Tackling the double burden of malnutrition in low and middle-income countries: response of the international community

Research

By Alexandra Rutishauser-Perera

Alexandra Rutishauser-Perera is a Humanitarian Nutrition Adviser with Save the Children. She has ten years of experience of public health nutrition with several international non-governmental organisations in West and East Africa and South-East Asia.

This article summarises key findings of a Masters dissertation undertaken by the author in 2015. The author acknowledges her MSc supervisor, Dr Cecile Knai, for her support.

Location: LMICs

What we know: The double burden of malnutrition (DBM) affects many low and middle-income countries (LMICs); there is growing recognition of the emerging problem.

What this article adds: A recent study assessed existing activities, barriers and enablers of 19 international organisations in tackling the DBM in LMICs. Most work has been at policy level which has not yet translated into interventions. Ten agencies were not implementing related programming; barriers included lack of funding, obesity prevention not a life-saving intervention, lack of agency expertise, lack of guidelines and lack of impact evaluation. Shortage of evidenced interventions and donor engagement/funding particularly limit progress. Most respondents favoured using existing international fora to facilitate necessary information exchange. Recommendations include systematically including overweight/obesity data in nutrition surveys; researching the impact of acute malnutrition treatment/rapid weight gain on chronic disease; and monitoring possible conflicts of interests in public/private partnerships.

The double burden of malnutrition (DBM) affects many low and middle-income countries (LMICs). The rate of increase of childhood overweight and obesity in LMICs is more than 30% higher than in developed countries (Wang & Lobstein, 2006) and there are more overweight and obese children in LMICs than in high-income countries (WHO 2015). Physical inactivity and unhealthy diet characterise socio-economic transition (Boutayeb & Boutayeb, 2005). Additionally, the emergence of nutrition-related non-communicable diseases (NR-NCDs) may be compounded by problems of undernutrition, which themselves increase the risk of developing NCDs in adulthood (Darnton-Hill et al, 2004). A child who grows inadequately can be under-nourished in infancy but become overweight or obese later in life if the individual consumes energy-dense foods in excess. The same household can sometimes comprise both an under-nourished child and an overweight adult (WHO, undated). Childhood obesity increases the child’s risk of mental and physical health effects, which most LMICs are not equipped to treat ((Boutayeb & Boutayeb, 2005), placing an additional burden on already fragile health systems. 

There is growing international recognition of the emerging problem of overweight and obesity in LMICs. However, in practice NGO-led nutrition programming focuses on alleviating wasting and stunting, with very few tackling the problem of obesity (INFPR, 2014).

A recent study assessed existing activities of international organisations and UN agencies in tackling the DBM in LMICs, as well as evaluating the barriers and enablers they face in doing so.

Methods

A mix of purposive and snowball sampling was used to identify participants for semi-structured interviews. The interview transcripts were analysed using a framework analysis (Ritchie & Spencer, 1993). Participants (representatives of international organisations involved in agency nutrition strategy development) were identified from International Conference on Nutrition (ICN2) participants, those engaged in the Scaling Up Nutrition (SUN) Movement and researcher contacts. Nineteen interviews were conducted (only one per agency).

Results

All participants were senior staff at agency headquarters categorised in five programming sectors: Children (n=5), Food Security (n=1), Health (n=8), Nutrition (n=4) and Relief (n=1), although most had overlap. Ten organisations had more than 20 years of experience. The majority of organisations implemented programmes (n=14); four were policy-based (three UN agencies) and one was an advocacy organisation. Ten agencies were working in both developed and developing countries; nine in developing countries only.

Nine (47%) of the organisations did not integrate any obesity or NR-NCD related activities within their work. Three agencies (16%) integrated the theme of DBM within health education and two agencies (11%) did so within social and behaviour-change activities. Four agencies (26%) had a policy on DBM. Two organisations (10%) had no plans to address DBM, and seven (37%) had only just begun internal conversations about obesity prevention and NR-NCD programmes.

Most work to date has been at a policy level and was conducted by UN agencies to address malnutrition in all its forms, mainly in response to the nutritional landscape faced in the Syria crisis (UNICEF, 2014; (Dolan et al, 2014). However, very few DBM interventions were identified amongst implementing agency respondents. Two programme examples were: a ‘One Goal’ programme led by World Vision in India (Edwards, 2015) and the ‘Double Fardeau of Nutrition’ (DFN) Project in West Africa, partly supported by Helen Keller International (Pôle Francophone Africain, 2015).

Reported barriers to including DBM activities were lack of funding (n=13), the fact that obesity prevention was not a lifesaving intervention (n=12), lack of agency expertise (n=11), lack of guidelines and impact evaluation on prevention of obesity (n=9), and lack of specific disaggregated data (n=7). Some found it difficult to judge whether DBM was a health or nutrition problem.

The most commonly cited enabler for DBM programing was having more evidence (n=12). The types of evidence needed included disaggregated data on prevalence, the determinants of obesity, evidence-based programming on prevention of obesity, and cost effectiveness of activities targeting overnutrition. Addressing micronutrient deficiencies by focusing on food quality and higher intake of fruits and vegetables (e.g. school feeding in South Africa), or treating undernutrition (which at a young age can predispose to obesity later in life) were suggested as entry points to develop activities on DBM (n=7).  Other factors that contributed to decisions to become involved in DBM programming included existence of a donor strategy to address DBM (n=6), being operational in a country affected by obesity (n=4), obesity prevention included in the targets of the World Health Assembly (WHA) (n=3), and internal expertise (n=2).

