Maria Helena D'Aquino Benício

Shifting obesity trends in Brazil

Objective: To describe secular trends in obesity in various settings and socio-economic groups of the adult population of Brazil.Methods: Trend analysis of the prevalence of obesity in adults aged over 20 y (body mass index ≥30.0 kg/m2) applied to anthropometric and socio-economic data collected by three comparable household surveys undertaken in the two most populated Brazilian regions in 1975 (n=95, 062), 1989 (n=15, 585) and 1997 (n=10, 680).Results: While previous trends (1975–1989) showed increasing obesity prevalence for all population groups except for men in rural areas, recent trends (1989–1997) have pointed to a much more complex picture where increases in obesity tend to be more intense in men than in women, in rural than in urban settings and in poorer than in richer families. Particularly notable was the fact that, in the recent period, obesity was actually reduced for women belonging to the upper income groups, especially in urban settings.Conclusion: Earlier obesity trends in Brazil entirely agree with what has been described for both developed and developing countries where reliable secular trend information exists, but the 1989–1997 trend of a substantial reduction in the prevalence of obesity among upper income urban women (12.8–9.2%, or a 28% reduction), is unique in a developing country and, indeed, up to now has only been detected in Scandinavian populations. It is speculated that this declining obesity trend may be a result of an intense mass media work focused on combating a sedentary life style and promoting better food habits.European Journal of Clinical Nutrition (2000) 54, 342–346

Narrowing socioeconomic inequality in child stunting: the Brazilian experience, 1974-2007

OBJECTIVE To assess trends in the prevalence and social distribution of child stunting in Brazil to evaluate the effect of income and basic service redistribution policies implemented in that country in the recent past. METHODS The prevalence of stunting (height-for-age z score below -2 using the Child Growth Standards of the World Health Organization) among children aged less than 5 years was estimated from data collected during national household surveys carried out in Brazil in 1974-75 (n = 34,409), 1989 (n = 7374), 1996 (n = 4149) and 2006-07 (n = 4414). Absolute and relative socioeconomic inequality in stunting was measured by means of the slope index and the concentration index of inequality, respectively. FINDINGS Over a 33-year period, we documented a steady decline in the national prevalence of stunting from 37.1% to 7.1%. Prevalence dropped from 59.0% to 11.2% in the poorest quintile and from 12.1% to 3.3% among the wealthiest quintile. The decline was particularly steep in the last 10 years of the period (1996 to 2007), when the gaps between poor and wealthy families with children under 5 were also reduced in terms of purchasing power; access to education, health care and water and sanitation services; and reproductive health indicators. CONCLUSION In Brazil, socioeconomic development coupled with equity-oriented public policies have been accompanied by marked improvements in living conditions and a substantial decline in child undernutrition, as well as a reduction of the gap in nutritional status between children in the highest and lowest socioeconomic quintiles. Future studies will show whether these gains will be maintained under the current global economic crisis.

Tendência secular do peso ao nascer na cidade de São Paulo (1976-1998)

