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

Regional Action for Global Public Goods

Lawrence HaddadInstitute of Development Studies

UK

Outline• 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?

Under-nutrition• 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

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

Over-nutrition• Consumption of too much fat, sugar, salt

& too little exercise• Manifestations

• Premature death• Obesity, overweight• Hypertension, diabetes• Heart disease• Depression

• Drivers• 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

Malnutrition

Western Countries

Double Burden Countries Pre- Double Burden Countries

The two burdens are connected

• Conceptuallyodiet, information asymmetrieso3 layers of drivers: immediate, underlying, fundamental

• Physiologically ometabolic programming: Barker hypothesis

• Financiallyowithin health budgets: competition between primary and tertiary spending

• PoliticallyoUrban vs rural, middle income vs lowest income

Western Countries

Double Burden 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 5’s 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 Vietnam’s footsteps, although it has not yet achieved the same pace of change in

undernutrition reduction.

Consequences

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

0

5

10

15

20

25

30

Cambodia Indonesia Lao PDR Myanmar Philippines Timor LesteDietary Risks Iron DeficiencyChildhood underweight sub-optimal breastfeedinghigh plasma fasting glucose high body mass indexhigh total cholesterol

Calculated from GBD Country Profiles at: http://www.healthmetricsandevaluation.org/gbd/country-profiles#c

Summary Consequences of UndernutritionUndernutrition = 11% of GNP in Asia and Africa

Undernutrition = 2-11% of GDP in Central America45% of all under 5 child deaths (3 million deaths) are caused by undernutrition: multi country

Underweight remains the number one contributor to the Burden of Disease in Sub-Saharan Africa and number 4 in South Asia

Reducing stunting adds about one grade to school attainment: multi country

One extra cm of adult height corresponds to a 4.5% increase in wage rates: multi country

Guatemala: Hourly earnings up by 20% Wage rates up by 48% 33% more likely to escape poverty women 10% more likely to own their

own business

The economic benefit of preventing LBW is $510 per infant: multi country

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

Stunted women are 3 times as likely to give birth to children who are stunted by 2 years of age

Preventing undernutrition will supercharge the demographic 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 China’s 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 Egypt’s GDP”• Brazil: “Costs of NCDs between 2005 and 2009 could equal 10% of Brazil’s 2003 GDP”• India: “Eliminating NCDs could have, in theory, increased India’s 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 PillarsSector Sustainable Food Security Food Safety Healthy Lifecycle NutritionHealth

Food safety and hygiene regulations

Promotion of healthy eating Micronutrient supplementation

Food inspections Limit availability inappropriate food Nutrition educationFood standards Promotion of exercise Nutrition surveillance

Infection control Baby friendly hospitalsFamily planning, Protection from child marriage

Public works/urban development

Rural roads

Water and sanitation

Urban bike lanes Smoke free home environments

Irrigation Pedestrian walkways Agriculture Food availability,

productionFood standards Locally available fruit and vegetables

Education

School gardens Hygiene education Physical exercise Nutrition education, including breastfeeding and complementary feeding education

School meals Life skills and sex education Anemia controlSocial welfare/security

Food access (cash transfers)

Unconditional & Conditional cash transfers

Industry/Trade/Commerce

Food availability (manufacturing and marketing)

Food standards

Food fortificationLocally available fruits and vegetablesWorkplace support for breastfeeding women

Public information

Marketing of food to children Code of marketing of breastmilk substitutes

Finance/Economy

Food subsidies

Food taxes Import/export restrictions

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

Framing

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)

Cambodia Indonesia Lao PDR Myanmar Philippines PNG Solomon Islands

Timor Lest

1 Good education

Good education

Good education

Good education

Good education

Good education

Good education

Good education

2 Better healthcare

Better healthcare

Better healthcare

Better healthcare

Better healthcare

Better healthcare

Honest and responsive government

Better Healthcare

3 Honest and responsive government

Honest and responsive government

Access to clean water

and sanitation

Honest and responsive government

Better job opportunities

Honest and responsive government

Better job opportunities

Affordable and nutritious

food

www.myworld2015.org

Priorities

Typology Country Priorities for further progress in reducing malnutrition Double Burden

Philippines Overall effectiveness of government programmes to improve Urgently need to develop an overnutrition strategy

PNG Commitment to malnutrition reduction Collect data on the nutrition situation Improve health environment Adolescents and WRA, Women’s Empowerment Food security policy needs to embed disaster risk reduction within it

Solomon Islands

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

On verge of double burden

Indonesia Use SUN to realise potential for a big push overnutrition on undernutrition Need to ramp up attention to Link women’s empowerment to nutrition efforts

Myanmar Use SUN to realise increased commitment to stunting reduction Improve health environment Strengthen social protection Focus on strengthening rights basis of service provision Develop an overnutrition strategy

On the way to double burden

Lao PDR Use SUN to realise increased commitment to stunting reduction Strengthen implementation capacity Adolescents and WRA Promote smallholder growth Build in accountability mechanisms

Timor Leste Commitment to malnutrition reduction Strengthen implementation capacity Adolescents and WRA Monitor any growing threat of overnutrition

Substantial progress in reducing undernutrition, no take-off of overnutrition

Cambodia Adolescents and women of reproductive age Improve health environment Ensure income growth continues to reduce stunting

Vietnam Focus more on improving infant feeding, enforce new legislation Need health system strengthening

Country priorities from desk

review

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

Australia’s 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 boom—a 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 burden—they 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