Workshop recommendations

A workshop including representatives from all of the case study countries was held in September 2005 to review the case study findings and draft a set of recommendations to address the double burden of malnutrition. The first set of recommendations relates to lessons learned during the process of compiling national-level time series data on the double burden of malnutrition. The second set of recommendations involves strategies at the individual and community levels to address the double burden. The third set of recommendations is aimed at identifying actions that can be taken at the national level. It is hoped that these recommendations will be useful for other countries interested in addressing the rising problem of the double burden of malnutrition.

Lessons learned and challenges faced during production of the country reports

The six case study countries faced certain common problems in the analysis of nationally representative time series data on the burden of malnutrition. A difficulty faced by many was the lack of systematically collected data on important dietary indicators, such as intakes of fruits and vegetables, saturated fats, processed food and food eaten outside the home. Only two countries (China and the Philippines) had nationally representative dietary intake data comparable over three or more time periods. Even in countries where repeated surveys had been conducted, there had often been an updating of methodology over time, for example updates to nutrient requirements or food composition tables, thus it was not always possible to compare directly older survey data with more recent data.

In terms of data on nutritional status and other risk factors for chronic disease, information on the spectrum of undernutrition was the most systematically and regularly collected. Time series data on other factors of interest, including physical activity, overnutrition in children and adults and risk factors for chronic diseases were lacking in most countries. In most countries, information on many risk factors of both under- and overnutrition was limited to data collected for specific small research projects. Typically these data were not nationally representative, and were collected for a very narrow research focus (e.g., vitamin A or iron deficiency). When another survey addressing the same or a similar nutritional problem was conducted, the data were often collected on different age or gender groups, thus restricting the potential to examine time series trends in indicators of nutritional status.

Another limitation noted was that of information management and related human resources. In some cases - particularly for older surveys - the raw data had been discarded and it was only possible to work with data from published reports. The presentation of data in published reports was not always compatible with more recent data structures; for example, changes were made to the ways in which foods were categorized. Computerized data storage systems in some countries did not exist or functioned poorly, and there was also a lack of trained personnel to help create appropriate data storage and management systems. Furthermore, some countries noted a lack of personnel skilled in higher-level data analysis.

Recommendations for addressing the double burden of malnutrition at the individual and community levels

Workshop participants listed underlying causes of the major malnutrition problems identified in the case study countries: overweight and obesity in adults, adolescents and children; undernutrition (stunting, wasting and underweight) in children; and micronutrient deficiencies, particularly iron but also other micronutrients, which are widespread in some countries. For each broad underlying cause, a matrix of determinants was elaborated and solutions were proposed. As part of this process, the solutions that were considered beneficial for reducing both under- and overnutrition were highlighted.

The following lists identify strategies that could be considered to address the spectrum of both under- and overnutrition. A more comprehensive list of the determinants and proposed strategies for each identified problem appears in Annex 1 at the end of this chapter.

Strategies to reduce the double burden of malnutrition in children

• Promote exclusive breastfeeding from birth to six months of age.
• Promote the introduction of complementary feeding at six months.
• Promote continued breastfeeding until two years of age or beyond.
• Promote age-appropriate complementary feeding.
• Promote eating a healthy breakfast at home.
• Promote the concept of bringing healthy meals and snacks prepared at home to school.
• Promote the consumption of home-prepared food at school.
• Make fruits and vegetables attractive and tasty.
• Promote the sale of healthy foods in the school environment (school shops, canteens and food vendors).
• Reduce children’s exposure to the advertising and vending of unhealthy foods.
• Implement nutrition education for children, parents and child care givers using teacher-child-parent nutrition education.
• Promote community involvement in healthy eating at schools.
• Eliminate soda sales and marketing in school environments.
• Promote the consumption of dairy products (low-fat if appropriate).
• Promote eating of a variety of animal foods.

• Promote age-appropriate physical activity.

Strategies to reduce the double burden of malnutrition in adults

• Promote the concept of bringing healthy snacks and meals prepared at home to work.
• Implement nutrition education.
• Encourage decreased consumption of soda, and its substitution with water (encourage people to drink more water).
• Promote a diversity of animal source protein (for overweight the emphasis should be on reducing dependence on red meat only).

• Make fruits and vegetables available at the workplace.

Promoting awareness of the double burden of malnutrition

In addition, the working group recommended actions at the national level to promote greater awareness of the double burden of malnutrition.

The working group:

• recognizes that the double burden of malnutrition requires an intersectoral process for effective action;

• recommends the establishment of a permanent high-level intersectoral coordinating committee/council (ISCC) - which is independent of individual ministry authority and adequately resourced - to develop strategies and policy options that address the double burden of malnutrition;

• recommends that the ISCC includes representatives from all relevant stakeholders and sectors, coordinates the development and implementation of a plan of action, and coordinates the monitoring and reporting of progress;

• recommends that countries adopt nutrition goals specific to the analysis of their problems with the double burden of malnutrition and in keeping with Millennium Development Goals.

Recommendations to improve national data collection and analysis of the double burden of malnutrition

The working group recognized that the following areas require improvement:

• Emphasize to the authorities the importance of collecting and making available nationally representative data from periodic surveys on nutritional status and physical activity in order to assess both under- and overnutrition.

• Coordinate and harmonize surveys to enable time series and trend analysis.

• Include variables that monitor both over- and undernutrition, and their health consequences.

