So where is malnutrition in Latin America? For a long time
we have thought of the countries of Latin America to be the epicenter of the
double burden of malnutrition, where countries are grappling with very serious
levels of undernutrition and overweight and obesity.
The latest global data, summarised in the 2015 Global Nutrition
Report, suggests that this characterization is no longer valid, at least in
terms of under 5 anthropometry. Consider
the following: out of 20 countries in the region for which comparable national
data are available, only 5 of them have stunting levels >20% and adult overweight (including obesity)
levels >35%: Guatemala, Ecuador, Honduras, Nicaragua and El Salvador. Using wasting, only 2 countries have levels of
wasting >5% and adult overweight
(including obesity) levels >35%: Suriname and Guyana.
And it looks like these patterns are stable. Of the 17 countries where we can assess
trends on stunting, the level is falling.
In 7 countries the declines are so rapid that countries will achieve the
targets implied by the global WHA 2025 target for stunting reduction. Meanwhile adult overweight and obesity has
increased in all countries between 2010-2104.
Upon closer inspection, however, we can see that the double
burden is very much alive: but rather than a combination of under 5
stunting/wasting and adult overweight/obesity, the enduring combination is primarily
one of micronutrient deficiencies and adult overweight/obesity. For example, 9 countries have rates of anemia
in women of reproductive age above 20% and
adult overweight/obesity rates above 35%.
What does this apparent evolution in the nature of the
double burden imply for actions to combat malnutrition in the region? It is
difficult to say with certainty.
Interventions such as the promotion of exclusive breastfeeding and
appropriate complementary feeding will remain central to the avoidance of
under-five overweight and obesity as well as the prevention of micronutrient
malnutrition. Access to improved water and sanitation will remain central to
keeping stunting and wasting rates low.
And of course national averages hide many geographic, income and ethnic
inequalities, so the battle against stunting and wasting is not yet being won
for significant segments of the population.
Nevertheless, perhaps the biggest shift in policy will be a
greater recognition of the centrality that food systems play in the causation
of malnutrition in all its forms.
Globalisation, urbanization and income growth, in tandem with increasing
concentration of control of the food system by large national and multinational
corporations will make it ever harder for consumers to make healthier food
purchase choices. The introduction and
enforcement of financial carrots and sticks to incentivize firms to invest more
in healthy foods and less in highly processed foods that are proven disease
risks will become ever more important, as will clear and simple labels on all
foods. Of course, these kinds of policy
are harder to implement compared to policy intended to reduce
undernutrition. There are vested
interests aligned against policies for both forms of malnutrition, but for
undernutrition they are not so powerful.
Food systems policies are also harder to evaluate. They don’t, for example, yield readily to
randomization of interventions.
These changes in the nature of the malnutrition problem in
the region pose several challenges for nutrition researchers the world over:
*The need to work across levels as well as across sectors. We now need to be able to trace food from
farm to fork and understand where the possibilities for positive intervention
are greatest.
*The need to understand the private sector more. This does not necessarily mean working with
businesses, but it means a greater emphasis on understanding them: what
motivates them apart from profit? Are they all the same and if not what drives
the differences? Where do they work and how do they actually operate?
*The need to strengthen our ability to undertake policy
research. Not all research can bend to
the demands of randomisation of interventions. Nor should it. The nature of the
problem and the intervention should determine the evaluation approach. In particular, governance and political
science approaches are likely to add significant value to these efforts given
the non-alignment of interests and power imbalances between different food
system stakeholders.
The 2015 Global Nutrition Report puts forward ideas on how
we can assess the nutrition friendliness of food systems (in a similar spirit
to the baby friendliness of hospitals) and how trust, transparency and
enforcement can be strengthened when engaging with businesses.
The final challenge for nutrition researchers the world over
is to get access to high quality data that is comparable over time, and, if
possible, globally. The Global Nutrition
Report notes that in 20 Latin American countries only 9 have comparable data to
assess progress on the following 6 nutrition indicators: under 5 stunting, wasting
and overweight, anemia in women of reproductive age, exclusive breastfeeding
and adult overweight/obesity. Of those 9
countries, none are on course to meet WHA targets for all 6 indicators, and
only one (Colombia) is on track to meet 4.
In the past 20 years Latin America has made enormous strides
in reducing under 5 undernutrition. These efforts must continue, but a new set
of problems also needs to be taken on; problems that are increasingly rooted in
food systems that do not serve vast segments of the population. To take these emerging problems on,
nutrition research teams all over the world will have to reinvent their
approaches –and their perceptions.
(A Spanish
language version of this article is on the SLAN 2015 website.)
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