The COVID-19 Pandemic: potential long-term impacts on the nutritional status of Ghanaian children

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The current coronavirus (COVID-19) pandemic has halted social and economic activities across much of the world. As of 09 April 2020, over one million COVID-19 cases have been recorded worldwide, and about 23% (336,780) of these have recovered. Sadly, about 6% (89,435) have died from the virus or related complications.1

Africa was the last continent to be hit by the pandemic, and Ghana was not spared. In Ghana, the first case of the virus was recorded on 12 March 2020, a day after it was officially declared a pandemic by the World Health Organisation. Since then, the government has put in place several measures to curtail its spread, including terminal screening at ports of entry, quarantining and testing of exposed, testing of symptomatic individuals, contact tracing, travel, and social restrictions. In his first address to the nation on the pandemic, President Nana Akufo-Addo announced the closure of all schools in Ghana, from the basic level to the tertiary level, beginning 16 March 2020, among other measures.

At the time of the first presidential update on the situation, six cases had been confirmed in the country. As the number of cases spiked, stricter measures were necessitated and accordingly, the President announced a two-week targeted lockdown in major Ghanaian cities beginning Friday, 27 March 2020. As of Thursday 09 April 2020 12:27:04 GMT+0000 (Greenwich Mean Time), 313 cases have been confirmed in Ghana, three people have recovered, six have died, 49 discharged (and under home management), and two in a moderately ill condition.2 Schools remain closed, and pupils/students have been out of school for nearly four weeks.

Looking at the worldwide trends, it appears the pandemic is far from over and the country might remain locked down for a longer period of time. This blog looks at the potential impact of the pandemic and the national response thereof, on the nutritional status of school children. It will focus on Ghanaian children in public sector basic schools (kindergarten to junior high public schools), using two potential scenarios.

Scenario 1: Limited access to food, reduced food intake and resulting undernutrition

As with any disruption to “normal” life activities caused by situations such as the current pandemic, groups that are mostly affected are the vulnerable (e.g. children). For decades, Ghana has been grappling with various forms of undernutrition that stem from micronutrient or macronutrient deficiencies. The government has responded to this nutrition challenge by implementing key interventions such as food fortification, micronutrient supplementation, community-based management of acute malnutrition, and the Ghana School Feeding Programme (GSFP).3

The GSFP, as one of the interventions for addressing undernutrition in Ghana, was instituted to provide one hot nutritious meal each school day to disadvantaged children in selected public sector schools. This meal is provided as lunch during schools’ lunch breaks.  Without the GSFP, many families would be unable to provide at least one nutritionally adequate meal each day for their children.4 It is therefore not surprising that the GSFP is associated with higher enrolment rates and lower drop-out rates in beneficiary schools compared to non-beneficiary schools.4 For many of these children, the GSFP meal is a very important source of daily nutrition.4 With the current closure of schools due to the COVID-19 pandemic, families who rely on the programme to provide a daily meal for their children will have to find alternative means of providing lunch for their children. According to recent data from the World Food Programme, about 368 million of the world’s children (about 1.7 million Ghanaian children inclusive) are missing out on school meals due to school closures.5 As more countries become affected by the pandemic, and more schools forced to close down, this number will likely rise.

To compound things further, many Ghanaians, who rely on casual labour to obtain their family’s daily bread may have difficulties doing so now because of movement restrictions. Additionally, the panic buying of food within the few days preceding the targeted lockdown has resulted in higher food prices. This has limited the purchasing power of lower socioeconomic status households. The Daily Graphic (a state-owned newspaper) in an article titled “Coronavirus: Mad rush for foodstuffs over fear of COVID-19 lockdown” reported on 23 March 2020, that food prices had soared in anticipation of the lockdown. It is possible that some poor households could not stock up on food and will, therefore, need to adopt coping strategies such as reducing the quantity of meals or reducing the frequency of mealtimes, which may subsequently result in children of such households becoming undernourished. Our earlier work identified various coping strategies used by some food-insecure Ghanaian households – including skipping an entire day’s meal, reducing portion sizes, reducing the number of meals per day or relying on cheap energy-dense foods.6

