Instituto de Nutrición de Centro América y Panamá - INCAP-

Double burden of malnutrition – situation analysis from Latin America

Manuel Ramirez-Zea, MD PhD mramirez@incap.int

Instituto de Nutrición de Centro América y Panamá - INCAP-

Nutrition Transition • Replacement of traditional diets by energy dense diets and sedentary

lifestyles. • Increase in overweight, obesity and nutrition related non communicable

diseases. • Rapid shift in Latin America, where most countries still have high

undernutrition prevalences and are unprepared to face the burden of overnutrition.

• Double burden of malnutrition (DBM): coexistence of under and overnutrition.

Instituto de Nutrición de Centro América y Panamá - INCAP-

Double Burden of Malnutrition Levels

National

Coexisting prevalences of malnutrition in the same

country

Household

Undernourished children and

over nourished mothers in the

same household

Individual

Opposite conditions

in the same individual

Instituto de Nutrición de Centro América y Panamá - INCAP-

Participating countries MEXICO

GUATEMALA

CUBA

COLOMBIA

ECUADOR

BRASIL

CHILE URUGUAY

Instituto de Nutrición de Centro América y Panamá - INCAP-

1. Descriptive Information

National Representative Surveys

Prevalences

• Height-for-age <2 z score

Stunting:

• BMI-for-age >+2 z scores

or • Weight-for-height

>+2 z scores

OW/OB in Children:

• Overweight BMI ≥25 and < 30 • Obesity BMI ≥30

OW/OB in Women:

Children: • Hb <11 g/dL

Women: • Hb<12g/dL

Anemia:

Instituto de Nutrición de Centro América y Panamá - INCAP-

2. DBM Assessment

At household and individual level

Following standardized methodology

Expected Prevalence: under the assumption of independent distributions of the conditions.

Expected Prevalence= Prevalence Condition 1

Prevalence Condition 2

100

Overweight/Obesity = 50%

Stunting = 50%

50∗50100

= 25

Instituto de Nutrición de Centro América y Panamá - INCAP-

2. DBM Assessment

At household and individual level

Following standardized methodology1

Observed Prevalence: both conditions currently present in the same household or individual.

Comparison of expected VS observed prevalences using a Chi2 test.

1Dieffenbach and Stein 2012, p.772

Instituto de Nutrición de Centro América y Panamá - INCAP-

RESULTS

Instituto de Nutrición de Centro América y Panamá - INCAP-

48.0

25.3

13.6 13.2 10.9

8.1 7.1 4.9

8.6 9.0 5.2

9.5 8.7 7.3

49.2

25.7 23.3

27.5 31.5

15.4

21.8

0.0

10.0

20.0

30.0

40.0

50.0

60.0

Guatemala Ecuador México Colombia Uruguay Cuba Brazil

Stunting Overweight & Obesity Anemia

National Prevalence of Stunting, Overweight and Anemia in Children <5y in LAC

Rivera JA, et al. Am J Clin Nutr 2014.

Instituto de Nutrición de Centro América y Panamá - INCAP-

National Prevalence of Excess Weight and Anemia in Women of Reproductive Age (12-49y) in LA

73.0

66.5 64.9 64.3

55.2 49.5

11.9 15.0

30.6

4.4 6.6

25.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

México Ecuador Brazil Chile Colombia Guatemala

Overweight & Obesity Anemia

Rivera JA, et al. Am J Clin Nutr 2014.

Instituto de Nutrición de Centro América y Panamá - INCAP-

20.0

13.1

8.4

6.3 5.1

2.7

0.0

5.0

10.0

15.0

20.0

25.0

Guatemala Ecuador México Uruguay Colombia Brazil

Prev

alen

ce (%

)

*Observed vs expected prevalence significantly lower P < 0.05

*[22.9]

*[14.3]

*[9.1]

*[6.9]

*[1.3]

[7.0]

Household level: National prevalence of Overweight/Obese mother – Stunted Child Pairs in LA

Rivera JA, et al. Am J Clin Nutr 2014.

