S7 7 ARTIGO ARTICLE
O besity trends and determinant factors
in Latin America
Te nd e nc ias e n la o b e sid ad y fac to re s
d e te rminante s e n Amé ric a Latina
1 In stitu to d e N u trición y Tecn ología d e los Alim en t os, U n iv ersid a d d e Ch ile. Ca silla 138- 11, Sa n t ia go, Ch ile. jk a i n @u ec.i n t a .u ch i le.cl Ju lia n a Ka in 1 Fern a n d o Vio 1 Cecilia Alb a la 1
Abstract Ob esit y ra t es h a v e in crea sed m a rk ed ly in La t in Am erica , esp ecia lly d u rin g t h e la st 10-1 5 yea rs, b eco m i n g a p u b l i c h ea l t h p ro b l em i n m o st co u n t ri es. Prev a l en ce o f o b esi t y a m o n g p resch o o l ch i l d ren rem a i n s l o w , w h i l e a m o n g sch o o l ch i l d ren i t h a s i n crea sed co n si d era b l y. Prev a len ce is h igh in t h e a d u lt p op u la t ion , esp ecia lly a m on g w om en w it h less sch oolin g. In d e-v elop ed p op u la t ion s, ob esit y occu rs m ore freq u en t ly a m on g t h e p oor; t h e op p osit e occu rs in less d ev elo p ed so ci et i es, w h ere i n h o u seh o ld s u n d ergo i n g n u t ri t i o n a l t ra n si t i o n , u n d erw ei gh t ca n coex ist w it h ob esit y. T h e m ost im p ort a n t d et erm in a n t fa ct ors in v olv ed in t h e in crea sin g ob esit y p rev a len ce a re fet a l a n d in fa n t n u t rit ion a l con d it ion s (st u n t in g), ed u ca t ion a n d socioecon om ic co n d i t i o n s, d i et a ry ch a n ges (esp eci a lly i n crea sed t o t a l en ergy i n t a k e), a n d p h ysi ca l i n a ct i v i t y. Beca u se ch ro n i c d i sea ses a re t h e m a i n ca u ses o f d ea t h i n t h e R egi o n a n d o b esi t y i s o n e o f t h e m a in risk fa ct ors for t h ese d isea ses, p olicies t o im p rov e econ om ic a n d ed u ca t ion a l lev els w it h t h e im p lem en t a t ion of h ea lt h p rom ot ion a n d p rev en t ion sh ou ld b e a p riorit y in ev ery cou n t ry. Key words Ob esit y; N u t rit ion a l St a t u s; Risk Fa ct ors
Resumen En Am érica La t in a la ob esid a d h a a u m en t a d o con sid era b lem en t e llega n d o a con v ert irse en u n p rob lem a d e sa lu d p ú b lica en ca si ert od os los p a íses. La p rev a len cia d e ob esid a d es b a ja en t re los p reescola res, p ero h a a u m en t a d o sign ifica t iv a m en t e en t re los escola res. En los a d u l -t os, la p rev a len cia es a l-t a , esp ecia lm en -t e en -t re la s m u jeres con m en or ed u ca ción . En socied a d es m á s d esa rrolla d a s, la ob esid a d a p a rece m á s frecu en t em en t e en t re los p ob res, lo op u est o ocu rre en p ob la cion es p ob res, d on d e, a d em á s, p u ed e coex ist ir la d esn u t rición ju n t o a la ob esid a d . Los fa ct ores d e riesgo m á s im p ort a n t es rela cion a d os con el in crem en t o d e la ob esid a d son : la s con d i -cion es fet a les y la sit u a ción n u t ri-cion a l d u ra n t e la in fa n cia (t a lla b a ja ), ca ra ct eríst ica s socioe-con óm ica s y n iv el ed u ca cion a l, a sp ect os d iet ét icos y la in a ct iv id a d física . Por ello, y d eb id o a q u e l a s en f erm ed a d es cró n i ca s co n st i t u yen l a p ri n ci p a l ca u sa d e m u ert e en t o d o s l o s p a í ses d e l a región , y la ob esid a d es u n o d e los p rin cip a les fa ct ores d e riesgo d e ést a s, la im p lem en t a ción d e p olít ica s y p rogra m a s q u e a p u n t en m ejora r la sit u a ción econ óm ica y ed u ca cion a l d e los m á s p o b res y a l m ism o t iem p o ca m b ia r los h á b it os d e v id a d e t od a la p ob la ción es a b solu t a m en t e p rio -rit a rio.
Introduction
La t in Am e r ica is u n d e r go in g a r a p id d e m o grap h ic, ep id em iological, an d n u trition al tran -sition . Im p rovem en ts in overall socioecon om ic st a t u s (SES) a n d h e a lt h a n d e d u ca t io n a l in d i-ca t o r s a r e o ccu r r in g in m o st co u n t r ie s. Th e ep id em iological tran sition h as b een ch aracter-ized m ain ly b y th e u rb an ization p rocess, wh ich h as p rod u ced d eleteriou s effects on th e d ietary an d p h ysical activity p attern s of th e p op u lation (Po p kin , 1998). In t e rm s o f d ie t , ru ra l in h a b i-ta n ts ten d to ea t tra d itio n a l d iets th a t a re h igh in grain s, fru its, an d vegetables; wh en th ey m ove t o t h e cit ie s t h e y in cre a sin gly a d o p t a “West -e rn -t yp -e ” d i-e t , h igh in fa t a n d r-e fin -e d su ga rs. Th e se ch a n ge s, a cco m p a n ie d b y a m a rke d in -cre a se in se d e n t a ry b e h a vio r, a re t h e p rim a ry risk fa ct o rs fo r t h e e xp lo sive rise in o b e sit y, wh ich t o ge t h e r wit h a n in cre a se in t h e co n -su m p tion of tob acco an d alcoh ol an d stress-re-la t e d a ilm e n t s a r e a sso cia t e d wit h t h e r isin g p reva len ce o f n o n -co m m u n ica b le ch ro n ic d is-eases (NCCD) (Pop kin et al., 1995). In fact, th ese d ise a se s t o ge t h e r co n st it u t e t h e first ca u se o f d eath in every Latin Am erican cou n try. It is im -p o rt a n t t o -p o in t o u t t h a t o f a ll t h e risk fa ct o rs a sso cia te d with m o rta lity fro m NCCD, o b e sity is t h e o n e t h a t h a s u n d e r go n e t h e la r ge st in -crea se a n d is n o w th e m a in n u tritio n a l d isea se in m o st La tin Am erica n co u n tries (Ua u y et a l., 2001).
