Double-duty solutions for the double burden of malnutrition
Authors: William H Dietz
Journal: The Lancet (2017)

In The Lancet, the NCD Risk Factor Collaboration1NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.Lancet. 2017; (published online Oct 10.)http://dx.doi.org/10.1016/S0140-6736(17)32129-3Google Scholar describe trends in body-mass index (BMI), underweight, overweight, and obesity in almost 130 million children, adolescents, and adults from 200 countries worldwide. Findings of the study provide grounds for both optimism and concern. The good news is that from 1975 to 2016, the prevalence of undernutrition in children aged 5 years and older decreased, and obesity in some regions had slowed. The bad news is that the prevalence of overweight and obesity in adults (aged ≥20 years) and children and adolescents (5–19 years) in other regions of the world was increasing. These findings are consistent with other published studies.2NCD Risk Factor Collaboration (NCD-RisC)Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants.Lancet. 2016; 387: 1377-1396Summary Full Text Full Text PDF PubMed Scopus (3143) Google Scholar, 3Stevens GA Finucane MM Paciorek CJ et al.Trends in mild, moderate, and severe stunting and underweight, and progress towards MDG 1 in 141 developing countries: a systematic analysis of population representative data.Lancet. 2012; 380: 824-834Summary Full Text Full Text PDF PubMed Scopus (242) Google Scholar This article by the NCD Risk Factor Collaboration1NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.Lancet. 2017; (published online Oct 10.)http://dx.doi.org/10.1016/S0140-6736(17)32129-3Google Scholar goes beyond other publications to compare concurrent changes by region in the prevalence of mean BMI among adults and children and rates of underweight in children. Several important findings emerge. First, in a number of regions, the increase in mean BMI among children and adolescents has slowed or plateaued in high-income countries, such as high-income English-speaking countries and northwest Europe, whereas the mean BMI of adults is increasing. In middle-income and high-income countries where plateaus are occurring, rates of change differ by sex, age, socioeconomic status, and ethnic origin.4Pan L Freedman DS Sharma AJ et al.Trends in obesity among participants aged 2–4 years in the special supplemental nutrition program for women, infants, and children—United States, 2000–2014.MMWR Morb Mortal Wkly Rep. 2016; 65: 1256-1260Crossref PubMed Scopus (71) Google Scholar Second, the rate of increase in the prevalence of obesity in children and adolescents is greater than the rate of decline in undernutrition. If current trends continue, by 2022 the prevalence of obesity in children and adolescents will exceed the prevalence of undernutrition. Third, a double burden of nutritional disease now exists in many regions of the world, such as the Middle East and north Africa. Fourth, the changes in obesity and undernutrition by sex and region among adults and children are quite heterogeneous. Finally, in a study of children younger than 5 years old in 36 low-income and middle-income countries, the average reported prevalence of overweight among stunted children was 9·9%, and was considerably greater in middle-income countries.5Tzioumis E Kay MC Bentley ME Adair LS Prevalence and trends in the childhood dual burden of malnutrition in low- and middle-income countries, 1990–2012.Public Health Nutr. 2016; 19: 1375-1388Crossref PubMed Scopus (51) Google Scholar Increases in obesity have been associated with urbanisation and increases in gross domestic product (GDP), which have also been associated with multiple shifts in food intake and reduced physical activity. Increased consumption of foods of animal origin, as well as the intake of ultra-processed foods, could have contributed to the substantial increased intakes of fat and sugar, particularly sugar in sugary drinks.6Popkin BM Hawkes C Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses.Lancet Diabetes Endocrinol. 2016; 4: 174-186Summary Full Text Full Text PDF PubMed Scopus (444) Google Scholar Urbanisation and GDP also reduce physical activity levels,7Kohl 3rd, HW Craig CL Lambert EV et al.The pandemic of physical inactivity: global action for public health.Lancet. 