CRISIS AND OPPORTUNITY OF THE DOUBLE BURDEN ⇢ page 12 Ulla Lohmann © DOUBLE BURDEN OF MALNUTRITION 76 113 130 DOUBLE BURDEN HOW TO GET CONSUMERS TO NEW FRAMEWORK AT INDIVIDUAL LEVEL CHOOSE FRUITS AND NOT FRIES FOR PPPS FOR NUTRITION Contents 05 Editorial 76 Double Burden of Malnutrition at the Individual Level 08 Glossary 82 From What to How 10 When Biological Systems Meet Food Systems 86 Maximizing the Potential of Multisectoral 12 Infograph: Shared drivers of the double burden Nutrition Policies for Double-duty Actions of malnutrition across the life course 94 BMI and Adiposity in Children Food for Thought 98 Addressing Capacity Challenges 14 Addressing the Double Burden of Malnutrition as both Crisis and Opportunity 103 Equipping Chefs with the Language of the Sustainable Development Goals Research-Based Evidence 108 Putting Food in Food 18 A Life-course Approach for Influencing Policies to Prevent Childhood Malnutrition 113 How to Get Consumers to Choose Fruits, not Fries 24 The Double Burden of Malnutrition 119 A Children’s Rights Approach to the 29 Consumption of Empty-calorie Snack Foods Double Burden of Malnutrition Raises Cost of Nutritious Diet 125 The Double Food and Environmental Pyramid 40 Essential Nutrient Requirements not Met by Diets High in Staple Foods 130 A New Framework for Public-Private Partnership for Nutrition 49 Breastfeeding Special Feature 55 Malnutrition among Adolescents in Low- and Middle-income Countries 140 “ You Are What Your Mother Ate” Perspectives in Nutrition Science 149 The Sizanani Mzanzi Marketing Mix 64 Time to Recalibrate Nutrition Improvement Strategy? The Bigger Picture 72 Eat. Think. Solve. 156 A Day in the Life of Arlette Eulert Checa Congress Reports 160 EAT Forum 2018 163 The Carotenoids and Retinoid Interaction Group (CARIG) Conference Meets in Boston 167 Sight and Life Elevator Pitch Contest 2018 Field Reports 172 Nutrient Density as a Dimension of Dietary Quality 177 Preventing Micronutrient Deficiencies Using African Indigenous Vegetables in Kenya and Zambia 182 OBAASIMA 186 What’s new 196 Letters to Sight and Life 200 Reviews & Notices 202 Imprint 05 Welcome The Double Burden or The New Norm The nutrition policy arena has made laudable efforts in pro- In his recently published book Factfulness, the late Dr Hans viding a space to bring all forms of malnutrition onto the policy Rosling beautifully compares people’s different standards of agenda. Although the double burden remains a largely untapped living to levels of a computer game whereby everyone wishes area for integrated action, there are opportunities to act. The to move from Level 1 (living on US$1 per day), to Level 2 (living Decade of Action on Nutrition, which calls for coordinated ac- on US$4 a day) and Level 3 (living on US$16 a day), all the way tion through coherent and cross-cutting policies, initiatives and to Level 4 (living on more than US$32 a day).1 While 200 years programs, represents a unique entry-point to comprehensively ago, 85 percent of the world was living in extreme poverty, on address the double burden of malnutrition.4 Level 1 today, the vast majority of people are spread out in the In recent years, several major global policy developments middle, across Levels 2 and 3, thanks to remarkable improve- – including the G20 meeting in Berlin in 2017, the G7 Agricul- ments in health, education, water and sanitation, hygiene and tural Ministerial meeting in Bergamo and the Global Nutrition economic growth, among many other factors.1 Summit in Milan – amplified the opportunity of using a food- Although there is still a long way to go, it is important to cel- systems approach to tackle the multiple challenges of hunger, ebrate these developments while keeping sight of the challenges obesity, climate change, jobs, inequality and growth, and helped ahead. It was only three years ago that the optimist in each one to maintain momentum towards creating a sustainable future.5 of us applauded the soaring progress by many countries to- Progress toward the 2030 Agenda for Sustainable Development wards achieving the Millennium Development Goal of eradicat- continues, as the United Nations Statistical Commission formal- ing extreme poverty and hunger. In recent decades, as low- and ly adopted the indicator framework to track progress on meeting middle-income countries made economic advances and under- the Sustainable Development Goals (SDGs). went the nutrition transition, their undernutrition rates declined (despite the latest increase in the past two years as confirmed “Key questions remain unanswered” in the 2017 and 2018 SOFI report). Yet here we are, grappling with the inconvenient truth that 462 million people are under- weight,2 that over 2 billion people are overweight or obese, and Key questions, however, remain unanswered, and a lack of that this latter estimate is used to describe the number of people scientific consensus is slowing down governments, businesses who suffer from hidden hunger. 