O besity prevalence in Latin America
O besity in preschool and schoolchildren
In form ation on ob esity tren d s in Latin Am erica is n o rm a lly lim it e d t o p re sch o o l ch ild re n a n d ch ild b earin g-age wom en . Martorell et al. (1998, 2000) r e vie we d n a t io n a l su r ve ys co n d u ct e d from 1982 on ward to assess m atern al an d ch ild ob esity in Latin Am erica. Most of th e d ata were o b t a in e d fr o m t h e D e m o gr a p h ic a n d H e a lt h Su rve ys In st it u t e fo r Re so u rce De ve lo p m e n t (D H S/ IRD ); o f t h e 26 d a t a se t s u se d , 16 ca m e fr o m D H S/ IRD. Ob e sit y in ch ild re n wa s d e -fin ed as weigh t-for-h eigh t > 2Z (WH O, 1995).
Re su lt s sh o w t h a t o b e sit y p re va le n ce wit h d ata d erived from cross-section al su rveys from d ifferen t Latin Am erican cou n tries is q u ite low. Th is is e sp e cia lly tru e in le ss d e ve lo p e d co u n -t rie s, su ch a s Gu a -t e m a la (1.7%), H o n d u ra s (1.4%), a n d Bo livia (2.1%). Ob e sit y wa s m o r e p re va le n t a m o n g girls; re sid e n ce in u rb a n a r -e a s, h igh SES, a n d h igh -e r m a t -e rn a l sch o o lin g were a sso cia ted with h igh er ch ild h o o d o b esity
p re va le n ce in m o st co u n t rie s. On e im p o rt a n t p oin t stressed b y th e au th ors is th e fact th at n a -tion al p revalen ce figu res d o n ot reflect region al d iffe re n ce s, wh ich e xist e sp e cia lly in la rge r cou n tries like Mexico an d Brazil.
Ot h e r a u t h o r s (D e On is & Blö ssn e r, 2000) h ave also d eterm in ed th e ob esity p revalen ce in La tin Am erica n p resch o o l ch ild ren . Th e a n a ly-sis was b ased on n ation al su rvey d ata collected from 1970 u n til th eir p u b lication . Th e d ata orig-in ated from th e WHO Glob al Datab ase on Ch ild Gro wth a n d Ma ln u tritio n (De On is & Blö ssn er, 1997). For all th e Latin Am erican cou n tries, th e d a ta rep orted a re b a sed on sa m p les, excep t for Argen tin a, Ch ile, Uru gu ay, an d Ven ezu ela, wh ere e st im a t e s we r e b a se d o n n a t io n a l n u t r it io n su rve illa n ce syst e m s. Ta b le 1 sh o ws t h e la t e st figu res for m ost Latin Am erican cou n tries.
As sh o wn in Ta b le 1, Arge n t in a , Ch ile , a n d Co sta Rica h a ve th e h igh est ra tes (7.3, 7.0, a n d 6.2% resp ectively), wh ile th e lowest p revalen ce is o b se rve d in le ss d e ve lo p e d co u n t rie s, su ch as Haiti an d Bolivia.
It is im p ortan t to p oin t ou t th at alth ou gh th e so u rce s fro m wh ich t h e se t wo st u d ie s b a se d th eir an alyses are d ifferen t, b oth rely p rim arily o n n a t io n a l sa m p le s co n d u ct e d d u r in g t h e sa m e o r sim ila r p e r io d s, b u t t h e r e su lt s t u rn o u t t o b e q u it e d iffe re n t in so m e co u n t rie s. Th is m a ke s it d ifficu lt fo r p o licy- m a ke rs a n d oth ers to ob tain a clear p ictu re of th e situ ation .
Tab le 1
Late st natio nal p re vale nc e o f o b e sity in p re sc ho o l
c hild re n b y c o untry.
Count ry (year) % obese*
Arg e ntina (1994) 7.3
Bo livia (1998) 6.5
Brazil (1996) 4.9
Chile (1996) 7.0
Co lo mb ia (1995) 2.6
Co sta Ric a (1996) 6.2
Do minic an Re p ub lic (1996) 2.8
El Salvad o r (1993) 2.2
G uate mala (1995) 4.0
Haiti (1994-1995) 2.8
Me xic o (1988) 3.7
Parag uay (1990) 3.9
Pe ru (1996) 6.4
Urug uay (1992-1993) 6.2
Ve ne zue la (1997) 3.0
Mon teiro et al. (2002) an alyzed fou r n ation -wid e Bra zilia n su rve ys (1975, 1989, 1996, a n d 1997) co n d u ct e d in t h e N o r t h e a st , t h e co u n -try’s m o st eco n o m ica lly d isa d va n ta ged regio n , a n d th e So u th e a st, th e m o st e co n o m ica lly a d -va n ced . Th ese su rveys in clu d ed a n th ro p o m et-ric d ata for b oth you n g ch ild ren an d ad u lts.
