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The double burden of malnutrition (DBM) is escalating in low- and middle-income countries (LMICs), including in Rwanda, most notably in urbanizing areas. The 2019–2020 Rwanda Demographic Health Survey (DHS) revealed that 33% of children under 5 years old are stunted while 42% of women in urban areas are overweight or obese. This coexistence has contributed to a surge in non-communicable diseases (NCDs), particularly in secondary cities. Using the World Health Organization’s (WHOs) “double-duty action” (DDA) concept, this study aims to identify and evaluate interventions with double-duty potential in Rwanda’s Rusizi and Rubavu districts and generate key recommendations for their improvement. A desk review of national policies pinpointed four programs with the greatest DDA potential: early childhood development (ECD) centers, the school feeding program, farmer field schools (FFS), and the provision of nutrition-sensitive direct support. In-person interviews with key stakeholders assessed the implementation of each program and a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis was used to generate context-specific recommendations for their improvement. The main finding of this research is that Rwanda’s potential to address the DBM can be improved across multiple sectors by implementing a few key changes: targeting beliefs surrounding nutrition, improving trainings for community educators, enhancing parent–particularly father–involvement, and engaging in close monitoring and follow-up. These findings offer actionable streps that governments and nutrition stakeholders can take to improve similar interventions in other rapidly urbanizing LMICs.

The double burden of malnutrition (DBM) is a condition in which malnutrition coexists with overweight, reflecting a new layer of malnutrition. Our objectives were to assess prevalence; test associations between DBM and 24-hour movement behaviors; and investigate whether DBM is associated with clusters of social determinants. Methods: This multicenter cross-sectional study included 1152 adolescents (12 to 17 years old) from four Brazilian cities. Body mass index (BMI, kg/m2) was used to estimate overweight, and the adopted cutoff points took into account the curves established for age and sex: Z-score > 1 and ≤2 (overweight) and Z-score > 2 (obesity). The serum concentration of 25-hydroxyvitamin D [25(OH)D] was stratified into three levels: vitamin D deficiency ≤ 20 ng/mL; vitamin D insufficiency = 21–29 ng/mL; optimal vitamin D ≥ 30 ng/mL. We used multilevel Poisson regression models to estimate prevalence ratios (PRs) and their respective 95% confidence intervals (95%CI) and to analyze the association between DBM and covariates. A significance level of p < 0.05 was considered. Cluster analyses were performed by applying a combination of hierarchical and non-hierarchical methods. Results: A population prevalence of DBM of 7.3% (95% CI: 5.9–8.9) was revealed. A percentage of 19.2% (95% CI: 17.0–21.6) of adolescents were overweight, and 8.3% (95% CI: 6.8–10.1) were obese. A total of 41.5% (95% CI: 38.7–44.4) had vitamin D deficiency, and 25.8% (95% CI: 23.4–28.4) had vitamin D insufficiency. However, 24-hour movement behaviors were not associated with DBM. Adolescents living in the southern region of the country, from public schools whose mothers have higher education, have a 1.94 [PR = 2.94 (95% CI: 1.20–7.23)] times greater chance of developing DBM. These results highlight the importance of specific factors to improve the nutritional health of adolescents, considering the specific social determinants identified in this study.

Mozambique has one of the highest child undernutrition rates in Sub-Saharan Africa. The aim of this study was to characterize the profile of children from 1 to 14 years old hospitalized for undernutrition and to explore associated risk factors. Clinical, demographic, socioeconomic, and environmental data were collected. Anthropometric measurements and stool samples were collected from a child and their caretaker. The wealth index was determined using Principal Components Analysis. A total of 449 children and their caretakers were enrolled. The children had a median age of 1.0 year [IQR: 1.0–2.0], and 53.9% (242/449) were male. Most were admitted with severe undernutrition (35.7%, 159/449 kwashiorkor and 82.0%, 368/449 with −3SD Z-score indexes). The most common co-morbidities were HIV (30.0%, 120/400), diarrhea (20.0%; 80/400), and anemia (12.5%; 50/400). Among the caretakers, 9.5% (39/409) were underweight, 10.1% (40/397) were overweight, and 14.1% (56/397) were obese. Intestinal parasites were found in 24.8% (90/363) children and in 38.5% (77/200) caretakers. The majority of children (60.7%, 85/140) came from low- to middle-wealth households. Most were severely undernourished, suggesting that they seek medical care too late. The finding of overweight/obese caretakers in combination with undernourished children confirms that Mozambique is facing a double burden of malnutrition.

