Till recently, experts on human nutrition were divided into two separate worlds—often in polemical conflict over competing priorities. Those who studied ‘undernutrition’ saw underweight, wasted or stunted children, or thin and anaemic adults as deficient in calories and essential nutrients. This was strongly associated with poverty, calling for societal action. Overweight and obesity were viewed by them as a problem of overconsumption due to faulty individual choices, often associated with affluence. Others saw this as a societal problem created by commercial drivers. This dichotomy arose from conflating nutrition with calories and not looking at the overall nutrient composition of the food consumed. Unfortunately, even economists fell into the trap of defining poverty in terms of calorie deficiency rather than nutritional inadequacy, and policymakers spoke of food security instead of nutrition security.
However, there are several connections between the two forms of impaired nutrition. Undernourished babies, suffering from poor nutrition in the womb and early childhood, can suffer rebound adiposity as they grow older and convert calories to fat rather than lean muscle. This puts them at great risk of suffering from early onset of diabetes and heart disease in adulthood, even if they are thin. About a third of persons with diabetes in India are thin, though their abdominal fat is often incongruously prominent as a potbelly. Persons who are clearly obese can also be consuming diets deficient in protective micronutrients and fibre. Other cross-connecting pathways between the two forms include the gut microbiome and inflammation.
It is rational to regard both these forms of inadequate or inappropriate nutrition as faces of malnutrition. The world of nutrition conventionally saw progression from one form to the other in any society as sequential, linked to the stage of economic development. This was labelled ‘nutrition transition’. Then came clear evidence that both forms of malnutrition could coexist in the same country, province, family, or even within the same individual. Further, overweight and obesity emerged as major problems of the poor in western societies as the social gradient reversed, with the rich adopting healthier diets and the poor lured to consume junk foods and beverages that load their bodies with empty calories. This reversal is now manifesting in many low- and middle-income countries. No longer is there a biologically distinctive dichotomy, nor is a sequential progression of one form to the other invariably linked to a leap in economic development.
Recognising this duality of malnutrition, the medical journal Lancet and the World Health Organisation recently published a joint report on the Double Burden of Malnutrition, calling it the ‘new nutrition reality’ (December 15, 2019). Several countries of Asia and Sub-Saharan Africa were noted to currently manifest this dual danger to health. Notably, the report points a finger at flawed food systems as being responsible for the twin manifestations of faulty nutrition, because of their failure to deliver healthy diets to all people. This failure is a consequence of distortions in production, pricing, and promotion of foods.
The report describes a healthy diet as having ‘an appropriate calorific intake and consisting of a diversity of plant-based foods, low amounts of animal source foods, unsaturated rather than saturated fats and low amounts of refined grains, highly processed foods and added sugars’. It calls for greater than 50% reduction in global consumption of unhealthy foods such as red meat and sugar, and greater than 100% increase in consumption of healthy foods such as nuts, fruits, vegetables, and legumes. There will be many regional variations, but the broad configuration of a healthy diet is based on the balanced nutrition it provides to nurture and protect health across the life course.
Fortunately, the world of nutrition has moved on from its excessive preoccupation with single nutrients that can be supplemented and sold in pills and pouches, or individual food items that could be demonised or extolled, to composite diets that deliver all needed nutrients in the right dose and combination.
Why is it that our food systems are failing to deliver such diets to all? Mainly because food systems have veered away from their original social mission of producing and supplying the ingredients of healthy diets, driven as they currently are by commercial considerations which are the principal propellants of agriculture and food processing. It is now time to restore that original social mission, to rid ourselves of both forms of malnutrition. Otherwise, there will be 653 million undernourished persons and 3.2 billion persons globally by 2030.
The Global Panel on Agriculture and Food Systems defines a food system as ‘going beyond agricultural production to include the storage, transport, processing and sale of food, as well as factors influencing consumer choice’. The food environment comprises food supply, transformation and retail, marketing, and demand. It involves areas like trade, subsidies, food price volatility, technological innovations, food safety, and food waste (glopan.org). In a climate challenged world, it also calls for food and agricultural production systems that do not damage the environment.
All of these determinants of healthy nutrition need to be studied and steered to ensure that the food system serves its prime purpose of promoting dietary diversity through crop diversity and deploying food processing techniques that do not cause harm. As climate change threatens to reduce crop yields and diminish the nutrient quality of both staple and non-staple foods, there is need to develop food system resilience through climate-smart agriculture. This holds true for marine food too.
India has seen drifts and distortions in the food system, with excessive production of staples like rice and wheat displacing pulses and millets which are nutrient-rich and water-sparing. Tobacco has usurped arable land from nutrient crops. Vagaries of fruit and vegetable production and protection resulted in per capita daily consumption levels that are a third of the WHO norm. Ultra-processed foods are aggressively ubiquitous. It is time that we reorient our food, agriculture and public distribution systems and put regulatory shackles on junk foods, to provide true nutrition security for all, at all ages.