The double burden of malnutrition among women of reproductive age and preschool children in low- and middle-income countries: A scoping review and thematic analysis of literature.

The aim of this review was to map the literature on the double burden of malnutrition (DBM) among women of reproductive age (WRA) and preschool children in low- and middle-income countries (LMICs). The study aimed to provide an understanding of how DBM construct has been defined in the current literature and to elucidate plausible mechanisms underlying DBM development and its common risk factor among the two subgroups. We systematically searched for literature from the following databases: EMBASE, CINAHL, MEDLINE, LILACS, Scopus and ProQuest Dissertations & Thesis Global and identified articles that specifically reported on the coexistence of undernutrition and overnutrition sequalae at the population, household, or individual levels among WRA and preschool children in LMICs. A thematic analysis using the Braun and Clarke approach was conducted on excerpts from the articles to reveal emerging themes underlying the occurrence of DBM from the included studies. Of the initial 15 112 articles found, 720 met the inclusion criteria. Anthropometric measures for overnutrition and undernutrition including body mass index for WRA and height-for-age, weight-for-age, and weight-for-height Z-scores for preschool children were frequently used indicators for defining DBM across all levels of assessment. In fewer cases, DBM was defined by the pairing of cardiometabolic risk factors (e.g., hypertension) as measures for overnutrition and micronutrient deficiency (e.g., iron deficiency) as measures for undernutrition. The following themes emerged as plausible mechanisms for DBM development: nutrition transition, breastfeeding, diet behavior, biological mechanism, and statistical artifact. Factors such as child age, child sex, maternal age, maternal education, maternal occupation, household food security, household wealth, urbanicity, and economic development were commonly associated with most of the DBM phenotypes. Our review findings showed that the understanding of the DBM in current literature is very ambiguous. There is need for future research to better understand the DBM construct and its etiology.

Trends and Disparities of Energy Intake and Macronutrient Composition in China: A Series of National Surveys, 1982-2012.

BACKGROUND: China's diet transition might offer guidance to undeveloped countries on the way to prosperity. This report describes the trends and disparities in energy and macronutrient composition among Chinese adults, and between subpopulations. METHODS: Data for the current study were obtained from the 1982, 1992, 2002, and 2010-2012 China National Nutrition Survey (CNNS) rounds, which were nationally representative cross-sectional surveys. We applied 24-h dietary recall and food weighing to assess dietary intake. RESULTS: There were 204,877 participants aged 20 years or older included in the current analysis. From 1982 to 2012, the estimated energy intake declined from 2614.7 kcal to 2063.9 kcal. The trend in the estimated percentage of energy intake from fat showed a spike. It increased from 16.3% to 33.1% (1992 vs. 1982 difference, 7.6%; 95% CI 7.4% to 7.7%; 2002 vs. 1992 difference, 7.7%; 95% CI 7.6% to 7.9%; 2012 vs. 2002 difference, 1.6%; 95% CI 1.4% to 1.7%; p < 0.01 for trend). The trends coincided in all the subgroups (all p < 0.01 for trend) except for the subgroup of those educated over 15 years, whose percentage of energy intake from fat declined from 37.4% to 36.6% (2012 vs. 2002 difference, -0.8%; 95% CI -1.6% to 0.0%). The estimated percentage of energy intake from carbohydrates declined from 74.0% to 55.0%. The ranges of the estimated percentage of energy intake from fat, within population subgroups stratified by education level, area and Gross national product (GNP) level, were narrowed. CONCLUSIONS: Quick improvements in society and the economy effectively curbed undernutrition, but easily triggered overnutrition. Disparities persistently existed between different subpopulations, while the gaps would narrow if comprehensive efforts were made. Education might be a promising way to prevent overnutrition during prosperous progress. The low-social profile populations require specific interventions so as to avoid further disease burdens.

Nutritional assessment among adult patients with suspected or confirmed active tuberculosis disease in rural India.

