OBESITY AND CHILDHOOD OBESITY
IN LATIN AMERICA
A report by the World Heart Federation
February 2007
Obesity and children obesity in Latin America
1.
Context
Obesity is traditionally seen as a developed country issue, where people’s waistlines
expand as they consume unhealthy products and settle for a sedentary lifestyle typical of
economies dependent upon the tertiary services sector. Concurrently, cardiovascular
diseases, for which obesity and overweight are major risk factors, are also perceived as the
health care burden of rich and industrialized countries, leaving low- and middle-income
countries to face public health issues pertaining to infectious diseases.
The real picture appears to be very different however. Over the past decades, obesity
prevalence (and its correlated diseases) has increased rapidly in developing countries as
well, especially in those experiencing economic growth and social transformations. This is
the case of Latin American (LA) countries, among them Colombia, which is undergoing a
nutritional and epidemiological transition, leading to a radical change in the public health
issues these countries have now to face. Indeed, the dramatic changes in lifestyles and food
types available, coupled with a sharp decline of physical activity provoked by rapid
urbanization, mean that while under nutrition has declined, the prevalence of obesity and
overweight has increased.
Moreover, LA countries display a complex picture, as this trend exhibits important
variations between the countries of this region; even more problematic is the fact that the
situation within countries is not clear cut. Indeed, when some LA countries were in the
early stages of development, obesity prevalence rose among the higher income groups as
those people attained a new affluence and altered their patterns of consumption; but as
these countries became more and more developed, the obesity levels started to increase as
well among low-income groups. This follows the trend observed in western industrialized
countries where poor people are at higher risk of becoming obese. Therefore, in many LA
countries, we currently find a coincidence of the “rich fat” and the “poor fat” phenomena,
which makes it difficult to have a clear picture of the situation and clear public health
policies.
2.
Obesity in LA countries and Colombia: Facts
A striking fact that comes out from the various studies on the issue is that, of all the risk
factors associated with cardiovascular diseases, obesity is the one that has undergone the
fastest increase in LA countries and is now the main nutritional disease in this refgion1.
1
Uauy et al., 2001, cited in Obesity trends and determinants factors in Latin America, J.Kain, F.Vio,
C.Albala, 2003
Concurrently, cardiovascular disease has become the first cause of death in every country
of the region.
Taking a closer look at the research currently available, we can see that obesity, although
increasing throughout the whole population of LA countries, seems to be a particularly
acute health problem for women and children. In Chile, a survey showed that obesity rose
from 6 % to 11% in men and from 14% to 24% in women in just 4 years2. A study focused
on all LA countries found an obesity level of over 6% in children in five of the countries
surveyed3. In Mexico City, 30% of residents are obese, one third of the female population
and one fifth of the male population4.
The situation is worrying in Colombia as well. Although most reports rightly point out that
there is a lack of recent global studies on the issue, they all state that punctual studies
confirm that overweight and obesity have dramatically increased in the region. The
Asociacion Colombiana de Obesidad y Metabolismo estimates a figure of 40% of the
population suffering from overweight. A closer look seems to confirm this preoccupying
picture: the report Estudio de Factores de Riesgo Coronario en Colombia, produced by the
Colombian Society of Cardiology, found out that 8% of the country population has a Body
Mass Index (BMI5) superior to 30, meaning they are clinically obese. 29% have a BMI in
between 25 and 30, which indicates they are overweight. Furthermore, this study showed
that obesity was as prevalent in the higher as in the lower classes of society: 7% of the
people of the low-income group are obese, while 9% of the people of the high-income
group are. La Encuesta Nacional de la Situacion Nutricional en Colombia en 2005,
produced by the Insituto Colombiano de Bienestar Familial, displays a similar picture.
Between 0 and 4 years old, 3.1% of children suffer from overweight; this figure rises to
4.3% for children between 5 and 9 years old. For those between 10 and 17 years old, the
rate increases to 10.3%. These rates shoot up during adulthood: between 18 and 64 years
old, 39.9% of Colombian men suffer from overweight or obesity, while 49.6% of
Colombian women encounter the same problems. In total, between the age 18 and 64 years
old, 46.1% of Colombians are concerned by overweight or obesity (32.3% are overweight,
13.8% are obese). This is especially worrying given that overweight and obesity have been
clearly linked with an increased risk of cardiovascular disease: the WHO 2002 World
Health Report estimates that 21% of heart disease globally is attributable to excessive BMI.
The problem does not stop there, however. Coupled with other existing risk factors in
Colombia, such as hypertension (19% of the population) and smoking (22% of the
population smoke, 29.8% of young people, mostly between 13 and 15 years old, are
smokers6. It is important here to stress that as much as 20% of cardiovascular death is
attributable to smoking7), obesity can lead to increase in the prevalence of cardiovascular
2
Ibid.