In the short term, undernourished children are more likely than well-nourished children to have poor growth outcomes, poor mental well-being, and increased susceptibility to illnesses. In the long term, undernourished children may perform poorly in school, have poor overall health, and possibly reduced economic productivity in adulthood compared to well-nourished children.7  Lastly, it is important to note that childhood undernutrition has been linked to adult obesity and other noncommunicable diseases.8

Scenario 2: Increased consumption of highly processed foods, increased overall food intake, reduced physical activity and resulting weight gain

Another potential impact of the pandemic may be an increase in overnutrition in school children. This may occur because of increased food intake, particularly increased consumption of processed foods coupled with a reduction in physical activity. Many families (particularly families of high socioeconomic status), in preparation for the lockdown, and in a state of uncertainty regarding when things will normalise, may have stocked up on food produce and processed foods. It is highly likely that they have stocked up more on the latter, which are more convenient and less perishable.   There is ample evidence linking the consumption of ultra-processed foods (e.g. sugar-sweetened beverages and sweet/savoury snacks) to weight gain because of the high amounts of total energy, fats, added sugars and salt (sodium) that these foods contain.9 An increased consumption of such foods over time could result in weight gain and associated sequelae.

Physical activity plays a major role in preventing excessive weight gain and schools are key players in providing an avenue for children to engage in physical activity. Some Ghanaian children usually walk to and from schools and engage in physical activity during breaks. In addition, some schools in Ghana have physical education subjects that incorporate some form of physical activity. With schools closed until further notice, and given that many households in the cities where the current lockdown has been imposed are situated in densely-populated areas with limited safe spaces for physical activity, many children would default to sedentary lifestyles. Evidence suggests that at home, many children mostly engage in sedentary leisure activities such as playing digital games and snacking whilst watching television.10 It is likely that we will observe a similar situation during this crisis if appropriate measures are not put in place. Excess weight gain in children may lead to overweight and obesity, which are in turn linked to high blood pressure, high cholesterol—all of which increase the risk of non-communicable diseases such as type 2 diabetes and cardiovascular disease in the long-term.11

It is important to note that the two scenarios described above could occur concurrently, creating a co-existence of two forms of malnutrition (undernutrition and overnutrition) referred to as the double burden of malnutrition (DBM). DBM poses a complex challenge for countries which have to deal with the consequences of both forms of malnutrition occurring simultaneously.12 It’s been argued that, DBM be addressed through double-duty actions13. We pay heed, and therefore note that, while it is necessary to address the immediate impact of the COVID-19 pandemic, it is also important that we think carefully about the immediate and possible long-term negative externalities of our responses on the population, particularly on school children. The government has recommended distance learning, and the Ministry of Education together with the Ghana Education Service have provided virtual platforms to ensure that children’s educational needs are met during this challenging time, but what are we doing to meet their nutritional needs? It is equally important to implement measures to address children’s nutritional needs to maintain the progress the country has made in combating malnutrition in all its forms. On Sunday,  05 April 2020, the President, in his fifth COVID-19 update to the nation revealed that certain Ministries, together with Metropolitan, Municipal and District Chief Executives, the National Disaster Management Organisation, and some faith-based organisations have begun the delivery of dry food packages and hot meals to vulnerable populations in areas affected by the lockdown directive. This action is commendable, and the writers recommend a roll-out of this intervention to all food-insecure communities. It is also important to ensure the safety and nutritional quality of provided foods in order not to do more harm than good. Other measures that could potentially avert the negative impact of the pandemic on the nutritional status of children include nutrition education and physical activity education (such as showing examples of home-based exercises) via television and other media.