OBJECTIVES: Our study goal was to evaluate a set of nutritional indicators among adults with confirmed or suspected active tuberculosis disease in southern India, given the limited literature on this topic. Study objectives were to assess the: I) double burden of malnutrition at individual and population levels; II) relative performance of anthropometric indicators (body mass index, waist circumference) in diabetes screening; and III) associations between vitamin D and metabolic abnormalities. DESIGN: Cross-sectional study. SETTING: Hospital in rural southern India. PARTICIPANTS: Among adult patients (n = 834), we measured anthropometry, body composition, and biomarkers (vitamin D, glycated hemoglobin, hemoglobin) of nutritional status. Subsets of participants provided blood and sputum samples. RESULTS: Among participants, 91.7% had ≥ 1 malnutrition indicator; 34.6% had both undernutrition and overnutrition indicators. Despite the fact that >80% of participants would be considered low-risk in diabetes screening based on low body mass index and waist circumference, approximately one-third had elevated glycated hemoglobin (≥ 5.7%). The lowest quintile of serum 25-hydroxyvitamin D was associated with an increased risk of glycated hemoglobin ≥ 5.7% (adjusted risk ratio 1.61 [95% CI 1.02, 2.56]) compared to the other quintiles, adjusting for age and trunk fat. CONCLUSIONS: Malnutrition and diabetes were prevalent in this patient population; since both can predict poor prognosis of active tuberculosis disease, including treatment outcomes and drug resistance, this emphasizes the importance of dual screening and management of under- and overnutrition-related indicators among patients with suspected or active tuberculosis disease. Further studies are needed to determine clinical implications of vitamin D as a potential modifiable risk factor in metabolic abnormalities, and whether population-specific body mass index and waist circumference cut-offs improve diabetes screening.

The Double Burden of Malnutrition in Bangalore, India.

The double burden of malnutrition (DBM), i.e., coexistence of under- and overnutrition, is an emerging issue in most of the low- and middle-income countries of the world. Using field survey data conducted in and around the city of Bangalore, India in 2018, we examine the patterns of DBM among women, young children (0-6 years), older children (7-18 years), and intrahousehold DBM between mothers and children. A unique aspect of the survey is that it is conducted in an area undergoing rapid urbanization, which is one of the factors responsible for DBM and can inform on the future of DBM in India. Compared to undernutrition, the prevalence of overnutrition is much higher in our study area. We find that, like other developing countries, the socioeconomic distance in prevalence of under- and overnutrition among women has decreased over time. Additionally, overnutrition among women is no longer an urban phenomenon. Similar trends were observed for older children. For younger children, on the other hand, the socioeconomic and locational differences persist, suggesting that this age group is not witnessing nutrition transition yet. The intrahousehold burden of DBM has also increased over time and the risk increases with maternal education. Although under- and overnutrition are opposite in nature, both have several common drivers, suggesting that an integrated approach might work better in tackling DBM. Several existing programs in India, such as ICDS, PDS, and the school meal program, provide excellent infrastructure to roll out policies and interventions, especially diet-based programs, aimed at both under- and overnutrition.

Using Body Composition Assessment to Evaluate the Double Burden of Malnutrition.

BACKGROUND: Populations in low- and middle-income countries are increasingly experiencing a double burden of malnutrition (DBM), incorporating both persistent levels of child undernutrition and rising prevalence of overweight/obesity at later ages. A growing number of individuals experience both components of the DBM through the life-course, thereby accumulating high susceptibility to noncommunicable disease (NCD). SUMMARY: Measurements of body composition may prove valuable for assessing NCD risk at the level of the individual. The capacity-load model provides a simple conceptual framework for integrating data on different components of body composition to predict NCD risk. Poor growth in early life, indexed by becoming wasted or stunted, constrains the development of lean mass components such as muscle and organ mass, each of which contribute to the metabolic capacity for homeostasis. Catch-up weight gain in early life, or the development of excess weight from childhood onwards, is associated with elevated adiposity, especially abdominal adiposity, which challenges cardio-metabolic homeostasis and elevates NCD risk. Key Messages: A variety of techniques are now available for the measurement of body composition, helping research the association of the DBM with NCD risk. Reference charts allow raw data to be converted to age- and sex-specific z-scores, aiding interpretation.

Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: African Region.

