Decades ago, discussion of an impending global pandemic of obesity was thought of as heresy. But in the 1970s, diets began to shift towards increased reliance upon processed foods, increased ...away‐from‐home food intake, and increased use of edible oils and sugar‐sweetened beverages. Reductions in physical activity and increases in sedentary behavior began to be seen as well. The negative effects of these changes began to be recognized in the early 1990s, primarily in low‐ and middle‐income populations, but they did not become clearly acknowledged until diabetes, hypertension, and obesity began to dominate the globe. Now, rapid increases in the rates of obesity and overweight are widely documented, from urban and rural areas in the poorest countries of sub‐Saharan Africa and South Asia to populations in countries with higher income levels. Concurrent rapid shifts in diet and activity are well documented as well. An array of large‐scale programmatic and policy measures are being explored in a few countries; however, few countries are engaged in serious efforts to prevent the serious dietary challenges being faced.
Background
In low- and middle-income countries, the distribution of childhood nutritional diseases is shifting from a predominance of undernutrition to a dual burden of under- and overnutrition. This ...novel and complex problem challenges governments and health organizations to tackle opposite ends of the malnutrition spectrum. The dual burden may manifest within a community, household, or individual, but these different levels have not been addressed collectively.
Objective
To critically review literature on the prevalence, trends, and predictors of the dual burden, with a focus on children from birth to 18 years of age.
Methods
We reviewed literature since January 1, 1990, published in English, using the PubMed search terms nutrition transition, double burden, dual burden, nutrition status, obesity, overweight, underweight, stunting, body composition, and micronutrient deficiencies. The findings were classified and described according to dual burden level (community, household, or individual).
Results
Global trends indicate decreases in diseases of undernutrition, while overnutrition is increasing. On the community level, economic status may influence the extent of the dual burden, with obesity increasingly affecting the already undernourished poor. In a household, shared determinants of poor nutritional status among members can result in disparate nutritional status across generations. Within an individual, obesity may co-occur with stunting or anemia due to shared underlying determinants or physiologic links.
Conclusions
The dual burden of malnutrition poses a threat to children's health in low- and middle-income countries. We must remain committed to reducing undernutrition while simultaneously preventing over-nutrition through integrated child health programs that incorporate prevention of infection, diet quality, and physical activity.
Abstract From infancy through adolescence, more and more children are becoming overweight. National prevalence data show that more than 17% of youth have a body mass index (BMI) above the 95th ...percentile of the US age and sex-specific reference. Particularly alarming are rates in children as young as 2 years of age, and among minority children. Periods of heightened vulnerability to weight gain have been identified, and research supports the notion that obesity has its origins in early life. This paper focuses on susceptibility to increased adiposity during the prenatal period, infancy, mid-childhood and adolescence, and how factors operating in each of these periods influence risk of becoming overweight. Prenatal exposure to over or undernutrition, rapid growth in early infancy, an early adiposity rebound in childhood, and early pubertal development have all been implicated in the development of obesity. The persistence of obesity from young ages emphasizes the importance of understanding growth trajectories, and of developing prevention strategies to overcome strong influences of obesigenic environments at young ages.
No longitudinal analyses using national data have evaluated the increase in obesity from adolescence into early adulthood. We examined obesity incidence, persistence, and reversal in a nationally ...representative cohort of US teens followed into their early 30s, using measured height and weight data, in individuals enrolled in wave II (1996; 12–21 years), wave III (2001; 17–26 years), and wave IV (2008 early release data; 24–32 years) of the National Longitudinal Study of Adolescent Health (N = 8,675). Obesity was defined as a BMI ≥95th percentile of the 2000 Centers for Disease Control/National Center for Health Statistics growth charts or ≥30 kg/m2 for individuals <20 years and ≥30 kg/m2 in individuals ≥20 years. In 1996, 13.3% of adolescents were obese. By 2008, obesity prevalence increased to 36.1%, and was highest among non‐Hispanic black females (54.8%). Ninety percent of the obese adolescents remained obese in 2008. While annual obesity incidence did not decline in the total sample across the two study intervals (2.3% per year 1996–2001 vs. 2.2% per year 2001–2008), rates among white females declined (2.7 to 1.9% per year) and were highest among non‐Hispanic black and Hispanic females (3.8 and 2.7% per year, 1996–2001 vs. 3.0 and 2.6% per year, 2002–2008, respectively). Obesity prevalence doubled from adolescence to the early 20s, and doubled again from the early to late 20s or early 30s, with strong tracking from adolescence into adulthood. This trend is likely to continue owing to high rates of pediatric obesity. Effective preventive and treatment efforts are critically needed.
