by Marion Nestle

Currently browsing posts about: Malnutrition

Oct 24 2016

Rethinking nutrition policy in developing countries

I recently coauthored an editorial on international development.  It appeared first in French, and now in English in Ideas for Development, a blog coordinated by the French Agency for Development.

Rethinking nutritional policies in developing countries taking into account the double burden of malnutrition

By , Marion Nestle, and

The world now experiences two forms of malnutrition which may seem contradictory: “undernutrition” (which includes micronutrient deficiencies) and “overnutrition” (obesity and its health consequences).The problem of malnutrition in developing countries is approached by most aid bodies (donors, international organisations and NGOs) and governments solely from the angle of undernutrition. And yet in these countries, the complex and multi-faceted challenge which malnutrition now presents can justifiably be called the double burden of malnutrition. In addition to the continuing problem of undernutrition there are now major issues linked to overnutrition and its associated illnesses.

Rapid nutrition transition

The stereotyped image of skeletal young children with protruding bellies saved by souls of goodwill in sub-Saharan Africa is still too widespread. Severe acute malnutrition still persists of course, especially among the victims of extreme poverty, natural catastrophes and wars. Naturally, this deadly disease must continue to be addressed and treated, as numerous NGOs are doing.

The treatment of malnutrition should focus not only on severe malnutrition in children. Less severe malnutrition, going back to life in the foetus and resulting from malnutrition in women even prior to their pregnancy, continues to contribute to stunting, which affects 23.8% of all children under the age of 5 throughout the world.

In parallel with acute and chronic undernutrition, the “nutrition transition” in low-income countries, driven by globalisation, urbanisation and technological progress and linked to “overnutrition,” leads to a swift increase in obesity and other chronic diseases – mainly diabetes and cardiovascular diseases. Nutrition transition is the term used to describe the progressive Westernisation of eating patterns, typified by a sharp increase in the consumption of animal fats and processed foods all over the world, combined with an increasingly sedentary lifestyle. It is easy to see how this transition encourages the increase in overweight and obesity.

Today, undernutrition alone is not the major issue; the greatest problem is the double burden of undernutrition and overnutrition. According to estimates from 129 countries with available data, 57 experience serious problems of both undernutrition in children and overweight in adults[i]. And Africa is not exempt from this double burden where undernutrition and overweight are undeniably linked. In West Africa, 50% of women of child-bearing age are anemic while at the same time 38% are overweight and 15% are obese. For the whole of sub-Saharan Africa, 40% of children have stunted growth characteristic of chronic undernutrition, while 7.5% of adults suffer from obesity. Malnutrition early in life increases the subsequent risk of chronic diseases in places where obesity is encouraged by the environment. Obesity is now on the increase among children in all developing countries. The World Health Organization (WHO) reports that between 1990 and 2015 the number of overweight or obese African children doubled from 5 to 10 million. 

The responsibilities of the industrial food system

It is often said that communication aimed at changing food habits is the best way to prevent obesity, a problem reserved for rich people in low-income countries. This cliché contains three errors:

  • The first is the claim that preventing nutrition-related chronic relies entirely on the capacity of individuals to make appropriate choices regarding food, physical activity or lifestyle. This claim ignores the well-documented effects of the food system and the socio-cultural factors which play a determining role and which influence the choice of individuals.
  • The second error is to believe that significant changes cannot be made to the eating practices of limited-income groups in the absence of an increase in resources. Yet several studies show the opposite, whether they are about exclusive breastfeeding for the first six months of life and improved complementary feeding, or else hygiene measures and supplies of drinking water.
  • The third error is to consider that obesity continues to be only a problem of the rich in low-income countries. Obesity is escalating and affecting growing numbers of not so well-off people, particularly in cities.

When analysing the impact of the food system, it is necessary to account for the agri-food industry (Big Food). On a world-wide scale Big Food is primarily responsible for the nutrition transition” towards processed food. “Globalised” industrial food is gradually replacing traditional cooking and locally produced foods, with ultra-processed foods’ (food-like substances as Michael Pollan calls some of them) undeniable appeal for city-dwellers and young people as these products are strongly associated with Western-style fast food and heavily promoted by the media. This appeal is reflected in profound changes in consumption trends in developing countries. Global sales of highly processed foods increased by 44% from 2000 to 2013, but only by 2% in North America as opposed to 48% in Latin America and 71% in Africa and the Middle East.

