Namrata Tyagi* and Vijayaraghavan M Chariar
Received: July 17, 2023; Published: July 25, 2023
*Corresponding author: Mitsuru Sakitani, Director of the Institute CCC, Ibukidai-Higashimachi, Nishi ward, Kobe, Hyogo, Japan
The dual burden of malnutrition (DBM) is a serious public health issue affecting billions all over the globe resulting in disability-adjusted life years (DALYs), productivity losses, and economic burden. The primary fuel to the rising global disease burden is the poor-quality diet and lifestyle responsible for multiple forms of malnutrition. This review paper discusses the present challenges, interventions, and approaches to target the root of DBM problems, as healthcare treatment is unaffordable and inaccessible to all, especially for those at the bottom of the pyramid. Also, this review focuses majorly on the double duty actions targeting both undernutrition and overweight and obesity simultaneously that can help in taking appropriate measures to control the prevalence of the disease burden. The outcome of this study provides an overview of double-duty actions for an integrated DBM management system as a preventive measure that could be helpful in policymaking, strategy development, and program planning to put less burden on the healthcare system.
Keywords: Obesity; Undernutrition; Dietary Assessment; Anthropometrics; Dual Burden of Malnutrition; Nutrition Surveillance Framework
Abbreviations: DBM: Dual Burden of Malnutrition; DALYs: Disability-Adjusted Life Years; HDDS: Household Dietary Diversity Score; IDDS: Individual Dietary Diversity Score; FCS: Food Consumption Score; CNNS: Comprehensive National Nutrition Survey; NNMB: National Nutrition Monitoring Bureau; NFHS: National Family Health Survey; DLHS: District Level Household Survey; RSoC: Rapid Survey on Children
The current dietary transitions and changing food environments result in the double burden of malnutrition, including undernutrition (stunting, wasting, underweight, and micronutrient deficiencies) and overweight, obesity, and diet-related non-communicable diseases (WHO, 2017). According to the 2017 Global Nutrition Report, progress in addressing global malnutrition challenges and meeting targets set for 2025 is slow. The report states that a significant number of children are affected by malnutrition, with 150.8 million experiencing stunted growth, 50.5 million suffering from wasting, and 38.3 million being overweight. Additionally, the report notes that a large proportion of adults are also overweight or obese, with 2.01 billion affected. There is an urgent need to address malnutrition in all its forms to achieve SDG 2 and Target 3.4 and the Rome Declaration on Nutrition’s Commitments within the U.N. Decade of Action on Nutrition (WHO, 2017). DBM is posing a serious threat and also taking a faster pace as a silent epidemic in the country, and the present healthcare system is not conducive to solving the crisis, especially for the vulnerable population (Plan, et al. ). 5.87 million deaths, i.e., nearly 60% of total deaths, are due to NCDs in India, and it accounts for nearly two-thirds of all deaths in SEAR of WHO due to NCDs (Global Status Report on NCDs ). It is projected that diet-related health costs could be more than 1.3 trillion U.S. dollars a year, and GHG emissions cost the U.S. $1.7 trillion a year by 2030. Shifting to healthy diets can reduce health costs by up to 97% and climate costs by 74% (SOFI). Hence, there is an urgent need to transform food systems towards the household level to overcome malnutrition’s double burden. There is a raging nutrition transition in LMICS even amongst the rural population that now have access to processed and high calorie but nutrient deficient and high salt and sugary food that has replaced the traditional Indian diverse diets (The Lancet ). The Disability-adjusted life years (DALY) attributed to malnutrition is of major concern as malnutrition is the leading risk factor in all age groups, indicating 4% of the total DALY of 64% population in 2017 (Swaminathan, et al. ). The dual burden of malnutrition (DBM) is a serious public health issue affecting billions all over the globe resulting in disability-adjusted life years (DALYs), productivity losses, and economic burden. Hence this review aims to study integrated and multifaceted approaches to address this issue.
