As countries are reeling in the face of the COVID-19 pandemic-induced lockdowns, associations between access to healthy diets, physical activity and mental health are more important than ever -- especially given the growing evidence of links between obesity and COVID-related death.
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Malnutrition, in all its forms, is the largest single risk factor for the global burden of disease. Every country is affected, and many countries are dealing with a ‘double burden’ characterized by the coexistence of undernutrition with overweight, obesity or diet-related non-communicable diseases. Physical inactivity is another major risk factor for premature death worldwide.
Both malnutrition and physical inactivity are connected to broader socio-political determinants of disease which act synergistically (or ‘syndemically’) where they cluster in poorer and more marginalized populations. One neglected pathway is mediated by poor mental health. Evidence is mounting on the associations between food insecurity and anxiety, stress and depression (independent of other indicators of low socio-economic status) in both resource-rich and resource-poor settings. Stress brought on by food insecurity may cause non-homeostatic eating and may lead to the selection of ‘comfort’ foods, or highly palatable foods that are rich in fat, sugar, and sodium.
This paper responds to recent calls to review efforts to create enabling environments for ‘double-duty actions.’ In their potential for preventing or reducing several forms of malnutrition simultaneously by targeting shared drivers, double-duty actions hold great promise.
A scoping review (2010-2020) was conducted to explore pathways from combined physical activity and nutrition promotion interventions, with potential synergistic effects on outcomes other than obesity. We find that 33 of the 36 studies meeting inclusion criteria are limited to focusing or reporting on obesity outcomes. Also notable is the fact that 22 of the 34 programs that satisfied quality assessment were implemented in one country (USA), with three others from Canada, and one each from an additional eight countries, and just one multi-country initiative.
Findings across implementation settings suggest that even in situations where interventions are framed in terms of obesity prevention and control, there are unexploited pathways for broader outcomes of relevance to nutrition and health and wellbeing more generally.
Most health promotion interventions have traditionally focused on changing individual behavior rather than targeting broader socio-political or environmental determinants that influence behavior. Multi-component and longer-term interventions however are needed to ensure sustainability beyond the initial short-term outcomes of single component interventions. To sustain large-scale change, those involved in delivering nutrition and physical activity interventions must address not only individual lifestyle behaviors, but also the underlying and structural causes of health inequalities, perceptions of body and health, and stigma.
There may be a trade-off between the intensity of the intervention that can be delivered and resources needed to sustain intensive, multi-component, multisectoral programs over time. Even while working towards Universal Health Coverage, effective targeting needs to be taken into account in intervention design and implementation as part of a new thrust towards progressive universalism. This includes better informed decisions about the different needs and preferences of different population groups. Nutrition interventions targeting mothers, infants and children remain high priority. But studies here report multiple benefits of targeting affected populations later in the life-course -- including adolescents, or adults in the workplace -- for prevention and control of comorbidities later in life. High risk groups can also be specifically targeted via referral services or community and home outreach, though it will be important to prevent such targeted services becoming the source of new stigma.
The importance of understanding the wider context of implementation was highlighted in many studies. Programs need to be developed with local stakeholders, tailored to the social, economic, cultural, and demographic features of a region, and designed with regard to age, gender, socioeconomic status, cultural identities and spheres of influence of participants. Strengthening the existing capacity of people and networks and building on community initiatives is key.
This review contributes to the evidence base for double duty action. Future design and evaluation of multisectoral approaches will benefit from an explicit framing of interventions as double-duty oriented. At the very least, single issue interventions should attempt to specify whether and how they ensure that no harm is caused to other forms of malnutrition and wellbeing. Implementers and evaluators alike would benefit from a clearer framework of how this is to be achieved, in order to satisfy the requirements for effective double duty action set out by the World Health Organization and, more broadly, for the achievement of the Sustainable Development Goals (SDGs).
Laura Casu is a freelance consultant based in Brighton, UK. Stuart Gillespie is a Senior Research Fellow at the International Food Policy Research Institute, who conducts work as part of A4NH's Research Flagship on Supporting Policies, Programs, and Enabling Action for Research. Nick Nisbett is a Senior Research Fellow at the Institute for Development Studies. The analysis and opinions expressed in this piece are solely those of the authors.
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