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Levels, Determinants, Consequences, Policy Options and Australia's strategic role
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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
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
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
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.
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.
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
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
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
• 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
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