Double burden on the poor
Populations in more than one in three low-income countries are hit by a double burden of malnutrition in the form of both obesity and undernutrition. Effective nutrition programmes can help countries overcome the double malnutrition challenge
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Malnutrition in its various forms affects every country in the world. According to the Global Nutrition Report 2020, 149 million children under five are stunted (short for their age) and 49.5 million are wasted (thin for their height). At the other end of the spectrum, tens of millions of adults and children are obese.
Conventional wisdom used to suggest that under-nutrition mainly affected developing countries, while obesity was only a problem in developed economies. But this picture is now out of date. Worldwide, food systems that used to change very slowly, across centuries, are now being transformed within generations. The result is that many low and middle-income countries (LMICs) now face a “double burden of malnutrition” (DBM), seeing a rapid rise in obesity levels while still struggling to reduce the number of children and adults who are severely undernourished.
A recent series of papers published in UK-based medical journal The Lancet reported that of 126 LMICs for which data exist, 48 are seeing a severe DBM, where a significant percentage of children are undernourished and at least 20% of adults are overweight or obese. Research also suggests the problem is shifting towards countries in the lowest income bracket in sub-Saharan Africa and Asia, whose health systems are least equipped to cope with it.
Malnutrition in all its forms exerts a heavy toll, not only on people’s health but on economic growth. The United Nations Food and Agriculture Organization (FAO) estimates that undernutrition costs up to $2.1 trillion a year. It estimates the costs of overweight and obesity at US$ 1.4 trillion a year, which includes the costs of diet-related non-communicable diseases (NCDs).
Children who are undernourished as infants and become overweight as adults are at higher risk of developing diet related NCDs, such as type 2 diabetes or certain cancers. The impact of increased healthcare costs and reduced productivity throughout life can perpetuate a cycle of ill-health and poverty, according to the World Health Organization (WHO).
Call for double-duty actions
In 2016, the United Nations declared a Decade of Action on Nutrition, with the aim of “eliminating malnutrition in all its forms” by 2025. A year later, the WHO published a policy brief that urged countries and international agencies to tackle the DBM where it exists. It calls for the use of evidence-based “double-duty actions”, described as interventions that have the potential to improve undernutrition and reduce obesity at the same time. Actions start with programmes of healthcare and nutrition for pregnant women and children under two and include policies to provide access to healthy foods throughout the life course.
Programmes to promote breastfeeding, subsidised or free school meals and social security safety nets are already established in many LMICs. But not all policies that deal with undernutrition in childhood are designed with the additional aim of minimising the risk of obesity and NCDs in later life. Examples of counter-productive programmes might be those that provide subsidised foods that are high in fat, sugar and salt, or provide cash to buy foods where unhealthy foods are cheap and available.
“Double-duty or even triple-duty programmes and policies aren’t rocket science,” says Lucy Westerman at the NCD Alliance, an international network of 2000 organisations that campaigns for NCD prevention and control. Triple-duty adds sustainable development and climate change. “We’d like to say progress on these actions, which efficiently give multiple returns, has been booming,” she says. “But the prevalence of diet-related NCDs and obesity is rising in all countries, including those where undernutrition has previously dominated nutrition concerns.”
Despite the high-level focus on the challenge of the DBM, evidence suggests that few countries have fully embraced the concept of taking a holistic approach to the problem. According to the Global Nutrition Report, 42% of countries have nutrition targets that include undernutrition and obesity, while 84% have targets for tackling overweight or obesity in adults. But advocates and funding streams for different forms of malnutrition often operate as separate action silos, says Lawrence Haddad, executive director of the Global Alliance for Improved Nutrition (GAIN). “People who are concerned with undernutrition tend to approach it through the health system, while those who worry about obesity and NCDs work through the food system and infrastructure—healthy food choices and exercise,” he says.
“But food and food systems are at the core of all forms of malnutrition.”
GAIN recently launched an online Food Systems Dashboard together with the UN’s FAO and the Johns Hopkins Alliance for a Healthier World. The dashboard presents data on food systems in 230 countries, covering up to 170 indicators from 35 sources. Its stated aim is to halve the time it takes policymakers to describe, diagnose and make decisions on food system challenges in their countries.
“We’ve designed the dashboard very much with the DBM in mind,” says Haddad. “We are filtering evidence from peer-reviewed reports that translates into plausible, feasible actions that have been shown to work. The aim is to help policymakers make no-regrets decisions that will improve weaker spots in their food systems.”
Other resources for policymakers include the NOURISHING policy framework and database, set up by the World Cancer Research Fund (WCRF) to highlight where governments need to take action to promote healthy diets and reduce overweight and obesity.
