Poverty

The Double Burden of Malnutrition in Mothers

and the Intergenerational Impact
HÉLÈNE F. DELISLE
Department of Nutrition and WHO Collaborating Centre on Nutritional Changes and
Development, Université de Montréal, Canada

Women are doubly vulnerable to malnutrition, because of their high nutritional requirements for
pregnancy and lactation and also because of gender inequalities in poverty. Undernutrition and
overnutrition coexist in developing countries undergoing rapid nutrition transition, and women
are susceptible to this double burden of “dysnutrition,” often cumulating stunting or micronu-
trient malnutrition with obesity or other nutrition-related chronic diseases. The purpose of the
present paper is to describe the adverse impact of income and gender inequities on women’s
nutritional health, and the dramatic consequences, not only for women themselves, but for chil-
dren, families, and societies. Improving women’s resources, including health, nutrition, education,
and decisional power, is critical for equity and for the health of children and adults of future
generations, since poor fetal and infancy nutrition is another risk factor for chronic diseases,
in particular abdominal obesity, type 2 diabetes, hypertension, and cardiovascular disease. Ad-
dressing malnutrition and nutrition-related chronic diseases simultaneously is a challenge facing
developing countries, and examples of promising initiatives are provided. Focusing on women
along the lifecycle, according to the continuum of care approach, is essential to achieving the
Millennium Development Goals and to breaking the intergenerational cycle of poverty, malnutri-
tion, and ill-health.

Key words: maternal nutrition; poverty; double burden of malnutrition; gender inequalities

Introduction Poverty and the Dual Forms

The purpose of the present paper is to describe the
adverse impact of income and gender inequities on
women’s nutritional health, and the dramatic conse-
quences not only for women themselves, but for chil-
dren, families, and societies. Improving women’s re-
sources, including health, nutrition, education, and
decisional power, is critical not only on the basis of
equity, but also out of concern for the health of chil-
dren and adults of several generations. Addressing the
dual nutritional burden which weighs so heavily on
women of developing countries (DCs) is a challenge,
and promising approaches will be discussed. Moving
beyond simply describing these problems as they af-
fect women toward taking action for change is pivotal
for the Millennium Development Goals (MDGs) to be
achieved, since nearly all of them are directly or indi-
rectly connected with improved condition of women.
Address for correspondence: Hélène F. Delisle, Ph.D., Department of
Nutrition, Faculty of Medicine, Université de Montréal, PO Box 6128
Downtown Station, Montreal Que, Canada H3C 3J7.
helene.delisle@umontreal.ca
of Malnutrition [Dysnutrition]
Poverty is the root cause of malnutrition and ex-
plains to a large extent its persistence in the developing
world. Since the turn of the century, poverty and mal-
nutrition have declined, but in an uneven fashion.1
There are varying degrees of poverty. Three quarters
of the 162 million ultra-poor (living on less than $0.50
per day) are concentrated in sub-Saharan Africa, and
the remainder are in South Asia. It is in those regions,
where poverty and hunger are severe, that progress
has been particularly slow. The Global Hunger In-
dex is lowest in sub-Saharan Africa and South Asia.
However, at variance with South Asia, there was little
progress since 1990 in child underweight and under-
five mortality rates in sub-Saharan Africa, although
food-energy deficiency declined by 10%, which points
to the slow progress of maternal health and nutrition.
Poverty goes beyond income inequality, encompass-
ing health, social, and gender inequalities. It also refers
to various types of deprivation and exclusion. It has
been defined as including the different conditions of
life with lack of access to basic needs, resources, and

Ann. N.Y. Acad. Sci. 1136: 172–184 (2008). 

