UOFT Food Security Summary Paper

Description

Don't use plagiarized sources. Get Your Custom Essay on
UOFT Food Security Summary Paper
Just from $13/Page
Order Essay

Your task is to write a brief summary based on three articles, in 12 point size, and 1.5-2 spaced. APA citation style is to be used. One page to one and half page is required in total.

Series
Double Burden of Malnutrition 1
Dynamics of the double burden of malnutrition and the
changing nutrition reality
Barry M Popkin, Camila Corvalan, Laurence M Grummer-Strawn
The double burden of malnutrition (DBM), defined as the simultaneous manifestation of both undernutrition and
overweight and obesity, affects most low-income and middle-income countries (LMICs). This Series paper describes
the dynamics of the DBM in LMICs and how it differs by socioeconomic level. This Series paper shows that the DBM
has increased in the poorest LMICs, mainly due to overweight and obesity increases. Indonesia is the largest country
with a severe DBM, but many other Asian and sub-Saharan African countries also face this problem. We also discuss
that overweight increases are mainly due to very rapid changes in the food system, particularly the availability of
cheap ultra-processed food and beverages in LMICs, and major reductions in physical activity at work, transportation,
home, and even leisure due to introductions of activity-saving technologies. Understanding that the lowest income
LMICs face severe levels of the DBM and that the major direct cause is rapid increases in overweight allows identifying
selected crucial drivers and possible options for addressing the DBM at all levels.
Introduction
The global health community has been slow to
acknowledge the challenge of the large proportion of lowincome and middle-income countries (LMICs) facing the
double burden of malnutrition (DBM), which is the
coexistence of undernutrition (ie, micronutrient defi­
ciencies, underweight, and childhood stunting and
wasting) and overweight, obesity, and diet-related noncommunicable diseases. 2∙28 billion1 or more children
and adults worldwide are estimated to be overweight and
more than 150 million children are stunted.2,3
Several studies describe the double burden of nutri­
tional deficiencies (childhood stunting or wasting, and
micronutrient deficiencies) and overweight and obesity
affecting countries, households, and individuals.
Included are the first studies that measured the DBM at
the household level,4–6 now this is represented by growing
literature that has focused on understanding the
dimensions of the problem, causes, consequences, and
possible solutions.7–13 The analysis has pinpointed several
reasons for this health crisis, many related to the stage of
the nutrition transition dominated by reduced physical
activity and increased access to less healthy, highly
processed foods and beverages.14–21 However, how to
translate this evidence into effective actions is unclear.
Building on the 2013 Lancet Series on maternal and
child undernutrition22 and complementing other major
scientific initiatives such as the EAT-Lancet Commission
on healthy diets from sustainable food systems23 and the
Lancet Commission on the global syndemic of obesity,
undernutrition, and climate change,24 this Series
highlights the new nutrition reality: that there are
multiple forms of malnutrition that overlap in different
ways and in different places.13 Additionally, addressing all
forms of malnutrition will require new ways of designing,
targeting, and implementing programmes and policies
to accelerate progress in improving nutrition globally.
www.thelancet.com Vol 395 January 4, 2020
We also want to acknowledge that the effect of
undernutrition over the past four to five decades will
affect our health for many future years. Although
stunting has declined greatly from the early 1990s, the
stunting from the past three to four decades will
subsequently have a great effect decades later on
increases in visceral fat and greater risks of major noncommunicable diseases as discussed by Wells and
colleagues,25 in the second paper in this Series,26 and in
the key cohort studies.27–29
This 2019 Series is timely, with the recent UN Decade
of Action on Nutrition and the Sustainable Development
Goals shifting focus from predominantly undernutrition,
or single sides of malnutrition, to all forms of mal­
nutrition.30,31 Further, major UN and other international
institutions and donors are revisiting their strategies to
reconsider the scope of nutrition priorities, developing
strategy documents, and formulating initiatives to focus
on overweight and obesity as well as undernutrition.32
The papers in this Series take this concern for
malnutrition in all forms a step further and focus on not
only the epidemiology and larger societal changes in the
food system and other major demographic and economic
dimensions, but also the biological underpinnings of
stunting and subsequent adiposity and the risk of noncommunicable disease.25
The papers in this Series also take the issue of the DBM
into the programme and policy area33 by building on the
work of double-duty interventions,11 which focus on
reducing both undernutrition and overweight and obesity.
This Series also shows how ignoring obesity in
prog­
rammes focused on preventing malnutrition at
various ages has affected obesity and the DBM33 and
focuses on the economic effects of health programmes
and policies.34 This Series paper introduces the
epidemiology of the DBM, presents changes in global
estimates of the DBM and its components, and uses
Lancet 2020; 395: 65–74
Published Online
December 15, 2019

S0140-6736(19)32497-3
This is the first in a Series of four
papers about the double burden
of malnutrition
See Editorial page 2
Department of Nutrition and
Carolina Population Center,
University of North Carolina at
Chapel Hill, Chapel Hill, NC,
USA (Prof B M Popkin); Institute
of Nutrition and Food
Technology (INTA), University
of Chile, Santiago, Chile
(C Corvalan PhD); and
Department of Nutrition for
Health and Development,
World Health Organization,
Geneva, Switzerland
(L M Grummer-Strawn PhD)
Correspondence to:
Prof Barry M Popkin, Carolina
Population Center, University
of North Carolina, Chapel Hill,
NC 27516, USA
popkin@unc.edu
65
Series
Key messages
• In low-income and middle-income countries (LMICs), stunting and wasting, and
thinness in women are declining while overweight is increasing in most age groups.
