The Lancet published a new series of papers on The Double Burden of Malnutrition—the combination of undernutrition (stunting, wasting, and micronutrient deficiencies) with overweight, obesity, and associated non-communicable diseases (NCDs). This term has been around for nearly three decades, but the rapid shifts in global and national food systems and their profound implications for the nutritional well-being of most people on the planet—and for the planet itself—justify the journal’s label, “a new nutrition reality.”
The four papers in the series—on dynamics, etiological pathways and consequences, double-duty actions and economic effects of the double burden—are all excellent.
But there’s something missing.
The series is relatively blind to the political and commercial drivers behind the double burden, and to the way in which different forms of inequity drive food system dysfunctionality.
The introductory commentary—“A New Nutrition Manifesto for a New Nutrition Reality”—does surface the political dimension well (e.g. “we must address the underlying drivers that incentivize endless market and consumption growth over human and planetary health”). But these issues and challenges are not systematically addressed in what follows.
In Dec. 2016, Ilona Kickbusch and colleagues published a Lancet commentary titled “Commercial Determinants of Health” arguing for a new framing of a “synergistic, multidisciplinary field that addresses the drivers and channels through which corporations propagate the non-communicable diseases pandemic.”
A whole slew of papers has emerged in the last few years on the commercial determinants of health (including NCDs), but nutrition tends to be treated relatively apolitically, while simplistic statements about the private sector abound. And yet, now more than ever—given this “new reality” and given the momentum building towards the Tokyo Nutrition for Growth Summit in 2020—we need a much stronger focus on the commercial determinants of malnutrition.
There is a risk that the recommendations for commitments being developed by the Tokyo 2020 working groups fail to adequately take into account commercial drivers—the way in which the products and practices of many transnational food companies continue to drive the problem, as their corporate social responsibility people argue for a seat at the table. Again, the commentary captures this well.
….we must recognise the damage and mistrust that result from incompatible partnerships with stakeholders whose behaviour runs counter to human or planetary health. The food industry has an important role in implementing and delivering change. However, companies cannot be allowed to influence and interfere in public policy making or bias the science that underpins this process. While constructive dialogue is necessary, a default seat at the table for private-sector representatives should not be assumed and policy development processes need to be firewalled from vested interests:
As an aside here, if we are serious about human and planetary health, why is “growth” still the main focus of the Tokyo event? As Johanna Ralston asked at the London launch of the Lancet series—why not “Nutrition for Sustainable Development”?
Interestingly, the political dimension became quite prominent in the discussion at the London launch when a question was raised about an international code or framework convention on ultra-processed foods. Similarly, the excellent Lancet Commission report on The Global Syndemic of Obesity, Undernutrition, and Climate Change (released in Jan. 2019 and discussed here) made a call for such a framework convention. The report included a strong analysis of the political and corporate drivers of the syndemic—perhaps the links between this series and that earlier work could have been strengthened.
Relatedly, we need to raise the profile of human rights. In October, 180 health and nutrition experts from 38 countries signed this open letter to the UN High Commissioner for Human Rights and the Director-General of the World Health Organization calling on them to initiate an inclusive process to develop guidelines on human rights, healthy diets and sustainable food systems. The successful application of rights-based thinking and action in addressing the HIV pandemic was cited.
Nine of the 10 double duty actions recommended by the double burden series relate to redesigning and scaling up priority interventions and programs in health, social protection, education, and agri-food systems. The 10th focuses on implementation of policies to improve food environments. But before we get to policy implementation, we need to look upstream to understand how political attention and policy traction is achieved (or not) in countries where the double burden is prominent.
Over six years ago, the Lancet Maternal and Child Nutrition 2013 series included a paper on the politics of reducing malnutrition. While we focused more on undernutrition in this paper, the questions raised are relevant to the double burden:
“… how can enabling environments and processes be cultivated, sustained and ultimately translated into results on the ground”? How has high-level political momentum been generated? What needs to happen to turn this momentum into results? How to ensure that high-quality, well-resourced interventions for nutrition are available to those who need them, and that agriculture, social protection, water and sanitation systems and programmes are proactively reoriented to support nutrition goals?