Figu re 1 sh o ws t h e t re n d s in a ve ra ge o ve r -weigh t p reva len ce for ch ild ren 1-4 yea rs of a ge b y re gio n a n d fo r b o t h re gio n s co m b in e d (re -p orted as cou n try -p revalen ce, as th e North east a n d So u t h e a st in clu d e a p p r o xim a t e ly 70% o f th e total Brazilian n ation al p op u lation ).
As th e au th ors p oin t ou t, accord in g to th ese re su lt s t h e Bra zilia n n a t io n a l o b e sit y p re va len ce is q u ite low an d rem ain ed p ractically u n -ch a n ged over th e yea rs. Th e ra tes a re h igh er in t h e m o r e d e ve lo p e d So u t h e a st , a n d a lt h o u gh th ey in creased in th is region over tim e, th e rate of in crease was n ot sign ifican t.
Alth o u gh o b esity a m o n g p resch o o lers m a y n o t b e a p u b lic h e a lt h p ro b le m in d e ve lo p in g co u n t rie s, it is d e fin it e ly a p ro b le m in sch o o l-ch ild ren from p ost-tran sition al cou n tries. Su l-ch is th e ca se in Ch ile, fo r exa m p le, wh ere u n d er-n u t rit io er-n h a s virt u a lly b e e er-n e ra d ica t e d , wh ile o b e sit y p re va le n ce in sch o o l-a ge ch ild re n h a s sh o wn a n im p re ssive rise (Alb a la e t a l., 2001; Ka in et a l., 2002). Figu re 2 sh o ws th a t th e o b e -sit y p re va le n ce a m o n g b o ys a t t e n d in g first gr a d e in cr e a se d fr o m 6.5% in 1987 t o 17% in 2000; in girls, from 7.8% to 18.6%. Th ese figu res a re in d ica t ive o f a sign ifica n t p ro b le m , co m -p rom isin g n ot on ly th eir fu tu re h ealth as ad u lts b u t also th eir p resen t h ealth .
O besity in adults
An an alysis of th e n u trition al situ ation of Latin Am e r ica n wo m e n (15- 49 ye a r s) a lso d e r ive d fr o m t h e sa m e D H S/ IRD d a t a se t s d e scr ib e d p re vio u sly is p re se n t e d fo r se le ct e d co u n t rie s (Ma rt o re ll e t a l., 1998). Ta b le 2 p re se n t s t h e ob esity p revalen ce in wom en (d efin ed as a BMI cu t-off of ≥30kg/ m2).
Th e lo we st p re va le n ce wa s fo u n d in so m e o f th e p o o rer n a tio n s, in clu d in g H a iti, Bo livia , a n d H o n d u ra s. Th e a u t h o rs fo u n d t h a t m o re sch o o lin g wa s a sso cia ted with o b esity in Ha iti, Gu a t e m a la , a n d Pe ru , wh ile in o t h e r p o o r n a t io n s su ch a s Bo livia a n d t h e D o m in ica n Re -p u b lic, th is association was n ot -p resen t.
In gen eral, an in creasin g ob esity p revalen ce in wo m e n wa s fo u n d in co u n t rie s wit h h igh e r p er cap ita in com e an d in th ose with lower rates o f st u n t in g in ch ild re n . A re ce n t WH O (Wo rld H e a lt h Orga n iza t io n )/ PAH O (Pa n - Am e rica n Health Organ ization ) p u b lication on ob esity in
O BESITY IN LATIN AMERICA S7 9
Latin Am erica (Peñ a & Bacallao, 2000) revealed a n in cre a sin g t re n d in o b e sit y a s co u n t rie s e m e r ge fr o m p o ve r t y, e sp e c ia lly in u r b a n a r -e a s. In co n t r a st , in m id d le - in co m e co u n t r ie s an d even m ore in d evelop ed cou n tries, ob esity ten d s to d eclin e as in com e in creases, esp ecial-ly for wom en (Aran ceta et al., 2001).
Mo n t e iro e t a l. (2002) a lso a n a lyze d t h e ad u lt p op u lation (20 years an d old er) b ased on t h e fo u r n a t io n wid e su r ve ys fr o m Br a zil d e -scrib e d a b o ve . Th e a u t h o rs d e t e rm in e d t h e a ge-a d ju sted o b esity p reva len ce b y gen d er fo r th e North east an d th e Sou th east region s. Table 3 sh ows th ese resu lts.
Th e tab le sh ows th at th e p revalen ce of ob e -sity in cre a se d in b o th ge n d e rs. At th e n a tio n a l le ve l, t h e r a t e fo r wo m e n wa s a lm o st d o u b le th at of m en . As d iscu ssed b y th e au th ors, in th e la st p erio d , o b esity in wo m en in crea sed in th e p oorer region , wh ile it d eclin ed for th ose in th e m o re d e ve lo p e d re gio n . No t sh o wn h e re , b u t rep orted b y th e au th ors, is th e fact th at in h igh -e r - in co m -e wo m -e n fr o m t h -e N o r t h -e a st a n d in lo we r- in co m e wo m e n fro m t h e m o re d e ve lo p e d Slo u t h e a st , t h e ra t e lo f in cre a se wa s d ra -m a tic a n d exa ctly th e sa -m e, fro -m 6% to 14% in 20 years.
