Science and Politics of Nutrition

Nutrition disparities and the global burden of

malnutrition

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
Strategies to tackle stunting, obesity, and micronutrient deficiencies must take into account the

S
inequities in which these diseases are rooted, argue Rafael Perez-Escamilla and colleagues
ocial determinants of health are The main objectives of this article are to: inequities.6 17 The challenges associated
understood to be key to grasping describe nutrition disparities in stunting with facilitating optimal pre-conception
why inequalities in health out- in LMICs and obesity in both LMICs and nutrition are rooted in many societal
comes exist within, and between, HICs; discuss disparities in micronutrient processes and sectors. These need to be
populations. They are also impli- malnutrition using anaemia as an example; tackled by equity focused policies and
cated in the differences in dietary intake, describe the critical role of breastfeeding systems through changes in community
dietary patterns, and dietary quality seen in for maternal-child health and identify capacity building, advocacy, and political
some groups, leading to an unequal burden challenges to its practice; and consider will7 18-20 (fig 1).
of disease and morbidity. Nutrition dispari- whether an integrated, equity focused,
ties are reflected in the higher prevalence multisectoral approach, focused on the Patterns of nutrition disparities
of undernutrition; overweight and obesity SDoH, could tackle both stunting and To have a better understanding of socio-
(overnutrition); or both, in inequitable social obesity. economic inequities in nutrition outcomes
conditions, such as poverty. They happen across countries with different levels of
more often in low and middle income coun- The maternal-child life course economic development, this section first
tries (LMICs) compared with high income Nutritional disparities and the DBM must presents data on the distribution of stunt-
countries (HICs), and also in subpopulations be considered from a life course perspec- ing, obesity, and anaemia among LMICs,
within these countries. The double burden of tive. Research focusing on women of child- followed by the distribution of obesity
malnutrition (DBM) refers to the coexistence bearing age living in socioeconomically in HICs as a function of family socioeco-
of under- and overnutrition that can happen deprived circumstances has documented nomic status.
at the individual, household, or population the intergenerational transmission of both Iron deficiency anaemia was
level. stunting and obesity.6-8 Albeit less studied, chosen because it is the most common
Tackling the coexistence of stunting and paternal excessive body weight has also micronutrient deficiency related condition
overweight (including obesity) has been been associated with increased obesity risk all over the world, 21 there are clear
identified as a formidable challenge for in children.9 inequities in its distribution, and it has
LMICs, requiring integrated, multisectoral Over 2 billion people are overweight proven to be difficult to tackle through
actions.1 2 These two DBM components and almost two thirds live in LMICs.2 10 simple supplementation or fortification.22 23
have common elements rooted in the social Obesity among women of childbearing
determinants of health (SDoH). For example, age and children is increasing globally.11 Stunting, obesity, and anaemia in low and
household food insecurity, a condition Women who enter pregnancy overweight middle income countries
related to poverty that limits access to a are more likely to gain excessive weight An analysis of 80 countries by world
nutritious and safe diet, has been consistently during pregnancy, develop gestational regions, as classified by UNICEF, shows that
associated with both undernutrition in diabetes, deliver large for gestational age stunting and overweight are not randomly
children and overweight in women.3-5 The or premature newborns, and are less likely distributed within any given population.
first 1000 days of life offer a window of to breastfeed.11 Children born to overweight In all regions, stunting prevalence among
opportunity to prevent both stunting and women have increased risks of developing children under 5 decreases as wealth
obesity, and are a worthwhile focus for obesity that persist as they mature. Women increases (fig 2). The highest prevalence of
strategies to tackle nutrition disparities. then pass to their children an increased stunting and widest wealth driven gaps are
risk of obesity that persists into later life, in south Asia, and the narrowest in eastern
perpetuating the cycle.6 12 13 Europe and central Asia.
Maternal stunting, underweight, and By contrast, child overweight (fig 3)
Key messages gaining less weight than recommended is positively associated with wealth in
• As a feature of the double burden of during pregnancy are associated with all regions, with west and central Africa
malnutrition (DBM), child undernutri- intrauterine growth restriction, which showing the smallest gaps. However,
tion and adult obesity coexist in low has also been associated with increased although absolute obesity prevalences are
and middle income countries (LMICs) risk of stunting.2 As with obesity, stunting still higher among the wealthier in LMICs,
is transmitted from one generation to obesity rates are growing much faster
• The DBM in LMICs and obesity in high
income countries (HICs) are concen- the next, possibly through epigenetic among the socioeconomically vulnerable,
trated among the poor mechanisms,14 and stunting is a risk factor including indigenous groups defined as the
for the development of obesity.15 16 This original inhabitants of a region.24 25
• Nutrition specific interventions alone
early onset risk is difficult to reverse after Inequities are also present with respect
have not been able to make a significant
infancy, underscoring the high priority for to iron deficiency anaemia, which is highly
dent on the DBM in LMICs
very early intervention to achieve normal prevalent among young children in LMICs.
• Multisectoral policies that tackle weight among all women and men. Demographic and Health Survey (DHS)
the social determinants of health are
Intergenerational transmission of risk data, collected between 2005 and 2016
needed to prevent and reduce inequities
for malnutrition is heightened in the from 52 low, lower-middle, and upper-
in undernutrition and obesity globally
presence of social, economic, and gender middle countries, showed an overall

the bmj | BMJ 2018;361:k2252 | doi: 10.1136/bmj.k2252  1

Science and Politics of Nutrition

Behavioural Biological
Lifestyle and habits Inheritability
Psychological factors Epigenetic

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
Early life experience
High birthweight, premature birth,
risk of excess weight gain
Infants
aged 0 to 2 Low birthweight, higher mortality,
Reduced physical labour capacity, impaired mental health, increased
lower educational attainment, risk of adult chronic disease
restricted economic potential,
shortened life expectancy,
reduced capacity to care for child
Low paid, repetitive jobs with Baby Inadequate catch up growth;
inflexible opportunities for untimely or inadequate feeding;
physical activity; less frequent infections; inadequate
Adult
encouragement and social support; food, health, and care; reduced
more likely to experience mental health capacity
discrimination in health services; Child
financial hardship from No breastfeeding, less exposure
consequences of illness to healthy foods and flavours,
food insecurity, stunting,
overweight and obesity
Pregnancy

Higher maternal mortality, Adolescent

low weight gain, Preconception,
inadequate fetal nutrition pregnancy,
post partum Reduced physical labour capacity,
lower educational attainment
Maternal obesity, excess weight
gain, gestational diabetes, Continued excess weight gain;
epigenetic changes, unhealthy diet; low physical
post partum weight retention activity; obesity and
related health problems
Social and demographic Environmental
Food supply and systems
Socioeconomic disadvantage and poverty Food portion sizes and cost
Food insecurity Cultural and social aspects
Urban and built environment
Trade and trade policy