There is little evidence on the prevalence of the double burden and association between body mass index (BMI) and iron deficiency among young children living in high-income countries. We conducted a cross-sectional study of healthy children, 12–29 months of age, recruited during health supervision visits in Toronto, Canada, and concurrently measured BMI and serum ferritin. The prevalence of a double burden of underweight (zBMI < −2) and iron deficiency or overweight/obesity (zBMI > 2) and iron deficiency was calculated. Regression models examined BMI and serum ferritin as continuous and categorical variables, adjusted for covariates. We found the following in terms of prevalence among 1953 children (mean age 18.3 months): underweight 2.6%, overweight/obesity 4.9%, iron deficiency 13.8%, iron-deficiency anemia 5.4%, underweight and iron deficiency 0.4%, overweight/obesity and iron deficiency 1.0%. The change in median serum ferritin for each unit of zBMI was −1.31 µg/L (95% CI −1.93, −0.68, p < 0.001). Compared with normal weight, we found no association between underweight and iron deficiency; meanwhile, overweight/obesity was associated with a higher odds of iron deficiency (OR 2.15, 95% CI 1.22, 3.78, p = 0.008). A double burden of overweight/obesity and iron deficiency occurs in about 1.0% of young children in this high-income setting. For risk stratification and targeted screening in young children, overweight/obesity should be added to the list of important risk factors.

Haiti is one of the most food-insecure (FIS) nations in the world, with increasing rates of overweight and obesity. This study aimed to characterize FIS among households in urban Haiti and assess the relationship between FIS and body mass index (BMI) using enrollment data from the Haiti Cardiovascular Disease Cohort Study. FIS was characterized as no/low, moderate/high, and extreme based on the Household Food Security Scale. Multinomial logistic generalized estimating equations were used to evaluate the association between FIS categories and BMI, with obesity defined as BMI ≥ 30 kg/m2. Among 2972 participants, the prevalence of moderate/high FIS was 40.1% and extreme FIS was 43.7%. Those with extreme FIS had higher median age (41 vs. 38 years) and were less educated (secondary education: 11.6% vs. 20.3%) compared to those with no/low FIS. Although all FIS categories had high obesity prevalence, those with extreme FIS compared to no/low FIS (15.3% vs. 21.6%) had the lowest prevalence. Multivariable models showed an inverse relationship between FIS and obesity: moderate/high FIS (OR: 0.77, 95% CI: 0.56, 1.08) and extreme FIS (OR: 0.58, 95% CI: 0.42, 0.81) versus no/low FIS were associated with lower adjusted odds of obesity. We found high prevalence of extreme FIS in urban Haiti in a transitioning nutrition setting. The inverse relationship between extreme FIS and obesity needs to be further studied to reduce both FIS and obesity in this population.

The double burden of malnutrition (DBM) is a condition in which malnutrition coexists with overweight, reflecting a new layer of malnutrition. Our objectives were to assess prevalence; test associations between DBM and 24-hour movement behaviors; and investigate whether DBM is associated with clusters of social determinants. Methods: This multicenter cross-sectional study included 1152 adolescents (12 to 17 years old) from four Brazilian cities. Body mass index (BMI, kg/m 2 ) was used to estimate overweight, and the adopted cutoff points took into account the curves established for age and sex: Z-score > 1 and ≤2 (overweight) and Z-score > 2 (obesity). The serum concentration of 25-hydroxyvitamin D [25(OH)D] was stratified into three levels: vitamin D deficiency ≤ 20 ng/mL; vitamin D insufficiency = 21-29 ng/mL; optimal vitamin D ≥ 30 ng/mL. We used multilevel Poisson regression models to estimate prevalence ratios (PRs) and their respective 95% confidence intervals (95%CI) and to analyze the association between DBM and covariates. A significance level of p < 0.05 was considered. Cluster analyses were performed by applying a combination of hierarchical and non-hierarchical methods. Results: A population prevalence of DBM of 7.3% (95% CI: 5.9-8.9) was revealed. A percentage of 19.2% (95% CI: 17.0-21.6) of adolescents were overweight, and 8.3% (95% CI: 6.8-10.1) were obese. A total of 41.5% (95% CI: 38.7-44.4) had vitamin D deficiency, and 25.8% (95% CI: 23.4-28.4) had vitamin D insufficiency. However, 24-hour movement behaviors were not associated with DBM. Adolescents living in the southern region of the country, from public schools whose mothers have higher education, have a 1.94 [PR = 2.94 (95% CI: 1.20-7.23)] times greater chance of developing DBM. These results highlight the importance of specific factors to improve the nutritional health of adolescents, considering the specific social determinants identified in this study., Competing Interests: The authors declare no conflicts of interest.

