The double burden of malnutrition among young children in South Asia: Policy and programme options

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Dr Angela de Silva is the Regional Adviser, Nutrition and Health for Development, WHO Regional Office for South-East Asia. 

Dr Ayoub Al Jawalhdeh is the Regional Adviser, Nutrition, WHO Regional Office for the Eastern Mediterranean. 

1.  What is the current nutrition situation regarding overweight among young children in the region? 

The levels of overweight in young children under five years of age in South Asia are not high compared to other regions, but the upward trend is significant and worrying. Generally, the overweight prevalence is higher in children aged 0-23 months than those aged 24-59 months.

Table 1: Prevalence of overweight in young children in South Asia

*Disaggregated data not available

As shown in Table 1, there are disparities in the prevalence of child overweight between countries in the region. The prevalence of overweight in children aged 0-23 months is highest in Afghanistan (5.3%) and the Maldives (4.5%), and is below 3% in India, Nepal, Pakistan and Sri Lanka. The key point is that, although prevalence rates are low compared to wasting and stunting, they are substantial in terms of numbers and the growing upward trend is worrying. Other factors to note are that overweight prevalence is higher in urban settings and that there is generally no difference between boys and girls. Overweight is more common in higher socioeconomic groups, which is different to the situation in high-income countries, although we are beginning to see overweight emerging among the lowest income groups, too.

2.  Can you share any examples of countries in the region that have policies or programmes to protect the diets of young children and promote healthy eating?

All countries in South Asia have infant and young child feeding (IYCF) policies or strategies that promote healthy complementary feeding in children aged 6-23 months and, although they are not specifically targeting child overweight, they focus on optimal feeding practices (breastfeeding and complementary feeding). The food-based dietary guidelines or national IYCF guidelines of most countries (Afghanistan, Bangladesh, India, Maldives, Nepal, Pakistan, Sri Lanka) are based on WHO [World Health Organisation] global guidance, which is being updated, and cover the life cycle, including the 6-23 months age group. In terms of legislative protection, commercially manufactured complementary foods are covered in Bangladesh, Maldives, Sri Lanka and India, with each country covering different age groups.

3.  What are the most effective policy options that countries could consider, in terms of creating systems that promote healthy diets in early childhood? 

A key point to remember for South Asia, where the predominant burden is undernutrition, is that we need to ensure policy options promote an optimal diet for young children that covers all aspects of malnutrition. Some existing interventions could be expanded so that they address both undernutrition and overweight within one programme package – the so-called ‘double-duty’ actions. Double-duty actions include interventions, programmes and policies that have the potential to simultaneously reduce the risk or burden of both undernutrition (including wasting, stunting and micronutrient deficiency or insufficiency) and overweight, obesity and diet-related, non-communicable diseases (including type 2 diabetes and cardiovascular disease). WHO’s essential nutrition actions and the recommendation of the Commission on Ending Childhood Obesity suggest a number of policy interventions that countries could implement to more effectively address undernutrition and overweight simultaneously. These include:

• Legislation and regulatory actions to tackle issues of unhealthy commercial complementary foods and set nutrient targets and standards for sugars and fats (including trans-fatty acids elimination); 
• Enforcement of the implementation of the International Code of Marketing of Breastmilk Substitutes (‘the Code’), including addressing the inappropriate promotion of foods and beverages to young children;
• Programmatic actions to encourage breastfeeding and adequate complementary feeding and prevent micronutrient deficiencies;
• Develop food standards for government food-supplementation programmes that target specific recipients, rather than blanket programmes;
• Promote physical activity for young children;
• Increase community awareness of the importance of healthy feeding and risk of overweight as, to date, the messaging in South Asia has focused on undernutrition and communities are often unaware of the problem. There are cultural connotations of ‘chubby’ being seen as healthy.

Each country will need to allocate additional resources, develop capacity, address coverage and quality of current programmes, and prioritise the ‘menu’ of actions according to its specific realities. 

4.  What do you see as the main challenges to addressing the double burden in South Asia? How can these barriers be overcome?

Governance: To date, the policy focus in countries has been on different forms of undernutrition, since they are more prevalent and can increase in the countries experiencing protracted crises (such as conflict and civil unrest, as seen in Afghanistan and Pakistan). However, policymakers need to understand the common drivers of all forms of malnutrition. Extensive advocacy is key to utilising data and information that also take account of commercial food products. 

Health systems: These are mainly responsible for programme delivery for IYCF and can be constrained in many countries in terms of resources, capacity and monitoring. Fragile health systems are resource-scarce, often with low coverage of interventions and having to deal with competing priorities. 

Poor convergence between systems (food; health; water, sanitation and hygiene (WASH); and social protection systems): In this situation, bringing in the dimension of overweight adds another layer of complexity. Despite efforts to set up multisector platforms for coordinated actions to address undernutrition in young children, the reality is that there is often little coordination in evidence on the ground. Merely adding overweight to such platforms is unlikely to be successful unless there is a review of the performance of multisector platforms in each country and rectification of existing constraints, so that policy and programme convergence is addressed systematically. 

Development and adoption of guidelines, legislation and regulatory frameworks: There is a lack of guidance and legislation. Where they do exist, poor enforcement and monitoring is a concern; as seen, for example, in the implementation of the Code (and subsequent resolutions), including inappropriate promotion of unhealthy foods and beverages for young children. 

Community empowerment: Communities have so far heard about stunting and wasting; adding another dimension has to be done with appropriate communications and messaging that address social norms of ‘chubby babies’. 

5.  What are the plans for next steps on this agenda at a regional level?

Specific directions and actions have been identified in the Strategic Action Plan to reduce the double burden of malnutrition in South-East Asia (2016-2025) and endorsed by all member countries¹. Member states in the Eastern Mediterranean (which includes Afghanistan and Pakistan) have also supported a new nutrition framework (2020-2030) that includes actions to address overweight/obesity².

Health-system strengthening to increase access to primary care is being supported by WHO. The actions relating to young children’s diets and nutritional situation are:

• At a regional level, conduct a policy and programme mapping to assess the current situation of the double burden as baseline information, including maternal care and older children. Countries can then be supported to examine their situation and address gaps in their policies, infant and young child feeding strategies, guidelines and programmes.
• Support prioritisation of actions for feeding of children aged 6-23 months. 
• At a regional level, we also need to better identify indicators that can measure a healthy diet. The current indicators need to be supplemented.
• Context-specific research is also needed on overweight in the 6-23 months age group in terms of specific drivers and dietary counselling messaging. To support young children’s diets, we have initiated a nutrient-profiling activity whereby the nutrient content of commercial complementary foods is assessed and countries can be supported to move towards healthier snacks and commercial complementary foods.

Footnotes

¹https://www.who.int/docs/default-source/searo/india/health-topic-pdf/strategic-action-plan-to-reduce-the-double-burden-of-malnutrition-in-sear-2016-2025.pdf?sfvrsn=a73ab5d1_2

²https://apps.who.int/iris/handle/10665/330059