Regional Overview on the Double Burden of Malnutrition and Examples of Program and Policy Responses: Latin America and the Caribbean

Regional authorities for the Americas remain focused on addressing the main causes and drivers of malnutrition and to identifying potential solutions. As part of the regional session at the International symposium on “Understanding the Double Burden of Malnutrition (DBM) for Effective Interventions” [1], Member States aim to share best practices in addressing the DBM and support the use of nuclear science and technology to address major sustainable development priorities targeting optimal feeding and proper nutrition.

The Americas region has made substantial and rapid progress in reducing the prevalence of stunting and wasting, yet regional averages may mask inequities in this progress between and within countries. Currently, in the Americas, 6.3% of children under 5 years are stunted [2], 0.9% are wasted [3], and 7.2% are overweight [4]. As well, 19.1% of women of reproductive age are anemic [5], 62.5% of adults over 18 years are overweight [6], and 28.6% of adults are obese [7]. The Americas is now the region with the highest prevalence of overweight and obesity in the world [8]. In addition, the prevalence of noncommunicable diseases (NCDs), such as cardiovascular disease, cancer, diabetes, and chronic pulmonary diseases, continues to increase in all age groups [9]. Current evidence shows that hunger, food insecurity, stunting, wasting, anemia, overweight, and NCDs may coexist in the same person, household, and community [10, 11]. The DBM in the region is linked to the consumption of ultraprocessed foods that are energy-dense, high in sugar, salt or fat, and nutrient-poor [12], which are an important cause of disability and premature death. Such dietary changes create an urgency to transform the food supply chains and food environments to increase access of healthy foods and consequently end all forms of malnutrition [13, 14].

At the regional level, in 2014, Member States of the Pan American Health Organization (PAHO) unanimously approved the Plan of Action for the Prevention of Obesity in Children and Adolescents [15], which is an example of a comprehensive policy to address the DBM. The overall goal of this Plan of Action is “to halt the rise of the rapidly growing obesity epidemic in children and adolescents, through multisectoral life-course approach that is based on the social-ecological model and focuses on transforming the current obesogenic environment into opportunities for increased intake of nutritious foods and improved physical activity.” The plan encourages the Member States to formalize a series of policies aimed at preventing childhood obesity through specific environmental approaches (Table 1). For example, the plan encourages countries to develop clinical guidelines to prevent and manage overweight and obesity and promote healthy eating and physical activity in primary health care, adopt and monitor the implementation of the International Code of Marketing of Breastmilk Substitutes, certify at least 50% of maternity health facilities as Baby Friendly Health Hospital, create an enabling school environment to improve nutrition and increase physical activity. Other policies promoted include regulating marketing, food labeling, and taxation of food and beverages high in sugar, salt, or fat and promote family farming to reduce relative price of healthy foods.

Achievements by Member States of the Americas [16] related to the Plan of Action are summarized in Table 2. What follows is a synopsis of broad activities in the Americas that aim to prevent undernutrition and obesity while promoting policies to prevent the DBM. For example, The Caribbean Public Health Agency (CARPHA) [17] is a collective response to strengthening health system and policy actions in the Caribbean. The agency has been actively involved in the implementation of evidence-based programs to prevent stunting, wasting, overweight, and obesity, which have been identified as the main problems among school-age children in the Caribbean. CARPHA is also actively involved in providing technical assistance for the development of school nutrition policies that restrict or ban the use of sugar-sweetened beverages and unhealthy snacks and promote strategies and activities for creating health-promoting environments within schools and their surrounding communities. Through its World Diabetes Foundation-funded projects, CARPHA has and continues to collaborate with Ministries of Health, Education and Sport for the development and implementation of school-based lifestyle interventions. The first of these projects ran from 2008 to 2012 and targeted select high schools in 4 countries (Grenada, St Kitts and Nevis, St Vincent, and the Grenadines and Trinidad and Tobago). Currently, the agency has a similar project being conducted in select primary schools in Grenada and St Lucia. Both projects adopt an intervention-control design that targets students, schools, families, and communities. CARPHA continues to advocate for such behavioral interventions to be adapted/adopted in schools across the region by utilizing resources already in existing in country and encouraging/supporting regular training activities facilitated by various stakeholders (government ministries, NGOs etc.).

In Chile, maternal and infant health and nutrition programs have been recognized as key to enhance human capital. The comprehensive child protection system “Chile Crece Contigo” (Chile Grows with You) integrates health, social development, and educational activities from early pregnancy to 4–5 years of age. This system aimed to optimize growth and childhood cognitive-motor development [18] was implemented in 2007 and institutionalized by the Intersectoral Social Protection System.

