To summarise the findings from this supplemental issue on the distribution of malnutrition (stunting/short stature, anaemia and overweight) by wealth, education and ethnicity within and between ten Latin American countries.

We retrieved information from each country’s article and estimated the average difference in the prevalence of malnutrition between groups. We estimated the associations between countries’ malnutrition prevalence and GDP, percentage of women with high education and percentage of non-indigenous ethnicity.

Nationally representative surveys from ten Latin American countries conducted between 2005 and 2017.

Children (<5 years), adolescent women (11–19 years) and adult women (20–49 years).

Socially disadvantaged groups (low wealth, low education and indigenous ethnicity) had on average 15–21 (range across indicators and age groups) percentage points (pp) higher prevalence of stunting/short stature and 3–11 pp higher prevalence of anaemia. For overweight or obesity, adult women with low education had a 17 pp higher prevalence; differences were small among children <5 years, and results varied by country for adolescents by education, and for adults and adolescents by wealth and ethnicity. A moderate and strong correlation (–0·58 and –0·71) was only found between stunting/short stature prevalence and countries’ GDP per capita and percentage of non-indigenous households.

Overweight was equally distributed among children; findings were mixed for ethnicity and wealth, whereas education was a protective factor among adult women. There is an urgent need to address the deep inequalities in undernutrition and prevent the emerging inequalities in excess weight from developing further.

To assess the prevalence of five forms of malnutrition (wasting/underweight, overweight, obesity, stunting/short stature and anaemia) by socio-economic wealth (SEW) and educational level (EL) among children, adolescents and women of reproductive age in Argentina.

Analysis from a cross-sectional survey. Anthropometric indicators and prevalence of anaemia were estimated. SEW was classified according to the proportion of contributors in the household, employment status, EL and medical coverage. EL was categorized by years of formal education.

National Health and Nutrition Survey, 2005.

Children (n 27 015) <5 years, adolescent girls (n 1729) 11–19 years, women (n 4401) 20–49 years.

In Argentina, 26 % of households lived with unsatisfied basic needs and 23 % received at least one form of food assistance. Any form of malnutrition affected 23 % of children, 36 % of girls and 56 % of women. Children were especially affected by anaemia, overweight/obesity and stunting (15·2, 9·9, 7·4 %, respectively). Girls were affected by overweight/obesity, anaemia and stunting (22·5, 15·2, 6·2 %). Women were strongly affected by overweight/obesity, anaemia and stunting (43·8, 19·8, 10·5 %). Stunting or short stature was higher in low-SEW settings, doubling in prevalence between low and high levels, increasing four times among women in reproductive age (P < 0·05). Excess weight among children was higher in high-SEW settings, in women the tendency was inverse. Anaemia showed different tendency according to SEW.

In 2005, Argentina had high rates of excess weight and anaemia, moderate prevalence of stunting and low frequency of wasting/underweight. All forms of malnutrition showed a strong relationship with socio-economic and educational inequality.

To estimate the prevalence of malnutrition (undernutrition and excess BMI) among children under the age of 5 years and women of reproductive age in Bolivia considering three socioeconomic indicators: wealth, education and ethnicity.

We used the 2008 nationally representative Bolivian Demographic and Health Survey (DHS). Malnutrition’s prevalence was estimated by wealth, ethnicity and educational level. Wealth index was measured based on the DHS methodology and nutritional status by using WHO standards and indicators. Education level (EL) was categorized by years of formal education.

Bolivia.

In total, 5·903 children <5 years, 3·345 adolescent women (15–19 years) and 12·297 women (20–49 years) with available information on anthropometric measurements·

A disproportionate prevalence of malnutrition was observed among different wealth groups: lower wealth tertiles show the higher prevalence of stunting (>30 %) and anaemia (>40 %) in all ages· The prevalence of overweight and obesity tends to rise with age from childhood (10·02–11·60) to adolescence (27·9–31·03), reaching highest levels in women of reproductive age (56·02–57·76). According to wealth tertiles, higher prevalence of overweight and obesity was found in children of high tertile (12·23), adolescent women of low (32·56) and adult women of medium tertile (63·08).

