Double Burden of Malnutrition in Pakistan

The global landscape of malnutrition has undergone a fundamental transformation. For decades, international development efforts centered primarily on combating undernutrition, addressing hunger, micronutrient deficiencies, and stunting in low- and middle-income countries. However, this narrative has shifted dramatically with the rapid rise of overweight, obesity, and diet-related non-communicable diseases (NCDs). Today, countries around the world, including Pakistan, are confronted with the double burden of malnutrition (DBM), the simultaneous presence of undernutrition and overnutrition within the same populations, communities, and even households (Popkin et al., 2020). This paradox reflects the increasingly complex food environments shaped by globalization, rapid urbanization, aggressive marketing of ultra-processed foods, and reductions in physical activity.

The economic implications of this dual crisis are enormous. Childhood stunting still affecting more than 140 million children worldwide has long-term consequences for cognitive development, educational attainment, and adult earnings. The World Bank (2023) estimates that affected countries lose 2–3% of their GDP annually due to diminished productivity and weakened human capital. At the same time, the surge in overweight and obesity is generating an equally severe economic strain. Globally, obesity-related healthcare expenditures, lost productivity, and premature deaths cost an estimated $2 trillion each year, a burden comparable to that of smoking or armed conflict (World Obesity Atlas, 2023).

Pakistan exemplifies this double burden vividly. While millions of children suffer from stunting, wasting, and micronutrient deficiencies, obesity and diabetes are rising at alarming rates. The national economic cost of malnutrition, estimated at $7.6 billion annually or about 3% of GDP, is a stark reminder of its scale (World Bank, 2023). Meanwhile, the country faces one of the fastest-growing diabetes epidemics in the world, with over 33 million adults affected (IDF, 2021). This convergence of undernutrition and NCDs places extraordinary pressure on a healthcare system already stretched thin, undermining progress toward poverty reduction, human development, and long-term economic stability.

Pakistan exemplifies the double burden of malnutrition (DBM) with remarkable intensity, reflecting deep structural inequalities in its food and health systems. The coexistence of widespread undernutrition and rapidly rising overweight and obesity underscores a nutritional landscape marked by contradiction and fragmentation. National Nutrition Survey (2018) data reveal that 40.2% of children under five are stunted, indicating chronic undernutrition that impairs physical and cognitive development. Additionally, 17.7% of children experience wasting, a sign of acute food insecurity and recurrent illness. These figures remain among the highest in South Asia and reflect persistent vulnerabilities tied to poverty, inadequate maternal nutrition, poor sanitation, and limited access to diverse diets.

At the same time, Pakistan is facing an escalating epidemic of overweight and obesity. Recent estimates show that more than 50% of adults are overweight or obese, with women disproportionately affected (NCD-RisC, 2023). This surge is driven by rapid urbanization, lifestyle changes, and a food environment increasingly dominated by ultra-processed, calorie-dense, nutrient-poor products. These foods are often cheaper, more convenient, and more heavily marketed than healthy alternatives, making them a default option for low- and middle-income households. The nutritional transition is further accelerated by declining physical activity, expanding sedentary occupations, and the normalization of sugary beverages and fast foods across all socio-economic groups.

One of the most striking manifestations of this crisis is the intra-household double burden, where an undernourished child and an overweight or obese mother coexist under the same roof (Ali et al., 2020). This phenomenon highlights the deep disconnect between food quantity and diet quality, revealing that access to calories does not necessarily translate into access to nutrients. It also reflects gendered inequalities in food distribution, caregiving responsibilities, and health awareness within households.

Compounding these issues are economic instability, recurrent climate-induced disasters, and rising food prices, all of which disproportionately affect vulnerable populations. As families cope by prioritizing cheaper, filling foods over nutritious options, the cycle of malnutrition, both under and over, continues to intensify.

Gaps in Literature

Despite increasing global attention to the double burden of malnutrition (DBM), significant research gaps limit the ability of policymakers and practitioners to design effective, evidence-based interventions in Pakistan and similar low- and middle-income countries. One of the most pressing gaps is the lack of life-course evidence. While it is well established that early childhood undernutrition can increase the risk of obesity and chronic diseases later in life, there is limited longitudinal research from South Asian populations that follows individuals across childhood, adolescence, and adulthood. Without such data, policymakers struggle to understand how early nutritional deficits interact with later exposure to ultra-processed foods, sedentary behaviors, and socio-economic pressures.

A second gap concerns the gendered dimensions of malnutrition, particularly the disproportionately high rates of overweight and obesity among women in Pakistan. Existing evidence points to sociocultural norms, restricted mobility, heavy domestic burdens, and limited access to recreational facilities as contributing factors. However, comprehensive studies that unpack these dynamics in rural versus urban settings, or across income groups, remain inadequate. This limits the development of targeted interventions that address women’s unique vulnerabilities.

Another critical shortcoming lies in integrated nutritional monitoring. Pakistan’s existing surveillance systems tend to measure undernutrition indicators such as stunting and wasting, while data on overweight, obesity, and diet-related NCDs receive far less systematic attention. The absence of sub-national, regularly updated databases that track both forms of malnutrition simultaneously makes it difficult to monitor trends, identify hotspots, or evaluate the effectiveness of programs.

Finally, psychosocial drivers of dietary behavior, especially among youth, are insufficiently explored. The influence of mental health stressors, aggressive marketing of unhealthy foods, digital media exposure, and shifting aspirations on food choices is poorly documented. Without understanding these behavioral determinants, nutrition interventions risk oversimplifying the complex environment shaping young people’s diets.