Sub-Saharan Africa is experiencing the double burden of malnutrition (DBM) with high levels of undernutrition and a growing burden of overweight/obesity and diet-related noncommunicable diseases (NCDs). Undernourishment in sub-Saharan Africa increased between 2010 and 2016. Although the prevalence of chronic undernutrition is decreasing, the number of stunted children under 5 years of age is increasing due to population growth. Meanwhile, overweight/obesity is increasing in all age groups, with girls and women being more affected than boys and men. It is increasingly recognized that the drivers of the DBM originate outside the health sector and operate across national and regional boundaries. Largely unregulated marketing of cheap processed foods and nonalcoholic beverages as well as lifestyle changes are driving consumption of unhealthy diets in the African region. Progress toward the goal of ending hunger and malnutrition by 2030 requires intensified efforts to reduce undernutrition and focused action on the reduction of obesity and diet-related NCDs. The World Health Organization is developing a strategic plan to guide governments and development partners in tackling all forms of malnutrition through strengthened policies, improved service delivery, and better use of data. It is only through coordinated and complementary efforts that strides can be made to reduce the DBM.

Regional Overview on Maternal and Child Nutrition and Examples of Nutrition Governance and Policy Responses: Europe, Central Asia and Eastern Mediterranean Regions.

The Eastern Mediterranean Regions and Europe and Central Asia Regions are facing an epidemiological and nutrition transition, especially among vulnerable groups including mothers, children and adolescents. This has led to a double burden of malnutrition (DBM). Poor infant and young child feeding (IYCF), poor dietary diversity, excessive consumption of energy dense unhealthy foods, a growing obesogenic environment for children, including aggressive marketing of unhealthy foods for children, and reduced physical activity are among the main causes. In addition, several countries in the region lack the nutrition governance capacity to respond effectively to the DBM. This article reviews the context and provides a set of conclusions in which countries are called to reduce the marketing of unhealthy foods for children, enforce the fortification of staple foods with micronutrients to reduce micronutrient deficiencies and improve IYCF, including breastfeeding in the region. Also, the call is strong for cross-border multi-sectoral efforts to address the DBM in these regions.

Regional Overview on Maternal Nutrition and Examples of Health System Programme and Policy Responses: Asia and the Pacific.

BACKGROUND: The double burden of malnutrition in Asia and the Pacific is driving a renewed focus on maternal malnutrition. SUMMARY: Though adverse consequences of maternal malnutrition have been long recognized, there is slow progress in addressing nutritional problems of women/adolescent girls. Coverage and quality of current maternal nutrition interventions, mostly delivered through antenatal care programmes vary across countries, and are often sub-optimum. Further, despite a marked increase in overweight and obesity in women of reproductive age, at present, most programmes are focused on under-nutrition and micronutrient deficiencies. Key Messages: The recent antenatal care recommendations released by World Health Organization provide a benchmark for countries to evaluate their programmes and identify gaps and challenges to improving maternal nutrition. Asian and Pacific countries need to address all forms of maternal malnutrition. For countries that historically focused on maternal under-nutrition, expanding their programmes to incorporate interventions to address overweight and obesity will be challenging. Innovative methods for nutrition counselling, both in terms of content and using novel channels of communication, are needed. Protocols and guidance on managing excessive weight gain as well as determining appropriate pregnancy weight gains are needed, while managing micronutrient deficiencies, particularly in settings where inherited disorders of red blood cells exist.

Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: Latin America and the Caribbean.

BACKGROUND: Hunger, food insecurity, stunting, anemia, overweight, and noncommunicable diseases (NCDs) may coexist in the same person, household, and community in Latin America and the Caribbean (LAC). The double burden of malnutrition (DBM) is an important cause of disability and premature death, which could be addressed with comprehensive policies such as the Plan of Action for the Prevention of Obesity in Children and Adolescents. This paper summarizes the main policies and actions aimed to prevent undernutrition and obesity. SUMMARY: Several countries are implementing the Plan of Action, Caribbean Public Health Agency is actively supporting Ministries of Health, Education, and Sport to develop school nutrition policies and strategies to create health-promoting environments at school and in their surrounding communities. Chile is implementing the comprehensive child protection system "Chile Crece Contigo" that integrates health, social development, and educational activities to optimize growth and childhood cognitive-motor development. Brazil is implementing policies and plans to commit to international targets regarding food and nutrition security, NCDs and their risk factors. Key Messages: The DBM exists in the Americas and contributes to disability and premature death. The Region is making progress implementing policies and actions addressing the DBM. However, stronger political will and leadership are needed to enact legislation and policies that create and support enabling -environments.

