7th International Conference on Public Health

Best Western Hotel in Solo (Indonesia), on June 17-18, 2020



“Childhood Stunting, Wasting, and Obesity, as Critical 
Global Health Issues: Forging Cross-Sectoral Solutions”




Childhood malnutrition is a global health crisis. It is a complex issue that makes up the main cause of death and disease in the world. The World Health Organization (WHO) defines malnutrition as: “…deficiencies, excesses or imbalances in a person’s intake of energy and/or nutrients” (WHO, 2018).

The term malnutrition addresses 3 broad groups of conditions: (1) “Undernutrition”, which includes stunting (low height for age), wasting (low weight for height), underweight (low weight for age); (2) “Micronutrient-related malnutrition”, which includes micronutrient defficiency (a lack of important vitamins and minerals) or micronutrient excess; and (3) “Overnutrition”, which includes overweight, obesity, and diet-related non-communicable diseases (such as heart disease, stroke, diabetes, and cancer) (WHO, 2018). Figure 1 shows the various forms of malnutrition (Gonzalez, 2019).

1. Why Malnutrition Matters

Malnutrition presents a real threat to human progress and retards development across the world. It causes ill health and is associated with higher death rates. An  estimated 155 million children under 5 years of age are stunted around the world, 52 million are wasted, and 17 million are severely wasted. Undernutrition (stunting, wasting, and underweight) contributes to about 45% of deaths among children under five. Stunted children are at higher risk of cognitive impairments such as delayed motor development, impaired brain function, and poor school performance (UNICEF, 2019; Global Nutrition Report, 2020; WHO, 2020a).

Figure 2

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The rates of childhood overweight and obesity continue to increase in low- and middle-income countries (LMICs). About 41 million children under five are overweight or obese. Overweight and poor diets elevate the risk of non-communicable diseases (NCDs) which in turn contribute to death and disability worldwide. Health consequences of overweight and obesity explain an estimated 4,000,000 deaths, contributing to 7.1% of all deaths (UNICEF, 2019; Global Nutrition Report, 2020; WHO, 2020b). Figure 2 shows that malnutriton accounts for 54% of deaths in  children younger than five years of age (WHO, 2004).

Malnutrition, in all its forms, carries huge direct and indirect costs to individuals, families, and to entire nations. The estimated impact on the global economy could be as high as US$3.5 trillion per year, or US$500 per individual. Such enormous costs result from economic growth foregone and lost investments in human capital associated with preventable child deaths, 45% of which can be ascribed to poor nutrition, as well as premature adult mortality linked to diet-related non-communicable diseases (NCDs). Further costs are incurred through impaired learning potential, poor school performance, compromised adult labour productivity, and increased health care costs (Global Panel, 2016; Global Nutrition Report, 2020).

2. Stunting

Stunting refers to low height-for-age, when a child is short for his/her age but not necessarily thin. It is also known as “chronic malnutrition” and carries long-term developmental risks. The impaired growth and development result from poor nutrition, repeated infection, and inadequate psychosocial stimulation (The Mother and Child Health and Education Trust, 2020; The Power of Nations, 2020).

Childhood stunting can be measured using the height-for-age nutritional index. It is defined as Z-scores less than −2 standard deviations of median height for age or length for age, independent of their weight-for-age. Some stunted children may have excess weight for their stature length deficiency (WHO and UNICEF, 2009; WHO, 2020a; Gebre et al., 2019).

There is income inequality concern regarding stunting (Figures 3 and 4). A closer look at Figures 3 and 4 reveal that there are disparities in childhood stunting among regions. Three regions had very high rates of stunting with approximately one third of children affected: (1) South Asia; (2) Eastern and Southern Africa; and (3) West and Central Africa.  (UNICEF, 2019).

figure 3a

In almost all countries, the stunting rate is more than double among the poorest children than the richest, indicating dispartity in stunting distribution. Children from the poorest 20 per cent of the population have stunting rates twice as much the rate of the richest quintile. In South Asia, the absolute disparities in stunting distribution between the richest and poorest children are greater than in any other region. While the overall rates of stunting are lower, the rate among the poorest is more than 4 times higher than among the richest in Latin America and the Caribbean, indicating even greater disparity of stunting in this region (UNICEF, 2019).

Figures 3 and 4 show that four regions had low or very low rates of stunting: (1) Eastern Europe and Central Asia; (2) Latin America and the Carribean; (3) East Asia and the Pacific; and (4) North America. However, vast disparities within the low prevalence regions can also exist. As Figure 1 shows, in Latin America and the Caribbean, some individual countries faced medium, high, and in even some cases very high stunting rates despite the low rate overall. Chronic undernutrition in Latin America and the Caribbean can vary widely between neighboring countries (UNICEF, 2019).

figure 4a

2.1 The Causes of Stunting

Stunting has its origins from conception to the first 2 years of life, referred to as the 1,000 days. Stunting results from the exposure of the fetus and/or young child to nutritional deficiency and infectious disease. Maternal undernutrition results in fetal growth restriction, whereas infectious disease in pregnancy can result in preterm delivery. Both of these conditions are important contributors to early childhood stunting (Black and Heidkamp, 2018).

