Article Text

Economic inequality in malnutrition: a global systematic review and meta-analysis
  1. Rotimi Alao1,
  2. Hayaan Nur1,
  3. Emily Fivian1,
  4. Bhavani Shankar2,
  5. Suneetha Kadiyala1,
  6. Helen Harris-Fry1
  1. 1Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
  2. 2Department of Geography, The University of Sheffield, Sheffield, UK
  1. Correspondence to Dr Helen Harris-Fry; helen.harris-fry{at}


Objective To describe the evidence on global and regional economic inequality in malnutrition, and the associations between economic inequality and malnutrition.

Methods We conducted a systematic review and meta-analysis. Between 1 November 2020 and 22 January 2021, we searched Medline, Embase, Global Health, Eldis, Web of Science and EBSCO Discovery Service. We contacted 39 experts and tracked citations. We included any study reporting a concentration index (CIX) relating economic status and nutritional status and any multilevel study reporting an association between economic inequality and nutritional status. Nutritional status was measured as stunting, wasting, anaemia, or overweight in children (<5 years), or underweight, overweight or obesity, or anaemia in adults (15–49 years). We had no study date or language restriction. Quality was assessed using the Appraisal Tool for Cross-Sectional Studies (AXIS tool). We mapped estimates and pooled them using multilevel random-effects meta-analyses.

Results From 6185 results, 91 studies provided 426 CIX (>2.9 million people) and 47 associations (~3.9 million people). Stunting (CIX −0.15 (95% CI −0.19 to −0.11)) and wasting (−0.03 (95% CI −0.05 to −0.02)) are concentrated among poor households. Adult overweight and obesity is concentrated in wealthier households (0.08 (95% CI −0.00 to 0.17)), particularly in South Asia (0.26 (95% CI 0.19 to 0.34)), but not in Europe and Central Asia (−0.02 (95% CI −0.08 to 0.05)) or North America (−0.04 (95% CI −0.10 to 0.03)). We found no association between 0.1 increase in Gini coefficient and adult underweight (OR 1.03 (95% CI 0.94 to 1.12)) or overweight and obesity (0.92 (95% CI 0.80 to 1.05)).

Conclusions There is good evidence that the prevalence of malnutrition varies by levels of absolute economic status. Undernutrition is concentrated in poor households, whereas concentration of overweight and obesity by economic status depends on region, and we lack information on economic inequalities in anaemia and child overweight. In contrast, links between malnutrition and relative economic status are less clear and should not be assumed; robust evidence on causal pathways is needed.

PROSPERO registration number CRD42020201572.

  • systematic review
  • nutrition

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  • RA and HN are joint first authors.

  • Handling editor Seye Abimbola

  • Contributors HH-F, RA and SK conceptualised the systematic review with inputs from BS, EF and HN. RA and HN conceived and ran the search strategy with inputs from HH-F. HN, RA and EF screened references retrieved, selected eligible studies based on the eligibility criteria and critically appraised studies. HN conducted the statistical analyses, with support from HH-F. RA, HN and HH-F wrote the manuscript with inputs from SK, EF and BS. Guarantors HH-F, RA, and HN accept full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.

  • Funding Funding of RA and HN was provided by Innovative Methods and Metrics for Agriculture and Nutrition Actions (IMMANA). IMMANA is cofunded with FCDO from the UK government (Project 300654) and the Bill & Melinda Gates Foundation (Investment ID INV-002962). Funding of author HH-F was provided by a Sir Henry Wellcome grant (210894/Z/18/Z). All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Disclaimer The study funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. We confirm the independence of researchers from funders.

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  • Competing interests All authors have completed the ICMJE uniform disclosure form at and declare: HN, RA and EF had financial support from IMMANA (co-funded by FCDO and Bill & Melinda Gates Foundation) and HH-F had financial support from Wellcome Trust for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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