Mo n t e iro e t a l. (2000a ) a lso p o in t o u t t h a t th e re h a s b e e n lim ite d e vid e n ce o n th e tre n d s in ob esity, esp ecially related to social class. Th e t h re e n a t io n a l su rve ys d e scrib e d a b o ve h a ve p rovid ed im p ortan t in form ation regard in g
sec-Fig ure 1
Se c ular tre nd s in the ave rag e p re vale nc e o f o b e sity (% ) fo r 1-4 ye ar-o ld c hild re n
b y Re g io n. Brazil, 1975-1996.
u la r tre n d s in o b e sity a m o n g a d u lts in va rio u s se t t in gs a n d so cio e co n o m ic co n d it io n s. Th e a n a lyse s o f th e se su rve ys sh o w th a t fro m 1975 t o 1989, t h e e vid e n ce is cle a r t h a t o b e sit y a m o n g a d u lt m a le s a n d fe m a le s in cr e a se d am on g all age grou p s, b u t in th e last p eriod , al-t h o u gh al-t h e p re va le n ce a lso in cre a se d in b o al-t h ge n d e rs, t h e u p wa rd t re n d wa s o n ly cle a r in m e n fo r a ll a ge gro u p s. In fa ct , fo r wo m e n t h e in cre a se wa s st a t ist ica lly sign ifica n t o n ly fo r th e first p eriod . In term s of socioecon om ic sta -tu s a n d u rb a n / ru ra l settin g, Tab le 4 sh ows th at
o b e sit y p re va le n ce wa s h igh e r in u rb a n a re a s, e sp e cia lly a m o n g a ll lo we r- in co m e m e n a n d wo m e n . Pa rticu la rly im p o rta n t is th e fa ct th a t in wom en from h igh er-in com e grou p s, ob esity d e clin e d d u r in g t h e la st p e r io d in b o t h r u r a l an d u rb an settin gs an d was statistically sign ifi-can t on ly in u rb an areas (28% red u ction ).
Accord in g to a recen t p u b lication b y Rivera e t a l. (2002), t h e m o r e d e ve lo p e d in d u st r ia l Sta tes in th e North of Mexico h a ve very sim ila r e p id e m io lo gica l in d ica t o rs t o t h o se o b se rve d in d e ve lo p e d co u n t rie s, wh ile t h e le ss d e ve l-o p ed Cen tra l a n d Sl-o u th ern Mexica n Sta tes ex-h ib it p re-tra n sition a l con d ition s. Tex-h e Na tion a l Nu t rit io n Su rve y ca rrie d o u t in 1988 a n d 1999 (In st it u t o N a cio n a l d e Sa lu d Pú b lica , 1999) sh o we d t h a t t h e n a t io n a l o ve rwe igh t p re va -le n ce (BM I ≥30) fo r a d u lt wo m e n in cr e a se d sign ifican tly, from 9.4% in 1988 to 24.4% in 1999. Figu res at th e region al level were m arked ly d if-fe re n t ; in t h e No rt h , t h e m o re a fflu e n t re gio n , t h e se r a t e s in cr e a se d fr o m 11.8% t o 31.3%, wh ile in th e Sou th th ey in crea sed from 8.2% to 20.8%. Th e se re su lt s sh o w t h a t a lt h o u gh t h e p revalen ce is lower in th e Sou th , th e rate of in -cr e a se in t h e p e r io d wa s t h e sa m e . Th is sa m e su r ve y a lso in clu d e s a n t h r o p o m e t r ic d a t a o n in fa n t s a n d p re sch o o l ch ild re n . In t h is a ge b ra cke t a s a wh o le , o b e sit y p re va le n ce a t t h e n ation al level d eterm in ed as a weigh t-for-h eigh t > 2Z score (WHO) was in itially 4.2%, in creasin g t o 5.3% in 1999. Alt h o u gh t h e h igh e st p r e va -len ce rates were ob served in th e North , th e rel-Fig ure 2
Tre nd s in the p re vale nc e o f o b e sity o f Chile an first-g rad e c hild re n*.
* O b e sity is d e fine d with a we ig ht/ he ig ht > 2Z WHO re fe re nc e . So urc e : Alb ala e t al. (2002).
Tab le 2
Pre vale nc e o f o b e sity in wo me n fro m se le c te d
Latin Ame ric an c o untrie s.
Count ry (year) Women (%)*
Bo livia (1994 7.6
Brazil (1996) 9.7
Co lo mb ia (1995) 9.2
Do minic an Re p ub lic (1996) 12.1
Haiti (1995) 2.6
Ho nd uras (1996) 7.8
G uate mala (1995) 8.0
Me xic o (1987) 10.4
Pe ru (1996) 9.4
* BMI = 30.
O BESITY IN LATIN AMERICA S8 1
a t ive ch a n ge s we re m u ch la rge r in t h e So u t h , th e less d evelop ed area.
In Ch ile , th e n u tritio n a l situ a tio n o f a d u lts h as b een stu d ied in p regn an t wom en wh o h ave t h e ir re gu la r p re n a t a l ch e ck-u p s in t h e p u b lic h e a lt h ca r e syst e m (wit h a co ve r a ge o f 70%) a n d a lso in la rge sa m p les o f th e gen era l p o p u lation from San tiago an d Valp araiso (th e cou n -try’s two largest cities). Am on g p regn an t wom en , p re va le n ce o f o b e sit y p a ra lle ls t h a t o b se rve d a m o n g sch o o lch ild re n , in cre a sin g fro m 12.9% in 1987 t o 32.7% in 2000 (U a u y e t a l., 2001). Wit h re ga rd t o t h e a d u lt p o p u la t io n , t wo su r -ve ys co n d u ct e d in 1988 a n d 1992 in Sa n t ia go (Be rrío s, 1994), sh o we d a m a rke d in cre a se in o b e sity, fro m 6% to 11% in m e n a n d fro m 14% to 24% in wo m en o ver th e fo u r-yea r p erio d . In Va lp a ra iso , a st u d y o n risk fa ct o rs fo r ch ro n ic d ise a se s in 1997 sh o we d o b e sit y p re va le n ce r a t e s o f 15.7% fo r m e n a n d 23% fo r wo m e n ( Ja d u e e t a l., 1999). Figu re 3 sh o ws h o w t h e p re va le n ce o f o b e sit y va rie s wit h a ge , ge n d e r, a n d so cio eco n o m ic sta tu s in th is sa m p le. With
re ga rd t o ge n d e r a n d a ge , p re va le n ce is m u ch h igh e r fo r wo m e n , a n d in cre a se s wit h a ge . In fact, in th e 55-64 age-category, 27% of m en an d 30% of wom en are ob ese. Both m en an d wo m en o f h igh SES h a ve lo we r p re va le n ce ra t e s. Th is sit u a t io n re p e a t e d ly a p p e a rs in p o st - t ra n si-tio n a l so cieties a n d d evelo p ed co u n tries, su ch as Sp ain , wh ere old er, low-in com e wom en with less sch o o lin g a p p ea r to b e th e m o st su scep ti-b le grou p to weigh t gain (Aran ceta et al., 2001).