Fig 1 | The double burden of malnutrition through the life cycle and across generations and shared drivers17 19

anaemia prevalence of 54.2% among findings, in all three country income undernutrition among the poor is still the
children less than 5 years old. Disparities groupings, children in households in the predominant problem.30 As previously indi-
were found as a function of both World poorest quintile had the highest anaemia cated, overweight prevalence is increas-
Bank country income classification26 and prevalence and those in households in the ing rapidly among the poor, including in
wealth index as defined by DHS.27 The wealthiest quintile had the lowest (fig 4). rural areas and indigenous communities.31
unweighted mean prevalence of anaemia Prevalence increases with social disadvan-
was highest in the 22 lower income Obesity inequities in high income countries tage, as illustrated for the US and England
countries (61.7%) and lowest in the six Both maternal and child obesity are more in figs 5 and 6.32 33 Additionally, inequities
upper-middle income countries (39.4%), prevalent among the poor in HICs. 28 29 affecting ethnic minority populations are
and in between in 24 lower-middle income However, an initial pattern of more obe- pronounced (figs 7 and 8).32 33 Children in
countries (51.7%). Consistent with these sity among the wealthy is seen where ethnic minority populations living in HICs,
including the US, often experience social
Poorest 2nd 3rd 4th Richest Poorest 2nd 3rd 4th Richest inequities disproportionately.34
60 15
Stunting prevalence (%)

Overweight prevalence (%)

50
Poorest 2nd 3rd 4th Richest
40 10 70
Anaemia prevalence (%)

60
30
50
20 5
40
10
30
0 0 20
ia

ca

fic

an

ia

ca

an

S
ifi
si

ric

si

ric
CI

CI
As

As

10
fri

i
ci

be

e
r
A

c
Af

Af
b
d

d
Pa

Pa
lA

lA
h

rn

n
rib

rib
an

an
er
ut

ut
rth

rth
he

tra

ra
d

0
Ca

Ca
h
So

So

E
an

an
nt
no

no
CE

CE
ut

ut
en

d
e
so

so
a

a
c

c
an

an
d

e
Am Asi

Am Asi

dl

dl
an

an
d

Lo
d

d
an

an
a

id

id
an

an
st

st
ic

ic
st

st

rm

m
t

t
er

er
Ea

Ea
Ea

Ea
rn

rn
es

es

r
we

pe
e

e
W

W
e

e
st

st
dl

dl

Up
Lo
Ea

Ea
tin

tin
id

id
M

M
La

La

From the Demographic and Health Survey Stat compiler

CEE: Central and eastern European countries; CEE: Central and eastern European countries;
www.statcompiler.com
CIS: Commonwealth of Independent States CIS: Commonwealth of Independent States
For details of methods, see web annexe For details of methods, see web annexe
Fig 4 | Percentage of children less than 5
Fig 2 | Stunting prevalence in children under Fig 3| Overweight prevalence in children years old with anaemia (Hb < 11 g/dL) by
5 years old, according to wealth quintiles by under 5 years according to wealth quintiles, World Bank country income classifications
world regions ordered by prevalence in the by world regions ordered by prevalence in the and Demographic and Health Surveys wealth
poorest quintile poorest quintile index

2 doi: 10.1136/bmj.k2252 | BMJ 2018;361:k2252 | the bmj

 Science and Politics of Nutrition

Age (years) 30 poor environmental sanitation, poverty,

Obesity prevalence (%)

2-5 6-11 12-19 food insecurity and hunger, and lack of
25
40
Obesity prevalence (%)

20 access to quality healthcare and education.

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
30 Countries like Brazil, Chile, and Peru
15
have been successful at tackling chronic
10
20 malnutrition through more equitable
5 social and economic policies. 44-46 The
10 0 case study of Brazil illustrates the value
0 5 10 15 20 25 30 35 40 45
Index of multiple deprivation score 2015
of nutrition sensitive interventions in
0
Less than Secondary More than (higher score=greater deprivation) concert with those focused on SDoH (box
secondary school secondary
school school 2). Tackling stunting does require effective
Fig 6 | Association of overweight children
Education of household head with neighbourhood deprivation, 10-11 year
and equitable policies and civil society
old children in England participation in governance structures
Fig 5 | Association of childhood obesity with that facilitate inclusive, equitable,
educational attainment in the US
and sustainable economic growth:
multisectoral strategies that tackle cultural
Strategies for tackling undernutrition and diversity, eating styles, and both local and
programmes focused on protein energy
overweight global food systems,47 as well as access to
malnutrition and micronutrient deficiency
Given the well established excessive stunt- clean water and sanitation, healthcare, and
with obesity prevention initiatives.5 35 38
ing risk among the poor, and the growing education.48
concentration of overweight in socioeco- Undernutrition Anaemia
nomically vulnerable groups, it is impor- Stunting Systematic reviews of several RCTs of
tant to explore potential solutions to the Prevention of child stunting through nutri- micronutrient powders (MNPs) in Africa,
DBM in LMICs and the obesity epidemic in tion specific interventions, such as lipid Asia, and the Caribbean have found a
HICs at different levels of the socioecologi- based nutrient spreads (LNSs), has been reduction in the risk of anaemia and
cal model, taking into account other nutri- suggested, but effectiveness trials have iron deficiency of around 30% and 50%,
tion related problems, including anaemia had mixed results. 39-41 A recent review respectively.49 50 A recent Cochrane review
(box 1). found that small quantity (SQ)-LNS that included 13 RCTs from Africa, Asia,
T h e re i s i n c re a s i ng re cog n i t i o n are generally well accepted but remain and Latin America found that provision of
that early life strategies to tackle unproven for efficacy in improving lin- MNPs (containing between 2 and 18 vita-
undernutrition should take into account ear growth or preventing growth falter- mins and minerals) to young children led to
other forms of malnutrition, including ing.39 These findings are consistent with lower risk of anaemia and iron deficiency.51
obesity. 18 35 Otherwise, solving one an expert review of eight pregnancy and However, although MNP interventions were
problem can magnify another. Global early childhood randomised controlled overall well accepted, adherence was con-
food security initiatives, for example, trials (RCTs) conducted in Asia, Africa, text specific and in several studies compa-
often promote the production and the Caribbean, and Latin America. 41 rable to the same benefit as using standard
availability of specific staple crops Thus, drawing on insights from the social iron supplementation interventions.50 In
such as grains or starchy vegetables. ecological model, which postulates that addition, the effect of MNPs on diarrhoea
health behaviours are shaped by the inter- risk needs to be further examined.51 LNS
Such programmes have succeeded in
actions of people with their larger social, interventions havsse also reduced anae-
increasing the availability of plant
cultural, economic, and environmental mia prevalence40 41 although it is unclear
protein and food energy,36 but have been
contexts,42 tackling stunting simply as a if either MNPs or LNSs provide benefits
criticised for distorting markets and
food problem to be solved with nutrition above and beyond standard approaches.50
potentially promoting obesity and non-
specific interventions in the absence of As with stunting,48 sustainable reductions
communicable disease (NCD) risk by
tackling SDoH is not enough.43 in anaemia prevalence require well coordi-
making healthier foods less affordable
As described above, stunting in children nated, effective, multisectoral policies that
for consumers, leading to less varied,
is more concentrated in LMICs where include health, nutrition, agriculture, water
more energy dense diets for consumers.37
living standards are suboptimal—these and sanitation, education, and social pro-
I n te r n a t i o n a l i n i t i a t ive s f o r f o o d
environments asssre characterised by tection sectors.52
security are now considering balancing

Non-Hispanic white 20
Obesity prevalence (%)

Non-Hispanic black Boys Girls

Hispanic 15
30
Obesity prevalence (%)

