Comment
The changing context of overnutrition and undernutrition in Pakistan The Lancet Maternal and Child Nutrition Series1 noted the emergence of overweight and obesity in lowincome and middle-income countries while also documenting the unfinished agenda in undernutrition, sometimes in the same countries and populations. Furthermore, the Series reported analyses of data from Brazil, Nigeria, and Bangladesh, which emphasised inequalities in nutritional status by wealth and urban versus rural location. In The Lancet Global Health, Mariachiara Di Cesare and colleagues2 describe the methods and results of the 2011 Pakistan National Nutrition Survey (NNS)—a multistage, district-specific, nationally representative survey of nutritional status and its association with socioeconomic status and geographical location in women and young children in Pakistan. The NNS is a large survey with a high response rate that Di Cesare and colleagues have analysed with appropriate statistical methods. These methods weight the prevalence estimates to account for the complex survey methods and reduce the variance of district specific estimates with a Bayesian approach that borrows data from surrounding districts. A unique contribution of this study to the scientific literature is the district-specific estimation that can be of value to programme planners and could help target interventions to individuals most in need, if and when this strategy is appropriate. A related contribution is the description of inequities in nutritional status and the extent to which socioeconomic factors explain these inequities. Findings from this study add to those of The Lancet Maternal and Child Nutrition Series by also documenting the emergence of overweight and obesity in women and the geographical and socioeconomic variation in these disorders. Similarly, the study documents overweight and obesity in children, especially in those in higher socioeconomic circumstances. By contrast, some households had overweight and obese mothers with underweight or stunted children. This double nutritional burden is a more complex problem to address than is obesity
www.thelancet.com/lancetgh Vol 3 April 2015
or underweight alone and needs a distinct set of behavioural messages and interventions. Although such trends in nutritional status have been documented in middle-income countries for some time, these concerns have been more recently reported in India, Bangladesh, and others.3,4 Di Cesare and colleagues’ study now provides nationally representative data from Pakistan showing a similar double burden of both overnutrition and undernutrition. We are now in the year when the Millennium Development Goals are supposed to have been met. Most reporting of the progress towards these goals has been country specific, but concerns have been expressed about whether meeting overall country-specific goals mighty mask socioeconomic or geographical inequalities within countries. The results described in the present study provide a good example of why surveys should be designed and powered to estimate regional and socioeconomic variations in health and development indicators if inequity is to be recognised and addressed in future development goals.
See Articles page 229
Joanne Katz Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA [email protected] I declare no competing interests. Copyright © Katz. Open access article distributed under the terms of CC BY-NC-ND. 1
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Black RE, Victora CG, Walker SP, et al, Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 382: 427–51. Di Cesare M, Bhatti Z, Soofi SB, Fortunato L, Ezzati M, Bhutta ZA. Geographical and socioeconomic inequalities in women and children’s nutritional status in Pakistan in 2011: an analysis of data from a nationally representative survey. Lancet Glob Health 2015; 3: e229–39. Corsi DJ, Kyu HH, Subramanian SV. Socioeconomic and geographic patterning of under- and overnutrition among women in Bangladesh. J Nutr 2011; 141: 631–38. Paciorek CJ, Stevens GA, Finucane MM, Ezzati M, on behalf of the Nutrition Impact Model Study Group (Child Growth). Children’s height and weight in rural and urban populations in low-income and middle-income countries: a systematic analysis of population-representative data. Lancet Glob Health 2013; 1: e300–09.
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The changing context of overnutrition and undernutrition in Pakistan The Lancet Maternal and Child Nutrition Series1 noted the emergence of overweight and obesity in lowincome and middle-income countries while also documenting the unfinished agenda in undernutrition, sometimes in the same countries and populations. Furthermore, the Series reported analyses of data from Brazil, Nigeria, and Bangladesh, which emphasised inequalities in nutritional status by wealth and urban versus rural location. In The Lancet Global Health, Mariachiara Di Cesare and colleagues2 describe the methods and results of the 2011 Pakistan National Nutrition Survey (NNS)—a multistage, district-specific, nationally representative survey of nutritional status and its association with socioeconomic status and geographical location in women and young children in Pakistan. The NNS is a large survey with a high response rate that Di Cesare and colleagues have analysed with appropriate statistical methods. These methods weight the prevalence estimates to account for the complex survey methods and reduce the variance of district specific estimates with a Bayesian approach that borrows data from surrounding districts. A unique contribution of this study to the scientific literature is the district-specific estimation that can be of value to programme planners and could help target interventions to individuals most in need, if and when this strategy is appropriate. A related contribution is the description of inequities in nutritional status and the extent to which socioeconomic factors explain these inequities. Findings from this study add to those of The Lancet Maternal and Child Nutrition Series by also documenting the emergence of overweight and obesity in women and the geographical and socioeconomic variation in these disorders. Similarly, the study documents overweight and obesity in children, especially in those in higher socioeconomic circumstances. By contrast, some households had overweight and obese mothers with underweight or stunted children. This double nutritional burden is a more complex problem to address than is obesity
www.thelancet.com/lancetgh Vol 3 April 2015
or underweight alone and needs a distinct set of behavioural messages and interventions. Although such trends in nutritional status have been documented in middle-income countries for some time, these concerns have been more recently reported in India, Bangladesh, and others.3,4 Di Cesare and colleagues’ study now provides nationally representative data from Pakistan showing a similar double burden of both overnutrition and undernutrition. We are now in the year when the Millennium Development Goals are supposed to have been met. Most reporting of the progress towards these goals has been country specific, but concerns have been expressed about whether meeting overall country-specific goals mighty mask socioeconomic or geographical inequalities within countries. The results described in the present study provide a good example of why surveys should be designed and powered to estimate regional and socioeconomic variations in health and development indicators if inequity is to be recognised and addressed in future development goals.
See Articles page 229
Joanne Katz Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA [email protected] I declare no competing interests. Copyright © Katz. Open access article distributed under the terms of CC BY-NC-ND. 1
2
3
4
Black RE, Victora CG, Walker SP, et al, Maternal and Child Nutrition Study Group. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013; 382: 427–51. Di Cesare M, Bhatti Z, Soofi SB, Fortunato L, Ezzati M, Bhutta ZA. Geographical and socioeconomic inequalities in women and children’s nutritional status in Pakistan in 2011: an analysis of data from a nationally representative survey. Lancet Glob Health 2015; 3: e229–39. Corsi DJ, Kyu HH, Subramanian SV. Socioeconomic and geographic patterning of under- and overnutrition among women in Bangladesh. J Nutr 2011; 141: 631–38. Paciorek CJ, Stevens GA, Finucane MM, Ezzati M, on behalf of the Nutrition Impact Model Study Group (Child Growth). Children’s height and weight in rural and urban populations in low-income and middle-income countries: a systematic analysis of population-representative data. Lancet Glob Health 2013; 1: e300–09.
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