The Double Burden of Malnutrition: A recent research on World Obesity Day

The double burden of malnutrition (DBM) is the coexistence of both undernutrition (I.e., underweight, and childhood stunting and wasting) and overweight, obesity, and noncommunicable diseases. DBM affects most low-income and middle-income countries (LMICs). There are three types of DBM: [1]

• Country-level DBM is defined as having a high prevalence of both undernutrition and overweight in at least one population group.
• Household-level DBM is defined as one or more individuals with wasting, stunting, or thinness and one or more individuals with overweight or obesity within the same household.
• Individual-level DBM is defined as a child having both stunting and overweight.

Double-duty actions, which aim to simultaneously tackle both undernutrition and problems of overweight, obesity, and diet-related noncommunicable diseases (DR-NCDs), have been proposed to effectively address malnutrition in all its forms. [2]

Dynamics of the double burden of malnutrition and the changing nutrition reality[1]

Key points:

• This study analyzed data from 126 LMICs, where 38% of countries were facing DBM (using the 20% overweight prevalence cutoff).
• Based on World Bank Regions, country-level DBM is especially prevalent in sub-Saharan Africa, south Asia, and east Asia and the Pacific.
• The prevalence of household-level DBM ranges from less than 3% to nearly 35%, among LMICs analyzed.[1]
• The proportion of children (aged 0-4 years) who have both stunting and overweight ranges from less than 1% to more than 15%, among LMICs analyzed.
• People in the poorest income quintile face a greater prevalence of overweight and obesity than do those in higher income quintiles.
• Countries that have a new DBM (developed DBM since the 1990s) at any overweight or obesity prevalence threshold are predominantly in the lowest quartiles of GDP (I.e., lower income countries). This reflects increases in overweight/obesity among lower income countries where population levels of stunting and/or wasting have not declined.
• These increases in overweight/obesity are largely the result of rapid, increased availability and consumption of ultra-processed foods.
  • Changes in the retail food environment have contributed to this shift. Fresh markets are increasingly disappearing, with large and small food retailers (who sell more processed packaged foods) replacing them.
  • The actors who control the food supply are also changing. In LMICs, control of the food supply has shifted from the public sector to food retailers, food agribusinesses, global food companies, and the food service sector often have direct contracts with farmers, and thus, greater control of the food system.

Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms[2]

Key points:

• Drivers of malnutrition include:
  • Early-life nutrition: inadequate nutrient intake in early life leads to undernutrition in infants and predisposes infants to a more central distribution of body fat if they gain weight later in life. Compared to adults who did not experience early undernutrition, individuals who did experience early undernutrition experience DR-NCDs at lower body-mass index (BMI) thresholds.
  • Diet quality: high-quality diets reduce the risk of malnutrition in all its forms by promoting healthy growth, development, and immunity, and preventing obesity and DR-NCDs. The components of healthy diets are: optimal breastfeeding practices in the first 2 years; a diversity and abundance of fruits and vegetables, wholegrains, fibers, nuts, and seeds; modest amounts of animal food sources; and minimal amounts of processed meats, and foods high in energy, free sugar, saturated fat, trans fat, and salt.
  • Food environments: the foods available to people, the costs of these foods, and how they are marketed and promoted are common drivers of DBM due to their role in shaping what people eat. Evidence shows that healthier food environments are associated with greater intake of nutritious foods.
  • Socioeconomic factors: Income and education are important drivers for the risk of undernutrition, obesity, and DR-NCD. Rises in income per capita are associated with reductions in child stunting. Education, which is closely associated with income and wealth, has generally positive influences on nutrition.
• This paper identifies ten double-duty actions in four broad categories that have strong potential to reduce the risk of both undernutrition, obesity, and DR-NCDs:
  • Health services
• Scale up new WHO antenatal care recommendations
• Scale up programs to protect, promote, and support breastfeeding
• Redesign guidance for complementary feeding practices and related indicators
• Redesign existing growth monitoring programs (GMPs)
• Prevent undue harm from energy-dense and micronutrient fortified foods and ready to use supplements
  • Social safety nets
• Redesign cash and food transfers, subsidies, and vouchers
  • Educational settings
• Redesign school feeding programs and devise new nutritional guidelines for food in and around educational institutions
  • For example, ensure that guidelines for school feeding programs and food provided by the commercial sector in day care, preschools, and schools meet energy and nutrient needs and restrict foods, snacks, and beverages high in energy, sugar, fat, and salt
  • Agriculture, food systems, and food environments
• Scale up nutrition-sensitive agriculture programs
• Design new agricultural and food system policies to support healthy diets
• Implement policies to improve food environments from the perspective of malnutrition in all its forms These policies include:
  • Eliminate the promotion of breastmilk substitutes and reduce marketing of foods, snacks, and beverages high in energy, sugar, fat, and salt
  • Monitor and restrict nutrition and health claims on foods, snacks, and beverages high in energy, sugar, fat, and salt
  • Use well targeted taxes on foods, snacks, and beverages high in energy, sugar, fat, and salt and subsidies for nutritious foods
  • Improve nutritional quality of the food supply through incentives to community food production, fortification, biofortification, and reformulation
  • Set incentives and rules for retailers and traders to ensure a healthier community food environment