Ten participants felt it was not necessary to create a new forum to exchange information on DBM. Only three respondents favoured development of a DBM-specific forum. The top five forums suggested were the SUN Movement (n=7), ICN (n=5), ENN (n=5), UNSCN (n=5), and the Committee on World Food Security (CFS).

Potential negative consequences of current nutrition programming on DBM were: promotion of energy-dense food (n=8); public/private or NGO/private partnerships (n=7); and rapid catch-up growth in infancy for underweight infants or young children potentially increasing childhood obesity prevalence (n=4). Seven participants suggested ways to mitigate negative consequences, including more systematic quantitative analysis of those potential risks; concentrating on effective activities such as breastfeeding; having a more food-based approach regarding the prevention of undernutrition; and including nutrition and counselling in all food security and nutrition programmes.

Discussion

Development assistance providers have started to include prevention and management of NCDs in their programme activities. However the scope of these interventions is still limited geographically and not integrated into nutrition programming. The US ASSIST project still focuses on Europe and Central Asia, with only a few NCD projects in India and Uganda (USAID).The UK Department for International Development (DFID) is exceptional in that it includes commitment to prevent and treat the four major NCDs (cardiovascular disease, cancer, chronic respiratory disease and diabetes) in its 2010-2015 policy.

Despite global improvement in reporting the prevalence of overweight/obesity in different age groups, the data reported are still national-level only (Global Nutrition Report, Malnutrition Mapping Project) (INFPR, 2014; GAIN 2015). The international guidelines on nutrition surveys do not include indicators on overweight/obesity (AAH, 2006). Additionally, there is also a lack of consensus on how to define overweight/obesity in childhood and adolescence (Poskitt, 2009). Data on the economic consequences of obesity in adults in high-income countries are now well reported, but concentrate mostly on healthcare expenditure; the consequences of childhood obesity are almost never mentioned (Bhutta et al, 2008).

Many believe that the SUN Movement provides an opportunity to address the DBM.  However, an external evaluation of the 2014 SUN movement suggested that the movement might dilute its advocacy if it stops focusing solely on undernutrition.

ICN2 focused on the problems of overweight, obesity and undernutrition. However, the timing of the event limits its utility for timely exchange of information. The Committee on World Food Security (CFS), an intergovernmental body created to serve as a forum for review and follow up of food security policies, has agreed to integrate the problem of overweight and obesity into its agenda (FAO, 2015). The CFS is interlinked with the UN Standing Committee on Nutrition (UNSCN), which connects UN agencies and partners working on nutrition and food policy. The UNSCN has a dedicated section on Nutrition and NCDs (UN 2015), but funding issues seem to impede its scope of work (WPHNA 2011).

Among the most cited forums in the study, ENN is the most used by field nutrition workers. Since its special edition of Field Exchange on the Syria response in March 2015, ENN now includes articles on the double burden of malnutrition in its communications (Dolan et al, 2014).

The potential for negative consequences of prevention and treatment programmes for undernutrition on childhood obesity are reflected in the literature. Examples include:

• Promotion of sweet, energy-dense products may send misleading messages to parents as well as habituate children’s tastes for sugar-rich and calorie dense foods (GIFA 2014).
• Rapid catch-up growth may lead to obesity, rather than increase the height of children, especially when used in prevention (WPHNA; Gupte 2013).
• Action Contre la Faim argues that the potential risk of ready-to-use therapeutic food (RUTF) leading to obesity needs to be further researched, but will continue to use RUTF to treat SAM until the risk is verified (ACF 2012).

The need to evaluate those risks objectively in field programmes persists.

An increase in public/private partnerships and inherent risks to public health are also concerns. The Lancet series on the global obesity pandemic noted: “Governments and international organisations such as the UN need to provide global leadership on these issues and not abdicate them to the private sector” (Swinburn et al, 2013). A positive example of private sector engagement was given in feedback, noting that not all public-private partnerships are the same. Actors working in the field of nutrition request more transparency and monitoring of those partnerships in order to be able to “maximise benefits and minimise risks” (Kraak et al, 2012).  

Conclusion and recommendations

This study identified that, despite increased interest among international organisations and UN policy development on prevention of obesity and NCDs, there is an intervention gap in LMICs in catering for the DBM. Lack of donor engagement/funding and lack of evidenced interventions limit progress. There are concerns regarding consequences of current undernutrition treatment programmes for future NCD burden. Key recommendations emerging from this study include:

1.      The collection and reporting of childhood and maternal overweight/obesity data should be systematically included in all nutrition surveys;

2.      Advocacy for the inclusion of the WHA target on childhood obesity in the SDGs is needed;

3.      Epidemiological and operational information on DBM should be integrated into existing international nutrition forums, and particularly more systematically within the SUN movement;

4.      More research is needed on the impact of the promotion of RUTF and rapid weight gain in acute malnutrition treatment programmes; and

5.      Greater monitoring of possible conflicts of interests in public/private partnerships is required.

Further research, involving a full mapping of DBM activities of international organisations and an exploration of operational evidence on prevention of obesity in LMICs, has the potential to contribute to the halt in the rise of diabetes and obesity as recommended in the WHA target. The link between undernutrition and overnutrition may also be an entry point to advocating with donors to add the DBM to their development agenda.

For more information, contact: a.rutishauser-perera@savethechildren.org.uk

Watch Alexandra Rutishauser-Perera’s talk on this topic at the TEDx LSHTM: https://www.youtube.com/watch?v=G7AG-DvobHE

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