OBJETIVO: Resgatar a tendencia secular da distribuicao do peso ao nascer na cidade de Sao Paulo, SP, bem como examinar suas possiveis causas, com base em dados coletados por dois inqueritos domiciliares sobre condicoes de saude na infância realizados em 1984/85 e em 1995/96, complementados por informacoes procedentes de levantamento de prontuarios de maternidades e por informacoes do Sistema Estadual de Declaracoes de Nascidos Vivos. METODOS: Os inqueritos domiciliares estudaram amostras probabilisticas da populacao infantil de Sao Paulo com idade inferior a cinco anos (n=1.016 em 1984/85; n=1.280 em 1995/96). O levantamento de prontuarios estudou uma amostra probabilistica dos partos ocorridos nas maternidades da cidade no ano de 1976 (n=5.734). As declaracoes de nascidos vivos referem-se as coortes de criancas nascidas na cidade entre 1993 e 1998 (cerca de 200 mil criancas por ano). O estudo da distribuicao social do peso ao nascer levou em conta a renda familiar per capita e a escolaridade materna. A estrategia analitica para estudar os determinantes da tendencia secular do peso ao nascer empregou modelos hierarquicos de causalidade, analises multivariadas de regressao e procedimentos analogos aos utilizados para calcular riscos atribuiveis populacionais. RESULTADOS/CONCLUSOES: A distribuicao do peso ao nascer na cidade de Sao Paulo (media de 3.160 g com 8,9% de pesos <2.500 g) e inferior aquela esperada quando sao otimas as condicoes do crescimento fetal (media de 3.400-3.500 g com cerca de 4-5% de pesos <2.500 g). Essa distribuicao pouco se modificou nos ultimos 22 anos (1976-1998). Entretanto, no periodo, ha evidencias de evolucao desigual do peso ao nascer segundo o nivel socioeconomico (NSE) da populacao. Nos estratos de baixo NSE, a evolucao tem sido favoravel e isso se deve, aparentemente, ao melhor desempenho do crescimento intra-uterino, o qual poderia decorrer de melhorias em condicoes economicas, no peso e na altura das gestantes, na assistencia pre-natal e, possivelmente, do declinio no habito de fumar. Nos estratos de alto NSE, a evolucao do peso ao nascer tem sido desfavoravel devido, aparentemente, ao aumento na frequencia de recem-nascidos prematuros, tendencia provocada por fatores ainda nao conhecidos.

Validade do peso e da altura auto-referidos: o estudo de Goiânia

OBJECTIVE To assess the validity of self-reported weight and height at the time of diagnosing obesity, and to identify the sociodemographic and individual characteristics that might be a source of information bias. METHODS This was a cross-sectional population-based study carried out in the city of Goiânia in 2001. Interviews were conducted with 1,023 individuals aged 20-64 years, in their homes, to collect sociodemographic and self-reported weight and height information. On the same occasion, weight and height measurements were made on these individuals. The mean differences and correlation coefficients between self-reported and measured data were calculated according to age, body mass index (BMI), schooling, income and height. RESULTS Both the men and women overestimated their heights (p<0.05), by 0.9 cm and 2.2 cm, respectively. There was no difference between self-reported and measured weights, either for the men (-0.44 kg; p=0.06) or for the women (-0.03 kg; p>0.05). The behavior of overestimating height was influenced by age, schooling, height and body mass index. Although this index obtained from the self-reported data was underestimated (p<0.05), by 0.27 kg/m(2) and 0.67 kg/m(2) for men and women respectively, the measured and self-reported data presented a high degree of agreement. Both the sensitivity and specificity of the self-reported body mass index were high, in relation to identifying the measured index. CONCLUSIONS In epidemiological studies for monitoring the prevalence of excess weight in populations, self-reported weights and heights constitute reliable data, which gives validity to the methodology utilized.

Circunferência da cintura e índice de massa corporal como preditores da hipertensão arterial

OBJECTIVE: To evaluate the association between anthropometric indexes - body mass index (BMI) and waist circumference (WC) - and hypertension, and to evaluate the predictive value of these indexes in detecting hypertension. METHODS: Cross-sectional population study conducted in the city of Goiânia (GO) with a sample of 1,238 adults aged twenty to 64 years, in 2001. Total obesity was defined as BMI > 30 kg/m2; abdominal obesity was defined as level 2 WC > 88 cm for women and > 102 cm for men, and hypertension was defined as systolic pressure > 140 mmHg, or diastolic pressure > 90 mmHg, or utilization of hypotensive drugs). Multiple logistic regression analysis was used to evaluate the associations between anthropometric indexes and hypertension. The Receiver Operating Characteristic (ROC) curve analysis was used to evaluate sensitivity and specificity of BMI (> 30) and level 2 WC as predictive factors of hypertension, and to determine the best predictive cut-off points for hypertension. RESULTS: WC was associated with hypertension in both genders. Level 2 WC and BMI >30 kg/m2 showed a low sensitivity in identifying hypertension. The best predictive cut-off points for hypertension coincided with level 1 WC (> 80 cm) and with BMI >25 kg/m2 (overweight) for women, and were lower than the values of level 1 WC and of overweight for men. CONCLUSION: Level 2 WC and BMI > 30 kg/m2 are not adequate to identify the groups at the highest risk of hypertension, since this risk rises with small increases in adiposity.