C 2008 New York Academy of Sciences.
doi: 10.1196/annals.1425.026 172
Delisle: Poverty and Intergenerational Malnutrition
services, and it is often characterized by lack of free-
dom, education, and opportunities, in addition to lack
of income and inequalities.2 Maternal health dispari-
ties are primarily evidenced in wide differences in ma-
ternal and neonatal death rates. Nearly all maternal
and newborn deaths occur in DCs where women have
inadequate access to health care.3 “Time poverty” has
been used to describe the situation of African women
whose production and domestic (unpaid) work leaves
little time for leisure or even for child care or for partic-
ipating in development activities.4 Time poverty rep-
resents a critical dimension of women’s poverty. Work
burdens are gender-differentiated, and this may even
be exacerbated in contexts of HIV/AIDS.4 In Benin,
we found, in rural as well as urban households, that
women engaged in less demanding physical activities,
but worked much longer hours than men, to such an
extent that no leisure time was left.5
Hunger and overall undernutrition are usually con-
sidered synonymous. However, a more insidious form
of malnutrition, that of “hidden hunger,” consists
of specific micronutrient deficiencies, such as iron,
iodine, and vitamin A deficiency disorders, to mention
only the most prevalent. Micronutrient malnutrition is
widespread and the consequences are life threatening
for women and children.
Another form of malnutrition that is now spreading
in DCs is related to obesity and other chronic diseases.
It is often regarded as the opposite of undernutrition
and is sometimes referred to as “overnutrition.” How-
ever, “overnutrition” is somewhat a misnomer because
while obesity, for instance, is the result of energy in-
take in excess of requirements, it may also overlap with
dietary inadequacies in micronutrients and fiber. We
therefore suggest the term “dysnutrition” to encom-
pass the whole range of nutritional problems: mal-
nutrition, which comprises undernutrition and spe-
cific micronutrient deficiencies, and nutrition-related
chronic diseases (NRCDs) including disorders of over-
nutrition and dietary imbalances.6 While malnutrition
(undernutrition and micronutrient deficiencies) is tra-
ditionally considered a problem of the poor, NRCDs
are seen as problems of the affluent, and this is one of
the reasons NRCDs have been neglected in DCs up
to recently. While hunger (or food insecurity) typifies
poverty, obesity may also be associated with poverty.
Indeed, except in extreme poverty, food insecurity of-
ten translates into energy-sufficient and even excessive,
but poor quality, diets. Obesity of poverty is observed in
industrialized countries, as well as in DCs undergoing
the nutrition transition. Obesity and other NRCDs,
such as diabetes and cardiovascular disease (CVD) are
on the rise in DCs, even in low-income countries (but
173
then particularly in cities), and they can no longer be
considered diseases of affluence.7 Additionally, there is
mounting evidence that the two forms of malnutrition
are synergistic. According to the theory of the early ori-
gins of chronic diseases,8 nutritional insults in utero or
during infancy permanently change the body’s struc-
ture, function, and metabolism in such a way that the
risk of chronic diseases, including diabetes and CVD
is increased in later life. Therefore, early malnutrition
exacerbates the health risks associated with the nutri-
tion transition. Prevention of NRCDs is now a public
health priority worldwide, and the World Health As-
sembly adopted in 2004 the WHO Global Strategy on
Diet, Physical Activity, and Health.9
The Vulnerability of Women
to Both Forms of Dysnutrition
Preschool children are one of the two groups
most vulnerable to malnutrition. The second group
is women and girls, who are also disproportionately af-
fected by nutritional disorders associated with hunger
or undernutrition and micronutrient deficiencies, but
also affected by nutrition-related chronic conditions,
such as obesity and diabetes. Yet women are more
resilient physiologically than men. Given similar eco-
nomic and health resources, they tend to live longer
than men, although inequalities and discrimination
may blunt this advantage. The most striking excep-
tions are in Qatar, Pakistan, Maldives, and Bangladesh,
where average healthy life expectancy is at least
2.5 years higher in men than women.10
Women are doubly vulnerable to undernutrition or
micronutrient deficiencies, owing to their high nutri-
tional requirements for pregnancy and lactation, and
also because of gender inequalities in poverty. In some
but not all poor regions, gender discrimination in food
allocation may also contribute to women’s nutritional
vulnerability. In Vietnam, for example, based on two
sets of household surveys 5 years apart, men reaped
proportionally more nutritional benefit from economic
development than women, as reflected in food access
and body weight data.11 This sort of discrimination was
also observed in Guatemala when comparing dietary
intake of boys and girls.12 Malnutrition usually evokes
the specter of severely wasted children and adults,
but it is not necessarily visible. Moderate malnutri-
tion, with stunted growth, is also responsible for excess
mortality in children,13 not only the clinical and severe
forms of kwashiorkor and marasmus. It is estimated
that malnutrition is involved in 50% of child deaths in
DCs, according to WHO. In women of reproductive
174
age, malnutrition is a major contributor to maternal
mortality, and it is evidenced by stunting, chronic en-
ergy deficiency (CED), and micronutrient malnutri-
tion. Maternal malnutrition is a major determinant of
low birth weight in DCs. According to Harvey, iron
deficiency anemia is responsible for 22% of maternal
deaths and 24% of neonatal deaths.14
Women are also more vulnerable than men to
obesity and other NRCDs, which have not replaced
malnutrition-related diseases in DCs, resulting in the
double burden of dysnutrition, primarily in southern
Asia and sub-Saharan Africa. This double burden is
now observed in low- and middle-income DCs. It is
partly the result of the rapid nutrition transition char-
acterized by major shifts of populations’ eating patterns
and lifestyles.15 Fueled by globalization, urbanization,
technological evolution, and income changes, the nu-
trition transition involves progressive westernization
of diets, with increased consumption of energy-dense,
highly processed foods and drinks,16,17 and a more
sedentary lifestyle owing to motorized transportation
and mechanized work.
In a recent general press paper on world hunger,
Pinstrup-Anderson and Cheng describe the dual nu-
tritional problem of deficiencies and hunger in some
households and obesity and related diseases in oth-
ers.18 They remind that poverty is the main rea-
son that hunger and nutritional deficiencies persist.
However, they do not refer to obesity associated with
poverty.
Nutrition-related Chronic Disease
Risk Factors in Women
of Developing Countries
The burden of chronic diseases in DCs is much
higher than usually perceived. In 2005, chronic
diseases—mainly CVDs, cancer, chronic respiratory
diseases, and diabetes—were responsible for 50% of
total disease burden in 23 countries which account
for 80% of chronic disease mortality in DCs.19 WHO
insisted on the need to address noncommunicable dis-
eases, a neglected problem in DCs.20 Women are at
a disadvantage: their age-standardized death rate for
chronic diseases is 86% higher in DCs than in de-
veloped countries, whereas in men, it is 54% higher
in DCs compared to developed countries.19 Further-
more, these deaths occur at an earlier age in DCs com-
pared to high-income countries, depriving families and
societies of adults in their productive years.
The nutrition transition fuels the increase of the
metabolic syndrome, which is a clustering of CVD
Annals of the New York Academy of Sciences
risk factors (obesity, insulin resistance, high blood pres-
sure, dyslipidemia) in DCs, including sub-Saharan
Africa.21,22 Urbanization is one determinant of the nu-
trition transition and the resulting upsurge of chronic
diseases, such as abdominal obesity, type 2 diabetes,
hypertension, dyslipidemia, and CVD. The interac-
tion of adaptation, modernization, and stress is at play
in the disease changes that accompany urbanization.23
DCs may be particularly vulnerable to nutrition tran-
sition because of recent or concurrent undernutrition,
as it may compound the chronic disease risk associ-
ated with higher-fat diets, lack of physical activity, and
other lifestyle patterns, such as tobacco smoking. In
other words, as is so well put by Adair and Prentice,
prenatal factors contribute to a phenotype that may
be more sensitive to lifestyle factors associated with the
development of obesity and the chronic diseases.24
Vorster and Kruger explored possible mechanisms
to explain the known relationships among poverty, un-
dernutrition, and CVD in DCs.2 They postulated that
the link between poverty and CVD in South Africa
could be explained by the high prevalence of un-
dernutrition in children aged 1–9 years (9% under-
weight, 23% stunting, 3% wasting), the high preva-
lence of overweight in adults (54.5% in men and
58.5% in women), and the negative changes in di-
ets (and lifestyles) when Africans urbanize, acculturate,
and adopt western patterns.
Among resource-poor populations, women may be
at greater risk of CVD, which is the single largest cause
of women’s deaths, accounting for one-third of the to-
tal worldwide.25 CVD risk factors are also increasing
in women of DCs and will contribute to more women’s
than men’s deaths by 2040.25 Some risk factors play
a greater role in women than men: high triglyceride
concentrations, low HDL-cholesterol, and diabetes. In
the THUSA (Transition and Health during Urban-
ization in South Africa) study on CVD risk factors in
South Africa, there were indications that while in men
the CVD burden was heavier among the better-off, in
women overweight/obesity (prevalence of 58.5%) and
some other risk factors affected the rich and the poor.26
Although there are more similarities than differ-
ences in CVD risk factor trends in developed and
DCs according to a recent review,27 one risk factor
is particularly critical in DCs, and it is the risk as-
sociated with poor early growth and nutrition.28 In-