This review discusses in detail about the co-existence of DBM, drivers, determinants and risk factors, current challenges, interventions majorly related to double duty actions and throws light on the major surveillance systems in India for malnutrition monitoring. Also, it provides an overview of the present progress and research gaps in the existing literature are discussed along with future scope. A range of literature was searched from various databases like Web of Science, NCBI, Scopus, Google Scholar, and Science Direct for the related articles. The keywords used were double burden malnutrition, double duty actions, surveillance, monitoring, policy, strategy, or interventions. The search was focused on literature from the last decade (2011-2021). A search using the following keywords search was performed, and the retrieved documents were analysed: ((dual OR double ) burden AND malnutrition ) AND ( surveillance OR monitor* OR evaluat* ) AND ( double AND duty OR dual OR action* OR strateg* OR polic* OR intervention* ))
The global problem of co-existence of DBM is characterized by the prevalence of undernutrition resulting in either stunting, wasting, or micronutrient deficiencies or diet-related non-communicable diseases parallelly with overweight or obesity. As per WHO, this can occur at multiple levels: individually, within a household, at a community level, or across a population. Overweight/obesity and undernutrition can occur in the same being. For example: At the individual level, it is commonly observed that one may experience stunted growth while also being overweight or obese; may have a short stature and carry excess weight around the abdomen; Overweight/obesity with micronutrient deficiencies (e.g., iron deficiency anemia) in children and adults. Prenatal undernutrition that results in less birth weight of the child may result in more adiposity at later stages of life. The co-existence at the household level is more common in middle-income countries.
Drivers of DBM
The main drivers of the DBM are behavioural factors such as lifestyle- related, habits, psychological factors; social factors and demographics such as SES, food insecurity in that region, environmental factors such as food systems, food supply, food cost, trade policies, built environments, cultural and social aspects, and biological factors such as epigenetics, inheritance and early life experience (Wells, et al. ). The nutrition transition results in complex intergenerational cycles of undernutrition associated with energy/ micronutrient inadequate diets and overweight associated with an energy-dense diet. The undernutrition cycle leads to the decreased metabolism for homeostasis and hampers the growth of an individual. On the other hand, the overnutrition cycle results in increased adiposity, compromising homeostasis. Hence, nutrition transition helps to link the biological connection with DBM (Dietz ). Inadequate and uncertain access to food in terms of quality, quantity, and continuity relates to the multiple forms of malnutrition. Inappropriate intake of calories, vitamins, protein, and minerals results in stunting, wasting, and micronutrient deficiencies taking undernutrition pathway. On the other hand, high calorie, nutrient-poor food, and disordered eating pattern take an obesogenic pathway resulting in overweight and obesity.
Anthropometrics as an Indicator of Malnutrition
The anthropometric status indicators that are used to measure nutritional imbalances are stunting (low height for age), wasting (low weight for height), underweight (low weight for age) and overweight (high weight for age); MUAC (mid-upper-arm circumference) in children and BMI for adults (Anthropometric Status Indicators) According to WHO, BMI cut-offs for adults above 20 years of age is depicted in the Table 1.
Note: For adolescents, as per 2007 WHO growth references the operational definition values (Hadush, et al. ) is depicted in the table 2.
Other Indicators of DBM
Other indicators that are also used to track the progress on malnutrition as per the Global Nutrition Report as nutrition indicators are: minimally acceptable diet, minimal dietary diversity, raised blood pressure, salt intake, minimal meal frequency, low birth weight and breastfeeding (Global Nutrition Report ).
Dietary Diversity as an Indicator of Malnutrition
Dietary diversity plays a very important role in tackling the challenges related to nutritional imbalances and a diverse diet helps in combating multiple forms of malnutrition. It represents the household’s availability and accessibility to a range of different type diverse foods and This metric is used as a representation of the nutritional needs being met for a person and is seen as a measure of their nutritional adequacy. FAO recommends two dietary diversity scores HDDS (Household Dietary Diversity Score) and IDDS (Individual dietary diversity score) based upon twelve and nine food groups respectively The HDDS system categorizes food items into the following groups: cereals, white tubers and roots, vegetables, fruits, meat, eggs, fish and other seafood, legumes, nuts and seeds, milk and milk products, oils and fats, sweets, spices, condiments and beverages. IDDS categorizes food items into nine groups: staples such as grains and roots, dark green leafy vegetables, fruits and vegetables high in vitamin A, other fruits and vegetables, organ meats, animal-based protein sources such as meat and fish, eggs, legumes, nuts and seeds, and dairy products. The majority of diets consumed are heavily focused on starchy staples and lack variety, with inadequate or less intake of fruits and vegetables and more intake of grains, resulting in deficiencies in essential nutrients. IDDS is used to predict the nutrient adequacy in an individual and is calculated based upon the food consumption score (FCS), frequency of consumption of the nine food groups recommended by an individual in a week (Islam, et al. ) If an individual consumes more than 4 or 4 out of the nine food groups then it is considered as adequate else inadequate if lesser than 4 out of the nine food groups recommended by WHO (Hadush, et al. ).