25 10
20
5
15
10 0
sh

ed

an

hi

an

an

er

p
an
he

he

ou

5
es

h
iti

di

be

ric
ix

st
ot

ot

ot

gr
M

ad
Br

In

Af
ki

rib
te

ic
Pa

ac
ia
te

ng

0
k
Ca
hi

hn
ac
As
hi

Bl
W

Ba

Aged Aged Aged

et
k
W

Bl
ac

er

2-5 years 6-11 years 12-19 years

Bl

th
yo
An

Fig 7 | Obesity prevalence among US children from

diverse racial groups Fig 8 | Prevalence of child overweight among 4-5 year olds in diverse ethnic groups in England

the bmj | BMJ 2018;361:k2252 | doi: 10.1136/bmj.k2252 3

Science and Politics of Nutrition

Box 1: Nutrition disparities: where do we go from here? Overweight

The social ecological model has also wid-
Context
ened our understanding of the causes of
• Poverty and other social inequities are associated with poor nutrition in both LMICs obesity beyond biomedical or psychologi-

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
and HICs, also among certain population subgroups within countries
cal paradigms. Population level obesity is
• The double burden of malnutrition (DBM), defined as the coexistence of undernutri- recognised as the result of the complex,
tion (for example, stunting) and overnutrition (overweight or obesity) at the popula-
multilevel interplay of biology, behaviour,
tion, family, or individual level, is highly prevalent in LMICs
and environments.53 For management of
• HICs are experiencing a major obesity epidemic. Socioeconomic inequities have been obesity and prevention in high risk groups,
associated with both under- and overnutrition within HICs
there is a role for individual level interven-
What is known
tion in clinical and community settings.
• In all regions where LMICs are located, stunting prevalence among children under 5 However, relative increases in inequities
is inversely associated with family wealth
associated with social disadvantage indi-
• The prevalence of adult obesity continues to concentrate more among the poor in cate that current individually focused obe-
LMICs and in the US
sity prevention efforts in the absence of
• The obesity epidemic continues to be unabated in HICs. Multisectoral life course structural changes to facilitate behaviour
strategies are needed to tackle it
changes may be doing harm by widening
• DBM occurs in the context of widespread micronutrient deficiencies wealth driven inequities.12 To be broadly
• LMICs do not have well coordinated strategies to effectively tackle the DBM effective, population level obesity preven-
Areas of consensus
tion must account for the wider social and
• Tackling inequities in the distribution of the DBM in LMICs and the obesity epidemic environmental contexts in which people
in HICs requires also tackling the social determinants of health, including access to
make food choices.54 Specifically, obesity
food security, healthcare, education, and jobs that pay reasonable wages
prevention requires collectively tackling
• Nutrition specific interventions during the first 1000 days of life including precon- behavioural, biological, environmental,
ceptional nutrition, nutrition during pregnancy, and optimal breastfeeding and com-
social, and demographic drivers from the
plementary feeding are key for tackling the prevention of infectious diseases and
individual level to the population level,
non-communicable diseases globally.
paying strong attention to equity (fig 1).
• The DBM requires avoiding strategies that solve one nutrition problem while magnify- Consumer oriented policies are an
ing another one such as the use of sugar as a vehicle for micronutrient fortification.
important focus of strategies to tackle
Areas of controversy
obesity. In HICs, reconciling the roles and
• We don’t know if micronutrient specific interventions such as lipid nutrient supple- responsibilities of individuals, communities,
ments reduce the risk of stunting in low income countries
governments, and markets has been
• It’s unclear how to improve access to social determinants of health in different con- a major challenge. 55 Although there is
texts given that this requires equitable and sustainable economic growth which is
consensus that tackling unhealthy eating
lacking among the populations that are most vulnerable to experiencing nutrition
behaviours is fundamental for curbing
inequities
the obesity and NCDs epidemics,1056 57
Future directions in this field
there is limited agreement on how this
• Implementation of science research based on complex systems frameworks is needed should be achieved. The dominant
for understanding how to scale up cost effective, multisectoral interventions that can
paradigm of placing responsibility with
simultaneously tackle stunting, overweight, and micronutrient deficiencies
the consumer, exemplified by individually
focused education, is now shifting to
population level consumer information
based interventions, such as menu labels
Box 2: How did Brazil reduce levels of stunting and change breastfeeding practices?
in restaurants,58 labels on manufactured
Brazil has shown impressive improvements in stunting levels and breastfeeding foods, 59 and nutrition oriented shelf
practices since the mid-1970s.46 109 Stunting prevalence among children younger labels in supermarkets. 60 The impact
than 5 years has dropped from 37% in 1975 to 19% in 1989 and to 7% in 2007. of informational approaches has been
Exclusive breastfeeding (< 6 months) underwent a remarkable improvement from limited, in part because the majority of
4.7% in 1986 to 37% in 2006 and relative stabilisation between 2006 and 2013109; food related decisions are not the result of
during the same period, the median duration of breastfeeding increased from around rational reflection and deliberation, but
2.5 months to 14 months.46 rather automatic and habitual behaviours,
This progress is derived from a strong political commitment in reducing cued by the food retailing environment and
malnutrition and corresponding inequities following a socioecological approach. Up reinforced by cultural norms.61 Moreover,
to the mid-2010s, Brazil had tackled three key components of social determinants of information based approaches can
health and nutrition through well thought out multisectoral policies46 reflected in: potentially widen inequalities, because they
more equitable wealth distribution; improved social protection and public health generally work best in higher socioeconomic
programmes (for example, conditional cash transfer programme Bolsa Família status populations, which have more
and improvements in water and sanitation); restructuring and strengthening of psychosocial and material resources to act
the health sector by expanding coverage and quality of public health programmes upon health related information.62 This
(promotion of breastfeeding, oral rehydration, and immunisations), universal reinforces the importance of tackling these
healthcare coverage, and implementing multiple national and state-wide effective epidemics through multisectoral policies
maternal and child health and nutrition programmes and policies, including paid that tackle the SDoH.38
maternity leave.
This case study illustrates that improving breastfeeding and reducing stunting Critical role of breastfeeding
require both nutrition sensitive and nutrition specific approaches delivered though Whereas above we discussed the highly
a socioecological, multisectoral, well coordinated framework.79ss specific micronutrient fortification

4 doi: 10.1136/bmj.k2252 | BMJ 2018;361:k2252 | the bmj

 Science and Politics of Nutrition

i­ nterventions as a way to tackle anaemia, it high income women while declining among ent with public health goals.87 Fiscal incen-
is important to also take into account that low income and indigenous women.78 tives for the production of a variety of fruits,
there are key nutrition specific interven- Improving breastfeeding duration vegetables, and sustainable protein sources
tions, such as breastfeeding, that involve and exclusivity require policy based should be considered.57 88