Obesity and weight change related to parity and breast-feeding among parous women in Brazil

OBJECTIVE Studies on the independent role of parity in long-term body weight change in economically developing countries are scarce and inconclusive, and only a few studies have taken into account patterns of breast-feeding. This association was examined in a national cross-sectional survey representative of Brazilian parous women. DESIGN AND SETTING The survey conducted in 1996 measured womens height and weight in the household and data on weight prior to the first pregnancy, parity and breast-feeding were recalled. SUBJECTS A sample of 2338 parous women, 15 to 49 years of age, 29 months after last delivery on average, had current body mass index (BMI, in kg m(-2)) modelled through hierarchical multiple linear regression analysis. Explanatory variables included parity, days of predominant breast-feeding, BMI pre-pregnancy, socio-economic, geographic, demographic and other reproductive variables. RESULTS Prevalences of overweight (BMI = 25.0-29.9 kg m(-2)) and obesity (BMI > or = 30.0 kg m(-2)) were 25.2% and 9.3%. The overall mean weight gain per year after the first pregnancy was 0.90 kg for an average time since first pregnancy of eight years. BMI pre-pregnancy modified the association between current BMI and parity. Therefore, weight change attributed to parity calculated for a woman of average height (1.56 m) was 0.60 kg greater for primiparous women with a BMI pre-pregnancy of 30 kg m(-2), compared with women with BMI pre-pregnancy of 25 kg m(-2). This greater weight retention among obese women was 1.21 kg for women with two children and 1.82 kg for women with three or more children. Parity reduced the effect of weight loss associated with lactation (1.75 kg for six months of lactation among primiparous women and 0.87 kg among women with three or more children). For the sub-sample of 793 primiparous women, a weight decrease of 300 g was associated with each month of predominant breast-feeding for all prior BMI levels. CONCLUSIONS In this study, weight change associated to reproduction was highly dependent on BMI previous to pregnancy and the effects of parity and lactation were small.

Wheezing conditions in early childhood: prevalence and risk factors in the city of São Paulo, Brazil

OBJECTIVE To investigate the prevalence and risk factors for wheezing disorders in early childhood in São Paulo, Brazil, the largest metropolitan area of South America. METHODS A population-based cross-sectional survey of 1132 children aged 6-59 months was carried out between 1995 and 1996 to obtain information on recent wheezing and on independent variables such as demographic, socioeconomic, environmental, maternal and nutritional variables and immunization status. Intestinal parasitic infections were diagnosed using standard techniques. Multiple unconditional logistic regression was used to describe associations between outcome and independent variables. FINDINGS The prevalence of recent wheezing (one or more reported episodes in the past 12 months) was 12.5%; 93% of children with wheezing were also reported to have a medical diagnosis of asthma. Recent wheezing was associated with low per capita income, poor quality of housing, day-care attendance, low birth weight and infection with intestinal helminths. CONCLUSION Wheezing in early childhood in São Paulo, although more common than in most developing countries, remains less prevalent than in urban areas of industrialized countries. Low income and conditions associated with poverty (poor housing, low birth weight and parasitic infections) are some of the main risk factors for wheezing disorders among young children in this city.

Causas do declínio acelerado da desnutrição infantil no Nordeste do Brasil (1986-1996-2006)