Nutrition Transition: a Review of Latin America Profile, RM Barria, H. Amigo, 2006
4
Obesity and Central Obesity in Elderly People in Latin America and the Caribbean, F. Drumond Andrade,
2006
5
See Glossary at the end
6
Estudio de Factores de Riesgo Coronario en Colombia
7
US Department of Health and Human Services
3
diseases. Indeed, according to the WHO, in Colombia 28% of all deaths are caused by
cardiovascular diseases, a rate similar to those of Europe or USA.
3.
Causes of the obesity epidemics in LA countries and Colombia
The main explanatory factor behind the rise of obesity prevalence in LA countries seems to
be the nutrition transition undergone by this region. Indeed, this phase is characterized by
dramatic changes in lifestyles that all contribute to weight problems.
a) Diets
The most obvious change that has occurred in LA these past decades is the one
pertaining to the dietary habits of the population. The rapid urbanization (75% of the Latin
America population now lives in cities) has translated itself into a move away from
traditional rural diets into cheap, quick and readily available high energy density foods
made available both by the food industry and the informal economy. One of the
explanations of this sudden change of diet lies with simple economics: a study published in
The Lancet8 shows that in 1965, people from all income levels had similar diets. While it is
true that lower income groups ate cheaper cuts of meat and less fruits and vegetables, they
still had a varied and balanced diet. Since the 90s however, the diet of the poor seems
limited to 22 basic products that are selected to satisfy the appetite, but are high in fats and
sugar. The problem here is a problem of access: in 1970, a poor family in Latin America
spent 45% of its income on food. By 1992, this share had risen to 67%. When you
compare real food purchases to what the “ideal” basket ought to be, you observe that the
actual food purchases cost 30% less than the ideal one, and will feed the family for almost
10 days more. As in industrialized countries, one problem is that unhealthy foods are often
cheaper than healthy ones; moreover, the food industry tailors its products to this demand,
reinforcing inadequate nutritional habits. The result is the phenomenon of the “gordo
pobre”, or the “fat poor”, a situation which is common in high-income countries as well.
In Latin America, however, the situation is somewhat more complex. Indeed, LA countries
have seen the rise of “gordos ricos”, or “fat rich people”, along the “gordos pobres”.
In fact, as reported by the Instituto Colombiano de Bienestar Familial, even when money is
available to buy healthy foods, people are not inclined to do so because they lack proper
nutrition education. 90% of the Colombian population consumes rice daily, regardless of
their income level. A study of the University of Antioquia, a Colombian region, estimates
that the five foods composing the diet of more than 30% of the region households are rice,
bread, oil, kidney beans and potato. The first vegetable that appears on the list of
consumed foods is tomato, at the 9th place, and the first fruit is lemon, at the 15th place.
In Bogota, the picture looks similar: the data of the Plan Maestro de Abastecimiento de
Alimentos show that, while residents of the city eat a daily average of 325 grams of cereals
and potatoes, they only consume 43 grams of vegetable and 47 grams of fruits. To
8
Latin America’s urbanization is boosting obesity, B. Fraser, 2005
compare, WHO recommends 5 servings of fruits and vegetables each day, which should
amount to about 400g.
In Colombia, carbohydrates account for 65% of the total caloric value consumed each day,
while fats and saturated fats account for 35% and 10% respectively of the daily total caloric
value9. As a point of comparison, the WHO recommendation for daily fat intake is that it
should be maintained at less than 30% of total food consumption. Adding to the issue of
“gordos ricos” is the fact that obesity can be perceived as a symbol of wealth and status in
many LA countries.
According to the Encuesta Nacional de la Situacion Nutricional en Colombia en 2005,
63% of Colombian children between 6 and 23 months never eat fruits that contain Vitamin
A, and 60% never eat vegetables that contain the vitamin. Vitamin A plays an important
role in the formation and maintenance of healthy skin, hair, and mucous membranes. It is
necessary for proper bone growth, tooth development, and reproduction. It also helps
regulate the immune system. In addition, 36% of the total population never consumes
fruits, and 28% never consumes vegetables. Among children between 9 and 13 years old,
34% do not eat fruits and 31% do not eat vegetables. Unbalanced diets are not reserved for
the poor, but rather concern the whole population, with expected consequences on
overweight and obesity levels.
b) Physical activity
Alongside unhealthy dietary habits, the lack of physical activity is also a contributing factor
to overweight and obesity in LA countries. The move from rural to urban areas has meant
less opportunity to exercise and a reduction in outdoor activity, particularly among
children. 32% of 5 to 8 years old spend 2 to 3 hours daily watching TV. 18.9% of the
same age group spends 4 or more hours in front of the TV each day. Between 9 and 12
year olds, this rate increases to 36% spending 2 to 3 hours daily in front of the TV, while
24.7% watch it 4 hours or more each day10. Citizens of Bogota are sedentary 75% of their
spare time. This trend, which is similar throughout most LA countries, has certainly
contributed to the rise of obesity in the region, especially when coupled with unhealthy
food choices.
c) Mothers to children
As we have mentioned above, this increase in obesity levels affect women more than men.
