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THE DOUBLE BURDEN OF
MALNUTRITION (DBM)
BY: DOROTHY ONYANGO, MPH
UNDERNUTRITION
OVERNUTRITION
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.
• 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.
• 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 lifethreatening and very difficult to treat in places
with limited resources and already overburdened
health systems.
• 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).
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 overnutrition.
• 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)
• 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).
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)
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)
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
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 noncommunicable diseases such as type e diabetes
and cardiovascular diseases later in the life
course
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
• 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.
Models for the causality of obesity
a.
b.
c.
d.
The biological/health environment
The economic/food environment
The physical/built environment
The socio cultural environment
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.
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.
• “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.
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
– 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
• 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
• 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.
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
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.
Causes: Analytical Framework Based on the UK
Foresight Project on Obesity 2007
SOLUTION FOR DBM
1.
2.
3.
1.
1.
2.
Programmatic and Policy Interventions
Health/Biological Environment
Economic/Food Environment
- Availability
- Distribution
- Improving Access to Healthy Food Products
- Consumption
Physical/Built Environment
- Increase opportunities for exercise
- Limit the role of automobiles
Socio-Cultural Environment
Cultural Norms and Beliefs