The double burden of under- and overnutrition among Bangladeshi women: Socioeconomic and community-level inequalities.

BACKGROUND: The prevalence of overweightness in Bangladesh is increasing, while underweightness also continues to persist. A better understanding of the patterns and socioeconomic risk factors of both conditions, particularly among women, is critical in order to promote the development of interventions to improve maternal health in Bangladesh. This study therefore sought to assess the patterns of under- and overweightness between 2004 and 2014 and to examine the predictors of individual and community-level inequalities of under- and overnutrition in Bangladesh. METHODS: Cross-sectional data of 10, 431, and 16,478 ever-married nonpregnant women aged between 15 and 49 years who did not give birth in the two months preceding the survey were extracted from the 2004 and 2014 Bangladesh Demographic and Health Surveys, respectively. Body mass index was used to measure weight status, and underweightness, at-risk for overweightness, overweightness, and obesity were the main outcome variables. Patterns of nutritional change over time was examined by considering the annual average rate of change. Multilevel multinomial logistic regression and quantile regression were used to identify the inequalities. RESULTS: In 2014, the age-adjusted prevalence values of underweightness, at-risk for overweightness, overweightness, and obesity were 19.7%, 14.9%, 18.1% and 4.0%, respectively. A higher average annual rate of reduction of underweightness was found among wealthier, highly educated, and wealthier community-living women, while a rate of increase of overweightness was found among poorer, uneducated, and poor community-living women. Individual and community-level inequalities of malnutrition were observed among these populations. In comparison with women living in low wealth communities, women from wealthier communities were at an increased risk of being at-risk for overweightness [adjusted odds ratio (AOR): 1.53, 95% confidence interval (CI): 1.23-1.91], overweight (AOR: 1.60, 95% CI: 1.27-2.00), and obese (AOR: 2.12, 95% CI: 1.42-3.18). CONCLUSIONS: This study suggests the coexistence of a double burden of under- and overnutrition in Bangladesh and that the prevalence of overweightness surpasses that of underweightness. The burdens of under- and overnutrition are strongly associated with women's individual socioeconomic positions and the nature of the community in which they live.

A multicentre Study of Nutrition Risk Assessment in Adult Patients with Inflammatory Bowel Disease Attending Outpatient Clinics.

BACKGROUND: Overnutrition and undernutrition can affect patients with inflammatory bowel disease (IBD). Although all IBD outpatients should be screened for nutrition risk, screening is not routinely performed, potentially leading to reduced identification and treatment. This study aimed to estimate the prevalence of nutrition risk in adult IBD outpatients and the proportion of cases who discussed diet and/or nutrition during their routine clinical appointment. METHODS: Adults with IBD attending outpatient clinics at 4 hospitals in Greece and in UK were recruited. Demographic and anthropometric data were collected using face-to-face patient interviews and clinical records. Patients were classified as high (i.e., body mass index [BMI] < 18.5 or 18.5-20 kg/m2 and weight loss > 5%), moderate (i.e., BMI 20-25 kg/m2 and weight loss > 5%) or low risk of undernutrition and high risk of obesity (i.e., BMI 25-30% and weight gain > 5%). The proportion of patients who discussed diet and/or nutrition during their clinical appointment was calculated. RESULTS: In total, 390 IBD patients participated. Sixteen (4%) patients were underweight, 113 (29%) were overweight and 71 (18%) were obese. Twenty-one (5%) patients were at high risk of undernutrition; of these 4 (19%) were under dietetic care. Of those at high risk of undernutrition, 11 (52%) had discussed diet and/or nutrition during their routine clinical appointment. Fifty-six (14%) patients had gained more than 5% weight since their last recorded/reported weight and 19 (5%) were at high risk of obesity. CONCLUSIONS: Few patients were identified to be at high risk of undernutrition and less than a fifth of these were under dietetic care. Overnutrition is a growing problem in IBD with almost half of adult patients being overweight or obese. Diet and/or nutrition were not routinely discussed in this group of IBD outpatients.

