Examination of the Double Burden of Malnutrition in Malawi: Implications for Nutrition Surveillance Pubblico
Rhodes, Elizabeth (Summer 2018)
Abstract
The nutrition transition is advancing in low- and middle-income countries (LMICs), contributing to a rise in overweight and obesity on top of ongoing problems of undernutrition. The co-existence of under- and overnutrition, termed the ‘double burden of malnutrition’, has been documented in every region of the world, even in the poorest countries in sub-Saharan Africa like Malawi. However, due to limited nutrition surveillance, many LMICs lack up-to-date information about the prevalence and trends in overweight and obesity and conditions of undernutrition, especially micronutrient deficiencies. Furthermore, little is known about the co-occurrence of overweight and micronutrient deficiencies within the same individual. This dissertation investigated the double burden of malnutrition at the population and individual levels using data from serial nationally representative, cross-sectional Malawi Micronutrient Surveys conducted in 2001, 2009, and 2015-16. Malawi offered an opportunity to conduct this research, given that it is one of the few LMICs that has routinely collected data to assess micronutrient status. Taking advantage of the potential to learn from Malawi’s experience collecting national nutrition data, we also evaluated the implementation process of the 2015-16 Malawi Micronutrient Survey using qualitative research methods. Main findings showed that: (1) from 2001 through 2015-16, there were declines in the prevalence of anemia and vitamin A deficiency, and while overweight and obesity prevalence did not change, nearly 15% of women were overweight or obese in 2015-16; (2) more than one in ten women had co-occurring overweight and micronutrient deficiencies; and (3) there was strong interest within the Government of Malawi to conduct the 2015-16 Malawi Micronutrient Survey, but the implementation process involved serious challenges, such as complex field logistics and high time investment. This dissertation work adds to the growing body of literature on the double burden of malnutrition and makes an important contribution by providing evidence on the challenges of collecting national nutrition data. Altogether, the findings highlight the need for enhancing nutrition surveillance systems to monitor all forms of under- and overnutrition as LMICs undergo the nutrition transition, with special attention to developing population-based survey models that can be implemented effectively and efficiently.
Table of Contents
Chapter 1: Introduction. 1
Chapter 2: Background. 3
Nutrition transition. 3
Defining the double burden of malnutrition. 4
Population level double burden of malnutrition. 5
Individual level double burden of malnutrition. 7
Research needs. 8
Chapter 3: Methodological Approach. 9
Extended qualitative research methods. 9
Participant recruitment 9
Data collection. 10
Data analysis. 11
Malawi Micronutrient Survey data. 12
2001 and 2009 Malawi Micronutrient Surveys. 12
2015-2016 Malawi Micronutrient Survey. 13
Indicators for vitamin A deficiency and iron deficiency. 14
Multiple imputation methods. 15
Chapter 4: Integrating Micronutrient Status Assessment into the 2015-2016 Malawi Demographic and Health Survey: A Qualitative Evaluation. 17
Abstract 17
Introduction. 18
Key messages. 19
Methods. 19
Context 19
Participant recruitment 20
Data collection. 21
Data analysis. 22
Results. 23
Rationale for the MDHS and MNS Operational Design. 23
Stakeholder buy-in. 23
Survey management structure. 24
Nutrition indicators and data quality. 28
Lack of full integration. 29
Discussion. 30
Conclusion. 33
Chapter 5: Recent Trends in Under- and Overweight, Anemia, and Micronutrient Deficiencies among Women in Malawi 37
Abstract 37
Introduction. 38
Methods. 40
Data sources and study population. 40
Measures of nutritional status. 41
Statistical analysis. 43
Results. 44
Discussion. 45
Chapter 6: Urban Residence is Associated with Higher Prevalence of Individual-Level Double Burden of Malnutrition in Malawian Women. 57
Abstract 57
Introduction. 59
Methods. 61
Data source and study population. 61
Characterizations of the double burden of malnutrition at the individual level 62
Measurement of overweight and conditions of undernutrition. 62
Statistical analysis. 63
Results. 64
Prevalence of single conditions of malnutrition. 65
Prevalence of co-occurring overweight and anemia or micronutrient deficiencies. 66
Observed versus expected prevalence of co-occurring overweight and anemia or micronutrient deficiencies 68
Discussion. 69
Chapter 7: Summary and Conclusions 86
Summary of main findings. 86
Strengths and limitations. 88
Public health implications. 91
Contribution to the public health literature. 91
Implications for nutrition surveillance and interventions. 92
Concept of the double burden of malnutrition. 95
Future research directions 96
Single conditions of malnutrition. 96
Double burden of malnutrition. 97
Nutrition surveillance. 99
Conclusion. 101
References 102
Appendix. 110
Appendix A: Qualitative In-Depth Interview Guide. 110
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