Background: Ultraprocessed products (UPPs) have been associated with unfavorable health outcomes; however, until now, they have not been associated with the coexistence of undernutrition and overnutrition, known as the double burden of malnutrition (DBM) at the individual level. Methods: Cross-sectional analyses were performed on data collected from children and adolescents participating in the 2006 and 2016 Mexican National Health and Nutrition Surveys. The food and beverages reported in the food frequency questionnaire (SFFQ) were classified as UPPs as defined by the NOVA classification system. Associations of UPPs with anemia, excess weight, and the DBM were estimated with logistic regression models. A pseudo-panel was generated using the cohorts of children born from 1997 to 2001 to estimate the effect of the UPPs on anemia, excess weight, and the DBM. Results: The consumption of UPPs (% energy) was higher in 2016 (children 30.1% and adolescents 28.3%) than in 2006 (children 27.3% and adolescents 23.0%) in both age-groups. The higher contribution of UPPs was positively associated with excess weight and the DBM in children’s lower tertile of socioeconomic status (SES) and the DBM in higher tertile of SES in adolescents. The pseudo-panel analysis shows the positive association between UPPs and DBM in lower SES. Conclusions: These results provide evidence of the association between the consumption of UPPs and the DBM and excess weight in children and adolescents.

Background: While high protein intake during infancy may increase obesity risk, low qualities and quantities of protein contribute to undernutrition. This study aimed to investigate the impact of the amount and source of protein on infant growth during complementary feeding (CF) in a country where under- and overnutrition co-exist as the so-called the double burden of malnutrition. Methods: A multicenter, prospective cohort was conducted. Healthy term infants were enrolled with dietary and anthropometric assessments at 6, 9 and 12 months (M). Blood samples were collected at 12M for IGF-1, IGFBP-3 and insulin analyses. Results: A total of 145 infants were enrolled (49.7% female). Animal source foods (ASFs) were the main protein source and showed a positive, dose–response relationship with weight-for-age, weight-for-length and BMI z-scores after adjusting for potential confounders. However, dairy protein had a greater impact on those parameters than non-dairy ASFs, while plant-based protein had no effect. These findings were supported by higher levels of IGF-1, IGFBP-3 and insulin following a higher intake of dairy protein. None of the protein sources were associated with linear growth. Conclusions: This study showed the distinctive impact of different protein sources during CF on infant growth. A high intake of dairy protein, mainly from infant formula, had a greater impact on weight gain and growth-related hormones.

A dietary pattern transition is a risk factor for the double burden of malnutrition (DBM), but related information is limited. This study aimed to identify sex differences in dietary patterns of adults in a low–middle income country and to examine their association with DBM. A total of 8957 adults (4465 men and 4492 non-pregnant and non-lactating women) who participated in the 2013 Philippine National Nutrition Survey were included in the analysis. Logistic regression models were formulated to investigate the relationship between dietary patterns and DBM. The factor analysis derived seven dietary patterns for males and six patterns for females. Results showed that approximately 30% of Filipino adults suffered from DBM. The rice pattern was associated with lower odds of DBM for males only. The meat and sugar pattern in males and the protein-rich foods, cereal, and sugar pattern in females decreased DBM likelihood. An inverse relationship was observed for the vegetables and corn patterns, wherein females had an increased risk for DBM. Our findings suggest that rice-based and meat-containing patterns could play protective roles in DBM development among adults in the Philippines. Understanding sex-specific dietary patterns can be utilized to guide public health nutrition interventions in the prevention of malnutrition in all its forms.

