The double burden of malnutrition is characterised by the coexistence of undernutrition, alongside obesity and overweight or diet related non-communicable diseases within individuals, households and populations, across the life course (WHO 2018). The World Health Organisation (WHO 2017) issued a policy briefing regarding the double burden of malnutrition, which effects countries worldwide. This policy aims to highlight key issues that many countries are facing and why we need to act. Across the globe there are 1.9 billion adults classed as overweight and over 600 million are obese. Alongside this, there are 462 million adults underweight and 264 million women of reproductive age are affected by iron-amenable anaemia. The statistics for children are of equal concern, showing 41 million are overweight or obese, 155 million are stunted and 52 million are wasted (WHO 2017).
The increasing prevalence of malnutrition displays a rapidly growing health problem globally, the necessity for policy making and challenging action plans. A multitude of factors contribute to the double burden of malnutrition, with unhealthy diets being the most important cause (WHO 2018, The Nutrition Challenge) and most responsible for adult deaths compared to alcohol and tobacco. Urbanization, salary income, food production, marketing and availability has changed vastly over the last 50 years. Parts of the population are consuming high calorie diets, with high sugar and fat content. Contrastingly, others do not eat enough nutrients, vitamins and calories to support optimum health and growth. Other factors are food availability, cultural beliefs and socioeconomic status, all contributing to the increased prevalence seen in the statistics. Critical analysis of the current evidence and approaches used to tackle this global health problem is imperative to meeting the health targets.
Life starts at preconception, where maternal nutrition is vital for successful pregnancies for prevention of gestational diabetes, pre-eclampsia and normal growth and development of the foetus. Maternal body mass index (BMI) is relative to the weight of the offspring (WHO 2017). A high BMI has shown to increase the placenta size and increase the birthweight of the child, thus high risks of obesity, metabolic diseases and cardiovascular risks (WHO 2015). Whereas a low maternal BMI can result in small placenta development which effects nutrients and hormones for the foetus and thus a low birth weight. In paradox to this, low birthweights are associated with the same risks of obesity, but also possibility of stunted growth, autism and poor development of brain function and immune systems.
Maternal anaemia contributes to still births, miscarriages, prematurity and low birthweight (WHO 2014). Anaemia is interlinked with the five other global nutrition targets; stunting, low birth weight, childhood overweight, exclusive breastfeeding and wasting (WHO 2014). Anaemia is highly prevalent in South Asia, Central and West Africa but it can be common in those who follow a vegetarian diet for cultural or ethical reasons. Many who follow a vegetarian diet can be low in B12 and folate which could be detrimental for preconception, risk of anaemia and delayed growth.
Whilst vegetarian diets can be followed for cultural reasons, food availability can also be an issue for low Iron levels and poor development. In parts of India as well as Africa, Sorghum is used when nutrient foods are low cost and in demand (Ratnavathi and Patil 2013). Having different types of wholegrains to add to Roti or Couscous are of low priority when much of the population cannot afford this. The high milling process to support shelf life, takes away vitamins and minerals that we would see in wholegrains, which would support health and development (Tighe et al. 2010). Compared to wholegrains it is also lower in fibre, contains polyphenols which can inhibit other essential nutrients.
There is strong evidence which supports successful interventions to prevent low birthweights, anaemia, wasting and stunted growth (WHO 2017). At country or regional areas, interventions suggest improved access to sanitation and hygiene, food access systems, social protection systems and support for women’s empowerment for education. Interventions recommended at a community level are adequate nutrition for adolescent girls, where it is culturally acceptable to be married and pregnant, iron and folic acid supplements, smoking cessation and prevention of malaria risk during pregnancy (WHO 2014). Ensuring and improving access to healthcare to diagnose and treat low birthweight is key to addressing this problem. Alongside this, culturally sensitive approaches for woman is essential for those who face greater barriers to access healthcare (WHO 2014).
Another evidence based preventive measure is promoting exclusive breastfeeding. This is defined as the practice of providing sole nutrition for an infant 0-6months old which is a cornerstone for their growth, development for childhood and later in life (WHO 2014). Despite the many advantages of breastfeeding, global rates are still low at 38%. Arguably this is the starting point to avoid the increasing rates of malnutrition in children such as stunting, wasting and being overweight which are on the rise (WHO 2017). Evidence supports education and investing in post-natal care as approaches to improve the breastfeeding rates (WHO 2014).
