Coronavirus, Obesity and Undernutrition: The Triple Burden for Latin America

This post was written by Ada Cuevas, MD, MSc, from the Advanced Center for Metabolic Medicine and Nutrition (CAMMYN), in Santiago, Chile; and Claudia Batz, MPH, BSc, a Policy and Education Officer at the World Obesity Federation. Photo is courtesy of the World Obesity Federation.

Eleven weeks after confirming its first Coronavirus (COVID-19) case on February 25^th, 2020, Latin America has now reported over 420,000 confirmed cases and 20,000 deaths (Johns Hopkins Center, May 4^th)[i]. The continent may be relatively less affected by the virus at present, yet there exists an array of problems that undermine the preparedness of Latin American countries to face the spread of COVID-19[ii], one of which relates to the high levels of obesity and malnutrition across the region. Brazil was the first nation to report confirmed cases of COVID-19. Within weeks, countries across the continent closed borders and enforced lockdowns. Europe, China, and the USA (so-called developed countries) are making steady, but slow process with economies starting to open, and restrictions being lifted. However, for Latin America, the coming weeks are expected to show whether health systems in developing nations can cope with the peak of COVID-19, and whether the high levels of all forms of malnutrition, including high levels of obesity, will further add to these challenges.

Latin America has experienced a nutritional transition over the past 30 years, with rapid shift from undernutrition to overweight and obesity, and a subsequent increase in co-morbidities including type-2 diabetes, hypertension and cardiovascular disease (CVD)[iii] [iv]. Meanwhile, the emerging evidence base suggests that obesity in both young adults, and older age groups is a risk factor for the severe progression of COVID-19. A recent report from the Center of Disease Control and Prevention (CDC) in the United States highlighted that the most common underlying conditions for hospitalized patients are hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%), and cardiovascular disease (27.8%)[v]. Obesity is a main risk factor not only for these co-morbidities but for impaired metabolic health (such as dyslipidaemia and insulin resistance)[vi]. Although the underlying mechanism remains unclear, it is suspected that increased susceptibility to respiratory problems, inflammation, immunological disturbances and altered microbiomes in people living with obesity contribute to the exacerbation of COVID-19 amongst overweight and obese patients. Mitigation of risks for obesity should therefore be integrated into the COVID-19 response in Latin American Countries.

To add to the burden, low living standards in low SES populations including deficits in sanitization, immunization and undernutrition will only exacerbate the consequences of the COVID-19 pandemic[vii]. Social distancing also remains impossible in regions such as the Brazilian favelas that house approximately 13 million individuals[viii]. Humanitarian organizations including the International Committee of the Red Cross (ICRC) have made excellent adaptations to their programmmes in response to COVID-19, particularly among refugees, migrants and displaced persons or communities affected by violence[ix]. Yet there is equally a need to take real and effective action to ensure access to affordable and nutritious, foods in low-middle income countries.

The impacts of the COVID-19 on nutrition and obesity are likely to be wide-ranging and must be taken into consideration when responding to the pandemic. Some examples of the impact include:

1. Current efforts on breastfeeding, a crucial aspect to prevent childhood obesity, and later in the life, is likely to be undermined, primarily due to misinformation.

2. Price hikes on nutritious food including fruit and vegetable will significantly impact the quality of diets (both frequency, quantity and diversity), having implications on all forms of malnutrition, including the number of undernourished children.
3. Facilities for daily physical activity will be limited, posing a difficulty as the population strives to adopt healthy lifestyles.

Government authorities, health care professionals and the general population all have a responsibility to recognize obesity as a chronic disease which requires a range of effective prevention and management strategies both in response to COVID-19 and in the longer term. A whole of society approach involving effective strategies will help protect people living with obesity from COVID-19 complications, prevent a further increase in overweight and obesity prevalence and help mitigate impacts from future crises’ or pandemics. Top priorities during the pandemic therefore includes the continued dissemination of evidence-based guidance on food and physical activity, moreover ongoing support and counselling for families, and ensuring continuity of community-based programmmes. In addition, there are a number of specific actions that different actors can take, as summarized in the table below.

Several Latin American countries have implemented strategies to struggle with the increased epidemic of obesity amongst their child and adult populations. In Chile, a strict law of food labeling and advertising was implemented, that resulted in a 25% and 9% reduction in the purchase of sugar sweetened beverages (SSBs) and cereals, respectively. In addition, the Government has launched a healthy living campaign that promotes healthy nutrition, physical activities and provide high quality sports facilities to vulnerable communities. Moreover, the six-month postnatal maternity leave, that prioritizes breastfeeding, reinforces the initiatives to combat the high prevalence of obesity in the country. Similarly, Mexico have addressed obesity prevention measures, including educational campaigns and a 10% tax for junk food and sugar-sweetened beverages, that has decreased SSB consumption by 12%.

In summary, Latin America has witnessed a shift in which overweight and obesity are now a major, if not the major, malnutrition issue facing the region. Data from many developed countries is highlighting the increased risk of complications of COVID-19 amongst people living with obesity and has worrying implications for the Latin America region. There is an urgent need for strategies across the region to slow the spread of infection and protect people with obesity and healthcare resources in the short term, for strong and effective action that will help reduce obesity in the mid- to long term, as well to address some of the other drivers of obesity such as inequity which are likely to exacerbate the COVID-19 challenges faced by Latin America.

[i] https://coronavirus.jhu.edu/map.html

[ii] Burki, T., 2020. COVID-19 in Latin America. The Lancet Infectious Diseases, 20(5), pp.547-548.

[iii] Cuevas A, Alvarez V, Olivos C. The emerging obesity problem in Latin America.

Expert Rev Cardiovasc Ther. 2009 Mar;7(3):281-8

[iv] Cuevas A, Alvarez V, Carrasco F. Epidemic of metabolic syndrome in Latin America

Curr Opin Endocrinol Diabetes Obes. 2011 Apr;18(2):134-8

[v] Hospitalization Rates and Characteristics of Patients Hospitalized with Laboratory-Confirmed Coronavirus Disease 2019 — COVID-NET, 14 States, March 1–30, 2020 MMWR Morb Mortal Wkly Rep. 2020 Apr 17;69(15):458-464.

[vi] Stefan, N., Birkenfeld, A.L., Schulze, M.B. et al. Obesity and impaired metabolic health in patients with COVID-19. Nat Rev Endocrinol (2020). https://doi.org/10.1038/s41574-020-0364-6

[vii] Galicia L, de Romaña DL, Harding KB, De-Regil LM, Grajeda R. Tackling malnutrition in Latin America and the Caribbean. Challenges and opportunities. Rev Panam Salud Publica. 2016 Aug;40(2):138-146

[viii] Burki, T., 2020. COVID-19 in Latin America. The Lancet Infectious Diseases, 20(5), pp.547-548.

[ix] https://www.icrc.org/en/document/latin-america-and-icrc-time-covid-19-how-we-are-adjusting-our-action