Prevalence of DBM and Current Challenges
The pathways from inadequate food access results in DBM taking obesogenic and undernutrition pathway (SOFI - The State of Food Security and Nutrition in the World, n.d. ). The primary fuel to the rising global disease burden is the poor-quality diet responsible for multiple forms of malnutrition. The lack of any system to monitor what the population is consuming is a big challenge. Moreover, there is insufficient information on the collection of indicators of diet quality in terms of individual dietary data within a population across countries. One primary concern is related to the calories coming from non-staple food. The calories could be comparable from a population that consumes more fruits and vegetables to consuming more sugar and fats (Global Nutrition Report ). Biological pathways show a link with DBM, indicating that a person who suffered from undernutrition in childhood is at a high risk of becoming obese or overweight in adulthood and is more prone to diet related NCDs. There is a raging nutrition transition in LMICS even amongst the rural population that now have access to processed and high calorie but nutrient deficient and high salt and sugary food that has replaced the traditional Indian diverse diets (The Lancet ). The Disability-adjusted life years (DALY) attributed to malnutrition is of major concern as malnutrition is the leading risk factor in all age groups, indicating 4% of the total DALY of 64% population in 2017 (Swaminathan, et al. ). Childhood malnutrition resulting in overweight in later stages of life could be a result of gut dysbiosis, metabolic imbalances and dysregulation, inflammations, and impaired insulin signaling that results in a high risk for NCD’s later with a degraded potential for homeostasis due to increased metabolic loads (Wells, et al. ).
Interventions Targeting DBM
Interventions that aim to improve diet quality and lifestyle change are cost-effective and efficient ways to target the root of malnutrition problems as the healthcare treatment is unaffordable, with increased side effects and antimicrobial resistance related to drugs. Dietary interventions can play an essential role in improving health and reducing healthcare costs by contributing to rural areas’ overall development. Due to rapid urbanization and globalization, westernized diets have become the go-to food due to their availability and affordability and have replaced the traditional indigenous nutritional wisdom of ethnic foods and have many health implications. There is a vast wealth of traditional knowledge within rural communities related to traditional food systems and ethno-dietary practices. Many Indian fermented foods prepared by households have many health-promoting roles owing to beneficial microorganisms in them (Tamang, et al. ). Food-based intervention focusing on enhanced quality and diversity through household production and consumption or at the community level can help tackle the malnutrition and related nutritional deficiencies in that region. Community-based actions to more decentralized approaches are crucial where each household can ensure their food security and well-being by utilizing existing knowledge and resources and empowering women and marginal groups (Bisht ).
Primary Prevention to Address DBM
The most cost-effective and efficient solution for addressing DBM is primary prevention, including determining the major risk factors. Knowledge related to major risk factors from a population can help in taking preventing measures to control the prevalence of the disease burden. Hence there is a need for an efficient surveillance system for the assessment of significant risk factors of DBM for targeted interventions to address the issue. An integrated DBM surveillance system is crucial to take necessary preventive measures and help in policymaking, strategy development, and program planning to take preventive measures than corrective actions.
Knowledge of Shared Common Drivers as an Approach to Target DBM
Knowledge related to shared common drivers can help strategize the dual duty actions to target DBM. The DBM challenge calls for dual duty actions to address both the challenges simultaneously. There is little evidence suggesting that the dietary factors that results in undernutrition could also possibly lead to stunting and obesity in the same individual. For example, certain foods that are used as complementary foods containing breastmilk alternatives or snacks or any kind of processed foods might provide calories but not the appropriate nourishment and micronutrients to the body and therefore could result in a higher incidence of both undernutrition and obesity or stunting in the same individual. Thus, understanding the consumption patterns can help understand the linkages between the co-existence of DBM with the dietary pattern to understand the causal relationship between them and help strategize the double duty actions to target DBM (Dietz ). Table 2 highlights the current work done on strategies, interventions, factors and policies to target DBM.
Major Surveillance Systems to Address DBM
A surveillance system that can monitor these risk factors about what population consumes and information on the lifestyle can help in the primary prevention to address DBM. An integrated surveillance system to monitor these risk factors would help policy planning and is an essential part of any prevention program. It is evident that a more robust surveillance system adds more success to any program. Primary prevention of DBM includes monitoring the risk factors related to it that can be used as a tool to understand the current and future prevalence of the disease in the region, and this knowledge can then be applied to target possible interventions and programs beforehand rather than taking corrective measures. Current surveillance systems focus on collecting information on individual risk factors. For NCD, risk factors focus on tobacco consumption, alcohol intake, and diet, or significantly less emphasis is given to the information related to quality and quantity, and dietary diversity of food intake. A comprehensive view of the collection of dietary risk factors information plays an essential role in advocacy. Some of the major surveys and programs that are used to collect data on malnutrition in India are discussed (Table 3).
