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The Growing Double Burden of Malnutrition in Asia and the Pacific:

Regional Action for Global Public Goods

Lawrence Haddad Institute of Development Studies UK

What is the double burden of malnutrition? Classifying the 9 countries Consequences Policy menu Framing Priorities Evidence Gaps Implications for Australian stakeholders

What is the Double Burden?

Interaction of low calorie, low micronutrient diets & infection Manifestations
Premature death Low height for age, weight for age, weight for height Micronutrient diseases Cognitive deficits Immune system deficits Depression

Consumption of too much fat, sugar, salt & too little exercise Manifestations
Premature death Obesity, overweight Hypertension, diabetes Heart disease Depression

Emergence from poverty in a Westernised, increasingly urbanised , processed food context Information asymmetries Urban space that is not conducive to exercise Undernutrition at an early age in life

Poverty Food insecurity Poor care and feeding practices Poor health environment Lack of proven interventions Lack of government commitment

Double Burden Countries Western Countries

Pre- Double Burden Countries

The two burdens are connected

o diet, information asymmetries o 3 layers of drivers: immediate, underlying, fundamental

o metabolic programming: Barker hypothesis

o within health budgets: competition between primary and tertiary spending

o Urban vs rural, middle income vs lowest income

Double Burden Countries Western Countries

Pre- Double Burden Countries

Levels and Trends

Five Categories of Country

Double burden countries: PNG, the Solomon Islands and the Philippines
Philippines, undernutrition declining slowly, but adult overweight is high and child overweight is increasing PNG and the Solomon Islands, the double burden appears set to stay. Undernutrition is decreasing very slowly and adult overweight rates are very high.

On the verge of double burden: Indonesia and Myanmar

Undernutrition rates are declining quite rapidly and adult overweight is at medium levels relative to the other countries highlighted in this report. Indonesia is especially worrying given the rapid increase in overweight rates of under 5s

On the way to double burden: Lao PDR

Slow decline in undernutrition, medium levels of adult overweight, no increase in under 5 overweight

Undernutrition only, but worsening: Timor Leste

Very high undernutriiton, rates increasing. Overweight rates low and not increasing.

Progress on reducing undernutrition while overnutrition not taking off: Vietnam, Cambodia
Vietnam - star performer of the set of 9 countries, showing rapid declines in undernutrition, with a low and stable overnutrition situation. Cambodia following in Vietnams footsteps, although it has not yet achieved the same pace of change in undernutrition reduction.


Malnutrition (under and over) is responsible for 25% of DALYs

30 25 20

10 5

Cambodia Indonesia Lao PDR Dietary Risks Childhood underweight high plasma fasting glucose high total cholesterol Myanmar Philippines Timor Leste Iron Deficiency sub-optimal breastfeeding high body mass index

Calculated from GBD Country Profiles at:

Summary Consequences of Undernutrition

Undernutrition = 11% of GNP in Asia and Africa Undernutrition = 2-11% of GDP in Central America 45% of all under 5 child Underweight remains the Reducing stunting adds about one deaths (3 million deaths) number one contributor to the grade to school attainment: multi are caused by Burden of Disease in Sub-Saharan country undernutrition: multi Africa and number 4 in South country Asia One extra cm of adult The economic benefit of preventing Guatemala: Hourly earnings up by 20% height corresponds to a LBW is $510 per infant: multi 4.5% increase in wage rates: Wage rates up by 48% country 33% more likely to escape poverty multi country women 10% more likely to own their
own business

Preventing undernutrition and low birth weight early in life reduces the risk of chronic disease striking decades later

Stunted women are 3 times as Preventing undernutrition will likely to give birth to children supercharge the demographic who are stunted by 2 years of age dividend

Source: Haddad 2013

Summary of Consequences of Overnutrition

World Bank 2011:
China: Reducing cardiovascular mortality by 1% per year between 2010 and 2040 could generate an economic value equivalent to 68% of Chinas real GDP in 2010 or over PPP US$10.7 trillion World Bank 2011. Egypt: NCDs could be leading to an overall production loss of 12% of Egypts GDP Brazil: Costs of NCDs between 2005 and 2009 could equal 10% of Brazils 2003 GDP India: Eliminating NCDs could have, in theory, increased Indias 2004 GDP by 4%-10%

