Monteiro et al., Public Health Nutrition, Feb 2002

The IUNS Bellagio meeting on the nutrition transition in the developing countries.

THE RELATIVE BURDEN OF DISEASE DUE TO UNDER- AND TO OVER-NUTRITION:

EVIDENCE FROM BRAZIL

Carlos A. Monteiro (carlosam@usp.br)

São Paulo University, Brazil

Monteiro et al., Public Health Nutrition, Feb 2002

THE BURDEN OF DISEASE DUE TO UNDER- AND TO OVER-NUTRITION IN

THE DEVELOPING COUNTRIES

• What is the present situation?

• What has been the pace of change? Is over-nutrition replacing (or adding to) under-nutrition?

• Are young children, old children, and adults similarly affected?

• Are distinct social classes equally affected?

Monteiro et al., Public Health Nutrition, Feb 2002

THE BURDEN OF NUTRITIONAL DISEASES:COMPONENTS AND DEFINITIONS

• The under-nutrition burden: nutritional imbalances caused by insufficient consumption and/or excessive expenditure of energy and nutrients.

• The over-nutrition burden: nutritional imbalances caused by excessive consumption and/or insufficient expenditure of energy and nutrients.

Monteiro et al., Public Health Nutrition, Feb 2002

THE BURDEN OF NUTRITIONAL DISEASES:HOW TO MEASURE IT?

Diseases Direct indicators

Indirect indicators

Energy imbalances

(under or over)

Anthropometry Diet and physical activity evaluation

Energy-related nutrient imbalances

(under or over)

Biochemical and clinical tests

Diet evaluation

Anthropometry

Nonenergy-related nutrient imbalances

(under or over)

Biochemical and clinical tests

Diet evaluation

Monteiro et al., Public Health Nutrition, Feb 2002

BRAZIL

• Repeated national anthropometric surveys in the 70’s, 80’s , and 90’s.

• Great historical development contrasts between the poor northern regions and the rich southern regions.

• Great income disparities between and within the regions.

Monteiro et al., Public Health Nutrition, Feb 2002

BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

SOUTHEASTUS$ 4,490

NORTHEASTUS$ 1,635

GDP PER CAPITA (BRAZIL, 1994)

NORTHUS$ 2,299

CENTERWESTUS$ 3,650

SOUTHUS$ 3,983

Monteiro et al., Public Health Nutrition, Feb 2002

What is the relative burden of disease due to under- and to

over-nutrition?

- in the (less developed) northeastern Brazil

- in the (more developed) southeastern Brazil

Monteiro et al., Public Health Nutrition, Feb 2002

INDICATORS EMPLOYED TO ASSESS UNDER- AND OVER-NUTRITION

• In young children (1-4 y)height-for-age < -2 z; weight-for-height > + 2 z; international growth reference

• In old child/adolescents (10-17 y)BMI < 5th centile; BMI > 95th centile; the 1989 survey as the reference distribution

• In adults (20 y and +)BMI < 18.5 kg/m2; BMI 30.0 kg/m2

Monteiro et al., Public Health Nutrition, Feb 2002

THE RELATIVE BURDEN OF UNDER- AND OVER-NUTRITION

Northeastern and southeastern of Brazil 1996/7

19

5,94,8 5,3

4,22,7

4,6

8,5

5,2

12,9

10,4

5,9

0

10

20

youngchild

old child adult youngchild

old child adult

%

UNDER OVER

SOUTHEASTNORTHEAST

Monteiro et al., Public Health Nutrition, Feb 2002

Is over-nutrition replacing or adding to under-nutrition?

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN THE RELATIVE BURDEN OF UNDER- AND OVER-NUTRITION Brazilian young children: 1975-1996

47,1

1922,7

84,82,9 1,5 2,7 3,7 4,5 5,2

29,9

0

10

20

30

40

50

1975 1989 1996 1975 1989 1996

%

UNDER OVER

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN THE RELATIVE BURDEN OF UNDER- AND OVER-NUTRITION

Brazilian old child/adolescents: 1975-1997

8,9

5,9

8,2

3,9

5,3

1

2,5

4,6

2,5

7,3

12,9

4,9

0

5

10

15

1975 1989 1997 1975 1989 1997

%

UNDER OVER

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN THE RELATIVE BURDEN OF UNDER- AND OVER-NUTRITION

Brazilian adults: 1975-1997

12

5,9

9,8

5,14,2

2,7

5,1

8,5

5,4

9,910,4

7,4

0

5

10

15

1975 1989 1997 1975 1989 1997

%

UNDER OVER

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

Are distinct social classes equally affected by the nutrition transition?

Monteiro et al., Public Health Nutrition, Feb 2002

Is the under-nutrition gap between poor and rich being

eliminated ?

