Title: The double burden of malnutrition—further perspective
Abstract: In December, 2019, The Lancet published a Series on the double burden of malnutrition—the coexistence of overweight and obesity alongside undernutrition. Although micronutrient malnutrition was acknowledged as a component of undernutrition, it was not included in the estimates because of insufficient prevalence data. This is a valid problem, but the exclusion of micronutrient deficiencies from the general narrative results in a sizeable underestimate of the full extent of malnutrition globally and its impact on health, development, and survival. Furthermore, defining micronutrient malnutrition as a component of undernutrition does not acknowledge the fact that micronutrient deficiencies are also prevalent in normal-weight and overweight populations.1Laillou A Yakes E Le TH et al.Intra-individual double burden of overweight and micronutrient deficiencies among Vietnamese women.PLoS One. 2014; 9e110499Crossref Scopus (31) Google Scholar Both food insecurity and energy-dense, obesogenic foods result in micronutrient-poor diets. In addition, both undernutrition and overweight and obesity can further exacerbate the risk of micronutrient deficiencies through several physiological processes.2Subramanian S Huq S Yatsunenko T et al.Persistent gut microbiota immaturity in malnourished Bangladeshi children.Nature. 2014; 510: 417-421Crossref PubMed Scopus (752) Google Scholar, 3Cepeda-Lopez AC Melse-Boonstra A Zimmermann MB Herter-Aeberli I In overweight and obese women, dietary iron absorption is reduced and the enhancement of iron absorption by ascorbic acid is one-half that in normal-weight women.Am J Clin Nutr. 2015; 102: 1389-1397Crossref PubMed Scopus (60) Google Scholar Despite its inclusion in surveys, population micronutrient status data remain scarce, undermining appropriate policy development and effective targeting of interventions.1Laillou A Yakes E Le TH et al.Intra-individual double burden of overweight and micronutrient deficiencies among Vietnamese women.PLoS One. 2014; 9e110499Crossref Scopus (31) Google Scholar Nevertheless, data scarcity should not be an excuse for inaction, as the limited available information indicates that micronutrient deficiencies remain common and contribute importantly to specific disease risks, including risks of non-communicable diseases.4Black RE Victora CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-income countries.Lancet. 2013; 382: 427-451Summary Full Text Full Text PDF PubMed Scopus (4307) Google Scholar Double-duty actions are needed as part of a holistic approach to ending malnutrition in all its forms, including micronutrient deficiencies.5Hawkes C Ruel MT Salm L Sinclair B Branca F Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.Lancet. 2019; 395: 142-155Summary Full Text Full Text PDF PubMed Scopus (171) Google Scholar Additionally, evidence-based micronutrient-specific interventions, such as food fortification and supplementation,5Hawkes C Ruel MT Salm L Sinclair B Branca F Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.Lancet. 2019; 395: 142-155Summary Full Text Full Text PDF PubMed Scopus (171) Google Scholar are cost-effective strategies to meet nutrient requirements of vulnerable groups. THis is relevant because the required dietary shifts might not be immediately available to the poor or might have an unacceptably high negative environmental impact. The Series authors' recognition of the expanding range of nutritional challenges5Hawkes C Ruel MT Salm L Sinclair B Branca F Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.Lancet. 2019; 395: 142-155Summary Full Text Full Text PDF PubMed Scopus (171) Google Scholar is a positive step towards action. We urge the community to acknowledge the crucial relevance of micronutrient deficiencies and, wherever feasible, count them in the estimates of the double burden of malnutrition. Without this recognition, the burden of malnutrition in all its forms will remain underestimated, resulting in insufficient progress towards achieving the 2030 sustainable development goals agenda.5Hawkes C Ruel MT Salm L Sinclair B Branca F Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its forms.Lancet. 2019; 395: 142-155Summary Full Text Full Text PDF PubMed Scopus (171) Google Scholar We declare no competing interests. The double burden of malnutrition—further perspectiveIn the Lancet Series on the double burden of malnutrition, Corinna Hawkes and colleagues1 highlight the new nutrition reality, irrespective of the economic status of a country, and calls for concerted global action to address this serious public health challenge. In this context, we present a regional perspective to enrich the proposed double-duty action plan to tackle all forms of malnutrition.1 Full-Text PDF The double burden of malnutrition—further perspective – Authors' replyWe thank Saskia Osendarp and colleagues, Mohammad Sorowar Hossain and colleagues, and Christine Stewart and colleagues for their responses to the Lancet Series on the double burden of malnutrition. They make some relevant points that we would like to address here. Full-Text PDF The double burden of malnutrition—further perspectiveWe congratulate Corinna Hawkes and colleagues1 on their Series paper that proposes adoption of double-duty actions to combat all forms of malnutrition.However, we have concerns about the way that unhealthy foods are characterised and the description of potential risks associated with energy-dense micronutrient-fortified foods for the prevention or treatment of undernutrition. Full-Text PDF Double-duty actions: seizing programme and policy opportunities to address malnutrition in all its formsActions to address different forms of malnutrition are typically managed by separate communities, policies, programmes, governance structures, and funding streams. By contrast, double-duty actions, which aim to simultaneously tackle both undernutrition and problems of overweight, obesity, and diet-related non-communicable diseases (DR-NCDs) have been proposed as a way to effectively address malnutrition in all its forms in a more holisitic way. This Series paper identifies ten double-duty actions that have strong potential to reduce the risk of both undernutrition, obesity, and DR-NCDs. Full-Text PDF