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PUBH 642 :Global Nutrition and Food securityDouble burden of a condition means that the particular condition has two set of issues which can have an impact and should be overlooked and solved. When this concept of double burden is applied to health science, it reflects the mode of communicable or non-communicable aspect of the burden that the particular disease or the condition can result in or have an impact on the health.
In exploration of nutrition and its importance, the energy is identified as the fundamental requirement of life. The energy for most of the forms of life is produced by a source of nutrition. For humans the main source of the energy is the nutrition that should be gained or fulfilled by the source of food.

The lack of adequate nutritional elements and /or consuming excessive amount of nutrition which is termed as “Malnutrition” has identified as a major health related issue in the modern world. As it is defined by the World health organization, this concept of malnutrition has two main aspects of it namely Undernutrition and overnutrition. “Undernutrition” includes, having a low height for age is called “Stunting” and low weight for height is called “wasting” and deficiency or insufficiency of micronutrients such as vitamins and minerals. The other aspect of overnutrition is consist of obesity and diet related non communicable diseases such as diabetes, heart disease, cancers and other co morbid diseases (“What is malnutrition?”, 2018). Malnutrition is identified as a global problem as it affects people in every country and it is counted as over 1.9 billion of adults around the world are obese while 462 million adults are recognized as underweight. As an evidence to affirm the intensity of this health problem it is reported that over 41 million of children under the age of 5 years are ascertained to be over weight or obese where at the same time over 159 million children identified as stunted and another 50 million as wasted. To further emphasize the severity of this burden it is noted that over 528 million that accounts for a 29% of the women in reproductive age group world wide are affected with nutritional deficiencies (“What is malnutrition?”, 2018). Significant changes that has occurred in the context of nutritional landscapes, economy, urbanization, globalization and the diet related epidemiology has resulted the mismatch of the nutritional requirements and has raised this issue of dual burden of malnutrition within individuals, households and populations, and across the life course.
In comparison of this concept and the global statistics the countries in the south east Asia has been prominent among the other countries world wide. Sri Lanka is one of the south east Asian countries who are in the effect of the double burden of malnutrition. Despite the relatively high literacy rate among the rest of the south east Asian countries with 90.8% according to the census of 2006 and the current achievements in economic growth especially after defeating a long standing terrorism in a war ended in year 2009, the nutritional status of children is under satisfactory, and neither is that of adolescents and women in the community. According to the Demographic and health survey in year 2006 / 2007 the country’s low birth weight prevalence is 16.6%. Among the children under five years, 21.1% are underweight (compared to 22.8% revealed by DHS 2000), and about 14.7% under 5 years are wasted (15.5% in 2000). Stunting levels have declined from 18.4% in 2000 to 17.3% in 2007 (DHS). The nutrition status shows a wide variation across the districts ; as for wasting, it ranges from 10.5% to 28.1% substantiating the geographical disparity. A high prevalence of overweight which is about 31.2% in females aged 15-49 years (DHS.2007), and other diet-related non-communicable diseases such as diabetes mellitus, cardiovascular disease, hypertension and certain types of cancer. Comparatively high prevalence of overweight is seen in urban areas (7.6% in urban adolescents aged 11-19 years (MRI.2001)). Overweight and obesity are emerging challenges leading to a double burden (2018).

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According to the Food and Agriculture Organization of United Nations, food based dietary guidelines for Srilankans has been published by the Division of Nutrition, Ministry of health Sri Lanka in consultation with various government ministries, universities, nutrition associations and institutes, consumer and non-governmental organizations, and with the support of the World Health Organization and UNICEF. The food guide of Sri Lanka is a food pyramid which divided into six levels. Including rice, breads, other cereals and yams are at the base: vegetables and fruits on the second level; fish, pulses, meat and eggs are on the third level; followed by dairy products, nuts and oils, and fat and sugary products (“Sri Lanka”, 2018).

Sri Lankan Food Pyramid.

It is further advised to eat a variety of foods every day. Eating cereal-based foods three times a day is recommended. Adding plenty of vegetables and fruits daily and pulses, fish, dried fish, eggs, poultry and lean meat is suggested. Consuming milk or milk products daily is advised while moderate consumption of fat, limiting salt intake and using only iodized salt in endorsed. It is advocated to consume less sugar, sweets or sweetened drinks and to drink plenty of water. Also emphasized on maintaining a healthy body weight through a balanced food intake and regular physical activity. Furthermore, eating additional food during pregnancy and lactation, exclusively breastfeeding for 6 months, starting complementary feeding at the completion of 6 months is recommended by the guidelines. In addition to that it is also mentioned that the children and adolescents should take an adequate and nutritious diet while the elderly should eat foods with high nutritional value. Eating clean and safe foods with more emphasize on naturally occurring foods in preference to processed foods is guided.