According to the most recent surveys, a severe double burden of malnutrition (DBM)
is defined as wasting in more than 15% and stunting in more than 30% of children
aged 0–4 years, thinness in women (body-mass index 15%, stunting of >30%, and thinness in
women of >20%, and an adult or child overweight
prevalence of >20%, >30%, or >40%). The cutoffs for
undernutrition are defined as follows: a weight-forheight Z score of less than –2 for wasting; a height-forage Z score of less than –2 for children aged 0–4 years
66
Examining the changes in the DBM status by quartile of
gross domestic products (GDP) per capita in 1990, we
can see that increases in the number of countries
with a DBM from the 1990s to the 2010s are within the
lowest income quartile, whereas the number of countries
with a DBM has declined in the top three income
quartiles (figure 2). The largest increases in number of
the DBM countries were observed using the 20% and
30% adult overweight prevalence cutoffs.
This highlights the driving role of overweight in shaping
countries now facing a high DBM, with the greatest effect
among the countries in the lowest quartile of GDP per
capita. Figure 3 further highlights these changes in the
DBM by income quartile. At the same time, the total
number of countries with a severe DBM (ie, defined using
the 40% overweight cutoff) declined, related mainly to
substantial declines in wasting and stunting.
Household-level DBM
The DBM at the household level was defined as one or
more individuals with wasting, stunting, or thinness
and one or more individuals with overweight or obesity
within the same household. The DBM can occur in one
of four ways: a child is both stunted and overweight; the
mother is overweight and one of her children younger
than 5 years has wasting the mother is overweight and
one of her children younger than 5 years is stunted;
or the mother is thin and one of her children is
www.thelancet.com Vol 395 January 4, 2020
Series
A Countries with DBM in the 1990s according to weight and height data
DBM at >20% overweight
prevalence
DBM at >30% overweight
prevalence
DBM at >40% overweight
prevalence
No DBM
High-income countries
B Countries with DBM in the 2010s according to weight and height data
Figure 1: The global DBM in low-income and middle-income countries based on weight and height data from the 1990s (A) and 2010s (B)
DBM at the country level was defined as a high prevalence of both undernutrition (wasting and stunting in children aged 0–4 years, and thinness in adult
women) and overweight and obesity (defined according to three different overweight prevalence thresholds: 20%, 30%, and 40%) in at least one population
group. Data sources are UNICEF, WHO, World Bank, and NCD-RisC estimates, supplemented with selected Demographic and Health Surveys and other country
direct measures. DBM=double burden of malnutrition.
overweight. Appendix pp 14–15 shows the prevalence of
each of these scenarios and the total prevalence of
household DBM.
Household-level DBM is driven primarily by the
combination of women with overweight and children
with stunting (highest prevalence of all four possible
www.thelancet.com Vol 395 January 4, 2020
For more on the Demographic
and Health Surveys see

combinations in every country with the highest level of
change where increases in the prevalence of the DBM are
occurring). By contrast, the contribution of the fourth
category of the DBM (mother with thinness and child
with overweight) is extremely small, with less than 1%
prevalence in most countries.
67
Series
Economic development and the DBM at the household level
A DBM at 40% adult overweight prevalence
Number of countries
20
In appendix pp 12–15, the GDP per capita and householdlevel DBM relationship is similar in the two time periods
examined (1990s and 2010s), with the highest levels of
household DBM seen in the middle of the income range
(figure 4). However, the entire curve has shifted slightly
upward (about 2–3 additional percentage points) in the
most recent time period at all income levels.
1990s
2010s
16
12
8
8
4
1
1
4
3
2
2
1
0
B DBM at 30% adult overweight prevalence
Number of countries
20
16
14
12
8
8
4
10
5
5
3
4
1
0
C DBM at 20% adult overweight prevalence
Number of countries
15
16
12
13
12
13
7
8
5
4
0
1
Q1
Q2
Q3
Q4
Income quartile
Figure 2: Countries with a high DBM in the 1990s and 2010s, by overweight
prevalence threshold and income quartile
DBM at the country level was defined as a high prevalence of both
undernutrition (wasting and stunting in children aged 0–4 years, and thinness in
adult women) and overweight and obesity, defined according to three different
overweight prevalence thresholds: 20% (A), 30% (B), and 40% (C), in at least
one population group. Countries were only included here if they had DBM data
available for both time periods (1990s and 2010s). Q1 is lowest wealth and Q4 is
highest wealth according to gross domestic product per capita (purchasing
power parity). Data sources are UNICEF, WHO, World Bank, and NCD-RisC
estimates, supplemented with selected Demographic and Health Surveys and
other country direct measures for the 1990s. DBM=double burden of
malnutrition. Q=quartile.
The prevalence of total household-level DBM ranges
from less than 3% to nearly 35%, with over a quar­
ter of households experiencing a DBM in Azerbaijan,
Guatemala, Egypt, Comoros, and São Tomé and
Príncipe. The total household-level DBM is shown in
appendix p 22 for 22 countries with at least two surveys
of more than 15 years apart. Comparing the earliest and
the latest surveys in these countries, five countries
showed reductions in their DBM and 15 (including
India, China, and Indonesia) showed increases
(appendix p 22).
