1. THE DOUBLE BURDEN OF MALNUTRITION (DBM) BY: DOROTHY ONYANGO, MPH

2. UNDERNUTRITION OVERNUTRITION

3. INTRODUCTION What is DBM? – This is the problem of both undernutrition and overnutrition in the same population. – It is the coexistence of both undernutrition and overnutrition in the same population at the same time. – It is undernutrition, including micronutrient deficiencies, coexisting with overnutrition: overweight and obesity.

4. Globally there are 170 million underweight children, 3 million of whom will die each year as a result of being underweight. Additionally, WHO estimates worldwide at least 20 million children under five years of age are overweight, as well as more than a billion adults, and at least 300 million adults who are clinically obese. Malnutrition, in every form, presents significant threats to human health.

5. Hunger and inadequate nutrition contribute to early deaths for mothers, infants and young children, and impaired physical and brain development in the young. At the same time, growing rates of overweight and obesity worldwide are linked to a rise in chronic diseases such as cancer, cardiovascular disease and diabetes - conditions that are life- threatening and very difficult to treat in places with limited resources and already overburdened health systems.

6. The DBM occurs in populations, households, and individuals – At the global level, 17 percent of preschool children are underweight, 33 percent suffer from iodine deficiency, 40 percent of women of reproductive age have anemia (UNSCN 2010), while already 25 percent of the global population is overweight (Finuncane et al. 2011).

7. DBM Key Concepts and Indicators: Malnutrition refers to deficiencies, excesses or imbalances in intake of energy, protein and/or other nutrients. Contrary to common usage, the term 'malnutrition' correctly includes both under-nutrition and over- nutrition. Under-nutrition is the result of food intake that is continuously insufficient to meet dietary energy requirements, poor absorption and/or poor biological use of nutrients consumed. This usually results in loss of body weight. Over-nutrition refers to a chronic condition where intake of food is in excess of dietary energy requirements, resulting in overweight and/or obesity. Micronutrient malnutrition is the result of insufficient intake and or absorption of crucial micronutrients, such as Vitamin A, iron, iodine, and zinc, which can contribute to life-threatening conditions. (WHO)

8. Obesity is a disease associated with impaired functions related to alterations in the metabolism of steroid hormones, metabolic alterations including lipid and glucose levels, and increases in the turnover of free fatty acids that lead to insulin resistance syndrome (Seidell et al 1994, Turcato et al 2000, Rose et al 2002 and Eckel et al 2002).

9. Facts on DBM Undernutrition: about 104 million children worldwide (2010) are underweight undernutrition contributes to about one third of all child deaths stunting (an indicator of chronic undernutrition) hinders the development of 171 million children under age 5 according to 2010 figures 13 million children are born with low birth weight or prematurely due to maternal undernutrition and other factors a lack of essential vitamins and minerals in the diet affects immunity and healthy development. More than one third of preschool-age children globally are Vitamin A deficient maternal undernutrition, common in many developing countries, leads to poor fetal development and higher risk of pregnancy complications together, maternal and child undernutrition account for more than 10 percent of the global burden of disease (WHO)

10. Overweight and obesity: about 1.5 billion people are overweight worldwide, of whom 500 million are obese, in 2008 figures about 43 million children under age 5 were overweight in 2010 growing rates of maternal overweight are leading to higher risks of pregnancy complications, and heavier birth weight and obesity in children worldwide, at least 2.6 million people die each year as a result of being overweight or obese (WHO)

11. Who does DBM affect? Affects all countries In most LMICS, overweight seems to be increasing faster than underweight decreases (Popkin, 2001). At the population level it is most found among women Overweight seems to be increasing faster than underweight in low and middle income countries (LMICs) Obesity trend is shifting towards lower socio-economic groups with increase in national income DBM is often found with the same household; there is the coexistence of maternal over-nutrition and child under-nutrition in the same household