So what is the problem? Industrial food products (and drinks) are often a nutritional disaster: rich in calories, sugar, fat and salt, but low in essential nutrients and fiber. Even more, these products are relatively inexpensive, often less expensive than more nourishing local food products.

Changing the food environment

What is the explanation for the popularity of these “globalized” food products? Part of the answer lies in extremely effective advertising. Anyone travelling in Africa, for example, will see campaigns to promote salty stock cubes to replace traditional spices and vegetables. “Social marketing” efforts to change eating behaviour must be as forceful as these adverts, with commensurate budgets.

One idea is to impose a tax on soft drinks or other highly processed foods and use the revenues to finance cutting-edge nutrition education campaigns. This is what the United Kingdom has recently decided to do by taxing soft drinks.

It is especially important to rethink the nutrition programs created by NGOs and financed by international aid. Correcting the nutrition of malnourished mothers or children is only part of the problem.

A wider vision is needed to recognize the threat to world health posed by nutrition-related chronic diseases.

To cope with this new challenge, it will be important to address many determinants of health – education, social disparities, housing, and culture – as well as the food environment. The latest report on global nutrition1 points out the excellent return on investment of nutrition interventions (16 for 1), and challenges governments and decision-makers to identify and implement strategies that target the double burden of malnutrition. If this is not done, it will be difficult to reach the nutrition objectives set by the WHO for 2025 (see below). Solutions do exist, however, as can be seen from places such as Ghana, Brazil, or the state of Maharashtra in India, which have had encouraging results in fighting malnutrition in all its forms.

Global nutrition targets for 2025

  • Reduce the number of children with stunted growth by 40%
  • Reduce and keep the prevalence of acute malnutrition in under-five children (low weight) under 5%
  • Avoid any increase of overweight in children
  • Reduce the prevalence of anemia in women of child-bearing age by 50%
  • Increase exclusive breastfeeding for babies less than 6 months old by 50%
  • Reduce low birth weights by 30%
  • Avoid any increase in the prevalence of overweight, obesity and diabetes in adults.

The opinions expressed on this blog are those of the authors and do not necessarily reflect the official position of their institutions or of AFD.

[i] Global Nutrition Report 2016 www.globalnutritionreport.org
Jan 19 2016

Nutra-Ingredients special edition: world malnutrition

What is the role of the food industry in helping to address world malnutrition?  This collection of articles from Nutra-Ingredients.com begins with a viewpoint from Nestlé (no relation), the world’s largest food company.

Nestlé: Profit is not a dirty word in the race against global malnutrition

Big food companies like Nestlé are oft-criticised for being a factor in the spread of non-communicable diseases like obesity and diabetes with less healthy food offerings but all are engaged in shifting their portfolios to the healthier end of the spectrum, and their capacity to deliver benefits with fortified offerings to malnourished populations can be overlooked.“The food industry is a commercial enterprise – that won’t change – but it has immense power to bring nutrients to the populations that needs them the most.

Here are the other articles in this series.

Jan 12 2012

Some thoughts on high rates of child malnutrition in India

The New York Times reported a shocking statistic yesterday: about 42% of children under age 5 living in India suffer from malnutrition and are “wasted” (low weight for height). 

The figure comes from the Hungama survey of 73,000 Indian households conducted by the Naandi Foundation.  It reports an even more troubling statistic: nearly 59% of Indian children under age 5 are “stunted” (low height for age).

The Hangama report holds one hopeful note.  Rates of childhood malnutrition in India fell by 20% during the past 7 years.

But have they? 

According to a more detailed analysis in today’s New York Times

Despite the recent boom years of the 1990s and 2000s, there has been little improvement in overall nutrition in India, according to United Nations data. About 20 percent of India’s over 1 billion population remained “undernourished” during that time, meaning their “food intake regularly provides less than their minimum energy requirements.” The most recent”Global Hunger Index” shows that two-thirds of the 122 developing countries studied had reduced hunger levels in recent years, but that hunger levels in India have increased.

Ending malnutrition is a matter of political will.  If India wanted to address childhood malnutrition in any serious way, it could. 

