Classrooms to cash transfers: strategies to combat double burden of malnutrition

An outdoor street fruit market in Montevideo, Uruguay, South America. Credit: Alamy Stock Photo

A new review has looked at the impact of nutrition interventions on the double burden of malnutrition in low- and middle-income countries.

The double burden of malnutrition occurs when the same populations, households, or individuals suffer from both overnutrition (e.g. overweight and obesity) and undernutrition (e.g. stunted growth and deficiency in important micro-nutrients) – this represents a serious public health challenge.

The research, which has been published today in The Lancet Global Health, was in response to calls from the WHO to identify programmes and policies that could reduce the burden of both undernutrition and overnutrition as well as those that may unintentionally cause harm to some forms of malnutrition.

The study analysed existing papers that evaluated nutrition-based interventions but only included those that assessed the impact on both undernutrition and overnutrition, which totalled 26 papers. The authors highlight that a considerable number of papers focused on either undernutrition or overnutrition but not both.

The majority of included studies (20) evaluated nutrition-specific interventions. These programmes address immediate causes of malnutrition, such as making healthy foods available. Six of the studies evaluated nutrition-sensitive interventions, which tackle the underlying socioeconomic factors, such as poverty.

The study identified ten interventions that had the potential to improve both overnutrition and undernutrition simultaneously. Five of these were classed as school-based interventions, three as behavioural interventions among mothers and children and two as conditional cash transfers.

“We identified a range of promising policies to address the double burden of malnutrition. To mention one example, in Mexico, a national conditional cash transfer programme linking financial aid to low-income families' compliance with health check-ups and school attendance significantly reduced stunting and overweight in children five years after enrolment.” said Nora Escher, PhD student in the School of Public Health and lead author on the study.

The team identified 13 interventions that were effective at addressing undernutrition but also had unintended adverse impacts on overnutrition. For example, a programme in Guatemala that provided monthly fortified food rations to pregnant mothers reduced child stunting but also led to greater postpartum weight retention in a population with already high obesity rates.

“Certain interventions concentrating on a single aspect of malnutrition can pose higher risks of unintended harm, prompting a call for awareness and potential policy adjustments.” Added Nora Escher.

Dr Suparna Ghosh-Jerath, Program Head, Nutrition, The George Institute for Global Health, India and co-author, said: “An example of such policy adaptation is seen in the recent notification for the amendment of the nutritional prescription for children receiving supplementary nutrition under the Integrated Child Development Service as part of India’s National Food Security Act 2013. This amendment shifts from a uniform nutritional prescription for all children aged 6 months to 6 years to personalized nutritional standards tailored to individual age and nutritional status.”

The research team emphasises the fact that future studies evaluating nutrition-based interventions should monitor the impact on both undernutrition and overnutrition, regardless of the intervention’s target. This evidence will provide a much stronger case to influence nutrition policy in low- and middle-income countries, which increasingly face the public health consequences of the double-burden of malnutrition.

Full paper is available: (2024). The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review. The Lancet Global Health. 10.1016/S2214-109X(23)00562-4. 

https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00562-4/fulltext