Income groups: the 25% poorest and the 25% richest families in each region.

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN UNDER-NUTRITION GAPS lower income vs. upper income

young children

60,8

28,8

39,9

17,3

7,2

26,2

8,6

2,46

2,4 3

42,4

0

20

40

60

80

1975 1989 1997 1975 1989 1997

%

25% POOREST 25% RICHEST

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

Is the over-nutrition gap between rich and poor being reduced (or

even reversed) ?

Income groups: the 25% poorest and the 25% richest families in each region.

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN OVER-NUTRITION GAPS lower income vs. upper income

adult men

0,7

1,8 1,6

2,93,8

2,5

5,1

8,4

5,4

8,2

10,2

0,8

0

4

8

12

1975 1989 1997 1975 1989 1997

%

25% POOREST 25% RICHEST

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN OVER-NUTRITION GAPS lower income vs. upper income

adult women

3,1

7,76,1

11,2

14,1

6,7

9,8

14,5

7,9

14,4

8,9

5,2

0

5

10

15

20

1975 1989 1997 1975 1989 1997

%

25% POOREST 25% RICHEST

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

Is the net effect of the nutrition transition positive or negative to

the poor?

Income groups: the 25% poorest and the 25% richest families in each region.

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN UNDER- + OVER-NUTRITION lower income vs. upper income

young children

63,2

30,1

42,8

19,4

11,2

29,5

11,4 9,312,8 13,7 11,6

43,6

0

20

40

60

80

1975 1989 1997 1975 1989 1997

%

25% POOREST 25% RICHEST

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

TRENDS IN UNDER- + OVER-NUTRITION lower income vs. upper income

adult women

20,7

17,3

2017,6

23

19,1

15,9

20,1

14,7

18,7

12

16,4

0

10

20

30

1975 1989 1997 1975 1989 1997

%

25% POOREST 25% RICHEST

NORTHEASTERN BRAZIL SOUTHEASTERN BRAZIL

Monteiro et al., Public Health Nutrition, Feb 2002

BMI DISTRIBUTION lower income vs. upper income southeastern adult women, 1997

0

0,1

0,2

0,3

0,4

0,5

-3,5 -2,5 -1,5 -0,5 0,5 1,5 2,5 3,5

BMI Z-SCORE

Lower income Higher income

Monteiro et al., Public Health Nutrition, Feb 2002

DIET AND PHYSICAL ACTIVITY PATTERNS IN LOWER AND UPPER INCOME GROUPS

Monteiro et al., Public Health Nutrition, Feb 2002

DIETARY PATTERNS BY INCOMEBrazil metropolitan households, 1996

24,1

7,5

25,4

7,7

27,6

9,1

29,9

10,4

0

10

20

30

ENERGY FROM TOTAL FAT

ENERGY FROMSATURATED FAT

%

25% POOREST 25% 25% 25% RICHEST

Monteiro et al., Public Health Nutrition, Feb 2002

DIETARY PATTERNS BY INCOMEBrazil metropolitan households, 1996

13,9

2,3

14,3

2,4

12,7

3,5

9,8

5,2

0

5

10

15

ENERGY FROM SUGAR ENERGY FROM FRUITSAND VEGETABLES

%

25% POOREST 25% 25% 25% RICHEST

Monteiro et al., Public Health Nutrition, Feb 2002

ANY LEISURE-TIME PHYSICAL ACTIVITY BY INCOME, BRAZIL, 1997

8,3

1,3

12,7

6,5

21,5

7,2

31,5

18

0

10

20

30

40

MEN WOMEN

%

25% POOREST 25% 25% 25% RICHEST

Monteiro et al., Public Health Nutrition, Feb 2002

SMOKERS BY INCOME BRAZIL, 1989

52,9

33,8

49,4

28,8

44,1

27,1

38,6

24,4

0

20

40

60

MEN WOMEN

%

25% POOREST 25% 25% 25% RICHEST

Monteiro et al., Public Health Nutrition, Feb 2002

PREVALENCE OF OBESITY IN WOMEN BY SOCIOECONOMIC STATUS

29,3

21,1

36,8

14,1

25,8

43,4

0

20

40

60

Chile 1988 Curaçao 1994

% B

MI

> 3

0 kg

/m2

LOW MIDDLE HIGH

Sources: Berrios 1990; Grol 1997.

Monteiro et al., Public Health Nutrition, Feb 2002

PREVALENCE OF OBESITY IN WOMEN BY SCHOOLING LEVEL (1987-1996)

1,5

8,2

13,8

15,8

9,5

13,1

10,4 10

5,4

7,1

0

5

10

15

20

Haiti Guatemala Peru Rep. Dom. Mexico

% B

MI

> 3

0 kg

/m2

LOW HIGH

Source: Martorell et al. 2000