OBJECTIVE To describe changes in prevalence of child undernutrition in Northeastern Brazil in two successive time periods, identifying, in each period, the major factors responsible for these changes. METHODS Data analyzed are from probabilistic samples of underfives from three Demographic Health Surveys carried out in 1986 (n=1,302), 1996 (n=1,108), and 2006 (n=950). Identification of factors responsible for temporal changes in child undernutrition (height-for-age below < -2 z) took into account time changes in five potential determinants of child nutritional status, statistical modeling of the independent association between determinants and risk of undernutrition, and calculation of attributable fractions. RESULTS Prevalence of child undernutrition fell by one-third between 1986 and 1996 (from 33.9% to 22.2%) and by almost three-quarters between 1996 and 2006 (from 22.2% to 5.9%). Improvements in maternal schooling and in the coverage of water and sewage services were particularly important for the decline in child undernutrition in the first period, while increasing purchasing power of the poorest families and, again, maternal schooling were more relevant in the second period. CONCLUSIONS The acceleration of the decline in child undernutrition between the two periods was consistent with accelerated improvement of maternal schooling, water supply and sewage, health care, and maternal reproductive antecedents, as well as with the outstanding increase in purchasing power among the poor during the second period. If the rate of decline in growth deficits is kept at around the rate of the most recent period, child undernutrition will be controlled in the Brazilian Northeast in less than ten years. Achieving this will depend on sustaining the increase in purchasing power among the poor and on ensuring public investment in completing the universalization of access to essential services such as education, health, and sanitation.OBJETIVO: Descrever a variacao temporal na prevalencia de desnutricao infantil na regiao Nordeste do Brasil, em dois periodos sucessivos, identificando os principais fatores responsaveis pela evolucao observada em cada periodo. METODOS: Os dados analisados provem de amostras probabilisticas da populacao de criancas menores de cinco anos estudadas por inqueritos domiciliares do programa Demographic Health Surveys realizados em 1986 (n=1.302), 1996 (n=1.108) e 2006 (n=950). A identificacao dos fatores responsaveis pela variacao na prevalencia da desnutricao (altura para idade < -2 z) levou em conta mudancas na frequencia de cinco determinantes potenciais do estado nutricional, modelagens estatisticas da associacao independente entre determinante e risco de desnutricao no inicio de cada periodo e calculo de fracoes atribuiveis. RESULTADOS: A prevalencia da desnutricao foi reduzida em um terco de 1986 a 1996 (de 33,9% para 22,2%) e em quase tres quartos de 1996 a 2006 (de 22,2% para 5,9%). Melhorias na escolaridade materna e na disponibilidade de servicos de saneamento foram particularmente importantes para o declinio da desnutricao no primeiro periodo, enquanto no segundo periodo foram decisivos o aumento do poder aquisitivo das familias mais pobres e, novamente, a melhoria da escolaridade materna. CONCLUSOES: A aceleracao do declinio da desnutricao do primeiro para o segundo periodo foi consistente com a aceleracao de melhorias em escolaridade materna, saneamento, assistencia a saude e antecedentes reprodutivos e, sobretudo, com o excepcional aumento do poder aquisitivo familiar, observado apenas no segundo periodo. Mantida a taxa de declinio observada entre 1996 e 2006, o problema da desnutricao infantil na regiao Nordeste poderia ser considerado controlado em menos de dez anos. Para se chegar a este resultado sera preciso manter o aumento do poder aquisitivo dos mais pobres e assegurar investimentos publicos para completar a universalizacao do acesso a servicos essenciais de educacao, saude e saneamento.

Determinantes do ganho ponderal excessivo durante a gestação em serviço público de pré-natal de baixo risco

INTRODUCAO: O excesso de ganho de peso durante a gestacao pode ocasionar retencao de peso pos-parto e contribuir para a obesidade no sexo feminino. METODOLOGIA: Neste estudo, avaliou-se a influencia de fatores sociodemograficos, historia gestacional, tabagismo, trabalho fora de casa e estado nutricional inicial sobre o ganho ponderal excessivo (GPE). O GPE foi estimado a partir das. recomendacoes do IOM (ganho semanal >0,58g, >0,53g e >0,39g, correspondentes a estado de nutricional no inicio da gestacao: desnutrida, adequada e sobrepeso/obesidade, respectivamente). Estudou-se uma coorte de 141 gestantes saudaveis, inscritas em servico publico de pre-natal, entre marco de 1997 e marco de 1998. A influencia dos fatores de estudo sobre o GPE foi testada separadamente no 2o e 3o trimestres mediante analise de regressao de Poisson multipla hierarquizada. RESULTADOS: Dentre as 237 elegiveis houve 37,8% de perdas, nao se detectando diferencas estatisticamente significativas para as variaveis centrais do estudo. A incidencia de GPE no 2o trimestre foi de 38,6% (IC95% 30,5 - 47,2) e no 3o trimestre foi de 36,4% (IC95% 28,5 - 45,0). No 2o trimestre, apenas a escolaridade mostrou-se associada ao GPE. Em relacao as mulheres com menos de 5 anos de escolaridade, as gestantes com 5 a 8 anos e acima de 8 anos de escolaridade apresentaram riscos relativos correspondentes a 2,09 (IC95% 1,03 - 4,25) e 2,62 (IC95% 1,32 - 5,22), respectivamente. No 3o trimestre mostraram significância estatistica as variaveis: escolaridade >8 anos (RR=1,91 [IC95% 1,22 - 2,97], ausencia de companheiro (RR=1,66 [(IC95% 1,06 - 2,59], primiparidade (RR=2,13 [IC95% 1,20 - 3,85] e estado nutricional inicial adequado e sobrepeso/obesidade (RR=1,53 [IC95% 0,82 _ 2,84] e RR=2,02 [IC95% 1,04 - 3,92], respectivamente) em relacao as desnutridas. CONCLUSAO: Em funcao da elevada frequencia de GPE, particularmente em mulheres de escolaridade mais alta, as sem companheiro, as primiparas e aquelas com estado nutricional inicial adequado ou sobrepeso/obesidade durante a gestacao, mais atencao deveria ser dada a prevencao e ao controle do problema durante o pre-natal.

