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

Quantifying Overlapping Forms of Malnutrition Across Latin America: A Systematic Literature Review and Meta-Analysis of Prevalence Estimates

Estimating the prevalence of double burden of malnutrition (DBM) is challenging in the Latin American and Caribbean (LAC) region where various DBM typologies (e.g., obesity and stunting) are heterogeneous and estimates are scattered across literature This study aimed to assess the prevalence of DBM typologies in the LAC region. We searched PubMed, Embase, Scopus, and Web of Science to identify studies on the prevalence of DBM published between 1 January, 2000, and 23 January, 2023. Outcomes were the prevalence of the identified DBM typologies at the household, individual, or across life course levels. Random-effect meta-analyses of proportions were used to estimate pooled period prevalence for all outcomes. Heterogeneity was explored using meta-regressions. From 754 records identified, 60 (8%) studies were eligible, with a median of 4379 individuals. Studies reported data from 27 LAC countries collected between 1988 and 2017. Most studies used nationally representative surveys (68%) and scored as low risk of bias (70%). We identified 17 DBM typologies for which 360 estimates were analyzed. The prevalence of the identified DBM typologies ranged between 0% and 24%, with the DBM typology of "adult with overweight and child with anemia" having the highest prevalence (24.3%; 95% CI: 18.8%, 30.2%). The most frequently reported DBM typology was "adult with overweight and child with stunting," with a prevalence of 8.5% (95% CI: 7.7, 9.3). All prevalences carried large heterogeneity (I2>90%), modestly explained by subregions and countries. DBM across the life course could not be estimated owing to insufficient estimates. In conclusion, using available data, our study suggests that the burden of DBM in the LAC region ranges between 0% and 24%. In the most frequent DBM typologies, overweight was a common contributor. Substantial progress can be made in curbing the burden of DBM in the LAC region through strategies addressing excess weight within these population groups. This study was registered at PROSPERO as CRD42023406755.

Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

BACKGROUND

Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories.

METHODS

We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median).

FINDINGS

From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness.

INTERPRETATION

The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union.

Improving the Quality of the Delivery of Nutritional Care Among Children Undergoing Treatment for Cancer in a Low- and Middle-Income Country

PURPOSE

International twinning programs have been well-established between institutions in childhood cancer and have led to pediatric cancer units in low- and middle-income countries (LMICs) adopting multidisciplinary forms of care. To advance nutritional care in LMICs, the International Initiative for Pediatrics and Nutrition (IIPAN) provided the structural framework and personnel for the delivery of nutritional care. We describe the impact of a newly established nutrition program on the delivery of nutritional care and nutrition-related clinical outcomes in children and adolescents undergoing treatment for cancer in Nicaragua and Honduras.

METHODS

A prospective cohort (N = 126) collected clinical data over a 2-year period. Collection of IIPAN's nutritional services received during treatment and clinical data were abstracted from medical charts and registered in Research Electronic Data Capture (REDCap) database. Chi-square, ANOVA, and generalized linear mixed models were used; P < .05 was considered statistically significant.

RESULTS

Nutritional assessments led to a higher number of patients receiving recommended standard of care. Children classified as underweight during treatment presented higher number of infections and toxicities, length of hospital stay, and days of treatment delays during treatment. Overall, from the start to end of treatment, 32.5% of patients improved nutritional status, 35.7% maintained it, and 17.5% worsened. On the basis of metrics, the cost per consultation was less than 4.80 US dollars (USD; Honduras) and 1.60 USD (Nicaragua).

CONCLUSION

Integration and equitable access of the nutritional care process for all patients needs to be recognized as a component of the basic management in pediatric oncology care. IIPAN's nutritional program demonstrates that nutritional care is economical and feasible in a limited resource setting.

The projected burden of non-communicable diseases attributable to overweight in Brazil from 2021 to 2030

Although studies have quantified the current burden of diseases attributable to overweight and obesity in Brazil, none have estimated its burden in the future. The study aimed to estimate the potential impact of different scenarios of changes in the prevalence of overweight on non-communicable diseases (NCD) in the Brazilian adult population until 2030. We developed a multistate life table model including 11 body mass index (BMI) related diseases to estimate attributable NCDs cases and deaths under the following scenarios of changes in overweight over a 10-year simulation: (1) the continuity of the current trajectory of BMI increases, (2) reducing the rate of increase by half, (3) stopping future BMI increases, and (4) the reduction of the prevalence of overweight by 6.7%. In Brazil, if the current trends of BMI increase are maintained from 2021 to 2030, approximately 5.26 million incident cases and 808.6 thousand deaths from NCDs may occur due to overweight. If the annual increase in overweight was reduced by half until 2030, 1.1% of new NCD cases and 0.2% of deaths could be prevented (respectively, 29,600 cases and 1900 deaths). Alternatively, if the current prevalence of overweight is maintained, as set as a national goal in Brazil until 2030, the incident NCD cases and the deaths could be reduced by respectively 3.3% (92,900) and 1.5% (12,100) compared to continuation of current trends. If the prevalence of overweight is reduced by 6.7% until 2030, 6.5% (182,200) of NCD cases and 4.2% (33,900) of deaths could be prevented. The epidemiologic burden of overweight in Brazil tends to increase if bold policy interventions are not adopted in Brazil.

