THE CHALLENGE OF UNDER-NUTRITION AND OBESITY : ADDRESSING THE DOUBLE BURDEN MALNUTRITION ISSUE IN NIGERIA AUTHOR: MILO ESTEBAN INFUSO EDITOR: KUAN JU CHEN APRIL 2021
THE CHALLENGE OFUNDER-NUTRITIONAND OBESITY : ADDRESSING THEDOUBLE BURDENMALNUTRITION ISSUE INNIGERIA
AUTHOR: MILO ESTEBAN INFUSOEDITOR: KUAN JU CHEN
APRIL 2021
The Challenge of Under-nutrition and Obesity : Addressing the double burden
malnutrition issue in Nigeria
Milo Esteban INFUSO
Reviewed by: Kuan ju CHEN
Global Health Research Team, 2020-2021
Sciences Po
The views and opinions expressed in this document are those of the authors and do not
necessarily represent the views of HDRI. The designations employed and the presentation of
material throughout this review do not imply the expression of any opinion whatsoever on the
part of HDRI concerning the legal status of any country, territory, city or area or its authorities,
or concerning its frontiers or boundaries.
This research article was coordinated and edited by Kuan ju CHEN under the supervision of
Director of Publications, Alissa Mustre del Rio. The design of this article and its formatting
were done by the Communications Team, led by Directors Daniella Arrieta
First Author:
Milo Esteban INFUSO
Researcher, HDRI Global Health
Sciences Po
&
Second Author:
Kuan ju CHEN
Research Coordinator,
HDRI Global Health
Sciences Po
Abstract :
Since the 2000s, academic literature has emerged concerning the nutrition transition in Sub-
Saharan Africa. This term designates the change in nutrition habits, from cereal and fiber-rich
diets, to more sugar, salty, fat, and animal-sourced foods.
This “new problem”, resulting in high rates of obesity and associated chronic diseases, goes
hand in hand with an “older problem” : undernutrition. Both represent the double-burden
malnutrition. Nigeria is clearly subject to the double burden of malnutrition, featuring an
important rise in obesity, while not reaching satisfactory results for undernutrition reduction.
Both problems share common drivers which are socioeconomic status, environmental and
biological drivers. Solutions exist to face both problems simultaneously, to reduce malnutrition
effects in Nigeria. The aim of this paper is to introduce the double burden malnutrition,
understand how it applies to Nigeria, and then recommend pathways to address both problems.
Key Words : Nutrition transition, stunting, obesity, double-burden malnutrition,
breastfeeding, food policy
Introduction :
Did you know that while undernutrition remains high in Sub-Saharan Africa, obesity is
exploding? In fact, sub-Saharan countries are undergoing a nutrition transition, which is
characterized by a shift from cereal and fiber-rich diets, to more sugar, salty, fat, and animal-
sourced foods (Hawkes, 2006, p.2). This nutrition transition is the result of the opening of
African economies to world markets and Multinational food enterprises, the adoption of a
western lifestyle and urbanization (Ibid). There is a clear link between nutrition transition and
epidemiologic effects: Sub-Saharan Africa is experiencing a large increase in non-
communicable diseases (NCDs) (Gouda H., N. et al. 2019, p.1).
While the situation of child undernutrition remains high in many sub-Saharan countries,
causing stunted growth, a phenomenon known as the double burden of malnutrition has
emerged: this term can be defined as the coexistence of both undernutrition and overnutrition
in the same population across the life course (World Health Organization, 2020). The objective
of this paper is to examine this phenomenon, with a focus on Nigeria, and propose concrete
solutions.
