Associations between country-level macroeconomic factors and the double burden of malnutrition
Authors: Debabrata Talukdar, Satheesh Seenivasan
Journal: The Lancet Global Health (2022)

Given its widespread incidence and enormous costs for health and the economy in contemporary society, the double burden of malnutrition (DBM) remains a top priority public health challenge,1WHOThe double burden of malnutrition. Policy brief. World Health Organization, Geneva2017https://apps.who.int/iris/bitstream/handle/10665/255413/WHO-NMH-NHD-17.3-eng.pdfDate accessed: January 3, 2022Google Scholar particularly in low-income and middle-income countries (LMICs) that have witnessed rising percentages of overweight and obesity in the past two decades while still battling the undernutrition problem.2Popkin BM Corvalan C Grummer-Strawn LM Dynamics of the double burden of malnutrition and the changing nutrition reality.Lancet. 2020; 395: 65-74Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar In this issue of The Lancet Global Health, a study by Paraskevi Seferidi and colleagues3Seferidi P Hone T Duran A et al.Global inequalities in the double burden of malnutrition and associations with globalisation: a multi-level analysis of Demographic and Healthy Surveys from 55 low-income and middle-income countries 1992–2018.Lancet Glob Health. 2022; (published online Feb 8.)https://doi.org/10.1016/S2214-109X(21)00594-5Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar provides important insights in building the relevant knowledge base that can help to better address this DBM challenge. This study analysed the nature of empirical association between household-level DBM and the degree of country-level globalisation (along economic, social, and political dimensions), after controlling for household wealth and country income. Specifically, Seferidi and colleagues used serial cross-sectional data of 1·1 million children (aged <5 years) and their mothers (aged 15–49 years) from 189 Demographic and Health Surveys in 55 LMICs between 1992 and 2018. Using multilevel logistic regression models, they examined the multivariate associations of within-household DBM (defined as the case of a stunted child with an overweight mother), prevalence with household wealth (within-country wealth quintile to which a household belongs), national income in the form of gross national income (GNI), and national globalisation (political, social, and economic indices). Results showed that the household-level DBM was distributed unequally across household wealth quintiles within countries, and the direction of this inequality varied with GNI. Specifically, the richest household quintiles were more likely to experience DBM compared with the poorest quintiles in countries with low GNI. This directionality reversed in countries with high GNI. Economic globalisation was associated with higher odds of DBM among poorest households, and this association attenuated as GNI increased. Thus, the adverse impact of economic globalisation was mostly realised by the world's poorest. Social globalisation was associated with higher odds of DBM, independently of household wealth or country income. In summary, the study finds that increases in economic and social globalisation in a country are associated with higher incidence of within-household DBM, although the nature and strength of this association was heterogenous across different socioeconomic groups within countries, and varied as national incomes changed. A key implication of these findings is that actions to address the DBM challenge need to be context-specific and subpopulation-specific, and need to consider and address the potential negative and unequal effects from globalisation. To put the study by Seferidi and colleagues in the broader context, addressing the DBM challenge is of crucial importance in achieving the UN Sustainable Development Goal of ensuring healthy lives and wellbeing for all.1WHOThe double burden of malnutrition. Policy brief. World Health Organization, Geneva2017https://apps.who.int/iris/bitstream/handle/10665/255413/WHO-NMH-NHD-17.3-eng.pdfDate accessed: January 3, 2022Google Scholar To address this challenge, a recent Lancet Commission has called for double-duty policy actions that concurrently target the common drivers of all forms of malnutrition.2Popkin BM Corvalan C Grummer-Strawn LM Dynamics of the double burden of malnutrition and the changing nutrition reality.Lancet. 2020; 395: 65-74Summary Full Text Full Text PDF PubMed Scopus (364) Google Scholar, 4Hawkes C Ruel MT Salm L Sinclair B Branca F Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.Lancet. 2020; 395: 142-155Summary Full Text Full Text PDF PubMed Scopus (145) Google Scholar, 5Swinburn BA Kraak VI Allender S et al.The Global Syndemic Of Obesity, Undernutrition, and Climate Change: The Lancet Commission report.Lancet. 2019; 393: 791-846Summary Full Text Full Text PDF PubMed Scopus (883) Google Scholar To effectively develop any such prescriptive policy actions, an in-depth understanding of the concomitant association of DBM trends (over time as well as across different countries and subgroups within countries) with pertinent factors driven by macroeconomic policy tied to economic development remains a crucial imperative. However, the extant research stream investigating such association still remains scarce. By documenting the association between the DBM and globalisation, the study by Seferidi and colleagues3Seferidi P Hone T Duran A et al.Global inequalities in the double burden of malnutrition and associations with globalisation: a multi-level analysis of Demographic and Healthy Surveys from 55 low-income and middle-income countries 1992–2018.Lancet Glob Health. 2022; (published online Feb 8.)https://doi.org/10.1016/S2214-109X(21)00594-5Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar represents an important addition to this research stream. At the same time, it also points to the need for future complementary research on several issues. For example, what are the underlying mechanisms behind the association of the DBM with different dimensions of globalisation documented in the study? Also, the DBM can manifest itself at individual, household, and population levels, and has been defined using different public health or biological measures of undernutrition and overnutrition.1WHOThe double burden of malnutrition. Policy brief. World Health Organization, Geneva2017https://apps.who.int/iris/bitstream/handle/10665/255413/WHO-NMH-NHD-17.3-eng.pdfDate accessed: January 3, 2022Google Scholar, 6Davis JN Oaks BM Engle-Stone R The double burden of malnutrition: a systematic review of operational definitions.Curr Dev Nutr. 2020; 4nzaa127Crossref Scopus (15) Google Scholar Although this study provides insights into the association of globalisation with its specific definition of the DBM (stunted child and overweight mother), an important future research direction will be to investigate the nature of association of globalisation with other equally valid operational measures of the DBM. Given the usual national priority of pursuing higher economic affluence, another important and interesting policy-relevant question is what has been the historical nature of the association between the DBM in a country and its national per-capita income level. Does it point to the DBM as a negative externality—an undesirable societal outcome concomitant with a desirable societal goal (economic growth)? Or does it point to a declining DBM with rising income beyond some threshold income range? If so, what is that threshold income range? Given the clear importance of both economic growth and the DBM from a policy perspective, it is crucial that future research gains in-depth and systematic insights into these questions from available historical data. We declare no competing interests. Global inequalities in the double burden of malnutrition and associations with globalisation: a multilevel analysis of Demographic and Health Surveys from 55 low-income and middle-income countries, 1992–2018Increases in economic and social globalisation were associated with higher DBM, although the impacts of economic globalisation were mostly realised by the world's poorest. The economic patterning of DBM observed in this study calls for subpopulation-specific double-duty actions, which should further aim to mitigate the potential negative and unequal impacts of globalisation. Full-Text PDF Open Access