• Establish a research agenda to be pursued nationally/internationally that deals with changes in cut-offs, interpretation and analysis of data; encourages presentation of data as frequency distributions; provides access to public sector data sources for analysis; and looks at regional and genetic/ethnic differences and the effect of infant undernutrition on adult disease (Barker hypothesis).

• Carry out capacity building in developing countries to collect, analyse and interpret data from relevant sectors.

• Highlight the importance of emerging overnutrition amid undernutrition, i.e., the rise of the double burden, and that the problem is not only one of affluence but also closely linked to poverty.

Annexes

ANNEX 1: PROBLEM TREES ELABORATED DURING WORKING GROUP SESSIONS

The diagrams that follow represent the four main nutritional problems identified during working group sessions: overweight/obesity in children and adolescents; undernutrition in children and adolescents; overweight and obesity in adults; and iron-deficiency anaemia (IDA) and other micronutrient deficiencies in children, adolescents and adults. For each problem, a series of determinants were identified and a list of potential solutions suggested. Solutions that are shaded in grey were considered particularly appropriate for addressing problems of under- and overnutrition for the age group identified.

Problem tree for overweight/obesity in children and adolescents

Strategies related to diet (high-energy density)

• Promote exclusive breastfeeding from birth to six months of age.
• Promote age-appropriate complementary feeding.
• Promote a diversity of animal source protein to reduce the dependence on red meat only.
• Make fruits and vegetables attractive and tasty.
• Promote the bringing to school of healthy meals and snacks prepared at home.
• Implement nutrition education for children, parents and child care givers.
• Promote healthy options in fast foods/encourage fast food outlets to reduce the energy density of their meals.
• Reduce (trans) fat in fast foods.
• Encourage consumption of water instead of soda and sugar-sweetened drinks.

• Promote low-fat dairy products.

Strategies related to diet (poor eating habits)

• Promote the eating of a healthy breakfast at home.
• Promote the sale of healthy foods in the school environment (school shops, canteens and food vendors).
• Reduce children’s exposure to the advertising and vending of unhealthy foods.
• Implement nutrition education for children and their parents using teacher-child-parent nutrition education.
• Promote community involvement in healthy eating at schools.
• Eliminate the sale and marketing of soda in school environments.
• Promote dairy products.
• Promote the eating of a variety of animal foods.
• Make fruits and vegetables attractive and tasty.
• Reduce (trans) fat in fast foods.

• Encourage children to drink water.

Strategies related to physical activity

• Increase awareness of the importance of physical activity (PA) among teachers, parents and students.
• Increase time spent on PA in schools.
• Increase PA at home.
• At the local level, provide safe protected spaces for PA near the home.
• Promote sports days organized by schools/communities.
• Promote community exercise events.
• Increase awareness of the need for space for all children to do PA (young children, girls, etc.).
• Make PA an active part of school curricula (including homework).
• Provide incentives/awards for physical fitness in children.
• Increase awareness of the detrimental effects of TV viewing among teachers, parents and students.

• Encourage family exercise or participation in PA activities.

Problem tree for undernutrition in children and adolescente

Strategies to improve undernutrition in children and adolescents

• Promote exclusive breastfeeding from birth to six months of age.
• Promote the introduction of complementary feeding at six months.
• Promote continued breastfeeding until two years of age or beyond.
• Promote age-appropriate complementary feeding.
• Promote the eating of a healthy breakfast at home.
• Promote the bringing to school of healthy meals and snacks prepared at home.
• Promote the sale of healthy foods in the school environment (school shops, canteens and food vendors).
• Promote age-appropriate physical activity.
• Reduce exposure to advertising.
• Implement nutrition education for children and their parents using teacher-child-parent nutrition education.
• Promote community involvement in healthy eating at schools.
• Promote dairy products.
• Promote the eating of a variety of animal foods.
• Make fruits and vegetables attractive and tasty.
• Improve reproductive-age and maternal health and nutrition status.
• Promote the prevention, detection and appropriate management of infections.
• Promote correct feeding practices during illness and recovery.
• Carry out timely immunization.

• Raise awareness of alcohol/tobacco/drugs risks.

Problem tree for overweight and obesity in adults

Strategies to decrease overweight in adults (reducing the energy density of the diet)

• Promote the bringing to work of healthy snacks and meals prepared at home.
• Implement nutrition education.
• Make fruits and vegetables available at the workplace.
• Promote healthy options in fast foods/encourage fast food outlets to reduce the energy density of their meals.
• Reduce (trans) fat in fast foods.
• Encourage decreased consumption of soda and its substitution with water (encourage people to drink more water).
• Promote low-fat dairy products.

• Promote a diversity of animal source protein to reduce the dependence on red meat only.

Problem tree for iron-deficiency anaemia and other micronutrient deficiencies

Strategies to improve iron-deficiency anaemia and other micronutrient deficiencies

• Promote dietary diversification.
• Increase intake of fruits and vegetables.
• Promote exclusive breastfeeding until six months of age.
• Promote the introduction of complementary feeding at six months.
• Promote continued breastfeeding until two years of age or beyond.
• Promote age-appropriate weaning practices.
• Promote the use of iodized salt and other fortified foods.
• Promote the prevention, detection and appropriate management of infections/infestations.
• Improve reproductive-age and maternal health and nutrition status.
• Promote micronutrient-rich food in school environments.
• Reduce children’s exposure to the advertising and vending of unhealthy foods.
• Implement nutrition education for children and their parents using teacher-child-parent nutrition education.

• Promote community involvement in healthy eating at schools.