Why Businesses Should Help Tackle Malnutrition

There are multiple ways businesses can help drive better outcomes and ultimately, as our report shows, this also impacts companies’ bottom lines. If staff are undernourished or overconsuming calories and therefore obese, their productivity goes down and they take more time off work for illness, they take time off to deal with family illness and, when they are at work they might be not as productive as normal – so-called ‘presenteeism’. If companies have a well-nourished workforce, their bottom line improves.

Furthermore, if companies work with local communities, they are providing evidence for business with a purpose, so they gain from a CSR perspective and increasingly, as businesses are under the spotlight for whether or not they are providing social value as well as economic value to shareholders, these sorts of things become more important. So, there are multiple ways where businesses have an interest, a stake, in ensuring good nourishment for the communities in which they are embedded and the workforce that they employ.

Laura Wellesley: One of the challenges we faced in doing this research – and that I think the business community and other sectors face in trying to fathom what the role of business should be – is there is very little evidence of what works and even of what companies are doing – let alone its effectiveness in terms of trying to support workers’ nutrition. So one of the key things for businesses to think about going forwards is to make sure that whatever they do, however tangentially-related their programmes or policies are to improved nutrition, they track, monitor and report on that transparently so they contribute to generating a collective evidence and knowledge base of the different options for businesses, and their impacts and outcomes in terms of nutrition and health and wellbeing of their workers or of the target communities.

Have the costs of malnutrition to business been estimated in this way before? What is cutting-edge about this study?

Caroline Vexler: As far as I am aware our study is the first which does a specific deep dive on private sector impacts. There are some studies which look at the impacts on global or country-level productivity, but ours disaggregates the impacts of malnutrition by economic sector, and by the different forms of malnutrition. This allows us, in a more explicit way, to understand which industries in which countries are most impacted by the different forms of malnutrition. We estimate the prevalence and cost of malnutrition by sector within each of the countries we model. We do this by combining a number of different big data sources, including on nutrition outcomes, economic sector productivity, how much that sector relies on labour and capital for its output, as well as employment data. We combine the data with academic research to estimate how individuals working within each sector who are affected by different forms of malnutrition then see costs to their labour productivity.

The report says the estimated loss of $850 billion across low- and middle-income countries is likely to be an underestimate. Why is that? And how much of an underestimate can we take this to be?

Caroline Vexler: It is likely to be an underestimate because we are only capturing part of the nutrition problem. Firstly, we only capture some nutritional deficiencies. Our main model captures the cost of obesity and underweight and then we do a separate analysis on the cost of anaemia for an additional subset of countries. But that is only part of the nutritional deficiency problem, there are a lot of other micronutrient deficiencies we are not able to capture in our model. Secondly, we are only capturing the costs malnutrition to productivity while people are at work. We do not capture additional costs of having to miss work due to illness, having to spend more of their money on healthcare, or how it impacts people’s ability to enter the labour force at all. It is hard to say what the magnitude of that impact would be otherwise, but this report shows the scale of the cost is huge – and we are only capturing part of it.

Would you say businesses generally are aware of the issue of malnutrition and the associated costs more widely within the contexts they operate? Are some sectors doing more than others?

Laura Wellesley: On the awareness point, there are two parallel stories. Our interviews with companies showed there is a fairly high degree of awareness of undernutrition being a problem in low-income countries in which those companies operate but, at the same time, a low level of awareness of the degree to which that is likely impacting on the company. We saw a fairly consistent assumption that undernutrition is something that affects low-income and low-skilled workers and, by and large, the multinationals can ‘design out’ those workers in that they are hiring more skilled workers generally and are usually paying considerably above the average wage in those countries. Therefore the assumption is their worker cohort will not be the segments of the population affected by undernutrition either in childhood or adulthood.

On the obesity side, it is a different story. There is a higher level of awareness that obesity affects a significant share of the workforce, but a low level of understanding that it is a form of malnutrition and something on which businesses can take action. There is a fairly common assumption across our interviewees that obesity is the result of poor individual lifestyle choices, rather than a function of an unhealthy food environment generally, or of poor nutritional understanding, or of poor access to healthy, diverse, nutritious diets. That means companies are not seeing the opportunities to tackle obesity and the known costs associated with it. So, while interviewees were pointing to the links between obesity and musculoskeletal problems, or diet-related diseases like type-2 diabetes, which do have a significant burden on businesses, they were not seeing they could be a part of the solution.

