Double Burden of obesity and malnutrition in Western Sahara refugees

Summary of published research¹

There is growing recognition of a ‘double burden’ of malnutrition among populations in both affluent and less-affluent countries, i.e. the coexistence of undernutrition (e.g. stunting or underweight) with overweight, which has been observed at national and household levels. At present, little is known about whether undernutrition and overweight coexist among refugees in protracted settings, or about the proportion of refugee households that may be affected by this double burden. A recent study of refugees from Western Sahara aimed to use anthropometric data from a routine UNHCR nutrition survey to investigate the existence of the double burden of malnutrition in a refugee population highly dependent upon food assistance and living in a protracted emergency.

People from Western Sahara (also known as Sahrawi) have lived as refugees in camps near Tindouf city, in southwest Algeria, an area with a harsh desert environment. Their situation is considered a protracted emergency, as there is a stalemate to negotiations, with no sign of imminent resolution. Although accurate estimates are not available, the host country estimates that there are 165,000 people living in four camps (Awserd, Dakhla, Laayoune and Smara), mostly dependent on food assistance from international organisations.

A two-stage household cluster survey with four strata (one per camp) was conducted in October and November 2010 to collect nutrition indicators from children (<5y) and women of childbearing age (15-49y).The study sampled 2,005 households, collecting anthropometric measurements (weight, height and waist circumference) in 1,608 children (6-59 months) and 1,781 women (15-49y). The prevalence of global acute malnutrition (GAM), stunting, underweight, and overweight was estimated in children. Stunting, underweight, overweight and central obesity (waist circumference =than 80cm) prevalence was estimated in women. To assess the burden of malnutrition within households, households were first classified according to the presence of each type of malnutrition. Households were then classified as undernourished, overweight or affected by the double burden if they presented members with undernutrition, overweight or both, respectively.

The study found the prevalence of GAM in children was 9.1%, 29.1% of children were stunted, 18.6% were underweight, and 2.4% were overweight. Among the women, 14.8% were stunted, 53.7% were overweight or obese, and 71.4% had central obesity. Central obesity (47.2%) and overweight (38.8%) in women affected a higher proportion of households than did GAM (7.0%), stunting (19.5%), or underweight (13.3%) in children. Overall, households classified as overweight (31.5%) were most common, followed by undernourished (25.8%), and then double burden-affected (24.7%).

The authors of the study ask how a population that was previously nomadic, possibly experiencing chronic energy insufficiency, could have developed the observed high levels of overweight and obesity, while living in refugee camps in the absence of economic development. One factor suggested is that the Sahrawi were traditionally nomadic and culturally associate larger bodies with wealth and beauty. Thus fattening practices are common among Sahrawi, involving periods of ritual overfeeding and the use of appetite enhancers and traditional medication (suppositories composed of a mix of dates, seeds, and medicinal plants that are believed to increase peripheral fat accumulation). Urbanisation has possibly created synergy between these customs and the adoption of processed foods and modern medicines, thereby increasing the likelihood of obesity. Such a synergy might also affect those living as settled refugees, as they depend on food assistance and have limited access to local markets in Algeria. Another factor may be the excessive sugar consumption habit among the Sahrawi. One example is found in the frequent and widespread consumption of green tea (with an average reported consumption among refugees of three servings of 30 ml each, three times a day ), which is usually prepared adding about five teaspoons of sugar for each teaspoon of green tea leaves. Lastly, urbanised Sahrawi women with high Body Mass Index (BMI) values have been found to walk significantly less than those with normal BMI values, thereby reducing their energy expenditure.

These factors may help to partially explain the high prevalence of overweight in this population. However, they are complemented by other factors affecting refugees living in the camps, which may help explain the high prevalence of both undernutrition and overweight in this population. Importantly, some factors that are associated with undernutrition in early life appear to increase susceptibility to overweight in later life. Both nutritional deficiencies and food insecurity, which as observed in the study findings often result in wasting and stunting in early life, are also associated with subsequent obesity. The underlying mechanisms are still being established. For instance, studies from shanty towns in Brazil have suggested that stunted children have impaired fat oxidation capacity, a risk factor for obesity, although it is not known if this developmental adaptation occurs in other populations. Programming of leptin receptors in the brain is another potential mechanism receiving attention. There is also a growing understanding that individuals experiencing undernutrition early in life are more susceptible to developing obesity by subsequent exposure to refined, carbohydrate-rich diets and high sugar intake, features characteristics of this population’s diet. One crucial aspect is that Sahrawi refugees are dependent on food assistance to cover most of their nutritional needs and thus lack control over their food system. A typical food assistance basket for this population will often be rich in starchy foods (refined grain cereals, pulses, and blended foods) and sugar. The refugee food assistance package typically contains low quantities, if any, of fresh or dried vegetables and fruit, therefore providing a low diversity diet. Recent evidence suggests that a low diversity diet is related to obesity and associated comorbidities, as well as being associated with nutritional deficiencies. In other words, the quality of the diet deriving from the food assistance currently provided may be implicated in both nutritional extremes.

These findings raise numerous challenges. First, the emergence of obesity and the double burden of malnutrition have serious implications for how international organisations should plan and provide assistance, especially for those populations exposed to conflict or displacement of protracted duration. For example, food assistance policies need to be revised and adapted, as those currently designed to meet population minimum needs during an acute emergency will need to consider their potential contribution to the later development of non-communicable diseases (NCDs). Additionally, efforts are needed to promote long-term food security and higher nutrition adequacy in protracted emergencies. The actions needed range from improved food security assessments, with special focus on diversity within food groups, to provision of cash or vouchers, to community involvement in sustainable livelihood programmes such as gardening and small-scale businesses. The Sahrawi refugees have been residing in camps since 1975. Generations of adults from birth have received food assistance as their main source of food. Their children are now the second or third generation exposed to a consistently low quality diet. The intergenerational impact of this exposure is of serious concern in this and similar protracted emergencies.

Second, efforts are needed to evaluate and monitor the health impact of obesity and the double burden in refugee situations. Obesity and NCDs should be routinely included in nutrition and health assessment exercises in protracted refugee settings, and should be incorporated into the UNHCR Health Information System database.

Third, the development of appropriate and effective behaviour change interventions to prevent and tackle obesity in these contexts will need innovative approaches. These will require health personnel and community participation in the identification of needs and implementation of solutions. Additionally, a detailed economic assessment is needed to correctly evaluate the resources needed for prevention and treatment. Lastly, careful policy and advocacy work will be required to convey the complexity of the situation, and to ensure that continued support for life-saving food assistance programmes and the tackling of undernutrition and nutritional deficiencies is not jeopardised as the threat of obesity to refugee health receives the attention it deserves.

¹Grijalva-Eternot. C et al (2012). The Double Burden of Obesity and Malnutrition in a Protracted Emergency Setting: A Cross-Sectional Study of Western Sahara Refugees. PLOS Medicine, October 2012, volume 9, Issue 10, e1001320, pp 1-12