In mid 2020 the database had more than 700 policies and was collecting additional policies from around the world. “Policy makers will have access to even more information about how governments are taking action,” says Kate Oldridge-Turner, head of policy and public affairs at the WCRF.
Governments cannot afford to allow coronavirus to shelve smart, cost-effective, evidence-based policies that improve nutrition
As well as good data, education for healthcare professionals and policymakers is also key to building malnutrition prevention over a lifetime, says Roger Shrimpton, a former secretary of the UN Standing Committee on Nutrition.
“Child survival is a compelling motive for donors and leaders to support programmes for undernutrition, but there’s a lack of understanding about the causes of overnutrition,” he says. “There’s an assumption that obesity is a result of simply eating too much, whereas it’s a question not just of how much, but what you eat.”
Shrimpton is a founder member of the World Public Health Nutrition Association, which offers training and certification to help public health workers achieve health and nutrition objectives within their own food systems.
Shrimpton says he is “not very optimistic” about the ability of individual governments and NGOs to withstand global forces affecting food and health.
The world cancer fund’s Oldridge-Turner agrees there are difficulties in a world where global companies and institutions dominate many food systems. “Our research has found that industry interference is one of the most significant, overarching challenges to designing robust nutrition policies that promote healthy diets,” she says. “This can range from attempting to derail policy development processes to issuing legal challenges to implemented policies.”
Lack of cost data
A stronger case for double-duty actions still needs to be made to influence countries to act, says Rachel Nugent, vice president of global non-communicable diseases at RTI International in Washington DC. “One thing that’s needed is an agreed definition of DBM that easily shows what’s harmful about it,” she adds.
The cost of the combined effects of obesity and undernutrition to healthcare systems and economies is hard to pin down—and this in turn makes it harder to measure the cost-effectiveness of interventions to tackle the DBM. Nugent says her work in this area is hampered by not having evidence of effective outcomes stemming from DBM-specific interventions.
“I’m not very confident that use of double-duty interventions will be widely adopted until we do better measurement of DBM impacts in a wide range of nutrition programming, ranging from emergency to school feeding to agricultural policy,” she says.
That said, the UN’s Shrimpton believes policymakers should not let a lack of gold-standard evidence deter them from implementing what is likely to work. “If we know an intervention is effective, we should do it,” he says. “You don’t need absolute certainty that a double-duty intervention will give you a bigger bang for your buck. The evidence will add up over time.”
With the covid-19 pandemic still rampant in many countries in mid-2020, predicting the future toll of the outbreak on healthcare and food security requires a crystal ball. In the short term, the impact of lockdowns and reduced economic activity is already causing severe disruption, with potentially catastrophic outcomes for LMICs. Preliminary assessments by the FAO suggest the number of undernourished people in the world, estimated at 690 million in 2019, will increase by up to 132 million in 2020 and that recovery in 2021 will not fully reverse the trend.
In many LMICs, initiatives such as malnutrition monitoring, vaccination programmes, mother-and-baby clinics, access to fresh foods and school meals are also being devastated by the pandemic, posing short-term and long-term risks to health, especially for women and children. “Governments were already off-track to meet WHO targets for malnutrition and NCDs by 2025 and at pre-covid-19 progress rates, also faced an uphill effort to reach the nutrition-related Sustainable Development Goal targets by 2030,” says Westerman of the NCD Alliance.
“Governments cannot afford to allow coronavirus to shelve smart, cost-effective, evidence-based policies that improve nutrition,” she says.
Focus on diet-related NCDs
In the longer term, some researchers say covid-19 may prompt health agencies worldwide to return their attention to the prevention of diet related NCDs with greater vigour than before the pandemic.
“I think covid provides an important opportunity to actually measure and respond to the links between infectious and non-communicable diseases, which have become quite visible in relation to obesity and covid severity,” says Nugent of RTI International. “I am hopeful and will argue for greater attention to NCD prevention as a means of increasing resilience of health systems and reducing pandemic risks.”
GAIN’s Haddad is also optimistic that the pandemic will act as a ”mini-trigger” to focus more attention on NCD prevention. The evidence of the impact of co morbidities such as obesity on covid-19 speaks for itself. “As six of the top ten risks to public health are diet-related even in normal times, the food system was already bankrupting the health system in many countries,” he says. “There’s an opportunity to develop food systems that are resilient, diverse and able to provide nutritious diets to address all forms of malnutrition if the food industry, policymakers and the public sector are able to work together and be creative about solutions.”
TEXT Christine Michael — ILLUSTRATION Clara Selina Bach — PHOTO Jeison Higuita