68
The second paper in this Series26 addresses the underlying
developmental origins biology that can lead to a child
having both stunting and overweight. The prevalence of
individual-level DBM for children aged 0–4 years is
shown in the appendix (pp 14–15, 22). The proportion of
children who have both stunting and overweight ranges
from less than 1% in Myanmar, Colombia, and Nepal to
more than 15% in Albania. Among the 20 countries with
earliest-to-latest-year data spanning 15 or more years,
about half showed that the DBM was declining in
children at the individual level and half showed that it
was increasing (appendix p 22).
Changes in malnutrition over time: equity
considerations
19
20
Individual-level DBM
Nearly all countries saw declines in child wasting or
stunting, with a third declining by more than one per­
centage point per year (appendix pp 16–17). Conversely,
nearly all countries saw an increase in overweight among
women, with over a third of countries increasing by more
than one percentage point per year (appendix pp 18–19).
From a public health perspective, where this overweight
is emerging and whether the burden is now, or in the
future, and greater among people living in poverty is
important to know. To provide some sensitivity to where
increased overweight is occurring, we looked at the
prevalence and annualised changes in prevalence in all
countries with 2 years of anthropometric data and
examined the differences in the changes in the prevalence
of overweight and obesity between the poorest and the
highest-wealth quintiles in the earliest and most recent
survey periods (figure 5).
A positive annualised difference indicates that people
in the poorest quintile face a greater prevalence of
overweight and obesity than do those in higher wealth
quintiles and suggests increasing disparities between the
lowest and the highest wealth quintiles (see appendix
p 19 for the data and appendix pp 1–5 for the
methodology). We show a growing prevalence of
overweight and obesity among lower-wealth households
in most countries in Latin America and the Caribbean,
eastern Europe and central Asia, and east Asia (led by
China and Indonesia). By contrast, sub-Saharan Africa
and south Asia have the largest increases in prevalence of
overweight and obesity among higher-wealth households
(appendix p 19). We cannot predict with existent data
whether these regions will see a shift toward greater
www.thelancet.com Vol 395 January 4, 2020
Series
overweight among lower-wealth households in the
future. A study shows that in all LMICs other than
south Asia and sub-Saharan Africa, rural overweight
and obesity is growing faster than in urban areas and
highlights the need for shared solutions targeted to both
urban and rural areas.43
The next section explores the global food systems
linked with a new nutrition reality now affecting even the
poorest LMICs.
Transitions that explain the current shifts in the
DBM towards lower-income countries
We found that of the countries that have a new DBM at
any overweight or obesity prevalence threshold, the
largest proportion were in the lower quartiles GDP per
capita purchasing power parity (figure 3). At the same
time, the number of countries in the upper income
quartiles with a DBM decreased. This result reflects
increasing overweight among lower-income countries
that have not reduced stunting, wasting, or thinness
below the WHO-UNICEF cutoff levels. We focus the
following discussion on the changing food system and
new nutrition reality that these poorest LMICs are facing.
Economic change certainly has been crucial to the
reductions in wasting, stunting, and thinness as well as
declines in physical activity and major shifts in the food
system that have resulted in an increase in consumption
of ultra-processed foods.16,20,21,44–49 In longitudinal studies
in China, the increases in overweight were fuelled by a
massive reduction in physical activity and most probably
also in energy expenditure derived from the introduction
of modern technology in market economic work, home
production (eg, rice cookers, refrigerators, stoves), and
transportation systems.18–21,48,50
However, very rapid changes in the diets and the food
systems of most LMICs are where most of the recent
change in energy imbalance that causes weight gain is
focused. Offsetting the effects of any ultra-processed
food is difficult—eg, by drinking a 355 mL bottle of
sugar-sweetened beverage, the consumer would be
required to undertake a 1∙5 mile walk or run for at least
15 min.39 Thus, we discuss later on mainly the shifts in
the food system and diet changes over time. We
conceptualise the food system as the entire process from
production to the consumer.51–53
This system includes the activities, infrastructure, and
people involved in feeding the global population. Over
the past several decades the relative influence and power
among the various actors who affect and direct food
production has increased, as has the penetration of
modern food retailing and marketing throughout most
LMICs. In this Series paper we touch on these dramatic
changes only briefly. A more in-depth discussion of these
changes can be found elsewhere16 and in more detail for
Latin America and the Caribbean.53 These food system
changes are clearly important for weight gain and
overweight status but the literature on how these changes
www.thelancet.com Vol 395 January 4, 2020
No longer had a DBM
DBM at 20% adult overweight
prevalence
Q4
Q3
Q2
Q1
Began having a DBM
–4
–10
4
–7
5
11
–4
DBM at 30% adult overweight
prevalence
–3
Q4
Q3
Q2
Q1
DBM at 40% adult overweight
prevalence
–8
3
–3
6
–2
13
–3
Q4
Q3
Q2
Q1
–7
1
–1
–1
–15
–10
–5
1
2
0
5
10
15
Number of countries
Figure 3: Number of countries that changed DBM status from the 1990s to 2010s, by gross income quartile
DBM at the country level was defined as a high prevalence of both undernutrition (wasting and stunting in
children aged 0–4 years, and thinness in adult women) and overweight and obesity (defined according to
three different overweight prevalence thresholds: 20%, 30%, and 40%), in at least one population group.
Countries were only included here if they had DBM data available for both time periods (1990s and 2010s).
Q1 is lowest wealth and Q4 is highest wealth according to gross domestic product per capita (purchasing power
parity). Data sources are UNICEF, WHO, World Bank, and NCD-RisC estimates, supplemented with selected
Demographic and Health Surveys and other country direct measures for the 1990s. DBM=double burden of
malnutrition. Q=quartile.
affect undernutrition is unclear and this association is
understudied.
