The definition of double burden of malnutrition is coexistence of undernutrition along with overweight and obesity, or diet-related non-communicable diseases across the life course. There are multiple forms of malnutrition including: stunting, wasting, micronutrient deficiencies (vitamins and minerals), overweight or obesity, and non-communicable diseases (NCDs). Double burden of malnutrition is more evident in lower and especially middle income countries who experienced an economical growth leading to nutritional, epidemiological and demographic transitions which resulted in the coexistence of both under and overnutrition within the population.
Nutritional transitions include the shift in patterns of diet, and energy consumption and expenditure that are associated with economic growth, globalization, and urbanization. Epidemiological transitions is the alteration in the disease patterns among the population that is associated with the economic growth (e.g. increase in NCDs), while demographic transitions describe the increase in life span and the concurrent increase in the NCDs (WHO, 2017a) The double burden of malnutrition is the result of exposure to multiple factors including biological, lifestyle, socioeconomic and environmental factors through different stages in life starting from conception and pregnancy and continue to adulthood and later stages of life. evidence suggesting chronic NCDs has developmental origins in which maternal nutrition, fat deposition, and stress hormones factors are affecting the developing fetus during pregnancy and results in increased risk for developing chronic NCDs particularly diabetes type 2, and cardiovascular disease (Hales and Barker, 1992).
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This is more evident when the fetal development and adulthood are different in terms of nutrition e.g. undernutrition during fetal development with resulting in both extremes of birth weight and followed by overnutrition and diet rich food in adulthood which will predispose for increased risk of chronic especially in developing countries who experienced economic changes (Bruce and Hanson, 2010). Other study showed protein restriction in maternal diet will lead to alteration in adipocyte gene expression and changes can persist and continue into adulthood might contribute to metabolic diseases (Bol et al., 2009). Other findings of maternal obesity and high fat diet during early development is associated with adults suffering from impaired glucose tolerance, hypertension, and hyperlipidemia. It is believed that high fat diet result in stretching of metabolic plasticity beyond its capacity leading to development disruption (Elahi et al., 2009).
Epigenetic modifications can lead to permanent changes through programming mechanisms via signaling pathways which can be represented in adulthood as non communicable diseases (Pujadas and Feinberg, 2012, Bruce and Hanson, 2010). Maternal nutrition play an important role for optimal fetal development through control of maternal obesity and preventing further low / high birth weight with its associated complications in future. Several studies showed an inverse relationship between birth weight and development of heart disease later in life with 10-20% decrease in risk if IHD with every 1 Kg increase in birth weight, this is may be related to maternal undernutrition during pregnancy and subsequent gene alteration that might lead the newborn more prone to chronic illnesses (Owen et al., 2007) The first 2 years of life is very crucial for the development as the body undergo a rapid maturation of all organs especially brain. Inappropriate diet during this period may lead to long lasting effects. Exclusive breastfeeding is highly recommended especially during the first 6 months and it is associated with decreased incidence of obesity, and type 1 and type 2 diabetes (Schanler, 2014).
Infants and children are more prone for protein energy malnutrition and micronutrient deficiencies especially iron, zinc, folate, iodine, and poly unsaturated fatty acids that will result in irreversible damage to cognitive and neurodevelopment leading to stunting, decreased learning outcomes, and later in life obesity and NCDs (Perng and Oken, 2017). On the other hand, over nutrition in infancy is associated with changes in dietary habits and development of life long obesity and type 2 diabetes (Singhal et al., 2010) Iron deficiency anemia usually happen in young children after weaning from breastmilk and iron fortified formula and shifting to solid food that is not rich in iron. Iron deficiency anemia can result in long term intellectual and behavioral problems and this can be prevented by providing iron rich foot to young children and toddlers such as lean meats, fish, poultry, eggs, legumes, and iron-enriched whole-grain breads and cereals (Kazal, 2002). Nutritional needs increased with growing up, and the tendency toward eating selective diet is high among toddlers and school age children and this is influenced by the family environment, social factors, and the media. Advertisements have an impact on children eating attitudes and attracts them towards sugary products, fatty fast-foods, excess calories, refined ingredients, and sodium which will predispose to obesity later in life (Zimmerman and Snow, 2012).