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
complex maternal-infant behaviours and interventions that empower women Fiscal, demand side interventions are
their interactions within the context of and their families. 76 79 Relevant policy also important for tackling undernutrition
their surrounding social, economic, and targets include: infant formula marketing in LMICs, but unintended consequences
cultural environments. Breastfeeding regulation through enforcement of may arise. Conditional cash transfer
is an example of an early life nutrition the international code of marketing of programmes (CCTs), which provide cash to
behaviour that has implications for both breastmilk substitutes and subsequent poor households that agree to participate in
undernutrition and infectious diseases, as r e l e v a n t Wo r l d H e a l t h A s s e m b ly education and health promotion activities,
well as obesity and chronic diseases in the resolutions80; pre-service breastfeeding have reduced child stunting in some
child, and also offers major health benefits education and training in medical, nursing, settings and population subgroups.89-91
to the mother. and allied health schools; breast pump However, CCTs have also been associated
There are also exclusive breastfeeding access; family leave policies; flexibility of with increased risk of obesity and greater
inequities that need to be tackled through work hours or locations, and protections intake of sugar and sugar sweetened drinks
the socioecological model lens.63 Sufficient for women in informal work sectors; and among adults.89 92 93 CCTs are designed to
duration of breastfeeding is critical for accommodations for breastfeeding mothers supplement the incomes of low income
maternal and child health 64 and also in workplaces and childcare settings.74 79 families and can be used for anything
facilitates obesity prevention, especially Empirical evidence for the effectiveness of the family needs or wants, not only food,
for children at high biological risk of excess such policy approaches relies primarily on as long as they meet the programme
weight gain.65-67 Breastfeeding may also observational studies but is consistent with conditions (participation in education
help to break the cycle of intergenerational the underlying known structural factors and health services). Studies have shown,
transmission by facilitating maternal affecting breastfeeding.79 81 The case of however, that CCT funds do help reduce
postpartum weight loss,68-70 decreasing Brazil illustrates how nutrition sensitive food insecurity in target families.91
the mother’s risk of being more overweight and nutrition specific interventions Another fiscal demand side intervention
in a subsequent pregnancy. This applies through a social ecological, multisectoral, indicates that subsidies for healthy foods in
especially in HICs but is becoming relevant well coordinated framework can have the form of vouchers or discounts ranging
to those LMICs where the majority of an impact on improving breastfeeding from 10% to 50% can have beneficial
women of reproductive age are overweight outcomes79 (box 2). effects on food purchasing in LMICs.66 94-97
or obese. 69 71 Overall, breastfeeding Targeted food taxes may also be effective.
prevalence and duration are lower and Tackling the social determinants of health The tax on sugar sweetened beverages and
obesity rates higher in HICs than in Given the central role that social deter- energy dense snack foods in Mexico98 has
LMICs 64 68 72; obesity is more common minants of health play in nutrition and reduced the purchase of these products,
among women in low income and ethnic health outcomes across the life course, with effects strongest in lowest income
minority populations in HICs 32 73; and strategies that tackle social determinants households.66 Likewise, Hungary’s tax,
breastfeeding is less common among will be key to tackling the DBM in LMICs which is partly determined by sugar
women with obesity.68 74 and the obesity epidemic in HICs. The content of food and drink, has resulted
Breastfeeding traditions in some social ecological model has been used to in a substantial decline in consumption
indigenous and established or new understand the aetiology of child under- of the taxed products. 99 Preliminary
immigrant racial or ethnic minorities nutrition82 and overweight across the life evaluations of more recently implemented
in HICs may be associated with higher course,42 83 without recognising that both taxes on sugar sweetened drinks in Chile,100
breastfeeding prevalence compared may have common structural determinants. Barbados,101 South Africa, and some US
with the host population but may not be The common pathways suggest the poten- municipalities are showing promising
sustained with continued exposure to tial for integrated SDoH strategies.1 35 84 The results.102
contexts that favour formula feeding.75 recent trend of tackling economic and envi-
Breastfeeding promotion involves “baby ronmental determinants of unhealthy diets Implications for dietary guidelines
friendly” initiatives in hospitals and various will likely result in greater equity in obesity Tackling the DBM requires taking into
education and counselling approaches prevention in HICs and may also be effec- account food systems in the context of
to motivate and support breastfeeding tive for tackling obesity in LMICs.66 In these socioeconomic inequities. Therefore, it
in community and family settings. 76 countries, rising consumption of processed is key for influential policy instruments,
Studies in diverse countries indicate that food products high in sugar, salt, and fats such as government issued dietary guide-
such interventions typically improve one has been attributed largely to structural lines, to take these inequities into account
or more key breastfeeding outcomes— factors stemming from economic develop- when selecting evidence based policies
initiation, duration, or exclusivity77—in ment, particularly rising incomes, urbani- and programmes. The DBM demands a
some cases with relatively larger effects sation, and globalising economies enabling new strategy for dietary guidelines that
among women in less educated or ethnic foreign investment, and imports of cheap, seek to simultaneously curb the stunt-
minority populations that have especially processed foods.10 30 85 86 Food consumption ing, obesity, and micronutrient deficiency
low breastfeeding rates.76 Breastfeeding in is inherently an economic activity, with epidemics while taking into account the
LMICs tends to last longer among poorer implications for the political economy of profound inequities upon which they are
and rural women than in the rest of the the food system, and the interests of power- rooted. Food based dietary guidelines are
population, and breastfeeding is one ful stakeholders within it. In the long term, needed not only for consumers but also
of the few healthy behaviours that are agriculture sector policies that prioritise for providers across sectors and for the
more common among the poor. However, commodity crops that provide a cheap and development of evidence based policies
in several middle income countries steady source of starch, fat, and sugar in and programmes.103-105 Dietary guidelines
breastfeeding rates are increasing among the food supply will need to change consist- and ancillary products are being issued

the bmj | BMJ 2018;361:k2252 | doi: 10.1136/bmj.k2252 5

Science and Politics of Nutrition

globally 106 107 but few tackle the impor- sugar fortification with micronutrients, middle-income countries. Lancet 2013;382:427-51.
doi:10.1016/S0140-6736(13)60937-X
tance of the first 1000 days for stunting or agricultural policies that foster the 3 Gubert MB, Spaniol AM, Segall-Corrêa AM, Pérez-
and obesity prevention. Likewise, very few consumption of energy dense foods and Escamilla R. Understanding the double burden
are grounded on the principles of respon- sugar sweetened beverages); leveraging