The general concept of the nutrition transition is that in
each region of the world (not only countries but subregions
within countries), a transformation in the way people eat,
drink, and move at work, at home, in transport, and in
leisure has affected the distribution of body composition
and created nutritional problems.54,55
The transition has produced remarkable shifts in
physical activity and diets in LMICs and a rapid increase
in overweight, obesity, and nutrition-related non-com­
municable diseases.20,21,48,50 As we have noted we only
have suggestive information on ways that this transition
affects infant diets for those facing a high risk of stunting
and wasting.45,47,49,56 In the past decade, no studies have
been done on the exact causes of country-level or even
household-level DBM. But we will describe briefly a new
nutrition reality that is rapidly becoming the major
driver of overweight and obesity among lower-income
countries and also has unclear but increasing effects on
undernutrition.
The new nutrition reality
The new nutrition reality is particularly important to
acknowledge, because diet is an important driver of the
DBM.57,58 Although we understand that changes in the
past several decades in food marketing, access, and
purchase of packaged processed foods have demarcated a
new nutrition reality across the globe, this Series paper
focuses on the effect on all LMICs while attempting to
69
Series
A Earliest measure of DBM regressed on 1990 GDP
100
35
Prevalence at the household level (%)
B Most recent measure of DBM regressed on 2010 GDP
Predicted
Overweight and wasting or stunting
Egypt
30
25
Pakistan
Lesotho
Egypt
Guatemala
20
Guatemala
Azerbaijan
Comoros
15
10
5
0
Kazakhstan
0
2000
4000
6000
8000
10 000
1990 GDP per capita
0
2000
4000
6000
8000
10 000
2010 GDP per capita
Figure 4: The association between GDP per capita (purchasing power parity) and regressions relating GDP per capita to prevalence of household-level DBM
DBM at the household level was defined as one or more individuals with wasting, stunting, or thinness and one or more individuals with overweight or obesity within
the same household. Data sources are the Demographic and Health Surveys with the exceptions of China (China Health and Nutrition Survey), Indonesia (Indonesian
Family Life Survey), Mexico (Mexico National Survey of Health and Nutrition), Brazil (Brazil National Health Survey), and Vietnam (Vietnam Living Standards Survey).
DBM=double burden of malnutrition. GDP=gross domestic product.
understand the effects on countries in different regions
and with varying income levels.59–61 The growth in retail
food59,62,63 and the control of the entire food chain in
many countries by agribusinesses, food retailers, food
manufacturers, and food service companies have changed
markedly.53,64 This change has been accompanied by the
increased consumption of ultra-processed food purchases
in LMICs.65,66 Ultra-processed, packaged foods rich in
refined carbohydrates, fat, sugar, and salt are relatively
inexpensive and often ready to eat.67
Evidence suggests these ultra-processed foods play a
major role in increased obesity and non-communicable
diseases. A randomised controlled trial done by a team at
the US National Institutes of Health showed that adults
with normal weight lost 0∙9 kg in 2 weeks when fed a realfood diet and gained 0∙9 kg when fed a diet composed of
ultra-processed foods, following a cross-over design.14
Whether the hyperpalatability of ultra-processed food
or the much higher energy density of these foods
causes such a weight gain is unclear from this study.
Additionally, two large European cohorts have shown a
strong positive relation between ultra-processed foods
and cardiovascular disease and all-cause mortality.68–70
The role of ultra-processed foods on stunting remains
less clear, although, we would expect a negative effect if
they are replacing nutrient-rich, energy-dense foods.14,69,70
Intake of ultra-processed foods during the first 1000 days
of life is increasing and represents a newly emerging
probable contributor of stunting,44–47,49,56,71,72 therefore
perpetuating the DBM.
The retail revolution
The retail revolution, which has led to fresh markets
increasingly disappearing and large and small food
retailers replacing them, has swept the globe, as a series
70
of studies by Reardon and others shows.59,60,62–64,73 In Latin
America and the Caribbean, sales of packaged processed
food increased from about 10% of all food expenditures
(both in-cash and in-kind sales) in 1990 to 60% in 2000.
The bulk of this increase appears to be in ultra-processed
unhealthy foods and beverages and the growth continues
in this region.53,62,74 Similar increases in the penetration of
modern food retailers emerged at different rates across
Asia, Africa, and the Middle East.63
The Persian Gulf states63 have not been studied as
carefully, although increased penetration of modern food
retailers in this region presumably occurred even earlier
than in other regions, because the area urbanised and
had rapid growth in incomes. The changes vary across
sub-Saharan Africa, north Africa, east Asia, southeast
Asia, and south Asia but are accelerating in most
countries in these regions.59,60,75 Urban areas were already
dominated by a modern food retail sector in the
mid-1990s, but most growth in the sub-Saharan African
market has occurred in the 21st century.61
Controlling the food supply
The actors who control the food supply are changing. At
the time of the green revolution and the growth of the
global agricultural research sector between 1950 and
1969, countries, large agribusiness firms in the seed and
fertiliser sector, and global foundations generated the
change.51,53,64,73,74,76 Although these players still have major
roles in producing new technology, control of the food
chain is transforming. Case studies from China,
Bangladesh, and India were the first to remark on this
transformation64 and later research showed similar trends
in Africa.60
These studies showed that the global and national
public sectors were no longer the major influences of
www.thelancet.com Vol 395 January 4, 2020
Series
diets in LMICs. Rather, food retailers, food agribusinesses,
global food companies, and the food service sector and
their domestic local counterparts have contracts directly
with farmers.