adequate growth and nutrition in utero is associated
with increased chronic disease risk, according to the
theory of the early origins of chronic diseases.8 Poor
nutrition in infancy, which is still highly prevalent in
DCs, also appears associated with later chronic dis-
ease, although the evidence is less documented than in
Delisle: Poverty and Intergenerational Malnutrition
the case of intrauterine malnutrition. Several mecha-
nisms may explain the link between early life under-
nutrition and chronic diseases, including programmed
metabolic adaptation to an environment of scarcity
in utero, by virtue of developmental plasticity.29 High
blood pressure is the chronic disease risk factor which
has been the most consistently associated with poor
early growth in several population and age groups.30
Insulin resistance, abdominal obesity, and CVD have
also shown links with fetal malnutrition reflected in low
birth weight.31
Hypertension is widespread in DCs, particularly in
sub-Saharan Africa.32–34 Its prevalence is not consis-
tently higher in urban or better-off settings, which
our studies in Benin confirmed (unpublished data). In
poor Nordeste, Brazil, hypertension was more preva-
lent among women than men (38.5% versus 18.4%,
respectively).35 Some studies suggest that illiterate and
underweight women are at greater risk of being hy-
pertensive than educated or normal weight women,
although overweight/obese women are also at higher
risk compared with normal weight women.36 Low
socio-economic status (SES) was a significant risk fac-
tor for high blood pressure in both adolescent males
and females in Congo.37 A U-curve may be postulated
for the association of nutritional or economic status
with the risk of hypertension.
The prevalence of overweight and obesity is much
higher among women than men in most DCs. In low-
income countries, the risk of obesity (and comorbidi-
ties) is higher in more affluent groups, but the burden
shifts to poorer groups as GNP rises; the shifting point
is the middle national income, according to the World
Bank grouping of countries based on per capita in-
come.38 Obesity is increasing rapidly under the in-
fluence of urbanization and westernization of diets,
lifestyles, and culture. Cultural factors may also con-
tribute to the higher prevalence of overweight or obe-
sity in women compared to men. In several African
countries, the ideal of beauty is not leanness, in contrast
with western countries, but rather overweight, which is
also a social status symbol.39,40 The gender difference
occurs already at adolescence. In semi-urban areas of
Congo (Kinshasa), the prevalence of overweight and
obesity was 68.5% in female school adolescents, versus
24% in male adolescents.37
Physical inactivity as a CVD risk factor in DCs is
of concern: 60–85% of the population of developed
countries or DCs do not undertake sufficient physi-
cal activity to gain health benefits.25 Lack of physical
activity is more of a problem in women in several set-
tings, and particularly so among adolescent girls and
low SES women. Studies in sub-Saharan countries,
175
including in South Africa41 and Benin5 confirm that
inactivity is related to women’s overweight/obesity.
The Double Nutritional
Burden in Women
The shift toward obesity and related chronic dis-
eases in DCs does not mean that malnutrition (under-
nutrition and micronutrient deficiencies) is no longer
a problem. In actuality, both forms often coexist and
characterize the double burden of dysnutrition. The
double nutritional burden weighs heavily on already
inadequate and overextended health budgets of DCs.19
The double burden is also deleterious for societies and
families. It may be observed at the individual level, and
especially among women. The double burden is also
observed within households, and it is usually reflected
in the coexistence of maternal overweight/obesity and
child chronic or acute malnutrition. Its increasing
prevalence at the household, community, or country
level is typical of rapidly transitioning countries, and
is becoming a major public health concern. It may
take the form of overlapping stunting or micronutrient
malnutrition and obesity, as well as underweight in part
of the population and overweight and obesity-related
comorbidities in the other.
Double Burden of Malnutrition
at the Country Level
Women are more exposed than men to the double
burden. In Brazil, for instance, there were roughly two
cases of underweight for one case of obesity in 1975; the
ratio was reversed in 1997.38 Low-income women were
more susceptible to both underweight and obesity. The
combined prevalence, considered by the authors as a
proxy for the total burden of nutritional diseases, was
significantly higher in low-income than high-income
women in both surveys: 22% versus 17% in 1975, and
22% versus 15% in 1997, respectively.
The double burden of dysnutrition is currently most
problematic in middle-income DCs of Latin Amer-
ica and North and South Africa. While CED or
underweight (BMI < 18.5 kg/m2 ) remains the major
nutritional problem among women of low-income
countries, the double burden of underweight and
overweight/obesity (BMI ≥ 25 kg/m2 ) is emerging in
South Asia and sub-Saharan Africa. In Bangladesh,
for instance, in nationally representative samples of
women of reproductive age, the prevalence of CED
between 2000 and 2004 was 38.8% among rural and
29.7% among urban poor women, while 4.1% and
9.1%, respectively, were overweight or obese. It has
been suggested to lower the BMI cutoffs of overweight
176
TABLE 1. Nutritional status of women aged 25–60 years in three sites in Benin (West Africa)
Large city
(Cotonou) N = 100
Underweight (BMI < 18.5 kg/m2 ) 2 7.1
Normal weight (18.5 ≤ BMI < 25) 34
Overweight (25 ≤ BMI < 30) 36
Obese (BMI ≥ 30) 28
and obesity in Asian populations because of evidence
of emerging CVD factors and diabetes below the stan-
dard overweight cut-point of 25 kg/m2 , possibly be-
cause of a proportionally higher percentage of body
fat for any BMI in Asians compared to Caucasians.42
In Bangladeshi women, an additional 9.6% of ru-
ral and 18.9% of urban poor women were consid-
ered at risk of overweight, with a BMI at or above
23 kg/m2 .43 Although in urban poor areas, the com-
paratively wealthier group had a higher prevalence of
overweight/obesity (12.2%), the rate was 8.4% among
the poorest women. Over the 5-year period, CED de-
clined and overweight/obesity increased in both set-
tings, but the increasing trend of high BMI was more
marked in rural than urban women. In The Gambia,
data collected a decade ago showed that the preva-
lence of CED was 18% and affected all social strata,
whereas obesity was primarily a problem of urban
women, with one-third affected beyond the age of 35
years.44
In resource-poor countries, a still-predominant fea-
ture of the double burden is that undernutrition
tends to cluster among the impoverished and over-
weight/obesity among the more affluent. This is typi-
cal of the early stages of the nutrition transition. How-
ever, the situation is rapidly evolving, and overnutrition
coexists increasingly with undernutrition even among
the poor.
The Food and Agriculture Organization of the
United Nations, on the basis of case studies in six DCs,
proposed a typology of countries with respect to the
double burden of malnutrition.45 Three country types
are delineated, corresponding to advancing stages of
the nutrition transition. The first group includes India
and the Philippines. These countries are still in the
early transition stages, with persistent undernutrition
and micronutrient deficiencies in children and adults,
and only emerging problems of obesity, diabetes, and
high blood pressure in urban areas. The second type
is illustrated by South Africa, where child stunting and
micronutrient malnutrition are still widespread, but
overweight/obesity is more a problem than undernu-
trition in adults. The third type, corresponding to a still
more advanced stage of the nutrition transition (China,
Annals of the New York Academy of Sciences
Medium-size city Semi-rural outskirts
(Ouidah) N = 85 (Ouidah) N = 85
22.4
38.8 45.9
29.4 18
24.7 12.9
Egypt, Mexico), is characterized by a low prevalence of
undernutrition, but the overlap of stunting and over-
weight/obesity in children, while in adults obesity is
high or rapidly increasing, with increasing diabetes
and coronary heart disease rates as correlates.
In Benin (West Africa), our on-going studies on the
nutrition transition and cardiometabolic risk factors in
adults of urban and semi-rural areas show that un-
derweight is as prevalent in semirural women as over-
weight/obesity is among city women (see TABLE 1).
Income and gender inequalities appear to have ad-
ditive or compound effects. In India, for instance, it was
found that state income inequality increased the like-
lihood of both undernutrition and overweight among
women, that is, of the double nutritional burden, even
after adjusting for several individual and state-level co-
variates.46 For one standard deviation increment in
income inequality measured by the Gini coefficient,
the odds ratio of being underweight increased by 19%
(P = 0.02) while the odds ratio of being obese increased
by 21% (P < 0.001). The adverse effect of state income
inequality is also observed for overweight. The contex-
tual inequality appears to exacerbate the known im-
pact of individual SES as low SES women experience
the greatest risk of underweight whereas the high SES
ones are exposed to higher obesity risk. The authors
suggested that, in regions in economic transition and
growth, focusing on reducing economic inequalities is
likely to address the dual burden.
Double Nutritional Burden Households
The phenomenon of coexistence of child undernu-
trition and maternal overweight/obesity in the same
households has been described in several DC set-
tings, including South Africa, China, Brazil, Haiti, and
Benin.47,48 Comparing Russia, China, and Brazil, the
prevalence of the double burden among households
was very similar: 8% in Russia and China, and 11%
in Brazil, based on national surveys.48 In a poor rural
community of Malaysia, 15.7% of mother/child pairs
showed the double burden,49 which is quite similar to
what we observed in a shanty town of Port-au-Prince,
Haiti (14%) and in poor neighborhoods of Cotonou,
Benin (16%).50,51
Delisle: Poverty and Intergenerational Malnutrition 177

