{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T16:58:31Z","timestamp":1790614711903,"version":"4.1.0"},"reference-count":64,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,1,21]],"date-time":"2021-01-21T00:00:00Z","timestamp":1611187200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nutr."],"abstract":"<jats:p><jats:bold>Background:<\/jats:bold> Although reasonable to assume, it is not yet clear whether malnourished countries are at higher risk for severe or fatal coronavirus disease 2019 (COVID-19). This study aims to identify the countries where prevalent malnutrition may be a driving factor for fatal disease after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold> Using estimates from the Global Burden of Disease 2019, country-level burden of malnutrition was quantified using four indicators: death rates for child growth failure (underweight, stunting, and\/or wasting) and years lived with disability (YLD) attributed to iron and vitamin A deficiencies and high body mass index (BMI). Global mortality descriptors of the ongoing COVID-19 pandemic were extracted from the European Centre for Disease Prevention and Control, and case fatality ratios (CFRs) were calculated introducing a lag time of 10 weeks after the first death of a confirmed case. Bivariate analyses for 172 countries were carried out for malnutrition indicators and fatal COVID-19. Correlations between burden indicators were characterized by Spearman's rank correlation coefficients (\u03c1) and visually by scatterplots. Restricted cubic splines and underlying negative binomial regressions adjusted for countries' age-structure, prevalent chronic comorbidities related to COVID-19, population density, and income group were used to explore non-linear relationships.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> Stratified by the World Bank income group, a moderate positive association between YLD rates for iron deficiency and CFRs for COVID-19 was observed for low-income countries (\u03c1 = 0.60, <jats:italic>p<\/jats:italic> = 0.027), whereas no clear indications for the association with child growth failure, vitamin A deficiency, or high BMI were found (\u03c1 &amp;lt; 0.30). Countries ranking high on at least three malnutrition indicators and presenting also an elevated CFR for COVID-19 are sub-Saharan African countries, namely, Angola, Burkina Faso, Chad, Liberia, Mali, Niger, Sudan, and Tanzania, as well as Yemen and Guyana.<\/jats:p><jats:p><jats:bold>Conclusions:<\/jats:bold> Population-level malnutrition appears to be related to increased rates of fatal COVID-19 in areas with an elevated burden of undernutrition, such as countries in the Sahel strip. COVID-19 response plans in malnourished countries, vulnerable to fatal COVID-19, should incorporate food security, nutrition, and social protection as a priority component in order to reduce COVID-19 fatality.<\/jats:p>","DOI":"10.3389\/fnut.2020.619850","type":"journal-article","created":{"date-parts":[[2021,1,21]],"date-time":"2021-01-21T05:56:26Z","timestamp":1611208586000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":69,"title":["The Burden of Malnutrition and Fatal COVID-19: A Global Burden of Disease Analysis"],"prefix":"10.3389","volume":"7","author":[{"given":"Elly","family":"Mertens","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jos\u00e9 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