Food-based dietary guidelines for children and adolescents

Objective

This study aimed at reviewing food-based dietary guidelines (FBDGs) with content targeted at children and adolescents to present their main characteristics, thus enabling comparisons among countries.

Design

We conducted a search of the FBDGs available on the Food and Agriculture Organization (FAO) website, followed by a scoping review with a gray literature search to find FBDGs for children or adolescents non-listed on the FAO's website. Data extraction included the year of publication, language, and guidelines for the target group.

Results

From FAO website searches, 109 documents were found, and 17 of them could not be translated. The Scoping review search conducted in 5,190 articles, and none led to new guidelines, nor from the gray literature. Regarding the 92 FBDGs explored, 41 were specific for infants under 24 months old, children, and/or adolescents, and 51 were for the general population with information for the studied group. Twelve percent of the general FBDG and 35% of the specific ones have food icons. All of the guidelines were published after 2001. Latin America and the Caribbean were the regions that presented more specific FBDGs and the majority of countries with guidelines for fruits and vegetables. The information about fat (15 countries) and sugar (26 countries) consumption reduction is frequent. Reduction of sodium intake appears to be in the majority of guidelines after 2015. Food hygiene guidelines are recurrent in Latin American documents. NOVA classification was adopted in five countries and 21 countries approach recommendations for mealtimes. Both exclusive and continued breastfeeding guidance and healthy complementary feeding orientation are present in over 50% of the specific FBDG for infants and children under 24 months old.

Conclusion

Food-based dietary guidelines are diverse due to both the nutritional and political aspects of each region. Latin America stands out for its orientations for the studied group. Further studies should measure the possible impacts and comprehension of FBDGs.

Prevalence and socioeconomic determinants of the double burden of malnutrition in mother-child pairs in Latin America and the Caribbean

Background

The double burden of malnutrition (DBM), which refers to the coexistence of overnutrition and undernutrition among populations, households or individuals, is a growing problem in low/middle-income countries. The Latin America and the Caribbean (LAC) region has been particularly affected by the DBM, following a nutrition transition and a rapid increase in overweight, obesity and diet-related disease, while high levels of undernutrition persist. This study aims to describe the prevalence of four different DBM definitions in mother-child pairs across nine LAC countries and investigate the socioeconomic determinants of overweight mothers with at least one stunted child (SCOM).

Methods

We used cross-sectional data from the Demographic and Health Surveys for all analyses. We used descriptive statistics to obtain prevalence rates and conducted multiple logistic regression analyses to investigate the association between SCOM households and socioeconomic determinants, including wealth index, maternal education, place of residency and whether the mother was working, adjusted for a range of variables.

Results

Overweight/obese mothers with at least one anaemic child were the most common type of DBM, with a prevalence of 19.39%, followed by SCOM with a prevalence of 10.44%. Statistically significant socioeconomic predictors of SCOM were households with a lower wealth index, lower maternal education and living in rural areas.

Conclusion

This study showed that the overall prevalence of most DBM definitions examined was high, which points to the need for urgent interventions in the LAC region. The unique set of socioeconomic predictors of SCOM identified in this study calls for future double-duty policies that simultaneously target food affordability, nutrition education and access to healthy food.

Challenges and perspectives of the double burden of malnutrition in Latin America

Nutrition is a key factor in the development of non-communicable chronic diseases (NCCDs), especially cardiovascular diseases (CVD) and their risk factors. The "double burden of malnutrition" (DBM) is the coexistence of undernutrition and overnutrition in the same population across the life-course. In Latin America, the transition from a predominantly underweight to an overweight and obese population has increased more rapidly than in other regions in the world. Undernutrition and the micronutrient deficiencies particularly iron, zinc, and vitamins A and D, present high heterogeneity in Latin American countries, and are currently considered important public health problems. In this region, NCCDs account for 50% of the disability-adjusted life-years, led by CVD. The most prevalent cardiovascular risk factors are overweight, obesity, hypertension, dyslipidemia and type 2 diabetes mellitus. Because of the cost of treatment and the potential years of life lost due to premature death, CVD is known to affect the poorest segments of the population, affecting communities, and governments. More than 80% of CVD deaths occur in low- and middle-income countries. The persistence of damage in some cells due to undernutrition may explain certain findings regarding the increase in NCCD. These aspects together with epigenetic changes have highlighted the importance of a lifelong approach to nutritional policy development. Reducing DBM requires major societal interventions in public health and nutrition to achieve holistic change that can be sustained over the long term and spread throughout the global food system. The implementation of effective state policies of double impact actions should influence both sides of the burden and be considered an urgent priority, considering country-specific inequalities and socio-demographic differences in the Latin American region, using diverse and multidisciplinary strategies.