Economic effects of the double burden of malnutrition[3]

Key points:

• There are several challenges to estimating the economic effects of the double burden of malnutrition. Existing economic models are not designed to measure the effects of DBM, as there are different long-term health outcomes for chronic undernutrition and overweight, which are often evaluated separately, not easily measured health and economic effects of poor nutrition, and a scarcity of data on malnutrition.
• Some studies have modeled the effects of undernutrition or overweight/obesity.
  • The economic effects of stunting include cognitive and other developmental deficits that affect lifetime productivity, greater incidence of parasitic and infectious disease that cause physical impairments, and greater risk of chronic disease in adults, leading to high medical and indirect costs.
    • One estimate of the economic costs of chronic undernutrition found GDP losses of up to 12% in some LMICs and totaling 8% of global GDP during the 20^th century. [4]
  • Studies of the economic burden of overweight generally look at the cost-of-illness from obesity and related noncommunicable diseases, direct and indirect medical costs, or productivity losses associated with early mortality and morbidity.
• Few studies have measured the economic costs of DBM.
  • One model developed by the Economic and Social Commission of Latin America and the Caribbean, and the World Food Programme (known as the ECLAC-WFP model) separately measures effects of undernutrition and obesity. Results from this model find the economic burden of DBM to range from 0.2% of GDP (in Chile) to 4.3% of GDP (in Ecuador). [5]
• Programs and policies can be designed to address malnutrition in all its forms. These “double-duty” interventions may simultaneously reduce undernutrition and overweight. One example of these programs are school feeding interventions, which have been shown to have positive effects on stunting and obesity.
  • This study modeled the economic effects of school breakfast feeding programs on DBM in developing countries (specifically Guatemala, Indonesia, and Nigeria). In all three countries, school breakfast programs provided substantial benefits that outweighed the costs of implementation.
    • The benefits of the program include the economic value of increased education (and future earnings) for children who avoid stunting and the economic value of averting premature mortality due to obesity related causes. Net benefits ranged from US$ 206 million (in Guatemala), 2.3 billion (in Nigeria), and 3.1 billion (in Indonesia).

The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable[6]

Key points:

• The nutrition transition is a model that describes the large shifts that have occurred in human diets and activity patterns. Over the last three to four decades, many countries and regions have dramatically moved into the stage of the nutrition transition defined by high consumption of ultra-processed foods (UPFs) and significant reductions in physical activity.
• These dietary changes contribute to increasing rates of noncommunicable diseases (NCDs).
• These shifts are causing many countries, including India, Indonesia, and sub-Saharan Africa countries, to face high levels of DBM.
  • In addition to undernutrition and overweight/obesity, many countries are also experiencing micronutrient malnutrition, known as the triple burden of malnutrition.
•  A number of factors have contributed to these dietary shifts towards increased UPF consumption, including:
  • Urbanization: the increasing spread of urban functions to smaller towns and rural areas has led to rapid increases in obesity among rural populations, with rural obesity being more prevalent than urban obesity in many countries.
  • Incomes: rising incomes globally have changed what we eat, the proportions of our diets consumed away from home, and our snacking habits. Rising income inequalities have also been found to be linked to prevalence of individuals with obesity. UPFs have a relatively cheap cost per calorie, and their ready-to-eat availability saves time costs for urban workers.
  • Increased formal labor force participation: as incomes rise, workers increasingly seek and consume processed foods as they are seen to save time and money.
  • Food industry: the industry has created affordable, convenient and hyperpalatable UPFs that are ready to eat or ready to heat, displacing traditional food preparation methods.
• The prolonged dominance of UPFs is not inevitable, and can be counteracted with policies that support healthful diets, such as:
  • Chile’s multipronged, mutually reinforcing set of policies that includes mandatory front of pack warning labels, marketing restrictions, and school food bans.
  • Brazil’s National School Feeding Program, which reaches over 150,000 schools and over 40 million children. This is the first national school food program in the world with a mandatory farm-to-school component to increase healthy food in schools and support local farmers and economies.

References

1. Popkin BM, Corvalan C, Grummer-Strawn LM. Dynamics of the double burden of malnutrition and the changing nutrition reality. The Lancet 2020;395(10217):65-74

2. Hawkes C, Ruel MT, Salm L, Sinclair B, Branca F. Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms. The Lancet 2020;395(10218):142-55

3. Nugent R, Levin C, Hale J, Hutchinson B. Economic effects of the double burden of malnutrition. The Lancet 2020;395(10218):156-64

4. Horton S, Steckel RH. Malnutrition: global economic losses attributable to malnutrition 1900–2000 and projections to 2050. How Much Have Global Problems Cost the Earth? A Scorecard from 1900 to 2013;2050:247-72

5. Martínez R, Fernández A. Model for analysing the social and economic impact of child undernutrition in Latin America: ECLAC, 2007.

6. Popkin BM, Ng SW. The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra‐processed foods is not inevitable. Obesity Reviews 2021

[1] Countries with a household-level DBM prevalence above 20% include: Albania, Azerbaijan, Comoros, Egypt, Guatemala, Indonesia, Lesotho, Morocco, Sao Tome and Principe, Sierra Leone, Swaziland, and Tajikistan