Figure 5 shows that the growth rate of the fetus is very high (>100 cm/year) early in gestation declining to about 50 cm/year at birth. Many conditions can adversely affect fetal growth, including maternal infections and other morbidities, which may also increase the risk of premature delivery (Black and Heidkamp, 2018).

Figure 5

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Figure 6  shows the UNICEF conceptual framework of child undernutrition (stunting, wasting, and underweight) (Levinson and Balarajan, 2013). This framework describes the immediate, underlying, and basic causes of child undernutrition, as well as nutrition-specific and nutrition-sensitive interventions.

Figure 6

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The immediate causes of undernutrition include inadequate nutrition (not eating enough or eating foods that lack growth-promoting nutrients). Recurrent infections or chronic or diseases cause poor nutrient intake, absorption or utilization. This level includes the intergenerational causes of stunting and the potentially effective dietary interventions in pregnancy and early childhood to prevent stunting (Black and Heidkamp, 2018; WHO, 2020a).

The underlying causes include food insecurity, insufficient caregiving resources, unsafe and unhygienic housing conditions, and limited access and utilization of health services. Poor home environment undermines the need for a supportive, clean, safe and stimulating environment to adequately nurture both mother and child. At this level, nutrition-sensitive programs and approaches for agriculture and food security, social safety nets, women’s empowerment, child protection, availability of high quality health services, and water/sanitation could beneficially affect growth and development in childhood (Black and Heidkamp, 2018; WHO, 2020a).

The basic causes are multisectors, including agriculture, health, environment, water and sanitation, infrastructure, gender, and education. At this level, important determinants include social, economic, and environmental factors, poor governance, misguided policies and politics, weak leadership, and limited technical capacity in nutrition (Black and Heidkamp, 2018; WHO, 2020).

A large number of studies support the UNICEF conceptual framework. For example, recent evidence from Indonesia (Beal et al, 2018) showed that child stunting is associated with  male sex, premature birth, short birth length, nonexclusive breastfeeding for the first 6 months, short maternal height, low maternal education, low household socio‐economic status, living in a household with unimproved latrines and untreated drinking water, poor access to healthcare, and living in rural areas.

Another evidence from Indonesia (Rahayu et al., 2018) reported that the risk of stunting increases with poor maternal knowledge, low maternal education, poor maternal nutritional status, low birthweight, and infants receiving no exclusive breastfeeding.

2.2 The Impact of Stunting

The consequences of undernutrition are both short- and long-terms. Stunting affects  health and human capital development throughout the lifecycle and on future generations. Stunting increases the risk of illness in children and impaired child mental and physical development. As such stunted children are less likely to achieve adulthood  full height and cognitive potentials (WHO, 2020a; The Power of Nations, 2020).

Stunting children have higher susceptibility to disease and infection, poor cognition, poor educational performance, and lost productivity, low adult wages, and therefore grow up to be economically disadvantaged.  If excessive weight gain co-exists later in childhood, stunting  increases the risk of nutrition-related chronic diseases in adult life such as diabetes and heart disease (WHO, 2020a; The Power of Nutritions, 2020).

An estimated 43 percent of children under five in low and middle-income countries are at elevated risk of poverty because of stunting. In turn, stunted children earn 20 percent less as adults than their non-stunted counterparts (The Power of Nutritions, 2020).

2.3 The Prevention of Stunting

The first 1,000 days of life is  the key opportunity to prevent child stunting, promote child nutrition, growth and development, which will have a lasting effect over the child’s whole life. Providing nutrient-rich foods, ensuring good feeding and caregiving practices, and controlling exposure to infectious agents are critical to support healthy growth. Interventions in the first 2 years of life include promotion of exclusive breastfeeding for the first 6 months of life and continued breastfeeding for at least the first 2 years, nutritional counseling to assure adequate complementary feeding, and, if necessary in food insecure areas, the provision of supplemental food to be given to the child. Reductions in the stunting prevalence in some low-income countries are observed as the result of a combination of socioeconomic changes, specific infection control, and dietary interventions (Black and Heidkamp, 2018).

To address childhood undernutrition, multisectoral nutrition programming has been of interest to the international nutrition community since the 1970s. Such interest emerged from understandings of the diverse causality of malnutrition, the importance of addressing causes and not simply manifestations, and of stressing integrated systems rather than simply technical fixes (Levinson and Balarajan, 2013).

3. Wasting

Wasting is a major health problem due to its associated risks for morbidity and mortality. Wasting refers to low weight-for-height  where children are thin for their height but not necessarily short. It can be measured using the weight-for-height nutritional index or mid-upper arm circumference (MUAC). Wasting is defined as Z-scores less than −2 standard deviations of median weight for height (WHO, 2012).

Wasting occurs because of acute food shortages or disease. Where stunting is known as “chronic malnutrition”, wasting is also known as “acute malnutrition”, meaning that it is characterized by a rapid deterioration in nutritional status over a short period of time in children under five years of age. There are different levels of severity of acute malnutrition. Based on anthropometric criteria, acute malnutrition can be divided into severe or moderate that needs different approaches of treatment (The Mother and Child Health and Education Trust, 2020; WHO, 2020c).

figure 7a

By 2018, 49 million children under five were wasted globally, of which nearly 17 million were severely wasted. This translates into a prevalence of 7.3 per cent and 2.4 per cent, respectively (Figure 7). In 2018, more than half of all wasted children lived in South Asia and about one quarter in sub-Saharan Africa, with similar proportions for severely wasted children (UNICEF, 2019).