It is not a secret that Sri Lanka is very famous for three main aspects and they are, its beauty with natural beaches and water falls, its rich culture and the delicious authentic food. Srilankans’ main food is rice and the curries are all made with coconut cream and they are cooked in coconut oil. With the above mention high energy food culture, the effects of globalization and the changes in the traditional occupations, economy and modern busy lifestyle with lack of physical exercises have lead to imbalance of energy division and consumption enhancing the dual burden of nutrition.

To overcome the dual burden of nutrition and to achieve and maintain the nutritional well-being of all Sri Lankans the following objectives and goals are developed to implement interventions.

1. To ensure optimal nutrition throughout the life cycle
2. To enhance capacity to deliver effective & appropriate interventions
3. To ensure effective management of adequate nutrition to vulnerable populations
4. To ensure food and nutrition security for all citizens
5. To strengthen advocacy, partnerships and networking
6. To strengthen research, monitoring and evaluation
On ensuring optimal nutrition throughout the life cycle Nutritional status throughout the stages of the life cycle is interrelated. Foetal malnutrition due to poor maternal nutrition sets-up a vicious cycle affecting all stages of life and even future generations. Thus, in-order to reduce this inter-generational impact of malnutrition, the National Nutrition Policy will focus on a life-cycle approach and aims to ensure appropriate and adequate nutrition and related services for all pregnant women throughout the pregnancy enabling a delivery of a healthy baby with an adequate birth weight. Also, to ensure supportive family environment, services and regulatory safety nets to enable mothers to provide optimal care including exclusive breastfeeding for 6 months and continuation of breast feeding for 2 years and beyond. Furthermore, ensure a good foundation for all infants and young children during their early childhood years by providing optimal nutrition through provision of exclusive breast-feeding for 6 months followed by complementary feeding together with continued breast feeding for 2 years and beyond. With regards to pre-school and primary school children, they have been enabled to get access to adequate and safe nutrition, which will optimise their growth and development. To reduce undernutrition and obesity (malnutrition) among adolescents, enabling them to be healthy and productive adults by promotion of appropriate nutrition for adults and elderly to ensure prevention and control of nutrition related Non-Communicable Diseases. In addition to these, enhancing capacity to deliver effective and appropriate interventions by empowering all the stakeholders achieved through capacity building, which is vital for successful interventions. National Nutrition Policy therefore aims to promote behaviour change in all sections of population enabling them to make right food choices and care practices. Policy states strengthen capacity building of health staff and community–based workers for effective behaviour change with regards to nutrition promotion in all sections of the community. Empowering the community by reorganizing grass root level community organizations, in programme planning, implementation and monitoring of nutrition intervention programmes. Ensuring dissemination of appropriate nutrition messages and promotion programmes through media in a responsible and ethical manner. Vulnerable populations are worst affected particularly during man made and natural disasters as well as during illnesses. Hence National Nutrition policy aims to ensure targeting of nutritional interventions to underserved areas, plantation community, urban poor and areas identified by the nutrition surveillance system. This also ensures access to adequate nutrition for people affected by emergencies (conflict or natural disasters) and ensure emergency preparedness and response plans to adequately address the basic nutrition needs of all people.

Special amendments to ensure adequate nutrition during and after illness with special considerations on those affected with chronic diseases and people living with HIV / AIDS are beimg implemented. More importantly ensuring food and nutrition security for all citizens as food and nutrition security is a major factor in achieving nutritional wellbeing at individual and household level. National Nutrition Policy also aims to ensure access to adequate, nutritious, safe and quality food at affordable price throughout the year. It emphasizes on promoting the consumption of a wide variety of foods ensuring intake of all macro and micronutrients to prevent deficiency disorders and diet related chronic diseases. Policy Statement also promote and facilitate improvement of quality of commonly consumed food items such as food fortification to ensure micronutrient supplementation for vulnerable groups. The policy Statement enact and implement appropriate legislations and other regulatory mechanisms to ensure provision of safe nutrition to all citizens of Sri Lanka. Strengthening the advocacy, partnerships and networking appreciating the cross-cutting nature of nutrition interventions, measures will be taken to advocate incorporation of nutritional objectives and components into national development and other relevant policies and programmes and aims to establish a mechanism for regular consultation and discussions between political leaderships, policy planners and other stakeholders to ensure sustainability of programmes in coherence with the nutrition related policies. Additionally, it strengthens the partnerships and networking with relevant sectors and stakeholders including private sector for undertaking collaborative programmes to improve nutrition at community level. Policy also anticipates strengthening the researches, monitoring and evaluation on timely information and updated knowledge as it is vital for evidence based programme planning and management. The National Nutrition Policy will promote establishment and operation of National Nutrition Surveillance System providing policy makers, programme managers and nutrition care providers with evidence needed for better programme management. It has prioritised the need of and support research oriented activities to utilize evidence for regular monitoring and periodic evaluations of nutrition programmes.