Tim Benton: The one thing that surprised me most is that – and it is not surprising with hindsight – companies tend to medicalize issues as something to do with an individual as opposed to it being a general issue for the workforce. Undernutrition is largely seen as a public health issue and therefore not much to do with businesses so, with a lack of awareness within a company of the general issue, it is hard to find somebody within the organization who naturally has it within their purview. There often was not a company view on malnutrition as there would be a company view on sustainability, for example. One of the things Laura had to battle with was being shuttled between CSR departments, sustainability people, HR, and medical teams. It is an issue lots of companies say they have a view on, but very often that view is chiselled away in a relatively obscure part of the company, rather than it being centrally managed by HR as part of employee health and wellbeing.

You say more research is needed to expand on the model used for this report. Where would you like to see efforts focused as a priority?

Caroline Vexler: In my opinion, understanding the impacts of anaemia should be prioritized because, for the five countries we modelled, we found some shocking disparities between men and women. Most studies on the overall burden or prevalence of anaemia generally focus on women because biologically women are more likely to be anaemic. But other social factors compound this and increase the likelihood of women to be anaemic. For example, in some areas of the world women are less likely to have access to animal protein or other iron sources than males within the same household. Our modelling found that men and women in the same occupation in the same country – where theoretically they should be earning the same amount of money – had significant differences in likelihood of being anaemic, with women in some countries nearly three times as likely to be anaemic as men.

That was just a deep dive into five countries, so there is a lot more work to be done to understand where anaemia is high, and where the gaps are between men and women, particularly those earning the same income levels or in the same occupations. We know anaemia has a high impact on people’s productivity levels, so this could be a big factor in limiting women’s ability to participate fully in the workforce.

There also needs to be more research into the nutritional impact on long-term economic development. We know that, on a year-to-year basis, malnutrition creates quite significant costs to the private sector’s productive capacity and so there are probably quite large impacts in the long term. If some sectors are more productive than others – especially if because of good nutritional outcomes – it could change the overall structure of the economy or the labour force. If there are sectors that are being held back because the workforce is suffering from nutritional deficiencies, it might hold back overall economic development and people’s opportunities for employment.

In the report you also touch on the issue of wages and the importance of paying a fair living wage. Many companies operating in low- and middle-income countries – notably high-street fashion retailers – have been criticized for failing to pay local workers a fair living wage. How important is this in helping to tackle malnutrition?

Tim Benton: According to the EAT-Lancet Commission in 2019 which created a nominal planetary and personal health diet, if you cost that personal health diet up, something like 1.58bn people around the world cannot afford to actually eat it. Billions of people around the world cannot afford to eat a healthy and nutritious diet and that is as true in the UK as much as in places like Malawi. The way the food system is currently configured, it is normally possible in most areas – and in many LMICs (low- and middle-income countries) – for people to get access to cheap calories from starchy grains, fat, and sugar. Lots of ultra-processed foods in packets, ready meals, and snacks are relatively cheap but food to support a healthy diet, such as fruits, vegetables, salads, small amounts of livestock products – meats, dairy, eggs – are often the most expensive. If in a country such as the UK – as COVID-19 has shown us – many millions of people cannot afford to access a healthy diet, imagine what it is like in other parts of the world?

Economically, the ability to access a healthy diet is crucially dependent upon family income, and in LMICs, this is typically dependent on a single wage earner in each family so, if that wage earner is not getting a decent salary, the whole family suffers. In the UK, it is slightly different because we tend to have multiple wage earners and if each one gets paid minimum wage there is nominally often a larger pot of money to call on, but not so in the developing world. There is a real issue that if companies based in low-income countries are not paying fair wages, it becomes even more difficult for people to fulfil their nutritional requirements.

Laura Wellesley: It is not only about asking companies to ensure they are paying a fair wage. It is also important for companies to take responsibility for their suppliers and supply chain so there is due diligence in place to ensure that they are not sourcing from companies or actors who themselves do not pay a fair wage, or suppliers without sufficient economic access to a healthy diet.

One company involved in this research, Olam, has examined the cost of diet in communities who supply their raw commodities, such as cocoa and coffee, and where they find farmers are struggling to afford a healthy diet, they are trying to tackle it through various different means, such as home gardens but also more broadly by assessing their food and nutrition security and then committing to taking some form of action with other partners in the supply chain. It is not only about the four walls of the company when you are talking about fair wage and ensuring economic access to a healthy diet.

Tim Benton: A further broader issue is the economic flow from corporate earnings in a country to the government through taxation. Companies have a responsibility to not find creative ways to minimize their tax burden in any given country, but instead make sure they are good corporate citizens and there is a financial flow to governments so they can help tackle public health issues associated with malnourishment.

The report states that nutrition is the missing link in the SDG agenda. How can businesses play a role in helping to achieve sustainable growth?