Indeed, they tend to sacrifice their health for that of their family, surviving on unhealthy
foods while trying to feed their families with better ones. This leads to higher rates of
obesity in women which, in turn, has unexpected repercussions on their children.
It is not uncommon in LA countries to find obese or overweight mothers with
malnourished children. Though obese, these mothers are often anemic and poorly
nourished from a diet lacking iron and essential micronutrients.
9
Encuesta Nacional de la Situacion Nutricional en Colombia en 2005
Encuesta Nacional de la Situacion Nutricional en Colombia en 2005
10
As a result, their children are often born underweight, and because they eat inadequate
foods as they grow, they remain underweight throughout childhood. Paradoxically, this
may increase their risk of obesity later in life11.
The process responsible for this is thought to be “thrifty metabolism”, a hypothesis which
postulates that certain genes evolve to maximize metabolic efficiency and food searching
behavior. This means that individuals with a history of under nutrition are predisposed to
diseases caused by excess nutritional intake, such as obesity, when they attain a situation of
relative food abundance, as their metabolism has altered towards energy conservation.
Although this is only a hypothesis that still calls for more research, it might explain why, as
obese mothers give birth to underweight children, these are more likely to encounter excess
weight problems as they become adults.
4.
Consequences of obesity for LA countries and Colombia
The first immediate consequences for adults suffering from overweight and obesity is being
at a higher risk of cardiovascular diseases. Indeed, combined with other existing risk
factors in LA countries, such as smoking, hypertension or diabetes, a high prevalence of
obesity translates into an increase in cardiovascular diseases. This is what seems to be
happening in the region currently, as 31 of the 35 countries belonging to the LA region now
report cardiovascular diseases as the leading cause of death12. In Colombia, which today
ranks third behind Brazil and Mexico on obesity levels among the population, CVD is the
number one killer.
For children, obesity is often less of an immediate health concern, except for cases of
morbid obesity (BMI of 40 or more). This does not mean, however, that obesity has no
impact on children: rather, the consequences are often psychological, such as low self
esteem, poor peer acceptance, low participation in social and sports activities, as a study of
the International Journal of Obesity shows13. Equally worrying is the concern that
childhood obesity continues into adulthood, as many studies suggest that the influence of
childhood obesity on adult status rises as children age.
5.
Where are we today?
Most of the literature used to prepare this report underlines the lack of recent and global
studies on the issue of obesity in LA countries. The main problem seems to be that studies
covering a whole country are quite rare, although investigations by regions do exist, as is
the case for Colombia.
The lack of comprehensive studies often means that we can only get a fragmented picture
of what the situation really is in this part of the world.
Latin America’s urbanization is boosting obesity, B. Fraser, 2005
Estudio de Factores de Riesgo Coronario en Colombia)
13
Overweight and obesity in preschool children from developing countries, R. Martorell, L. Khan, 2000
11
12
Moreover, the fact that wide variations exist within the same country, with obese adults
living with malnourished children within the same households in some cases, means that it
is hard to design coherent national public health policies.
As far as public action is concerned, the literature also notes wide disparities in this area,
with some countries having not yet acknowledged the depth of their problem, while others
are getting active in promoting healthier lifestyles.
This is the case of Colombia, where the city of Bogota has become very dynamic with
regards to physical activity, notably via the set up of a large network of bicycle roads 14. In
any case, it seems that public health policies and various projects aiming at slowing down
the obesity epidemics in Latin America will need to work on their key targets: women and
children.
Glossary of terms
BMI: Body Mass Index (BMI) is a relationship between weight and height that is
associated with body fat and health risk. The equation is BMI = body weight in
kilograms/height in meters squared. Research has identified the health risks associated
with a wide range of BMIs (both high and low values). Normal weight is within the BMI
range of 18 to 25. A BMI of over 25 is considered overweight, obesity is taken to start at a
BMI of 30 and morbid obesity at 40. A BMI of 18-20 is defined as mild starvation and
severe starvation begins when BMI falls below.
Overweight: The state between normal weight and obesity. Overweight is a BMI of
between 25 and 30.
Obesity: The state of being well above one's normal weight. A person has traditionally
been considered to be obese if they are more than 20 percent over their ideal weight. That
ideal weight must take into account the person's height, age, sex, and build. Obesity has
been more precisely as a BMI of 30 and above (a BMI of 30 is about 30 pounds
overweight).
14
Promoting active lifestyles and healthy urban spaces: the cultural and spatial transformation of Bogota, R.
Montezuma, PAHO