Tendência secular da doença respiratória na infância na cidade de São Paulo (1984-1996)

OBJETIVO: Estimar a prevalencia e a distribuicao social da doenca respiratoria na infância, estabelecer a tendencia secular dessa enfermidade e analisar sua determinacao, com base nos dados coletados por dois inqueritos domiciliares realizados na cidade de Sao Paulo, SP, em 1984/85 e em 1995/96. METODOS: Os inqueritos estudaram amostras probabilisticas da populacao residente na cidade com idades entre zero e 59 meses (1.016 em 1984/85 e 1.280 em 1995/96). Nos dois inqueritos estimou-se a prevalencia instantânea da doenca respiratoria alta (acima da epiglote) e da doenca respiratoria baixa com e sem chiado a ausculta pulmonar. A ocorrencia da doenca respiratoria foi aferida por exames clinicos realizados em dias aleatorios, nos proprios domicilios das criancas, por medicos pediatras devidamente treinados e padronizados quanto ao diagnostico da doenca. Os exames clinicos incluiam a anamnese do dia, antecedentes de doenca respiratoria e o exame fisico completo da crianca, incluindo inspecao da orofaringe, otoscopia e ausculta pulmonar. Nos dois inqueritos, os exames foram distribuidos ao longo de um periodo de cerca de 12 meses, de modo a garantir uma varredura uniforme das varias areas da cidade ao longo das quatro estacoes. O estudo da distribuicao social da doenca respiratoria levou em conta tercis da renda familiar per capita em cada um dos inqueritos. A estrategia analitica para estudar os determinantes da evolucao da prevalencia da doenca na populacao empregou modelos hierarquicos de causalidade, analises multivariadas de regressao e procedimentos analogos aos utilizados para calcular riscos atribuiveis populacionais. RESULTADOS/CONCLUSOES: Houve entre os inqueritos aumentos expressivos na prevalencia instantânea da doenca respiratoria alta (de 22,2% para 38,8%) e da doenca respiratoria baixa sem e com chiado (de 6,0% para 10,0% e de 0,8% para 2,8%, respectivamente). No caso da doenca alta e da doenca baixa sem chiado, o aumento e generalizado nos varios estratos sociais, o que nao altera, no periodo, a situacao discretamente menos favoravel dos estratos de menor renda. No caso da doenca baixa com chiado, o aumento se restringe aos estratos de renda baixa e intermediaria, sendo particularmente intenso no estrato de menor renda, o que determina o surgimento de uma forte relacao inversa entre a doenca e a renda familiar. Mudancas positivas em determinantes distais das doencas respiratorias (renda familiar e escolaridade materna) e em variaveis relacionadas a salubridade das moradias justificariam declinio modesto e nao aumento das doencas respiratorias na cidade. O aumento na frequencia a creches, observado no periodo, poderia contrabalancar o efeito positivo das melhorias em variaveis socioeconomicas e ambientais, mas nao seria suficiente para justificar o aumento das doencas respiratorias na cidade.