The present study shows that currently Bolivia is in a transitional stage, faces not only the problem of undernutrition but also those of overnutrition, showing strong inequalities according to socioeconomic and education status. This study calls for state-specific policies keeping in view of the nature of inequality in malnutrition in the country and its differential characteristics across wealth status.

To describe malnutrition (undernutrition and excess weight) by income, education and race/ethnicity in the Brazilian population.

Cross-sectional study.

Brazil.

Children aged <5 years (n 14 580), adolescents aged 11–19 years (n 31 892) and adults aged 20–49 years (n 84 660).

Among children, prevalence of excess weight, wasting and stunting was 16·9, 2·8 and 6·0 %, respectively. Differences related to income, education and race/ethnicity were verified, except for prevalence of wasting by education level. Girls and boys presented 18·4 and 20·5 % of excess weight, 2·8 and 3·7 % of underweight and 5·5 and 7·3 % of stunting, respectively. Prevalence of excess weight was lower among poorer, lower-educated (only for boys) and white adolescents, while stunting was lower among higher-income, higher-educated and white adolescents. Over three-quarters of women and almost half of men presented excess weight. Among adults, 3·9 % of women and 1·7 % of men were underweight, and 5·7 % of women and 0·2 % of men presented short stature. Prevalence of excess weight for women was higher among lower education and black, while for men it was higher among higher income and education and white. Short stature was more prevalent among black and mixed-race, low-educated and low-income women. Underweight prevalence was higher among low-educated, black and mixed-race women.

In Brazil, the prevalence of excess weight was at least threefold higher than that of undernutrition for children and adolescents and at least sevenfold higher for adults. Social inequalities were observed in the distribution of malnutrition across the lifespan and by gender.

To assess the relationship between malnutrition, socioeconomic status (SES) and ethnicity in Chilean adult population.

Nationally representative survey (ENS) conducted in 2016–2017. Sociodemographic information, weight, height and hemoglobin (Hb) were measured (2003 ENS). Excess weight was defined as BMI ≥25 kg/m2. Undernutrition included underweight (BMI <18·5 kg/m2), short stature (height <1·49 m in women and <1·62 m in men) or anaemia (Hb <12 g/l). Education and household income level were used as indicators of SES; ethnicity was self-reported. We applied linear combinations of estimators to compare the prevalence of excess weight and undernutrition by SES and ethnicity.

Chile.

In total, 5082 adults ≥20 years (64 % women) and 1739 women ≥20 years for anaemia analyses.

Overall, >75 % of women and men had excess weight. Low SES women either by income or education had higher excess weight ((82·0 (77·1, 86·1) v. 65·0 (54·8, 74·1)) by income; (85·3 (80·6, 89·0) v. 68·2 (61·6, 74·1) %) by education) and short stature (20–49 years; 31(17·9, 48·2) v. 5·2 (2·2,11·4) by education); obesity was also more frequent among indigenous women (20–49 years; 55·8 (44·4, 66·6) v. 37·2 (32·7, 42·0) %) than non-indigenous women. In men, excess weight did not significantly differ by SES or ethnicity, but short stature concentrated in low SES (20–49 years; 47·6 (24·6, 71·6) v. 4·5 (2·1, 9·5) by education) and indigenous men (21·5 (11·9, 5·5, 11·9) v. 8·2 (5·5, 11·9)) (P < 0·05 for all).

In Chile, malnutrition is disproportionately concentrated among women of low SES and indigenous origin; these inequalities should be considered when implementing prevention policies.

To examine the association of all forms of malnutrition and socioeconomic status (SES), educational level and ethnicity in children <5 years, non-pregnant adolescent women (11–19 years) and non-pregnant adult women (20–49 years) in Colombia.

Cross-sectional analysis of data from the 2010 Colombian National Nutrition Survey. The prevalence of malnutrition was compared across categories of SES, educational level and ethnicity.

Colombia.

The sample for the current analysis comprised children <5 years, non-pregnant adolescent women (11–19 years) and non-pregnant adult women (20–49 years).