The coexistence of maternal overweight and child

5.3 (0.93; 30.48)a

0.057 (0.07; 0.49)∗∗

0.14 (0.03; 0.60)∗∗

3.98 (0.77; 20.75)

0.17 (0.03; 0.99)∗

1.06 (0.31; 3.62)

underweight in the same household portrays rapid

OR (95% CI)
Double burden households (n = 24)
nutrition transition.52 It suggests that similar circum-

vs. maternal overweight/obesity

stances, whether environmental, behavioral, or in-
dividual, favor the development of underweight in
children and overweight in mothers.53 It may also illus-

(n = 29)
trate the differential rate of change of the prenatal and
postnatal environment.29 The prenatal environment is

0.009
0.049
0.009
0.10

0.92
0.06
determined by maternal size, body composition, and

P
metabolism, which is partly determined in turn by the
mother’s own growth in utero and during infancy and

1.38

0.62
1.67

−2.87
−1.77
−1.98
childhood. In the nutrition transition context, small

β
mothers have small babies because of maternal size

TABLE 2. Predictors of the concurrent presence of malnutrition in at least one child and maternal overweight51
constraints, and then the children grow rapidly owing
to more favorable factors in the postnatal environment.

a
4.45 (0.81; 24.54)

0.13 (0.02; 0.96)∗

0.21 (0.04; 0.99)a
Mothers exposed to the nutrition transition context

1.37 (0.31; 6.06)

