The document discusses the global double burden of malnutrition, where populations experience both undernutrition and overweight/obesity. It finds that from the 1990s to 2010s, the number of countries facing this double burden increased and shifted towards lower-income countries. Key drivers include economic growth, urbanization, women's employment, and increased access and marketing of ultra-processed foods. The COVID-19 pandemic is likely exacerbating the double burden due to decreased physical activity and increased consumption of unhealthy foods.

1. Dynamics of the Double Burden
of Malnutrition and the
Changing Nutrition Reality
Barry Popkin
W. R. Kenan, Jr. Distinguished University Professor
Department of Nutrition
Gillings School of Global Public Health
School of Medicine
Department of Economics
The University of North Carolina at Chapel Hill
THE W RLD IS FAT
Based on a paper with Camila Corvalan and Laurence Grummer-Strawn

2. Figure 1. The global double burden of malnutrition in low- and middle-income countries
based on 1990s and 2010s weight and height data*
(using UNICEF, WHO, World Bank, and NCD-RisC estimates, supplemented with selected DHS and other country direct measures)
DBM at 40% overweight prevalence
DBM at 30% overweight prevalence
DBM at 20% overweight prevalence No double burden
High-income countries
1a. 1990s double burden countries
according to weight/height data
1b. 2010s double burden countries
according to weight/height data
* Double burden of malnutrition (DBM) = at least 1 child, adolescent, or adult in household with severe levels of
wasting/stunting/thinness and 1 with overweight/obesity (shown at 20%, 30%, or 40% overweight prevalence)

3. Figure 2. Countries with high double burden of malnutrition* in 1990s and 2010s,
by time period and GDP/capita (PPP) quartile**
3
5
10
4
14
8
5
1
0
4
8
12
16
20
Qtl 1 Qtl 2 Qtl 3 Qtl 4
2b. DBM at 30% adult
overweight prevalence
12
15
13
5
19
13
7
1
0
4
8
12
16
20
Qtl 1 Qtl 2 Qtl 3 Qtl 4
2c. DBM at 20% adult
overweight prevalence
1
2
8
4
1
3
2
1
0
4
8
12
16
20
Qtl 1 Qtl 2 Qtl 3 Qtl 4
Numberofcountries
2a. DBM at 40% adult
overweight prevalence
* Double burden of malnutrition (DBM) = at least 1 child, adolescent, or adult in household with severe levels of
wasting/stunting/thinness and 1 with overweight/obesity (shown at 20%, 30%, or 40% adult overweight
prevalence); countries only included here if they had DBM data available for both time periods (1990s and 2010s)
** Quartile (Qtl) 1 is lowest-wealth, Qtl 4 is highest-wealth
Data sources: Based on UNICEF, WHO, World Bank, and NCD-RisC estimates supplemented with selected DHS
and other country direct measures for the 1990’s
1990s 2010s

4. 1
2
1
13
6
3
11
5
4
-1
-1
-7
-3
-2
-3
-8
-3
-4
-7
-10
-4
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
[CELLRANGE]
-15 -10 -5 0 5 10 15
DBM at 20%
adult overweight
prevalence
Ended DBM Became DBM
Number of countries
Figure 3. Number of countries that changed double burden of malnutrition*
status from 1990s to 2010s, by GDP/capita (PPP) quartile
* Double burden of malnutrition (DBM) = at least 1 child, adolescent, or adult in household with severe levels of
wasting/stunting/thinness and 1 with overweight/obesity (shown at 20%, 30%, or 40% adult overweight prevalence);
countries only included here if they had DBM data available for both time periods (1990s and 2010s)
** Quartile (Qtl) 1 is lowest-wealth, Qtl 4 is highest-wealth
Data sources: Based on UNICEF, WHO, World Bank, and NCD-RisC estimates supplemented with selected DHS and
other country direct measures for the 1990’s
DBM at 30%
adult overweight
prevalence
DBM at 40%
adult overweight
prevalence

