THE DOUBLE BURDEN OF MALNUTRITION IN EAST ASIA AND THE PACIFIC: EVIDENCE AND LESSONS FOR A Public Disclosure Authorized MULTISECTORAL RESPONSE DISCUSSION PAPER DECEMBER 2016 Roger Shrimpton Nkosinathi Vusizihlobo Mbuya Public Disclosure Authorized Anne Marie Provo Public Disclosure Authorized Public Disclosure Authorized THE DOUBLE BURDEN OF MALNUTRITION IN EAST ASIA AND THE PACIFIC: Evidence and Lessons for a Multisectoral Response Roger Shrimpton Nkosinathi Vusizihlobo Mbuya Anne Marie Provo December 2016 1 ii Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: [email protected]. © 2016 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW Washington, DC 20433 All rights reserved. iii Health, Nutrition, and Population (HNP) Discussion Paper The Double Burden of Malnutrition in East Asia and the Pacific: Evidence and Lessons for a Multisectoral Response Roger Shrimpton,a Nkosinathi Vusizihlobo Mbuya,b Anne Marie Provoc a Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, USA b Health, Nutrition, and Population Global Practice, The World Bank, Washington, DC, USA c Health, Nutrition, and Population Global Practice, The World Bank, Washington, DC, USA Paper prepared in support of The World Bank’s work on nutrition in the East Asia and Pacific region with financial support from Australian Department of Foreign Affairs and Trade (DFAT) Abstract: Global trends indicate that overlapping burdens of undernutrition and overnutrition—the double burden of malnutrition (DBM)—are the new normal (IFPRI 2014); indeed, most East Asia and Pacific (EAP) countries now have a DBM problem. This report explores the nature of nutrition problems affecting EAP countries to understand the sectoral and system-wide actions necessary for a coordinated approach to improving nutrition. The report (i) synthesizes evidence related to the burden of malnutrition in EAP, (ii) identifies the rationale for a multisectoral approach to DBM practitioners working across sectors in EAP, and (iii) provides an overview of the types of actions and interventions needed to address the DBM in a coordinated fashion across the life course. Actions across health and nonhealth sectors—ranging from implementation of national- level policy measures and complemented by interventions at the community and individual levels to support behavior change—are needed to prevent escalation of overweight and obesity. Among sectoral priority actions, the health sector plays an important role in monitoring health and nutrition outcomes, preventing and treating infectious and noncommunicable diseases associated with malnutrition, and providing interventions that affect individuals’ nutrient intakes. Similarly, nonhealth sectors have expertise and resources to deliver interventions related to the underlying causes of malnutrition. Further, systems-strengthening efforts are needed to support an environment that addresses the DBM across the life course, including increasing DBM-sensitivity of policy frameworks; leadership, coordination, and accountability; workforce capacity; and knowledge and evidence. iv Reducing the DBM is fundamental to sustainable development in EAP. EAP countries must shift from dichotomized policies addressing either undernutrition or overnutrition and develop coherent frameworks to address malnutrition in all forms for all life stages. Integrated preventive and curative interventions for undernutrition and overnutrition— implemented across the life course by multiple sectors—can forestall massive economic and human development consequences for future generations. Keywords: nutrition, malnutrition, stunting, overweight, East Asia and Pacific Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Nkosinathi V. Mbuya, World Bank, 1818 H St N.W., Washington, DC 20433. Email: [email protected], v Table of Contents FIGURES AND TABLES ........................................................................................ VIII ACKNOWLEDGMENTS………………………………………………………………….. EXECUTIVE SUMMARY ........................................................................................... X I. INTRODUCTION ..................................................................................................... 8 II. THE MAGNITUDE AND TRAJECTORY OF THE DOUBLE BURDEN OF ............ MALNUTRITION .................................................................................................. 8 III. CAUSES AND CONSEQUENCES OF THE DBM .............................................. 14 1. CAUSES OF THE DBM ................................................................................... 14 A. UNDERNUTRITION .............................................................................. 14 B. OVERNUTRITION ................................................................................ 17 2. CONSEQUENCES OF THE DBM ....................................................................... 25 IV. ACCELERATING PROGRESS IN PREVENTING AND MITIGATING THE DBM........................................................................................................... 28 1. HEALTH ....................................................................................................... 29 2. AGRICULTURE .............................................................................................. 31 3. SOCIAL PROTECTION .................................................................................... 34 4. EDUCATION .................................................................................................. 35 5. PUBLIC INFORMATION .................................................................................... 37 6. FINANCE ...................................................................................................... 38 7. TRANSPORT, PUBLIC WORKS, AND URBAN AND RURAL DEVELOPMENT ............. 39 8. INDUSTRY, TRADE, AND COMMERCE ............................................................... 41 V. CHALLENGES AND OPPORTUNITIES IN THE APPLICATION OF MULTISECTORAL APPROACHES TO TACKLE THE DBM .......................................................... 42 1. STRENGTHENING SYSTEMS ........................................................................... 42 A. POLICY FRAMEWORKS ........................................................................ 42 B. LEADERSHIP, COORDINATION, AND ACCOUNTABILITY ............................ 43 C. WORKFORCE CAPACITY ..................................................................... 46 vi D. KNOWLEDGE AND EVIDENCE ............................................................... 47 2. SCALING UP INTERVENTIONS ......................................................................... 50 3. PROMOTING BEHAVIOR CHANGE .................................................................... 51 VI. CASE STUDIES .................................................................................................. 51 A. INDONESIA ............................................................................................... 54 B. THAILAND ................................................................................................. 55 C. BRAZIL ...................................................................................................... 57 D. FRANCE .................................................................................................... 59 VII. CONCLUSIONS AND RECOMMENDATIONS .................................................. 61 ANNEX 1. RISK FACTORS FOR UNDERNUTRITION AND OVERNUTRITION IN EAP 66 ANNEX 2. PRIORITY INTERVENTIONS FOR THE REDUCTION OF UNDERNUTRITION AND OVERNUTRITION ............................................................................................