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The Journal of Nutrition Vol. 128 No. 9 September 1998,
pp. 1464-1473
Department of International Health, The Rollins School of Public Health of Emory University, Atlanta, Georgia 30322 and * Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, Georgia 30341
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ABSTRACT |
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Abstract
Introduction
Methods
Results
Discussion
References
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National surveys conducted since 1982 were used to assess maternal and child obesity in Latin American and Caribbean countries and in U.S. residents of Mexican descent. Obesity in women, a body mass index (BMI) 
30 kg/m2, was 3% in Haiti, 8-10% in eight Latin American countries and 29% in Mexican Americans. Median BMI for Latin American women were near or above the 50th percentile of the general U.S. population; values exceeded the 75th percentile in the case of Mexican Americans. The prevalence of overweight (>1 SD above mean weight-for-height) in children 1-5 y of age ranged from 6% in Haiti to 24% in Peru among 13 countries. Overweight occurred in 24% of Mexican-American children. Prevalences of overweight in children and of obesity in women were greater in urban areas and in households of higher socioeconomic status. Overweight in children increased with higher maternal education; however, in some countries, obesity in women decreased with higher education. No general pattern of change over time was observed in eight countries in overweight in children. Obesity in women increased in the three countries with such data and in Mexican-American women and children. There was a tendency for greater national incomes to be associated with greater obesity levels in women and with lower levels of stunting in children. Levels of obesity in the region indicate a public health concern, particularly among women, considering that studies have identified mortality and morbidity risks associated with obesity in adults.
Undernutrition remains the nutrition problem of greatest concern in developing countries. However, there is increased recognition, particularly in Latin America, that dietary patterns and lifestyles are changing dramatically, and that as a result, chronic and degenerative diseases are becoming important public health concerns (Monteiro et al. 1995 Popkin (1994) Obesity is increasingly recognized as a growing problem in Latin America. Using national survey data from Brazil, researchers have shown that obesity increased between 1974 and 1989 in adults (Monteiro et al. 1995 Results from studies of selected samples complement those from national surveys. In Costa Rica, 14% of men in a rural area exceeded 130% of reference weight for height (i.e., a BMI of ~30 kg/m2) compared with 21% in an urban area; in women, the corresponding values were 33 and 39% (Campos et al. 1992 The above results suggest that obesity is a problem in Latin America, particularly in women. However, varying definitions of obesity and different age ranges of the subjects studied make cross-country comparisons difficult. Also, estimates of obesity have been reported for only a few of the many national nutrition surveys that have been carried out in the region. This omission reflects the fact that most surveys have been used to provide information about undernutrition in women and children. The scarcity of information on men and school age children also reflects the focus of most nutrition surveys on women and young children.
It is important for policy makers to have accurate information not only about the level of obesity at the country level, but about how values vary across subgroups of the population as defined on the basis of region, urban/rural residence, levels of education and socioeconomic status. Also useful to policy makers is information about changes in the extent of obesity over time.
The primary objective of this study is to estimate prevalences of obesity in women and children from Latin American countries based on national survey data collected since 1982. Uniform definitions of overweight and obesity are used to facilitate comparison across countries. A second objective is to investigate how obesity varies by area of residence, socioeconomic level and education. A third objective is to estimate trends in obesity.
National nutrition surveys from Latin America and the Caribbean collected since 1982 were the focus of study. These surveys typically contain height and weight information for children <5 y of age, sometimes for women of reproductive age (15-49 y) and almost never for men. Most surveys used were collected by the Demographic and Health Surveys (DHS/IRD, 1992) program, which has assisted countries since 1984 in conducting national surveys on fertility, family planning, and maternal and child health (Institute for Resource Development/MACRO International 1990). In these surveys, women of childbearing age were interviewed or measured with the use of standard survey instruments; the areas of data collection were family planning knowledge, attitudes and practices; maternal and child health; nutritional status of women and their children; and social and economic background indicators (Institute for Resource Development/MACRO International 1990). DHS surveys are available to investigators through the World Wide Web [http://www.macroint.com/dhs/rsqb;.
Obesity among women.
Sample sizes, age and anthropometric characteristics of the women are given in Table 2. Mean ages were very similar across surveys, but body sizes varied markedly. Women from Guatemala, Peru and Bolivia were very short in comparison to women from Haiti and the U.S. Mean BMI were between 23 and 25 kg/m2 for all but Mexican Americans who were the heaviest at 27.1 kg/m2 and Haitian women who were the leanest at 21.2 kg/m2. Similarly, the extent of obesity (
Overweight and obesity in children.
