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The latest global data, summarised in the 2015 Global Nutrition Report, suggests that this characterization is no longer valid, at least in terms of under 5 anthropometry.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.)