Summary Background Fast weight gain and linear growth in children in low-income and middle-income countries are associated with enhanced survival and improved cognitive development, but might ...increase risk of obesity and related adult cardiometabolic diseases. We investigated how linear growth and relative weight gain during infancy and childhood are related to health and human capital outcomes in young adults. Methods We used data from five prospective birth cohort studies from Brazil, Guatemala, India, the Philippines, and South Africa. We investigated body-mass index, systolic and diastolic blood pressure, plasma glucose concentration, height, years of attained schooling, and related categorical indicators of adverse outcomes in young adults. With linear and logistic regression models, we assessed how these outcomes relate to birthweight and to statistically independent measures representing linear growth and weight gain independent of linear growth (relative weight gain) in three age periods: 0–2 years, 2 years to mid-childhood, and mid-childhood to adulthood. Findings We obtained data for 8362 participants who had at least one adult outcome of interest. A higher birthweight was consistently associated with an adult body-mass index of greater than 25 kg/m2 (odds ratio 1·28, 95% CI 1·21–1·35) and a reduced likelihood of short adult stature (0·49, 0·44–0·54) and of not completing secondary school (0·82, 0·78–0·87). Faster linear growth was strongly associated with a reduced risk of short adult stature (age 2 years: 0·23, 0·20–0·52; mid-childhood: 0·39, 0·36–0·43) and of not completing secondary school (age 2 years: 0·74, 0·67–0·78; mid-childhood: 0·87, 0·83–0·92), but did raise the likelihood of overweight (age 2 years: 1·24, 1·17–1·31; mid-childhood: 1·12, 1·06–1·18) and elevated blood pressure (age 2 years: 1·12, 1·06–1·19; mid-childhood: 1·07, 1·01–1·13). Faster relative weight gain was associated with an increased risk of adult overweight (age 2 years: 1·51, 1·43–1·60; mid-childhood: 1·76, 1·69–1·91) and elevated blood pressure (age 2 years: 1·07, 1·01–1·13; mid-childhood: 1·22, 1·15–1·30). Linear growth and relative weight gain were not associated with dysglycaemia, but a higher birthweight was associated with decreased risk of the disorder (0·89, 0·81–0·98). Interpretation Interventions in countries of low and middle income to increase birthweight and linear growth during the first 2 years of life are likely to result in substantial gains in height and schooling and give some protection from adult chronic disease risk factors, with few adverse trade-offs. Funding Wellcome Trust and Bill & Melinda Gates Foundation.
Maternal nutritional deficiencies and excesses during pregnancy, and faster infant weight gain in the first 2 years of life are associated with increased risk of noncommunicable diseases (NCDs) in ...adulthood. The first 1,000 days of life (from conception until the child reaches age 2 years) represent a vulnerable period for programming of NCD risk, and are an important target for prevention of adult disease. This paper takes a developmental perspective to identify periconception, pregnancy, and infancy nutritional stressors, and to discuss mechanisms through which they influence later disease risk with the goal of informing age-specific interventions. Low- and middle-income countries need to address the dual burden of under- and overnutrition by implementing interventions to promote growth and enhance survival and intellectual development without increasing chronic disease risk. In the absence of good evidence from long-term follow-up of early life interventions, current recommendations for early life prevention of adult disease presume that interventions designed to optimize pregnancy outcomes and promote healthy infant growth and development will also reduce chronic disease risk. These include an emphasis on optimizing maternal nutrition prior to pregnancy, micronutrient adequacy in the preconception period and during pregnancy, promotion of breastfeeding and high-quality complementary foods, and prevention of obesity in childhood and adolescence.
To describe trends in country- and individual-level dual burden of malnutrition in children <5 years, and age-stratified (<2 years, ≥2 years) country-level trends, in thirty-six low- and ...middle-income countries (LMIC).
Using repeated cross-sectional nationally representative data, we calculated the prevalence of malnutrition (stunting, wasting, overweight) at each survey wave, annualized rates of prevalence change for each country over time, and trends before and after 2000, for all children <5 years and separately for those </≥2 years. We examined country- (ratio of stunting to overweight) and individual-level (coexistence of stunting and overweight) dual burden in children <5 years.
Demographic and Health Surveys from thirty-six LMIC between 1990 and 2012.
Children <5 years.
Overall malnutrition prevalence decreased in children <5 years, driven by stunting decreases. Stunting rates decreased in 78 % of countries, wasting rates decreased in 58 % of countries and overweight rates increased in 36 % of countries. Rates of change differed for children </≥2 years, with children <2 years experiencing decreases in stunting in fewer countries yet increases in overweight in more countries. Countries with nearly equal prevalences of stunting and overweight in children <5 years increased from 2000 to the final year. Within a country, 0·3-10·9 % of children <5 years were stunted and overweight, and 0·6-37·8 % of stunted children <5 years were overweight.
The dual burden exists in children <5 years on both country and individual levels, indicating a shift is needed in policies and programmes to address both sides of malnutrition. Children <2 years should be identified as a high-risk demographic.
