Tool for assessing food industry commitments and practices to address the double burden of malnutrition: a Delphi study

Klinger et al. Globalization and Health (2026) 22:14 https://doi.org/10.1186/s12992-025-01175-8 Globalization and Health Open Access RESEARCH Tool for assessing food industry commitments and practices to address the double burden of malnutrition: a Delphi study Carmen Klinger1,2* , Elochukwu C. Okanmelu1,2 , Peter Delobelle3,4 , Melissa A. Theurich1,2 , Daniela Rincón Camargo1,2 , Kurt Gedrich5 , Nicole Holliday1,2 , Eva A. Rehfuess1,2 , Olufunke Alaba6 , Zandile Mchiza7,8 , Estelle V. Lambert9 , Stefanie Vandevijvere10 , Lana Vanderlee11 , Gary Sacks12 and Peter von Philipsborn1,2,13 Abstract Background Many low- and middle-income countries face a double burden of malnutrition, i.e., a co-occurrence of undernutrition with overweight, obesity, or other diet-related noncommunicable diseases. In an increasingly connected global food system, multinational and domestic food industry actors – through their commercial practices and corporate political activity – both contribute to the double burden of malnutrition and hold potential to address it. Systematic monitoring of relevant industry commitments and practices may help to hold industry accountable and foster constructive engagement. The Business Impact Assessment - Obesity and population-level nutrition (BIA-Obesity) tool has been developed to assess and benchmark food companies’ commitments and practices related to obesity and support for healthy diets at a national level. Methods To enable the application of BIA-Obesity for countries facing a double burden of malnutrition, this study aimed to identify and select relevant best practice indicators for assessing food company commitments and practices regarding the double burden of malnutrition, with a focus on indicators not currently captured by the BIA-Obesity tool. A three-round Delphi study was conducted between April and October 2024, involving an international panel of experts. Results From 52 invited experts, 30 contributed to our expert panel (response rate 58%). Based on a systematic review, 16 best practice indicators addressing the double burden of malnutrition were proposed. Consensus (i.e., group agreement of 75% or higher) for inclusion was reached for 8 indicators covering the production, distribution and marketing of (i) breastmilk substitutes and (ii) complementary foods, (iii) breastfeeding support and (iv) parental leave for employees, (v) food fortification, (vi) use of traditional foods, (vii) use of discounts and donations, and (viii) healthy diets at work. One additional indicator on corporate strategy was included as an overarching indicator. Conclusions Food industry action may complement other efforts to address the double burden of malnutrition, such as public policies and investments. Tools like the extended BIA-Obesity framework can be used for a systematic *Correspondence: Carmen Klinger Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Klinger et al. Globalization and Health (2026) 22:14 Page 2 of 16 monitoring of relevant industry commitments and practices and may help to disseminate and establish favourable industry practices as part of broader efforts to address the double burden of malnutrition in low- and middle-income countries. Clinical trial number Not applicable. Keywords Undernutrition, Malnutrition, Food insecurity, Obesity, Noncommunicable diseases, Food industry, Commitments, Voluntary action, Expert consultation, Monitoring Background Many low- and middle-income countries (LMICs) face a double burden of malnutrition (DBM), defined as the co-occurrence of a relevant burden of undernutrition (wasting, stunting, underweight, and/or micronutrient deficiencies), alongside a relevant burden of overweight, obesity, or other diet-related noncommunicable diseases (NCDs) [1]. The DBM can be observed at the population level (community, municipality, local region, country, or world region), the household level, or at the individual level, at any given point in time or over the life course [1– 3]. To emphasise the role of micronutrient deficiencies as a separate aspect, some organisations use the term ‘triple burden of malnutrition’ instead (e.g., the United Nations Children’s Fund (UNICEF) [4], the Food and Agriculture Organization of the United Nations (FAO) [5], and the International Food Policy Research Institute (IFPRI) [6]). According to a 2020 Lancet series, regions particularly affected by the DBM are Sub-Saharan Africa, South Asia, and East Asia & the Pacific, with roughly a third of all LMICs facing a substantial DBM [2]. Since the 1990s, the DBM has shifted from primarily affecting upper-middle-income economies to now predominantly impacting lower-middle-income and low-income economies, driven by a rise in overweight and obesity without a substantial decline in undernutrition in these countries [2]. The emergence of the DBM has coincided with, and is arguably partly driven by the nutrition transition, a population-level shift in dietary consumption (from traditional, high-cereal, high-fibre diets towards diets rich in refined sugar, fat and salt) and energy expenditure (due to changes in physical activity patterns towards a more sedentary lifestyle) [7, 8]. The nutrition transition occurs alongside broader societal shifts such as economic growth, urbanisation, aging populations, and transitions from infectious diseases towards NCDs. It is also influenced by globalisation leading to changes in food systems (defined as “the people, institutions, places, and activities that play a part in growing, processing, transporting, selling, marketing, and, ultimately, eating food” [9]) and food environments (defined as the physical, economic, political, and socio-cultural contexts influencing people’s decisions about acquiring, preparing, and consuming food [7, 10, 11]. Industry actors, such as domestic and multinational food and non-alcoholic beverage manufacturers, supermarkets, and quick-service restaurants, play an important role in shaping national food environments through both their commercial practices and corporate political activity. Their (...truncated)