Determinant factors in increasing prevalence of obesity
Low birth weight and stunting
Se ve ra l st u d ie s h a ve sh o wn a re la t io n sh ip b e -t we e n fe -t a l a n d in fa n -t n u -t r i-t io n a l co n d i-t io n s a n d a d u lt - o n se t d ise a se s. Th is is re fle ct e d b y t h e h igh e r in cid e n ce o f o b e sit y a m o n g m e n wh o se m o t h e rs e xp e rie n ce d fo o d d e p riva t io n d u rin g p regn an cy, as rep orted b y Barker (1994). Tab le 3
Se c ular tre nd s in the p re vale nc e o f o b e sity in Brazilian ad ults b y re g io n.
Region O besit y prevalence (%)*
Male Fe male
1975 1989 1997 1975 1989 1997
No rthe ast 1.2 2.4 4.4 4.1 7.8 12.5
So uthe ast 2.9 5.8 8.4 7.8 14.0 12.3
Brazil 2.1 4.1 6.4 6.0 10.9 12.4
* BMI ≥30.
So urc e : Mo nte iro e t al. (2002).
Tab le 4
Se c ular tre nd in ag e -ad juste d p re vale nc e o f ad ult o b e sity (% ) b y g e nd e r, so c io e c o no mic le ve l,
and se tting . Brazil, 1975-1997.
Set t ing and family M ales Females
income 1975 1989 1997 1975 1989 1997
Rural
1stQ uartile 0.6 0.6 1.2 1.5 4.4 8.1
4thQ uartile 2.1 2.6 5.1 7.7 12.5 11.2
Urb an
1stQ uartile 1.8 3.6 4.7 6.5 10.2 14.1
4thQ uartile 4.8 8.4 9.4 7.8 12.8 9.2
Th e la tter a u th o r sh o ws th a t ch ild ren with lo w b irth weigh t are m ore likely to d evelop ab d om in a l o b e sity a n d o th e r d ise a se s re la te d to Syn -d r o m e X -d u r in g a -d u lt h o o -d . Th is is e sp e cia lly t ru e if a ra p id we igh t ga in o ccu rs in t h e first yea rs of life (Pop kin , 1998). On th e oth er h a n d , st u n t in g h a s b e e n a sso cia t e d wit h b o t h m e t a -b o lic a n d p h ysio lo gica l risk fa cto rs fo r o -b esity. Pop kin et a l. (1996) exa m in ed th is rela tion sh ip for ch ild ren aged 3-6 an d 7-9 years in n ation al-ly re p re se n t a t ive su rve ys fro m Ru ssia , Bra zil, So u t h Africa , a n d Ch in a . Re su lt s sh o we d t h a t in com e-ad ju sted risk ratios for overweigh t in a stu n te d ch ild ra n ge d fro m 1.7 to 7.8. H o ffm a n e t a l. (2000) r e p o r t e d in a st u d y o f st u n t e d Bra zilia n ch ild re n t h a t t h e y o xid ize d a lo we r p rop ortion of en ergy as fat, in com p arison with h ea lth y ch ild ren . Th e sa m e risk fa cto r fo r o b e -sity h a s b een sh o wn in o th er risk p o p u la tio n s. Sch roed er et al. (1999) sh owed in a p op u lation -b a se d co h o rt st u d y o f Gu a t e m a la n s -b o rn in t o lo w- in co m e e n vir o n m e n t s t h a t ch ild h o o d stu n tin g wa s a sso cia ted with a fu tu re in crea se in ab d om in al fat. Th is stu d y also d em on strated t h a t m igra t io n t o u rb a n a re a s in cre a se d t h is p ositive association in severely stu n ted wom en . Th e d ata are con sisten t with th ose of Sich ieri et a l. (2000), b a se d o n a su rve y in Rio d e Ja n e iro , sh o win g a n in cre a se d risk o f o b e sit y a m o n g sh o rt wo m en , with sh o rt sta tu re b ein g a m a rke r fo r rke a r ly u n d rke r n u t r it io n . Th rke a u t h o r s co n -clu d e d t h a t in co u n t r ie s wh e r e m a t e r n a l a n d c h ild m a ln u t r it io n c o e xis t s w it h u r b a n iz a
-t io n an d econ om ic growth , ob esity an d related ch ron ic d iseases are likely to in crease.