At 15.2 per cent (Figure 8), South Asia’s wasting prevalence represents a situation requiring a serious need for intervention with appropriate treatment programmes. (UNICEF, 2019).

figure 8b

3.1 The Causes of Wasting

Children become wasted when they lose weight rapidly, usually as a direct joint result of  infection and unsatisfied nutritional needs. The main underlying causes of wasting are (WHO, 2020d):

  1. Poor access to appropriate, timely, and affordable health care
  2. Inadequate caring and feeding practices (e.g. exclusive breastfeeding or low quantity and quality of complementary food)
  3. Poor food security due to humanitarian situations and an ongoing lack of food quantity and diversity commonly found in many resource-poor settings, along with inadequate knowledge of food storage, preparation and consumption
  4. Lack of a sanitary environment, including access to safe water, sanitation, and hygiene services.

These factors are related to each other. Infection has a reciprocal relationship with wasting. Poor diet leads to increased risk of infection, and infection has a profound effect on nutritional status. This is the “vicious cycle” between infection and wasting. In low-income countries diarrheal disease is the major cause of rapid weight loss occurring in an environment where hygiene and sanitation are poor  (WHO, 2020c).

3.2 The Consequences of Wasting

Wasting is an acute malnutrition that increases the risk of morbidity and mortality. Wasted children have a 5-20 times higher risk of dying from common diseases like diarrhoea or pneumonia than normally nourished children (The Mother and Child Health and Education Trust, 2020).

3.3 Treatment of Wasting

A child suffering from severe malnutrition is at risk of dying if not treated immediately. Decentralized outpatient treatment services are recommended for those with severe acute malnutrition (severe wasting and/or low MUAC and/or bilateral oedema), based on community identification and referral of cases. In addition, inpatient care is  provided for those with poor appetite, severe bilateral oedema, and/or additional medical complications (WHO, 2020c).

Treatment for severe wasting is vital and cost effective, with an estimated cost of US$ 200/ each severely wasted child. The 2013 Lancet series on undernutrition recognized treatment of severe acute malnutrition as the most cost effective of the various direct nutrition interventions. The earlier the child receives treatment, the cheaper it will be, due to less risk of developing medical complications and faster recovery (WHO, 2020c).

The package of “essential nutrition actions” is recommended for children aged 0–24 months with moderate wasting.  This intervention includes activities such as promotion of and support for breastfeeding, nutrition counselling for families on complementary feeding practices and the provision of food supplements.  For older children, the focus should be on improving family foods (diversity, quality and safety) (WHO, 2012; WHO, 2020c).

4. Nutrition-Specific and Nutrition-Sensitive Interventions

Nutrition-specific interventions are those that address immediate causes of childhood malnutrition, including inadequate dietary intake and ill-health. The 2013 Lancet Series on Maternal and Child Nutrition recommended ten direct interventions to be implemented at scale in countries with high rates of undernutrition. These interventions could reduce stunting by 20.3% (Nutrition Transform, 2020).

The nutrition-specific interventions include: micronutrient supplementation (including iron and folic acid, vitamin A and multiple micronutrients); infant and young child feeding (exclusive breastfeeding and complementary feeding); diarrhea prevention, improved water, sanitation and hygiene (WASH); and therapeutic and supplementary feeding (Transform Nutrition, 2020). Table 1 lists nutrition-specific and nutrition-sensitive interventions and programs (Hossain et al., 2017).

Nutrition-relevant outcomes include birth outcomes, diarrhea incidence, stunting and wasting. Birth risks are defined by maternal age, parity and spacing (Fanzo et al., 2014). Despite progress in understanding the technical aspects of nutrition interventions, there is a dearth of actionable research on how to scale up and sustain such interventions (Transform Nutrition, 2020).

tabel 1

Nutrition-sensitive interventions are those that address intermediate and underlying causes of malnutrition. These approaches draw upon relevant sectors such as agriculture, public health, social protection, early child development, education, environment and water and women’s affairs. These interventions aim to affect the underlying causes of undernutrition, including poverty, food insecurity, poor access, to adequate care resources, and health, water and sanitation services (Fanzo et al., 2014).

The nutrition-sensitive interventions should be designed to address the critical underlying determinants of nutrition, they should be implemented at a large-scale and must be effective at reaching all sections of society who are at risk of or already suffering from undernutrition. The interventions must also be focused on (1) prevention, (2) complementary to curative approaches needed to address undernutrition, and (3) providing the delivery platforms for nutrition-specific interventions (Fanzo et al., 2014).

A systematic review evaluated health and nutrition programmes to identify context-specific interventional packages that might help to prioritize the implementation of programmes for reducing stunting in low and middle income countries (LMICs). The authors concluded that, for all settings, a combination of interventions is associated with success when they include health and nutrition outcomes and social safety nets (Hossain et al., 2017).

An effective programme for stunting reduction should embrace country-level commitment together with community engagement and programme context, reflecting the complex nature of exposures of relevance. Figure 9  depicts the likely mechanism(s) behind successful programme outcome (stunting reduction) based on a systematic review (Hossain et al., 2017).