Non-essential foods and beverages
Sales of non-essential foods and beverages are growing
rapidly. Sales volume data from Euromonitor Inter­
national shows trends in increasing sales of non-essential
or junk foods and sugar-sweetened beverages in Chile,
South Africa, the Philippines, and Malaysia (appendix
p 23).77 Appendix pp 20–21 present the sales data from
Euromonitor International used to model the GDP
relationship with both sales volumes and annualised
changes in sales of sugar-sweetened beverages (appendix
p 24) and junk foods (appendix p 25) in LMICs using data
regressions.78
These results show that sales of sugar-sweetened
beverages were already high in lower-income countries
by 2017. The rapid growth of junk foods and sugarsweetened beverages in these countries exemplifies how
aggressive this food sector is. India and China are two of
the top five markets for sugary beverage manufacturers
(appendix pp 26–27) and sugary beverages are expected
to become these countries major markets in the next
decade. The speed of change is particularly important in
understanding how this nutrition reality is shifting.
Key drivers of the new nutrition reality
In LMICs, urbanisation, migration to cities, income
growth, infrastructure improvements, and global trade
policy liberalisation have spurred private investment in
the food sector.54,61,74,77 The roles of income growth78 and
other drivers associated with diet changes should not be
downplayed. Equally important is how the increase in the
number of women working outside the home53,79 and the
value of their time in work have shaped the demand for
food that is ready to eat or ready to heat.80 Monteiro calls
this convenience in food preparation and consumption
the ultra-processed food revolution.65,66
Modern marketing and access to mass media have
added to changes in conceptions of the ideal set of foods.
Although power is shifting to large-scale food retailers,
manufacturers, and food-service companies,53,64 the
informal sector and smaller local companies remain
understudied components of the food sector who are
often important sources of food for low-income and rural
populations.
Conclusion
This Series paper has shown that LMICs continue to have
a high DBM; however, countries with a high DBM have
lower incomes than the countries that had a high DBM
in the early 1990s. The analysis of the dynamics of
undernutrition and obesity suggest that the high DBM is
being driven by the rapid increases in the prevalence of
overweight and obesity occurring in these lower-income
www.thelancet.com Vol 395 January 4, 2020
East Asia and Pacific
Cambodia
Vietnam
Indonesia
China
Europe and central Asia
Armenia
Turkey
Kyrgyzstan
Kazakhstan
Latin America and the Caribbean
Nicaragua
Haiti
Mexico
Peru
Guatemala
Bolivia
Dominican Republic
Brazil
Colombia
Honduras
Middle East and north Africa
Morocco
Jordan
Egypt
South Asia
Nepal
Bangladesh
India
Sub-Saharan Africa
Sierra Leone
DR Congo
Cameroon
Uganda
Togo
Zambia
Republic of the Congo
Kenya
Rwanda
Mozambique
Ghana
Tanzania
Burkina Faso
Guinea
Côte d’Ivoire
Madagascar
Comoros
Ethiopia
Zimbabwe
Malawi
Nigeria
Chad
Mali
Niger
Lesotho
Namibia
Liberia
Gabon
Senegal
–3·0
–2·0
–1·0
0
1·0
2·0
3·0
4·0
Annualised difference in growth rate of overweight and obesity prevalence for
lowest-wealth minus highest-wealth groups between first and last survey waves
in selected countires
Figure 5: The shifting burden of overweight and obesity from higher-wealth to lower-wealth populations in
sample countries
Positive difference indicates higher annualised growth in overweight and obesity prevalence for the
lowest-wealth quartile. Countries presented here had earliest-to-latest-year data spanning 15 or more years,
latest-year data after 2010, and a population greater than approximately 15 million (with the exception of
Jordan and Kyrgyzstan, which both had smaller populations but were included for regional representation).
The data presented are from years spanning 1988 to 2016, but exact years vary by country. The span of
earliest-to-latest years collected ranges from 15 years to 24 years. All data are from the Demographic and
Health Surveys with the exceptions of China (China Health and Nutrition Survey), Indonesia (Indonesian Family
Life Survey), Mexico (Mexico National Survey of Health and Nutrition), Brazil (Brazil National Health Survey),
and Vietnam (Vietnam Living Standards Survey).
71
Series
countries that are also experiencing a slower decline in
the prevalence of undernutrition. A greater number of
new countries with a high DBM were in the lowest GDP
per capita (purchasing power parity) quartile of LMICs
than in the 1990s. We show that this new nutrition reality
is driven by important and rapid changes that have taken
place in the food system. Conversion of the global and
domestic retail food, food service, and agribusiness sectors
of the economy, along with other transformations,52,53,60,64
have resulted in an important increased availability of
ultra-processed foods in LMICs.
Ultra-processed food consumption has been linked to the
risk of overweight and obesity, and non-communicable
disease, and preliminary evidence shows that the
consumption of these foods during the first 1000 day
(pregnancy and infancy) early-life window could be also
linked to stunting. Understanding and tackling the drivers
of the food system shift, and enacting effective policies that
address the challenges of the DBM, are urgently needed.
Contributors
BMP drafted the paper, tables, and figures. LMG-S and CC reviewed,
suggested major revision of the structuring of the paper, and suggested
additional analyses. All authors reviewed and edited the final revision.
Declaration of interests
We declare no competing interests.
