The report, “Dynamics of the double burden of malnutrition and the changing nutrition reality,” underscores the issue of what the report calls the 'double burden of malnutrition' (DBM), which is the coexistence of undernutrition and obesity.
The study points out that more than a third of low and middle-income countries are estimated to experience these overlapping issues, with about 2.3 billion people overweight globally, and more than 150 million children having stunted growth.
It found that 14 additional countries among the world’s lowest incomes had developed this double burden of malnutrition by the 2010s compared with the 1990s, even though the prevalence of the issue fell in higher-income developing countries.
"We are facing a new nutrition reality where major food system changes have led the poorest countries to have high levels of overweight and obesity along with undernutrition," said Barry M. Popkin, lead author and W.R. Kenan Jr. Distinguished Professor of Nutrition at the University of North Carolina at Chapel Hill Gillings School of Global Public Health.
The researchers used survey data from low and middle-income countries in the 1990s and 2010s to determine which countries may face the double burden. The results found that over a third of low and middle-income countries had overlapping forms of malnutrition, 45 of 123 countries in the 1990s and 48 of 126 countries in the 2010s. The collision was prevalent in sub-Saharan Africa, with Indonesia being the largest country with a severe double burden. The overlap was also common in south Asia, and east Asia and the Pacific, where 29, seven and nine countries were impacted, respectively.
In the 2010s, 14 countries with some of the lowest incomes in the world had newly developed a double burden of malnutrition compared with the 1990s. However, fewer low and middle-income countries with the highest incomes, relative to others in that category, were affected. The authors say this reflects the increasing prevalence of people being overweight in the poorest countries, even as segments of the population face hunger.
The absence of nutritious food can go both ways, leading to either malnutrition or obesity. The study suggests people can be exposed to both forms of malnutrition at different points in their lifetimes, where a person could be malnourished as a child and obese later on in adulthood.
A reality driven by the modern food system
"Emerging malnutrition issues are a stark indicator of the people who are not protected from the factors that drive poor diets," Popkin said. "The poorest low- and middle-income countries are seeing a rapid transformation in the way people eat, drink and move at work, home, in transport and in leisure. The new nutrition reality is driven by changes to the food system, which have increased the global availability of ultra-processed foods that are linked to weight gain while also adversely affecting infant and preschooler diets. These changes include disappearing fresh food markets, increasing numbers of supermarkets, and the control of the food chain by supermarkets and global food, catering and agriculture companies in many countries."
Increases in overweight population are the result of changes in the global food system that make less nutritious food cheaper and more accessible, as well as to the decrease in physical activity due to major technological shifts in the workplace, home, and transportation.
Another important point worth mentioning is the increase in the number of women working outside the home, which has led to a higher demand for food that is ready to eat or ready to heat.
Double burden = double-duty
The report suggests "double-duty" interventions that reduce the risk of nutritional deficiencies while preventing obesity. The paper said addressing all forms of malnutrition will require new ways of designing, targeting, and implementing programs and policies to accelerate progress in improving nutrition globally.
The paper is part one of four in The Lancet series, which delves into the physiological impacts of the double burden of malnutrition. The second paper in the series addresses the underlying developmental origins of biology that can lead to a child having both stunting and overweight.
December 15, 2019 DOI:https://doi.org/10.1016/S0140-6736(19)32497-3
“Dynamics of the double burden of malnutrition and the changing nutrition reality"
Authors: B. Popkin, et al.