14 Oct 2015

The challenge to nutrition researchers everywhere: identify a set of actions that reduce malnutrition in all its forms

Corinna Hawkes Co-Chair, Global Nutrition Report Independent Expert Group

This article is cross-posted from The Lancet Global Health Blog

Policy makers in countries around the world are facing unprecedented challenges in identifying interventions that can help prevent or reduce malnutrition in its many forms. Readers of this journal and nutrition researchers everywhere need to help policymakers do the right thing. The 2008 and 2013 Lancet Series on maternal and child nutrition have played a major role in identifying a key set of actions that can help accelerate undernutrition. The Lancet Series on obesity in 2015 promises to do the same. The time has now come for unifying these two separate worlds and The Lancet family of journals can play a unique role in setting the research—and policy—agenda.

The Global Nutrition Report 2015 published in September tracks progress towards eight indicators of nutrition status that have been endorsed by the World Health Assembly: four relating to undernutrition and four to overweight, obesity, and diabetes. The good news is that there has been progress in reducing malnutrition in all its forms. Data on growth in children younger than 5 years—stunting, wasting, and overweight—reminds us of what can be achieved with the right focus, the right interventions, and policies and sustained commitment. Stunting shows particular progress: 39 countries are now on course to meet the global target, up from 24 last year. The bad news is that progress remains too slow and uneven. For example, progress in addressing anaemia among women is practically non-existent. The world is also completely failing to meet the global target of halting the rise in the rates of adult overweight and obesity as well as diabetes.

One way that researchers can help to effect change—which we write about in theGlobal Nutrition Report 2015—is to identify “double-duty” actions. That is, actions that can combat both undernutrition and obesity/non-communicable diseases (NCDs) at the same time. Although the synergies in approaches have been debated for more than two decades, more work is needed to bring together actions that address both undernutrition and unhealthy diets in an internationally agreed-upon package. We identify four key areas for double-duty thinking and action:

  1. A set of political actions and strategies to motivate and enable nutrition-improving environments
  2. The development of food environments that support healthy growth by providing diverse diets throughout the life course
  3. Interventions in the first 1000 days after conception as well as during mothers’ preconception period; and
  4. The promotion of nutrition-friendly food systems

While the definitive list of double-duty actions must wait until after the evidence has been compiled and analysed, we can begin to hypothesise about what is, and what is not, a double-duty action. It should not be too difficult to identify such a set given that the causes of these two broad sets of malnutrition are similar—an interaction of poor diets and unhealthy environments.

Candidates include interventions that promote healthy growth in the first 1000 days post-conception such as the promotion of exclusive breastfeeding and infant and young child feeding programmes. These promote healthy length and height and emerging evidence suggests that they may prevent or delay the onset of nutrition-related NCDs. Other candidates include actions that improve food environments: whatever their nutritional risk, people need environments where diverse and healthy diets are available and affordable. Schools have a role to play here: can school feeding programmes improve diets today while teaching children about why balanced diets are important and how to choose them? Interventions in food systems can also play a role—such as boosting investment in the productivity and affordability of pulses, fruits, and vegetables and carefully managing investments in cheap sources of sweeteners.

Are there any actions, policies, and interventions for which the tradeoffs between different types of malnutrition are potentially sharper and where such a double duty is not possible? Again, we speculate, but fortificants added to highly salty or sugary foods might inadvertently encourage the excess consumption of such foods. Policies that encourage meat consumption for those who consume too little may encourage too high a consumption for those with already high levels of consumption. Social protection programmes such as conditional cash transfers can help children go to health clinics and keep them in school but might inadvertently have adverse outcomes on adult body-mass index and diastolic blood pressure. Make no mistake about it, these interventions are very important for undernutrition, but they need to be managed to minimise the potential for overweight, obesity, and nutrition-related NCD risks.

We call on The Lancet journals to bring together researchers from across the nutrition spectrum to begin exploring this space and, with rigour, bring evidence to bear on these hypotheses. The process of doing that will be as important as the end result, signalling the beginning of the end for the extreme divide between the parallel research and policy worlds of undernutrition and overweight/obesity and nutrition-related NCDs. The data have moved countries into the reality of multiple faces of malnutrition—as the Global Nutrition Report 2015 points out, at least 45% of countries are facing undernutrition as well as overweight or obesity. We need to help policymakers address this “new normal” by identifying actions that serve “double duty”, addressing malnutrition in all its forms.