Acknowledgments
Funding is from the National Institutes of Health (R01DK108148 and
P2C HD050924). Funding for the preparation of the Series was provided
by WHO, through a grant from the Bill & Melinda Gates Foundation.
The funder had no role in the analysis and interpretation of the evidence
or in writing the paper and the decision to submit for publication.
We thank Karen Ritter and Emily Busey for great programming,
research, and graphics support, Frances Burton for administrative
support, and Francesco Branco and the other authors of the Double
Burden of Malnutrition Series for suggestions.
References
1
World Health Organization. Obesity and overweight factsheet. 2016.
(accessed
May 1, 2017).
2
International Food Policy Research Institute. 2017 global food policy
report. Washington, DC: International Food Policy Research
Institute (IFPRI), 2017.
3
FAO, IFAD, UNICEF, WFP, WHO. The state of food security and
nutrition in the world 2018: building climate resilience for food
security and nutrition. 2018.
publications/foodsecurity/state-food-security-nutrition-2018/en/
(accessed Nov 7, 2019).
4
Doak CM, Adair LS, Bentley M, Monteiro C, Popkin BM. The dual
burden household and the nutrition transition paradox. Int J Obes
2005; 29: 129–36.
5
Doak CM, Adair LS, Monteiro C, Popkin BM. Overweight and
underweight coexist within households in Brazil, China and Russia.
J Nutr 2000; 130: 2965–71.
6
Garrett JL, Ruel MT. Stunted child-overweight mother pairs:
prevalence and association with economic development and
urbanization. Food Nutr Bull 2005; 26: 209–21.
7
Victora CG, Rivera JA. Optimal child growth and the double burden
of malnutrition: research and programmatic implications.
Am J Clin Nutr 2014; 100: 1611S–12S.
8
Rivera JA, Pedraza LS, Martorell R, Gil A. Introduction to the
double burden of undernutrition and excess weight in Latin
America. Am J Clin Nutr 2014; 100: 1613S–16S.
9
Kroker-Lobos MF, Pedroza-Tobías A, Pedraza LS, Rivera JA.
The double burden of undernutrition and excess body weight in
Mexico. Am J Clin Nutr 2014; 100: 1652S–58S.
72
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
World Health Organization. Double-duty actions for nutrition:
policy brief. 2017. publications/
double-duty-actions-nutrition-policybrief/en/ (accessed
Nov 7, 2019).
Hawkes C, Demaio AR, Branca F. Double-duty actions for ending
malnutrition within a decade. Lancet Glob Health 2017; 5: e745–46.
Tzioumis E, Adair LS. Childhood dual burden of under- and
overnutrition in low- and middle-income countries: a critical review.
Food Nutr Bull 2014; 35: 230–43.
Global Nutrition Report independent expert group. 2018 global
nutrition report: shining a light to spur action on nutrition. 2018.
(accessed Nov 7, 2019).
Hall KD, Ayuketah A, Brychta R, et al. Ultra-processed diets cause
excess calorie intake and weight gain: A one-month inpatient
randomized controlled trial of ad libitum food intake. Cell Matab
2019; 30: 1–10.
Popkin BM. Nutrition, agriculture and the global food system in
low and middle income countries. Food Policy 2014; 47: 91–96.
Popkin BM. Relationship between shifts in food system dynamics
and acceleration of the global nutrition transition. Nutr Rev 2017;
75: 73–82.
Popkin BM, Reardon T. Obesity and the food system transformation
in Latin America. Obes Rev 2018; 19: 1028–64.
Monda KL, Adair LS, Zhai F, Popkin BM. Longitudinal relationships
between occupational and domestic physical activity patterns and
body weight in China. Eur J Clin Nutr 2008; 62: 1318–25.
Monda KL, Popkin BM. Cluster analysis methods help to clarify
the activity-BMI relationship of Chinese youth. Obes Res 2005;
13: 1042–51.
Ng SW, Norton EC, Guilkey DK, Popkin BM. Estimation of
a dynamic model of weight. Empir Econ 2012; 42: 413–43.
Ng SW, Popkin BM. Time use and physical activity: a shift away
from movement across the globe. Obes Rev 2012; 13: 659–80.
Horton R, Lo S. Nutrition: a quintessential sustainable development
goal. Lancet 2013; 382: 371–72.
Willett W, Rockström J, Loken B, et al. Food in the Anthropocene:
the EAT-Lancet Commission on healthy diets from sustainable food
systems. Lancet 2019; 393: 447–92.
Swinburn BA, Kraak VI, Allender S, et al. The Global Syndemic of
Obesity, Undernutrition, and Climate Change: The Lancet
Commission report. Lancet 2019; 393: 791–846.
Wells JCK, Wibaek R, Poullas M. The dual burden of malnutrition
increases the risk of cesarean delivery: evidence from India.
Front Public Health 2018; 6: 292.
Wells JC, Sawaya AL, Wibeak R, et al. The double burden of
malnutrition: aetiological pathways and consequences for health.
Lancet 2019; published online Dec 15.
S0140-6736(19)32472-9.
Adair LS, Fall CH, Osmond C, et al. Associations of linear growth and
relative weight gain during early life with adult health and human
capital in countries of low and middle income: findings from
five birth cohort studies. Lancet 2013; 382: 525–34.
Stein AD, Wang M, Martorell R, et al. Growth patterns in early
childhood and final attained stature: data from five birth cohorts from
low- and middle-income countries. Am J Hum Biol 2010; 22: 353–59.