Global Stance and the Rise of “Double-Duty Actions”

The global response to the double burden of malnutrition (DBM) reflects a growing awareness that undernutrition and overnutrition are not isolated challenges, but interconnected outcomes of the same dysfunctional food and health systems. Recognizing this complexity, international organizations such as the World Health Organization (WHO) have championed the concept of “double-duty actions” strategies that can address both forms of malnutrition at once. These interventions maximize impact by leveraging shared drivers and overlapping pathways. For example, promoting and protecting breastfeeding not only reduces infant mortality and stunting, but also lowers the risk of childhood obesity and related chronic diseases later in life. Similarly, fiscal measures like Mexico’s sugar-sweetened beverage tax, which successfully reduced consumption by 7.6% within two years (Colchero et al., 2017), demonstrate how economic levers can reshape dietary patterns at a population level.

Global frameworks continue to reinforce this integrated approach. Pakistan’s participation in the Scaling Up Nutrition (SUN) Movement since 2013 reflects a national commitment to multi-sectoral action, bringing together government, civil society, and development partners. The 2021 UN Food Systems Summit further emphasized the need to realign agricultural, trade, and food policies with nutrition-sensitive outcomes, stressing that food systems must nourish people rather than simply supply calories.

Understanding the root causes of DBM is essential for designing these effective, dual-purpose interventions. In Pakistan, the drivers form a “perfect storm” of biological, economic, and social factors. Early-life undernutrition primes the body for rapid weight gain later a phenomenon explained by the “thrifty phenotype” hypothesis. This vulnerability is amplified by increasingly obesogenic food environments, where ultra-processed, high-calorie foods are widely available, heavily marketed, and often cheaper than nutritious alternatives. Rapid urbanization has further constrained opportunities for physical activity, while shifts in work and lifestyle patterns promote sedentary behaviors.

Cultural perceptions also play a role, with larger body size sometimes equated with prosperity or good health, slowing recognition of obesity as a major health concern. Meanwhile, fragmented health systems, designed historically to fight infectious diseases or, more recently, non-communicable diseases (NCDs), struggle to deliver integrated preventive nutrition services.

New Strategies for a New Challenge

Addressing the double burden of malnutrition (DBM) requires a fundamental shift from isolated, single-issue interventions to holistic and interconnected strategies. Because undernutrition and overnutrition share many underlying drivers, including poverty, weak food systems, and inadequate health services, solutions must be designed to work across sectors and create benefits at multiple levels of society. One of the most effective approaches begins with strengthening maternal and child health (MCH). Proven interventions such as exclusive breastfeeding for the first six months of life, micronutrient fortification, and balanced protein-energy supplementation have long-term benefits, reducing the risk of both stunting in early childhood and obesity or metabolic disorders later in life. Evidence shows that early-life nutrition sets the foundation for future health, making MCH a critical entry point for double-duty policies.

Creating healthier food environments is equally vital. Fiscal tools such as taxes on sugar-sweetened beverages and subsidies for fruits, vegetables, and other nutrient-rich foods can shift consumer behavior on a large scale. Complementing these policies with strong regulations such as front-of-package warning labels and restrictions on marketing junk foods to children helps reshape dietary choices and protect vulnerable populations from the influence of unhealthy food marketing. Social protection programs also play a transformative role. Pakistan’s Ehsaas Nashonuma initiative illustrates how conditional cash transfers linked to health and nutrition counselling can improve diet diversity and maternal-child health outcomes in low-income households.

Strengthening and integrating health systems is another key strategy. Frontline health workers must be equipped to address both undernutrition and obesity, offering screening, counselling, and referrals for NCD prevention within primary healthcare settings. Finally, tackling DBM requires strong multisectoral governance. Effective coordination between health, agriculture, finance, education, and social protection ministries ensures that national policies are aligned and nutrition sensitive. Together, these new strategies form a comprehensive blueprint to confront a complex nutritional landscape and build a healthier, more resilient population.

Conclusion

The double burden of malnutrition (DBM) presents one of the most urgent and complex public health challenges of our time, and Pakistan stands at its epicenter. The coexistence of chronic undernutrition and rapidly rising overweight, obesity, and diet-related non-communicable diseases reflects deep structural weaknesses in the food, health, and economic systems. This article has highlighted how poverty, climate stress, food price volatility, and aggressive penetration of ultra-processed foods intersect to create a nutritional paradox that affects millions across the country. The intra-household double burden where undernourished children and overweight adults live side by side captures the profound disconnect between caloric intake and true nutritional well-being.

Addressing this crisis demands integrated, evidence-based action. Global momentum around “double-duty actions” offers a powerful opportunity to design interventions that can reduce both stunting and obesity simultaneously. At the national level, Pakistan must prioritize investments in maternal and child nutrition, regulate unhealthy food environments, enhance social protection programs like Ehsaas Nashonuma, and strengthen primary healthcare to address undernutrition and NCD risks together. Equally important is the need for improved data systems and gender-sensitive research to fill critical knowledge gaps.

References: Ali et al.; Colchero et al; Heidkamp et al; IDF; NCD-RisC; Government of Pakistan; Popkin et al; Raza et al; World Bank; WHO; World Obesity Federation.

Please note that the views expressed in this article are of the author and do not necessarily reflect the views or policies of any organization.

The writer is s affiliated with the Institute of Home Sciences, University of Agriculture, Faisalabad, Pakistan and can be reached at sidrakousar023@gmail.com

Related Stories