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
of malnutrition in food insecure households in
sive parenting and feeding which has been existing actions designed to tackle one Brazil. Matern Child Nutr 2017;13. doi:10.1111/
mcn.12347
shown to be crucial for childhood obesity type of malnutrition to simultaneously 4 Shamah-Levy T, Mundo-Rosas V, Morales-Ruan C,
prevention.107 Future guidelines will need reduce other types, especially maternal- Cuevas-Nasu L, Méndez-Gómez-Humarán I,
to take this knowledge into account as well child nutrition programmes during the Pérez-Escamilla R. Food insecurity and maternal-
child nutritional status in Mexico: cross-sectional
as the increasing evidence on effective first 1000 days; and identifying the shared analysis of the National Health and Nutrition Survey
policies to implement the WHO code on upstream nutrition sensitive drivers 2012. BMJ Open 2017;7:e014371. doi:10.1136/
marketing of breastmilk substitutes80 and between different forms of malnutrition bmjopen-2016-014371
5 Farrell P, Thow AM, Abimbola S, Faruqui N, Negin J.
subsequent relevant World Health Assem- (such as food systems). Tackling the
How food insecurity could lead to obesity in LMICs:
bly resolutions, and to limit consumption double burden of malnutrition through When not enough is too much: a realist review of
of unhealthy foods and drinks, provide double duty equitable actions will be of how food insecurity could lead to obesity in low- and
consumers with more information, and critical importance in achieving both the middle-income countries. Health Promot Int 2017.
doi:10.1093/heapro/dax026.
encourage product reformulation to reduce ambitions of the UN’s Decade of Action on 6 Pérez-Escamilla R, Bermúdez O. Early life nutrition
or eliminate added sugars and trans fats.64 Nutrition and the Sustainable Development disparities: where the problem begins? Adv
Goals.108 Implementation science research Nutr 2012;3:71-2. doi:10.3945/an.111.001453
Conclusions 7 Pérez-Escamilla R, Kac G. Childhood obesity
based on complex systems frameworks is prevention: a life-course framework. Int J Obes
Can an integrated multisector strategy can needed for understanding how to scale up Suppl 2013;3(Suppl 1):S3-5. doi:10.1038/
be designed to prevent both stunting and cost effective, multisectoral interventions ijosup.2013.2
obesity in LMICs? International develop- that can simultaneously tackle stunting, 8 Every Woman Every Child. Nutrition and women’s,
children’s and adolescents’ health. 2015.
ment agencies have identified the devel- overweight, and micronutrient deficiencies. www.everywomaneverychild.org/wp-content/
opment of multicomponent strategies to uploads/2015/02/09__Nutrition_and_womens_
We thank the World Health Organization, Department
tackle the coexistence of contrasting forms of Nutrition for Health and Development, Evidence childrens_and_adolescents_health_230315_
of malnutrition across the life course as a and Programme Guidance which generously provided FB__2015-03-24.pdf.
the DHS analyses on anaemia used in the paper. 9 Veena SR, Krishnaveni GV, Karat SC, Osmond C,
priority. This should be possible because, Fall CH. Testing the fetal overnutrition hypothesis;
as the evidence presented here highlights, Contributors and sources: SK and PM contributed the relationship of maternal and paternal
common drivers of the food and nutri- to the review of obesity inequalities and population adiposity to adiposity, insulin resistance and
level prevention of obesity. CV contributed with the cardiovascular risk factors in Indian children. Public
tional components of the DBM, and the epidemiological analysis of stunting and obesity Health Nutr 2013;16:1656-66. doi:10.1017/
obesity epidemic in HICs, are: intergen- disparities. CL and OB contributed with anaemia S1368980012003795
erational transmission; environmental review. RPE, GSB, and SK contributed with policy 10 Ford ND, Patel SA, Narayan KM. Obesity in low
and breastfeeding reviews. RPE conceptualised and middleincome countries: burden, drivers,
and socioeconomic influences (for exam- and drafted the initial manuscript outline, all and emerging challenges. Annu Rev Public
ple, the ability to access nutritious foods authors participated in the writing and critical Health 2017;38:145-64. doi:10.1146/annurev-
and adopt healthier nutrition habits and review of manuscript drafts. RPE is the guarantor publhealth-031816-044604
behaviours); and a lack of shared multi- of this article. 11 Poston L, Caleyachetty R, Cnattingius S, et al.
Preconceptional and maternal obesity: epidemiology
sectoral delivery platforms (fig 1). Com- Competing interests: We have read and understood and health consequences. Lancet Diabetes
mon platforms for delivering actions can BMJ’s policy on declaration of interests and all authors Endocrinol 2016;4:1025-36. doi:10.1016/S2213-
declare they have no conflict of interests.
offer an opportunity for alignment and 8587(16)30217-0
Provenance and peer review: Commissioned; 12 World Health Organization. Report of the Commission
coordination of cost effective integrated on Ending Childhood Obesity. World Health
externally peer reviewed.
actions and can be a catalyst for tackling Organization, 2016.
policy challenges beyond health—includ- This article is one of a series commissioned by The 13 Dolton P, Xiao M. The intergenerational transmission
BMJ. Open access fees for the series were funded by of body mass index across countries. Econ
ing reducing health and social inequities Swiss Re, which had no input into the commissioning Hum Biol 2017;24(Supplement C):140-52.
within populations and raising educational or peer review of the articles. doi:10.1016/j.ehb.2016.11.005
attainment.35 It is important to acknowl- Rafael Perez-Escamilla, professor of public health1 14 Martorell R, Zongrone A. Intergenerational influences
edge that, even though multisectoral coor- on child growth and undernutrition. Paediatr Perinat
Odilia Bermudez, associate professor of public Epidemiol 2012;26(Suppl 1):302-14. doi:10.1111/
dination is needed for delivery of effective health and community medicine2 j.1365-3016.2012.01298.x
programmes to prevent stunting, obesity, Gabriela Santos Buccini, postdoctoral associate1 15 Hoffman DJ, Sawaya AL, Verreschi I, Tucker KL,
and micronutrient deficiencies through Shiriki Kumanyika, research professor3 Roberts SB. Why are nutritionally stunted children
at increased risk of obesity? Studies of metabolic
common interventions, recovery from Chessa K Lutter, senior nutrition researcher4
rate and fat oxidation in shantytown children from
stunting and obesity does require different Pablo Monsivais, associate professor5 São Paulo, Brazil. Am J Clin Nutr 2000;72:702-7.
sets of interventions once these conditions Cesar Victora, emeritus professor of epidemiology6 doi:10.1093/ajcn/72.3.702
are established. 1 16 Hoffman DJ, Roberts SB, Verreschi I, et al. Regulation
Yale School of Public Health, New Haven,
of energy intake may be impaired in nutritionally
Our conclusions are congruent with the Connecticut, USA
stunted children from the shantytowns of São Paulo,
“double duty actions” recently proposed 2
Tufts University, Boston, USA Brazil. J Nutr 2000;130:2265-70. doi:10.1093/
by WHO.35 These actions call for policies 3
Drexel University, Philadelphia, USA jn/130.9.2265
17 World Health Organization (WHO). Obesity and
and programmes that can simultaneously 4
RTI International, Washington DC, USA
Inequities in Europe. Guidance for addressing
reduce the risk or burden of both 5
Washington State University, Spokane, USA inequities in overweight and obesity, 2014.
undernutrition and overweight, obesity, 6
Federal University of Pelotas, Pelotas, Brazil 18 Hanson M, Barker M, Dodd JM, et al. Interventions
or diet related to NCDs through common to prevent maternal obesity before conception,
Correspondence to: R Perez-Escamilla
during pregnancy, and post partum. Lancet Diabetes
interventions following three levels of rafael.perez-escamilla@yale.edu
Endocrinol 2017;5:65-76. doi:10.1016/S2213-
recommended actions 35 108 : ensuring 1 World Health Organization (WHO). The double 8587(16)30108-5
that current interventions, policies, and burden of malnutrition. Policy brief. World Health 19 Administrative Committee on Coordination/
Organization, 2017. Sub−Committee on Nutrition. 4th report: the world
programmes designed to tackle one form nutrition situation: nutrition throughout the life
2 Black RE, Victora CG, Walker SP, et al, Maternal and
of malnutrition do not inadvertently Child Nutrition Study Group. Maternal and child cycle. In: The UN system’s forum for nutrition. United
increase the risk of another (for example, undernutrition and overweight in low-income and Nations, 2000.