Overweight/obesity (OWOB) often co-occurs with anemia or micronutrient deficiencies (MNDs) among women of reproductive age (WRA) in Ghana; identifying the risk factors of these conditions is essential for prevention. We aimed to examine the prevalence of OWOB, anemia, and MNDs and their co-occurrence and risk factors among non-pregnant women 15–49 years of age in Ghana. Data were from a 2017 two-stage national survey of 1063 women. We estimated the weighted prevalence of single and co-occurring malnutrition, and used logistic regression to explore risk factors. The prevalence of OWOB, anemia, and ≥1 MND was 39%, 22%, and 62%, respectively; that of OWOB co-occurring with anemia was 6.7%, and OWOB co-occurring with ≥1 MND was 23.6%. There was no significant difference between observed and expected prevalence of co-occurrence OWOB with anemia or MND. Risk factors were: living in southern (vs. northern) belt, high- (vs. low-) wealth household, being ≥ 25 years old, and being married (vs. single) for OWOB, and living in northern (vs. southern) belt and medium- (vs. low-) wealth household for anemia and ≥1 MND, respectively. Different interventions are required for addressing OWOB in WRA than those for anemia and MNDs.

Background: Little evidence exists on the relationship between diet-related factors and child/adolescent malnutrition in Nigeria. This study aimed to assess the associations between household food insecurity (HFI), dietary diversity (DD), and dietary patterns (DP) with the double burden of malnutrition (DBM) among 6–19-year-olds in two Nigerian States. Methods: This community-based cross-sectional study was carried out among 1200 respondents (6–19 years in age) in the Gombe and Osun States of Nigeria. HFI was assessed using the HFI access scale. DD was assessed using a 24-h dietary recall. DP were determined by principal component analysis using a 30-day food frequency questionnaire. DP scores were categorized into quartiles (Q) for statistical analysis. Diet-related predictors of DBM were assessed using logistic regression. Results: HFI was experienced by 568 (47.3%) respondents. The median DD score was 7.0 (maximum of 14). Two DPs were identified, diversified DP (DDP) and traditional DP (TDP). TDP was significantly associated with both thinness (Q4:OR: 2.91; 95% CI: 1.52–5.55; Ptrend: 0.002) and overweight/obesity (Q4:OR: 2.50; 95% CI: 1.43–4.35; Ptrend: 0.007), while DDP was inversely related with thinness (Q4:OR: 0.36; 95% CI: 0.21–0.61; Ptrend: 0.008) as compared to Q1. Conclusions: TDP increased the odds for DBM, while the DDP reduced the odds.

The double burden of malnutrition (DBM) affects many low- and middle-income countries. However, few studies have examined DBM at the individual level, or undernutrition and overnutrition co-occurring within the same person. This study aims to investigate the prevalence and determinants of DBM among adults in the Philippines. Data from the 2013 National Nutrition Survey were used. The sample size in the analysis was 17,010 adults aged ≥20 years old, after excluding pregnant and lactating women. DBM was defined as the co-occurrence of overweight/obesity and anemia (definition #1), overweight/obesity and anemia or vitamin A deficiency (definition #2), and overweight/obesity and anemia or vitamin A deficiency or iodine insufficiency (definition #3). Anthropometric measurements and biochemical markers were used for DBM assessment. Data were analyzed using descriptive statistics, the chi-square test, and logistic regression by R software. Results showed that definition #3 is the predominant type of DBM (7.0%) in the general population, whereas the prevalence of DBM has increased to 23.7% in overweight/obese persons. Sex, age, educational attainment, marital status, household size, wealth quintile, and smoking status were the determinants of DBM. This study revealed that Filipino adults experience malnutrition critically and must be addressed through food and nutrition interventions.

Background: In many developing countries, nutritional and epidemiological transitions are contributing to continuous undernutrition and escalating overnutrition, resulting in coexisting forms of malnutrition often referred as the “double burden of malnutrition” (DBM). This complex phenomenon constitutes an unprecedented challenge to global public health and has been prioritized by international health organizations, prompting governments to swift action. Specifically, five years ago the World Health Organization (WHO) proposed a roadmap to tackle the DBM though so-called “double-duty actions”. The objective of this review was to synthesize the literature on interventions which address the DBM. Methods: We developed a scoping review to identify interventions addressing the DBM. We searched PUBMED for papers reporting interventions until December 2019. Articles examining interventions, government policies, or tools at the individual, household, or community level to address the DBM were included. Results: Seven articles met the inclusion criteria. Three were from sub-Saharan Africa, one was from Southeast Asia, and one was from Central America. Two were modelling studies, with one covering 24 low-income countries and the other focusing on Ghana. Conclusion: Notwithstanding the pressing issue of the DBM, there is a paucity of studies examining double-duty actions despite the attention that it has garnered within the global nutrition community. Whilst nutrient deficiencies may be curbed by poverty reduction measures, for obesity prevention nutrition, education and promotion of physical activity, along with the encouragement of local food production, may be instrumental.