2.15 (0.66; 7.07)

0.48 (0.12; 2.03)
OR (95% CI)
(n = 24) vs. normal households
may become overweight or obese, while their children

Double burden households

are stunted, perhaps since intrauterine life. In an anal-
ysis of secondary data on more than 600 mother/child
pairs in Mexico, it was found that maternal central

(n = 30)
obesity and child stunting were present in 6% of pairs.
The odds of having a stunted child were twice as great

0.087

0.046
0.050
0.68

0.21
0.32
P
in mothers with a waist-hip ratio (WHR) around 1,
compared with those with a WHR of 0.65.54
In Benin, we found that “double burden” house-

0.32

0.77
1.49

−2.05
−1.58
−0.72
holds had a higher SES than households with a mal-
β

nourished child and no maternal overweight. Interest-

ingly, we also found that a more diversified diet was
protective of the double burden, implying that food in-
∗∗

0.11 (0.03; 0.49)∗∗

15.4 (2.48; 95.3)
1.91 (0.47; 7.91)
0.19 (0.26; 1.42)

0.68 (0.16; 2.86)

1.67 (0.58; 5.16)
OR (95% CI)

security contributes to both adult overweight and child

Double burden households (n = 24)
vs. malnourished child households

malnutrition (see TABLE 2). Thus, maternal obesity and

child stunting do not have opposite causes but appear
as responses to the same insults at different stages of
(n = 43)

the lifecycle. We also found in the same study that

compared with households with only maternal over-
weight, those with a malnourished child had poorer
0.003

0.003
0.37
0.11

0.60
0.38
P

household sanitation. Similarly, in a study in the North

West Province of South Africa, poor hygiene practices
were a major determinant for child undernutrition.55
2.73
0.65
−1.65
−2.18
−0.39
0.51

Low education of mothers was also a major determi-

β

nant of child undernutrition, which again underlines

the role of maternal profile for child nutritional status.
β, beta-coefficient; OR, odds ratio.
Intermediate vs. low dietary diversity

City living: ≥10 years vs. <10 years

P < 0.1; ∗ P < 0.05; ∗∗ P < 0.01.

Double Nutritional Burden in Individuals

High vs. low home sanitation
High vs. low dietary diversity

The most widely studied phenotype of the double

burden at the individual level is that of stunting and
Middle vs. low SES

overweight/obesity, whether in children or in adults.

High vs. low SES

Other types are the overlap of stunting with hyperten-

sion or insulin resistance, and of anemia and obesity.
According to published data, all these manifestations of
the double burden of dysnutrition are more common
a

in women than in men.

178
The association between stunting in infancy and
obesity later on in life has been reported in several stud-
ies conducted in nutrition-transitioning countries.56
And stunting in infancy is already present at birth in
many cases, as a result of maternal constraint or poor
nutrition. The mechanism is not yet elucidated, but it
has been proposed that defective fat oxidation, as ob-
served in stunted children in Brazil, may be a culprit.57
In Egypt, the odds of being overweight/obese were
80.8% higher in women of reproductive age who were
possibly deficient in micronutrients based on per capita
supply of vitamin A, iron, and zinc in the house-
hold.58 This study concludes that the overlap between
micronutrient inadequacies and obesity is not given
enough attention by policy makers and researchers as
well, and one of the implications is that food subsidies
aggravate the obesity problem as these target energy-
dense foods, which become important for the poor.
In a study of 315 families of an urban slum area
in Nordeste, Brazil, it was found that high blood pres-
sure was significantly more prevalent among stunted
adults compared to normal-height adults, particularly
in women.35 Short stature, an epidemiological indi-
cator of chronic malnutrition in early life, was more
strongly associated with high blood pressure in women
than men. The odds ratio for hypertension in stunted
women compared to nonstunted ones was 1.98 (95%
CI [Confidence Interval] 1.22–2.96). The negative as-
sociation of stature with hypertension, as well as with
obesity, was observed in women, but not in men. In-
deed short stature was the single most important risk
factor for hypertension in women. In the Congo, it
was observed that in male adolescents but not in female
adolescents, chronic malnutrition as well as obesity was
a risk factor for high blood pressure.37
A small case–control study conducted in Mexico
showed that men who had suffered malnutrition in
their early years were more prone to insulin resistance
when they developed abdominal obesity, suggesting
that obesity may have more adverse effects in individ-
uals who were exposed to early malnutrition.59 This
study was only conducted in men, but several other
reports linked low birth weight with increased insulin
resistance in men and women, including a study on
600 men and women aged 45 years in China.60
Probably the most prevalent phenotype of double
dysnutrition is the simultaneous presence of micronu-
trient malnutrition and overweight/obesity, as “transi-
tional” diets are typically energy dense but micronutri-
ent poor. This situation is of concern not only because
of the adverse health outcomes of both forms of dys-
nutrition, but also because micronutrient deficiencies
may actually contribute to chronic diseases.61,62 The
Annals of the New York Academy of Sciences
evidence is still limited and research in this area is
direly needed, but micronutrients in short supply in
several DCs, including folate and antioxidants, such as
iron, zinc, vitamin C, and carotenoids, may contribute
to CVD (and certain types of cancer). Zinc deficiency
is widespread in DCs. It could contribute to oxida-
tive stress and to the development and progression of
diabetes as well, by virtue of its antioxidant proper-
ties and also because of the metabolic links between
zinc and insulin in the pancreas.61 Analysis of cross-
sectional data from Egypt, Mexico, and Peru revealed
that overweight women did not necessarily meet their
iron requirements. The prevalence of overweight was
above 50% in all three countries, reaching 77% in
Egypt. While the odds of anemia were lower in over-
weight/obese women in Egypt and Peru, there was no
difference among BMI groups in Mexican women.
The Insidious Impact
of Maternal Dysnutrition on the Health
of Whole Societies
Gill et al. reviewed the evidence linking maternal
health with development and proposed an interesting
framework on the key links at the individual, fam-
ily, and society level.63 Women are mothers and in-
dividuals; they are also family members and citizens.
This framework is useful to better comprehend how
women’s health, and notably their nutritional status,
impacts all those levels, and in the present and future
generations. Women’s health is connected with their
own status, their education, employment, and deci-
sional power. Their status is conducive to better health,
and conversely, their health contributes to their status
and condition. It is primarily as mothers that women
have been the focus of health efforts. Maternal health
affects women’s survival and the health and survival of
their children. Nutrition is critical for maternal health
and for reducing maternal mortality in DCs. For in-
stance, as already mentioned, iron deficiency anemia
reportedly accounts for 22% of maternal deaths and
for 24% of neonatal deaths.14 Indeed, interventions to
improve maternal diets and to promote breastfeeding
are relevant everywhere.
Women’s status, health, and nutrition also impact
families’ income, welfare, and well-being, and it has
been shown in several settings that maternal income,
more than that men’s income, is directly reflected in
better nutrition and health of children.64 That poor
maternal health and nutrition perpetuates the cycle of
ill-health and malnutrition across generations is further
described below. Although more research is required
Delisle: Poverty and Intergenerational Malnutrition 179

