A workshop including representatives from all of the case study countries was held in September 2005 to review the case study findings and draft a set of recommendations to address the double burden of malnutrition. The first set of recommendations relates to lessons learned during the process of compiling national-level time series data on the double burden of malnutrition. The second set of recommendations involves strategies at the individual and community levels to address the double burden. The third set of recommendations is aimed at identifying actions that can be taken at the national level. It is hoped that these recommendations will be useful for other countries interested in addressing the rising problem of the double burden of malnutrition.
The six case study countries faced certain common problems in the analysis of nationally representative time series data on the burden of malnutrition. A difficulty faced by many was the lack of systematically collected data on important dietary indicators, such as intakes of fruits and vegetables, saturated fats, processed food and food eaten outside the home. Only two countries (China and the Philippines) had nationally representative dietary intake data comparable over three or more time periods. Even in countries where repeated surveys had been conducted, there had often been an updating of methodology over time, for example updates to nutrient requirements or food composition tables, thus it was not always possible to compare directly older survey data with more recent data.
In terms of data on nutritional status and other risk factors for chronic disease, information on the spectrum of undernutrition was the most systematically and regularly collected. Time series data on other factors of interest, including physical activity, overnutrition in children and adults and risk factors for chronic diseases were lacking in most countries. In most countries, information on many risk factors of both under- and overnutrition was limited to data collected for specific small research projects. Typically these data were not nationally representative, and were collected for a very narrow research focus (e.g., vitamin A or iron deficiency). When another survey addressing the same or a similar nutritional problem was conducted, the data were often collected on different age or gender groups, thus restricting the potential to examine time series trends in indicators of nutritional status.
Another limitation noted was that of information management and related human resources. In some cases - particularly for older surveys - the raw data had been discarded and it was only possible to work with data from published reports. The presentation of data in published reports was not always compatible with more recent data structures; for example, changes were made to the ways in which foods were categorized. Computerized data storage systems in some countries did not exist or functioned poorly, and there was also a lack of trained personnel to help create appropriate data storage and management systems. Furthermore, some countries noted a lack of personnel skilled in higher-level data analysis.
Workshop participants listed underlying causes of the major malnutrition problems identified in the case study countries: overweight and obesity in adults, adolescents and children; undernutrition (stunting, wasting and underweight) in children; and micronutrient deficiencies, particularly iron but also other micronutrients, which are widespread in some countries. For each broad underlying cause, a matrix of determinants was elaborated and solutions were proposed. As part of this process, the solutions that were considered beneficial for reducing both under- and overnutrition were highlighted.
The following lists identify strategies that could be considered to address the spectrum of both under- and overnutrition. A more comprehensive list of the determinants and proposed strategies for each identified problem appears in Annex 1 at the end of this chapter.
Strategies to reduce the double burden of malnutrition in children
Promote age-appropriate physical activity.
Strategies to reduce the double burden of malnutrition in adults
Make fruits and vegetables available at the workplace.
Promoting awareness of the double burden of malnutrition
In addition, the working group recommended actions at the national level to promote greater awareness of the double burden of malnutrition.
The working group:
recognizes that the double burden of malnutrition requires an intersectoral process for effective action;
recommends the establishment of a permanent high-level intersectoral coordinating committee/council (ISCC) - which is independent of individual ministry authority and adequately resourced - to develop strategies and policy options that address the double burden of malnutrition;
recommends that the ISCC includes representatives from all relevant stakeholders and sectors, coordinates the development and implementation of a plan of action, and coordinates the monitoring and reporting of progress;
recommends that countries adopt nutrition goals specific to the analysis of their problems with the double burden of malnutrition and in keeping with Millennium Development Goals.
Recommendations to improve national data collection and analysis of the double burden of malnutrition
The working group recognized that the following areas require improvement:
Emphasize to the authorities the importance of collecting and making available nationally representative data from periodic surveys on nutritional status and physical activity in order to assess both under- and overnutrition.
Coordinate and harmonize surveys to enable time series and trend analysis.
Include variables that monitor both over- and undernutrition, and their health consequences.
Establish a research agenda to be pursued nationally/internationally that deals with changes in cut-offs, interpretation and analysis of data; encourages presentation of data as frequency distributions; provides access to public sector data sources for analysis; and looks at regional and genetic/ethnic differences and the effect of infant undernutrition on adult disease (Barker hypothesis).
Carry out capacity building in developing countries to collect, analyse and interpret data from relevant sectors.
Highlight the importance of emerging overnutrition amid undernutrition, i.e., the rise of the double burden, and that the problem is not only one of affluence but also closely linked to poverty.
ANNEX 1: PROBLEM TREES ELABORATED DURING WORKING GROUP SESSIONS
The diagrams that follow represent the four main nutritional problems identified during working group sessions: overweight/obesity in children and adolescents; undernutrition in children and adolescents; overweight and obesity in adults; and iron-deficiency anaemia (IDA) and other micronutrient deficiencies in children, adolescents and adults. For each problem, a series of determinants were identified and a list of potential solutions suggested. Solutions that are shaded in grey were considered particularly appropriate for addressing problems of under- and overnutrition for the age group identified.
Problem tree for overweight/obesity in children and adolescents
Strategies related to diet (high-energy density)
Promote low-fat dairy products.
Strategies related to diet (poor eating habits)
Encourage children to drink water.
Strategies related to physical activity
Encourage family exercise or participation in PA activities.
Problem tree for undernutrition in children and adolescente
Strategies to improve undernutrition in children and adolescents
Raise awareness of alcohol/tobacco/drugs risks.
Problem tree for overweight and obesity in adults
Strategies to decrease overweight in adults (reducing the energy density of the diet)
Promote a diversity of animal source protein to reduce the dependence on red meat only.
Problem tree for iron-deficiency anaemia and other micronutrient deficiencies
Strategies to improve iron-deficiency anaemia and other micronutrient deficiencies
Promote community involvement in healthy eating at schools.