Also in Bra zil, a st u d y co n d u ct e d in d e st i-t u i-t e n e igh b o r h o o d s o f Ma ce ió , a cii-t y in i-t h e No rth ea st (Flo ren cio et a l., 2001), sh o wed th a t a m o n g ch ild re n (< 10 ye a rs), p re va le n ce o f wa st in g a n d st u n t in g wa s h igh , wit h n o o ve r weigh t. In ad olescen ts, p revalen ce of u n d ern u t rit io n wa s a lso im p o rt a n t , wit h a lo w p re va -le n ce o f o ve rwe igh t . Me a n wh i-le , in a d u lt s, p reva len ce o f o verweigh t wa s h igh er th a n th a t o f u n d e rwe igh t. An a sso cia tio n wa s fo u n d b e -t we e n s-t u n -t in g a n d cu rre n -t o ve rwe igh -t in a d u lt s: a m o n g st u n t e d a d u lt s, 30% we re o ve r -we igh t . Th is st u d y co n clu d e d t h a t in 30% o f h o u se h o ld s, u n d e r n u t r it io n co e xist e d wit h o ve rwe igh t . “T h ese resu lt s m a y in d ica t e t h a t better livin g con d ition s in u rban areas in a p op u la t ion ‘a d a p t ed ’ t o ch ron ic fa m in e m igh t in -crease th e su scep tibility to obesity”(Floren cio et al., 2001:277). Th e sam e p h en om en on h as b een rep o rted in o th er co u n tries a s well. Do a k et a l. (2000) fo u n d t h a t u rb a n h o u se h o ld s in Ch in a a n d Ru ssia wit h a n u n d e rwe igh t m e m b e r a lso freq u en tly in clu d ed an overweigh t p erson . Th e p r o p o r t io n o f t h is t yp e o f h o u se h o ld in t h e t h re e co u n t rie s wa s re la t e d t o t h e n u t rit io n a l tran sition . Th e p rop ortion was h igh est in Brazil, p ro b a b ly d u e t o a m o re ra p id t ra n sit io n . In Ch ile, u n d ern u trition a n d ob esity a lso coexist-e d d u rin g a p coexist-e rio d o f ra p id t ra n sit io n in t h coexist-e 1980s, wh en a h igh p ro p o rtio n (40%) o f m o th e rs o f u n d e rn o u rish e d ch ild re n a t t e n d in g n u -Fig ure 3
Pre vale nc e o f o b e sity* ac c o rd ing to ag e , g e nd e r, and so c io e c o no mic status (SES). Valp araiso , Chile , 1997.
O BESITY IN LATIN AMERICA S8 3
tritio n reco very d a yca re cen ters were fo u n d to b e ob ese (Alb ala et al., 1986; Vio et al., 1985).
Education and socioeconomic status
D e ve lo p in g co u n t r ie s u n d e r go in g t h e n u t r i-t io n a l i-t ra n sii-t io n e xh ib ii-t lo we r a d u li-t o b e sii-t y ra tes a m o n g h igh er in co m e gro u p s, ju st a s d e -velo p ed co u n tries. Ed u ca tio n , wh ich is a sso ci-a t e d wit h so cio e co n o m ic st ci-a t u s ci-a n d cci-a n b e u sed as a p roxy for in com e, h as also b een sh own t o in flu e n ce BMI (e sp e cia lly in wo m e n ). It is like ly t h a t t h e in flu e n ce o f e d u ca t io n o n d i-e t a ry in t a ki-e , o b i-e sit y, a n d ca rd io va scu la r risk fa ct o r s ch a n ge wit h t im e , d e p e n d in g o n t h e co u n t r y’s d e gr e e o f e co n o m ic d e ve lo p m e n t . In it ia lly, in cr e a sin g e d u ca t io n (a n d p r o b a b ly in co m e) m a y b e a sso cia ted with a less h ea lth y d ie t ; o ve r t im e , t h e a sso cia t io n b e co m e s re -versed . Th is ap p ears to b e th e situ ation in Hon g Ko n g, wh ere Wo o et a l. (1999) in a stu d y o n a n a d u lt Ch in e se p o p u la t io n fo u n d t h a t BMI a n d waist-h ip s ratio were lower with in creasin g lev-els of ed u ca tion in wom en , p rob a b ly rela ted to a h ealth ier d iet con su m ed b y th ese wom en .
Mo n te iro e t a l. (2001) fu rth e r a n a lyze d th e 1997 su rvey to d eterm in e if th ere wa s a n in d e -p en d en t effect of in com e an d ed u cation on risk o f o b e sit y. Th e y fo u n d t h a t r isk o f o b e sit y in m en stron gly in creased with in com e in th e two region s. Level of ed u cation d id n ot in crease th e r isk o f m a le o b e sit y in t h e le ss d e ve lo p e d r e -gio n b u t , in t h e m o re d e ve lo p e d o n e , b e t t e re d u ca t re d m re n h a d sligh t ly lre ss ch a n cre o f b re -co m in g o b e se . In t h e N o rt h e a st , o b e sit y in wo m e n wa s a sso cia t e d wit h b o t h in co m e (d i-re ct ly) a n d e d u ca t io n (in ve rse ly), wh ile in t h e So u t h e a st , o n ly e d u ca t io n in flu e n ce d t h e risk o f o b e sit y, a n d a re d u ct io n in o b e sit y p re va le n ce wa s r e p o r t e d a m o n g u p p e r in co m e u r -b a n resid en ts ( Ta-b le 4). Th is red u ction was associated with regu lar p h ysical exercise b y h igh -in co m e u rb a n wo m e n (26.3% o f t h e se wo m e n e xe rcise d o n a we e kly b a sis a s co m p a re d t o 2.8% in th e lowest-in com e u rb an q u in tile). Th e a u t h o rs co n clu d e d t h a t in t ra n sit io n a l so cieties, in com e is a risk factor for ob esity, wh ere a s ed u ca tio n a l level is p ro tective. Th e a sso cia t io n b e t we e n t h e se va r ia b le s a n d o b e sit y d e p en d s on gen d er an d th e level of econ om ic d e -velop m en t.
An im p rovem en t in ed u cation al level, esp e-cia lly in wo m e n , is o n e wa y t h e rise in o b e sit y rates m ay b e atten u ated , as is th e case of Sp ain . From 1987 to 1997 th e in crease in ob esity p revalen ce wa s less th a n exp ected (a p ossib le exp la -n a t io -n wa s t h e i-n cre a se i-n ye a rs o f sch o o li-n g a m o n g Sp a n ish wo m e n d u rin g t h e sa m e p e
ri-o d ) (Arta lejri-o et a l., 2002). Th is fa ct a grees with th e d eclin e in o b esity o b served in No rth Ka re -lia a n d Ku o p io , wh e re t h e d e clin e in fe m a le o b esity wa s m o re evid en t in th e u p p er so cio e -con om ic grou p s (Mon teiro et al., 2000b ).
