Unveiling the crisis of the double burden of malnutrition
Authors: Biniyam Sahiledengle, Lillian Mwanri
Journal: The Lancet Global Health (2024)

Malnutrition is one of the intractable public health problems that need to be addressed by all nations, and it is intricately linked to several Sustainable Development Goals (SDGs). One of the key intersections between good nutrition and the SDGs is found in goal 2, which aims to end hunger, achieve food security, and improved nutrition. Nutrition is also directly linked SDG 3: "ensure healthy lives and promote well-being for all at all ages".1UNTransforming our world: the 2030 Agenda for Sustainable Development.from: https://sdgs.un.org/2030agendaDate accessed: December 7, 2023Google Scholar These goals build on the increasing momentum to eradicate hunger and malnutrition and uphold human rights to sufficient food, nutrition, and health. Globally in 2020, undernutrition was a contributing factor in approximately 45% of child deaths for children younger than 5 years. It is also estimated that in 2020, stunting affected 149 million children younger than 5 years, and wasting affected 49 million.2UNICEFWHOInternational Bank for Reconstruction and DevelopmentThe World BankLevels and trends in child malnutrition: key findings of the 2019 Edition of the Joint Child Malnutrition Estimates. World Health Organization, Geneva2019Google Scholar More recently, low-income and middle-income countries (LMICs) have faced a rising problem of the double burden of malnutrition (DBM). According to WHO, the DBM is characterised by the coexistence of undernutrition along with overnutrition (overweight and obesity) or diet-related non-communicable diseases.3WHODouble burden of malnutrition.http://www.who.int/nutrition/double-burden-malnutrition/en/Date: 2022Date accessed: December 7, 2023Google Scholar More than one in three LMICs are affected by the DBM at the country level, and The Lancet's Series on the DBM highlights this new nutrition reality,4Popkin 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 (637) Google Scholar whereby overnutrition and undernutrition can no longer be considered separately. Although undernutrition has long been recognised as a public health issue, a growing body of research shows that the DBM poses a particular challenge in LMICs.5Kosaka S Umezaki M A systematic review of the prevalence and predictors of the double burden of malnutrition within households.Br J Nutr. 2017; 117: 1118-1127Crossref PubMed Scopus (58) Google Scholar, 6Akombi BJ Chitekwe S Sahle BW Renzaho AMN Estimating the double burden of malnutrition among 595,975 children in 65 low- and middle-income countries: a meta-analysis of demographic and health surveys.Int J Environ Res Public Health. 2019; 162886Crossref Scopus (17) Google Scholar In response, WHO has proposed double-duty actions as an efficient way to tackle the DBM. Double-duty actions refer to nutrition interventions that address overnutrition and undernutrition simultaneously.7Hawkes 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 (220) Google Scholar However, research on the simultaneous effect of nutrition-specific and nutrition-sensitive interventions on the DBM remains scarce, and their effects on the DBM remain unclear in LMICs. Nora Alessandra Escher and colleagues8Escher NA Andrade GC Ghosh-Jerath S Millett C Seferidi P The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review.Lancet Glob Health. 2024; (published online Jan 29.)https://doi.org/10.1016/S2214-109X(23)00562-4Google Scholar summarise evidence on the simultaneous effect of nutrition-specific and nutrition-sensitive interventions on overnutrition and undernutrition. Escher and colleagues synthesise 26 studies that reported the effect of nutrition-specific and nutrition-sensitive interventions on the DBM in LMICs. Seven studies identified that maternal and child health interventions involving food provision or supplementation were associated with adverse side-effects on child or maternal adiposity (ie, DBM-harmful effects), and three studies suggested DBM-beneficial effects. Among school-based interventions, four were DBM-beneficial, one DBM-neutral, and one potentially DBM-harmful. However, among nutrition-sensitive interventions (conditional cash transfers and social policies targeting malnutrition), two evaluations suggested DBM-beneficial effects in children, and one indicated potentially harmful effects on maternal overweight. Escher and colleagues have generated clear and informative findings relevant to further research and programmes; they highlight that both nutrition-sensitive interventions and nutrition-specific interventions had diverse results in different settings. Overall, the authors' findings suggest that the included studies were very diverse in terms of the intervention study design, target population, outcome assessment, duration of the intervention, and the quality of studies. The authors conclude that there is considerable potential for adapting pre-existing nutrition interventions to mitigate the rising challenges posed by the DBM. Escher and colleagues also highlighted that the current interventions should consider DBM; be sensitive; and report both undernutrition and overnutrition outcomes in all nutrition interventions, regardless of the intervention's target, since interventions targeting undernutrition could have unexpected negative effects on obesity. We strongly believe more global and regional studies across different socioeconomic levels are necessary to determine the nature of the DBM and to evaluate the combined effect of nutrition-sensitive and nutrition specific interventions in LMICs. Again, existing nutrition interventions must be closely evaluated to make substantial and concerted efforts to combat the growing concern of the DBM in LMICs. Furthermore, consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is crucial to expanding the evidence on the DBM in LMICs. We declare no competing interests. The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic reviewThere is considerable scope to repurpose existing nutrition interventions to reduce the growing burden of the DBM in LMICs. In settings undergoing rapid nutrition transition, specific policy attention is required to ensure that food-based or supplement-based MCH programmes do not unintentionally increase maternal or child overweight. Consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is essential to expand the evidence base to identify and promote interventions maximising benefits and minimising harms on the DBM. Full-Text PDF Open Access