A special attention shall be paid to children of vegetarians and vegans in which the diet has to fulfill all the nutritional needs of the children. In case the children eating animal products then they can meet the nutritional needs for protein and other micronutrients required for development. Otherwise, the parents shall provide alternatives that can compensate for protein and micronutrients including iron, calcium, vitamin B12, and vitamin D. Legumes and nuts can be eaten in place of meat, soy milk fortified with calcium and vitamins D and B12 can replace cow’s milk (Zimmerman and Snow, 2012) During the last 50 years, food quality and quantity changed in terms of processed food quality and portion size. This promotes overeating which will have a negative impact on health and nutritional status of population with subsequent development of obesity later on. Processed food and meals with high energy content offered in restaurants now are larger, cheaper, and more accessible by all population (Livingstone and Pourshahidi, 2014). This is more evident in poor neighborhoods who can’t afford to buy fresh food and obliged to buy unhealthy food mainly grains, added sugars and fats. (Drewnowski, 2012). There are certain practices and beliefs running in certain society related to food and health. These include food taboos and proscriptions. Food taboos are of permanent nature e.g. religious taboos including pork meat among Muslims and beef meat among Hindu populations (Briones Alonso, 2015).
Food taboos can be gender specific in certain communities. In Africa for example, permanent taboos against females starts from infancy, in which females receive low nutrient diets and earlier weaning compared to males infants. In later stages of life females are deprived from high protein food such as eggs, animal meat, fish, and milk. Females and especially pregnant and lactating mothers will be suffering from iron and protein deficiencies which will have an impact on mother and child health later in life with high association of maternal and infant mortality rates and low life expectancy (UN-OHCHR, 1995). The double burden of malnutrition is a global public health challenge with serious and negative impacts on population. It is seen as a dual nutrition challenge to simultaneously overcome the burden of both undernutrition (including stunting, wasting and micronutrient deficiencies) and overweight, obesity, and NCDs. This needs an integrated complex approach involving multiple levels and actors to have interventions, policies, and programs fighting malnutrition through different stages of life (WHO, 2017a) Different approaches and interventions can be done through different life stages as listed below (WHO, 2017b):
- Maternal nutrition and antenatal care: Paying attention to maternal nutrition during period of pregnancy play an important role to ensure pregnant woman receive optimum nutrition especially iron and folic acid which both are crucial for the development of the fetus. Gestational weight during pregnancy shall be monitored as both extremes of weight might pose a risk on the mother and fetus with higher probability of NCDs in future.
- Exclusive breast feeding: Encouraging exclusive breast feeding for the first six month of infant life will provide essential nutrition required for development and reduce risk of obesity later in life a. In addition, breast milk has various benefits to mother including controlling weight during postpartum period and protecting against obesity and NCDs (WHO, 2004).
- Early and complimentary infant feeding: To ensure the infant receive the proper nutrition especially micronutrients with continuation of breast feeding up to 2 years of life.
- Children and school age: Careful monitoring of this age group with proper guidance and advice to have proper diet and nutrition. School specific nutrition programs that might help in controlling obesity among children. Awareness and education for the families regarding unhealthy food and its adverse impact on health of an individual and especially children. Physical activity also an important factor in controlling obesity.
- Regulations on food advertisement and marketing: This might change children food preference and shift the desire towards healthier habits. - Increase awareness regarding harmful beliefs in certain communities including food taboos, son preference, and deprivation of females from proper nutrition.
Finally, among all listed possible interventions above, optimal nutrition in the first 1000 days of life including pregnancy and up to 2 years of life is crucial for the health of both the mother and fetus, and regarded as a base for future “healthy” development later in life.
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