Dietary factors
D ie t a ry fa ct o rs a re a sso cia t e d wit h t h e m a in cau ses of d eath in Latin Am erican cou n tries. As in com e in creases, so d oes overall en ergy in take a n d t h a t o f t o t a l fa t , e sp e c ia lly sa t u r a t e d fa t . On t h e o t h e r h a n d , co n su m p t io n o f ce re a ls, le gu m e s, a n d o t h e r fib e r- rich fo o d s su ch a s ve ge t a b le s a n d fru it s h a s re m a in e d st a b le o r e ve n d e clin e d . Th e re la tive co n trib u tio n o f fa t t o e n e rgy in t a ke a s we ll a s t h e t yp e o f fa t co n -su m ed is closely related to th e stage of th e ep i-d e m io lo gica l t ra n sit io n (Po p kin e t a l., 2001). Not on ly h as th ere b een a sh ift in th e typ e of d i-et as exp lain ed ab ove, b u t th e rate of ch an ge in La t in Am e r ica is a cce le r a t in g (Po p kin , 2001) a n d t h e b u rd e n o f a h igh e n e rgy-d e n se d ie t is greater am on g th e p oor.
-p le x ca rb o h yd ra te s in th e d ie t, th e in cre a se in th e con su m p tion of su gar h as b een sign ifican t. Dietary factors are p rob ab ly in volved in th e h igh p r e va le n ce o f h o u se h o ld s wit h u n d e r -we igh t ch ild re n co e xist in g wit h o n e o r m o re o ve rwe igh t a d u lt . As re p o rt e d b y Do a k e t a l. (2000), u rb a n re sid e n ce a n d in co m e a re in -vo lve d . U rb a n re sid e n ce is lin ke d t h ro u gh t h e a sso cia t io n wit h e n e rgy- d e n se d ie t s, wh ich h a ve a ffe cte d fa m ily m e m b e rs d iffe re n tly, d u e n o t o n ly t o t h e t yp e o f fo o d b u t a lso t o in t ra -h ou se-h old d istrib u tion .
Sedentary lifestyle
Sed en ta ry b eh a vio r is o n e o f th e m a in risk fa c-to rs o f in cre a sin g o b e sity ra te s. U rb a n iza tio n , o n t h e o t h e r h a n d , is o n e o f t h e m a in co n -trib u tin g factors to in activity. Peop le from
low-er so cio eco n o m ic levels m o vin g fro m ru ra l a r-eas to th e cities gen erally ad op t sed en tary work, le a vin g b e h in d a ct ive wo rkin g live s in vo lvin g h ea vy m a n u a l la b o r (H o ffm a n , 2001). Ch a n ges in a ct ivit y p a t t e r n s h a ve b e e n a s r a p id a s d i-e t a r y ch a n gi-e s (Po p kin , 2001). Th i-e d i-e clin i-e in e n e r gy e xp e n d it u r e d u e t o a ch a n ge in la b o r p ra ctice s ca n b e su b sta n tia l. Th e se rvice s se tor h as grown rap id ly, wh ile in d u stria l p rod u c-tion is d om in ated b y cap ital-in ten sive p rocess-e s wit h p r o fo u n d ch a n grocess-e s in t im rocess-e a llo ca t io n p a t t e rn s. U n fo rt u n a t e ly, t h e wo rk fo rce is n o t on ly extrem ely sed en tary in th eir job s, b u t also a t h o m e , d u e t o n e w h o u se h o ld t e ch n o lo gie s (activity-savin g ap p lian ces). In ad d ition , a m ore p rofou n d sh ift h as occu rred in leisu re activities (Po p kin , 2001), n a m ely excessive TV wa tch in g, co m p u t e r ga m e s, a n d in cre a se d u t iliza t io n o f m otor veh icles. For exam p le, in Ch ile, th e n u m -b e r o f ca r s p e r 1,000 in h a -b it a n t s wa s 38.9 in 1970, in creasin g to 136.6 in 1998, an d th e n u m -b er o f TV sets in crea sed fro m 12,170 in 1970 to m o r e t h a n t wo m illio n in 1998 (Alb a la e t a l., 2002). In Bra zil, Mo n t e iro e t a l. (2002) re p o rt th a t th e services secto r o f th e eco n o m y h a s in -cre a se d m a rke d ly. Th e p r o p o r t io n o f p e r so n s e m p lo ye d b y t h is se ct o r wa s 29% in 1970, in -crea sin g to 55% in 1999. Du rin g th e sa m e p eri-od , Brazilian h ou seh old s with TV sets in creased from 24% to 88%.
Re ga rd in g t h e co e xist e n ce o f u n d e r- a n d overn u trition in u rb an h ou seh old s, Doak et al., (2000) rep ort th a t ch a n ges in b oth p h ysica l a c-tivity an d d iet are p rob ab ly exp erien ced d iffer-en tly b y variou s fam ily m em b ers. Th is, p lu s th e in flu e n ce o f so cio e co n o m ic fa ct o rs, re su lt s in som e b ecom in g u n d erweigh t an d oth ers ob ese. Data are scarce on sed en tary b eh avior in all cou n tries. A recen t rep resen tative su rvey of th e Ch ile a n a d u lt p o p u la t io n (MIN SAL, 2001) r e -vea led th a t on ly 8.8% p erform ed 30 m in u tes of re gu la r p h ysica l a ct ivit y t h re e t im e s a we e k. Me n we re sligh t ly m o re a ct ive t h a n wo m e n (11% ve rsu s 7%). Wit h r e sp e ct t o e d u ca t io n a l le ve l, se d e n t a ry b e h a vio r in cre a se d a s fo rm a l ed u cation d eclin ed .
