Triple Burden What? Talk About Micronutrient Deficiencies

If you thought double burden of malnutrition (coexistence of undernutrition and obesity) was bad, there is even a Triple Burden. Triple burden of malnutrition is the coexistence of three diseases: undernutrition, micronutrient deficiency and obesity. Micronutrient deficiency is also referred as ‘hidden hunger’ which is the lack of vitamins and minerals. 

Compared with the other two diseases, micronutrient deficiency does not necessarily have to be visible from the outside. Undernutrition and micronutrient deficiency together is a problem which often affects individuals, but micronutrient deficiency and obesity is a combination that occurs as well. This happens when an individual eats too many calories a day, but not the right minerals, vitamins etc. The intertwining of all three of these contribute to the triple burden. This burden can be traced back to poverty, a lack of access to adequate diet, poor infant feeding practices, and the sales of unhealthy and cheap processed foods that combined, all lead to undernutrition, micronutrient deficiency, and overweight and obesity! 

There are different symptoms micronutrient deficiency, because there are different micronutrients. Deficiency in iron for example, can cause fatigue, weakness, headaches, and pale skin. It can even cause cravings to items which isn’t food, like clay. Another example of micronutrient deficiency is calcium deficiency. Symptoms are weak hair and nails, memory loss, and seizures. The list is long of the different micronutrient deficiencies and I could go on forever, but the picture is clear that micronutrients are important. So eat your veggies kids.

plaatjeMaybe you noticed, but besides the symptoms of micronutrient deficiencies that may not be very pleasant, they also can vary. So there are not really distinctive symptoms that says “You have a micronutrient deficiency.” For instance in some studies they used mid-upper-arm circumference to detect nutrient deficiency. The smaller the mid-upper-arm circumference, the greater the chance of having a micronutrient deficiency. But think about this– For the combination undernutrition and micronutrient deficiency, this would be a good method, but for the combination of obesity with micronutrient deficiency, this would not work. And also for people with a normal BMI (and thereby normal mid-upper-arm circumference) this method would not be suitable. 

Anyways, going back to Indonesia. A lot of children (and adults) are undernourished and also have a micronutrient deficiency, however, obesity is also a problem that occurs additionally. Therefore, the triple burden of malnutrition is present in Indonesia! 

So by tackling the problem undernourishment, strategies should also take the micronutrient deficiency in consideration, as well as the problem of obesity in Indonesia. The Australian government actually helped to use strategies to combat undernutrition and micronutrient deficiency for Indonesia. The Australian government did not try to just provide food, but also made up for the micronutrient deficiency. However, they did not take into consideration the problem of obesity when implementing the interventions. What can be a good way to implement all three problems into one intervention? Is it possible?

Fun factDid you know you could have micronutrient deficiency which is not food related?

A micronutrient deficiency of vitamin D. You get this vitamin of the sun, but if an individual does not get in a lot of contact with the sun, he or she can not get this vitamin. In Indonesia this problem occur, especially with women. This is because they cover up a lot of there body for their religion.

Written by: Una

The Faces of Malnutrition. (2016, July 20). Retrieved December 1, 2016, from

How the Trouble Doubled

So what exactly is a double burden of malnutrition?

So what does it mean? The definition of WHO is

The double burden of malnutrition is characterised by the coexistence of undernutrition along with overweight and obesity, or diet-related noncommunicable diseases, within individuals, households and populations, and across the lifecourse.

Low- and middle-income countries are especially affected by the double burden of malnutrition. The rate of the double burden of malnutrition in low-and middle-income countries is 30% faster than in high income countries. Although the number of undernourished children in Indonesia has overall been decreasing over the past 14 years, more and more children are also becoming overweight. However as the specific number of undernourished children is decreasing throughout the years, there are still 8.4 million children stunted due to undernutrition, which is 37.2% of children under the age of five.

The double burden of malnutrition does not only apply on the national level, but could also be applied on an individual-level.  For example, a child who is undernourished, will have a higher risk of getting non-communicable diseases such as diabetes. Even in the utero – before they are even born – a lower weight (underweight) can lead to diabetes and heart diseases later in life. The double burden of malnutrition could also be practiced in just one household: a mother could be overweight, but her child could be undernourished mainly due to feeding practices.

1975-lHow is the double burden of malnutrition even possible? Undernourishment is understandable. Lack of money and poverty can lead to the lack of food and thereby undernourishment. But somehow a country who deals with this poverty problem, also has to deal with obesity, which can imply that people are consuming too much food or more specifically, an overconsumption of sugary and fatty foods.

Well, as technology and  (food) industries developed throughout the years, lifestyle changed as well. Nowadays, fast food is quite accessible and can be cheap. We all know that too much of this type of food isn’t healthy, because it contains, for example, “bad” saturated fats, too much sugars, too much added salt and so on, which can lead to obesity. Furthermore we are leading a more sedentary lifestyle with our cars, tv’s, mobiles, tablets and computers around us, which also contributes to the obesity problem because of the lack of exercise to live a healthy life. And than we have smoking, drugs and drinking: famous lifestyle habits that influence our health in a negative way and makes the chances of developing non communicable diseases(NCD’s) even higher.

But wait a minute, there is another definition of double burden of disease! Yes, this refers to a country which is tackling NCD’s and communicable diseases (CD’s). To understand this definition, you should understand the epidemiological and demographic transition.

The epidemiological transition refers to a slow shift of a country’s health status from a situation in which the presence of communicable diseases (CD’s) are dominant towards a situation in which the presence of non-communicable diseases (NCD’s) are dominant and the CD’s are reduced. These transitions have already occurred in high income countries. Did you notice that high income countries are more concerned with NCD’s like cancer, diabetes, vascular diseases and so on, instead of infectious diseases? This is because infectious diseases are much better controlled nowadays in the high income countries than it used to be in the 19th century.


So let’s talk about the demographic transition (we are getting to the double burden of disease…). This is a transition that refers to a change of a country’s demographic status from high fertility and high mortality to low fertility and low mortality. Again, just like what happened in the high income countries. This transition is for example due to the introduction of contraceptives, which made family planning possible, but the transition is also closely related to the epidemiological transition, since NCD’s are chronic conditions that most of the time causes a long duration of sickness whilst infectious diseases causes mortality much more rapidly. But there has been other theories as well. Maybe parents would make more offspring if they are uncertain about the survival chances of their kids. According to Fabrice Murtin however, the main contributor to the reduction in fertility was education, primary education in particular. Do you want to read more on that? You can find the source below!

So what about the double burden of disease? As Indonesia is going through both transitions, the country is now facing the double burden of disease. The battle against communicable disease are still on the agenda, but more space on the agenda is needed with the rise of non-communicable diseases due to the changes in lifestyle (which also resulted in the double burden of malnutrition).

It looks like Indonesia has a lot on their plate. Yes, unfortunately this is true. They have to tackle undernutrition, over nutrition (obesity), and non-communicable and communicable diseases. These four seem to be all related, but that doesn’t make it easier to combat the burdens.

Written by: Jessica
Co-editor: Una


Murtin, F. (2013). Long-term determinants of the demographic transition, 1870-200. Review of Economics and Statistics, 95 (2), 617-631.

Skolnik, R (2016). Global Health 101 (3rd edition). Burlington: Jones & Barlett learning.

Mackenback, J.P. Stronk, K. Volksgezondheid en gezondheidszorg. Zesde, geheel herziene druk. Reed Business, Amsterdam. Page 18 – 31.