This requires a focus on the political economy of the double burden, and on the dynamics and pathways of (policy) change—another research priority to add to the list in the third paper. A recent initiative—Stories of Challenge—aims to shed light on some of these issues and questions in the coming months, and it is hoped this will be a prominent theme of the forthcoming World Public Health Nutrition Association conference in Brisbane in April 2020.
Previously published on ifpri
The framing of malnutrition as a global problem that affects
us all is long overdue. This view demands more systemic approaches, engaging
the whole of society, that align with the universality of the UN Sustainable
Development Goals. This framing also highlights certain challenges, some of
which nutrition actors are not currently addressing well.
Food environments and food systems intersect with health and
environmental systems in complex ways that may be harmful to nutrition. Private sector
organizations—especially large transnational corporations—are major actors in
these systems. Their products and practices may help address this nutrition
problem, or they may drive, exacerbate, or deliberately confound it.
Governments and public agencies therefore need to ask themselves questions
about whether to engage with certain companies, for what purpose, when, and
Until now, there has been a tendency to frame this issue as
“either/or” in terms of whether to engage with the private sector, or
not. This is far too simplistic. There’s a lot of space in between these
extremes where negotiations can take place and collaborations can be developed.
While stated engagement principles do exist, there are few
examples of clear, practical guidelines, and even fewer examples of how they
have been applied in real-world contexts. Principles tend to become
individualized and atomized rather than widely agreed-upon norms. We argue that
these issues need to be surfaced and debated openly, as part of a
consensus-building process that leads to practical guidance, including where
and how to draw red lines.
As nutrition researchers and advocates, we often have cause
to think about our engagement with the private sector—particularly in terms of
from whom we take money, or with whom we share an alliance or even a platform.
Debates rage on, with positions ranging from full engagement to strict
The private sector does not exist on a different planet; it
is all around us, encompassing a huge range of actors from small farmers and
shopkeepers to huge corporations, all of whom have a job of delivery within the
food system. Of course, we need to engage with the private sector. This fact
does not—as many pro-engagement advocates imply—mean that non-engagement with
particular companies is a ridiculous position. In other spheres of development,
e.g. public health, climate change, and green investment more generally, there
are a number of clear cases of “no-go companies”—tobacco, climate
disinvestment, child labor, alcohol, gambling.
When does working with a particular private sector actor
become unpalatable for malnutrition researchers and advocates? We all have our
own examples, but it has been interesting to see how relative this is.
Companies that we find unpalatable, e.g. serial Breast-milk Substitute Code offenders,
and large unreformed transnationals that derive the greatest share of their
profits from products and practices associated with obesity, are in
relationships with other organizations that we respect in the nutrition world.
This has led us to examine our own reasoning, bias, and
subjective assumptions about partners with whom we will and won’t work. We
wonder whether ours and others’ reasoning about the seeming illogic of
combining, for example, public health approaches with sugar-sweetened beverage
distribution (which we see as similar to combining public health with tobacco
retail) could be better channeled into the development of a clear set of
practical processes and indicators.
Indices like the Access to Nutrition Index (ATNI) could
help. The methodology involves an assessment of corporate and product profiles.
The former assesses companies’ performance against “international
guidelines, norms and accepted good practices, except when such guidance was
not available” (which again highlights the gap we face). Product profiles
assess the “healthiness” of products that generate the greatest
revenue for the company. Since its inception, companies that perform highly
(scoring 6-7 or above out of 10) only do so in relative terms. Many score below
3 out of 10. Companies tend to score better on stated commitment and governance
than on product healthiness. Implementation lags behind commitments, and ATNI
has been criticized for
focusing too much on the latter. Nestlé is an interesting case: a company that
has done a lot to reform and consistently ranks highly on the ATNI and yet
doesn’t seem to manage a year without Code violations.
We argue that companies need to show pro-nutrition actions (not
just words) over a reasonable length of time before discussions on engagement
or partnerships start. To this end, we would need consensus on what this would
look like, including what metrics, indicators and targets are sufficient to
demonstrate institutional commitment to better nutrition.