6 doi: 10.1136/bmj.k2252 | BMJ 2018;361:k2252 | the bmj

 Science and Politics of Nutrition

20 Stephenson J, Heslehurst N, Hall J, et al. Before 41 USAID/Food and Nutrition Technical Assistance. 57 Pearson-Stuttard J, Bandosz P, Rehm CD, et al.
the beginning: nutrition and lifestyle in the Meeting report: evidence and programmatic Reducing US cardiovascular disease burden
preconception period and its importance for future considerations for the use of small quantity lipid and disparities through national and targeted
health. Lancet 2018;391:1830-41. doi:10.1016/ based nutrient supplements for the prevention of dietary policies: A modelling study. PLoS

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
S0140-6736(18)30311-8. malnutrition. 2016. Med 2017;14:e1002311. doi:10.1371/journal.
21 Camaschella C. Iron-deficiency anemia. N Engl 42 Ohri-Vachaspati P, DeLia D, DeWeese RS, Crespo NC, pmed.1002311
J Med 2015;372:1832-43. doi:10.1056/ Todd M, Yedidia MJ. The relative contribution of 58 Bleich SN, Economos CD, Spiker ML, et al.
NEJMra1401038 layers of the Social Ecological Model to childhood A systematic review of calorie labeling and
22 Schümann K, Solomons NW. Perspective: what obesity. Public Health Nutr 2015;18:2055-66. modified calorie labeling interventions: impact on
makes it so difficult to mitigate worldwide anemia doi:10.1017/S1368980014002365 consumer and restaurant behavior. Obesity (Silver
prevalence? Adv Nutr 2017;8:401-8. doi:10.3945/ 43 Ruel MT, Alderman H, Maternal and Child Nutrition Spring) 2017;25:2018-44. doi:10.1002/oby.21940
an.116.013847 Study Group. Nutrition-sensitive interventions 59 National Academies of Sciences, Engineering, and
23 World Health Organization. The global prevalence of and programmes: how can they help to accelerate Medicine. Front-of-package nutrition rating systems
anaemia in 2011. World Health Organization, 2011. progress in improving maternal and child nutrition? and symbols: promoting healthier choices. 2011.
24 Corvalán C, Garmendia ML, Jones-Smith J, et al. Lancet 2013;382:536-51. doi:10.1016/S0140- http://nationalacademies.org/HMD/Reports/2011/
Nutrition status of children in Latin America. 6736(13)60843-0 Front-of-Package-Nutrition-Rating-Systems-and-
Obes Rev 2017;18(Suppl 2):7-18. doi:10.1111/ 44 Weisstaub G, Aguilar AM, Uauy R. Treatment Symbols-Promoting-Healthier-Choices.aspx.
obr.12571 and prevention of malnutrition in Latin 60 Hersey JC, Wohlgenant KC, Arsenault JE, Kosa KM,
25 Rivera J, Gonzalez de Cossio T. Pobreza, nutrición y America: focus on Chile and Bolivia. Food Muth MK. Effects of front-of-package and shelf
salud. En: Los determinantes sociales de la salud en Nutr Bull 2014;35(Suppl):S39-46. nutrition labeling systems on consumers. Nutr
México, 2012. doi:10.1177/15648265140352S106 Rev 2013;71:1-14. doi:10.1111/nure.12000
26 World Bank. New country classifications by income 45 Huicho L, Segura ER, Huayanay-Espinoza CA, et 61 Marteau TM, Hollands GJ, Kelly MP. Changing
level: 2017-2018. https://blogs.worldbank.org/ al, Peru Countdown Country Case Study Working population behavior and reducing health disparities:
opendata/new-country-classifications-income- Group. Child health and nutrition in Peru within exploring the potential of “choice architecture”
level-2017-2018. an antipoverty political agenda: a Countdown interventions. In: Kaplan R, Spittel M, David D, eds.
27 Demographic and Health Survey). Wealth index to 2015 country case study. Lancet Glob Population Health: Behavioral and Social Science
construction. www.dhsprogram.com/topics/wealth- Health 2016;4:e414-26. doi:10.1016/S2214- Insights. Agency for Healthcare Research and
index/Wealth-Index-Construction.cfm. 109X(16)00085-1 Quality and Office of Behavioral and Social Sciences
28 Organisation for Economic Co-operation and 46 Victora CG, Aquino EM, do Carmo Leal M, Research. National Institutes of Health, 2015:
Development. Obesity update 2017. www.oecd.org/ Monteiro CA, Barros FC, Szwarcwald CL. Maternal 105-26.
els/health-systems/Obesity-Update-2017.pdf. and child health in Brazil: progress and challenges. 62 Adams J, Mytton O, White M, Monsivais P. Why are
29 Inchley J, Currie D, Young T, et al. Growing up Lancet 2011;377:1863-76. doi:10.1016/S0140- some population interventions for diet and obesity
unequal: gender and socioeconomic differences 6736(11)60138-4 more equitable and effective than others? the role of
in young people’s health and wellbeing, Health 47 Pérez-Escamilla R. Food security and the 2015- individual agency. PLoS Med 2016;13:e1001990.
Behaviour in School aged Children (HBSC) 30 Sustainable Development Goals: from human doi:10.1371/journal.pmed.1001990
Study, international report from the 2013/2014 to planetary health. Current Developments in 63 Pérez-Escamilla R, Sellen D. Equity in breastfeeding:
survey. WHO Regional Office for Europe, 2016. Nutrition 2017. where do we go from here? J Hum Lact 2015;31:12-
30 Popkin BM, Adair LS, Ng SW. Global nutrition 48 Huda TM, Hayes A, El Arifeen S, et al. Social 4. doi:10.1177/0890334414561062
transition and the pandemic of obesity in developing determinants of inequalities in child undernutrition in 64 Victora CG, Bahl R, Barros AJ, et al, Lancet
countries. Nutr Rev 2012;70:3-21. doi:10.1111/ Bangladesh: aA decomposition analysis. Maternal & Breastfeeding Series Group. Breastfeeding in
j.1753-4887.2011.00456.x Child Nutrition 2018;14(1):e12440-n/a. the 21st century: epidemiology, mechanisms,
31 Rivera JA, Pedraza LS, Martorell R, Gil A. Introduction 49 Salam RA, MacPhail C, Das JK, Bhutta ZA. and lifelong effect. Lancet 2016;387:475-90.