In children <5 years, a low SES and maternal educational level were significantly associated with a lower prevalence of overweight/obesity compared with high levels of SES and maternal education, that is, the prevalence of overweight/obesity was 1·4 and 1·6 times lower in categories of low SES and educational levels, respectively. In contrast, the prevalence of wasting, stunting and anaemia was higher in the lowest SES and maternal educational categories (the prevalence was between 1·1 and 1·8 times higher for these indicators). In women, the lowest SES (11 and 19 years) and educational levels (20 and 49 years) exhibited a higher prevalence in all forms of malnutrition compared with their counterparts in the highest categories (i.e. overweight/obesity, stunting and anaemia). Additionally, indigenous or Afro-Colombian children and women had the highest prevalence of malnutrition in comparison with other ethnicities.

These results suggest that public policies should address all forms of malnutrition that occur in the most vulnerable populations in Colombia using multiple strategies.

To describe and quantify the magnitude and distribution of stunting, wasting, anaemia, overweight and obesity by wealth, level of education and ethnicity in Ecuador.

We used nationally representative data from the 2012 Ecuadorian National Health and Nutrition Survey. We used the Multidimensional Poverty Index (MPI) as a proxy of wealth. The MPI identifies deprivations across three dimensions (health, education and standard of living). We defined education by years of schooling and ethnicity as a social construct, based on shared social, cultural and historical experiences, using Ecuadorian census categories.

Urban and rural Ecuador, including the Amazon rainforest and the Galapagos Islands.

Children aged <5 years (n 8580), adolescent women aged 11–19 years (n 4043) and adult women aged 20–49 years (n 15 203).

Among children <5 years, stunting and anaemia disproportionately affected low-wealth, low-education and indigenous groups. Among adolescent and adult women, higher rates of stunting, overweight and obesity were observed in the low-education and low-wealth groups. Stunting and short stature rates were higher in indigenous women, whereas overweight and obesity rates were higher in Afro-Ecuadorian women.

Malnutrition differs significantly across sociodemographic groups, disproportionately affecting those in the low wealth tertile and ethnic minorities. Rates of stunting remain high compared with other countries in the region with similar economic development. The effective implementation of double-duty actions with the potential to impact both sides of the double burden is urgently required.

To analyse disparities of malnutrition in all its forms by socio-economic indicators in children aged <5 years, adolescent girls and women of reproductive age (WRA).

We defined wasting/underweight, stunting/short stature, overweight and obesity following the WHO criteria for children aged <5 years, adolescents and WRA. We evaluated the prevalence of malnutrition by wealth status, education level and ethnicity (indigenous/non-indigenous).

Guatemalan 2014–2015 National Maternal and Child Health Survey.

Children aged <5 years (n 11 962), adolescent girls aged 15–19 years (n 1086) and WRA aged 20–49 years (n 11 354).

Stunting/short stature prevalence among children, adolescents and WRA was 2·8, 2·1 and 2·0 times higher in the poorest compared with the richest; 2·9, 2·9 and 2·1 times higher in the lower educational level than in the highest; and 1·7, 1·7 and 1·6 times higher in the indigenous than in the non-indigenous population. In contrast, overweight/obesity prevalence among children, adolescents and WRA was 1·6, 2·1 and 1·8 times higher in the richest compared with the poorest; 1·6, 1·3 and 1·3 times higher in the higher educational level than in the lowest; and 1·3, 1·7 and 1·3 times higher in the non-indigenous than in the indigenous population.

Stunting/short stature is more prevalent among low-income, low-education and indigenous populations in all age groups. In contrast, overweight/obesity is more prevalent in high-income, high-education and non-indigenous populations in all age groups. These outcomes demonstrate socio-economic and ethnic disparities for malnutrition in all its forms.

To compare the prevalence of malnutrition (undernutrition and excess weight) by wealth, education level, ethnicity and urban/rural areas in Mexican children and women of reproductive age.

We compared the prevalence of overweight, obesity, wasting/underweight, stunting/short stature and anaemia by socioeconomic and ethnic indicators. For each indicator, we estimated prevalence ratios (PR) adjusted by all other socioeconomic and ethnic indicators. We analysed if results differed by urban/rural areas.

Mexican National Health and Nutrition Survey 2012.

Children <5 years, non-pregnant women 11–19 years and non-pregnant women 20–49 years (n 33 244).