Even though this is a general phenomenon that took place in pretty much every recent country-
development path, the choice has been made to focus on Sub-Saharan Africa, and more
precisely Nigeria, for several reasons: first, Nigeria - like other sub-Saharan countries - is still
at the early stage of its nutrition transition, and if concrete actions are taken now, both
continuing the fight against stunted growth, but taking into account its adverse effects in term
of overweight-risk, good results can be achieved (Abrahams et al.,2011, pp.10-12). Second,
Nigeria has a tremendous demographic and urbanization pattern, which already makes Lagos
the most populous city in Africa, and Nigeria the fourth most populated country globally
(United Nations, 2020). This is accompanied by an important economic boom. A direct
consequence of this is that it will be possible to draw policy recommendations at least for
countries that will someday follow the Nigerian economic development in Sub-Saharan Africa.
Furthermore, Nigeria has the second-highest burden of stunted children in the world. with a
national prevalence rate of 32 percent of stunted children under five. An estimated 2 million
children in Nigeria suffer from severe acute malnutrition (SAM), but only two out of every 10
children affected are currently reached with treatment. (Unicef Nigeria, 2020). Last, but not
least, the obesity prevalence in the overall population is also growing, two-thirds of middle and
high-income Nigerians being overweight.
I-) Where does Nigeria stand in the double burden of malnutrition?
Understanding the geographic, ecological, and socioeconomic aspects of both undernutrition
and overnutrition is vital to face the issue. A shocking prevalence of 37% stunting was observed
among children under 5 years of age in 2018, without having decreased significantly since
2013. There is extreme geographic diversity in children stunting: in the North-West, around
57% of children are stunted, while in the south, particularly South-East this proportion is about
14%. Furthermore, stunting is more likely to happen around the 24th month of life. Thus
adaptive solutions must be proposed in regards to this important diversity. Among children,
stunting remains the main problem in Nigeria, since only 2% of children were reported
overweight (Nigeria demographic and health survey, 2019, p. 255). Principal drivers of
stunting among children include wrong breastfeeding practices, along with undiversified
nutrient intake, and mother’s education. In fact, the more educated the mother, the lower the
chance for her offspring to be stunted (Nigeria demographic and health survey, 2019, pp. 259-
263).
Mother behavior regarding children has many implications in health. Deriving from that
consideration, many studies take into account maternal health. Thus, among the population of
adults, we will here focus on women for the adult population.
The nutritional status of Nigerian women clearly states the double burden of malnutrition. In
fact, in 2018, 12,5% of women age 15-49 are thin, and 28% percent are overweight or obese
(Nigeria demographic and health survey, 2019, p. 255). Again, among the Nigerian territory,
obesity and thinness are unequally distributed with a prevalence of 36,4% in urban settings and
20,7% in rural settings. (Nigeria demographic and health survey, 2019, p.289).
The double burden of malnutrition is a multiscalar object of study. As cited above, it appears
clearly from a population point of view in adult women. However, a growing literature has
observed on a household level the phenomenon of having stunted children and an
overweight/obese adult in the same household (James L. Garrett and Marie T. Ruel, 2003).
Known as Maternal Overweight and obesity with Childhood Sunting (MOCS), this
phenomenon revealed to be more observed in rural settings in Nigeria (Senbanjo, I. O.,
Senbanjo, C. O., Afolabi, W. A., & Olayiwola, I. O.,2019, p 272). Yet, it is affected by the fact
that stunted children are more likely to be located in rural settings and that even if superior in
urban settings, the rate of obese women tends to increase in rural settings as well (James L.
Garrett and Marie T. Ruel, 2003, p.2). The results of this study suggest that the prevalence of
MOCS is higher in Nigeria - 10,3% - than in other Sub-Saharan countries, around 5%. It is
comparable to Mexico, and indicate the consumption of high energy and low-nutrient foods
(Senbanjo et al, 2019, p. 272). In any case, there is an ongoing debate about whether or not this
mother children diad represents a distinct statistical entity or artifact. (Ibid, 2012)
The second important feature linking both extreme nutrition patterns is the fact that stunted
children in their youth have more chances to be overweight later in life (Popkin, 2020, p.2). It
is not clear yet how stunting affects the probability of being overweight, but important
physiologic and hormonal modifications are thought to intervene in the process. (Hoffmann,
2000, pp. 5-10).