Children who are overweight or obese have increased risk of cardiovascular disease, diabetes, and some cancers now and later in adult life. Obesity increases chances of bullying, low self-esteem, poor school attendance and poor job prospects (WHO 2018). Schools are now implementing anthropometric screening to tackle this problem by starting treatment earlier (WHO 2017). Understanding that treatment and support is needed for the whole family rather than just the child will support successful change.
Changes in key messages from the food industry is another approach for prevention of overweight and obesity across the lifespan. Promotional marketing, food labelling and manufacturing are some of the parts of the systems that require evaluation. Only recently have fruit and vegetables been commercially televised in the campaign, by Veg Power (2019). This advertisement aims to promote fruit and vegetables, which recognises childhood obesity and the dislike for vegetables being a potential reason for the prevalence.
An example of a successful children’s public health initiative is change4life, a government plan to support healthier lifestyles attempting to tackle childhood obesity. The campaign recognises a sedentary lifestyle of video games and watching television, are potential changes in ‘modern life’ that have been drivers for the increase of childhood obesity. Families are encouraged to sign up for meal ideas, supporting caregivers to ensure appropriate nutrition and exercise. Diets high in free sugars, particularly fructose consumption is associated with malnutrition (MacDonald 2016). The campaign identifies the high sugar content children consume by providing ‘sugar swaps’, agreed by Arsenault (2017) that ‘chronic overconsumption of sugar-sweetened beverages (SSBs) is amongst the dietary factors most consistently found to be associated with obesity, type 2 diabetes (T2D) and cardiovascular disease (CVD) risk in large epidemiological studies’.
Increased sedentary lifestyle tips energy balance, leading to overweight or obesity and is a causing factor in rising childhood Rickets. Research carried out by Michigan’s Children Hospital (2008) confirms that lack of Vitamin D in diet, sunlight and low levels of activity are contributing factors. Cultural differences such as Muslims who wear burkas, alongside those who did not breastfeed, presented higher percentages in the data. Despite a controversial topic regarding sun exposure and cancer risk, Vitamin D supplementation is required as a minimum to support breastfeeding to ensure adequate amounts are reached.
Policies by the World Health Organisation have been produced to highlight, tackle and help understanding of the current health issues in relation to malnutrition. However parallel to this, there is also the rise of mental health disorders such as Anorexia Nervosa, Binge eating and Bulimia (Marsh 2018). Appetite regulation has become a topical global issue, with eating disorders on the rise especially in the developed nations. NHS England (2018) increased funding to support the demand for eating disorders service by £30 million.
Eating Disorders are interlinked with the same complex psychological, obesogenic environment as well as a triggering social media platform. The population may be lost with mixed health messages and no longer able to recognise appropriate nutrition for themselves despite education. Mindful eating and behaviour change are useful tools for binge eating disorders (BED) and potentially a support for those overweight or obese. Ursula Philpots (2018) utilises behaviour change as a central part of treatment for those with binge eating disorders, with evidence that Guided Self Help (GSH) is a useful tool for Dietitians to use in the community for BED and weight management. Personalised Nutrition considers eating habits and appetite control (Rogers 1999). This way of managing diet is less traditional that previous dietetic advice but it addresses not only the food intake and environment but the genotype of the person as well to tailor their nutritional needs. This approach for weight management could tackle the burden of malnutrition globally.
In summary, there are numerous consequences to malnutrition globally and the WHO have created policies to tackle each aspect for cultural differences, food systems, socioeconomic status as well as strengthening access to healthcare and prevention. A holistic approach to malnutrition is needed, through understanding that stunting, wasting and micronutrient deficiencies can occur in the same child, family and community, and ensuring services for undernutrition are implemented in a more cohesive fashion. A strengthened healthcare system, early identification and treatment with clear health messages, could help support the reduction in prevalence of child and adult obesity. Further successful approaches for preventing malnutrition across the lifespan include change in food advertisement and availability, initiatives to support families and schools in understanding of eating habits and development of psychological methods for weight management and appetite control. Further randomised controlled trials exploring successful interventions will strengthen or identify new methods which can support the targets, to tackle the burden of malnutrition.
References
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