to explore these interrelationships in a more explicit

manner, women’s health is also an important deter-
minant for their own productivity and for economic
development at the macro level.63
A seminal paper by Asmani and Sen discusses the
relationship of gender inequality and women’s depri-
vation, on the one hand, and the health cost of these for
the whole population, men included.65 Some adverse
consequences of women’s poor health and nutrition
harm the entire population because the offspring are
affected, as children and as future adults. The authors
describe an overlapping health transition with two dis-
ease regimes, the old and the new regime. Gender
inequality, which results in maternal poverty, malnu-
trition, and poor health, exacerbates the old regime
through child undernutrition. It also exacerbates the
new disease transition through the theory of the early
origins of chronic diseases.8 Thus, gender inequality
leads to this double jeopardy connected with mater-
nal malnutrition, itself connected with inequality and
deprivation. “What begins as the neglect of the in-
terests of women ends up causing adversities in the
health and survival of all in the developing world.”65
The consequences of maternal undernutrition are de-
picted in FIGURE 1, adapted from that of Asmani and FIGURE 1. The burden of gender inequalities in nutrition
Sen.65 Fetal growth restriction associated with mater- on population health.
nal stunting (malnutrition in her early life), CED status,
or poor diet are now known to be associated with low neonates have a low birth weight, that is, nearly three
birth weight for gestational age and with a high risk times as many as in developed countries.69 Adequate
of malnutrition in the children who survive. The off- growth should be sought in the first 2 years of life,
spring of malnourished mothers are also subsequently with particular attention to infants born small whose
at increased risk of CVD, abdominal obesity, hyper- catch-up growth in height can only be achieved over
tension, and diabetes. Additionally, female offspring of this period. During childhood, the avoidance of accel-
malnourished mothers are at higher odds of becom- erated weight gain, even among those of normal BMI
ing stunted women themselves and to have low–birth is the main strategy to reduce the risk of obesity and
weight babies, thereby perpetuating the vicious cycle metabolic syndrome.67,70
of malnutrition. Thus, malnutrition in mothers is re-
sponsible for intergenerational dysnutrition, especially
in regions undergoing the nutrition transition.66,67 In- Policy and Strategies to Curb
tergenerational dysnutrition is also related to maternal the Double Nutritional Burden
obesity, which exposes the offspring to increased health
risk associated with gestational diabetes and macroso- Poverty is complex and multidimensional, and so
mia.68 The long-term adverse impact of fetal malnu- is dysnutrition. The causal links between the two,
trition is an additional and compelling argument to for there are, are bidirectional. In order to roll back
concentrate on improving nutritional status of young poverty, measures to curb dysnutrition are essential.
girls and women, preferably before, but if not, as early And conversely, investing in social capital of the poor,
as possible, and throughout pregnancy.28 including through nutrition programs, may yield high
Data from developed and DCs suggest that not returns in terms of improved health, especially of moth-
only small size at birth, but also postnatal growth re- ers and children.
tardation in infancy followed with rapid weight gain Much has been recommended, discussed, written,
in childhood, are independent factors of increased and planned in order to hasten progress in health and
risk of adulthood obesity, diabetes, hypertension, and development, including the now famous MDGs. How-
CVD. This is of concern for DCs, because 17% of the ever, it is disconcerting that nutrition is still so much
180
ignored or seriously neglected in policies for health,
education, gender equality, or poverty reduction, par-
ticularly in sub-Saharan Africa, considering that it is
the worst region in the world as regards child and ma-
ternal malnutrition and mortality rates. In the Com-
mission for Africa report, for instance, Chopra and
Darnton-Hill criticize the fact that the chapter on ed-
ucation and health devotes less than half a page to
nutrition, and only to address parasite control and mi-
cronutrient support.71 Similarly, it was a surprise to us
not to see a single mention of nutrition, diet, dietary
education, or even food (except for food availability)
in a whole paper on the management of diabetes in
sub-Saharan Africa,72 given that healthy eating is the
cornerstone of treatment as well as prevention of type 2
diabetes. Much advocacy effort is needed for nutrition
to be mainstreamed, and particularly so for addressing
chronic diseases connected with the nutrition transi-
tion in resource-poor DCs.
Nonetheless, there are encouraging policies and
strategies as regards gender equality, women’s health
and nutrition, and empowerment. Women’s educa-
tion is empowering,73 and it may bring about major
improvements in maternal and child nutrition.74 Ad-
ditionally, women’s empowerment is one of the most
effective ways of cutting down birth rates.65 Mater-
nal malnutrition is responsible for excess maternal and
neonatal mortality; improvements in women’s nutri-
tion will decrease mortality, while increasing the nu-
tritional status of surviving children. Additionally, im-
proved maternal nutrition will contribute to enhancing
the economic productivity of women and decreasing in
their progeny the chronic disease risk associated with
poor nutrition in early life. As stated in a UNICEF re-
port on the state of children, gender equality is central
to realizing the MDGs.75 More gender equality will
empower women to overcome poverty and will assist
their children, families, communities, and countries as
well. Improving nutrition, particularly that of women,
is also considered key to meeting the MDGs.14 Based
on the premise that investing in nutrition and gender
is an investment in MDGs with a high return, the In-
ternational Center for Research on Women and its
partners successfully implemented the Nutrition Gen-
der Initiative in Ghana, India, and Bangladesh be-
tween 2002 and 2005.76 The goal of the Nutrition and
Gender Initiative (NGI) is to add nutrition and gender
objectives and actions into development programs and
thereby contribute to achieving the following MDGs,
through action research, communication, and advo-
cacy: eradication of poverty and hunger; achievement
of universal primary education; reaching gender equal-
Annals of the New York Academy of Sciences
ity and empowerment of women; reduction of child
mortality; and improvement of maternal and repro-
ductive health. The project views nutrition as a cross-
cutting issue, interconnected with gender, and involv-
ing several development sectors and players. The NGI
strives to find suitable approaches to addressing malnu-
trition throughout the lifecycle as a means of improving
gender equality, along with enhancing institutional ca-
pacity for gender analysis, nutrition programming, and
advocacy.
Several risk factors and opportunities for preven-
tion are similar for chronic diseases, such as cancer,
CVD, and diabetes. Additionally, the same behavioral
risk factors are observed in developed countries and
DCs.33,34 However, programs to prevent obesity and
related chronic diseases are rather new in several DCs.
A wide range of such programs was described in a sum-
mary paper77 and encompassed worksite, community-
based school, and national programs to improve diet
and increase physical activity in 14 DCs. The tem-
plate presented by van der Sande and colleagues for
the prevention and control of CVD in sub-Saharan
Africa is still highly relevant.78 As suggested in this pa-
per, a comprehensive program will be more acceptable
and effective if it combines prevention and treatment.
As noted for South Africa, the poor, however, may
have limited knowledge on, or interest in, primary
prevention of CVD behavioral risk factors, as meet-
ing their basic needs takes up all their attention and
energy.2 Furthermore, the poor have limited access
to secondary prevention. They are therefore at high
risk and should be targeted, but promoting healthy
lifestyles, including an adequate but prudent diet, may
not be enough inasmuch as limited access to resources
is a major constraint to healthful behaviors. Means of
increasing access to resources are therefore needed,
and particularly so among women, who are dispropor-
tionately poor and disproportionately affected in their
own health and that of their children by poverty. Means
of coupling nutritional improvement with women’s in-
come generation should be sought and exploited as
much as possible. This was the concept behind the red
palm oil development project in Burkina Faso, with
the dual objective of improving vitamin A nutrition
of mothers and children and of generating income for
women extracting and retailing the oil.79
The overlap of malnutrition and NRCDs in the
same population groups is a challenging issue to health
bodies. Creative initiatives are direly needed. Govern-
ments have to be involved in the prevention and con-
trol of chronic diseases, were it only to help individu-
als to make informed choices regarding risk behaviors
Delisle: Poverty and Intergenerational Malnutrition
through fostering the generation of relevant informa-
tion, and making this information widely available and
understood.19 Addressing obesity and chronic diseases
simultaneously is not simple. It even creates a “cul-
tural shock” among decision makers,80 as policies and
programs have been focusing on food insecurity, un-
dernutrition, and micronutrient deficiencies. Vorster
and Kruger plead for an integrated, transdisciplinary,
and multisectoral approach to break the vicious cy-
cle of poverty and undernutrition for the long-term
prevention of CVD.2 Governments must feel the pres-
sure. Diabetes may be a key word, as the associated
health costs are enormous, and health ministries are
well aware of them, more so than of the health risk
associated with obesity.81 Linking diabetes with child
obesity and with maternal risk may be a worthy strat-
egy.
Promoting diets that are adequate, well-balanced,
and safe yet affordable and in line with cultural prac-