Stuckler 2008
Multi-country study: for every 10 percent increase in NCD related mortality, annual economic growth would by reduced by 0.5 percent (Stuckler 2008), an estimate that led the World Economic Forum to rank NCDs as one of the top global threats to economic development

Abegunde 2008
In the ASEAN region, a total of seven billion dollars is estimated to have been lost between 2006 and 2015 as a result of NCDs in just five ASEAN nations: Myanmar, Indonesia, the Philippines, Thailand and Vietnam.

Policy Menu

Nutrition Policy Pillars

Sector Sustainable Food Security Food Safety Healthy Lifecycle Nutrition

Policy menu
Overwhelming or an opportunity? Need to start somewhere Importance of prioritisation Countries need support to prioritise action Some cross learning across high, middle, low income countries


Priorities for post 2015 as voted for by citizens of the countries:

Reduce undernutrition for better education, Reduce overnutriton for reduction in healthcare needs
Rank (out of 16) 1 2 Cambodia Good education Better healthcare Indonesia Good education Better healthcare Lao PDR Good education Better healthcare Access to clean water and sanitation Myanmar Good education Better healthcare Honest and responsive government Philippines Good education Better healthcare Better job opportunities PNG Good education Better healthcare Honest and responsive government Solomon Islands Good education Honest and responsive government Timor Lest Good education Better Healthcare

Honest and Honest and responsive responsive government government

Better job Affordable opportunities and nutritious food



Country Philippines PNG

Country priorities from desk review

Double Burden

S olomon Islands Indonesia

On verge of double burden



On the way to double burden Timor Leste

S ubstantial progress in Cambodia reducing undernutrition, no Vietnam take-off of overnutrition

Priorities for further progress in reducing malnutrition Overall effectiveness of government programmes to improve Urgently need to develop an overnutrition strategy Commitment to malnutrition reduction Collect data on the nutrition situation Improve health environment Adolescents and WRA, Womens Empowerment Food security policy needs to embed disaster risk reduction within it Improve sanitation levels Increased promotion of environments that are conducive to increased physical exercise Food security policy needs to embed disaster risk reduction within it Use S UN to realise potential for a big push overnutrition on undernutrition Need to ramp up attention to Link womens empowerment to nutrition efforts Use S UN to realise increased commitment to stunting reduction Improve health environment S trengthen social protection Focus on strengthening rights basis of service provision Develop an overnutrition strategy Use S UN to realise increased commitment to stunting reduction S trengthen implementation capacity Adolescents and WRA Promote smallholder growth Build in accountability mechanisms Commitment to malnutrition reduction S trengthen implementation capacity Adolescents and WRA Monitor any growing threat of overnutrition Adolescents and women of reproductive age Improve health environment Ensure income growth continues to reduce stunting Focus more on improving infant feeding, enforce new legislation Need health system strengthening

Evidence Gaps
PNG hardly any data until very recently Myanmar, Timor Leste have more data but too little analysis Estimates of consequences of under and over nutrition from the region Little evidence on what works to combat overnutrition No tools for prioritisation and sequencing of actions

Australias Role?

Malnutrition in the region is not in Australian self interest

G20 commitment to add 2% to growth projections over next 5 years-malnutrition is an economic drag Region benefitted from resource boom, coming to an end, but demographic dividend is on horizon: time to invest in a new resource booma human one

Regional Leadership for an invaluable set of Global Public Goods

Bolster commitment: only 3 of 9 countries are SUN members Build the evidence base that everyone outside the region will rush to use Develop the capacity that everyone outside the region will learn from Support civil society to address the double burdenthey are currently split Innovate around role of private sector Support a regional data revolution
e.g. support INFORMAS

Solidarity and cross-learning

Problems and solutions everywhere