Forging a strategy to tackle double malnutrition burden

We spoke with Stineke Oenema, Global Coordinator of the UN System Standing Committee on Nutrition about what the current double burden of malnutrition in low and middle-income countries looks like and what needs to be done to tackle its presence.

In Lancet’s research series exploring the double burden of malnutrition​, the authors emphasize that it is no longer possible to identify countries as low-income and undernourished, or alternatively, high-income and therefore only experiencing obesity. The presence of double malnutrition does not display simplistic divergence in this way.

Understanding the cause and effect of DBM​

The double burden of malnutrition (DBM) is defined as the “simultaneous manifestation of both undernutrition and overweight and obesity”.​ Notably, it affects most low-income and middle-income countries (LMICs), the research paper stated.

Undernutrition is recognized throughout the globe by micronutrient deficiencies, underweight individuals, childhood stunting and wasting. The coexistence of undernutrition and overweight, obesity, and diet-related non-communicable diseases is present. Yet, around the world, the international health community has been “slow to acknowledge the challenge of the large proportion of LMICs”,​ experiencing DBM.

The DBM has grown in the poorest LMICs and notably, mainly due to an increase in the number of overweight individuals, the paper pointed out. The prevalence of overweight is also mainly as a result of “very rapid changes in the food system, particularly the availability of cheap ultra-processed food and beverages in LMICs, and major reductions in physical activity at work, transportation, home, and even leisure due to introductions of activity-saving technologies”​.

Researchers identify that LMICs continue to have a high DBM. Yet, high-DBM countries have lower incomes than the countries that previously had a high DBM in the early 1990s. It is the “rapid increases in the prevalence of overweight and obesity occurring in these lower-income countries that are also experiencing a slower decline in the prevalence of undernutrition”, ​that is driving high DBM levels.

To directly tackle the severe levels of DBM that the lowest LMICs are facing, strategic emphasis needs to focus on equipping organizations and individuals with knowledge on the key drivers of DBM and the potential ways to address it at all levels.

Diverging malnutrition ​

Commenting on what is causing the growth of both forms of diverging malnutrition, Stineke Oenema, Global Coordinator of the UN System Standing Committee on Nutrition states that “there is a set of common drivers that are causing these multiple forms of malnutrition”. ​

In addition to dietary factors, other caution factors include early life nutrition, food systems and food environments, governance, socio-economic factors and biology.

While we, as individuals, are unable to change some of the factors, “some we can”​, Oenema reveals. Stating that “breastfeeding is essential”​, for example, Oenema highlights the importance of early life nutrition, along with the quality of our diets, our food environments and socio-economic factors such as income and education.

Socio-economic aspects, for example, which is “very much related to inequality” ​through factors such as income, gender and ethnicity, are an “important base cause of poverty and malnutrition”​.

Calls for nutrition overhaul​

Analysis into the health and nutrition crisis explores the stage of the nutrition transition as a core problem, epitomized by lowered physical activity and increased access to less healthy, highly processed foods and beverages. However, the paper emphasizes that “how to translate this evidence into effective actions is unclear”.​

The nutrition reality is characterized by “multiple forms of malnutrition that overlap in different ways and in different places​”. In addition, if we are to effectively tackle and address all forms of malnutrition, globally we will need to design, target and implement programs and policies to accelerate progress in improving nutrition globally.

Data in the research study shows there is a growing prevalence of overweight and obesity among lower-wealth households in numerous countries in Latin America and the Caribbean. However, in Colombia, for example, the proportion of children that have both stunting and overweight ranges from less than 1%.

Dietary choices and changes ​

However, today, the “biggest risk factor for the global burden of disease is unhealthy diets”​, Stineke Oenema, Global Coordinator of the UN System Standing Committee on Nutrition revealed.

The rise in retail food has led to a transformation in the entire food supply chain, which namely involves agribusinesses, retailers, manufacturers and foodservice providers. These actors have also replaced global and national public sectors as the key influences of diets in LMICs as they have contracts directly with farmers.

Simultaneously, the consumption of ultra-processed food purchases in LMICs has increased, largely due to their low cost and convenience. In Latin America and the Caribbean, research indicates that packaged processed food sales have grown from approximately 10% of all food expenditures in 1990 to 60% in 2000.

In Chile, for example, non-essential food and beverage or junk foods and sugar-sweetened beverages sales have increased in popularity, sales volume data from intelligence provider Euromonitor International revealed.

Society at large​

Urbanization, city migration, growing incomes, improving infrastructure and trade policy liberations are core factors heavily influencing investment in the food sector in LMICs.

A power shift towards large-scale food retailers, manufacturers and food-service companies have dominated global markets, following contemporary marketing techniques and mass media access. However, the paper highlights how both smaller local businesses and the informal sector “remain understudied components of the food sector who are often important sources of food for low-income and rural populations”. ​

Current challenges ​

The biggest challenges to overcoming the DBM relates to nutrition governance. Nutrition is “multi-sectoral”​, Oenema states. As a result, managing nutrition “needs to account for the impact on nutrition from several sectors”. ​Emphasizing the associated challenges of these numerous influences, Oenema rhetorically asks: “Who is leading in the end?”​.

While many countries are establishing nutrition coordination mechanisms in higher levels of government, “finance needs to follow the double burden”​ instead of the current reality, where “a lot of finance is still geared towards undernutrition”​. This “needs to change”​. Revealing the imbalance in financial distribution for obesity, for example, Oenema highlights how obesity is still “excluded from the global estimates of costs of the elimination of malnutrition”​.

While separate frameworks for undernutrition and overweight/obesity exist, combined frameworks are lacking, Oenema stated. As a result, “research in this area is recommended”​, to progress efforts to address and overcome the prevalence of the DBM.

In Latin America, there are divergent views on tackling malnutrition​, which requires analysis and strategic answers, DPE International Consulting’s David Pineda Ereño revealed speaking to NutraIngredients LATAM in 2019.

Actions spearheading progress​

In 2020, a number of key actions are taking place to tackle double malnutrition. Delivering actions through health services, social safety nets, education and schools, and agriculture are core mechanisms to communicate and overcome the prevalence of DBM.

The mid-term review of the Decade of Action ​on nutrition (2016-2025), along with the Nutrition for Growth​ event, calls upon actors to do specific measurable realistic and timebound commitments (SMART) to tackle malnutrition. “These commitments will lead to increased investments in nutrition and (hopefully) in increased double-duty actions,”​ Oenema relayed.

Avoiding a siled approach moving forward, research shows that the new reality shows that undernutrition and overnutrition are interconnected. As a result, “double-duty actions that simultaneously address more than one dimension must be implemented for policy solutions to be effective”,​ the Lancet revealed in its discussion on A future direction for tackling malnutrition​.

“Understanding and tackling the drivers of the food system shift, and enacting effective policies that address the challenges of the DBM, are urgently needed,”​ the DBM report stated.