Comprehensive National Nutrition Survey: The CNNS of India (2016-2018) conducted by MoHFW and UNICEF is the largest micronutrient survey that was used to measure malnutrition by collecting data on the nutritional status of school-age children of age group 5-9 years along with pre-schoolers of below five years of age and adolescents of age group 10-19 years. The survey monitored the nutritional status using interviews (food intake), anthropometric measurements (height/ length, MUAC, triceps, and subscapular skinfold thickness; waist circumference), and biochemical tastings (biological samples: blood, urine, and stools) for biochemical, nutritional indicators like anaemia, proteins, micronutrients, inflammatory markers, and NCDs. The survey also measured NCD risk factors such as cholesterol, diabetes, hypertension measuring blood pressure, blood glucose levels, lipid profile, renal function, along with the details on micronutrient deficiency in children and adolescents. CNNS proved to help predict the micronutrient deficiencies, risk factors of NCDs, and co-existence of DBM (Comprehensive National Nutrition Survey ).
National Nutrition Monitoring Bureau (NNMB): ICMR set up NNMB to assess the dietary intake at the individual and household level along with assessing the ongoing national nutrition programs for assessing the nutritional situation in rural and urban areas along with tribal areas. NNMB’s main objectives are to access various nutritional and dietary problems that are there in the community and to monitor the nutritional situation of the country.
National Family Health Survey (NFHS): NFHS is a large-scale country wide survey set up by MoHFW to collect information on nutrition, anemia, reproductive health, maternal and child health, fertility, family planning, infant and child mortality. NFHS - 5 (2019-2020) collected data on child nutrition indicators: stunting, wasting, overweight along with other parameters and the data indicated that malnutrition in the country has worsened (NFHS 5).
District Level Household Survey (DLHS): DLHS set up by MoHFW is the first district level survey in India to access the data related to maternal and child health (MCH), hemoglobin levels, reproductive health, further to access information on the utilisation of heathcare services (District Level Household & Facility Survey). Under DLHS 4, the data related to health of individuals and households was accessed on collecting information related to their anthropometrics (weight, height) and biochemical parameters (BP, blood glucose and hemoglobin and relevant data related to lifestyle related diseases (Ladusingh, n.d.)
Rapid Survey on Children (RSoC): RSoC (2013-2014) conducted by Ministry of Women and Child Development with UNICEF was used to access the status of malnutrition over NFHS-3. Under RSoC, the nutritional status was accessed by recording data on height and weight of children (0-4 years) and adolescent females (10-18 years). The survey helped in the assessment of prevalence of child stunting (low, medium and high) and wasting (low, medium and high) across the country (Rapid Survey of Wasting and Stunting in Children) [17- 52].
Research Gaps in The Existing Literature
There is a lack of an integrated surveillance system that can target the co-existence of both undernutrition and overnutrition within a population. Current surveillance systems focus upon behavioral, physical, and biochemical measurements that are exhaustive and expensive. Biochemical measurements are not always culturally accepted by some individuals, and these use invasive methods, for example, drawing out blood samples. Carrying out biochemical measurements also requires technical expertise and proper storage and handling of the samples, which increases the process’s overall cost. Current nutrition surveys focus on calories, total fat, saturated fat without considering food type, quality, and processing. Energy adequacy is calculated in calories only without considering if calories are obtained from a healthy or unhealthy source. Current studies don’t touch upon the importance of desired quality and quantity of food, its nature, ingredients in it, proper food, appropriate consumption manner, appropriate utensils and cooking methods and techniques as a whole. Current actions to target the dual burden of malnutrition focus on reductionistic approaches of considering single nutrient or micronutrient deficiencies linked to a specific disorder rather than working upon holistic approaches. There is a lack of a multidisciplinary framework that can address DBM by exploring the synergistic potential of integrated approaches.
The co-existence of the dual burden of malnutrition is a major public health problem. The current interventions to target DBM focus either on reducing the prevalence of stunting, wasting, and micronutrient deficiencies or on overweight, obesity, or non-communicable diseases. There needs to be an integrated system that can address DBM in a single approach. The double-duty actions targeting multiple forms of malnutrition can help take appropriate measures to control the prevalence of the disease burden. An integrated DBM system is crucial to assist in policy making, strategy development, and program planning. Holistic Nutritional Interventions might help decision-makers strengthen Healthcare Environment to address the double burden of malnutrition and primarily target those at the bottom of the pyramid.
The author sincerely thanks IIT Delhi for supporting throughout.
The authors declare that they have no financial or personal relationships or affiliations that may influence the author’s work or interpretation of the research findings.