A traffic light rating system could work. At present, most
companies assessed by ATNI would be red or amber. Such a system (which would
need to be grounded in a consensus on appropriate metrics) could improve
clarity, and better incentivize the reds and the ambers to reform.
We recognize the complexities and the fact that things are
changing, day by day. It is not, for example, as simple as considering whether
to engage with any one organization. Some of the larger organizations have
linked corporate social responsibility units and linked foundations which may
be supporting pro-nutrition activities that in themselves are positive for
nutrition. And yet, their core business practices encompass products and/or
practices that continue to damage nutrition—at a much larger scale. There is
also the distinct possibility that ignoring the “major bad” to focus
on the “minor good” lets the companies off the hook, and even
disincentivizes reform of their harmful core business practices. This suggests
we need to go beyond judging the merits of any one project or any one type of
engagement, to also look at the bigger picture of what the company is doing.
A traffic light system also aligns with the reality that nothing is static. The situation is dynamic; companies are changing. The question for wider discussion becomes one of how to judge whether and when a company’s net impacts are sufficiently “pro-nutrition” to become eligible for potential collaboration. This again will require a discussion of metrics, thresholds, and red lines. These are issues and challenges that should not be over-simplified, fudged, or hidden—especially at this time. Many in the nutrition community are gearing up for a major nutrition summit, linked to the Tokyo 2020 Olympics, in which pledges and commitments will be made to address malnutrition in all its forms. The arena for nutrition action now—compared to the last Nutrition for Growth event in 2013—is a lot wider and there are many more (actual and potential) actors. Principles and practical guidance are needed more than ever. On this basis, we want to start a new kind of conversation and would welcome views.
Stuart Gillespie and Nicholas Nisbett
Obesity is increasing in most countries, in both urban and rural settings, across socio-economic levels, among children and adults. Consequences include a heightened risk of noncommunicable diseases, including type 2 diabetes, hypertension, dyslipidemia, and various cancers. This alarming global trend coincides with limited and patchy progress in driving down rates of undernutrition, as shown by the Joint Child Malnutrition Estimates, 2019, from UNICEF, WHO, and the World Bank Group.
The concept of a “double burden of malnutrition” — first posited in 1992 at the first International Conference on Nutrition — relates to the co-existence of undernutrition and overweight/obesity. Initially, the reference was to national burdens, before it became clear that the dual burden also existed within communities, households, and even within individuals (who may be overweight following growth stunting in childhood). As we learn more about the etiology and epidemiology of the double burden, we come to realize these are not separate conditions. They overlap and interact in space and time, and they have shared drivers that derive from dysfunctional agri-food and health systems, and the environments within which they operate. Accordingly, it is more appropriate to frame the problem as “malnutrition in all its forms.” Among others, the Global Nutrition Report championed this focus while the 2019 Lancet Commission on the Global Syndemic of Obesity, Undernutrition, and Climate Change recognized these interactions and the urgency of transformational change, discussed in this recent A4NH blog post.
In recent years, IFPRI and several major programs it leads — Transform Nutrition, POSHAN, and A4NH — have assembled a rich body of work on the drivers of relative success in reducing undernutrition in different countries. The “Stories of Change” initiative included in-depth case studies from Senegal, Ethiopia, Zambia, India, Bangladesh, and Nepal, with more in the pipeline from Rwanda, Tanzania, Vietnam, Ghana, Nigeria, Burkina Faso, and several Indian states. These case studies used mixed methods to investigate drivers of change, and to glean the perceptions of key actors, from community to national levels. The emerging stories were fed back to participants in national consultations (to be critiqued, endorsed, and sharpened) before the studies were finalized and ultimately published in different forms (journal articles, briefs, audio-visuals, etc.).
Four years later, considering the framing of “malnutrition in all its forms,” we recognize a need to balance this work with a new focus on how countries are addressing the challenge of overweight and obesity. Here, there is much less of a history to mine for data, evidence, experiences, and stories. This is why A4NH’s Flagship research Program SPEAR is now embarking on a new wave of case studies, called “Stories of Challenge,” to investigate how political commitment and policy traction are being generated in real time to deal with overweight and obesity. Four case studies will be developed by teams including local researchers in South Africa, Ghana, Vietnam, and Indonesia, with a mini-case study on Brighton, UK. These will be linked with other work, including a qualitative evidence synthesis of drivers of obesogenic behaviors, a review of approaches adopted to set priorities for nutrition, and a narrative synthesis of integrated approaches to promoting nutrition and physical activity.