to the double burden of undernutrition and Effectiveness of Micronutrient Powders doi:10.1016/S0140-6736(15)01024-7
excess weight in Latin America. Am J Clin (MNP) in women and children. BMC Public 65 Pérez-Escamilla R. Is breastfeeding protective against
Nutr 2014;100:1613S-6S. doi:10.3945/ Health 2013;13(Suppl 3):S22. childhood obesity? 2016. https://nam.edu/can-
ajcn.114.084806 50 De-Regil LM, Suchdev PS, Vist GE, Walleser S, Peña- breastfeeding-protect-against-childhood-obesity.
32 Public Health England. Patterns and trends in child Rosas JP. Home fortification of foods with multiple 66 Pérez-Escamilla R, Lutter CK, Rabadan-Diehl C,
obesity: slide presentation. 2017. www.slideshare. micronutrient powders for health and nutrition in et al. Prevention of childhood obesity and food
net/PublicHealthEngland/patterns-and-trends- children under two years of age. Cochrane Database policies in Latin America: from research to practice.
inchild-obesity-june-2017. Syst Rev 2011;(9):CD008959. Obes Rev 2017;18(Suppl 2):28-38. doi:10.1111/
33 Ogden CL, Carroll MD, Lawman HG, et al. Trends in 51 De-Regil LM, Jefferds MED, Peña-Rosas JP. Point- obr.12574
obesity prevalence among children and adolescents of-use fortification of foods with micronutrient 67 Oken E, Fields DA, Lovelady CA, Redman LM. TOS
in the United States, 1988-1994 Through 2013- powders containing iron in children of preschool scientific position statement: breastfeeding and
2014. JAMA 2016;315:2292-9. doi:10.1001/ and school-age. Cochrane Database Syst obesity. Obesity (Silver Spring) 2017;25:1864-6.
jama.2016.6361 Rev 2017;11:CD009666. doi:10.1002/oby.22024
34 Bogard K, Murry VM, Alexander C. Perspectives on 52 World Health Organization. Strategies to prevent 68 Neville CE, McKinley MC, Holmes VA, Spence D,
health equity and social determinants of health. anaemia: recommendations from an expert group Woodside JV. The relationship between
In: Bogard K, Murry VM, Alexander C, eds. National consultation. New Delhi, India, 5-6 December 2016. breastfeeding and postpartum weight change--a
Academy of Medicine. 2017. 53 McPherson K, Marsh K, Brown MT. Tackling obesities: systematic review and critical evaluation. Int J Obes
35 World Health Organization). Double-duty actions for future choices: modelling future trends in obesity and (Lond) 2014;38:577-90. doi:10.1038/ijo.2013.132
nutrition. Policy brief: World Health Organization, the impact on health. 2007. www.bis.gov.uk/assets/ 69 López-Olmedo N, Hernández-Cordero S, Neufeld LM,
2017. foresight/docs/obesity/14.pdf. García-Guerra A, Mejía-Rodríguez F, Méndez Gómez-
36 Pingali PL. Green revolution: impacts, limits, 54 Kumanyika SK, Obarzanek E, Stettler N, et Humarán I. The associations of maternal weight
and the path ahead. Proc Natl Acad Sci U al, American Heart Association Council on change with breastfeeding, diet and physical activity
S A 2012;109:12302-8. doi:10.1073/ Epidemiology and Prevention, Interdisciplinary during the postpartum period. Matern Child Health
pnas.0912953109 Committee for Prevention. Population-based J 2016;20:270-80. doi:10.1007/s10995-015-
37 Pingali P. Agricultural policy and nutrition outcomes: prevention of obesity: the need for comprehensive 1826-7
getting beyond the preoccupation with staple grains. promotion of healthful eating, physical activity, 70 Horta BL, Loret de Mola C, Victora CG. Long-term
Food Secur 2015;7:583-91. doi:10.1007/s12571- and energy balance: a scientific statement consequences of breastfeeding on cholesterol,
015-0461-x. from American Heart Association Council on obesity, systolic blood pressure and type 2 diabetes:
38 Dietz WH. Double-duty solutions for the double Epidemiology and Prevention, Interdisciplinary a systematic review and meta-analysis. Acta
burden of malnutrition. Lancet 2017;390:2607-8. Committee for Prevention (formerly the expert Paediatr 2015;104:30-7. doi:10.1111/apa.13133
doi:10.1016/S0140-6736(17)32479-0 panel on population and prevention science). 71 NCD Risk Factor Collaboration (NCD-RisC). Worldwide
39 Matsungo TM, Kruger HS, Smuts CM, Faber M. Circulation 2008;118:428-64. doi:10.1161/ trends in body-mass index, underweight, overweight,
Lipid-based nutrient supplements and linear CIRCULATIONAHA.108.189702 and obesity from 1975 to 2016: a pooled analysis
growth in children under 2 years: a review. 55 Roberto CA, Swinburn B, Hawkes C, et al. Patchy of 2416 population-based measurement studies
Proc Nutr Soc 2017;76:580-8. doi:10.1017/ progress on obesity prevention: emerging in 128·9 million children, adolescents, and adults.
S0029665117000283 examples, entrenched barriers, and new thinking. Lancet 2017;390:2627-42. doi:10.1016/S0140-
40 Hess SY, Abbeddou S, Jimenez EY, et al. Small- Lancet 2015;385:2400-9. doi:10.1016/S0140- 6736(17)32129-3
quantity lipid-based nutrient supplements, 6736(14)61744-X 72 NCD Risk Factor Collaboration (NCD-RisC). Trends
regardless of their zinc content, increase growth 56 Scarborough P, Nnoaham KE, Clarke D, Capewell S, in adult body-mass index in 200 countries
and reduce the prevalence of stunting and wasting Rayner M. Modelling the impact of a healthy diet from 1975 to 2014: a pooled analysis of 1698
in young burkinabe children: a cluster-randomized on cardiovascular disease and cancer mortality. population-based measurement studies with 19·2
trial. PLoS One 2015;10:e0122242. doi:10.1371/ J Epidemiol Community Health 2012;66:420-6. million participants. Lancet 2016;387:1377-96.
journal.pone.0122242 doi:10.1136/jech.2010.114520 doi:10.1016/S0140-6736(16)30054-X

