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Combatting the Double Burden of Malnutrition in Indonesia, Kenya, Nigeria and Zambia

May 13th, 2020

As the world is evolving so is the nutrition space globally, leaving no exception in lower to middle-income countries (LMICs). Urbanization, food security, economic and income growth are key drivers of the nutrition and lifestyle transition. Busier and more demanding lifestyles have altered consumer behavior with increased trends in consumption of packaged and easily accessible ready-made foods filled with high energy and low nutrient value. Additionally, the advancement in technology has increased overall sedentary levels, sparing little to no time on outdoor or physical activities.  

What impact does this have on nutrition status?

This remarkable shift has led to an increase in overnutrition at a population level within countries that are still endemic to undernutrition, causing a Double Burden of Malnutrition (DBM). An individual can have simultaneous forms of malnutrition such as vitamin deficiency and obesity which can also manifest at household and population level. Obesity and overweight increase the susceptibility to Diet-Related Noncommunicable Diseases (DR-NCDs, i.e. cardiovascular diseases, diabetes, hypertension). To achieve global health and nutrition goals focus on the prevention of DBM and DR-NCDs is fundamental. 

With this elevated burden, is there one policy or intervention that can combat DBM in LMICs? What are the similarities and differences in national policies and implementation approaches towards DBM prevention in LMICs? To respond to these questions, Choices International conducted a comparative analysis on DBM policies in Indonesia, Kenya, Nigeria and Zambia. The study used data on the four countries, previously collected by Choices International. I conducted this research as an intern at Choices, as part of my Master study Nutrition and Health in Wageningen University & Research. 

What is being implemented? 

The research findings indicated that the four countries studied predominantly based their nutrition policies on Lancets nutrition-specific and nutrition-sensitive framework. This approach lacks strategies explicitly preventing malnutrition in all its forms. World Health Organization (WHO) recommended the incorporation of potential double-duty actions into nutrition policies, strategies and interventions that collectively have the capability to alleviate multiple forms of malnutrition. Some of the approaches were present in all the country’s national nutrition policies such as child and maternal nutrition in the first 1000 days and nutrition education through schools. Fundamental approaches recommended by International organizations towards alleviating DBM and DR-NCDs included food labelling, reformulation, and multi-sectoral approach. The implementation of these approaches differed accordingly depending on the nutrition and DBM prevention priority in the countries. Back of pack (BOP) nutrition labels provide information on the nutrient quantity of food products while Front of Pack (FOP) nutrition labels guide consumers on healthy food choice through interpretive nutrition information. BOP nutrition labels were mandatory in Indonesia and Nigeria in the presence of health claims, voluntary in Kenya while in Zambia information was lacking. FOP nutrition labels were present in Indonesia, Nigeria and Zambia. Nutrition criteria for healthy foods guiding FOP nutrition labels were developed in Indonesia, Nigeria and Zambia. The Zambian nutrition criteria was adapted from the Choices International nutrition criteria. Indonesia adapted its nutrition criteria in alignment with guidelines from neighboring countries, while Nigeria adapted its criteria from international nutrition guidelines. A multi-sectoral approach involving key nutrition actors was targeted in all national nutrition policies. Scaling Up Nutrition acted as a facilitator for a multi-sectoral approach in all the countries with the Sun Business Network (SBN) fostering Public-Private Partnerships (PPP). The good food logo in Zambia was a significant example of PPP between government and SBN co-convened by World Food Program. 

What are the challenges?

Alleviating DBM has been seen to be a formidable challenge globally due to its multifaceted nature of determinants. This was distinctly indicated in the study. Despite considerable efforts and advancements of prevention of DBM and DR-NCDs, the countries are faced with similar disparities in the implementation of national nutrition policies. This includes inadequate resources, varying political goodwill, a curative approach in tackling DR-NCDs, lack of nutrition prioritization, consumer illiteracy on adequate nutrition practices, disjointed departmental approach, differing mandates between government ministries and data incoherence. 

How can DBM and DR-NCDs be prevented in LMICs?

To tackle DBM in its entirety, an integrated food system approach is required intervening through the entire food value chain paying attention to diet quality, quantity as well as safety. As recommended by WHO, double-duty actions such as the retrofit approach should be included in the national nutrition policies to attain maximal impact on DBM prevention. The retrofit approach entails the incorporation of strategies targeting all forms of malnutrition into already existing nutrition policies and interventions. This approach is seen to be easily adaptable, cost-effective and highly beneficial. Policies and strategies aimed at alleviating DBM should be accurately developed and implemented so as not to prevent one form of malnutrition yet aggravate another.

There is no “one size fits all” policy that can combat DBM in LMICs. Food consumption is an economic activity and political economy of the food system with varying drivers. Therefore, nutrition policies should be locally contextualized deriving from an understanding of nature, distribution and causes as well as existing environment including infrastructure, resources, and capacity for implementation. Context-specific strategies adequately influence long term positive consumer choice. To alleviate DBM in LMICs collaboration between all stakeholders in nutrition is fundamental, ensuring their strategies are aligned with national, regional, and international public health and nutrition goals. 

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