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2.2 The double burden of diseases in

Hunger and malnutrition remain among the most devastating problems facing the majority of the world’s poor and needy people, and continue to dominate the health of the world’s poorest nations. Nearly 30% of humanity are currently suffering from one or more of the multiple forms of malnutrition (19).

The tragic consequences of malnutrition include death, disability, stunted mental and physical growth, and as a result, retarded national socioeconomic development. Some 60% of the 10.9 million deaths each year among children aged under five years in the developing world are associated with malnutrition (20). Iodine deficiency is the greatest single preventable cause of brain damage and mental retardation worldwide, and is estimated to affect more than 700 million people, most of them located in the less developed countries (21). Over 2000 million people have iron deficiency anaemia (22). Vitamin A deficiency remains the single greatest preventable cause of needless childhood blindness and increased risk of premature childhood mortality from infectious diseases, with 250 million children under five years of age suffering from subclinical deficiency (23). Intrauterine growth retardation, defined as birth weight below the 10th percentile of the birth-weight for-gestational-age reference curve, affects 23.8% or approximately 30 million newborn babies per year, profoundly influencing growth, survival, and physical and mental capacity in childhood (24). It also has major public health implications in view of the increased risk of developing diet-related chronic diseases later in life (25-31).

Given the rapidity with which traditional diets and lifestyles are changing in many developing countries, it is not surprising that food insecurity and undernutrition persist in the same countries where chronic diseases are emerging as a major epidemic. The epidemic of obesity, with its attendant comorbidities - heart disease, hypertension, stroke, and diabetes - is not a problem limited to industrialized countries (32). Children are in a similar situation; a disturbing increase in the prevalence of overweight among this group has taken place over the past 20 years in developing countries as diverse as India, Mexico, Nigeria and Tunisia (33). The increasing prevalence of obesity in developing countries also indicates that physical inactivity is an increasing problem in those countries as well.

In the past, undernutrition and chronic diseases were seen as two totally separate problems, despite being present simultaneously. This dichotomy has obstructed effective action to curb the advancing epidemic of chronic diseases. For example, the prevailing approach of measuring child undernutrition on the basis of the underweight indicator (weight for-age) can lead to gross underestimation of the presence of obesity in populations that have a high prevalence of stunting. Use of this indicator could lead aid programmes to feed apparently underweight people, with the undesirable outcome of further aggravating obesity. In Latin America, close to 90 million people are beneficiaries of food programmes (34) but that group actually comprises only 10 million truly underweight people (after correcting for height). The two facets of nutrition-related problems need to be brought together and treated in the context of the whole spectrum of malnutrition.

2.3 An integrated approach to diet-related and nutrition-related diseases

The root causes of malnutrition include poverty and inequity. Eliminating these causes requires political and social action of which nutritional programmes can be only one aspect. Sufficient, safe and varied food supplies not only prevent malnutrition but also reduce the risk of chronic diseases. It is well known that nutritional deficiency increases the risk of common infectious diseases, notably those of childhood, and vice versa (35, 36). There is, therefore, complementarity in terms of public health approaches and public policy priorities, between policies and programmes designed to prevent chronic diseases and those designed to prevent other diet-related and nutrition-related diseases.

The double burden of disease is most effectively lifted by a range of integrated policies and programmes. Such an integrated approach is the key to action in countries where modest public health budgets will inevitably remain mostly devoted to prevention of deficiency and infection. Indeed, there is no country, however privileged, in which combating deficiency and infection are no longer public health priorities. High-income countries accustomed to programmes designed to prevent chronic diseases can amplify the effectiveness of the programmes by applying them to the prevention of nutritional deficiency and food related infectious diseases.

Guidelines designed to give equal priority to the prevention of nutritional deficiency and chronic diseases, have already been established for the Latin American region (37). Recent recommendations to prevent cancer are reckoned also to reduce the risk of nutritional deficiency and food-related infectious diseases (38), and dietary guidelines for the Brazilian population give equal priority to the prevention and control of nutritional deficiency, food-related infectious diseases, and chronic diseases (39).

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