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5. Overweight and Obesity

Childhood overweight and obesity is a serious global health problem. Childhood obesity has reached epidemic levels in developed as well as in developing countries. Overweight and obesity in childhood are known to have significant impact on both physical and psychological health. Overweight and obese children are likely to stay obese into adulthood and more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age (Sahoo et al., 2015).

Overweight is excess weight-for-length/-height or high-BMI-for-age (Uauy et al., 2014). Overweight and obesity are defined as BMI > 25 and > 30 kg/m2, respectively, in adults. The childhood equivalents of these cut points are established using the International Obesity Task Force (IOTF) or WHO reference (Tzioumis and Adair, 2014).

Global childhood obesity prevalence is on the rise with an increase from 4.2% in 1990 to 6.7% in 2010, predicting to be 9.1% by 2020 (Uijtdewilligen et al., 2016). Figure 10 shows that, by 2018 globally, 5.9 per cent of children under five were overweight. As Figures 10 and 11 show, Eastern Europe and Central Asia had the highest overweight prevalence in 2018 with 14.9 per cent affected, followed by Middle East and North Africa at 11.2 per cent and North America at 8.8 per cent. Indonesia falls into country category with 10 – <25% (high) prevalence of overweight children under five.

figure 10b

East Asia and the Pacific had the highest number of overweight children in 2018 with 9.7 million affected, followed by Middle East and North Africa with an estimated 5.4 million overweight. Overall the two Asian regions (East Asia and the Pacific and South Asia) account for more than one out of every three overweight children in the world (UNICEF, 2019).

figure 11a5.1 The Causes of Childhood Obesity

Children become overweight and obese for a variety of reasons. The most common causes are genetic factors, lack of physical activity, unhealthy eating patterns, or a combination of these factors. Only in rare cases is being overweight caused by a medical condition such as a hormonal problem (WebMD, 2020).

Although weight problems run in families, not all children with a family history of obesity will be overweight. Children whose parents or brothers or sisters are overweight may be at an increased risk of becoming overweight themselves, but this can be linked to shared family behaviors such as eating and activity habits (Ash et al., 2017; WebMD, 2020).

The mechanism of obesity development is not fully understood and it is believed to be a disorder with multiple causes. Environmental factors, lifestyle preferences, and cultural environment play pivotal roles in the rising prevalence of obesity worldwide. In general, overweight and obesity are assumed to be the results of an increase in caloric and fat intake. In addition, there are supporting evidence that excessive sugar intake by soft drink, increased portion size, and steady decline in physical activity have been playing major roles in the rising rates of obesity all around the world (Sahoo et al., 2015).

Gene-environment (GE) interaction is a foundational concept in child development, with experts positing that the influence of genes on a trait will depend on the configuration of particular environmental variables. In the context of childhood obesity, the home environmental variables that might be involved in GE interaction are plentiful (eg, parenting practices, chaos vs structure within the house, and amount of books on shelves) and probably specific to the particular disorder or disease being studied. With respect to childhood obesity, genes can exert their influence on bodyweight through how they interact with the environment. On the GE interaction in influencing the development of childhood obesity, Faith and Epstein (2018) quoted Bray’s metaphora “The genetic background loads the gun, but the environment pulls the trigger”.

5.2 The Impact of Overweight and Obesity

Like underweight, being overweight, or obese during childhood and adolescence is associated with adverse health consequences throughout the life-course. Childhood obesity can profoundly affect children’s physical health, social, and emotional well-being, and self esteem. It is also associated with poor academic performance and a lower quality of life experienced by the child. Many co-morbid conditions like metabolic, cardiovascular, orthopedic, neurological, hepatic, pulmonary, and renal disorders are also seen in association with childhood obesity (Sahoo et al., 2015).

There are some explanations of these impacts. First, gaining excess weight in childhood and adolescence is likely to lead to lifelong overweight and obesity with its associated consequences. Second, being overweight in childhood and adolescence is associated with greater risk and earlier onset of chronic disorders such as type 2 diabetes. Third, childhood and adolescent obesity has adverse psychosocial consequences and lowers educational attainment. Fourth, children and adolescents are more susceptible to food marketing than adults, hence they are more exposed to harmful obesogenic foods (NCD Risk Factor Collaboration, 2017).

5.3 The Prevention of Overweight and Obesity

Given the serious implications associated with childhood and adolescent obesity, effective measure is imperative to address this problem. However, treatment for obesity in children and adolescents is mostly unsuccessful. Therefore, prevention is the most important measure to tackle this problem (Widhalm et al., 2018).

A wide range of interventions has been implemented and tested to prevent obesity in children. While everyone agrees that childhood overweight and obesity is a problem, there is less consensus on what are effective measures for prevention or management (Jackson et al., 2014). There remains the need for clear guidance on what combinations of interventions are likely to be most effective in different contexts across the globe, and the surveillance and accountability mechanisms required for stakeholders at multiple levels (Jackson et al., 2014; WHO, 2014; Ash et al., 2017).

Life-course studies suggest that interventions in early life, when biology is most “plastic” and amenable to change, are likely to have sustained effects on health, particularly because they can influence responses to later challenges such as living in an obesogenic environment. Interventions aimed at preventing childhood obesity would lead to a reduction in comorbidities in children, and to a reduction of the long-term burden of noncommunicable diseases (WHO, 2014).