Victora CG, Adair L, Fall C, et al. Maternal and child undernutrition:
consequences for adult health and human capital. Lancet 2008;
371: 340–57.
WHO. United Nations decade of action. 2016.
nutrition/decade-of-action/en/ (accessed March 1, 2019).
Nilsson M, Griggs D, Visbeck M. Policy: map the interactions
between Sustainable Development Goals. Nature 2016;
534: 320–22.
UN Children’s Fund. Implementing taxes on sugar-sweetened
beverages: an overview of current approaches and the potential
benefits for children. 2019.
implementing-taxes-on-sugar-sweetened-beverages-an-overview-ofcurrent-approaches/ (accessed March 19, 2019).
Hawkes C, Ruel MT, Salm L, Sinclair B, Branca F.
Double-duty actions: seizing program and policy opportunities to
address malnutrition in all its forms. Lancet 2019; published online
Dec 15. S0140-6736(19)32506-1.
www.thelancet.com Vol 395 January 4, 2020
Series
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
Nugent R, Levin C, Hale J, Hutchison B. Economic effects of the
double burden of malnutrition. Lancet 2019; published online Dec 15.
S0140-6736(19)32473-0.
de Onis M, Borghi E, Arimond M, et al. Prevalence thresholds for
wasting, overweight and stunting in children under 5 years.
Public Health Nutr 2019; 22: 175–79.
Colin Bell A, Adair LS, Popkin BM. Ethnic differences in the
association between body mass index and hypertension.
Am J Epidemiol 2002; 155: 346–53.
Albrecht SS, Mayer-Davis E, Popkin BM. Secular and race/ethnic
trends in glycemic outcomes by BMI in US adults: the role of waist
circumference. Diabetes Metab Res Rev 2017; 33: e2889.
Expert Consultation WHO. Appropriate body-mass index for Asian
populations and its implications for policy and intervention strategies.
Lancet 2004; 363: 157–63.
Heyward VH, Gibson A. Advanced fitness assessment and exercise
prescription 7th edition. Champaign Illinois: Human Kinetics
Publishing, 2014.
Misra A. Ethnic-specific criteria for classification of body mass index:
a perspective for Asian Indians and American Diabetes Association
position statement. Diabetes Technol Ther 2015; 17: 667–71.
Nair M, Prabhakaran D. Why do South Asians have high risk for
CAD? Glob Heart 2012; 7: 307–14.
Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial
infarction in South Asians compared with individuals in other
countries. JAMA 2007; 297: 286–94.
NCD Risk Factor Collaboration (NCD-RisC). Rising rural body-mass
index is the main driver of the global obesity epidemic in adults.
Nature 2019; 569: 260–64.
Pries AM, Huffman SL, Mengkheang K, et al. Pervasive promotion
of breastmilk substitutes in Phnom Penh, Cambodia, and high
usage by mothers for infant and young child feeding.
Matern Child Nutr 2016; 12 (suppl 2): 38–51.
Pries AM, Huffman SL, Mengkheang K, et al. High use of
commercial food products among infants and young children and
promotions for these products in Cambodia. Matern Child Nutr 2016;
12 (suppl 2): 52–63.
Vitta BS, Benjamin M, Pries AM, Champeny M, Zehner E,
Huffman SL. Infant and young child feeding practices among
children under 2 years of age and maternal exposure to infant and
young child feeding messages and promotions in Dar es Salaam,
Tanzania. Matern Child Nutr 2016; 12 (suppl 2): 77–90.
Huffman SL, Piwoz EG, Vosti SA, Dewey KG. Babies, soft drinks
and snacks: a concern in low- and middle-income countries?
Matern Child Nutr 2014; 10: 562–74.
Bell AC, Ge K, Popkin BM. Weight gain and its predictors in
Chinese adults. Int J Obes Relat Metab Disord 2001; 25: 1079–86.
Pries AM, Filteau S, Ferguson EL. Snack food and beverage
consumption and young child nutrition in low- and middle-income
countries: a systematic review. Matern Child Nutr 2019;
15 (suppl 4): e12729.
Bell AC, Ge K, Popkin BM. The road to obesity or the path to
prevention: motorized transportation and obesity in China. Obes Res
2002; 10: 277–83.
Anand SS, Hawkes C, de Souza RJ, et al. Food consumption and
its impact on cardiovascular disease: importance of solutions
focused on the globalized food system: a report from the workshop
convened by the World Heart Federation. J Am Coll Cardiol 2015;
66: 1590–614.
Reardon T, Timmer CP. The economics of the food system
revolution. Annu Rev Resour Econ 2012; 4: 225–64.
Popkin BM, Reardon T. Obesity and the food system transformation
in Latin America. Obes Rev 2018; 19: 1028–64.
Popkin BM. The shift in stages of the nutrition transition in the
developing world differs from past experiences! Public Health Nutr
2002; 5: 205–14.
Popkin BM, Adair LS, Ng SW. Global nutrition transition and the
pandemic of obesity in developing countries. Nutr Rev 2012;
70: 3–21.
Pries AM, Huffman SL, Adhikary I, et al. High consumption of
commercial food products among children less than 24 months of
age and product promotion in Kathmandu Valley, Nepal.
Matern Child Nutr 2016; 12 (suppl 2): 22–37.
www.thelancet.com Vol 395 January 4, 2020
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
Forouzanfar MH, Alexander L, Anderson HR, et al. Global, regional,
and national comparative risk assessment of 79 behavioural,
environmental and occupational, and metabolic risks or clusters of
risks in 188 countries, 1990–2013: a systematic analysis for the
Global Burden of Disease Study 2013. Lancet 2015; 386: 2287–323.
