A total of 139 low and middle-income countries (LAMICs) were included in this review. Of them, 36 were low-income countries (LICs), 48 were lower-middle income countries (LMICs), and 55 were upper-middle income countries (UMICs). As also reported previously [1, 10, 33], LICs had a higher average prevalence of all types of undernutrition but lower prevalence of overweight compared to MICs. Regionally, undernutrition was more prevalent in South Asia compared to other regions. In contrast, overweight was more prevalent among LAMICs of Eastern Europe and Central Asia, but undernutrition was in the lowest magnitudes in this region compared to others. Despite the high magnitudes of undernutrition and overweight/obesity in LAMICs, only 37.9% had nutrition policies that could address the dual burdens. Moreover, of the 36 countries with available data, a higher proportion of LICs had weak nutritional governance compared to MICs. This study also found that strong nutrition governance is associated with lower magnitudes of undernutrition.
Like in previous studies, our study found that all undernutrition statuses were more prominent in LICs than in MICs [1, 10, 33]. Higher prominence of undernutrition in LICs than MICs is likely due to the predominance of the determinants of undernutrition [34, 35]. These include food insecurity, poor feeding practices, high burden of diseases, and other socio-economic disadvantages which are more common in poor settings . On the other hand, food abundance, sedentary lifestyles and urbanization have been responsible for the opposite extreme of nutrition—overweight and obesity, a trend that is on the rise in MICs [9, 10]. In addition, an increase in GDP per capita was associated with a decrease in the undernutrition prevalence while it was associated with an increase in prevalence of overweight. Also, such economic development may bring about increase in the number of educated caregivers who can impact children nutrition. We found an association between net school enrolments with the reduction of the prevalence of undernutrition. With rapid economic development and demographic transition, the magnitudes of undernutrition tend to improve . At the same time, populations that are well off and affluent, move to the other extreme end of nutrition statuses. During this process rates of overweight and obesity go up, but tend to continue to coexist with high levels of undernourishment-a phenomenon best described as nutrition transition .
Nutrition transition is evident in LAMICs. This study found a persistent magnitude of undernutrition that coexists with those of overweight in these countries. Despite such finding, only 37.9% of the countries had nutrition policies that could address both burdens. Without a nutrition strategy outlined in a country’s nutrition policy and adopted in overall health policy, efforts to control undernutrition may not reach the majority of the population and any efforts may yield poor outcomes [24, 25]. The majority of LICs had policies to address only undernutrition. This is clearly because of a historical concern over undernutrition in such countries . Under such settings, undernutrition was regarded as a problem of public health importance. A little is done for overweight, a condition that is also growing in such countries. With such growing threat, it is high time for these countries to include overweight in their health policies and national strategies.
This study found no significant association between nutrition policy to address undernutrition or overweight with reduction in the magnitudes of either undernutrition or overweight in LAMICs. Having policy alone may not be enough to bring down rates of undernutrition and overweight/obesity . To enact a policy, a country would need stewardship, adopting the policy and streamline it with national development agenda, having a nutrition strategic plan, funding for interventions included in the policy, and involving other sectors, in this case, a strong nutrition governance . Although nutrition policy is one component in the nutrition governance , to develop, enact, and initiate nutrition action, other components of nutrition governance are also important. Together, such components can bring about the desired change . Governance is also important for showing how a country is committed to accelerating nutrition actions [38, 39]. It is a measure of the country’s responsiveness to varied threats of nutrition, both undernutrition and obesity . In this study, MICs had stronger nutrition governance compared to LICs. Results of this study further showed that strong nutrition governance was more likely to be associated with improved magnitudes of undernutrition and showed a direction towards improving magnitudes of overweight, after controlling for other confounding variables.
Results of this study should be discussed in light of the following potential limitations. First, this study reviewed data whose sources might have used different methods and tools for collection. For example, we used nutrition status data, which is reported by the WHO, but originated from national sources, DHS, and other UN organizations. Although this could have lead to over- or under-estimation, these are the best estimates available and have been adopted globally. Second, to examine the changes of nutrition statuses over time, we used data for as many different years and different countries as we could get. Such analyses may have been more accurate if data for the same time intervals and years was available. To mitigate the effect of time differences, we controlled for the years in the regression analyses. We also collected data of GDP per capita and school enrolment that corresponded to the years of nutrition status data collection. We controlled nutrition policy and governance by matching them with years of anthropometric data. Third, only a few countries had data on nutrition governance. This could reduce the power of our results. Fourth, a few countries had data on nutrition governance, which was also our important independent variable. This might lead into under estimation of the association between it and nutrition statuses, or limit generalizability into countries with no such data. However, for the available data, we controlled important confounders to find independent association with nutrition statuses. Fifth, we used GINA database to collect data on nutrition policy. This database uses available policies in the country or ones that are provided upon request, in native languages. This may result in missing some policies or updates thereof. Sixth, while the problem of nutrition transition affects populations across age groups, we focused on child population. This was mainly because of the lack of nutrition data among adults in LAMICs and unclear nutrition policy to address such problems.
Despite the mentioned limitations, this study serves as the first to review nutrition policies to address the growing concern of nutrition transition in low and middle-income countries. It is also the first to examine the association of such policies and governance with the changes of undernutrition and overweight or obesity magnitudes.
In conclusion, this review found a low proportion of low and middle-income countries had nutrition policies to address both undernutrition and overweight/obesity. A higher proportion of LICs had nutrition policies to address undernutrition but not overweight and obesity compared to MICs. Presence of nutrition policy, however, was not associated with reduction in magnitudes of undernutrition or overweight. To ameliorate the threat of failing to address the challenges of the nutrition transition, stronger nutritional governance is necessary which is supported by updated policies that respond to the dynamic nutrition situation pertinent to a country setting. Low and middle-income countries should target both undernutrition and growing rates of overweight and obesity even if they are not yet of public health importance. Without having stronger nutrition governance, policies alone may not be enough to address the growing threat of nutrition transition.