tices and local food production appears as one of the
pillars of the prevention of the double burden of malnu-
trition,82 along with the promotion of physical activity.
The 2004 WHO global strategy on diet and physical
activity focused on food, agriculture, and multisectoral
policies to promote healthy eating and physical activ-
ity.9 Traditional diets, oftentimes more diversified and
higher in fruits and vegetables, need to be rehabilitated,
and physical activity has to become socially desirable.
Brazil offers an interesting example. A national food
and nutrition policy was designed early in the new
century to continue to combat nutritional deficien-
cies, while also addressing the prevention of NRCDs.83
The policy is essentially to promote, protect, and
support healthy eating and lifestyle patterns through
legislative measures, communication, and capacity
building.
As stressed by Eckhardt, the most important strat-
egy for reducing the double burden of micronutri-
ent malnutrition and overweight/obesity in nutrition-
transitioning countries is to enhance diet quality
throughout the life cycle.61 For this purpose, develop-
ing dietary guidelines appears important. Food-based
dietary guidelines should become available at the coun-
try or regional level in order to take account of cultural
patterns. For those individuals already diagnosed with
diabetes, health professionals should devise location-
specific and tailor-made eating plans based on up-to-
date international recommendations. For all of this to
happen, the current paucity of well-trained nutrition-
ists in several sub-Saharan regions urgently needs to
be remedied. Indeed a 2005 report by WHO insisted
on preparing the workforce for the growing burden of
chronic diseases.84
181
Preventing all forms of dysnutrition among women
is key, and measures should start early. The school
setting, for instance, is particularly appropriate for pre-
ventive actions.85,86 A recent WHO initiative intended
to fight the double burden of malnutrition in schools,
the “Nutrition-friendly School Initiative,” is being pro-
moted and tested. As suggested by some,39 young gen-
erations in emerging countries are likely to be respon-
sive to messages for the prevention of obesity, much
like in western countries, because of their exposure to
global media.
Maternal and child nutrition should not be di-
chotomized, however, because they are closely con-
nected. This is in line with the approach of the contin-
uum of care for maternal, newborn, and child health.87
Nutrition ought to be integrated in the continuum of
care, at adolescent, prepregnancy, neonatal, and child
care levels. For instance, adolescent and prepregnancy
nutrition is part of family and community care, and
folate and iron supplementation is integrated into re-
productive health care. It is argued in the same paper
that if the eight proposed continuum of care pack-
ages were implemented to reach most families, the
lives of 2/3 of the 10 million babies and children
dying every year could be saved, and many of the
half-million maternal deaths could be averted, along
with many stillbirths. However, the dual burden of
malnutrition in women and the dramatic adverse ef-
fects in the progeny is not explicitly considered in this
strategy.
Surveillance, which provides appropriate informa-
tion for advocating for policy and action tailored to
address the double burden of dysnutrition, is required,
as recently emphasized.71 Sawaya and colleagues, in a
review of the association between chronic undernutri-
tion and hypertension, also suggested that healthcare
practitioners working in low-income urban communi-
ties monitor blood pressure in order to detect and treat
in timely fashion high blood pressure that tends to be
associated with early life malnutrition.88
Research needs in the realm of the double bur-
den of dysnutrition in DCs are pressing. Research
priorities may include, in addition to epidemiological
and surveillance data on chronic disease risk factors
and the prevalence of the double burden, the links
between micronutrient malnutrition and chronic dis-
eases, the contribution of stress of life to chronic dis-
eases particularly in urban settings, changes in food
provisioning of urban and rural communities, and the
relevance and effectiveness of location-specific dietary
guidelines for simultaneously tackling undernutrition,
micronutrient malnutrition, overnutrition, and dietary
imbalances.
182
In summary, improving nutrition, in particular
women’s nutrition, is critical for health, poverty reduc-
tion, and development, and it has to be mainstreamed.
Healthy diets and lifestyles are obviously key for pre-
venting the various forms of under- or overnutrition,
but for the behavioral risk factors to recede, an en-
abling political, physical, socioeconomic, and cultural
environment is needed so that required changes are
feasible. The rising tide of NRCDs is now a compelling
reason to tackle the dual burden of malnutrition in
DCs. Research as well as surveillance should be uti-
lized to fuel advocacy efforts and to inform policy and
programming.
Conflicts of Interest
The author declares no conflicts of interest.
References
1. AHMED, A.U., R.V. HILL, L.C. SMITH, et al. 2007. The
world’s most deprived. Characteristics and causes of ex-
treme poverty and hunger. IFPRI. Washington. 2020 Dis-
cussion Paper No. 43.
2. VORSTER, H. H. & A KRUGER. 2007. Poverty, malnutrition,
underdevelopment and cardiovascular disease: a South
African perspective. Cardiovasc. J. Africa 18: 321–324.
3. SAVE THE CHILDREN. 2007. State of the World’s Mothers
2006. Save the Children. Wesport, CT.
4. BLACKDEN, M. & Q. WODON (Eds). 2006. Gender, time use
and poverty in Sub-Saharan Africa. Washington: World
Bank Working Papers No. 73.
5. NTANDOU, G., H. DELISLE, V. AGUEH & B. FAYOMI. 2008.
Physical activity and socioeconomic status explain rural-
urban differences in obesity: a cross-sectional study in
Benin (West Africa). Ecol. Food Nutr. (in press).
6. DELISLE, H. & O. RECEVEUR. 2007. Les <<dysnutritions>>
dans les pays en développement (lettre). [‘Dysnutrition’ in
developing countries (Letter)]. CMAJ 176: 65.
7. EZZATI, M., V.S. HOORN, C.M.M. LAWES, et al. 2005. Re-
thinking the “diseases of affluence” paradigm: global pat-
terns of nutritional risks in relation to economic develop-
ment. PLoS Med. DOI: 10.1371/journal.pmed.0020133.
8. BARKER, D.J.P. (Ed). 1992. Fetal and Infant Origins of Adult
Disease. BMJ Publ Group. London.
9. WHO. 2004. Global strategy on diet, physical activ-
ity and health. Fifty-seventh World Health Assembly.
WHO. Geneva. Available at: http://who.int/gb/ebwha/
pdf_files/WHA57/A57_R17-en.pdf.
10. WHO. 2007. World Health Statistics. WHO. Geneva. Avail-
able at: www.who.int/whosis/whostat2007/en/index.
html. (Accessed 2008 January 10).
11. MOLINI, V. & M. NUBÉ. 2007. Is the nutritional status of
males and females equally affected by economic growth?
Evidence from Vietnam in the 1990s. United Nations
Annals of the New York Academy of Sciences
University World Institute for Development Economics
Research. Amsterdam. Research Paper No. 2007/54.
12. FRONGILLO, E.A. & F. BÉGIN. 1993. Gender bias in food
intake favors male preschool Guatemalan children. J. Nutr.
123: 189–196.
13. PELLETIER, D. L. & E.A. FRONGILLO. 2003. Changes in child
survival are strongly associated with changes in malnutri-
tion in developing countries. J. Nutr. 133: 107–119.
14. HARVEY, P. 2007. Improving women’s nutrition: a require-
ment for achieving the Millennium Development Goals.
http://www.a2zproject.org/docs/HRHS_Harvey.pdfp.
15. POPKIN, B.M. 2006. Global nutrition dynamics: the world is
shifting rapidly toward a diet linked with noncommunica-
ble diseases. Am. J. Clin. Nutr. 84: 289–298.
16. PRENTICE, A.M. & S.A. JEBB. 2003. Fast foods, energy den-
sity and obesity: a possible mechanistic link. Obesity Rev.
4: 187–194.
17. DREWNOWSKI, A. & S. SPECTER. 2004. Poverty and obesity:
the role of energy density and energy costs. Am. J. Clin.
Nutr. 79: 6–16.
18. PINSTRUP-ANDERSON, P. & F. CHENG. 2007. Still hungry.
Sci. Am. 297: 96–103.
19. ABEGUNDE, D.O., C.D. MATHERS, T ADAM, et al. 2007. The
burden and costs of chronic diseases in low-income and
middle-income countries. Lancet 370: 1929–1938.
20. WHO. 2006. Preventing chronic disease: a vital investment.
WHO. Geneva.
21. PRENTICE, A.M. 2006. The emerging epidemic of obesity in
developing countries. Int. J. Epidemiol. 35: 93–99.
22. FEZEU, L., B. BALKAU, A.P. KENGNE, et al. 2007. Metabolic
syndrome in a sub-Saharan African setting: central obesity
may be the key determinant. Atherosclerosis 193: 70–76.
23. CARLIN, L., T. ASPRAY & R. EDWARDS. 2001. Civilization
and its discontents: non-communicable disease, metabolic
syndrome and rural-urban migration in Tanzania. Urban
Anthropol. 30: 51–70.
24. ADAIR, L.S. & A.M. PRENTICE. 2004. A critical evaluation
of the fetal origins hypothesis and its implications for de-
veloping countries. J. Nutr. 134: 191–193.
25. LOCKYER, L. & M. BURY. 2002. The construction of a mod-
ern epidemic. The implications for women of the gender-
ing of coronary heart disease. J. Adv. Nurs. 39: 432–440.
26. VORSTER, H.H., A. KRUGER, C.S. VENTER, et al. 2007. Car-
diovascular disease risk factors and socio-economic posi-
tion of Africans in transition: the THUSA study. Cardio-
vasc. J. Africa 18: 315–322.
27. GHOLIZADEH, L. & P. DAVIDSON. 2008. More similarities
than differences: an international comparison of CVD
mortality and risk factors in women. Health Care Women
Int. 29: 3–22.
28. DELISLE, H. 2002. Programming of chronic disease by
impaired foetal nutrition: evidence and implications
for policy and intervention strategies. WHO, Dept
Nutrition for Health and Development. Geneva.
WHO/NHD/02.3.
29. GLUCKMAN, P.D., M.A. HANSON & C. PINAL. 2005. The de-
velopmental origins of adult disease. Matern. Child Nutr.
1: 130–141.
30. LAW, C. 2005. Early growth and chronic disease: a public
health overview. Matern. Child Nutr. 1:169–176.
Delisle: Poverty and Intergenerational Malnutrition
31. BARKER, D.J. 2006. Adult consequences of fetal growth re-
striction. Clin. Obstet. Gynecol. 49: 270–283.
32. DENNISON, C.R., N. PEER, K. STEYN, et al. 2007. Determi-
nants of hypertension care and control among peri-urban
Black South Africans: the HiHi study. Ethn. Dis. 17: 484–
491.
33. YUSUF, S., S. HAWKEN, S. OUNPUU, et al. 2004. Effect of
potentially modifiable risk factors associated with myocar-
