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 overnutrition replacing (or adding to) undernutrition?
• 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 Anthropometry
(under or over)
Diet and physical
activity evaluation
Energy-related
nutrient imbalances
(under or over)
Nonenergy-related
nutrient imbalances
(under or over)
Biochemical and
clinical tests
Diet evaluation
Anthropometry
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
GDP PER CAPITA (BRAZIL, 1994)
NORTH
US$ 2,299
NORTHEAST
US$ 1,635
CENTERWEST
US$ 3,650
SOUTH
US$ 3,983
SOUTHEAST
US$ 4,490
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
UNDER
20
OVER
19
%
12,9
10,4
10
8,5
5,9
5,9
4,6
4,8 5,2
5,3
4,2
2,7
0
young
child
old child
adult
NORTHEAST
young
child
old child
adult
SOUTHEAST
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
50
UNDER
47,1
OVER
40
%
29,9
30
22,7
19
20
10
8
2,9
1975
3,7
4,5
4,8 5,2
1,5
2,7
1989
1996
1975
1989
1996
0
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
15
10
UNDER
8,9
OVER
12,9
8,2
%
7,3
5,9
4,9
5,3
4,6
5
2,5
3,9
2,5
1
0
1975
1989
1997
NORTHEASTERN BRAZIL
1975
1989
1997
SOUTHEASTERN BRAZIL
Monteiro et al., Public Health Nutrition, Feb 2002
TRENDS IN THE RELATIVE BURDEN
OF UNDER- AND OVER-NUTRITION
Brazilian adults: 1975-1997
15
UNDER
OVER
12
10
10,4
9,9
9,8
8,5
%
7,4
5,1
5,9
5,4
5,1
4,2
5
2,7
0
1975
1989
1997
NORTHEASTERN BRAZIL
1975
1989
1997
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
80
lower income vs. upper income
young children
25% POOREST
25% RICHEST
60,8
60
%
42,4
39,9
40
28,8
26,2
17,3
20
8,6
7,2
6
2,4
2,4
3
1989
1997
0
1975
1989
1997
NORTHEASTERN BRAZIL
1975
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
12
25% POOREST
25% RICHEST
10,2
8,4
8,2
%
8
5,4
5,1
3,8
4
2,9
2,5
0,7
1,8
1,6
1997
1975
0,8
0
1975
1989
NORTHEASTERN BRAZIL
1989
1997
SOUTHEASTERN BRAZIL
Monteiro et al., Public Health Nutrition, Feb 2002
TRENDS IN OVER-NUTRITION GAPS
lower income vs. upper income
adult women
20
25% POOREST
25% RICHEST
14,5
15
14,4
14,1
%
11,2
9,8
10
6,7
5
8,9
7,9
7,7
6,1
5,2
3,1
0
1975
1989
1997
NORTHEASTERN BRAZIL
1975
1989
1997
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
80
25% POOREST
25% RICHEST
63,2
60
%
43,6
42,8
40
30,1
29,5
20
11,4
9,3
1989
1997
12,8
19,4
13,7
1975
1989
11,211,6
0
1975
NORTHEASTERN BRAZIL
1997
SOUTHEASTERN BRAZIL
Monteiro et al., Public Health Nutrition, Feb 2002
TRENDS IN UNDER- + OVER-NUTRITION
lower income vs. upper income
adult women
30
25% POOREST
25% RICHEST
23
20,7
16,4
%
20
20,1
19,1
15,9
20
17,6
17,3
18,7
14,7
12
10
0
1975
1989
1997
NORTHEASTERN BRAZIL
1975
1989
1997
SOUTHEASTERN BRAZIL
Monteiro et al., Public Health Nutrition, Feb 2002
BMI DISTRIBUTION
lower income vs. upper income
southeastern adult women, 1997
Lower income
Higher income
0,5
0,4
0,3
0,2
0,1
0
-3,5
-2,5
-1,5
-0,5
0,5
1,5
2,5
3,5
BMI Z-SCORE
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 INCOME
Brazil metropolitan households, 1996
25% POOREST
%
30
24,1 25,4
27,6
25%
25%
25% RICHEST
29,9
20
10
7,5
7,7
9,1
10,4
0
ENERGY FROM
TOTAL FAT
ENERGY FROM
SATURATED FAT
Monteiro et al., Public Health Nutrition, Feb 2002
DIETARY PATTERNS BY INCOME
Brazil metropolitan households, 1996
25% POOREST
15
25%
25%
25% RICHEST
13,9 14,3
12,7
9,8
%
10
5,2
5
2,3
2,4
3,5
0
ENERGY FROM SUGAR
ENERGY FROM FRUITS
AND VEGETABLES
Monteiro et al., Public Health Nutrition, Feb 2002
ANY LEISURE-TIME PHYSICAL
ACTIVITY BY INCOME, BRAZIL, 1997
25% POOREST
25%
25%
25% RICHEST
40
31,5
30
%
21,5
18
20
12,7
10
8,3
6,5
7,2
1,3
0
MEN
WOMEN
Monteiro et al., Public Health Nutrition, Feb 2002
SMOKERS BY INCOME
BRAZIL, 1989
25% POOREST
60
52,9
25%
25%
25% RICHEST
49,4
44,1
38,6
40
33,8
%
28,8 27,1
24,4
20
0
MEN
WOMEN
Monteiro et al., Public Health Nutrition, Feb 2002
PREVALENCE OF OBESITY IN WOMEN
BY SOCIOECONOMIC STATUS
LOW
MIDDLE
HIGH
% BMI > 30 kg/m2
60
43,4
36,8
40
29,3
25,8
21,1
20
14,1
0
Chile 1988
Curaçao 1994
Sources: Berrios 1990; Grol 1997.
Monteiro et al., Public Health Nutrition, Feb 2002
PREVALENCE OF OBESITY IN WOMEN
BY SCHOOLING LEVEL (1987-1996)
LOW
HIGH
% BMI > 30 kg/m2
20
15,8
15
13,8
13,1
10,4
9,5
10
7,1
10
8,2
5,4
5
1,5
0
Haiti
Guatemala
Peru
Rep. Dom.
Mexico
Source: Martorell et al. 2000
Monteiro et al., Public Health Nutrition, Feb 2002