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.
What knowledge is needed to ride a bike? Is it enough to have a manual? Of course not… you need to get on the bike, fall off, get back on again… and eventually you’ll figure it out. The manual may provide information on “what” to do, but knowledge of “how” to do it is tacit knowledge that can only be acquired from experience. This important distinction was made in “The Concept of Mind” (1949) by Gilbert Ryle, a British philosopher – between “knowing that” and “knowing how”. In nutrition, as in many development arenas, we have a wealth of knowledge products (guidelines, toolkits, checklists) that focus on “what to do” but not enough documented experience of attempts (some successful) of how to do it.
In his recent book, “How Change Happens” Duncan Green uses the analogy of raising a child. What would a child turn out like if parents developed a logframe for child-rearing and slavishly followed it? And would they still be speaking, 20 years later? In the real world, parents make it up as they go along — they rely on experience and advice from other parents who have been there. “Learning by doing” is important for all of us sometimes succeeding, sometimes failing. But learning from someone else’s “doing” is also possible, so long as it’s documented and conveyed – ideally in a compelling narrative or story, so that it is more easily retrieved.
Addressing the challenge of multisectoral issues like malnutrition involves actions that occur within a complex system, and in which knowledge comes from both evidence (e.g. from published studies) and crucially, from experience.
This was the essential rationale for the Stories of Change (SoC) initiative, developed by Transform Nutrition. To meet the growing demand from many countries for experiential learning, SoC sought to systematically assess and analyse drivers of change in six high-burden countries (Bangladesh, India (Odisha), Ethiopia, Nepal, Senegal, and Zambia) that have had some success in accelerating improvements in nutrition.
All countries undertook analysis of changes over several decades in nutrition outcomes, changes in nutrition-specific and nutrition-sensitive drivers, and changes in nutrition-relevant policies and programs. Semi-structured key informant interviews – 434 in all – were carried out with a range of stakeholders at different levels, along with 14 focus group discussions. We set out to tell structured stories of what happened, drawing upon the experiences and memories of a range of key actors who were there – including policymakers, district government officials, NGO reps, private sector employees, frontline workers and women in high-burden communities.
These stories are brought together in a special issue of Global Food Security this month, comprising 10 papers – six national case studies along with papers dedicated to analyzing quantitative drivers of change, perceptions of change at the community level, a set of 10 commentaries from global and national champions, and an overarching synthesis paper.
Key ingredients of positive change that we see repeated in different contexts are commitment, coherence, accountability, data, leadership, capacity and finance.These all need to be present over time, for progress to be made and for it to be sustained – but they will not look the same in every place. The choice of actual policy and program actions (the “what”) will necessarily be driven by context — including the type of problems being faced, available solutions, and the capacity to act – these interlinked factors are the fundamental building blocks that determine how change happens, and can be (proactively) made to happen.
Change and challenge are almost the same words – and we see that many changes were triggered by the need to respond to a challenge and, turning it round, changes also generate challenges. Like “crisis and opportunity”, they are flip sides of the same coin. SoC interviewees discussed both – shining a light on how windows of opportunity may open up (e.g. political change) to address longstanding challenges and generate positive changeand how, as progress is made, new challenges come to the forefront. Many countries, for example, have made major gains in aligning policies and generating cross-sectoral consensus and coherence on nutrition. The new challenge is vertical coherence – that is, how to make this work in practice, from national through district to community levels.
Books about stories are proliferating! In the brilliantly titled “Houston, We Have a Narrative”, Randy Olson suggests that the single biggest problem facing science today is “narrative deficiency”. And in “The Myth Gap: what happens when evidence and argument aren’t enough?”, Alex Evans also makes the case for better stories – in his case to get the climate change message across. We’re in the same position with nutrition. Data and evidence are key, but not enough. We need stories of change that resonate and can themselves catalyse change — all the more important in the context of the multiple burdens of malnutrition we’re now facing. We need to build a library of experience, well curated and accessible – and we need to become better storytellers.