dial infarction in 52 countries (the INTERHEART study):
case-control study. Lancet 364:937–952.
34. STEYN, K., K. SLIWA, S. HAWKEN, et al. (INTERHEART
INVESTIGATORS IN AFRICA). 2005. Risk factors associated
with myocardial infarction in Africa. The INTERHEART
Africa Study. Circulation 112: 3554–3561.
35. FLORÊNCIO, T.T., H.S. FERREIRA, J.C. CAVALCANTE & A.L.
SAWAYA. 2004. Short stature, obesity and arterial hyper-
tension in a very low income population in North-eastern
Brazil. Nutr. Metab. Cardiovasc. Dis. 14: 26–33.
36. SHAKHATREH, F.M.N., A.A. SULEIMAN, F.I. MOHAMMED &
A.A. ALWAN. 2008. Hypertension among females in a
highly disadvantaged community in Jordan. Health Care
Women Int. 29: 39–53.
37. LONGO-MBENZA, B., E. LUKOKI LUILA & J.R. M’BUYAMBA-
KABANGU. 2007. Nutritional status, socio-economic status,
heart rate, and blood pressure in African school children
and adolescents. Int. J. Cardiol. 121: 171–177.
38. MONTEIRO, C.A., W.L. CONDE & B.M. POPKIN. 2004. The
burden of disease from undernutrition and overnutrition
in countries undergoing rapid nutrition transition: a view
from Brazil. Am. J. Pub. Health 94: 433–434.
39. SIERVO, M., P. GREY, O.A. NYAN & A.M. PRENTICE. 2006.
Urbanization and obesity in The Gambia: a country in
early stages of the demographic transition. Eur. J. Clin.
Nutr. 60: 455–463.
40. HOLDSWORTH, M., A. GARTNER, E. LANDAIS, et al. 2004.
Knowledge of dietary and behaviour-related determi-
nants of non-communicable disease in urban Senegalese
women. Int. J. Obesity Related Metab. Disord. 28: 1561–
1568.
41. KRUGER, H.S., C.S. VENTER, H.H. VORSTER, et al. 2002.
Physical inactivity is the major determinant of obesity in
black women in the North-West Province, South Africa:
the THUSA study. Nutrition: Int. J. Appl. Basic Nutr. Sci.
18: 422–427.
42. WHO EXPERT CONSULTATION. 2004. Appropriate body-
mass index for Asian populations and its implications for
policy and intervention strategies. Lancet 363: 157–163.
43. SHAFIQUE, S., N. AKHTER, G. STALLKAMP, et al. 2007. Trends
of under- and overweight among rural and urban poor
women indicate the double burden of malnutrition in
Bangladesh. Int. J. Epidemiol. 36: 449–457.
44. VAN DER SANDE, M.A.B., S.M. CEESAY, P.J.M. MILLIGAN,
et al. 2001. Obesity and undernutrition and cardiovascular
risk factors in rural and urban Gambian communities. Am.
J. Pub. Health 91: 1641–1644.
45. FAO. 2006. The double burden of malnutrition. Case stud-
ies from six developing regions. FAO. Rome. Food and
Nutrition Paper No 84.
46. SUBRAMANIAN, S.V., I. KAWACHI & G. DAVEY SMITH. 2007.
Income inequality and the double burden of under- and
183
overnutrition in India. J. Epidemiol. Community Health
61: 802–809. doi:10.1136/jech.2006.053801.
47. GARRETT, J.L. & M.T. RUEL. 2005. Stunted child-overweight
mother pairs: prevalence and association with economic
development and urbanization. Food Nutr. Bull. 26: 209–
221.
48. DOAK, C., L.S. ADAIR, C. MONTEIRO & B.M. POPKIN.
2000. Overweight and underweight coexist within house-
holds in Brazil, China and Russia. J. Nutr. 130: 2965–
2971.
49. KHOR, G.L. & Z.M. SHARIF. 2003. Dual forms of malnu-
trition in the same households in Malaysia—a case study
among Malay rural households. Asia Pacific J. Clin. Nutr.
12: 427–438.
50. RAPHAEL, D., H. DELISLE & C. VILGRAIN. 2005. Households
with undernourished children and overweight mothers:
is this a concern for Haiti? Ecol. Food Nutr. 44: 147–
165.
51. BOUZITOU NTANDOU, G.D., B. FAYOMI & H. DELISLE.
2005. Malnutrition infantile et surpoids maternel dans
des ménages urbains pauvres du Bénin. Cahiers Santé
15: 263–270.
52. DOAK, C.M., L.S. ADAIR, M. BENTLWEY, et al. 2005. The
dual burden household and the nutrition transition para-
dox. Int. J. Obesity 29: 129–136.
53. STEYN, N.P., D. LABADARIOS, E. MAUNDER, et al. 2005. Sec-
ondary anthropometric data analysis of the national food
consumption survey in South Africa: the double burden.
Nutrition 21: 4–13.
54. BARQUERA, S., K.E. PETERSON, A. MUST, et al. 2007. Coex-
istence of maternal central adiposity and child stunting in
Mexico. Int. J. Obes. 31: 601–607.
55. TLADINYANE, P. 2003. The difference in factors influencing
childcare between others/caregivers of undernourished
and well nourished children aged 1–4 years in Oukasie
(Brits), North West Provence (masters thesis). Pretoria:
MEDUNSA.
56. SAWAYA, A.L., P. MARTINS, D. HOFFMAN & S.B. ROBERTS.
2003. The link between childhood undernutrition and risk
of chronic diseases in adulthood: a case study of Brazil.
Nutr. Rev. 61:168–175.
57. HOFFMAN, D.J., A.L. SAWAYA, I. VERRESCHI, et al. 2000.
Why are nutritionally stunted children at increased risks
of obesity? Studies of metabolic rate and fat oxidation in
shantytown children from Sao Paolo, Brazil. Am. J. Clin.
Nutr. 72: 702–707.
58. ASFAW, A. 2007. Micronutrient deficiency and the preva-
lence of mothers’ overweight/obesity in Egypt. Econ.
Hum. Biol. 5: 471–483.
59. BOULÉ, N.G., A. TREMBLAY, J. GONZALEZ-BARRANCO, et al.
2003. Insulin resistance and abdominal adiposity in young
men with documented malnutrition during the first year
of life. Int. J. Obesity 27: 598–604.
60. MI, J., C. LAW, K. L. ZHANG, et al. 2000. Effects of infant
birthweight and maternal body mass index in pregnancy
on components of the insulin resistance syndrome. Ann.
Int. Med. 132:253–260.
61. ECKHARDT, C.L. 2006. Micronutrient malnutrition, obe-
sity, and chronic disease in countries undergoing the
nutrition transition: potential links and program/policy
184
implications. IFPRI. Washington. FCND Discussion Pa-
per 213.
62. ECKHARDT, C.L., L.E. TORHEIM, E. MONTERRUBIO, et al.
2007. The overlap of overweight and anaemia among
women in three countries undergoing the nutrition tran-
sition. Eur. J. Clin. Nutr. 21: 1–9.
63. GILL, K., R. PANDE & A. MALHOTA. 2007. Women deliver
for development. Lancet 370: 1347–1357.
64. SMITH, L., U. RAMAKRISHNAN & A. NDIAYE. 2003. The
importance of women’s status for child nutrition in devel-
oping countries. Washington: IFPRI Research Report No.
131.
65. ASMANI, S. & A. SEN. The hidden penalties of gender in-
equalities: the fetal origin of ill-health. Econ. Human. Biol
1: 105–121.
66. DELISLE, H. 2005. Early nutritional influences on obe-
sity diabetes and cardiovascular disease risk. Inter-
national Workshop, Université de Montréal, June 6–
9, 2004. Introduction. Maternal Child Nutr. 1: 128–
129.
67. DELISLE H. 2005. Nutrition in infancy and chronic disease
in later life: overview and public health significance for
developing countries. In H.H.Y. Vorster, R. Blaauw, &
M.A. Dhansay, et al., Eds.: Proceedings 18th International
Congress of Nutrition 19–23 September 2005 Durban,
South Africa. Annals Nutr Metab (online).
68. ESHRE [EUROPEAN SOCIETY FOR HUMAN REPRODUCTION
AND EMBRYOLOGY] CAPRI WORKSHOP GROUP. 2006. Nu-
trition and reproduction in women. Hum. Reprod. Up-
date 12: 193–207.
69. BALE, J.R., B.J. STOLL & A.O. LUCAS (Eds.) 2003. Improv-
ing birth outcomes: meeting the challenge of the devel-
oping world. Committee on Improving Birth Outcomes,
Institute of Medicine of the National Academies. National
Academies Press. Washington, DC.
70. DELISLE, H., P. GHADIRIAN, B. SHATENSTEIN & I. STRYCHAR.
2005. Early nutritional influences on obesity diabetes and
cardiovascular disease risk. International Workshop, Uni-
versité de Montréal, June 6–9, 2004. Evidence and im-
plications for research and action—a summary. Maternal
Child Nutr. 1: 216–222.
71. CHOPRA, M. & I. DARNTON-HILL. 2006. Responding to the
crisis in sub-Saharan Africa: the role of nutrition. Public
Health Nutr. 9: 544–550.
72. BERAN, D. & J.S. YUDKIN. Diabetes care in sub-Saharan
Africa. Lancet 368:1689–1695.
73. INTERNATIONAL CENTRE FOR RESEARCH ON WOMEN
[ICRW]. 2005. A second look at the role education plays
in women’s empowerment. ICRW. Washington.
74. WALLERSTEIN, N. 2007. What is the evidence on effec-
tiveness of empowerment to improve health? WHO Of-
fice for Europe. Copenhagen. Health Evidence Network
Annals of the New York Academy of Sciences
report http://www.euro.who.int/Document/E88086.pdf
(Accessed Nov 20, 2007).
75. UNICEF. 2007. The state of the world’s children 2007.
Women and children – The double dividend of gender
equality. UNICEF. New York.
76. KUSIN, J.A. & V.G. MARKELL. 2006. Report on the Nutrition
and Gender Initiative as implemented by the International
Center for Research on Women September 2002–2005.
Washington: ICRW.
77. DOAK, C. 2002. Large-scale interventions and programmes
addressing nutrition-related chronic diseases and obesity:
examples from 14 countries. Public Health Nutr. 5: 275–
277.
78. VAN DER SANDE, M.A.B., R.L. COLEMAN, M.F.S. VAN DER
LOEFF, et al. 2001. A template for improved prevention and
control of cardiovascular disease in Sub-Saharan Africa.
Health Policy Plann. 16: 345–350.
79. DELISLE, H. 2006. Potential of red palm oil for the con-
trol of vitamin A deficiency in sub-Saharan Africa:
Five years of research in Burkina Faso. Sight Life 3:
22–27.
80. SOLOMONS, N.W. 2005. Programme and policy issues re-
lated to promoting positive early nutritional influences to
prevent obesity, diabetes and cardiovascular disease in later
life: a developing countries view. Matern. Child Health 1:
204–215.
81. JAMES, P.T. 2004. Obesity: the worldwide epidemic. Clin.
Dermatol. 22: 276–280.
82. UAUY, R. & N.W. SOLOMONS. 2006. The role of the inter-
national community: forging a common agenda in tack-
ling the double burden of malnutrition. SCN News 32:
24–37.
83. COITINHO, D., C.A. MONTEIRO & B.M. POPKIN. 2002.
What Brazil is doing to promote healthy diets and active
lifestyles. Public Health Nutr. 5: 263–267.
84. WHO REPORT. 2005. Preparing a health care workforce for
21st Century: the challenge of chronic conditions. World
Health Organization. Geneva.
85. KAIN, J., R. UAUY, F. VIO, et al. 2004. School-based obesity
prevention in Chilean primary school children: method-
ology and evaluation of a controlled study. Int. J. Obes.
Relat. Metab. Disord. 28: 483–493.
86. DELISLE, H. & I. STRYCHAR. 2006. Obesity at adolescence:
prevention is timely even in low income countries. Stand-
ing Committee on Nutrition News 32: 51–57.
87. KERBER, K.J., E. DE GRAFT-JOHNSON, Z.A. BHUTTA, et al.
2007. Continuum of care for maternal, newborn, and
child health: from slogan to service delivery. Lancet 370:
1358–1369.
88. SAWAYA, A.L., R. SESSO, T.T. FLORÊNCIO, et al. 2005. Asso-
ciation between chronic undernutrition and hypertension.
Mat. Child Nutr. 1: 155–163.