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Changing the Face of Nutrition in Latin America
FNCE October 16, 2016
Disclosures
Ma. Fernanda Kroker-‐Lobos, M.Sc. [email protected] NutritionInstitute of Nutrition of Central America and Panama –INCAP-‐INCAP Research Center for the Prevention of Chronic Diseases–CIIPEC-‐
No conflict of interest
Learning Outcomes
• At the end of this session the participant will knowhow the rapid economic transition and multicultural factors impact diet, nutrition and health status in Latin American populations• Double burden of excess weight and undernutrition
• Will appreciate nutrition development in LatinAmerica and successful experiences on publichealth interventions in the region.
Outline• NUTRITION IN LATIN AMERICA –LAC-‐
• Background and History• Who is the nutritionist?
• HEALTH PROFILE AND NUTRITION TRANSITION• Nutrition transition• Double Burden of Malnutrition• Current Policies
• LEADERSHIP IN NUTRITION
• REFLECTIONS
Nutrition History in LatinAmerica
1933-‐1965 Professor Pedro Escudero Argentina
• Founder: National School of Dietitians and National Institute of Nutrition in Buenos aires.
• First School of Dietitians in LA withuniversity level: 3 years (Institutionalapproach)
• Escudero’s School trainned pioneersof dietetics in several Latin American countries.
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Shifting from Dietitians to Nutritionists in the 60´s
New curricula is recognized (Univers itydegree, 4 or 5 years ) des igned by theInstitute of Nutrition of Central America and Panama –INCAP-‐ s ince 1962.
Creation of the Commiss ion Studies onAcademic Programs in Nutrition and Dieteticsin Latin America –CEPANDAL-‐
Technical norms for nutrition and dieteticstrainning were reoriented integrating publicnutrition and shifting from “Dietetians to Nutritionis ts (CEPANDAL/PAHO, Venezuela, 1966).
Creation of the Latin America Society of Nutrition –SLAN-‐ and the Latin American Journal of Nutrition –ALAN-‐
“Academic Trainningof Nutritionistand Dietitians in LA” def iningacademic prof iles and curricula
Dietitians (graduated beforenew orientation) from all LA trainned at theSchool of Nutritionat INCAP forcomplementary courses on PublicNutrition
INCAP supported trainningof nutritionists in Central America
INCAP based curricula still in force in many countries
PAHO 1965-‐1973 INCAP and PAHO 1970’s and 1980’s
1. WHO IS THE NUTRITIONIST IN THE XXI CENTURY?: Labor Market Demands
CLINICAL NUTRITIONPrivate Practice
Sports NutritionHospitals and Institutional food
services
FOOD INDUSTRY
Food TechnologyFood ServicesMarketing
PUBLIC NUTRITION
Food Security
Community Health
Public Adminis tration
Food and Nutrition Education
RESEARCH/TEACHINGEpidemiology
Public HealthBasic Science
NUTRITIONIST
Graduate Programs Available for Nutritionists: The case of Brazil
Master courses: 28PhD courses: 12
Master Master + PhD
Source: Kac G and Chaves Dos Santos SM, Coordination for the Improvement of Higher Education Personnel, Braz il.
Scientific Production in Latin America:
Source: http:/ /www.scimagojr.com/
Health profile and Nutrition Transition
Economic Growth (Real GDP) 2004/2014
C.America S.America EuropeanUnion
China
Source: State of the region, 2016. (www.estadonacion.or.cr )
United States
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Per Capita Income and Public HealthExpenditure as % of GDP
Source: PAHO, 2012
30% do nothave accessto health hare
Sou rce: WHO, Global Heal th Ob servato ry Data Repo si to ry, con su lted onOctober 8, http ://app s.who .in t/gho /data/node.wrapper.nutri tio n-‐2 0 1 6&showon ly=nu tri tio n
AFRICA
ASIA
CENTRAL AMERICA
SOUTH AMERICACARIBBEAN
Percentage of Children Under 5y Stunted (Height-‐for-‐age<-‐2 SD), 1990– 2015
Trends of Childhood Overweight and Obesity in theAmericas
Caribbean Central America (and Mexico) South America
Source: Palmieri M, et al, INCAP 2015.
Mean Prevalences of Obesity (BMI >30) byUN Region
# 1 NorhAmerica# 2 Australia#3 Latin America
Source: Global Nutrition report ( IFPRI) , 2015
Comparative Risk Factors Assesment in LatinAmerican Countries, Global Burden of Disease 2015.