Early life is a window in the life-course where there is strong political consensus that action is desirable, including considerations of vulnerability, equity, the rights of the child and gender issues. The combination of short-term direct and indirect benefits and longer-term effects in the primary prevention of noncommunicable diseases (NCDs) creates a powerful economic and social argument for action (WHO, 2014).

figure 12a

Figure 12 depicts life-course model of obesity and other Non-Communicable Disease (NCD) risk. It shows period of plasticity in children and adolescents where provision of intervention can be effective. It also shows the period when unhealthy detrimental lifestyles affect greatly on the risk of NCDs (WHO, 2014).

The strategy focusing on primary prevention of childhood obesity complements and potentiates, but does not replace, the need for secondary and tertiary prevention and treatment of obesity and its sequelae. If childhood obesity could be successfully addressed, the benefits derived would include improved maternal and child health, greater human capital gain through academic achievements in young people today and in the next generation, improvements in productivity, longevity, and health and wealth capital (WHO, 2014).

Faith and Epstein (2018) highlighted the potential role of GE interaction based interventions in the prevention of childhood obesity. Homes promoting healthy eating and activity, if sustained, can partially offset children’s genetic susceptibilities to obesity. This can be a powerful and empowering message to families, courtesy of genetics research.

Family interventions are a key strategy in the effort of preventing childhood obesity for two reasons. First, parents have great influence and control over children’s energy-balance behaviors, including diet, physical activity, media use, and sleep (Ash et al., 2017). Second, obesity runs in families,with parents with higher body mass indexes (BMIs) tending to have children with higher BMIs. This familial transmission is in part because of genetic influences— that is, the heritability of obesity. Finding that childhood obesity is heritable is reliable and robust,with heritability estimates falling in the range of 60% to 85% (Faith and Epstein, 2018).

Family-based interventions combining dietary, physical activity, and behavioral components have been shown to be effective and are considered the current best practice in the treatment of childhood obesity in children under 12 years of age (Mead et al., 2017). Further, a systematic review was conducted  to obtain an overview of intervention programmes to preventing childhood obesity in Asia. The authors concluded that targeting preschool settings and applying a comprehensive multisectoral approach may increase the effectiveness and sustainability of childhood obesity prevention programmes (Uijtdewilligen et al., 2016).

Using schools as a setting appears to be another valuable opportunity to support change. Successful interventions, however, require highly motivated individuals or groups. Translating efficacy into effectiveness is another challenge (Jackson et al., 2014). For example, a meta-analysis of studies was conducted to assess the effects of diet, physical activity and behavioral interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years (Mead et al., 2017).

The authors reported that multi-component behavior-changing interventions that incorporate diet, physical activity and behavior change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The results of 37 trials in 4019 children reporting the BMI z score showed that on groups. The results of 24 trials in 2785 children reporting BMI indicated that on average was 0.53 kg/m2 lower in the intervention groups compared with the control groups. Likewise, the results of 17 trials in 1774 children reporting weight showed that on average was 1.45 kg lower in the intervention groups compared with the control groups.

Government and social policies could also potentially promote healthy behavior. Research indicates taste, followed by hunger and price, is the most important factor in adolescents snack choices. Adolescents associate junk food with pleasure, independence, and convenience, whereas liking healthy food is considered odd. This suggests investment is required in changing meanings of food, and social perceptions of eating behavior (Sahoo et al., 2015).

As proposed by the National Taskforce on Obesity in 2005, fiscal policies such as taxing unhealthy options, providing incentives for the distribution of inexpensive healthy food, and investing in convenient recreational facilities or the esthetic quality of neighborhoods can enhance healthy eating and physical activity (Sahoo et al., 2015).

6. Double Burden of Malnutrition

The double burden of malnutrition (DBM) is the coexistence of overnutrition (overweight and obesity) alongside undernutrition (stunting and wasting), at all levels of the population—country, city, community, household, and individual. Undernutrition and overweight have historically been considered and studied separately with contrasting risk factors. Undernutrition was linked with poverty, food insecurity, and infection, whereas obesity was linked with affluence, dietary richness, and sedentary behaviour (Wells et al., 2019).

Increasingly, however, the two forms of malnutrition is considered to co-exist within the same populations, communities, families, and even individuals. For example, an individual with obesity has deficiency of one or various vitamins and minerals. An adult with overweight might be stunted during childhood. At the household level, a mother may be overweight or anaemic and a child or grandparent is underweight. At the population level, a prevalence of both undernutrition and overweight can exist in the same community, nation or region (Wells et al., 2019).

The DBM affects low and middle income countries. Indonesia is the largest country with a severe DBM, but many other Asian and sub-Saharan African countries also face this problem. The DBM has increased in the poorest LMICs, mainly due to overweight and obesity increases. Obesogenic environments are expanding while the causes of undernutrition persist. An increasing proportion of individuals who were undernourished in earlier life now are overweight (Wells et al., 2019).

6.1 The Causes of Double Burden of Malnutrition

Rapid economic development and urbanization have brought about a nutrition transition. Diets become energy dense but nutrient poor, physical activity decreases, and sedentary lifestyles predominate. The disease burden shifts from primarily stunting, to a high prevalence of both under- and overnutrition, and finally to mainly overweight and obesity (Tzioumis and Adair, 2014).