References

  1. Johns Hopkins University. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University as of Thu Apr 09 2020 12:24:01 GMT+0000 (Greenwich Mean Time)- Johns Hopkins University [Internet]. 2020 [cited 2020 Apr 9]. Available from: https://coronavirus.jhu.edu/map.html
  2. Ghana Health Service. COVID-19 Ghana’s Outbreak Response Management Updates. Situation Update, Confirmed COVID-19 Cases In Ghana as of Thu Apr 09 2020 12:27:04 GMT+0000 (Greenwich Mean Time) [Internet]. 2020 [cited 2020 Apr 9]. Available from: https://ghanahealthservice.org/covid19/
  3. National Nutrition Policy for Ghana 2013-2017 [Internet]. 2013. Available from: http://extwprlegs1.fao.org/docs/pdf/gha145267.pdf
  4. World Food Programme. School Feeding in Ghana – Investment Case – Cost Benefit Analysis Report [Internet]. 2019. Available from: https://docs.wfp.org/api/documents/WFP-0000108072/download/?_ga=2.120577227.291610574.1586033360-1940500293.1586033360
  5. World Food Programme. Global Monitoring of School Meals During COVID-19 School Closures as of Thu Apr 09 2020 12:30:24 GMT+0000 (Greenwich Mean Time) [Internet]. 2020 [cited 2020 Apr 9]. Available from: https://cdn.wfp.org/2020/school-feeding-map/?_ga=2.112644679.291610574.1586033360-1940500293.1586033360
  6. Laar A, Manu A, Laar M, El-Adas A, Amenyah R, Atuahene K, et al. Coping strategies of HIV-affected households in Ghana. BMC Public Health [Internet]. 2015;15(1):166. Available from: https://doi.org/10.1186/s12889-015-1418-x
  7. UNICEF. The State of the World’s Children 2019. Children, Food and Nutrition: Growing well in a changing world [Internet]. 2019. Available from: https://www.unicef.org/media/60806/file/SOWC-2019.pdf
  8. Barquera S, Peterson KE, Must A, Rogers BL, Flores M, Houser R, et al. Coexistence of maternal central adiposity and child stunting in Mexico. Int J Obes [Internet]. 2007;31(4):601–7. Available from: https://doi.org/10.1038/sj.ijo.0803529
  9. Zobel EH, Hansen TW, Rossing P, von Scholten BJ. Global Changes in Food Supply and the Obesity Epidemic. Curr Obes Rep [Internet]. 2016;5(4):449–55. Available from: https://doi.org/10.1007/s13679-016-0233-8
  10. Hnatiuk JA, Salmon J, Hinkley T, Okely AD, Trost S. A review of preschool children’s physical activity and sedentary time using objective measures. Am J Prev Med. 2014;47(4):487–97.
  11. Güngör NK. Overweight and obesity in children and adolescents. J Clin Res Pediatr Endocrinol [Internet]. 2014 Sep;6(3):129–43. Available from: https://pubmed.ncbi.nlm.nih.gov/25241606
  12. Tzioumis E, Adair LS. Childhood dual burden of under- and overnutrition in low- and middle-income countries: a critical review. Food Nutr Bull [Internet]. 2014 Jun;35(2):230–43. Available from: https://pubmed.ncbi.nlm.nih.gov/25076771
  13. Hawkes, C., Ruel, M. T., Salm, L., Sinclair, B., & Branca, F. (2019). Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms. The Lancet.

 

Written by: Wilhemina Quarpong, Akua Tandoh, Gideon Senyo Amevinya, Krystal Rampalli, & Amos Laar

Wilhemina is an Early Career Researcher on the MEALS4NCDs Project
School of Public Health, University of Ghana

Akua is a Ph.D Student of the School of Public Health, University of Ghana, and an Early Career Researcher on the MEALS4NCDs Project

Gideon is an Early Career Researcher on the MEALS4NCDs Project
School of Public Health, University of Ghana

Krystal is a Ph.D. Candidate in the Department of Health Promotion, Education, and Behavior at the University of South Carolina – Arnold School of Public Health. She is currently based in Accra, Ghana, working with the MEALS4NCDs project.

Amos Laar is a lecturer at the School of Public Health, University of Ghana, and Principal Investigator of the MEALS4NCDs Project.

 

 

 

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