The double burden of malnutrition—the combination of undernutrition (stunting, wasting, and micronutrient deficiencies) with overweight, obesity, and associated non-communicable diseases (NCDs)—poses an increasingly urgent set of challenges around the world, now compounded by the COVID-19 pandemic. A Dec. 1 IFPRI virtual policy seminar explored these problems and emerging solutions.
“Optimal nutrition is critical to both population health and sustainable development,” said Francesco Branca, director of the World Health Organization Department of Nutrition for Health and Development. Now the double burden, panelists said, is undermining that goal, exacerbating global food insecurity, and endangering lives.
The double burden has shifted from being primarily a problem among middle-income countries and “is now highest in low-income countries,” said Barry Popkin, W. R. Kenan Jr. Distinguished Professor of Nutrition at the University of North Carolina. A major underlying cause of these shifts, he said, is economic growth: Rates of childhood wasting and stunting have dropped around the world, and most people have greater purchasing power now than in the 1990s. At the same time, urbanization and the expansion of modern retailing have made ultra-processed and less nutritious foods widely accessible and much cheaper, driving up rates of obesity and overnutrition. As a result, 38% of the 126 low- and middle-income countries face high or severe levels of the double burden of malnutrition.
The double burden operates on an intergenerational cycle, said Jonathan Wells, a Professor of Anthropology and Pediatric Nutrition at the UCL Institute of Child Health in London. “Mothers who are undernourished have an increased risk of having children who themselves are prone to undernutrition,” he said. “The same thing applies to overweight”—overweight mothers tend to have overweight children.
However, when a rapid nutrition transition—a widespread shift in diets that coincides with major demographic and/or economic changes—occurs, many people transition from one form of malnutrition to another, often from being undernourished to becoming overweight or obese, Wells said. Such changes are dangerous: People who were thin in early life but obese in adulthood are at elevated risks of diabetes, hypertension, strokes, cardiovascular diseases, and other NCDs.
Mexico has gone through such a transition, said Simon Barquera, Director of Nutrition Policy Research at Mexico’s National Institute of Public Health. “In the last four decades, we have observed that high obesity and chronic diseases have increased and become the main public health concern,” he said. “Economic development, free trade, and globalization, among other factors, transformed the food system, which, when paired with lack of adequate governance, caused a rapid epidemiological transition.”
Many nutrition experts are now pushing to persuade people to think about all forms of malnutrition in the design of programs and policies. Indeed, undernutrion and overnutrition share many driving factors, including poor nutrition in early life, unhealthy diets, gender inequality, and poverty. Actions that tackle these drivers thus have potentional to do “double-duty,” said Corinna Hawkes, Director of the Centre for Food Policy at City, University of London. For example, a program that promotes healthy diets in young children can help reduce the risk of both undernutrition and overweight.
Getting the balance right can be a problem. Some interventions geared towards alleviating hunger can perversely lead to increases in overweight, Hawkes noted. “Many efforts that we’ve seen—laudable efforts—designed to make sure that people have enough food haven’t really considered the quality of that food,” she said. For example, a cash transfer program in Mexico improved recipients’ general health and alleviated poverty, but also increased rates of maternal overweight, probably because beneficiaries use the cash to consume more calories, but not more nutritious diets. In theory, she said, such programs can be redesigned to take incorporate counseling on healthy diets and lifestyle and improve nutrition and prevent overweight.
Early research supports the effectiveness of double-duty interventions. Rachel Nugent, Vice President and Director at RTI International’s Center for Global Non-Communicable Diseases, worked on a study that, while based on modeling and thus not conclusive, found that a hypothetical double-duty school breakfast program would significantly improve recipients’ economic outcomes. By tackling undernutrition, the program would reduce student stunting rates and increase the number of years they spent in school, thus increasing their earnings later in life. By tackling obesity, the program would reduce students’ future medical costs by helping them to avoid developing obesity-related NCDs. Fifty four percent of the estimated economic benefits were associated with avoiding stunting and 46% were associated the benefits of avoiding obesity.
While reshaping social safety nets and food systems as double-duty actions may be effective, changing such systems is nearly impossible without “a really solid policy narrative” that relays the urgency of action, said Abigail Perry, Head of Nutrition Policy and Senior Nutrition Adviser at the UK Foreign, Commonwealth & Development Office. Victor Aguayo, UNICEF Programme Division Associate Director & Global Chief of Nutrition, also emphasized the challenge of communicating the public health threat that overweight and obesity pose, in addition to the persistent problem of childhood undernutrition.
Meera Shekar, the World Bank Global Lead on Nutrition, Health, & Population, closed the discussion by urging nutrition experts to use their work to trigger change: “How are we going to make sure that these … double-duty actions … are actually implemented at scale? That is absolutely critical. Otherwise, we keep talking in the academic world but it never gets translated into action, and that, I think, is one of nutrition’s many failings.”
“Political will is absolutely critical to make this happen,” Shekar said.
Timothy Karoff is a former IFPRI Communications Intern.