DBM is related to a series of changes occurring in the world called the nutrition transition. Nutrition transition is the shift in dietary consumption and energy expenditure that coincides with economic, demographic, and epidemiological changes. Specifically the term is used for the transition of developing countries from traditional diets high in cereal and fiber to more Western pattern energy-dense diets high in sugars, fat, and animal-source food (Shrimpton and Rokx, 2012; Wikipedia, 2020).

The current nutrition transition seen in the emerging markets of Asia, Latin America, the Middle East, North Africa, and urban areas of sub-Saharan Africa is largely a product of globalization. International food trade, investment, commercialization and marketing are drastically impacting the availability of and access to energy-dense but nutrient-deficient foods causing the aforementioned shift from traditional diet (Hawkes, 2007).

Nutritional transition affects and is affected by two other historic transitions. The first is the demographic transition.  As a byproduct of globalization, typically the populations shift from rural to ruban areas. Urban populations are more susceptible to nutrition transition owing to the improved transportation, commercial food distribution and marketing, less labor-intensive-occupation, and changes in household eating habit (Popkin et al, 2020).

Food demand is shaped by increases in urbanization and income. Urban populations in the rapidly developing nations accrue high income per capita, which allows larger spending in food. Urban people opt for more calorie-dense foods with high contents of sugar and fat (Popkin et al., 2020).

The second is the epidemiological transition. Typically this transition is represented by  a shift from high prevalence of infectious diseases associated with undernutrition, periodic famine, and poor environmental sanitation, to high prevalence of chronic and degenerative diseases associated with overnutrition and urban-industrial lifestyle (Popkin, 1993). The forces of globalization strongly influence many lifestyle changes in developing countries. The economic structures change from the agrarian economies to industrialized economies, which leads to a lack of physical activity (Popkin et al., 2020).

While increased food security is a major benefit of global nutrition transition, there are a myriad of coinciding negative health and economic consequences. Rates of obesity are soaring across the world and recent trends suggest that incidences of overnutrition in coming decades will overtake that of undernutrition in the developing world. As well there will be a marked epidemiological shift from infectious disease to degenerative, noncommunicable disease (NCDs) in these countries (Chopra et al., 2002).

6.2 “Double-Duty Actions” for the Double Burden of  Malnutrition

Global attention is transitioning from the predominant focus on hunger of the Millennium Development Goals (MDGs), to a broader focus on nutrition in the Sustainable Development Goals (SDGs), with targets on ending malnutrition in all its forms (Target 2.2) and reducing NCDs (Target 3.4). Since policy-makers have limited resources (fiscal, human and time), identification of opportunities to achieve multiple goals and targets with single interventions will be key. Addressing contrasting and confounding forms of malnutrition need not be a zero-sum game. There is a need for a set of “double-duty actions” to prevent or reduce the risk of nutritional deficiencies leading to underweight, wasting, stunting or micronutrient deficiencies, and overweight, obesity or diet-related NCDs (including type 2 diabetes, cardiovascular disease and some cancers), simultaneously with the same intervention, programme, or policy (WHO, 2017).

“Double-duty actions” have the potential to improve nutrition outcomes across the spectrum of malnutrition, through integrated initiatives, policies and programmes. The “double-duty actions” represent an intensified common interventions to address both sides of malnutrition. “Double-duty actions” are not necessarily new actions. They are often actions that are already used to address single forms of malnutrition but with the potential to address multiple forms simultaneously, which include areas such as (NCD Alliance, 2020; WHO, 2020d):

  1. Education – Redesign school feeding programmes to offer meals that meet children’s energy and nutrient needs
  2. Food systems – Scale up agriculture programmes that promote production and consumption of nutritious foods; design new agriculture and food policies with healthy and affordable diets; deliver public policies to improve food environments
  3. Health services – Scale up antenatal care programmes that include counselling on healthy eating and balanced energy and protein intake; scaling up programmes to promote optimal breastfeeding and eliminate promotion of breastfeeding substitutes; redesign complementary feeding that emphasizes healthy and diverse diets and snacks; redesign growth monitoring programmes to include diagnostics of overweight and obesity; prevent undue harm of energy dense and micronutrient fortified foods and supplements
  4. Social safety nets – Redesign social safety nets to include counselling on nutrients, healthy diets, and health education; and facilitation of access to beneficiaries of healthy foods, snacks, and beverages, or introduce rewards for transfers or vouchers spent on nutritious foods.

The potential for double-duty actions to impact both sides of the double burden arises from shared drivers (i.e. root causes) behind different forms of malnutrition, and from shared platforms (to take action) that can be used to address these various forms of malnutrition (see Figure 13). While the drivers of undernutrition may appear distinct from those for overweight, obesity or NCDs, evidence indicates there are shared (1) biological, (2) environmental, and (3) socioeconomic factors that contribute to the risk or prevalence of both sides (WHO, 2017).