A re a list ic wa y t o a t t e n u a t e risin g o b e sit y t re n d s is t o in cre a se le isu re t im e p h ysica l a c -t ivi-t y, a s o b se r ve d in -t h e Sp a n ish p o p u la -t io n (esp ecially wom en ) b y Artalejo et al. (2002). Th e a u t h o r s sp e c u la t e t h a t t h is a sp e c t , wit h t h e im p r o ve m e n t in e d u ca t io n a l le ve l, m a y h a ve h e lp e d slo w a risin g t re n d in o b e sit y t h a t o c -cu rred in Sp ain d u rin g th e last d ecad e.
Tab le 5
Availab ility o f to tal c alo rie s and ve g e tab le and animal fat in se le c te d Latin Ame ric an
c o untrie s, 1979, 1989, and 1999.
1979 1989 1999 Change (%)
Chile
Kc al/ d ay p e r c ap ita 2,660 2,485 2,858 + 7.4
% as fat p e r c ap ita 19.9 21.4 26.6 + 33.7
Ve g e tab le fat g / d ay p e r c ap ita 30.1 26.0 39.8 + 32.2
Animal fat g / d ay p e r c ap ita 28.7 33.1 44.6 + 55.4
M exico
Kc al/ d ay p e r c ap ita 2,982 3,087 3,168 + 6.2
% as fat p e r c ap ita 22.8 23.6 26.1 + 14.5
Ve g e tab le fat g / d ay p e r c ap ita 39.8 47.6 51.6 + 29.6
Animal fat g / d ay p e r c ap ita 35.9 33.4 40.2 + 12.0
Guat emala
Kc al/ d ay p e r c ap ita 2,191 2,405 2,331 + 6.4
% as fat p e r c ap ita 17.4 17.0 19.7 + 13.2
Ve g e tab le fat g / d ay p e r c ap ita 31.0 34.2 37.8 + 21.9
Animal fat g / d ay p e r c ap ita 11.4 11.2 13.2 + 15.8
Brazil
Kc al/ d ay p e r c ap ita 2,707 2,784 3,012 + 11.3
% as fat p e r c ap ita 21.5 25.9 27.0 + 25.6
Ve g e tab le fat g / d ay p e r c ap ita 38.7 49.0 45.6 + 17.8
Animal fat g / d ay p e r c ap ita 26.1 31.1 44.9 + 72.0
Hait i
Kc al/ d ay p e r c ap ita 2,039 1,734 1,977 - 3.0
% as fat p e r c ap ita 14.6 14.2 16.4 + 12.3
Ve g e tab le fat g / d ay p e r c ap ita 24.4 20.6 28.7 + 17.6
Animal fat g / d ay p e r c ap ita 8.6 6.7 7.4 - 14.0
O BESITY IN LATIN AMERICA S8 5
Conclusions
La t in Am e rica n co u n t rie s a re u n d e rgo in g d if-feren t sta ges o f th e ep id em io lo gica l a n d n u tri-t io n a l tri-t ra n sitri-t io n . Th e p o o re r co u n tri-t rie s in tri-t h e Region are still faced with th e d ou b le b u rd en of u n d e r- a n d o ve rn u t rit io n . As so cio e co n o m ic co n d it io n s im p ro ve , u n d e rn u t rit io n d e clin e s a n d o b esity in crea ses. Th e m o st im p o rta n t d e -term in an ts of ob esity are fetal an d in fan t n u trition al con d itrition s, esp ecially stu n tin g, econ om -ic an d ed u cation al levels, an d ad op tion of d iets t h a t a re h igh in fa t a n d su ga r wit h d e clin in g p h ys ic a l a c t ivit y (a c o n s e q u e n c e o f t h e u r -b a n iza t io n p ro ce ss). O-b e sit y p re va le n ce in p re sch o o l ch ild re n is lo w, b u t in cre a se s in sch o o lch ild re n . In a d u lt s, wo m e n (e sp e cia lly t h o se wit h le ss sch o o lin g) e xp e r ie n ce h igh e r ra t e s t h a n m e n . In u n d e rd e ve lo p e d so cie t ie s, o b esity p reva len ce is h igh er a m o n g th e h igh er
so cio e co n o m ic gr o u p s. A n e w co n ce r n h a s e m e rge d in u n d e rd e ve lo p e d so cie t ie s, wh e re h o u seh o ld s ca n in clu d e m em b ers with u n d ern u tritio ern a ern d o th e rs with o b e sity. Iern m o re d e -ve lo p e d so cie t ie s, o b e sit y is m o re p re va le n t a m o n g th e lo wer so cio eco n o m ic gro u p s, esp e -cially am on g wom en . Ob esity is associated with t h e m a in ca u se s o f d e a t h in La t in Am e r ica (WH O, 1998). Th e ch a llen ge is d ifficu lt a n d re -q u ire s a n in te gra te d e ffo rt to im p ro ve in co m e a n d e d u ca t io n o f t h e le ss d e ve lo p e d p o p u la -tio n s a n d a d d i-tio n a lly ch a n ge th e p o p u la -tio n’s b eh a vio r in term s o f d iet a n d p h ysica l a ctivity. Policies to im p rove in com e a n d ed u ca tion a n d to im p lem en t h ealth p rom otion an d p reven tive m e a su re s a re e sse n t ia l t o o ffse t t h e e co n o m ic b u rd en o f risin g ra tes o f ch ro n ic d isea ses. Tar-getin g sh ou ld n ot on ly con sid er m on itorin g th e p re va le n ce o f t h is d ise a se , b u t a lso it s so cia l d istrib u tion .
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