III-) What can be done about the double burden of malnutrition?
The sustainable development goal No.2 aims at improving nutrition and stopping hunger by
2030 (United Nations, 2015). In the particular case of double burden malnutrition, actions that
should be prioritized are the ones allowing Nigeria to face both undernutrition and overweight
issues simultaneously. It is possible to do so, especially because both sides of the double burden
share common drivers: socioeconomic status, environmental and biological drivers. The World
Health Organization, in the framework of the United Nations decade of action on nutrition
(2016), identified five main policy recommendations for this simultaneous fight to be
successful :
● “Exclusive breastfeeding needs to be encouraged in the first months of life and beyond
● Promotion of complementary nutrients in young children diets
● Maternal nutrition and antenatal care programs
● School food policies and programs
● Regulations on food marketing”
The goal of this paper is, at this stage, to understand how these recommendations are applied
or not, and to make necessary further recommendations to step up the fight against double
burden malnutrition.
Exclusive breastfeeding is defined by the World Health organization as “feeding on breast milk
or expressed breast milk only, excluding water, breast milk substitutes, other liquids, and solid
foods. Oral rehydration solution, vitamin drops, minerals, and medicines may be given.”
This specific action addresses both sides of the coin since breastfeeding is known to bring the
essential nutrients to avoid children stunting and wasting; that will allow the children not to
become obese later (Kramer et al, 2002). In Nigeria, the rate of children ever breastfed is high,
between 95 and 97 % (Nigeria national health survey, 2018); but exclusively breastfed children
rate is extremely low, with only 27% of infants exclusively breastfed between 0 and 5 months
of age. The Nigerian government put in place the Baby-Friendly Hospital Initiative, to promote
exclusive breastfeeding and provide a safe space for mothers to breastfeed. However, this
initiative did not succeed, and further research on exclusively breastfed drivers needs to be
carried out. (Kingsley et al, p.14, 2020). One key driver seems to be the antenatal clinical visit,
with which mothers were more likely to engage in proper breastfeeding. (Ibid p.6). This first
policy goes hand in hand with the promotion of complementary nutrients in young children’s
diets. Infant and Young Child Feeding practices (IYCF) policies have been designed at the
national level in Nigeria, from the 1990s onwards. Unfortunately, they did not translate in an
improvement of majors IYCF indicators, until 2017 (Ogbo et al, 2017, pp 6-9). Main
recommendations include a more ambitious national health budget1, community-based training
for mothers about early children feeding, and a better training for healthcare professionals, in
regards to early child nutrition. One of the main features of the insufficient implementation of
the different policies lies in the mismatch between international organizations standards and
their implementations in communities. For example, only 95 out of 25,000 hospitals, or
0.004%, as reported by Nigerian Ministry of Health were BFHI certified in 2015. (Ibid). For
1 Less than 15% of Nigerian government expenditures is devoted to health while the government had
committed to allocate at least 15% for health. The gap in funding for health is estimated around USD 600 million.
this translation to happen, sub-national committees, carrying monitoring and assessment are
encouraged (ibid). The authors stay optimistic on the possibility of a great improvement in
IYCF by 2025 if the practices mentioned are applied.
Marketing has proven to play a very important role in nutrition transitions. It applies to both
problems, since the rate of extremely processed foods is a problem both for adults, leading to
overweight, and for newborns: high energy but low nutrients.
Marketing in Nigeria is often reported as non compliant with national and international
standards. The violation of the International Code of Marketing of Breastmilk substitutes - even
though included in the national policy on infant and young child feeding in nigeria (2005) - has
been reported (National Agency for food and drug administration and control, 2018 and 2020).