Emerging from common drivers between the various forms of malnutrition are common platforms for delivering double-duty actions. Potential examples of shared platforms include the following: (1) National dietary guidelines; (2) National-level policies for overweight, obesity, noncommunicable disease and nutrition; (3) Health systems; (4) Humanitarian aid and emergency nutrition programmes; (5) Urban food policies and systems; (6) Social policies (WHO, 2017).

figure 13a

In order to advance the potential of double-duty actions, it will be vital to further examine the evidence of the effects of specific actions on outcomes associated with both sides of the double burden. Initial assessments of the evidence indicate the following are potential areas of action that could be levered for double duty: (1) Initiatives to promote and protect exclusive breastfeeding in the first 6 months, and beyond; (2) Promotion of appropriate early and complementary feeding in infants; (3) Maternal nutrition and antenatal care programmes; (4) School food policies and programmes; and (5) Regulations on marketing.

Tzioumis and Adair (2014) have proposed some additional candidates for achieving double duty, which include: (1) Improved anthropometric monitoring; (2) Feeding programs designed with both undernutrition and overnutrition in mind; (3) Increased focus on water, sanitation, and hygiene (WASH); (4) Constant appraisal and revision of local and national public health policies; and (5) A multifaceted and multi-institutional approach.

Routine monitoring of overweight must occur with the same frequency and urgency as monitoring of height. This will provide a more complete portrayal of childhood nutritional status, which is currently lacking in many areas that continue to focus solely on undernutrition. With accurate surveillance, governments will better understand the magnitude of the childhood nutritional problem and be better informed when allocating resources to programs (Tzioumis and Adair, 2014).

When designing interventions and feeding programs, the quality of foods and supplements as well as the energy content must be considered, so as not to inadvertently add to the burden of overweight in the same children the program is striving to help (Tzioumis and Adair, 2014).

Doing double duty is a process of starting to consider all forms of malnutrition when implementing and designing programmes and policies. Double-duty actions recognize that addressing contrasting and confounding forms of malnutrition need not be a zero-sum game, but that common policy and programmatic opportunities exist to holistically address the double burden of malnutrition. This can be achieved at three levels (see Figure 14): (1) Do no harm with existing interventions; (2) Retrofit existing interventions to be double-duty; and (3) De-novo double duty actions (WHO, 2017)

The first level of doing double duty is to assess and ensure that current initiatives (policies, programmes etc.) are not unintentionally increasing the risk of other forms of malnutrition or NCDs. For example, it is critical to ensure that efforts and initiatives to feed young children affected by acute undernutrition do not inadvertently increase  their long-term risks of overweight and NCDs (WHO, 2017).

The second level of implementing double duty is to look at what actions are already being implemented to tackle a certain form of malnutrition, and to assess the ability of those actions to generate external benefits on the other forms of malnutrition. For example, some school food programmes may target undernutrition by advancing healthy diets while at the same time preventing overnutrition (WHO, 2017).

The third level involves development of new actions designed specifically to do double duty. This is based on assessing which of the new actions are potentially the most powerful candidates to be implemented in a particular setting – reflecting the local epidemiology, policy, cultural, environmental and food contexts (WHO, 2017).

figure 14a

The type of action and its effectiveness will vary between and within countries. Designing for double duty is not an approach of “one size fits all” but a method of creating nutrition actions that are appropriate to the local setting (WHO, 2017).

6.3 The Need for Cross-Sector and Trans-Disciplinary Approaches

The large economic returns to nutrition specific interventions are clear. Likewise, the potential of nutrition sensitive interventions and the importance of an enabling environment for reduction of undernutrition are recognized. Most of the concepts and ideas that are developed about enabling environments apply to both undernutrition and the problems of overweight and obesity (Gillespie, 2013).

A new approach is needed to reduce the double burden of malnutrition simultaneously. The issues are increasingly connected with rapid changes in the food system and societal system. Cross-sector and trans-disciplinary approaches are needed to address the problem. This is because malnutrition is multicausal in nature, requiring action from many actors and organizations in different sectors at different levels, including public and private sector (Gillespie, 2013).

Multi-sectoral Approach

Chronic malnutrition is an important example of a global challenge that spans multiple sectors, specifically health, agriculture, and the environment. A multisectoral approach is needed to reduce the burden of both undernutrition (stunting and wasting) and overnutrition (overweight and obesity). Community programmes to ensure household access to proper sanitation, availability of clean water and diversified foods, poverty reduction support for families in need, education on how to feed young children and protect them from infection, and adequate, accessible health services to prevent and treat infections can collectively reduce stunting in populations (WHO, 2013, 2020; Reinhardt and Fanzo, 2014).

Existing evidence supports the need to scale-up interventions aimed at ensuring access to nutritious foods and breaking the intergenerational cycle of undernutrition and stunting (The Power of Nutritions, 2020).

To improve food security, nutrition, and population health, a qualitative study from Nepal suggests that multisector approach adapt to take into account the experiences and views of the stakeholders concerned (Gaihre et al., 2019).


Urban transformations are complex, dynamic, and systemic societal phenomena that have many positive and negative consequences, including nutrition and dietetic issues. In responses to children’s health challenges in the context of rapid urbanization, Lawrence (2019) asserts the importance of transdisciplinarity approach. Transdisciplinarity has been defined as the integration of the social and natural sciences in a common approach (interdisciplinarity), while at the same time including nonacademic knowledge systems in order to understand and solve socially relevant problems (Gillespie, 2013).

