 1991 was facing a severe food crisis and despite the
international relief response had received only one-half of the
amount of relief food that it requested (25). Numerous small-
scale surveys carried out during this time compared with
previous surveys by the Sudan Emergency and Recovery
Information and Surveillance Surveys indicated increases in
rates of childhood malnutrition and higher than expected
mortality rates in different regions of Sudan (25). Also, a survey
in squatter settlements around Khartoum showed that IMR was
240/1000 and more than double that expected (107/1000).
Mortality among children 14 y of age was estimated to be 4
times 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 pregnancy
outcomes such as low birth weight and preterm birth. There are
scant data on surveillance of nutritional status among women
during situations of crisis. Few examples when data were
collected are described here. During the late 1970s, increases in
world oil prices triggered a global recession that caused a debt
crisis in the Dominican Republic, which combined with struc-
tural adjustments imposed by the International Monetary Fund
created a dire economic condition (26). Following this, interna-
tional economic policies resulted in a further loss of revenue
from sugar exports, a reduction in gross domestic product, and
increased prices in the 1980s. This resulted in dramatic decreases
in government expenditures on health during this period and
despite inaccurate records and data, secular trends in IMR, low
Economic crisis and child mortality 179S
birth weight, preterm births, and maternal mortality rates
increased (26) (Fig. 2).
More recently during the Asian crisis, nutrient intakes of
macro- and micronutrients showed secular trends of decline
(27), whereas a survey of households in rural Java revealed
increases in maternal wasting as well as anemia during 1997
1998 (28). On the other hand, wasting among children was not
affected, suggesting that the limited food was preferentially
distributed to young children, but not women, within the
household. Rates of anemia among children, however, increased,
suggesting an impact on availability of the more expensive
micronutrient-rich foods across the board. Maternal thinness
(wasting) was also shown to be an indicator of increasing food
prices and nancial crisis in a Brazzaville, Congo, where surveys
conducted before and after a 50% devaluation of the CFA
(African Financial Community) franc revealed increases in this
indicator along with a decrease in child undernutrition and
intakes of complementary foods (29). The prevalence of women
with a low BMI (,18.5) increased from 11.3 to 15.6% from the
baseline 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 health
care, and care during illness may also decline, both of which can
result in deterioration in child health and survival.
Modeling the impact of the economic crisis and increase in
food prices using previous evidence of the relationship between
nutritional status and child survival is possible to do. Robust
estimates of the attributable risks for mortality are available to
enable modeling such impacts. For example the estimated global
burden of death and disease related to undernutrition and
vitamin A and zinc deciency can be used for this purpose (7).
However, nationally representative surveillance data on indica-
tors such as low birth weight, maternal and child nutritional
status, and micronutrient status that record the change in these
due to the economic crisis are not available in many places. Ad
hoc survey-based data on maternal and childhood nutrition
status are needed to estimate the magnitude of effects on child
mortality. Furthermore, it is not necessary that rates of under-
nutrition should increase for child mortality to increase or for
this to happen sequentially. Surveys conducted in drought-prone
areas of Ethiopia by Save the Children, UK, as part of the famine
early warning system have shown that child mortality increased
prior to declines in mean weight for length below 90% of the
reference, an indicator used for alerting a crisis situation
requiring intervention (30). Such surveillance data are needed
in many regions of the world and beyond areas that are drought
prone.
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 and
governments. Decreases in dietary intake (both due to eating less
and fewer meals) and poorer dietary quality and micronutrient
content can result in increased morbidity and mortality in
children. Declines in maternal nutritional status may result in
poor birth outcomes such as fetal growth restriction and preterm
birth, which are linked with infant and child mortality.
Economic crises experienced in the past 23 decades provide
examples 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. The
current crisis needs urgent attention but should also trigger a
broader response to the need of a large segment of the worlds
population 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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