2012; 380: 294-305Summary Full Text Full Text PDF PubMed Scopus (1747) Google Scholar but how these changes could affect the prevalence of obesity has not been as carefully studied. Nonetheless, shifts from walking and cycling to motorised transportation, changes in work-related physical activity, and increased reliance on technology8Popkin BM Global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases.Am J Clin Nutr. 2006; 84: 289-298Crossref PubMed Scopus (1070) Google Scholar suggest that daily energy expenditure attributable to physical activity has declined substantially. These observations also suggest that the contribution of changes in physical activity could be at least as important as changes in diet on the prevalence of obesity. The heterogeneity of these trends across regions indicate that various natural experiments are underway that could shed light on the drivers of the decline in undernutrition, the dissociation of the increases in child and adult obesity, and stunting and obesity in the same children. Changes in diet and physical activity reflect changes in demand that are only partly attributable to individual behaviour. The drivers of demand include forces that shape these behaviours, including intensive advertising of less healthful processed foods and sugary drinks, shifts in complementary foods for infants, increased numbers of food retailers that have increased the availability of processed foods, urban design that restricts active transport, and increased numbers of labour-saving devices in homes and workplaces. Another series of drivers underlie these forces, such as international trade agreements, the power of transnational corporations, subsidies that enable the production of inexpensive foods, and government policies or lack thereof related to food taxes or urban design. Mapping of policy changes that affect food9Hawkes C Jewell J Allen K A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework.Obes Rev. 2013; 14: 159-168Crossref PubMed Scopus (240) Google Scholar or physical activity systems10Giles-Corti B Vernez-Moudon A Reis R et al.City planning and population health: a global challenge.Lancet. 2016; 388: 2912-2924Summary Full Text Full Text PDF PubMed Scopus (608) Google Scholar against shifts in the country or regional prevalence of obesity, undernutrition, and stunting in association with obesity might help identify the most powerful drivers of these changes and begin to point to solutions. The double burden of nutritional disease adds an additional layer of complexity, but raises the possibility that double-duty actions11Hawkes C Demaio AR Branca F Double-duty actions for ending malnutrition within a decade.Lancet Glob Health. 2017; 5: e745-e746Summary Full Text Full Text PDF PubMed Scopus (44) Google Scholar could simultaneously reduce obesity and undernutrition. It is unclear whether the factors that affect undernutrition are similar to those that foster obesity in the population or to those that contribute to stunting and obesity in the same children. For example, increased use of breastmilk substitutes and processed foods as complementary foods and snacks for infants could provide calories without micronutrients,12Zehner E Promotion and consumption of breastmilk substitutes and infant foods in Cambodia, Nepal, Senegal and Tanzania.Matern Child Nutr. 2016; 12: 3-7Crossref PubMed Scopus (10) Google Scholar and thereby increase the likelihood of obesity, undernutrition, and stunting and obesity in the same children. Confirmation that consumption of these foods is associated with both stunting and obesity in the same children would increase the likelihood that this relationship is causal and suggest potential interventions. How to allocate scarce resources to address the double burden poses an important challenge for governments. Strategies to address undernutrition focus on young children and tend to be programmatic with little opposition, whereas strategies to address obesity focus on multisectoral policy and environmental changes that are often met with resistance from corporations with vested interests. Adverse consequences from undernutrition can be acute and therefore compel a more immediate response, whereas obesity is a chronic disease and might be perceived as less critical. Concern about the morbidity and costs of type 2 diabetes and its association with obesity could provide a more compelling rationale to invest in prevention to assess the prevalence of obesity and its complications. Improved understanding of obesity's proximal dietary and physical activity contributors is essential to assess and monitor progress. These data could also show that treatment of obesity exceeds the capacity of the health-care system, and could be used to make the case for prevention. In turn, successful prevention will depend on sustainable efforts to address the drivers of obesity at both country and global levels. I receive consulting fees as a member of the scientific advisory committee for Weight Watchers, as a member and chair of the JPB Foundation's Poverty advisory board, and as a consultant for the Research Triangle Institute: Feeding Infants and Toddlers Study. I have received a grant from Bridgespan to analyse National Health and Nutrition Examination Survey data on early childhood obesity. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adultsThe rising trends in children's and adolescents' BMI have plateaued in many high-income countries, albeit at high levels, but have accelerated in parts of Asia, with trends no longer correlated with those of adults. Full-Text PDF Open Access