Finally, Brazil has significantly reduced the prevalence of wasting and stunting since the 1990s in part due to intersectoral policies such as increasing formal employment, expanding conditional cash transfer programs, and expanding access to public education, health, and sanitation. Despite this, a high prevalence of these conditions may persist in marginalized and vulnerable populations. Meanwhile, due to changes in food patterns (i.e., increased availability of ultraprocessed foods and an intake of sugar, salt, and fat), the prevalence of obesity and overweight has increased across all age groups and socioeconomic levels. NCDs are responsible for over 70% of deaths in Brazil. Addressing this situation is a public health priority, and Brazil has built a comprehensive NCD prevention and control plan and is committed to meeting international targets regarding NCDs and its risk factors [19]. For example, in 2017, Brazil became the first country to adopt 3 major commitments to the Decade of Action on Nutrition [20]: prevent adult obesity; reduce consumption of sugar-sweetened beverages among adults by 30%; and increase the proportion of adults who eat fruit and vegetables by 17%. Brazil has also committed to intersectoral policies related to food and nutrition security, food reformulation for reducing sodium, sugar, and fat in foods, microcredit loans to farmers, and cash transfers to poor families to improve food security. To strengthen the regional efforts for the Decade of Action on Nutrition, the Ministry of Health of Brazil is coordinating 2 Networks of Action (Food-Based Dietary Guidelines and Sodium Reduction for Cardiovascular Disease Prevention), and the Ministry of Social Development has proposed additional Networks on Governance on Food and Nutrition Security and Food Procurement Policies. Brazil believes that tackling the DBM requires multistakeholder and intersectoral approaches and country and interagency cooperation. There is a strong belief that the Decade of Action on Nutrition provides an important setting for commitments and policy action.

It was evident from the presentations that the DBM exists in the Americas, the prevalence of which varies between LAC countries. The region is at particular risk for the DBM, which creates a significant socioeconomic and development challenge as many countries in the region are small with open, but vulnerable, economies due to trade policies, and the negative impact of multinational companies, along with hostile and highly vulnerable climatic conditions. At all levels, there was sharing of plans for adopting strategies and approaches aligned with international best practices to address aspects of the DBM in the non-Latin American countries of the Caribbean focused on childhood obesity and overweight. It was recognized that the region needs stronger political will and leadership to enact legislation and policies that create enabling environments by holding governments accountable, advocating for action, hosting empowered and better-informed people, and monitoring and evaluating progress.

Regional institutions, civil society, and academic institutions are increasingly addressing the DBM, but there is a need for greater interagency and institutional collaboration and greater application of a whole society approach, including effective participation of the private sector. Given the vast evidence of the DBM affecting all regions of the world, it is imperative that governments support integrated responses to achieve the Sustainable Development Goal (SDG) of ending malnutrition in all its forms (SDG 2) and ensuring healthy lives and promoting well-being for all (SDG 3). It is also imperative that regional governments and institutions work in tandem to promote and support multicomponent interventions that prioritize the main drivers of the DBM (social, demographic, behavioral, environmental, and biological). Such interventions include the following: the WHO double duty actions; cost-effective evidence-based interventions; optimal maternal and antenatal nutrition and care; protection, promotion, and support of breastfeeding and appropriate complementary feeding; programs that foster healthy diets in schools, public institutions, and workplaces; policies that improve food security; and initiatives that ensure access to healthy and sustainable diets from appropriate and resilient food systems [13]. In addition, it is essential to incorporate food and nutrition surveillance, program monitoring, implementation, and evaluation research in policy implementation to capture expected and unexpected outcomes. PAHO should take the lead to integrate and coordinate optimal multisectoral and interagency actions, including the productive sector when need it.

The authors would like to thank Daniel Hoffman, Cornelia Loechl, and Theodora Mouratidou for their critical reviews of the manuscript. We also would like to thank Sofia Segura Perez and Ana Carla Cepeda for taking notes during the seminar and sharing the information with us.

The authors have no ethical conflicts to disclose for this review because there were no humans or animals involved directly.

The authors have no conflicts of interest to declare. R.G. is a staff member of the PAHO. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent the decisions or policies of the Pan American Health -Organization.

No external funding source contributed to the writing of this paper.

Open access provided with a grant from the International Atomic Energy Agency.

All authors contributed to the conception of the work; T.H. provided the session notes; R.G. wrote the first draft of the paper; all authors subsequently critically revised it for important intellectual content; all authors approved of its current version and agreed to be accountable for all aspects of the work.

The statements, opinions and data contained in this publication are solely those of the individual authors and contributors, not of the publishers and the editor(s), and do not necessarily reflect the views of the cooperating organizations, IAEA, UNICEF and WHO. The use of particular designations of countries or territories does not imply any judgement by the cooperating organizations, as to the legal status of such countries or territories, of their authorities and institutions or of the delimitation of their boundaries. The mention of names of specific companies or products (whether or not indicated as registered) does not imply any intention to infringe proprietary rights, nor should it be construed as an endorsement or recommendation on the part of the cooperating organizations.

The article is part of the Proceedings of the International Symposium on Understanding the Double Burden of Malnutrition for -Effective Interventions organized by the International Atomic Energy Agency (IAEA) in cooperation with United Nations Children’s Fund -(UNICEF) and World Health Organization (WHO) (10–13 December 2018, -Vienna, Austria).