3 These different forms of mal- and civil society actors who want to take action. In this light, nutrition can coexist within countries and communities, within the EAT-Lancet Commission on Food, Planet, Health is taking on households, and even within the same person over their lifetime. these challenges and will soon provide a scientific consensus to The double burden of malnutrition has become the new norm in the global community and offer solutions as to how all actors many parts of the world. can provide populations with healthy diets from a sustainable food system. The International Symposium on Understanding An unparalleled opportunity the Double Burden of Malnutrition for Effective Interventions The data is alarming. While more than one in eight adults in organized by the International Atomic Energy Agency (IAEA) the world is obese, one in three women of reproductive age is in December 2018 in Vienna is another event that will provide anemic.3 We trust that this issue of Sight and Life magazine will further direction on the epidemiology, biology, assessment, in- sufficiently expose our readers to additional and similar data re- terventions and policy implications for the double burden. flecting this trend. Yet, in the midst of all this, optimism screams We hope that you will find this issue of Sight and Life maga- at us: global attention to addressing the multiple forms of mal- zine useful and thought-provoking. The aim of this publication nutrition is unparalleled. has always been to provide a space to share new knowledge and 06 EDITORIAL: THE DOUBLE BURDEN OR THE NEW NORM insights and to stimulate discussion rather than to solely pro- Unfortunately, no single solution or ‘one-size-fits all’ ap- vide answers and solutions. This special edition on the double proach exists due to the many factors that exacerbate this public burden seeks to bring all actors to the table and, more impor- health issue. In our ‘Food for Thought’ piece, we reflect on the tantly, to include new voices in the discourse. importance of science in the discussion. Consolidated data on the global landscape to understand its magnitude and extent, Beyond business as usual the impact of climate change and mass urbanization, food and Let us introduce you to Joy. She is 21 and lives with her three agricultural systems, legislation, consumer behavior and the children and husband in the fishing village of Nyanyano in role of the private sector are areas we need to understand to Ghana. Her husband is a fisherman who spends most of the ensure the problem is not viewed in isolation. month away from the village. Joy works selling fried food on Engagement with the food industry is often given lip service, the street. Her three children are malnourished, and her oldest but examples of real collaboration are rare. With a lack of trust, child has suffered from an eye infection for two years without due particularly to the marketing of unhealthy foods to children medical treatment. She feels alienated and alone. She can- and the lack of adherence to the breastfeeding code, relations not afford to take her children to hospital for treatment or get are strained. However, sustainable, lasting solutions to the dou- the food supplements the nurse recommends. The local clinic ble burden of malnutrition require us to engage the food indus- serves a population of 40,000 with just a handful of com- try through a sharing of goals. Food companies have technical munity nurses. Most children never visit the center because and marketing experience and expertise that can support the of the stigma it brings. development of affordable, nutritious foods, particularly for con- In the same village, Ana, aged 40, lives with her six children sumers at the base of the pyramid. These relationships should in a two-bedroomed house. Her husband left two years ago, and be managed through incentives and regulatory frameworks that she is the sole provider. She earns her living by selling fruit at support healthy eating principles. her market stall – fruit she and her family never eat, as it is their Low- and middle-income countries are continuing to tackle main source of income. Long hours and economic constraints undernutrition while finding themselves increasingly chal- result in her buying food that is available, convenient and cheap. lenged to fight growing rates of overweight and obesity. These Unfortunately, this often means consuming foods high in fat, countries cannot afford to ignore the potential of unhealthy salt and sugar and low in vitamins and minerals. Due to her in- diets. A food system that is efficient in delivering healthy food creased weight gain, she now struggles to stay on her feet all day, to all at an affordable price, in all situations, is required. High- and work is becoming more difficult.