Sociodemographic and geographical inequalities in under- and overnutrition among children and mothers in Bangladesh: a spatial modelling approach to a nationally representative survey.

OBJECTIVE: To investigate the sociodemographic and geographical variation in under- and overnutrition prevalence among children and mothers. DESIGN: Data from the 2014 Bangladesh Demographic and Health Survey were analysed. Stunting and wasting for children and BMI<18·5 kg/m2 for mothers were considered as undernutrition; overweight was considered as overnutrition for both children and mothers. We estimated the prevalence and performed simple logistic regression analyses to assess the associations between outcome variables and predictors. Bayesian spatial models were applied to estimate region-level prevalence to identify the regions (districts) prone to under- and overnutrition.Settings/SubjectsChildren aged<5 years and their mothers aged 15-49 years in Bangladesh. RESULTS: A significant difference (P<0·001) was observed in both under- and overnutrition prevalence between poor and rich. A notable regional variation was also observed in under- and overnutrition prevalence. Stunting prevalence ranged from 20·3 % in Jessore to 56·2 % in Sunamgonj, wasting from 10·6 % in Dhaka to 19·2 % in Bhola, and overweight from 0·8 % in Shariatpur to 2·6 % in Dhaka. Of the sixty-four districts, twelve had prevalence of stunting and thirty-two districts had prevalence of wasting higher than the WHO critical threshold levels. Similarly, fifty-three districts had prevalence of maternal underweight higher than the national level. In contrast, the prevalence of overweight was comparatively high in the industrially equipped metropolitan districts. CONCLUSIONS: Observed sociodemographic and geographical inequalities imply slow progress in the overall improvement of both under- and overnutrition. Therefore, effective intervention programmes and policies need to be designed urgently targeting the grass-roots level of such regions.

Double burden of diseases worldwide: coexistence of undernutrition and overnutrition-related non-communicable chronic diseases.

OBJECTIVE: This systematic examination and meta-analysis examined the scope and variation of the worldwide double burden of diseases and identified related socio-demographic factors. DESIGN: We searched PubMed for studies published in English from January 1, 2000, through September 28, 2016, that reported on double disease burden. Twenty-nine studies from 18 high-income, middle-income and low-income countries met inclusion criteria and provided 71 obesity-undernutrition ratios, which were included in meta-regression analysis. RESULTS: All high-income countries had a much higher prevalence of obesity than undernutrition (i.e. all the obesity/undernutrition ratios >1); 55% of the ratios in lower middle-income and low-income countries were <1, but only 28% in upper middle-income countries. Meta-analysis showed a pooled obesity-undernutrition ratio of 4.3 (95% CI = 3.1-5.5), which varied by country income level, subjects' age and over time. The average ratio was higher in high-income rather than that in lower middle-income and low-income countries (ß [SE] = 10.8 [2.6]), in adults versus children (7.1 [2.2]) and in data collected since 2000 versus before 2000 (5.2 [1.5]; all P values < 0.05). CONCLUSIONS: There are considerable differences in the obesity versus undernutrition ratios and in their prevalence by country income level, age groups and over time, which may be a consequence of the cumulative exposure to an obesogenic environment.

The double burden of under- and overnutrition and nutrient adequacy among Chinese preschool and school-aged children in 2009-2011.

BACKGROUND/OBJECTIVES: Coincident with economic development, China has experienced a marked transition from undernutrition to overweight/obesity over the last few decades. We aimed to explore the burden of under- and overnutrition and nutrient adequacy among 2-12-year-old Chinese children. SUBJECTS/METHODS: We included anthropometry, dietary intake and biomarkers from 2-12-year-olds who participated in the 2009-2011 China Health and Nutrition Survey (n=1191 in 2009; n=1648 in 2011). Dietary intakes were compared with the 2013 Chinese Dietary Recommended Intakes. RESULTS: In 2011, ~19% of 2-6-year-old children were underweight, 4% were stunted, 10% were overweight and 12% were obese. Among 7-12-year-old children, stunting was almost 0%, whereas ~21% were underweight, 13% were overweight and 6% were obese in 2011. Overweight and obesity were more prevalent among children from urban areas and higher income households. In particular, 2-6-year-old children from urban areas and higher income households experienced the highest increase in obesity from 2009 to 2011 (P<0.05). Children from urban areas and higher income households had overall higher intakes of total daily energy and most macro- and micronutrients (P<0.05). However, a significant proportion of children did not meet the recommendations for important micronutrients. CONCLUSIONS: Underweight and stunting currently coexist with overweight and obesity among Chinese children <12-year-old. We found critical disparities in the prevalence of under- and overweight/obesity, as well as in nutrient intakes and dietary adequacies between children from different incomes, revealing that the burden of childhood under- and overnutrition may constitute a public health concern in modern China.

