December 17, 2019
2 min read

‘Double burden’ of malnutrition grows in low- and middle-income countries

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One third of low- and middle-income countries have overlapping forms of extreme malnutrition, particularly in south and east Asia, sub-Saharan Africa and the Pacific, according to a series of reports published in The Lancet.

Nearly 2.3 billion adults and children are overweight globally, with over 150 million children stunted, researchers noted. These nutritional issues often overlap in low- and middle-income countries in families, individuals and communities, leading to what the authors described as a “double burden” of malnutrition.

“This condition has common drivers — biological drivers and socioeconomic drivers — for a food environment that is not conducive to a healthy diet,” Francesco Branca, MD, PhD, director of WHO’s Department of Nutrition for Health and Development, said at a recent news conference. “Having these different forms of malnutrition is, of course, leading to increased debt and disease for both communicable diseases, such as pneumonia or diarrhea, and noncommunicable diseases, such as hypertension, obesity and cardiovascular disease.”

Researchers examined survey data from low- and middle- income countries in the 1990s and 2010s to determine countries that met criteria for a double burden of malnutrition, which included wasting in more than 15% and stunting in more than 30% of children aged younger than 5 years, “thinness” — or a body-mass index of less than 18.5 mg/kg2 — in more than 20% of females aged between 15 and 49 years, and more than 20% of people being overweight. Of the 123 countries examined in the 1990s, 37% had overlapping forms of malnutrition. In the 2010s, 38% of the 126 countries examined met the criteria.

Throughout the 2010s, 14 of the world’s lowest income countries developed the double burden of malnutrition, but fewer low- and middle- income countries with the highest income levels were affected than in the 1990s. Researchers attributed this to the increasing prevalence of overweight in poorer countries that experience wasting, stunting and thinness.

“When it comes to malnutrition, we are failing on our agreed global target,” Alessandro Demaio, PhD, MPH, CEO of the Victorian Health Promotion Foundation in Melbourne, Australia, said at the news conference. “No country is immune, and this new nutrition reality now also hits lowest income countries due to a global rise in overweight and obesity.”


Researchers cited 10 “double-duty” actions — measures that can simultaneously reduce the risk for undernutrition, obesity and diet-related non-communicable diseases:

  • Scale up new WHO recommendations for antenatal care;
  • Scale up programs to promote, protect and support breastfeeding;
  • Redesign complementary feeding practice guidelines;
  • Redesign current growth monitoring programs;
  • Prevent unnecessary harm from micronutrient-fortified and energy-dense foods and ready-to-use supplements;
  • Redesign food and cash transfers, vouchers and subsidies;
  • Redesign school feeding programs and create new nutritional guidelines for food in and around education institutions;
  • Scale up nutrition-focused agriculture programs;
  • Design new food and agricultural system policies to promote healthy diets; and
  • Implement policies to improve food environments and prevent all forms of malnutrition.

The Lancet’s annual update on climate change in November cited malnutrition as a global threat to children’s health, noting it as a particular concern for infants.

“Addressing malnutrition cannot and need not be a zero-sum game,” Demaio said. “There are strong biological and environment linkages, and indeed intergenerational linkages, that mean that we must make a coordinated and connected approach to address malnutrition in all its forms.” by Eamon Dreisbach


Branca F, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)32690-X.

Hawkes C, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)32506-1.

Nugent R, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)32473-0.

Popkin BM, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)32497-3.

Wells JC, et al. Lancet. 2019;doi:10.1016/S0140-6736(19)32472-9.

Disclosures: The authors report no relevant financial disclosures.