How?  Feeding programs are emergency measures.  Long-term solutions require institution of social programs:

  • Promote breastfeeding,
  • Educate and empower women
  • Build toilets
  • Clean up water supplies
  • Eradicate worms
  • Reduce income inequality    

Two recent books summarize the research behind these ideas and explain what causes widespread hunger and what to do about it.  They make it clear that eradicating childhood malnutrition should be a first priority for any government:

  • Olivier De Schutter and Kaitlin Cordes, editors: Accounting for Hunger: The Right to Food in the Era of Globalisation (Studies in International Law), Hart, 2011.
  • Per Pinstrup-Anderson P and Derrill D. Watson II: Food Policy for Development Countries: The Role of Government in Global, National, and Local Food Systems, Cornell University Press, 2011.  
Sep 3 2010

The Plumpy’nut furor: International food politics in action

The New York Times Magazine has a long article this week about Plumpy’nut,  the peanut butter-based product designed to feed malnourished kids in emergency situations.  The product is made and patented by Nutriset, a French company.

You might think that a food product aimed at saving the lives of starving kids would be uncontroversial, but not when patents are involved.  Nutriset holds intellectual property rights to this product and defends them to the hilt.   The company extends its patent to line extensions of the product, as well.

Patents mean that people in developing countries who want to produce their own product based on local ingredients can’t do it.  It also means that anyone making the product has to follow the formula, even if ingredients are expensive and not locally available.

In September 2007, I wrote about Plumpy’nut, describing how peanut butter had become the basis of a “ready-to-use therapeutic food” (RUTF) for aiding recovery of severely malnourished children in Africa.

The study itself is published in Maternal and Child Nutrition and the authors make the point that people administering this RUTF do not need to be medically trained so this therapy can be used at home. I’m always amazed when researchers discover that feeding malnourished children helps them to recover. Peanut butter is highly concentrated in calories and the investigators mixed in some vitamins along with it, so I guess it can be considered a superfood.

Since then, much has been written about the controversy over this product, particularly about its formula, cost, and sustainability.

Its formula includes:

  • Peanut Butter
  • Dry Skim Milk
  • Vegetable oil
  • Powdered sugar
  • Minerals & vitamins

It contains about 500 calories in a 92-gram foil package.

Of these calories, one-quarter to one-third are from the added sugar.  No wonder kids like it!

What about its cost? A recent article about local production of Plumpy’ nut in Niger illustrates this particular problem.

UNICEF pays US$60 to purchase and ship a box of 150 packets from the main producer and patent holder of Plumpy’nut, Nutriset, in France. It costs $65 in Niger. The difference adds up to an extra $15,000 for the 3,000 boxes purchased in Niamey every week.

“The luxury of having no production delays and not fully depending on an external provider is a price we are willing to pay,” UNICEF’s nutrition manager, Eric-Alain Ategbo, told IRIN. Ategbo said it took at least eight weeks for the nutritious peanut butter-like paste to arrive from France.

Here are some other cost concerns:

Electricity is expensive, taxes are high and money is expensive as interest rates are high. It would be cheaper if the products we use were bought locally, but they are not available.  Peanuts are the only ingredient from Niger. Others, such as milk, sugar and oil, are purchased internationally. We also have the obligation to buy specific products [such as micronutrients and packaging] from Nutriset in order to respect the formula.

As for its sustainability:

  • Who is going to pay for these products?  And for how long?
  • Does it make sense to promote a peanut-based product in countries that do not grow peanuts?
  • Is it a good idea to give packaged, sweetened products to kids whose families cannot continue to provide such things once the crisis is over?
  • Is it a good idea to give kids the idea that sweet things in packages are what they supposed to eat?
  • Will products like this pave the way for other sweetened products in packages—soft drinks, for example?

These are all complicated issues.  Read the article and ponder.

Sep 13 2007

How’s This for a Use for Peanut Butter?

Peanut butter, it seems, is the basis of a “ready-to-use therapeutic food” (RUTF) for aiding recovery of severely malnourished children in Africa. The announcement of these results doesn’t say what kind. The study itself is published in Maternal and Child Nutrition and the authors make the point that people administering this RUTF do not need to be medically trained so this therapy can be used at home. I’m always amazed when researchers discover that feeding malnourished children helps them to recover. Peanut butter is highly concentrated in calories and the investigators mixed in some vitamins along with it, so I guess it can be considered a superfood.