23 June 2013

Double Burden of Malnutrition: Time to Drop "Double"?

One of the things that is apparent from the recent Lancet Nutrition Series is that it is becoming more and more difficult to keep the under and overnutrition agendas separate.

It is really tempting to keep them separate.

First, dealing with undernutrition is difficult enough without having to deal with overnutrition (basically overweight and obesity and the related chronic diseases of diabetes, coronary heart disease, high blood pressure and some forms of cancer).

And of course, dealing with undernutrition is one great way to help prevent overnutrition later in life.  In addition, dealing with overnutrition means having to grapple with the food industry and a whole range of factors outside of nutrition's comfort zone: urban development, education, trade, taxes and agriculture for example.

Also, there aren't exactly a range of interventions and policies that have been shown to be effective to inspire us to ramp up action on the overnutrition front.

Finally, it is not easy to get research funding to address the two in an integrated fashion.

But I think the separation (which I have also contributed to) is no longer sustainable.

First, overnutrition does not operate a different space: it is not just a later in life phenomenon--it is happening to under 5's; it is not just in urban areas and it is not just in middle and upper income countries--it is everywhere.

Second, the undernutrition community can't avoid engaging with the private sector--not having to deal with the private sector is no longer a reason for not getting involved overnutrition.

Third, we now know that the fight against undernutrition has to go way beyond health, and into the wider development space. This is something even more obvious in dealing with overnutriton.

All the reasons for separating the two are dissolving.

So, seemingly, something that is difficult (undernutriiton reduction) just got much harder (dealing with under and over nutrition). But is that really so? Can an integrated approach help us address both issues better? I think that may be the case. 

Making development more nutrition sensitive and making nutrition more politically aware surely brings the worlds of over and undernutrition together, indeed, shows they were never that far apart in the first place. They should no longer be separated at birth.

In this context, a new World Bank review of Global Evidence on the Double Burden of Malnutrition from the World Bank (by Roger Shrimpton and Claudia Rokx) is comprehensive and well done, but depressing (coming soon on the World Bank website). It is depressing because it shows how divided the two camps are and how that is to neither's advantage. Beyond the physiological linkages there has not been much thinking in the past 10 years on how to bring them together in the policy, programme, training, communication and advocacy spaces.

Perhaps the time is only now right to do this.

A paper in the Lancet from December 2012 by Moodle et. al. ("Profits and Pandermics") draws the parallels between the practices of the tobacco, alcohol and "ultra-processed food and drink" industries. They conclude that "despite the common reliance on industry self-regulation and public-private partnerships, there is no evidence of their effectiveness or safety". I think the evidence base upon which they draw is weak (not their fault), but their conclusions are in accord with my own sense of the situation and indeed I made the same parallels in Development Policy Review paper from 2003 where I go through the various triggers for successful government regulation of tobacco an see how they apply to obesity. 

I think policymakers are about to get a wake up call from advocacy groups, consumers, the health community, and even some industry leaders, to do something.

The Double Burden is here to stay. Perhaps it is time to drop the Double (on the double).


Anonymous said...

Dear Lawrence,
great blog and important topic. Indeed no time to waste. The UNSCN has been advocating for increased attention for the DBM and using the window of opportunity to tackle both undernutrition and overweigth/obesity. See the link to the discussion paper http://www.unscn.org/files/NutNCD/Nutrition_and_NCDs_discussion_paper_2011.pdf
Readers are welcome to join the NutNCD group as well. http://www.unscn.org/en/nutrition_ncd/nutrition_ncds_egroup.php

Lina (UNSCN Secretariat)

Anonymous said...

Dear Lawrence,
Great blog. I sit here in Viet Nam, swamped by the emerging non-communicable disease Tsunami epidemic of increasing childhood obesity rates and diabetes (over 20% annual increase in prevalence rates), unfortunately your article rings true.
What to do about it? Donors, development partners and various national institutes don't want to know about it. Plans are scattered and unsexy. It is uncomfortable and doesn't raise money. Pictures and stories of wasted / stunted children tug heart strings of traditional donors. Pictures of obese Vietnamese children get ridiculed. Development support is fragmented and projectised, with little incentive to see the more holistic picture.
Fast food industry representatives lobby Govt. and donors and fast food outlets rapidly increasing. I wish we could learn from the mistakes of our northern neighbour.
I work for a large bureaucracy and have been told non communicable diseases are not a priority and should remain anonymous on blogs. You have hit on an issue that is an unwelcome issue for dialogue in mainstream development institutions.

Lawrence Haddad said...

Thanks Lina and thanks Anonymous. The SCN has highlighted this issue for a while now and that will continue to be important.

On our friend in VietNam. It is disappointing that you are told you can't even blog about NCDs.

The only thing that really seems to get policymakers attention is the impact on economic grout. So we need to get better estimates of the impacts on economic growth of the rise in diet related NCDs vs the impacts on economic growth of the rise in the food industry. So many policymakers are afraid to do anything for fear of scaring off the private sector investment in their emerging economies, which is an understandable worry for them and their citizens (jobs are the main driver of poverty reduction). But I bet the former outweighs the latter, but even if not, we need the estimates to show that the former is very substantial..