Traditionally, the term “malnutrition” has been applied to problems such as micronutrient deficiencies, adult underweight, and childhood wasting (thinness) and stunting (shortness), seen largely in poor populations of low- and middle-income countries. In contrast, overweight, obesity, and diet-related noncommunicable diseases (NCDs) have been viewed as problems of affluence, affecting mostly wealthier populations in industrialized countries.
The new Lancet Series on the Double Burden of Malnutrition (DBM), launched Dec. 16 in London, highlights that overweight and obesity are also forms of malnutrition that now coexist with the persistent problems of nutritional deficiencies in most countries around the world, especially in low- and-middle income countries. As the first paper establishes, these multiple forms of malnutrition are now found within countries, communities, households, and even individuals and reflect a “new nutrition reality” that will require new strategies, programs, and policies to successfully tackle.
What is driving this new reality? The second paper examines the causes, and describes how the different forms of malnutrition are intrinsically linked through biological pathways that start as early as in utero and thread through lifetime nutrition and health trajectories. For example, people who experience early-life undernutrition are at a greater risk of becoming overweight or obese as they move into adulthood; and those who do become overweight or obese are more susceptible to developing diet-related NCDs, such as diabetes or cardiovascular diseases, than those well-nourished early in life.
These increased susceptibilities are now more acute than ever before because of the rapid nutrition transition taking place in low- and middle-income countries—that is, the changes in food systems and food environments that give everyone, even poor populations in rural areas, easy access to processed and ultra-processed foods that are too high in energy, (saturated) fats, and added sugar and salt, and that compete with or replace traditional diets rich in whole grains, pulses, and fresh fruits and vegetables.
The series’ third paper, which Corinna Hawkes and I co-authored with Leah Salm, Bryony Sinclair, and Francesco Branca, focuses on how to respond to this new nutrition reality. How can nutrition actions be redesigned to simultaneously tackle all forms of malnutrition? Which actions need redesigning? We argue that a paradigm shift is needed to break the silos of undernutrition and overweight and obesity, and that we must take a broader and more comprehensive view of malnutrition in all its forms as we develop programs and policies to improve nutrition at scale. It is crucial that we do so, because evidence shows that our current siloed approach can and has at times caused harm.
Unintended consequences
It may come as a surprise that some of the most lauded nutrition-sensitive programs for tackling food insecurity and childhood undernutrition have also had harmful unintended consequences. Take, for example, Mexico’s PROGRESA/Oportunidades program, which for three decades distributed cash to women in poor households to increase their incomes and access to food and promoted investments in children’s education, nutrition, and health. This rigorously evaluated program helped reduce poverty, improved child nutrition and education outcomes, and increased use of preventive healthcare services. But it was also associated with greater overweight and obesity and higher risks of diet-related NCDs in adult women compared with those in nonbeneficiary households.
Similarly, a maternal and child health and nutrition program in Guatemala that provided fortified food supplements to mothers and children during the first 1,000 days (from pregnancy until the child’s second birthday) succeeded in reducing child stunting. But it also led to greater maternal weight retention during the first two years after childbirth compared with nonbeneficiary women.
Both of these programs were targeted to poor populations and achieved their intended goals. Yet both inadvertently caused harm in mothers by exacerbating existing problems of overweight and obesity in the population, particularly among women. These programs had been designed to address poverty and food insecurity using traditional approaches and common poverty-targeting mechanisms, but they failed to take into account the fact that the targeted households already had access to sufficient or excess energy in their diets, even if access to high-quality, diverse diets was limited.
A third example comes from the Guatemala Oriente Study, which examined the long-term effects of early-life protein, energy, and micronutrient supplementation on nutrition and health, from early childhood to adulthood. The intervention was carried out in rural Guatemala in the late 1960s and early 1970s and targeted mothers during pregnancy and children up to age 7. The study tracked and followed the participants until adulthood.
The intervention succeeded in improving growth and cognitive development, especially for those exposed to the supplement before reaching 2 years of age. Follow-ups showed long-term benefits on child physical growth, development, and schooling, as well as on adult height, body composition, cognition, health, and economic productivity. The latest follow-up (when the subjects were between 37 and 54 years old), however, revealed mixed effects on diet-related NCDs—positive on reducing diabetes, but negative on increasing obesity, body mass index, and abdominal fat. By following participants through adulthood, the study showed that both long-term benefits and unintended harm may result from successful programs aimed at improving child nutrition.
“Double-duty” actions
The common thread in all three examples is the fact that the programs were implemented in countries undergoing rapid nutrition transition and food system modernization. The long-term changes in food systems in Guatemala since the 1960s and the penetration of processed and ultra-processed foods and fast food chains throughout the country, including in rural areas, were hard to foresee. Yet similar structural transitions are now happening, at much faster rates, all over Africa and South Asia. To avoid causing harm there while making nutrition gains, we must embrace a more holistic approach to nutrition that integrates actions to tackle all forms of malnutrition (“double duty” actions) and considers both the short- and long-term impacts.
We can do this using existing platforms in health, social protection, and education settings, and in agriculture, food systems, and food environments. Likewise, we do not need to completely overhaul how we design and implement nutrition programs and policy. Although some cases will require new program designs, often the necessary changes will demand only small adjustments to ongoing programs, such as broadening the scope of behavior change communication strategies for infant and young child feeding to include messaging on healthy snacks and beverages.
Before Mexico’s government shut down PROGRESA/Oportunidades in early 2019, for example, the program made such corrective adjustments—revamping its behavior change communication strategy to emphasize healthy diets and physical activity, changing micronutrient supplements to avoid providing unnecessary calories, and incorporating health check-ups for early detection of diet-related NCDs among adult family members. There are other examples of “early” double-duty actions implemented as a response to the realization of harm from social safety net or school feeding programs in other Latin American countries and in Egypt.
In our Lancet paper, we suggest a series of 10 double-duty actions that can be implemented in the short term in the areas of health services, social safety nets, education, and food systems.
Source: The Lancet/WHO based on Hawkes et al (2019)
Not only is designing and implementing such actions—using either new or ongoing programs—feasible, doing so is absolutely critical for a world that is free of all forms of malnutrition. At the Lancet Series launch, Corinna Hawkes said, “We need to stop saying that we focus on undernutrition or that we are experts in overweight and obesity. We need to think and act on all forms of malnutrition.” And indeed, in order for us to make such adjustments to program and policy design, we must first shift our mindset, strategy, and vision to tackle malnutrition in all its forms, everywhere, and for all people, at all stages of the life course.
Marie Ruel is Director of IFPRI’s Poverty, Health, and Nutrition Division.