Transdisciplinary contributions should be distinguished from multi- and inter-disciplinary contributions. Interdisciplinary refers to contributions involving intentional collaborative actions  applied by researchers in at least two different disciplines to achieve a shared research goal about a common subject. The interdisciplinary collaboration has created new disciplines, including architectural psychology and environmental sociology. Concepts and methods are shared between different disciplines. However, in contrast to trandisciplinary collaboration, the whole interdisciplinary process does not extend beyond scientific knowledge, protocols, and know-how (Lawrence, 2019).

Transdisciplinary refers to the contributions extending beyond scientific knowledge by including non-academic researchers and institutions, such as representatives of the private sector, public administrations, community associations and citizens. In contrast to multidisciplinary approach where each contributor applies disciplinary concepts and methods without intending to collaborate with others, transdisciplinary contributions enable the cross-fertilization of knowledge and the experiences of people educated in different disciplines, trained in different professions, and experienced in different policy making. Collaborative planning and participatory design are tangible ways of co-producing new built environments with the involvement of representatives from industry, researchers, practitioners, policy makers and citizens (Lawrence, 2019).

Transdisciplinarity aims to establish an acceptable process for discussion and negotiation among actors who jointly pursue a new understanding of a given problem or situation (Charron, 2012). Opportunities and challenges in coordination are linked to the engagement of multiple sectors and stakeholders, the contributions and expectations that political interest brings to programmes, and the pros and cons of dependence on donor funding. Coordination that successfully aligns the different sectors’ interests and goals requires socially-attuned leadership, communication, negotiation, and conflict & consensus management skills (WHO, 2013). There is a need for coherence among inter-dependent initiatives at national, subnational and grassroots levels.


Coordinated effort of multiple sectors and disciplines is required to address both the short and long-term determinants and drivers of malnutrition. Coordination is challenging given the many actors with diverse perspectives, interests, resources and practices need coordinating (Fanzo et al., 2014). Transdisciplinarity, i.e., collaboration across disciplines (e.g., public health, medicine, sociology, nutrition, agriculture, education, economics, environmental sciences, child development, etc.) calls for free information-exchange, modifying discipline-specific approaches, and sharing resources with the aim of achieving a common goal (Gillespie, 2013).

Childhood malnutrition requires coordinated action from many actors and organizations in different sectors and at different levels. Coordination takes place at the national, subnational, and community-household levels. Successful national coordination consists of: (1) Creating policy environments and governance structures to direct and support multiple stakeholder collaboration; and (2) empowering and equipping implementers to translate policies into action (WHO, 2020e).

Subnational implementation needs strategic and operational capacity to deliver appropriate and timely services to the population. This calls for strengthened infrastructures to bring high quality preventive and curative health care, safe water supplies, education, services in agriculture and environmental and social protection, etc. Implementers at this level should be equipped with the supplies, skills and motivation required to fulfil their role (WHO, 2020e).

Households and communities cannot be seen only as recipients of aid and recommendations on how to improve their lot. A lot more progress is achieved when they participate in decision-making and are seen as partners in the implementation of programme activities. Households and communities should participate as the main protagonists of healthy child growth and development. Community mobilization and engagement takes time but is important if programmes are to achieve lasting impact.

A study from India concluded that the creation of new partnerships between traditionally under-represented communities and local government can serve as vehicle for building social capital that can lead to a more accountable and accessible community health delivery system. The network expanded relationships at the village and block levels, reflecting the rise of bridging social capital (Ruducha et al., 2019).

Childhood malnutrition  calls for a well-thought out strategy to frame the problem in terms that resonate with local values and aspirations. Caregivers need to be sensitized to the causes and consequences of childhood manultrition and made aware that their actions (feeding, care, protection, stimulation) are critical because they directly impact how children grow and develop (WHO, 2020e).

Framing of malnutrition reduction is an important political issue. Political calculations are at the basis of effective coordination between sectors, national and subnational levels, private sector engagement, resource mobilization, and state accountability to its citizens. Overall, if the multiple stakeholders involved in childhood malnutrition reduction recognize the need for horizontal and vertical coherence, they will better appreciate both the significance and paucity of what they individually can contribute to the effort. This would also likely advance sense of mutual accountability among actors at different levels and across sectors (Gillespie, 2013).

Leadership for nutrition, at all levels, and from various perspectives, is fundamentally important for creating and sustaining momentum and for conversion of that momentum into results on the ground (Gillespie, 2013).

7. Conclusions

A key challenge to address childhood double burden of malnutrition is to determine the effective responses to be implemented. These collective responses should be more comprehensive than specific individual projects. They should be defined as societal transitions that become transformations at macro-, meso-, and micro-levels.

Addressing the double burden of malnutrition through “double-duty actions” is deemed to be critical importance in achieving the target of the Sustainable Development Goals. “Double-duty actions” include interventions, programmes and policies that have the potential to simultaneously reduce the risk or burden of both undernutrition (including wasting, stunting and micronutrient deficiency or insufficiency) and overweight, obesity or diet related NCDs.

Given the complex nature of these diverse intervention packages, strong political commitment, multi-sectoral collaboration, transdisciplinary collaboration, community-based service delivery platforms, wider programme coverage, and compliance, are all critical components of effective programmes to tackle the double burden of malnutrition problem. Programme managers and policy makers should consider specific contextual factors in order to determine the most suitable combination of interventions while planning and implementing programmes to defeat the double burden of malnutrition problem.


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