Influence of Diet and Levels of Zonulin, Lipopolysaccharide and C-Reactive Protein on Cardiometabolic Risk Factors in Young Subjects

A western diet and increased intestinal permeability may contribute to systemic inflammation and the development of cardio-metabolic alterations. The aim of this study was to assess the relationship between diet, biomarkers of intestinal permeability, and chronic low-grade inflammation on the cardiometabolic profile. A cross-sectional study was carried out in 238 young subjects aged 18–29 years, divided into two groups: with <3 cardiometabolic risk factors (CRF) and ≥3 risk factors. Anthropometric parameters, biochemical profile, and serum levels of zonulin, lipopolysaccharide (LPS), and high-sensitivity C-reactive protein (hs-CRP) were measured, and the macronutrient intake was evaluated. Interaction models showed elevated glucose levels in the presence of high biomarker levels: zonulin ≥51.6 ng/mL plus LPS ≥ 1.35 EU/mL (β = 1.1, p = 0.006), and LPS ≥1.35 EU/mL plus hs-CRP ≥ 4.3 mg/L (β = 1.2, p = 0.007). In addition, triglyceride levels increased in the presence of LPS ≥ 1.35 EU/mL and hs-CRP ≥ 4.3 mg/L (β = 3.9, p = 0.01). Despite having increased biomarker levels, a higher consumption of water (≥2100 mL), polyunsaturated fatty acids (≥6.0 g), or fiber (≥30 g) decreased triglyceride (β = −9.6, p = 0.03), total cholesterol (β = −5.1, p = 0.01), and LDL-C levels (β = −7.7, p = 0.01). These findings suggest that the increased consumption of water, PUFA and fiber may improve lipid profile in subjects with intestinal permeability dysfunction or low-grade systemic inflammation.

Dietary Inflammatory Index and Cardiometabolic Risk in Ecuadorian Women

Low-grade systemic inflammation is implicated in metabolic syndrome (MetS) and cardiometabolic diseases. Diet is hypothesized to be an important low-grade inflammation modifier. However, few studies have examined the association of dietary inflammation with MetS and cardiometabolic risk in Latin American populations and their findings are inconsistent. Our cross-sectional study examined the association of dietary inflammatory potential with MetS and cardiometabolic risk components in 276 urban Ecuadorian women. Dietary inflammation was evaluated using an energy-adjusted Dietary Inflammatory Index (E-DII), divided into quartiles (Q). E-DII scores ranged from −4.89 (most anti-inflammatory) to 4.45 (most pro-inflammatory). Participants in the most pro-inflammatory (Q4) compared to the least inflammatory E-DII quartile (Q1) had a 4.4 increased adjusted odds for MetS (95% C.I. = 2.0, 9.63; p < 0.001). Every one-unit increase in E-DII was associated with a 1.4 increase in MetS (95% CI = 1.22, 1.52; p < 0.001). In other adjusted models, the most pro-inflammatory E-DII quartile (Q4) was positively associated with total blood cholesterol and triglycerides (p < 0.001), LDL-c (p = 0.007), diastolic blood pressure (p< 0.002), mean arterial pressure (p < 0.006), waist circumference (p < 0.008), and Framingham risk score (p < 0.001). However, the previously identified associations with pulse wave velocity and BMI were no longer evident in the models. These findings suggest that more pro-inflammatory diets may contribute to poorer cardiometabolic health. Promoting healthier diets with a lower inflammatory potential may help to prevent or slow development of cardiometabolic disorders.

Food Sources of Shortfall Nutrients among Latin Americans: Results from the Latin American Study of Health and Nutrition (ELANS)

Increased consumption of energy-dense, nutrient-poor foods can lead to inadequate intakes of shortfall nutrients, including vitamin A, D, C, and E, dietary folate, calcium, iron, magnesium, potassium, and fiber. The objective was to examine the prevalence of inadequate intake of shortfall nutrients and identify food sources of shortfall nutrients in eight Latin American countries. Data from ELANS, a multi-country, population-based study of 9218 adolescents and adults were used. Dietary intake was collected through two 24 h Recalls from participants living in urban areas of Argentina, Brazil, Chile, Colombia, Ecuador, Peru, and Venezuela. Foods and beverages were classified using the adapted version of the NHANES "What We Eat in America" system. Nutrients inadequacy was estimated using the Institute of Medicine recommendations and descriptive statistics were calculated. Prevalence of inadequacy was above 50% for most of the nutrients, which the exception of vitamin C with a prevalence of inadequacy of 39%. Milk, cheese, seafoods, breads, and fruit juices/drinks were among the top 5 sources for each of the 10 shortfall nutrients examined. Many food categories were top contributors to more than one dietary component examined. Understanding the nutrient intake and food sources can help inform dietary guidance and intervention approaches.