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

milo.infuso@sciencespo.fr

&

Second Author:

Kuan ju CHEN

Research Coordinator,

HDRI Global Health

Sciences Po

kuanju.chen@sciencespo.fr

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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