Dynamics of the double burden of malnutrition and the changing nutrition reality

Abstract

The double burden of malnutrition (DBM), defined as the simultaneous manifestation of both undernutrition and overweight and obesity, affects most low-income and middle-income countries (LMICs). This Series paper describes the dynamics of the DBM in LMICs and how it differs by socioeconomic level. This Series paper shows that the DBM has increased in the poorest LMICs, mainly due to overweight and obesity increases. Indonesia is the largest country with a severe DBM, but many other Asian and sub-Saharan African countries also face this problem. We also discuss that overweight increases are mainly due to very rapid changes in the food system, particularly the availability of cheap ultra-processed food and beverages in LMICs, and major reductions in physical activity at work, transportation, home, and even leisure due to introductions of activity-saving technologies. Understanding that the lowest income LMICs face severe levels of the DBM and that the major direct cause is rapid increases in overweight allows identifying selected crucial drivers and possible options for addressing the DBM at all levels.

Figure 1.. The global double burden of malnutrition in low- and middle-income countries based on 1990s and 2010s weight and height data*

(using UNICEF, WHO, World Bank, and NCD-RisC estimates, supplemented with selected DHS and other country direct measures) * Double burden of malnutrition (DBM) = at least 1 child, adolescent, or adult in household with severe levels of wasting/stunting/thinness and 1 with overweight/obesity (shown at 20%, 30%, or 40% overweight prevalence)

Figure 2.. Countries with high double burden of malnutrition* in 1990s and 2010s, by time period and GDP/capita (PPP) quartile**

* Double burden of malnutrition (DBM) = at least 1 child, adolescent, or adult in household with severe levels of wasting/stunting/thinness and 1 with overweight/obesity(shown at 20%, 30%, or 40% adult overweight prevalence); countries only included here if they had DBM data available for bothtime periods (1990s and 2010s) ** Quartile (Qtl) 1 is lowest-wealth, Qtl4 is highest-wealth Data sources: Based on UNICEF, WHO, World Bank, and NCD-RisCestimates supplemented with selected DHS and other country direct measures for the 1990’s

Figure 3.. Number of countries that changed double burden of malnutrition* status from 1990s to 2010s, by GDP/capita (PPP) quartile

* Double burden of malnutrition (DBM) = at least 1 child, adolescent, or adult in household with severe levels of wasting/stunting/thinness and 1 with overweight/obesity(shown at 20%, 30%, or 40% adult overweight prevalence); countries only included here if they had DBM data available for bothtime periods (1990s and 2010s) ** Quartile (Qtl) 1 is lowest-wealth, Qtl4 is highest-wealth Data sources: Based on UNICEF, WHO, World Bank, and NCD-RisCestimates supplemented with selected DHS and other country direct measures for the 1990’s

Figure 4.. The association between GDP-PPP and regressions relating GDP per capita to household double burden

Sources: The data are from the Demographic and Health Surveys (DHS, https://dhsprogram.com/), with the exceptions of China (China Health and Nutrition Survey), Indonesia (Indonesian Family Life Survey), Mexico (Mexico National Survey of Health and Nutrition), Brazil (Brazil National Health Survey), and Vietnam (Vietnam Living Standards Survey).

Figure 5.. The shifting burden of overweight/obesity from higher- to lower-wealth populations in sample countries**

* Positive difference indicates higher annualized growth in overweight/obesity prevalence for the lowest-wealth quartile. ** Countries presented here had earliest-to-latest-year data spanning 15 or more years, latest-year data after 2010, and a population greater than ≈15 million (with the exception of Jordan andKyrgyz Republic, which both had smaller populations but were included for regional representation). The data presented is from years spanning 1988 to 2016, but exact years vary by country.The span of earliest-to-latest years collected ranges from 15 years to 24 years. All data are from the Demographic and Health Surveys (DHS, https://dhsprogram.com/) with the exceptions ofChina (China Health and Nutrition Survey), Indonesia (Indonesian Family Life Survey), Mexico (Mexico National Survey of Health and Nutrition), Brazil (Brazil National Health Survey), andVietnam (Vietnam Living Standards Survey).