Understanding and addressing the double burden of malnutrition at the household level in Guatemala

Malnutrition remains a major global public health challenge, encompassing both undernutrition and overnutrition. In low- and middle-income countries (LMICs), these forms increasingly coexist, giving rise to the double burden of malnutrition (DBM). Guatemala exemplifies this challenge, with persistently high levels of child stunting alongside a rapid increase in overweight and obesity. Despite its growing relevance, evidence on the magnitude, determinants, and potential interventions for DBM remains limited, particularly in Latin America and the Caribbean (LAC). This doctoral thesis aimed to: (1) assess the magnitude and associated factors of household- and individual-level DBM in the LAC region and Guatemala; and (2) identify key determinants of household-level DBM that can inform public health strategies in Guatemala. Results of this thesis include: a systematic review and meta-analysis of 60 studies across 27 LAC countries revealed substantial heterogeneity in DBM prevalence (0–24%), depending on the specific combination of malnutrition indicators. The most frequently reported form was the coexistence of child stunting and maternal overweight (CS-WO). In Guatemala, analysis of national survey data (1998–2015) showed that DBM affected approximately one in four households, with stable prevalence over time. CS-WO was the most common combination, affecting nearly one in five households. Further analyses identified key socio-demographic determinants. Lower odds of DBM were associated with rural residence, higher wealth, and women’s secondary education, while higher odds were linked to Indigenous background, maternal age above 25 years, and larger household size. Additional analyses highlighted both unique and shared determinants between DBM and single forms of malnutrition, underscoring the complexity of its drivers. Moreover, using longitudinal data, this thesis also demonstrated that maternal pre-pregnancy malnutrition, particularly short stature, underweight, and their coexistence with overweight, was associated with increased risk of severe growth faltering in children during the first two years of life. Finally, an evidence-informed issue brief was developed to support awareness and guide action in Guatemala, emphasizing the need for double-duty actions (DDAs) that simultaneously address under- and overnutrition. Overall, this thesis provides evidence of the high and persistent burden of DBM in LAC and Guatemala, driven by intersecting socio-demographic and biological factors. Addressing DBM requires integrated, multi-sectoral, and life-course approaches, with a particular focus on vulnerable populations such as women of reproductive age and young children.