Laura Wellesley: Big question. One of the key things we noticed, and others have noticed when looking at corporate action – or lack thereof – around nutrition, is companies are really missing a trick by not incorporating efforts to improve nutrition into existing CSR efforts, potentially undermining their own ability to deliver on commitments relating to the SDGs. That matters because investors are increasingly looking to companies to demonstrate social credentials and a capacity to deliver positive societal benefits as well as financial gains. What our report says, and what we know, is good nutrition is absolutely critical to the good health of an individual, to productivity on an individual and at a societal level, to a robust and resilient workforce that is not highly susceptible to diseases such as COVID-19. The long-term sustainability of businesses, and their efforts to demonstrate they are contributing to sustainable growth in and around the communities in which they operate, could be derailed by poor nutrition.

We hope, and expect, to see nutrition security increasingly become something that investors and ESG (environmental, social and governance) analysts and data collectors and providers look at specifically, because those links between good nutrition and many other aspects of the sustainability agenda are increasingly recognized. First and foremost, businesses should understand how nutrition relates to sustainability and recognize it is not a separate issue. If they are interested in women’s empowerment and gender equality, if they are interested in improving schooling outcomes amongst their communities, if they are interested in building a workforce to deliver against the needs of a business environment in ten or 20 years’ time, then they need to be thinking about how to ensure good nutrition and a healthy food environment for those communities.

Tim Benton: There has been a lot of focus in the last ten years, particularly since food price spikes at the end of the first decade in this century, on food security which has often been really narrowly interpreted, although not defined, in terms of having access to food and calories, so you are not starving. This report, along with others, emphasizes it is not just food, it is not just having access to food, it is access to the right sort of food. When you look at the SDGs, food security sits within SDG 2 in a relatively narrow way related to ‘zero hunger’. But being a fully functioning human being and addressing all the issues impacting poverty and women’s empowerment requires that you are not just ‘not starving’ but actually you are well-fed. Thinking about nutrition broadens the frame quite a long way beyond just a single SDG, and actually underpins multiple SDGs.

In the report, you make the point that now is the time to act. Why are the next 18 months so important?

Tim Benton: We used to call 2020 the ‘super year’ in terms of the concatenation of multiple international efforts around the biodiversity convention – the biodiversity COP – around the framework for climate change – COP 26 in Glasgow – and around the inaugural food systems summit the UN is hosting. All have now been pushed back to 2021.

Food systems are integral to climate change, and drive a significant amount of climate change, they are also integral to biodiversity because food systems undermine significant amounts of biodiversity, they are integral to nutrition. So, there is a commonality about getting our food systems right over the next 18 months because of this concatenation of major efforts. The world is waking up to the need for change, so this sequence of international meetings should hopefully provide real impetus for making food systems better – in delivering better health for people who eat the food, better livelihoods for the people who produce the food, but also importantly better overall environments through dealing with climate change and biodiversity. When you look at the commonality across those three areas there are solutions that will span all three, so accepting these are not three separate agendas but are interrelated is a key step.

Laura Wellesley: The Nutrition for Growth Summit is a culmination moment. The first one was in 2013 and since then they have not really gained a huge amount of attention beyond those immediately involved. In next year’s summit, what they are aiming for is a post-2020 – or 2021 – compact on accelerating progress towards improved nutrition because we are nearing the point where global targets on improved nutrition will not be met within their timeframe. Targets were set in 2015 for achievement by 2025 on childhood stunting, wasting, and breastfeeding rates, and most countries around the world are way off course to meet them. The 2020 summit was to be a moment to recognize progress has been slow, and to inject a new wave of momentum and finance into nutrition efforts. The hope is that governments and companies and international donor agencies commit to ramping up efforts.

Politically, it is an important moment to say we are failing on nutrition and now is our last chance to turn the tide. That was the hope before COVID-19 and now, ahead of December 2021 when the summit will take place, there will be more pressure, expectation, and enthusiasm for recognizing improved nutrition is absolutely critical to building societal resilience to pandemics and other crises in the future. This crisis has thrown a light on the fragility of food supply chains and the food system in the UK and in countries around the world, so it would be a significant failing on the part of the international community to not take this moment to double down on efforts to tackle pervasive malnutrition.

Tim Benton: As well as COVID-19 providing an extra lens through which to see the impacts of malnourishment, it is driving awareness of obesity and undernourishment as risk factors associated with mortality from the virus. Because governments are putting so much money towards economic recovery, there are new opportunities to make that recovery ‘face in the right direction’. Rather than build back to where we were beforehand, build an economic recovery that creates greater societal resilience, part of which is to require people not to be malnourished.