Black RE, Allen LH, Bhutta ZA, et al. Maternal and child
undernutrition: global and regional exposures and health
consequences. Lancet 2008; 371: 243–60.
Reardon T, Timmer CP, Minten B. Supermarket revolution in Asia
and emerging development strategies to include small farmers.
Proc Natl Acad Sci USA 2012; 109: 12332–37.
Reardon T, Tschirley D, Minten B, et al. Transformation of African
agrifood systems in the new era of rapid urbanization and the
emergence of a middle class. In: Badiane O, Makombe T, eds.
Beyond a middle income Africa: transforming African economies
for sustained growth with rising employment and incomes.
Washington: International Food Policy Research Institute,
2015: 62–74.
Tschirley D, Reardon T, Dolislager M, Snyder J. The rise of
a middle class in East and Southern Africa: Implications for food
system transformation. J Int Dev 2015; 27: 628–46.
Reardon T, Berdegué JA. The rapid rise of supermarkets in Latin
America: challenges and opportunities for development.
Dev Policy Rev 2002; 20: 371–88.
Reardon T, Timmer CP, Barrett CB, Berdegue JA. The rise of
supermarkets in Africa, Asia, and Latin America. Am J Agric Econ
2003; 85: 1140–46.
Reardon T, Chen KZ, Minten B, et al. The quiet revolution in
Asia’s rice value chains. Ann N Y Acad Sci 2014; 1331: 106–18.
Monteiro CA, Levy RB, Claro RM, de Castro IR, Cannon G.
Increasing consumption of ultra-processed foods and likely impact
on human health: evidence from Brazil. Public Health Nutr 2011;
14: 5–13.
Monteiro CA, Moubarac JC, Cannon G, Ng SW, Popkin B.
Ultra-processed products are becoming dominant in the global food
system. Obes Rev 2013; 14 (suppl 2): 21–28.
Poti JM, Mendez MA, Ng SW, Popkin BM. Is the degree of food
processing and convenience linked with the nutritional quality of
foods purchased by US households? Am J Clin Nutr 2015;
101: 1251–62.
Lawrence MA, Baker PI. Ultra-processed food and adverse health
outcomes. BMJ 2019; 365: l2289.
Rico-Campà A, Martínez-González MA, Alvarez-Alvarez I, et al.
Association between consumption of ultra-processed foods and all
cause mortality: SUN prospective cohort study. BMJ 2019;
365: l1949.
Srour B, Fezeu LK, Kesse-Guyot E, et al. Ultra-processed food intake
and risk of cardiovascular disease: prospective cohort study
(NutriNet-Santé). BMJ 2019; 365: l1451.
Feeley AB, Ndeye Coly A, Sy Gueye NY, et al. Promotion and
consumption of commercially produced foods among children:
situation analysis in an urban setting in Senegal. Matern Child Nutr
2016; 12 (suppl 2): 64–76.
Pries AM, Rehman AM, Filteau S, Sharma N, Upadhyay A,
Ferguson EL. Unhealthy snack food and beverage consumption is
associated with lower dietary adequacy and length-for-age z-scores
among 12–23-month-olds in Kathmandu Valley, Nepal. J Nutr
2019; published online July 16. DOI:10.1093/jn/nxz140.
Reardon T, Barrett CB, Berdegué JA, Swinnen JFM. Agrifood
industry transformation and small farmers in developing countries.
World Dev 2009; 37: 1717–27.
Reardon TA, Berdegué JA, Farrington J. Supermarkets and farming
in Latin America: pointing directions for elsewhere? Overseas
Development Institute, 2002.
files/odi-assets/publications-opinion-files/1949.pdf (accessed
Nov 7, 2019).
Hu D, Reardon T, Rozelle S, Timmer P, Wang H. The emergence
of supermarkets with Chinese characteristics: challenges and
opportunities for China’s agricultural development. Dev Policy Rev
2004; 22: 557–86.
Neven D, Odera MM, Reardon T, Wang H. Kenyan supermarkets,
emerging middle-class horticultural farmers, and employment
impacts on the rural poor. World Dev 2009; 37: 1802–11.
73
Series
77
78
79
74
Euromonitor. Market sizes- historical- total volume- kilograms or
litres per capita-packaged food, soft drinks, and hot drinks.
[Statistics]. Euromonitor Passport International London,
United Kingdom: Euromonitor; 2018.
Bennett M. The world’s food. Am J Agric Econ 1954; 36: 350–51.
Novta N, Wong J. Women at work in Latin America and the
Caribbean. 2017.
Issues/2017/02/14/Women-at-Work-in-Latin-America-and-theCaribbean-44662 (accessed Nov 7, 2019).
80
Mincer J. Market prices, opportunity costs, and income
effects. In: Christ CF, Friedman M, Goodman LA, et al, eds.
Measurement in economics: studies in mathematical economics
and econometrics in memory of Yehuda Grunfeld. Stanford:
Stanford University Press, 1963: 67–82.
© 2019. World Health Organization. Published by Elsevier Ltd. All rights
reserved.
www.thelancet.com Vol 395 January 4, 2020

Purchase answer to see full
attachment

Order a unique copy of this paper

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
Top Academic Writers Ready to Help
with Your Research Proposal

Order your essay today and save 30% with the discount code ESSAYHELP