Like its predecessor, “Stories of Challenge” will seek to foster learning across contexts – in this case, lessons on how individuals and organizations are striving to turn obesogenic into enabling environments, how they pre-empt or tackle obstacles, and how they are seizing opportunities to support a new raft of nutrition-relevant actions. More than ever, we need to understand how different actors, including the public and private sectors, civil society, academia, and the public at large, can come together to forge alliances — built on evidence, experience, trust and transparency — to drive and sustain change.
Watch this space…
A new report by the Lancet Commission on the Global Syndemic of Obesity, Undernutrition, and Climate Change delivers a powerful, incisive analysis of the drivers of those overlapping worldwide problems with some long-overdue and hard-hitting recommendations. The starting point is a recognition that malnutrition in all its forms is by far the biggest cause of ill-health globally, and that this is because we are in the midst of a “global syndemic”.
But what is a “syndemic”?
Obesity, undernutrition, and climate change are distinct, massive global challenges. But they also overlap in time and space, interact with each other, and share common underlying drivers. Collectively, they represent a syndemic. (Originally coined as “synergistic epidemic,” the term was first applied to the interactions between different disease outbreaks. Here, the Commission has expanded its scope.)
This syndemic has thus far been notably hard to treat. The patchy progress is largely due to policy inertia and a lack of effective solutions, caused by inadequate political leadership and governance; strong opposition to policies by powerful commercial interests; and a lack of demand for policy action by the public.
The global agri-food system is a major contributor to the syndemic. Currently, it prioritizes massive, energy-rich staple production with comparatively little attention to nutrient-rich foods such as fruits and vegetables. As a result, healthy diets are often expensive or inaccessible, while ultra-processed foods (e.g. noodles, potato chips) flood markets. The food system also contributes nearly one third of all anthropogenic greenhouse gas emissions, and in the process is causing rapid deforestation, soil degradation, and massive biodiversity loss.
The Commission brings a particularly sharp focus to the private sector, which should play a major role in any comprehensive set of responses. But that will require some significant reforms. Although most food businesses are small-to-medium-sized enterprises, large food corporations (“Big Food”) are explicitly driven by a fiduciary duty to prioritize financial returns to investors. Ultra-processing involves adding steps to the value chain, which enhances profit margins. Thus it’s ultra-processed products, manufactured on massive scales and marketed globally, that bring the greatest returns.
Big Food also uses multiple strategies to obstruct efforts to prevent obesity, the report notes – including “adopting self-regulation [e.g., voluntary restrictions] to pre-empt and delay state regulation, public relations to portray industry as socially responsible, undermining and contesting the strength of scientific evidence, direct lobbying of government decision makers, and framing nutrition as a matter of individual responsibility.”
Big Food’s go-to solution for obesity—self-regulation—does not work. It lacks the force of law and public accountability, and it preserves business as usual: Commercial success (wealthy corporations) co-existing with market failure (negative health and environmental outcomes).
Clearly, a new business model is needed that works for people and planet as well as profit. To strengthen the hand of nations against the enormous power of transnational food corporations, and ensure comprehensive action to address the global syndemic, the Commission calls for a Framework Convention on Food Systems (FCFS)—a global treaty to promote healthy diets and sustainable food production.
But policy inertia stems from other causes too. The Commission argues there is a major role for civil society and grassroots social movements in rallying political pressure and consumer demand for healthy diets from the ground up. These key stakeholders can also play a larger role in in monitoring and benchmarking progress towards meeting goals, to strengthen government and corporate accountability.
Better monitoring and research are also essential to addressing the food system role in the syndemic. A substantial infrastructure is already in place, but it needs strengthening. The INFORMAS network is cited as a shining example of food environment assessment and monitoring, along with the World Cancer Research Fund’s NOURISHING database of nutrition policies.