Instituto de Nutrición de Centro América y Panamá - INCAP-

Co-existence of stunted children and overweight mother (SCOM) in the same household (%)

20.0

28.2

14.4

0.0

5.0

10.0

15.0

20.0

25.0

30.0

All Indigenous Non-IndegenousRamirez-Zea et al, AJCN 2014

Instituto de Nutrición de Centro América y Panamá - INCAP-

Double burden of malnutrition at household level

Ramirez-Zea et al, AJCN 2014

Instituto de Nutrición de Centro América y Panamá - INCAP-

13.6

11.7

8.9

7.6

3.4

0

2

4

6

8

10

12

14

16

Brazil Guatemala Ecuador Mexico Colombia

Prev

alen

ce (%

)

*Observed vs expected prevalence significantly lower P < 0.05 *Observed vs expected prevalence significantly higher P < 0.05

*[12.7]

*[3.5]

*[7.2]

Individual level: National Prevalence of Women of Reproductive Age with Excess weight and Anemia

Rivera JA, et al. Am J Clin Nutr 2014.

Instituto de Nutrición de Centro América y Panamá - INCAP-

Co-existence of overweight/obesity and short stature in Guatemalan women in reproductive age (%)

13.7

22.0

8.7

0

5

10

15

20

25

All Indigenous Non-IndegenousRamirez-Zea et al, AJCN 2014

Instituto de Nutrición de Centro América y Panamá - INCAP-

Individual level: Children with Excess Weight and Stunting

2.8

1.8

1.0 1.0

0.1 0

0.5

1

1.5

2

2.5

3

5-11 y 6-59 mo 5-11 y 5-11 y 5-12 y

Ecuador Guatemala Mexico Brasil Colombia

*Observed prevalence is greater than expected prevalence P < 0.05 *Observed prevalence is lower than expected prevalence P < 0.05 Rivera JA, et al. Am J Clin Nutr 2014.

*[4.4]

*[2.3]

*[2.3]

*[0.5]

*[0.5]

Instituto de Nutrición de Centro América y Panamá - INCAP-

Conclusions • Undernutrition and excess body weight risks seem to be largely unrelated at

individual and household level

• Both types of conditions are highly common in Latin American countries: overweight and obesity coexist with undernutrition at the national level.

• These findings evidently indicate the need of policies and programs to tackle both conditions simultaneously in a coordinated fashion.

Instituto de Nutrición de Centro América y Panamá - INCAP-

Policies and programs • Countries like Ecuador and Guatemala have policies mostly

directed to undernutrition. • Uruguay, Brazil and Colombia have a number of programs

focused on one or the other side of malnutrition. • Some are in the process of redesigning programs and

policies. • Mexico is the only one considering the DBM in a single

program by scaling up “Oportunidades”

Instituto de Nutrición de Centro América y Panamá - INCAP-

Decision makers and program implementers need to:

• Be aware that individuals with different nutritional status may live within the same household

• Reformulate policies and programs: – Malnutrition in all its forms – Promote healthy growth (linear growth w/o excessive weight gain) – Promotion of healthy eating and physical activity throughout life course

• Appropriate evaluation and monitoring

Instituto de Nutrición de Centro América y Panamá - INCAP-

Supplement authors • Conde WL, Monteiro CA. Nutrition transition and double burden of undernutrition and excess of weight in Brazil. Am J

Clin Nutr. 2014 Dec;100(6):1617S-22S. • Atalah E, Amigo H, Bustos P. Does Chile’s nutritional situation constitute a double burden? Am J Clin Nutr. 2014

Dec;100(6):1623S-27S. • Sarmiento OL, Parra DC, González SA, González-Casanova I, Forero AY, García J. The dual burden of malnutrition in

Colombia. Am J Clin Nutr. 2014 Dec;100(6):1628S-35S. • Freire WB, Silva-Jaramillo KM, Ramírez-Luzuriaga MJ, Belmont P, Waters WF. The double burden of undernutrition

and excess body weight in Ecuador. Am J Clin Nutr. 2014 Dec;100(6):1636S-43S. • Ramirez-Zea M, Kroker-Lobos MF, Close-Fernandez R, Kanter R. The double burden of malnutrition in indigenous and

nonindigenous Guatemalan populations. Am J Clin Nutr. 2014 Dec;100(6):1644S-51S. . • Kroker-Lobos MF, Pedroza-Tobías A, Pedraza Zamora LS, Rivera Dommarco JA. The double burden of

undernutrition and excess body weight in Mexico. Am J Clin Nutr. 2014 Dec;100(6):1652S-58S. • Severi C, Moratorio X. Double burden of undernutrition and obesity in Uruguay. Am J Clin Nutr. 2014

Dec;100(6):1659S-62S.

Instituto de Nutrición de Centro América y Panamá - INCAP-

THANK YOU Manuel Ramirez-Zea, MD PhD

mramirez@incap.int Institute of Nutrition of Central America and Panama (INCAP)

INCAP Research Center for the Prevention of Chronic Diseases. (CIIPEC)