RESUMO
Background: Urban populations have grown globally alongside emerging simultaneous burdens of undernutrition and obesity. Yet, how heterogeneous urban environments are associated with this nutritional double burden is poorly understood. Objective: We aimed to determine: 1) the prevalence of the nutritional double burden and its components in urban, peri-urban, and rural areas of Bolivia; and 2) the association of residence in these areas with the nutritional double burden and its components. Design: We surveyed 3946 randomly selected households from 2 metropolitan regions of Bolivia. Census data and remotely sensed imagery were used to define urban, peri-urban, and rural districts along a transect in each region. We defined 5 nutritional double burdens: concurrent overweight and anemia among women of reproductive age (15-49 y), and children (6-59 mo), respectively; concurrent overweight and stunting among children; and households with an overweight woman and, respectively, an anemic or stunted child. Capillary hemoglobin concentrations were measured to assess anemia (women: hemoglobin <120 g/L; children: hemoglobin <110 g/L), and overweight and stunting were calculated from height, weight, and age data. Results: In multiple logistic regression models, peri-urban, but not urban residence, was associated with higher odds of concurrent overweight and anemia among children (OR: 1.8; 95% CI; 1.0, 3.2) and of households with an overweight woman and stunted child (1.8; 1.2, 2.7). Examining the components of the double burden, peri-urban women and children, respectively, had higher odds of overweight than rural residents [women (1.5; 1.2, 1.8); children (1.5; 1.0, 2.4)], and children from peri-urban regions had higher odds of stunting (1.5; 1.1, 2.2). Conclusions: Peri-urban, but not urban, residence in Bolivia is associated with a higher risk of the nutritional double burden than rural areas. Understanding how heterogeneous urban environments influence nutrition outcomes could inform integrated policies that simultaneously address both undernutrition and obesity.
Assuntos
Anemia/complicações , Índice de Massa Corporal , Transtornos do Crescimento , Obesidade/complicações , População Urbana , Adolescente , Adulto , Estatura , Peso Corporal , Bolívia , Pré-Escolar , Características da Família , Feminino , Hemoglobinas/metabolismo , Humanos , Lactente , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estado Nutricional , Razão de Chances , Características de Residência , Fatores Socioeconômicos , Adulto JovemRESUMO
Undernutrition is the single largest contributor to the global burden of disease and can be addressed through a number of highly efficacious interventions. Undernutrition generally has not received commensurate attention in policy agendas at global and national levels, however, and implementing these efficacious interventions at a national scale has proven difficult. This paper reports on the findings from studies in Bangladesh, Bolivia, Guatemala, Peru and Vietnam which sought to identify the challenges in the policy process and ways to overcome them, notably with respect to commitment, agenda setting, policy formulation and implementation. Data were collected through participant observation, documents and interviews. Data collection, analysis and synthesis were guided by published conceptual frameworks for understanding malnutrition, commitment, agenda setting and implementation capacities. The experiences in these countries provide several insights for future efforts: (a) high-level political attention to nutrition can be generated in a number of ways, but the generation of political commitment and system commitment requires sustained efforts from policy entrepreneurs and champions; (b) mid-level actors from ministries and external partners had great difficulty translating political windows of opportunity for nutrition into concrete operational plans, due to capacity constraints, differing professional views of undernutrition and disagreements over interventions, ownership, roles and responsibilities; and (c) the pace and quality of implementation was severely constrained in most cases by weaknesses in human and organizational capacities from national to frontline levels. These findings deepen our understanding of the factors that can influence commitment, agenda setting, policy formulation and implementation. They also confirm and extend upon the growing recognition that the heavy investment to identify efficacious nutrition interventions is unlikely to reduce the burden of undernutrition unless or until these systemic capacity constraints are addressed, with an emphasis initially on strategic and management capacities.
Assuntos
Desnutrição/prevenção & controle , Formulação de Políticas , Bangladesh , Bolívia , Política de Saúde , Promoção da Saúde/organização & administração , Humanos , Entrevistas como Assunto , Peru , VietnãRESUMO
A number of multilateral and bilateral food security and nutrition initiatives have been launched in the wake of the 2008 food crisis, many with the explicit intention of fostering country ownership, multisectoral action, and harmonization among international partners. These bear some resemblance to the failed multisectoral nutrition planning initiatives that followed the 1974 world food crisis, raising the question of whether the current initiatives are doomed to experience the same fate. This paper explores these questions in one country by focusing on the policy sustainability of Bolivia's Zero Malnutrition Program (ZM), a multisectoral initiative that appeared at its initiation to be buttressed by political support and strengthened by design features that differed in important ways from similar efforts of the 1970s. Retrospective and prospective data collected through an action research and grounded methodology revealed, however, that the real struggle in Bolivia came after ZM was launched. ZM champions made undeniable progress in the first 2 years of the program with health-sector interventions, but they underestimated the challenges of building and sustaining the commitment of high-level political leaders, mid-level bureaucrats, and local-level implementers in the majority of other sectors. These initial experiences from Bolivia hold important lessons for several global initiatives to scale up nutrition actions, which are being launched in great haste and so far have given scant attention to strategies for managing the nutrition policy process and strengthening the capacities for implementation.