Accept the double burden as the new normal
Separating the concept of malnutrition into undernutrition and obesity is a false dichotomy. Early malnutrition may be a risk factor for obesity as well as some type of chronic diseases in adults. Multiple burdens of malnutrition are the new normal and need to be considered together. This points to the importance of building alliances across different types of actors while recognising and managing the risks that this entails. Patrizia Fracassi, senior nutrition analyst and strategy advisor, SUN Movement Secretariat, Geneva, Switzerland, @pat_fracassi
Don’t ignore the risk of unhealthy diets
I agree with Patrizia and others about the false dichotomy between undernutrition and obesity ... But most people perceive them as very different problems from an ethical and political perspective. In some ways this is justified – not having enough to eat is very different to having too much. But in other ways it is not. Tackling undernutrition in ways that ignores the potential of unhealthy diets is a huge inefficiency. Corinna Hawkes, co-chair of Global Nutrition Report’s Independent Expert Group, Cambridge, UK, @corinnahawkes
Provide healthy, affordable food for all
While we see undernutrition declining, overweight and obese populations are increasing fast, particularly in middle-income countries. This is the result of an inadequate diet with too much sugars, salt and fat ... and few fruit and vegetables. A more efficient food system, capable of delivering healthy food to all at an affordable price and in all circumstances, is needed. This is a task for governments as well as other actors, including commercial. Francesco Branca, director at the department of nutrition for health and development, World Health Organization, Geneva, Switzerland, @WHO
Integrate to encourage innovation
I have really been struck by how separate the worlds of under- and over-nutrition are while working on the Global Nutrition Report (which aims to cover both in an integrated way). Time and again I come across people who are working on similar issues in the overweight/obesity/healthy diet domain. UN agencies, donors, researchers need to realign their organisational and incentive structures to the problems of the 21st century, not those of the 20th. Integrate your maternal and child nutrition and your nutrition-related non-communicable chronic disease teams. They have so much in common, but come at the issues from slightly different angles. This is always a stimulus to innovation. Lawrence Haddad, senior research fellow, International Food Policy Research Institute, London, UK.@l_haddad
Research childhood obesity
There is also a greater need to better understand how and when children become obese, particularly children under five, as we do not consistently know when this happens and this can vary by country. For example, some data from Egypt indicates that being overweight can start before a child is one year old. The consequences of childhood obesity compared to adult obesity are also different. Both segments of the population face similar longterm risk, but change is much harder for overweight children, who grow up to become obese adults. Becoming overweight in childhood becomes a permanent state, even into adulthood. Kavita Sethuraman, technical advisor maternal and child health and nutrition, FHI360, Washington DC
Focus on adolescent girls
Focusing on early life stages and maternal health, when good nutrition has the most impact, is crucial to tackling all forms of malnutrition. Infants who experience poor nutrition in the first 1,000 days of life are at an increased risk of being overweight in later life. It’s important, therefore, that we focus on hard-to-reach groups such as adolescent girls and women before they become pregnant. Adolescent girls, in particular, are difficult to reach through the public health system so we need to find innovative ways which involve influencers outside of the government system. Dominic Schofield, director, GAIN Canada, and senior technical adviser, policy and programmes. @dschofieldGAIN @GAINalliance
Track what governments spend on nutrition
It’s important to understand the way countries are tackling malnutrition. One of the ways to do so is to track the investments that governments make through national budgets. The Scaling Up Nutrition (SUN) Movement has been working with countries to track budget allocations on nutrition. This process has opened a debate on the design of some particular programmes, and how they might be improved to have a larger impact on nutrition. Clara Picanyol i Puig, public finance specialist, social policy programme, Oxford Policy Management
Include nutrition in urban planning
The food and physical activity environments are important issues both for obesity and undernutrition, and frequently not a part of urban planning. It is important to remember that access is not just a distance issue. A healthy food source may be just a short distance away but if a highway, river or any other barrier or obstacle exists, people may not be able to reach it. Bruce Y Lee, director of the Global Obesity Prevention Center and associate professor of international health, Johns Hopkins, Baltimore, US, @bruce_y_lee
Consolidate data to get a full global picture
There are many issues related to data on the two ends of the malnutrition spectrum, and it’s not simply about whether it’s available. We need all countries to have comparable data. Very often, high-income countries have data that are slightly different to accepted methods for global targets, such as the WHO target on overweight in children under 5, and so these numbers don’t enter the dialogue on how the world is doing. The UK is one such example. At the national level, countries need frequent surveys that assess both of these problems. India hasn’t had a national health survey for a decade now. We have enough data to give a good idea of the problem, which is large and alarming, but not a full picture by any measure. Komal Bhatia, data analyst, Global Nutrition Report Secretariat, Institute of Development Studies, London, UK, @KomalBhatia89 @IDS_UK
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