5. Senegal
Gabon
Liberia
Namibia
Lesotho
Niger
Mali
Chad
Nigeria
Malawi
Zimbabwe
Ethiopia
Comoros
Madagascar
Cote d'Ivoire
Guinea
Burkina Faso
Tanzania
Ghana
Mozambique
Rwanda
Kenya
Congo, Rep.
Zambia
Togo
Uganda
Cameroon
Congo, Dem. Rep.
Sierra Leone
India
Bangladesh
Nepal
Egypt
Jordan
Morocco
Honduras
Colombia
Brazil
Dominican Republic
Bolivia
Guatemala
Peru
Mexico
Haiti
Nicaragua
Kazakhstan
Kyrgyz Republic
Turkey
Armenia
China
Indonesia
Vietnam
Cambodia
East Asia
& Pacific
Europe &
Central Asia
Latin America
& the Caribbean
Middle East
& North Africa
South Asia
Sub-Saharan
Africa
* Positive difference indicates higher annualized growth in overweight/obesity prevalence for the lowest-wealth quartile. ** Countries presented here had earliest-to-latest-year data spanning 15 or
more years, latest-year data after 2010, and a population greater than ≈15 million (with the exception of Jordan and Kyrgyz Republic, which both had smaller populations but were included for
regional representation). The data presented is from years spanning 1988 to 2016, but exact years vary by country. The span of earliest-to-latest years collected ranges from 15 years to 24 years.
All data are from the Demographic and Health Surveys (DHS, https://dhsprogram.com/) with the exceptions of China (China Health and Nutrition Survey), Indonesia (Indonesian Family Life Survey),
Mexico (Mexico National Survey of Health and Nutrition), Brazil (Brazil National Health Survey), and Vietnam (Vietnam Living Standards Survey).
Figure 5. The shifting burden of overweight/obesity from higher- to lower-wealth populations in sample countries**
Annualized difference in growth rate of overweight/obese prevalence for lowest-wealth minus highest-wealth groups*
between first and last survey waves in selected countries**

6. Changes in overweight/obesity over time: equity
considerations
The shifting burden of overweight and obesity from higher-wealth to
lower-wealth populations in sample countries
Faster in
wealthiest
quintile
Faster in
poorest quintile
Faster in
wealthiest
quintile
Faster in
poorest quintile

7. Global and National Dynamics underlying the
major shifts in the Double Burden of
Malnutrition
• Economic growth
– Reduced wasting, stunting, thinness
– Reduced physical activity
– Increased purchasing power
• Food marketing and access
• Shifts in control of the food supply
• Urbanization
• Women’s employment
Rapid
increase
in Ultra-
processed
foods

8. • Technological shifts in the workplace, home, leisure and
transportation have reduced physical activity greatly but we can not
go back in time so need to focus much more on the diet drivers.
• Economic growth and increased purchasing power reduce
malnutrition
• The global food system makes ultra-processed food and other less
nutritious food cheaper and more accessible. We are finding this in
all regions. Underlying factors include urbanization, increased of-
farm employment for men and women, especially,
• Effective policies that address the challenges of the DBM across
the lifecycle are urgently needed
Why we are seeing these increases
in overweight status

9. • In LMIC’s, undernutrition is declining while overweight
is increasing — both at about the same rate for SSA
and overweight faster increase for many.
• However, stunting was highly prevalent, so increases
in overweight (20% or more in all countries) are
leading to high DBM levels.
• Of 126 LMICs, 38% face a DBM prevalence that we
define as very high or severe.
• The DBM is shifting toward countries in the poorest
income quartile, particularly in South and Southeast
Asia and sub-Saharan Africa
Key Messages on DBM

10. • First both undernutrition and obesity are associated with significant
reductions in immune function and greatly increased susceptibility to Covid.
• A recent metanalysis highlights this for COVID-19 (Popkin et al, Obesity
Reviews 2020, http://dx.doi.org/10.1111/obr.13128 PMCID: PMC7461480).
• Globally, large decreases in physical activity both because of Covid control
and also economic stress’s reduction of active employment and production,
• In most regions, we are seeing rapid increases in consumption of both
ultra-processed food and less-nutritious, cheaper food from vendors, stalls,
and home cooking. In a select few countries we are seeing increased
healthy eating among the poor. We have surveys from a number of low and
middle income countries during Covid.
• The result will be both increased overweight and undernutrition. Only
documented weight increases are in high income countries.
The COVID-19 pandemic has likely
greatly exacerbated the DBM