Concrete action would include more awareness campaigns, sanctions against practitioners
promoting and prescribing the wrong substitutes and sanctions against companies violating the
mentioned code
Marketing of high energy but low nutrient foods is also an important concern. As said in the
introduction, Nigeria is clearly undergoing the nutrition transition, and the rate of high
processed foods duly marketed is increasing in the population’s nutrition with major health
concerns deriving from it such as overweight and non-communicable diseases. Marketing has
proven to have considerable effects on children consuming behaviours, even though parents’
choices seem to have more effect in Nigeria (Oso 2012, p.11) (Rottimi, 2015, p.229). Nigeria’s
food advertising is regulated by the National Administration for food and Drug administration
and control and in the regulations issued by this agency it was difficult to find concrete
restrictions specifically shaped for fatty, salty or sweet aliments marketing. It is therefore
recommended to launch measures regulating food advertising, especially regarding high
processed, energy-dense and nutrient-poor foods.
Since children spend almost half of their meals at school, School food policies and programmes
are crucial for their health all life long. The first main challenge is to get children to go to
school; and this is no easy task in Nigeria : even though primary education is officially free and
compulsory, the country faces the highest population of out of school children in the world,
around 28 millions (UNICEF Nigeria, 2020). School nutrition programmes and take-home
meals for children are ways to improve school attendance, but also to improve the quality of
learning (World Food Programme, 2011). In 2004, the Nigerian government launched “Home
Grown School Feeding programme”(HGSF), aiming at providing one free meal per day,
but the project was an absolute failure. The following explanations of failure were listed by the
Food and agriculture organization (2016) :
● “Failure of the Universal Basic Education Commission (UBEC) to disburse funds to
pilot States as well as non-remittance of counterpart funds from participating States.
● Inadequate monitoring and evaluation.
● Inadequate sensitization and advocacy of relevant stakeholders, resulting in low
community involvement and participation.
● Lack of supporting infrastructure such as Water, Sanitation and Hygiene (WASH)
facilities.
● Institutional structure at the Federal level was not made fully operational.
● Inadequate policy and legal framework at the State and Federal level.
● Federal funding ceased in 2008.”
In 2016, a new programme was launched : Nigeria Home Grown School Feeding Strategic Plan
2016-2020. A local assessment study of the programme revealed that the programme has
positive effects, more directed towards attendance than academic achievements : an immediate
drop in attendance is also noted when meals are not delivered. (Murabakat et al, 2020).
Nevertheless, a nationwide assessment release is needed to know if the programme has been
successful.
Combating extreme malnutrition events also requires common tools. In this sense, the World
Health Organization recommended countries to have National dietary guidelines, that include
overweight and obesity phenomena. Nigeria's last National Plan of Action on Food and
Nutrition was released in 2004, and did not include overweight, obesity and related diseases. It
should do so to efficiently face the double burden of malnutrition. Since this issue is
multiscalar, the individual level is as important as the community level. In this sense the whole
health system needs to be as comprehensive as possible. The Nigerian Federal ministry of
Health launched on August, 6, 2019 its first Plan for the Prevention and Control of Non-
Communicable Diseases; it is yet too early to find evidence of the effects of this plan, but it is
encouraging to notice that a strong partnership between WHO, civil society organizations and
government was laid down.
Conclusion
In 2050, Nigeria will be the third most populous country in the World, with more than 400
million inhabitants (United Nations World Population Prospects, 2017, p. 4). This extreme
trend will go hand in hand with massive urbanization and changes in food markets and nutrition
patterns. Nigeria is at the crossroads regarding nutrition. It faces an important challenge : the
rate of stunted children decreases way too slowly; while the nutrition transition threatens to
translate into a tremendous increase in overweight people and health problems associated with
it. It also has an opportunity : take the relevant decisions to face both problems. Solutions exist
: they include massive investments in healthcare, adequate sub-regional programmes, emphasis
on reporting and program assessment, or marketing regulations. Nigeria is doing too little yet,
but taking action would be less costly than continuing to bear the multiple consequences of
malnutrition.
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