In most age groups, belonging to non-indigenous households, with high wealth, high education and in urban areas were inversely associated with stunting or short stature (PR ranging from 0·40 to 0·83), and wealth and education were inversely associated with anaemia (PR ranging from 0·53 to 0·78). The prevalence of overweight was similar across subgroups among children <5 years; however, among women 11–19 years, wealth, non-indigenous household and urban areas were positively associated (PR ranging from 1·16 to 1·33); and among women 20–49 years, education was inversely associated (PR 0·83).

Socially disadvantaged populations have a higher prevalence of undernutrition, whereas the prevalence of excess weight is either equal (children <5 years), slightly lower (women 11–19 years) or even higher (women 20–49 years) with lower education. These results highlight the need for specific actions to address social inequalities in malnutrition in the Mexican population.

To compare the distribution of malnutrition by socio-economic indicators (SEI) in Peruvian children under 5 years and women of reproductive age (WRA).

We analysed data from the National Demographic and Family Health Survey. WHO criteria were used to define malnutrition indicators (overweight/obesity combined (OW); wasting/underweight; stunting/short stature; anaemia). Linear combination test was used to compare the prevalence of malnutrition by SEI (wealth index as a proxy of socio-economic status (SES); education; ethnicity). Prevalence ratio (PR) was used to describe disparities and associations between malnutrition and SEI.

Peru (2015).

Children (n 22 833) under 5 years and WRA (n 33 503; 5008 adolescents and 28 495 adults).

The most prevalent form of malnutrition was anaemia (32·0 %) in children and OW in adolescent and adult WRA (31·3 and 65·1 %, respectively). Adjusted models showed that stunting and anaemia were significantly lower among children with high SES (PR = 0·25, 0·67), high-educated mothers (PR = 0·26, 0·76) and higher in indigenous children (PR = 1·3, 1·2); conversely, OW was higher among those with high SES and high-educated mothers (PR = 1·8, 1·6) compared with their lowest counterparts. In WRA, stunting/short stature was lower among those with high SES, high education and higher in indigenous adult women. OW in adolescents and adults was higher in high SES (PR = 1·4, 1·1), lower in indigenous adult women (PR = 0·84) and lower in high-educated adult women (PR = 0·86).

In the studied population, the distribution of malnutrition was associated with SEI disparities. Effective policies that integrate actions to overcome the double burden of malnutrition and reduce disparities are needed.

To describe the magnitude and distribution of malnutrition in all forms (stunting, wasting, overweight and obesity) by level of education and socio-economic status (SES).

Representative data from three national surveys were used: the socio-economic characteristics of Uruguayan households the 2012–2013; the Survey of Child Health, Nutrition and Development and the Survey of Chronic Disease Risks. We defined overweight, obesity, wasting/underweight and stunting/short stature according to WHO criteria. We conducted a comparison between malnutrition prevalence values per SES and education level.

In total, 1 183 177 households were surveyed, including 2265 children’s and 752 women’s households, forming a nationally representative sample in urban areas with more than 5000 habitants.

A total of 3079 children aged <4 years from the National Survey of Child Health, Nutrition and Development 2013 and 752 women aged 20–49 years from the National Survey of Chronic Disease Risks 2013 were included.

Among children aged <4 years, stunting and overweight disproportionately affected low-wealth groups, with 5·45 % of children in the lower income tertile and 3·44 % in the upper tertile presenting stunting (P < 0·05). Overweight and obesity were higher in the third tertile of income. Among the women, 54·8 % (95 % CI 48·0, 61·6) had excess weight (overweight and obesity) and significant differences were found between those with the lowest and highest levels of SES. Regarding excess weight with respect to educational level, significant differences were also found between the low and high levels and between the medium and high levels.

In Uruguay, there are slight differences in the prevalence of all forms of malnutrition according to SES and education levels in the populations considered. Excess weight in children and women poses the greatest public health nutritional challenge at all levels of SES and education. The fact that more educated mothers are more overweight differs from the findings in other countries and should be studied in more detail. Stunting in children is also important, requiring more focused interventions. Notably, excess weight is higher in more educated mothers, a fact that differs from other countries. Further analysis is important to understand this discrepancy.