In addition to this the World health organization held a workshop on nutrition labelling to promote healthy diet in South east Asian region in April 2018. During this regional workshop several publications have been highlighted in order to provide guidance in overcoming the double burden of malnutrition. These are namely, Sodium intake and iodized salt in south east Asia, Regional report on nutritional security in ASEAN, comprehensive implementation plan on maternal, infant and young child nutrition, WHO ambition and action in nutrition 2016 – 2025, WHO Nutrient Profile Model for South-East Asia Region and A practice guide to effective population-based food policy actions to promote healthy diets (“Nutrition”, 2018).
Th e National Nutrition Policy (NNP) upon adoption will serve as the base document on which the strategic approaches will be developed leading to the phase of implementation. Effective and sustainable institutional framework is a mandatory requirement for smooth implementation of this policy. Identifying and promoting establishment of required institutions and mechanisms are important to ensure efficient administration of policy and action plan. Comprehensive action plan will be drawn up in line with the NNP identifying the responsibility for each activity with a pre-determined time line for implementation and a means of verification. The policy will be implemented through bodies with well-defined responsibilities. The following bodies will be established to accomplish this objective. The proposed and formed committees are as follow.
1. National Nutrition Steering Committee (NNSC): This committee is to develop nationally important policy decisions and monitor these activities and comprise of high-level representatives of relevant ministries
2. National Nutrition Co-ordination Committee (NNCC): This committee is to develop major technical decisions and to review the action plans periodically to prioritize the activities. This is comprised of nutrition professionals of different sectors
3. Nutrition Coordinating Committee at Provincial level (NCCP): This committee performs duty on planning and managing the nutritional interventions and other programmes within the province
4. Nutrition Co-ordination Unit (NCU): This unit is functioning as a secretariat and it is responsible for coordination of the agencies that implies the key decisions made by the NNSC and NNCC. In addition to these, monitoring and evaluation system will be developed to ensure that the NNP is being implemented and the objectives are met.
According to a paper published by International Food Policy Research Institute of Monash University Australia in 2014 the major factors that have been emphasized to improve the nutrition quality and to overcome the issue of double burden of malnutrition in south east Asian countries including Sri Lanka are political and governmental commitment on the fact, inequality and poverty reduction by improving the domestic production growth and women empowerment (Haddad, Cameron & Barnett, 2018).

References
What is malnutrition?. (2018). Retrieved from http://www.who.int/features/qa/malnutrition/en/Double burden of malnutrition. (2018). Retrieved from http://www.who.int/nutrition/double-burden-malnutrition/en/(2018). Retrieved from https://extranet.who.int/nutrition/gina/sites/default/files/LKA%202010%20Sri%20Lanka%20National%20Nutrition%20Policy-English_0.pdfSri Lanka. (2018). Retrieved from http://www.fao.org/nutrition/education/food-based-dietary-guidelines/regions/countries/sri-lanka/en/Nutrition. (2018). Retrieved from http://www.searo.who.int/entity/nutrition/en/Kol?i?, I. (2018). Double burden of malnutrition: A silent driver of double burden of disease in low– and middle–income countries.

The ‘double burden of malnutrition’ – obesity on the rise in Indonesia. (2018). Retrieved from https://sydney.edu.au/news-opinion/news/2016/05/12/the-_double-burden-of-malnutrition–obesity-on-the-rise-in-indon.htmlDouble Burden of Malnutrition in South East Asia and the Pacific | Malnutrition | Obesity. (2018). Retrieved from https://www.scribd.com/presentation/209955621/Double-Burden-of-Malnutrition-in-South-East-Asia-and-the-PacificThe double malnutrition burden: time for Australia to lead. (2014). Blog. Retrieved from http://www.devpolicy.org/the-double-malnutrition-burden-time-for-australia-to-lead-20140307/Haddad, L., Cameron, L., & Barnett, I. (2018). The double burden of malnutrition in SE Asia and the Pacific: priorities, policies and politics. Retrieved from http://users.monash.edu.au/~clisa/papers/Published%20Article.pdfNovianti Rachmi, C., Li, M., & Alison Baur, L. (2018). The double burden of malnutrition in Association of South East Asian Nations (ASEAN) countries: a comprehensive review of the literature. Retrieved from http://apjcn.nhri.org.tw/server/APJCN/27/4/736.pdfSL women obesity rate exceeds 45%: UNICEF. (2018). Retrieved from http://www.dailymirror.lk/article/SL-women-obesity-rate-exceeds-UNICEF-149680.htmlUdomkesmalee, E. (2018). Double Burden of Malnutrition: Situation Analysis from Asia Pacific. Retrieved from https://humanhealth.iaea.org/HHW/Nutrition/Malnutrition/IAEA_WHO_UNICEF_workshop/05_Udomkesmalee.pdfUN unveils action plan to tackle southeast Asia’s malnutrition double burden. Retrieved from https://www.nutraingredients-asia.com/Article/2016/09/12/UN-unveils-action-plan-to-tackle-southeast-Asia-s-malnutrition-double-burden

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