The double burden of malnutrition (DBM) is a term used to describe the coexistence of undernutrition and overnutrition within the same country, community, household, and even individual. While public attention often separates extreme hunger from excessive weight gain, the World Health Organization (WHO) explicitly recognizes that malnutrition, in all its forms, includes undernutrition as well as overweight, obesity, and diet-related noncommunicable diseases (NCDs). This means that the answer to whether obesity is one side of the double burden of malnutrition is a definitive yes. This modern nutritional reality presents unique and complex challenges for global health and development, particularly in low- and middle-income countries (LMICs) experiencing a rapid 'nutrition transition'.
Understanding the Double Burden of Malnutrition
The two contrasting sides of the DBM are defined as follows:
- Undernutrition: This encompasses a range of issues resulting from inadequate intake or absorption of energy and nutrients. It includes stunting (low height-for-age), wasting (low weight-for-height), underweight, and micronutrient deficiencies (lacking vital vitamins and minerals). Traditionally associated with poverty and food insecurity, undernutrition stunts physical and cognitive development, weakens the immune system, and increases mortality, especially in young children.
- Overnutrition: This refers to the excessive consumption of energy and nutrients, leading to an unhealthy accumulation of body fat. This side of the burden includes overweight, obesity (Body Mass Index over 30), and the resulting diet-related NCDs, such as type 2 diabetes, heart disease, and certain cancers. Overnutrition has rapidly increased in prevalence globally, often coexisting with undernutrition in transitional economies.
How Do Undernutrition and Obesity Coexist?
The dual forms of malnutrition are frequently observed together at different scales:
- At the Individual Level: A person can be both overweight or obese and deficient in vital micronutrients, a phenomenon sometimes referred to as 'hidden hunger'. This is common with diets consisting primarily of calorie-dense but nutrient-poor processed foods, which are now widely accessible.
- At the Household Level: A notable example is a household where an overweight or obese mother lives with a child who is stunted or underweight. This scenario is particularly prevalent in LMICs and highlights the intergenerational cycle of malnutrition.
- At the Population Level: Entire communities or countries, especially those undergoing rapid economic and social change, may experience high rates of undernutrition alongside growing rates of overweight and obesity. These shifting patterns are often driven by changes in food systems and lifestyles.
The Drivers of DBM and Obesity
The underlying factors driving the DBM are complex and interrelated. A major contributor is the nutritional transition, which refers to a global shift in dietary patterns and physical activity levels. As countries develop economically, there is a trend towards a 'Western-style' diet, characterized by:
- Shift in Food Systems: Increased availability and affordability of energy-dense, nutrient-poor processed foods high in fat, sugar, and salt, which often replace healthier, traditional foods.
- Urbanization and Income Changes: Rapid urbanization, rising household incomes, and increased female economic participation contribute to a higher demand for convenient, processed foods. Urban dwellers often have more sedentary jobs and lifestyles compared to those in rural areas.
- Aggressive Marketing: National and transnational food companies use aggressive, unregulated marketing tactics to promote ultra-processed foods and sugary beverages, particularly in LMICs, further accelerating this unhealthy transition.
- Early Life Programming: Early undernutrition, even in the womb, can lead to metabolic adaptations that increase the risk of obesity and diet-related NCDs later in life. This biological pathway, combined with environmental factors like exposure to processed foods, contributes to the intergenerational nature of the DBM. For further information on the specific policies and actions being implemented globally, visit the World Health Organization's page on the double burden of malnutrition at WHO | The double burden of malnutrition.
Comparison Table: Undernutrition vs. Overnutrition
| Feature | Undernutrition | Overnutrition (including Obesity) |
|---|---|---|
| Underlying Problem | Insufficient intake or poor absorption of energy and/or specific nutrients (vitamins, minerals). | Excessive intake of energy and nutrients, leading to harmful fat accumulation. |
| Manifestations | Stunting (low height-for-age), wasting (low weight-for-height), underweight, and micronutrient deficiencies. | Overweight, obesity (BMI > 30), and diet-related non-communicable diseases. |
| Primary Causes | Poverty, food insecurity, poor sanitation, lack of dietary diversity, and recurrent illness. | Nutritional transition, sedentary lifestyle, cheap energy-dense processed foods, and aggressive marketing. |
| Associated Health Risks | Compromised immunity, developmental delays, increased mortality, and higher susceptibility to infectious diseases. | Cardiovascular disease, type 2 diabetes, certain cancers, musculoskeletal disorders, and chronic inflammation. |
| Common Coexistence | Can exist in the same individual (e.g., obese with micronutrient deficiency) or household (e.g., obese mother with stunted child). | Part of the same malnutrition spectrum, often with shared root causes like unhealthy food systems. |
| Long-Term Effects | Stunting and early undernutrition can predispose to obesity and metabolic diseases in later life. | Obesity from an early age significantly increases the risk of chronic diseases throughout adulthood. |
Solutions: Implementing Double-Duty Actions
Traditional approaches that tackle undernutrition and overnutrition as separate issues are no longer sufficient. To effectively address the DBM, the WHO advocates for a shift towards 'double-duty actions'—integrated policies and interventions that address both forms of malnutrition simultaneously. Examples of such strategies include:
- Strengthening Food Systems: Ensuring access to nutritious, high-quality, and affordable foods while regulating the production and marketing of unhealthy processed items.
- Health System Improvements: Equipping health systems, particularly primary care, to provide integrated prevention and treatment for both undernutrition and diet-related NCDs.
- Maternal and Child Nutrition Programs: Designing and implementing programs that promote breastfeeding and provide nutritionally-sound complementary feeding, avoiding formulas that can increase obesity risk.
- School Food Policies: Developing and enforcing school food standards that increase the availability of healthy options and limit unhealthy food purchases.
- Promoting Physical Activity: Creating safe environments and promoting active lifestyles for both children and adults to help balance energy intake.
Conclusion
Obesity is unequivocally one side of the double burden of malnutrition, a growing global health crisis characterized by the simultaneous existence of undernutrition and overnutrition. This dual challenge is driven by complex factors, including the nutritional transition and globalization of unhealthy food systems, and has severe consequences for individual and public health. Moving forward, confronting this crisis requires a paradigm shift from siloed interventions to coordinated, double-duty actions that address the shared drivers of all forms of malnutrition. By tackling the DBM holistically, policymakers can create a healthier future for all populations and work towards achieving sustainable development goals.
