The spectre of a Covid-19-malnutrition syndemic

We need ‘triple-duty actions’ to tackle undernutrition, overweight/obesity and Covid-19

The spectre of a Covid-19-malnutrition syndemic
In July 2020, a paper in The Lancet had estimated that ‘Covid-19 pandemic is expected to increase the risk of all forms of malnutrition’ (

By Ali Mehdi

A spectre is haunting India—the spectre of a Covid-19-malnutrition syndemic! ‘Syndemic’ is clustering and adverse synergisation of two or more health conditions at the biological/behavioural/ social level, facilitated by the prevailing socio-economic conditions, which increases the overall health and socio-economic burden of affected populations. ‘Malnutrition’ refers not just to undernutrition, as is widely believed, but also to overweight/obesity. It is very common to find undernutrition and overweight/obesity within the same country, community, household and even individual. For instance, 1.3% of under-five children in India were, at once, stunted–ie suffering from chronic or recurrent undernutrition (height-for-age more than two standard deviations below [< -2SD] WHO’s child growth standards median)—and overweight (+2SD from the median weight-for-height) according to the 4th round (2015-16) of the National Family Health Survey.

Available data indicates a flattening of the Covid-19 curve even before vaccinations have begun. However, recently released data on child and adult malnutrition from NFHS’ fifth-round (2019-20) highlights that malnutrition not only remains high but has increased, in most of the 22 states/UTs for which data has been released.

Child stunting remains 30%+ in 15 and 20%+ in the remaining seven states/UTs. With socio-economic development, stunting is supposed to decline over time but has actually increased in 13 states/UTs between NFHS-4 and 5, including in many states/UTs that have traditionally done relatively well on health indicators (Kerala, Goa and Lakshadweep, where stunting increased by 3.7, 5.7 and 5.2 ppt, respectively). In Lakshadweep, the percentage of overweight under-five children had also increased dramatically–from 1.6% in NFHS-4 to 10.5% in NFHS-5. In another UT, Ladakh, the increase was even more significant—from 4% to 13.4%. In both these UTs, more than 30% under-five children are stunted and more than 10% overweight, indicating a double burden of child malnutrition, as is the case in most other states/UTs.

As far as 15-49 year adults were concerned, 10 states had 30%+ women who were overweight/obese (BMI ?25.0 kg/m2), eight had 20%+, and the remaining four had 10%+. Only four states/UTs registered declines in female overweight/obesity between NFHS-4 and 5, while Ladakh registered the highest increase here as well—12 percentage points. In the case of male overweight/obese too, Ladakh had pride of place, registering an even larger increase, of 19 percentage points, followed by Lakshadweep. Only two states/UTs registered declines. During NFHS-5, two states/UTs even had 40%+ men who were overweight/obese (including Lakshadweep), 11 had 30%+, four had 20%+, while the rest had 10%+.

On the other hand, with some exceptions, the proportion of women and men with below-normal BMI (<18.5 kg/m2) has reduced in most states/UTs between NFHS-4 and 5; in many of them, prevalence during NFHS-5 remains substantial. The situation is more severe as far as anaemia among children and adults is concerned.

The exact period to which the presently released NFHS-5 data pertains is not clear from available documents. However, since it is for 2019-20, some part of the data collection could possibly have happened during the post-lockdown period of the Covid-19 pandemic. If yes, we could attribute some of the malnutrition increases to the disruptive impact of the Covid-19 pandemic.

If not, the present state of malnutrition would be much worse than the NFHS-5 data indicates, given the above impact. In July 2020, a paper in The Lancet had estimated that ‘Covid-19 pandemic is expected to increase the risk of all forms of malnutrition’ (

Covid-19 and malnutrition have a two-way relationship—1) those who are malnourished are at higher risk of infection; 2) Covid-19 has increased the prospect of malnutrition, both biologically (a) and socioeconomically (b). As far as (1) is concerned, it has long been known that malnutrition and immunodeficiency are interrelated, also in a two-way relationship. Evidence from Covid-19 adult patients shows a significant impact of malnutrition’ on health outcomes, with increased risk of ICU admission and death. As far as (2a) is concerned, a study of elderly Covid-19 patients in Wuhan city in early 2020 found a high prevalence of Covid-19 induced malnutrition among them ( Subsequent studies elsewhere have confirmed a similar trend in Covid-19 patients generally (

Many who have recovered from Covid-19 experience ‘chronic medical conditions that could be further exacerbated by unhealthy diets’. Finally, (2b) has come about due to disruption in socio-economic activity and access to health and nutritional services. If some part of NFHS-5 data collection has happened during the Covid-19 pandemic, it pertains to (2b). We need studies and surveys which focus on (1) and (2a) as well.

Even before Covid-19, malnutrition had been a leading determinant of human survival and health around the world. Economic growth, concomitant declines in poverty and improvements in food security, access to health care and education, led to reductions in the overall burden of malnutrition as well as changes in its composition. With declines in the prevalence and impact of undernutrition, there were increases in that of dietary risks—diets low in fruits, vegetables, whole grains, nuts and seeds, fiber, milk, calcium, omega-3 oils and polyunsaturated fatty acids, and high in sodium, red and processed meat, sweetened beverages and trans fats.

While undernutrition was responsible for a significant portion of the health burden and deaths due to communicable, maternal, neonatal and nutritional diseases, dietary risks have been responsible for the rising burden of non-communicable diseases. Low and middle-income countries like India are facing the double burden of malnutrition—undernutrition together with overweight/obesity—leading to calls for double-duty actions which simultaneously address both. Given the Covid-19-malnutrition syndemic, we require ‘triple-duty actions’ to tackle undernutrition, overweight/obesity and Covid-19 in an integrated/coordinated manner. Health and food systems/ministries need to work together in 2021.


Leads the Health Policy Initiative, ICRIER. Views are personal

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