China in the period of transition from scarcity and extensive undernutrition to emerging nutrition-related non-communicable diseases, 1949-1992.

This study uses unique official data to document nutritional changes in the 1949-1992 period. In 1949, widespread famine, high mortality and low life expectancy dominated. Economic progress was uneven; however, the longer term food supply changed greatly, and hunger was conquered. Diet composition shifted greatly over this period. Cereal consumption, already high, increased from 541.2 g d(-1) (70.0% coarse grains) in 1952 to 645.9 g d(-1) (15.9% coarse grains) in 1992. Consumption of animal-source foods, half of which were pork and pork products, tripled from 30.0 to 103.0 g d(-1). The proportion of energy intake from fat tripled from 7.6% to 22.5%, and that from carbohydrates decreased from 83.0% to 65.8% over the same period. Physical activity was high in all domains, but shifts were beginning to occur (e.g. the initial mechanization of work and the expansion of biking). Nutritional improvement was uneven, including increased undernutrition in the 1959-1962 period and a remarkable rebound and continued improvement thereafter. Overweight emerged only after 1982. Shifts in diet, activity and body composition in 1949-1992 set the stage for major shifts in nutrition in the subsequent decades.

Mapping the nutrition transition in Peru: evidence for decentralized nutrition policies.

The study objectives were to map the different stages of the nutrition transition for each department within Peru, and to determine the nutrition policy needs for each geographic area based on their current stage in the nutrition transition. Results show that most of the country is suffering from a double-burden of malnutrition, with high rates of stunting among children less than 5 years of age and high rates of overweight and obesity among women of reproductive age. Currently, Peru has only country-wide nutrition policies, administered by the Ministry of Health, that are primarily focused on stunting prevention. This study argues for the need to have decentralized nutrition policies that vary according to what type of malnutrition is being experienced in each geographic area.

Mapping the nutrition transition in Peru: evidence for decentralized nutrition policies / Cartografía de la transición nutricional en el Perú: datos que avalan la necesidad de políticas nutricionales descentralizadas

The study objectives were to map the different stages of the nutrition transition for each departmentwithin Peru, and to determine the nutrition policy needs for each geographic areabased on their current stage in the nutrition transition. Results show that most of the countryis suffering from a double-burden of malnutrition, with high rates of stunting among childrenless than 5 years of age and high rates of overweight and obesity among women of reproductiveage. Currently, Peru has only country-wide nutrition policies, administered by the Ministryof Health, that are primarily focused on stunting prevention. This study argues for the need tohave decentralized nutrition policies that vary according to what type of malnutrition is beingexperienced in each geographic area.

Los objetivos de este estudio consistían en trazar un mapa por departamentos yetapas de la transición nutricional en el Perú y determinar las políticas nutricionalesnecesarias en las distintas zonas geográficas en función de sus etapas en la transición.Los resultados demuestran que la mayor parte del país está sufriendo la llamada“doble carga de la malnutrición”, en la que coexisten tasas elevadas de desnutricióncrónica entre los menores de 5 años y tasas elevadas de sobrepeso y obesidad en lasmujeres en edad fecunda. En el Perú actual, las políticas nutricionales, gestionadaspor el Ministerio de Salud, están centralizadas y su prioridad es prevenir la detencióndel crecimiento. Este estudio aboga por la necesidad de contar con políticas nutricionalesdescentralizadas que varíen en función del tipo de malnutrición que se estépadeciendo en cada zona geográfica.