The Planetary Health Diet Index (PHDI) measures adherence to the sustainable dietary guidance proposed by the EAT-Lancet Commission on Food, Planet, Health. To justify incorporating sustainable ...dietary guidance such as the PHDI in the US, the index needs to be compared to health-focused dietary recommendations already in use. The objectives of this study were to compare the how the Planetary Health Diet Index (PHDI), the Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to cardiometabolic risk factors.
Participants from the National Health and Nutrition Examination Survey (2015-2018) were assigned a score for each dietary index. We examined disparities in dietary quality for each index. We used linear and logistic regression to assess the association of standardized dietary index values with waist circumference, blood pressure, HDL-C, fasting plasma glucose (FPG) and triglycerides (TG). We also dichotomized the cardiometabolic indicators using the cutoffs for the Metabolic Syndrome and used logistic regression to assess the relationship of the standardized dietary index values with binary cardiometabolic risk factors. We observed diet quality disparities for populations that were Black, Hispanic, low-income, and low-education. Higher diet quality was associated with improved continuous and binary cardiometabolic risk factors, although higher PHDI was not associated with high FPG and was the only index associated with lower TG. These patterns remained consistent in sensitivity analyses.
Sustainability-focused dietary recommendations such as the PHDI have similar cross-sectional associations with cardiometabolic risk as HEI-2015 or DASH. Health-focused dietary guidelines such as the forthcoming 2025-2030 Dietary Guidelines for Americans can consider the environmental impact of diet and still promote cardiometabolic health.
Contributions of age-period-cohort effects to increases in BMI and overweight among Chinese adults must be resolved in order to design appropriate interventions. The objectives were to (i) describe ...the period effect on BMI and overweight among Chinese adults from 1991 to 2009 and assess modification of this effect by age (e.g. cohort effect) and gender, and (ii) quantify the influence of household income and community urbanicity on these effects.
Data are from the China Health and Nutrition Survey, a prospective sample across nine provinces in China; 53,298 observations from 18,059 participants were collected over a 19-year period. A series of mixed effects models was used to explicitly assess differences in BMI within individuals over time (age effect) and population-wide differences in BMI over time (period effect), and implicitly assess differences in the experienced period effect across individuals of varying ages (cohort effect).
Stronger period effects on BMI and overweight were observed among males compared with females; and younger cohorts had higher BMIs compared with older cohorts. Simulations predicted that increases in income and urbanicity in the order of magnitude of that observed from 1991 to 2009 would correspond to shifts in the BMIs of average individuals of 0.07 and 0.23 kg/m(2), respectively.
Although period effects had a stronger influence on the BMI of males, interventions should not overlook younger female cohorts who are at increased risk compared with their older counterparts.
While thiamin and riboflavin in breast milk have been analyzed for over 50 years, less attention has been given to the different forms of each vitamin. Thiamin-monophosphate (TMP) and free thiamin ...contribute to total thiamin content; flavin adenine-dinucleotide (FAD) and free riboflavin are the main contributors to total riboflavin. We analyzed milk collected at 2 (n = 258) or 6 (n = 104), and 24 weeks (n = 362) from HIV-infected Malawian mothers within the Breastfeeding, Antiretrovirals and Nutrition (BAN) study, randomly assigned at delivery to lipid-based nutrient supplements (LNS) or a control group, to investigate each vitamer's contribution to total milk vitamin content and the effects of supplementation on the different thiamin and riboflavin vitamers at early and later stages of lactation, and obtain insight into the transport and distribution of these vitamers in human milk. Thiamin vitamers were derivatized into thiochrome-esters and analyzed by high-performance liquid-chromatography-fluorescence-detection (HPLC-FLD). Riboflavin and FAD were analyzed by ultra-performance liquid-chromatography-tandem-mass-spectrometry (ULPC-MS/MS). Thiamin-pyrophosphate (TPP), identified here for the first time in breast milk, contributed 1.9-4.5% to total thiamin. Free thiamin increased significantly from 2/6 to 24 weeks regardless of treatment indicating an active transport of this vitamer in milk. LNS significantly increased TMP and free thiamin only at 2 weeks compared to the control: median 170 versus 151 μg/L (TMP), 13.3 versus 10.5 μg/L (free thiamin, p<0.05 for both, suggesting an up-regulated active mechanism for TMP and free thiamin accumulation at early stages of lactation. Free riboflavin was consistently and significantly increased with LNS (range: 14.8-19.6 μg/L (LNS) versus 5.0-7.4 μg/L (control), p<0.001), shifting FAD:riboflavin relative amounts from 92-94:6-8% to 85:15%, indicating a preferred secretion of the free form into breast milk. The continuous presence of FAD in breast milk suggests an active transport and secretion system for this vitamer or possibly formation of this co-enymatic form in the mammary gland.
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