Another key element is funding. It’s shocking to see that globally, only 2 percent of health-related aid goes to the prevention and control of non-communicable diseases, such as diabetes, despite their being responsible for two-thirds of deaths in low- and middle-income countries. The Commission recommends philanthropies and other sources donate $1 billion to support civil society alliances (such as that which pushed for Mexico’s successful tax on sugary sodas) to advocate for relevant policy action.
We also need more research into the unique problems this syndemic poses. The report highlights three areas: Application of systems science to the syndemic; research into the sociocultural dynamics that enable or stymie action; and policy research to understand the current prevailing inertia and lack of traction. The new Agriculture for Nutrition and Health (A4NH) initiative Stories of Challenge—which explores how food system problems are solved on the ground – and can help respond to the Commission’s call for more positive examples and models. Stories are emphasized as a key component of the advocacy arsenal, and the report includes many perspectives from different actors participating in its panels.
The report concludes with principles to maximize impact: Think syndemically, join thinking with action, strengthen governance (global, national, municipal), support civil society engagement, reduce commercial influence on policy, strengthen accountability, focus research on drivers and actions, and build business models that are fit for the 21st century. A syndemic, by its nature, will generate complex impacts that resist the usual solutions; the report offers an important road map to confronting this challenge.
The first decade of the 21st century was one of widespread inertia toward the burgeoning “double burden,” that is, rising overweight co-existing with relatively stagnant undernutrition rates — even within the nutrition and public health world.
IFPRI first started to work in this field in the late 1990s, culminating in the 2003 book The Double Burden of Malnutrition in Asia: Causes, Consequences and Solutions. But not much happened for the next decade or so. Since then, the imperative for action on all forms of malnutrition has been reflected in the 2030 Agenda for Sustainable Development (especially SDG2), the World Health Organization (WHO)’s Global Nutrition Targets (2025), the UN Decade for Action on Nutrition (2016-25), and WHO’s Global Action Plan for the Prevention and Control of Non-communicable Diseases (NCDs) (2013—2020).
Against this backdrop, a greater priority is now being attached to “double duty actions” that target common or shared drivers of both undernutrition and overweight (WHO 2017). To date, the emphasis has been on single, nutrition-specific “double duty” interventions, such as exclusive breastfeeding promotion.
Crucially important, but more is needed.
Historically, nutritionists have viewed nutrition as an outcome, affected by several drivers that originate in different sectoral domains. Similarly, we now need to keep the “double duty” focus on outcomes, and the multiple drivers that lead to these outcomes. This means we need to continue to act multisectorally.
Synergies may be exploited by integrating interventions, e.g. those focused on healthy lifestyles (including diet and physical activity). We simply don’t know enough about multisectoral approaches to addressing the double burden. And we don’t know whether lessons learnt through “stories of change” in addressing undernutrition have relevance for the obesity challenge. More work is needed – which is why A4NH’s Flagship Research Program SPEAR is embarking on a new wave of case studies, this time called “Stories of Challenge,” to investigate how political commitment and policy traction is being generated to deal with overweight and obesity.
The double burden agenda also calls for innovation – especially in the context of the limited response, and dismally low levels of financing currently channeled, to obesity and NCD prevention and control. As the 2018 Global Nutrition Report shows, only $31m in aid is being spent each year to address obesity and NCDs — a mere 0.18 percent of official development assistance – and most of this comes from just three donors.
In December, the International Atomic Energy Agency (IAEA) hosted the International Symposium on Understanding the Double Burden of Malnutrition for Effective Interventions. My presentation focused on double duty innovations, highlighting an experimental approach (Pivotal Movement) for using social incentives and fitness tracking technology to incentivize activity that is then used to leverage matched financing for nutrition and health projects. Pivotal revolves around the strength and the links between three communities that all converge on a curated web platform: i) calorie burners (who cycle, run, walk, swim, with their data automatically uploaded at the end of the day), ii) investors or donors who match-fund this calorie burn according to pre-specified terms, and iii) implementing organizations who use the funds generated to support nutrition and health projects, locally or globally. If this works – it’s currently in trial – it could be a significant “win-win”, as the process of raising much-needed funding (via more people becoming more active) is in itself a major boost to health. More on this approach can be found at www.pivotal-movement.org.