Source: GBD 2015 Risk Factors Collaborators , Lancet 2016.
#3 Adult high BMI#2 High fasting plasma
glucose# 1 High Blood Pressure
Obesogenic Food Environments
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NUTRITION TRANSITION: TheDouble Burden of ExcessWeight
and Undernutrition in LatinAmerica
Supplement for the American Journal of Clinical Nutrition, 2014
¿Why it is important to study the Double Burden of Nutrition?
• It is a threat in growing economies of countries that should assume health care costs and losts in productivity and human capital.• Affects countries with different levels of economic growth: lack of institutionalism and resources.
• Situation compromises opportunities to reduce poverty and extreme poverty in the medium and long term.
• Need to strengthen political and public management.
Source: Palmieri M, et al, INCAP 2015.
Assesment of Double Burden of Nutrition–DBN-‐
MEXICO
GUATEMALA
CUBA
COLOMBIA
ECUADOR
BRASIL
CHILEURUGUAY
Overweight/obesemothers –stunted child
pairs
Undernutrition
Overnutrition
DBN
Over/undernutrition in the same individual
48,0
25,3
13,6 13,210,9
8,1 7,14,9
8,6 9,05,2
9,5 8,7 7,3
49,2
25,723,3
27,531,5
15,4
21,8
0,0
10,0
20,0
30,0
40,0
50,0
60,0
Guatemala Ecuador México Colombia Uruguay Cuba Braz il
Stunting Overweight & Obes ity Anemia
National Prevalence of Stunting, Overweight and Anemia in Children <5y in LAC
Stun tin g: <-‐2 SD Heigh t-‐fo r-‐age, WHO 2 0 0 6 ,Overweigh t and Obesi ty: > 2 SD Weigh t-‐fo r-‐h eigh t, WHO 2 0 0 6 Anemia: < Sex and age Hb cu to ffs, WHO
R ivera JA, et al . In trodu ction to th e doub le bu rden o f u ndernu tri tio n and excess weigh t in Latin America Am J C l in Nu tr 2 0 1 4 .
National Prevalence of Excess Weight and Anemia in Women of Reproductive Age (12-‐49y) in LA
7 3 ,0
6 6 ,5 6 4 ,9 6 4 ,3
5 5 ,2
4 9 ,5
1 1 ,91 5 ,0
3 0 ,6
4 ,46 ,6
2 5 ,9
0 ,0
1 0 ,0
2 0 ,0
3 0 ,0
4 0 ,0
5 0 ,0
6 0 ,0
7 0 ,0
8 0 ,0
México Ecuado r Brazi l Ch i le Co lomb ia Guatemala
Overweight & Obes ity Anemia
Overweigh t and obesi ty : > 1 SD BM I-‐fo r-‐age (1 2 -‐1 8 y), WHO 2 0 0 6 ; and BM I > 2 5 in adu ltsAnemia: Hb < 1 2mg/d l
R ivera JA, et al . In trodu ction to th e doub le bu rden o f u ndernu tri tio n and excess weigh t in Latin America Am J C l in Nu tr 2 0 1 4 .
Household level: National prevalence of Overweight/Obese mother – Stunted Child Pairs in LA
2 0
1 3 .1
8 .4
6 .35 .1
2 .7
0
5
1 0
1 5
2 0
2 5
Guatemala Ecuado r México Uruguay Co lomb ia Brazi l
Stun tin g: <-‐2 SD Heigh t-‐fo r-‐age, WHO 2 0 0 6 , Overweigh t : BM I > 2 5 in mo thers
R ivera JA, et al . In trodu ction to the doub le bu rden of undernutri tion and excess weigh t in Latin America. Am J C l in Nu tr 20 14
11/10/16
5
13,6
1 1 ,7
8 ,9
7 ,6
3 ,4
0
2
4
6
8
1 0
1 2
1 4
1 6
Brazi l Guatemala Ecuado r Mexico Co lomb ia
Individual level: National Prevalence of Women of Reproductive Age with Excess weight and
Anemia
*
Rivera JA, et al . In trodu ction to th e doub le bu rden o f u ndernu tri tio n and excess weigh t in Latin America Am J C l in Nu tr 2 0 1 4 .
