Nutrition on a Global Scale
Rafael Pérez-Escamilla works to create and implement public health nutrition programs around the world, but realizes that effective programs must take both a global and local view.
But despite efforts of governments and international organizations to equitably provide nutritious food supplies, more than 2 billion people worldwide are still malnourished. Working to further understand the variables at play, Rafael Pérez-Escamilla, professor of epidemiology and public health and director, Office of Community Health, Yale School of Public Health, has spent his career elucidating the roots of nutrition inequities—in addition to paving the way for practical solutions.
"Of course, it's important to understand the mechanisms of nutrition at the molecular and cellular levels," Pérez-Escamilla says. "But on the other hand, we have to be able to translate the vast knowledge that we now have into effective public health programs and there is a science to this too."
Measures & models
Pérez-Escamilla has used the precision of science to track the impact of food insecurity in Brazil. His efforts started on a small scale with an experience-based household survey of some 120 households in the city of Campinas, which quickly grew into a national project. This major undertaking has not only helped the Brazilian government target and monitor the impact of its hunger eradication programs but has also allowed researchers to identify the causes of food insecurity and how this condition affects human development.
Since being put into wide-scale use in Brazil, as well as Colombia and Mexico, the United Nations Food and Agricultural Organization has been disseminating the Latin America and Caribbean Food Security Scale, developed under the leadership of Pérez-Escamilla and colleagues, as a standard for the entire region. This is a major step forward for improving food security governance, as the scale allows key stakeholders to accurately measure strides in their efforts against household food insecurity and malnourishment.
"It's fundamental to be able to compare progress across countries but also for countries to have simple but valid measures that they can trust and build policies around," says Pérez-Escamilla.
With funding from The Bill & Melinda Gates Foundation, Pérez-Escamilla has also recently led the development of a breastfeeding scale up model that encourages new mothers to breastfeed. Exclusive breastfeeding for six months is one of the most cost-effective maternal-child health interventions, but many barriers have prevented the successful promotion of this optimal infant feeding behavior on a global scale. Pérez-Escamilla aims to overcome these barriers with well-coordinated, intersectoral strategies that engage new mothers in health facilities as well as in community settings.
Whether analyzing the best way to promote breastfeeding or crafting metrics to realistically paint pictures of household food insecurity and malnutrition around the world, Pérez-Escamilla's goal is to help "all people at all times to have access to sufficient, safe, nutritious food to maintain a healthy and active life." This seemingly simple definition of food security, crafted at the World Food Summit in 1996, provides an ideal expectation but in no way drafts a map to that end.
Understanding household food insecurity
Less-developed countries are increasingly inheriting some of the nutritional problems of more developed countries, largely because of the adoption of Western diets and lifestyles. For example, rates of overweight/obesity in some countries in Latin America and the Caribbean are now comparable to those in the United States, Pérez-Escamilla points out.
"It's fundamental to be able to compare progress across countries but also for countries to have simple but valid measures that they can trust and build policies around..."
"In middle income countries food insecurity at the household level is not really related as much to food quantity anymore as it is to dietary quality. A low quality diet among the poor is often times the result of lack of economic or physical access to nutritious foods such as fruits and vegetables and easy access to highly caloric, unhealthy foods," says Pérez-Escamilla. This is reflected in the alarming increases in obesity among the poor in these countries.
"Sadly, little is being done to try to apply lessons learned from countries more advanced in this nutrition transition to prevent the same outcome from happening in areas where the transition is less advanced, as in Sub-Saharan Africa. I believe addressing this gap should be a major global health focus."
In addition, Pérez-Escamilla has learned that people in developed countries are not immune to nutrition-related health inequities. This motivated him to lead a National Institutes of Health-funded study examining the impact of community health workers at improving behavioral, metabolic, and health outcomes among Latinos with Type 2 diabetes in the United States.
"When I came to Connecticut in the early '90s and learned about the major health inequities affecting Latinos in the wealthiest state in the country, I decided to reconsider the single focus of my work in developing countries," says Pérez-Escamilla. "As soon as I started doing this work, I realized how common the root of health inequities is regardless of geographical location. The root is what we now refer to as 'the social determinants of health' that calls for well-integrated, multi-level and multi-sectoral solutions developed and governed in strong partnership with affected communities."
A global effort
Just as systems biology analyzes the interplay between biological systems, the problems of malnutrition and global health are also intertwined and complex. "Global health is local health. I understand global as a complex system and local as the cells that form the system. As a result of globalization, local communities, or the cells, are strongly interlinked with each other both within regions and countries and across countries and global macro-regions," says Pérez-Escamilla.
"If the architecture of global health governance continues to be fundamentally inequitable, then the ultimate global health goal of attaining 'health for all' regardless of where a human being is born becomes impossible to achieve."
To increase the chances that such a goal is not only possible, but probable, Pérez-Escamilla is joining in the efforts of The Sackler Institute for Nutrition Science at the New York Academy of Sciences. "The Sackler Institute is focusing on an incredibly important issue, which is to identify nutrition-based global health research priorities in collaboration with the World Health Organization through a highly inclusive and well-managed consensus-building process," he says. Pérez-Escamilla is especially impressed with the Institute's "multi-level, interdisciplinary, and inclusive approach to guide this effort"— an important aspect to ensuring that the resulting research priorities reflect the most pressing needs.
"Having been a public health scholar based in academia practically all of my professional life, the Institute's contribution toward identifying the best approaches for developing a global public health nutrition workforce that meets the needs of the 21st century is indeed very close to my heart."
Marci A. Landsmann is a medical writer in Philadelphia.