the bmj | BMJ 2018;361:k2252 | doi: 10.1136/bmj.k2252 7

Science and Politics of Nutrition

73 Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, dominant in the global food system. Obes PLoS One 2015;10:e0144408. doi:10.1371/
Ogden CL. Trends in obesity among adults in the Rev 2013;14(Suppl 2):21-8. doi:10.1111/ journal.pone.0144408
United States, 2005 to 2014. JAMA 2016;315: obr.12107 99 World Health Organization. Using price policies to
2284-91. doi:10.1001/jama.2016.6458 87 Franck C, Grandi SM, Eisenberg MJ. Agricultural promote healthier diets. Regional Office for Europe,

BMJ: first published as 10.1136/bmj.k2252 on 13 June 2018. Downloaded from https://www.bmj.com/ on 7 January 2025 by guest. Protected by copyright.
74 Breastfeeding: achieving the new normal. subsidies and the American obesity epidemic. 2015.
Lancet 2016;387:404. doi:10.1016/S0140- Am J Prev Med 2013;45:327-33. doi:10.1016/j. 100 Caro JC, Ng SW, Taillie LS, et al. Designing a tax to
6736(16)00210-5 amepre.2013.04.010 discourage unhealthy food and beverage purchases:
75 Rasmussen KM, Whaley SE, Perez-Escamilla R, et al. 88 Puska P. Successful prevention of non-communicable the case of Chile. Food Policy 2017;71(Supplement
New opportunities for breastfeeding promotion diseases: 25 year experiences with North Karelia C):86-100. doi:10.1016/j.foodpol.2017.08.001
and support in WIC: review of WIC food packages, Project in Finland. Public Health Medicine 2002;4:5-7. 101 Alvarado M, Kostova D, Suhrcke M, et al,
improving balance and choice. J Nutr Educ Behav 89 Fernald LCH, Gertler PJ, Hou X. Cash component Barbados SSB Tax Evaluation Group. Trends in
2017;49(7S2):S197-S201 e1. of conditional cash transfer program is associated beverage prices following the introduction of a
76 Chapman DJ, Morel K, Anderson AK, Damio G, Pérez- with higher body mass index and blood pressure tax on sugar-sweetened beverages in Barbados.
Escamilla R. Breastfeeding peer counseling: from in adults. J Nutr 2008;138:2250-7. doi:10.3945/ Prev Med 2017;105S(Supplement):S23-5.
efficacy through scale-up. J Hum Lact 2010;26: jn.108.090506 doi:10.1016/j.ypmed.2017.07.013
314-26. doi:10.1177/0890334410369481 90 Bassett L. Can conditional cash transfer programs 102 Falbe J, Thompson HR, Becker CM, Rojas N,
77 Pérez-Escamilla R, Martinez JL, Segura-Pérez S. play a greater role in reducing child undernutrition? McCulloch CE, Madsen KA. Impact of the Berkeley
Impact of the Baby-friendly Hospital Initiative In: World Bank, Discussion Paper, 2008. excise tax on sugar-sweetened beverage
on breastfeeding and child health outcomes: a 91 Segura-Pérez S, Grajeda R, Pérez-Escamilla R. consumption. Am J Public Health 2016;106:
systematic review. Matern Child Nutr 2016;12: Conditional cash transfer programs and the health 1865-71. doi:10.2105/AJPH.2016.303362
402-17. doi:10.1111/mcn.12294 and nutrition of Latin American children. Rev Panam 103 Ministry of Health of Brazil. Guia alimentar para
78 Lutter CK, Chaparro CM, Grummer-Strawn LM. Salud Publica 2016;40:124-37. a população brasileira/Dietary guidelines for the
Increases in breastfeeding in Latin America and 92 Forde I, Chandola T, Garcia S, Marmot MG, Brazilian population. Brasília: Ministério da Saúde,
the Caribbean: an analysis of equity. Health Policy Attanasio O. The impact of cash transfers to poor Secretaria de Atenção à Saúde, Departamento de
Plan 2011;26:257-65. doi:10.1093/heapol/czq046 women in Colombia on BMI and obesity: prospective Atenção Básica, 2014.
79 Pérez-Escamilla R, Curry L, Minhas D, et al. Scaling cohort study. Int J Obes (Lond) 2012;36:1209-14. 104 Millen BE, Abrams S, Adams-Campbell L, et al.
up of breastfeeding promotion programs in low- doi:10.1038/ijo.2011.234 The 2015 dietary guidelines advisory committee
and middle-income countries: the “breastfeeding 93 de Bem Lignani J, Sichieri R, Burlandy L, Salles- scientific report: development and major
gear” model. Advances in nutrition (Bethesda, Md) Costa R. Changes in food consumption among the conclusions. Adv Nutr 2016;7:438-44. doi:
2012;3(6):790-800. Programa Bolsa Família participant families in Brazil. 10.3945/an.116.012120
80 World Health Organization. The International Code Public Health Nutr 2011;14:785-92. doi:10.1017/ 105 Pérez-Escamilla R. The Mexican dietary and physical
of Marketing of Breast-milk Substitutes: Frequently S136898001000279X activity guidelines: moving public nutrition forward
Asked Questions (2017 Update). World Health 94 Le HND, Gold L, Abbott G, et al. Economic evaluation in a globalized world. J Nutr 2016;146:1924S-7S.
Organization, 2017. of price discounts and skill-building strategies on doi:10.3945/jn.115.218784
81 Rollins NC, Bhandari N, Hajeebhoy N, et al, Lancet purchase and consumption of healthy food and 106 Food and Agriculture Organization of the United
Breastfeeding Series Group. Why invest, and what beverages: The SHELf randomized controlled trial. Nations. Food-based dietary guidelines. Secondary
it will take to improve breastfeeding practices? Soc Sci Med 2016;159(Supplement C):83-91. Food-based dietary guidelines 2017. www.fao.
Lancet 2016;387:491-504. doi:10.1016/S0140- doi:10.1016/j.socscimed.2016.04.015 org/nutrition/education/food-dietary-guidelines/
6736(15)01044-2 95 Ni Mhurchu C, Blakely T, Jiang Y, Eyles HC, Rodgers A. background/en.
82 Reifsnider E, Allan J, Percy M. Mothers’ explanatory Effects of price discounts and tailored nutrition 107 Pérez-Escamilla R, Segura-Pérez S, Lott M. Feeding
models of lack of child growth. Public Health education on supermarket purchases: a randomized guidelines for infants and young toddlers: a
Nurs 2000;17:434-42. doi:10.1046/j.1525- controlled trial. Am J Clin Nutr 2010;91:736-47. responsive parenting approach. 2017. http://
1446.2000.00434.x doi:10.3945/ajcn.2009.28742 healthyeatingresearch.org/wp-content/
83 Story M, Hannan PJ, Fulkerson JA, et al. Bright 96 Waterlander WE, de Boer MR, Schuit AJ, Seidell JC, uploads/2017/02/her_feeding_guidelines_
Start: Description and main outcomes from a Steenhuis IH. Price discounts significantly enhance report_021416-1.pdf.
group-randomized obesity prevention trial in fruit and vegetable purchases when combined 108 Hawkes C, Demaio AR, Branca F. Double-duty actions
American Indian children. Obesity (Silver Spring) with nutrition education: a randomized controlled for ending malnutrition within a decade. Lancet
2012;20:2241-9. doi:10.1038/oby.2012.89 supermarket trial. Am J Clin Nutr 2013;97:886-95. Glob Health 2017;5:e745-6. doi:10.1016/S2214-
84 Crawford L, Howard J, Karmali R, et al. Childhood doi:10.3945/ajcn.112.041632 109X(17)30204-8
obesity and possible policy interventions. Georgia 97 Klerman JA, Bartlett S, Wilde P, Olsho L. The 109 Boccolini CS, Boccolini PMM, Monteiro FR,
Institute of Technology, 2013. short-run impact of the healthy incentives pilot Venâncio SI, Giugliani ERJ. Breastfeeding indicators
85 Monteiro CA, Cannon G, Moubarac J-C, Levy RB, program on fruit and vegetable intake. Am J Agric trends in Brazil for three decades. Rev Saude
Louzada MLC, Jaime PC. The UN Decade of Nutrition, Econ 2014;96:1372-82. doi:10.1093/ajae/aau023. Publica 2017;51:108. doi:10.11606/S1518-
the NOVA food classification and the trouble with 98 Colchero MA, Salgado JC, Unar-Munguía M, Molina M, 8787.2017051000029
ultra-processing. Public Health Nutr 2017:21;1-13. Ng S, Rivera-Dommarco JA. Changes in prices after
86 Monteiro CA, Moubarac JC, Cannon G, Ng SW, an excise tax to sweetened sugar beverages was Cite this as: BMJ 2018;361:j2252
Popkin B. Ultra-processed products are becoming implemented in Mexico: evidence from urban areas. http://dx.doi.org/10.1136/bmj.j2252

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits
others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://
creativecommons.org/licenses/by/4.0/

8 doi: 10.1136/bmj.k2252 | BMJ 2018;361:k2252 | the bmj