Individual level:Children with Excess Weight and Stunting
2,8
1,8
1,0 1,0
0,10
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 Bras il Colombia
Observed Prevalence of DBM
*
*
*
*
*
*Observed p revalen ce i s greater th an expected p revalen ce P < 0 .0 5*Ob served p revalen ce i s lower th an expected p revalen ce P < 0 .0 5
*Stunting does notincrease incidenceof excess weight.
R ivera JA, et al . In trodu ction to th e doub le bu rden o f u ndernu tri tio n and excess weigh t in Latin America Am J C l in Nu tr 2 0 1 4 .
Current Policies
Uruguay• School-‐feeding program, “Baskets for nutritional risk”, “Fortified milk supply”, Cash transfer programs, Payment for health goals, Healthy eating at schools and high schools.
• Focused on one or the other side of the problem
Guatemala • Most actions addresses undernutrition: Zero Hunger Pact.
• National Healthy Schools Strategy and Food Security and Nutrition Policy of Central America and Dominican Republic mention the DB.
• Implementation strategies do not include this phenomenon.
Current Policies
Cuba• Iron Deficiency and Anemia Prevention.
• No policies considering the DB
Colombia• National Policy of Food and Nutrition Security• School Feeding Program• Childhood Breakfasts• Obesity Law• UNIDOS
• Not contemplating the DB
Current Policies
Ecuador• The priority is the reduction of the persistent high rates of under nutrition in children <5y.• Zero Under Nutrition• School lunch program,
• Considering regulating advertising and sale of processed foods
• Food Labelling system regulation
Brazil Dietary Guidelines: RedefiningWhat is a Food and What is a Product
• New public policy to reduce risk factors and mortality rate from non-‐communicable disease.
• New Dietary guidelines based on 4 recommendations and one golden rule
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Chile's Law on Food Labelling and Advertising: A Replicable Model for Latin America
• Nutrition interventions accordingly to the new epidemiological profile.
• Food environment regulations• Food composition limits • Banning of persuasive marketing targeted to children
• Food labelling system regulation
• Soda Tax (18%)
Research with Mission: Mexico“Would you give 12 spoons of sugar? So, why do
you give them soda?”• “Oportunidades”
• Promoting linear growth early in life and scaling up a strategy including obesity and NCD prevention in adults.
• Fortif ied milk distribution and Crusade against Hunger
• National Strategy to Prevent and Control overweight, obesity and type 2 diabetes
• Food Environment Regulations:• Reduction of access to unhealthy foods and
SSB in schools • Sodas and high-‐energy dens ity foods tax
(10%]
• Social Marketing campaign• Intake was reduced by 10%
• Regulation of marketing to children <12y
Latin America Leadership Program in Nutrition
1997: Created by leaders of Latin American Society of Nutrition –SLAN-‐
• Strengthening leadership, communication• Advocacy skills• Capacity in networking and teamwork.• To date: 150 leaders trainned
Latin America LeadershipProgram in Nutrition
Latin American Societyof Nutrition
LILANUT/SLAN Las Terrazas Cuba, 2012
Reflections• Historic evolution of Dietitians/ Nutritionists in LA is unique, responding to the needs and concernsof our cultures and health systems demands.
• Limited resources and health systems not prepared to cope with new nutritional profile.
• Double burden –DB-‐of undernutrition and excessweight it is present at national, household and individual level.• Guatemala has thehighest prevalence of Overweight/obese mother-‐stunted child
pair.• Most countries have failed to recognize DB in national policies
• New leaders in nutrition need to develope skills in communication, advocacy and networking to scale-‐up nutrition.
• In Latin America: Chile, Mexico and Brazil are taking the lead on integratingscientific evidence into public policy to tackle obesity and diet relatedchronic diseases
TAKE AWAYS: INMEDIATE APPLICATIONS
• Latin American Populations carry a history of undernutrition.• Stunted child and mother with excess weight might coexist in the same households.• Underlying determinants should be simultaneously addressed by appropriate public health policies.• Promotion of healthy growth before and after 3y.
• Nutritionist and Dietitians can learn from leadership models in Latin America to push public agendas towards healthier food environments.
THANK YOUContact: Ma. Fernanda Kroker-‐Lobos
Population Nutrition
Institute of Nutrition of Central America and Panama (INCAP)
INCAP Research Center for thePrevention of Chronic Diseases. (CIIPEC)
