The Double Burden of Malnutrition GCHB 6780 Roger Shrimpton John Mason Lisa Saldanha

1. The Double Burden of MalnutritionGCHB 6780Roger ShrimptonJohn MasonLisa Saldanha 14 January 2013 Class 1 : Introduction and overview

2. Content: • Introductions • Explanation of course objectives, methods and examinations • Overview of Double Burden of Malnutrition (DBM) • What is the DBM? • Who is most affected by DBM and with what consequences? • What are the causes of the DBM? • What are the solutions for the DBM?

3. HELLO! I am Roger Shrimpton My background is.....

4. Course Objectives • Describe the causes and consequences of the double burden of malnutrition, in relation to different stages of life (including in utero) and intergenerational effects, as a result of both broad (macro) developments and transitions, and specific dietary and life style influences; and including interactions between different aspects of malnutrition; and

5. Course Objectives 2. Assess status of DBM in different situations, and policy and program options for reducing the problem and preventing associated health problems, including principles for design of programs, including community-based.

6. Course methods and examinations • Lectures • 1-4 face to face • 5 to 13 by Skype • Mid term exams • a series of 10 questions, with five requiring a short three line explanation concerning the main aspects, including dimensions and definitions of the problem, together with two half page essays explaining the major concepts covered to date. • Final exam • based on 2 assignments, with the development of a 4 page (maximum) essays for each,

7. OVERVIEW

8. What is the Double Burden of Malnutrition? Popular Images of “Malnutrition”

9. What is the DBM? But! Malnutrition includes both undernutrition and overnutrition (even in the same household)

10. What is the DBM? • Process of Stunting Source: Victora et al 2010

11. What is the DBM? THIS THE DBM is undernutrition and overnutrition in the same population across the life course

12. Who is most affected by DBM • Women are most affected by the DBM, with populations frequently having women that are excessively thin, as well as those that are overweight. • Another form of the DBM, is overweight mothers and stunted children in the same household, although this is most common in Latin America. • The commonest type of DBM is anaemia and obesity, which again especially affects women at the individual level. Even the USA has this form of DBM.

13. Who is most affected by DBM • Children are less obese than women, but the combination of stunting and accelerated weight growth is important • Stunting is a reflection of adequacy of growth from conception to two years • Accelerated weight growth after two years in stunted children increases the risk of obesity in later life. • Asians are more affected than Caucasians • In adults the definition of overweight is BMI >25 and obese is >30 • In Asians the BMI cut offs are> 23 and >27

14. The consequences of the DBM • Early life undernutrition (ELU) causes a large proportion of young children to die • Among those that survive, their life long capacity to resist disease, to carry out physical work, to study and progress in school, are all impaired. • Survivors of ELU are more likely to suffer from diet related non-communicable diseases

15. What are the consequences of DBM? THIS Early life undernutrition increases the risk of later life overnutrition through “metabolic programming”

16. The Y-Y paradox John S Yudkin , Chittaranjan S Yajnik

17. Consequences of overnutrition Source: Potenza et al 2009 • The “inflammatory state” of obesity plays a key role in the development of type 2 diabetes and the metabolic syndrome • . Visceral adipose tissue is a key organ producing hormones which play an important role in the regulation of energy balance and controlling energy reserve distribution between visceral and subcutaneous fat

18. The consequences of the DBM • Later in the life course diet and nutrition and especially obesity, are among the main causes of many non-communicable diseases (NCDs) including hypertension, cancer, stroke, and ischaemic heart disease. • The risks of getting cardiovascular diseases are greatly increased by the metabolic syndrome (abdominal obesity, dyslipidaemia, high blood pressure, impaired glucose tolerance).

19. The consequences of the DBM Most NCD deaths occur in low and middle income countries AT ENORMOUS COST!

20. The Causes of the DBM • Secular trend - Intergenerational • Nutrition transition- Intra-generational • Four cross cutting themes for analysis of DBM in LMICS • Biological Health environment • Economic Food environment • The Physical Built environment • The Socio Cultural Environment

22. The Causes of the DBM • Biological/Health environment • Demographic transition • An aging population • Epidemiological transition • Mortality shift from infectious to noncommunicable diseases • Thrifty phenotype • Metabolic programming (foetal origins of adult disease) • Thrifty genotype • Is it genetic? • Adipose inflammation • Is obesity a disease?

23. The causes of the DBM? • Economic/Food environment • Increase in global wealth • Increase in global food production (20% over population growth) due to green revolution • Increasing global food trade, especially of processed foods • Processed foods benefit from food subsidies in EU and USA • Changes in food patterns (increases in fast foods) • Is era of cheap food over? (food price crisis) • Increasing food prices favours processed food consumption • Sustainability of current food system seriously questioned

24. The causes of the DBM • The Physical/Built environment • In urban areas (half world already urban) • Less physical expenditure (at work in the home etc) • Snacking increased • TV watching increased • Not easy to get exercise (walk, bike) • In rural areas • Household smoke • Lack of sanitation • Women do more work

25. The causes of the DBM • The Socio/Cultural Environment • In rural areas gender issues still strong (teenage pregnancy, women work hard, poor food access) • Television, internet, radio rapidly disseminate new ideas • Advertising of foods greatly increased especially to children • Peer pressure increases • Capacity to decide/choose only really mature at 18y

26. What are the solutions for the DBM? • Policy recommendations (from WHO) • For overnutrition • Nutrient intake and physical activity goals (2004) • For NCDs • Cardiovascular diseases, diabetes, cancers, chronic respiratory diseases • Obesity not included as a disease • For maternal and child undernutrition • Lancet Nutrition Series • But no overarching framework

27. What are the solutions for the DBM? • Programme recommendations (from WHO) • For overnutrition • Diet and Physical Activity Plan • For NCDs • Action Plan for Cardiovascular diseases, diabetes, cancers, chronic respiratory diseases (not obesity) • For maternal and child undernutrition • SUN movement • But few countries have programmes (especially with $) • No overarching framework

28. What are the solutions for the DBM? • Programmes needed for tackling the DBM • Evidence based Direct and Indirect interventions • Medical system interventions • School interventions • Worksite interventions • Community based interventions • By stage of the life course • Foetal • Young child • Child and adolescent • Adult

29. Programmes for Tackling the DBM

30. What are the solutions for the DBM? • Nutrition Capacity and Governance • Capacity to act in nutrition has been signalled as a critically low (Landscape Analysis) Need to build capacity • SUN movement (Scaling up Nutrition) and Framework • a coordinated, multi‐stakeholder approach; • Paris Accra Principles of Aid Effectiveness; • Country ownership • “Three Ones”:- • One policy framework • One national coordinating authority; • One agreed national monitoring and evaluation system; • nutrition specific and nutrition sensitive interventions, both need scaling up. • REACH • To help build capacity

31. What are the solutions for the DBM? • Nutrition Capacity and Governance • SUN is for undernutrition • But tackling MCU is important first step in DBM control • Obesity control needs inserting in NCD action plans • Multisectoral approach considered essential for SUN and DBM • (but this creates more need for capacity) • Poor nutritional governance identified as one of the main reasons for nutrition failure in the past • (need to create nutrition councils)

32. Conclusions • Due to economic growth and globalization most LMICs are experiencing the nutrition transition, with increasing rates of overweight/obesity in populations that are still stunted. • Due to “thrifty phenotype” phenomenon there will be an explosion of obesity linked NCD mortality unless action is taken soon • There are lots of evidence based interventions that could be put in place to help prevent this • But capacity to act in LMICs especially is still poor and need to be remedied • Plus “Overnutrition” activities do not attract funding