12. CONSEQUENCES OF DBM Child mortality Final adult height compromised Less schooling Reduced economic activity later in life Interferes with immunity Greater propensity for diet related non- communicable diseases such as type e diabetes and cardiovascular diseases later in the life course

14. CAUSES OF DBM The causes are related to a series of changes affecting societies which have been called the ‘nutrition transition.’ Nutrition transition encompasses changes in the demographic, economic, behavioral and epidemiological situations of countries and their populations. Nutrition transition began as a secular trend and caused inter-generational changes which now occurs as intra-generational changes

15. The DBM’s underlying causes are related to a series of historic changes affecting societies. These changes are known as: – the nutrition transition – the demographic transition, and – the epidemiological transition. People have gone from being hunters and gatherers to sedentary consumers. High fertility and early death are being replaced by low fertility and aging populations. Communicable disease burdens are being overtaken by non-communicable disease burdens.

16. Models for the causality of obesity a.The biological/health environment b.The economic/food environment c.The physical/built environment d.The socio cultural environment

17. The biological environment This is an individual’s starting point and includes the influence of health services and the burden of diseases as well as the individual metabolic and genetic influences. Health system and the disease burden – Demographic transition: there is a shift from high birth and death rate to low birth and death rates due to industrialization and improved hygiene and sanitation with increased antenatal care and family planning – Epidemiologic transition: infectious diseases are replaced by non communicable diseases as the most important causes of disability and mortality.

18. Biological aspects Genetic traits have been found to not only affect metabolic capacity to store energy, but also affect people’s perceptions of hunger and satiety. Studies have confirmed that heritable factors are likely to be responsible for 45-75% of inter-individual variations in BMI.

19. “The genetic background loads the gun, but the environment pulls the trigger” George Bray. The thrifty phenotype hypothesis says that constrained fetal growth is strongly associated with a number of chronic conditions later in life. Genetic factors could endow individuals that were able to efficiently collect and process food to deposit fat during periods of food abundance. The influences of today’s modern diet are likely to be greatest during the critical period of fetal and infant growth when plasticity is greatest and epigenetic changes most likely to be determining the many non communicable disease risks.

20. The economic/food environment Two parts Food availability and access – There is increased per capita/economy in global food availability which has led to increase in caloric supply – There is rising global food production which has outpaced demand due to green revolution – There is increasing large scale global trade of food which has led to food availability patterns becoming more similar throughout the world

21. – There is nutrition transition with adaptation of a ‘western diet’ of consuming more processed food, meat, and dairy products and low consumption of cereals, fruits, and vegetables – There is free trade which means an increase in food imports by most LMICS since imported foods are cheap – There is trade liberalization which removes barriers to foreign investment in food distribution leading to availability of processed foods

22. Food consumption – Erosion of breastfeeding – Increase in fat consumption – Change in type of unsaturated fats being used – Increase in the consumption of processed foods with different degrees of processing Group 1 processing Group 2 processing Group 3 processing

23. Group 1 are unprocessed or minimally processed foods Group 2 are processed culinary or food industry ingredients Group 3 are ultra-processed food products Imbalance consumption of these foods from the various groups may bring a problem.

24. The physical/built environment This includes factors that influence individual’s activity behavior including the type, frequency and intensity of physical activity as well as access to healthy food. – Activity environment: there is change of lifestyle brought about but urbanization – There is increase in the amount of time spent away from home leading to increased consumption of foods away from home and snacking

25. The socio-cultural environment This includes the influence of media, education, peer pressure or culture and how these impact or person’s individual drive for particular foods and consumption patters, or physical activity patterns or preferences.

26. Causes: Analytical Framework Based on the UK Foresight Project on Obesity 2007

27. SOLUTION FOR DBM 1.Programmatic and Policy Interventions 2.Health/Biological Environment 3.Economic/Food Environment - Availability - Distribution - Improving Access to Healthy Food Products - Consumption 1.Physical/Built Environment - Increase opportunities for exercise - Limit the role of automobiles 1.Socio-Cultural Environment 2.Cultural Norms and Beliefs