The double burden of malnutrition (DBM) and anaemia is a growing concern in developing countries. Using the cross-sectional Bangladesh Demographic Health Survey, 2011, 5763 mother⁻child pairs were examined. In households where the mother was overweight, 24.5% of children were stunted, 19.8% underweight, 9.3% wasted, and 51.7% anaemic. Significant regional differences were found in DBM and anaemia as well as drinking water source, while DBM alone was more common in more well-off households (based on wealth index) and where the father was employed in skilled or service occupations. More policy and awareness programmes are needed to address the coexistence of child undernutrition and maternal overweight/obesity and anaemia in the same household.

Low HDL-cholesterol (HDL-C), using as cut-offs 1.03 mmol/L in men and 1.29 mmol/L in women, was observed in more than 25% apparently healthy adults (n = 541) in a cross-sectional study on nutrition transition and cardiometabolic risk factors (CMRF) in Benin, West Africa. Both overweight/obesity (35.3%) and underweight (11.3%) were present, displaying the double burden of malnutrition. We examined in more depth the association of low HDL-C with nutrition and with other CMRF. Metabolic syndrome components were assessed, plus the ratio of total cholesterol (TC)/HDL-C and serum homocysteine. Insulin resistance was based on Homeostasis Model Assessment. We also measured BMI and body composition by bio-impedance. Dietary quality was appraised with two non-consecutive 24 h recalls. Low HDL-C was associated with much higher TC/HDL-C and more abdominal obesity in men and women and with more insulin resistance in women. The rate of low HDL-C was highest (41.9%) among the overweight/obese subjects (BMI ≥ 25), but it also reached 31.1% among the underweight (BMI < 18.5), compared with 17.3% among normal-weight subjects (p < 0.001). Lower dietary micronutrient adequacy, in particular, in vitamins A, B3, B12, zinc and calcium, was associated with low HDL-C when controlling for several confounders. This suggests that at-risk lipoprotein cholesterol may be associated with either underweight or overweight/obesity and with poor micronutrient intake.

(1) Background: The double burden of malnutrition has been increasing in countries experiencing the nutrition transition. This study aimed to determine the relationship between household food insecurity and the double burden of malnutrition, defined as within-household stunted child and an overweight/obese mother (SCOWT). (2) Methods: A cross-sectional survey was conducted in the urban city of Surabaya, Indonesia in April and May 2015. (3) Results: The prevalence of child stunting in urban Surabaya was 36.4%, maternal overweight/obesity was 70.2%, and SCOWT was 24.7%. Although many households were food secure (42%), there were high proportions of mild (22.9%), moderate (15.3%) and severe (19.7%) food insecurity. In a multivariate logistic regression, the household food insecurity access scale (HFIAS) category significantly correlated with child stunting and SCOWT. Compared to food secure households, mildly food insecure households had the greatest odds of SCOWT (adjusted odds ratio (aOR) = 2.789; 95% confidence interval (CI) = 1.540–5.083), followed by moderately food insecure (aOR = 2.530; 95% CI = 1.286–4.980) and severely food insecure households (aOR = 2.045; 95% CI = 1.087–3.848). (4) Conclusions: These results support the hypothesis that the double burden of malnutrition is related to food insecurity, and the HFIAS category is a predictor of SCOWT.

The double burden of malnutrition (DBM) and anaemia is a growing concern in developing countries. Using the cross-sectional Bangladesh Demographic Health Survey, 2011, 5763 mother⁻child pairs were examined. In households where the mother was overweight, 24.5% of children were stunted, 19.8% underweight, 9.3% wasted, and 51.7% anaemic. Significant regional differences were found in DBM and anaemia as well as drinking water source, while DBM alone was more common in more well-off households (based on wealth index) and where the father was employed in skilled or service occupations. More policy and awareness programmes are needed to address the coexistence of child undernutrition and maternal overweight/obesity and anaemia in the same household., Competing Interests: The authors declare no conflicts of interest.