Sample sizes, age, and anthropometric characteristics are given for children in Table 5. Stunting was pronounced in several countries, whereas wasting was less common. The country with the greatest proportion of stunted children was Guatemala (56%); the highest proportion of wasted children was observed in Haiti (8%). The percentage of overweight children (Z score > 1 for weight-for-height) or obese (Z score > 2) was highest in Mexican Americans and lowest in Honduras and Haiti. The samples with higher rates of obesity than the 2.3% value found in the reference population were the U.S. Mexican Americans (7.4%), Peru (4.7%), the Dominican Republic (4.6%), Brazil (4.1%), Mexico (3.9%) and Paraguay (2.7%).
Trends in obesity and overweight.
Repeated surveys for women were available for only four samples. Prevalences of obesity (BMI
Relationship with stunting and national incomes.
At the national level, there was a significant relationship between the level of overweight in children and per capita GNP (r = 0.53, P = 0.05, n = 14); however, excluding the data point for Mexican Americans (identified as U.S. in the figures), an outlier in terms of income, reduced the correlation to 0.11 (P = 0.72, n = 13; Fig. 3). The relationship between percentage of children stunted and GNP was negative and significant (r =
Women of reproductive age.
The definition of obesity emphasized in this report, a BMI Children.
Measuring obesity or overweight in children is difficult because body proportions, bone mass, and the ratio of lean-to-fat tissue changes during growth and maturation (Troiano and Flegal 1998 Obesity and social factors.
In their review of the world literature on the relationship between obesity and SES, Sobol and Stunkard (1989) found that the prevalence of obesity in adults and children increased with rising wealth in developing societies. In developed societies, in contrast, prevalence is lower with greater income, at least among women. Thus, developing countries in transition to greater wealth should be found along a continuum that begins with a positive relationship between obesity and SES in the poorest countries, to no relationship in those with middle incomes, to a negative relationship in those with the greatest wealth. The pattern of relationships between income and obesity described by Monteiro et al. (1995) Relationships with stunting and GNP.
The analyses at country level were limited by low statistical power such that most relationships examined were not significant, particularly after excluding the data for the U.S. In general, the results suggest that greater national incomes are associated with greater obesity levels in women and lower levels of stunting in children. Also, there was a tendency for greater levels of stunting in children to be associated with less obesity in women and in children. These results are consistent with our initial expectation that increased national wealth would be associated with less undernutrition and greater obesity.
INTRODUCTION
Abstract
Introduction
Methods
Results
Discussion
References
, Popkin 1994, Sinha 1995, Walker 1995). These changes are occurring at a time when undernutrition levels, although reduced over the years, still afflict large sectors of the population (Administrative Committee on Coordination/Sub-Committee on Nutrition 1992 and 1997).
notes that authors have emphasized the demographic (i.e., from high fertility and high childhood mortality to low fertility and low childhood mortality) and epidemiologic (i.e., shift in causes of mortality from infections to chronic diseases) changes occurring in many developing countries while neglecting what he calls the concurrent "nutrition transition." The latter includes adoption of "Western" diets (i.e., high in saturated fats, sugar and refined foods) and increases in levels of fatness and obesity. In addition to diet, reduced levels of physical activity, increased use of alcohol and tobacco and increased stress, particularly in the rapidly growing cities of developing countries, are among the determinants of obesity and other chronic and degenerative diseases.
, Sichieri et al. 1994) but not in children (Monteiro et al. 1995). Defining obesity as a body mass index (BMI)5 30 kg/m2, prevalences increased from 2.5 to 4.8% in men and from 6.9 to 11.7% in women (Sichieri et al. 1994). Obesity increased with family income in children (Monteiro et al. 1995) and adults (Monteiro et al. 1995, Sichieri et al. 1994). However, the relationship between adult obesity and income was nonlinear; at low and middle income levels, obesity increased with income but at high levels the pattern was reversed, just as in developed countries (Monteiro et al. 1995). Results from the 1988 National Nutrition Survey of Mexico suggest that obesity in women was as common in Mexico as in the United States in the 1970s (Hernandez et al. 1996). Approximately 17% of Mexican women aged 12-49 y exceeded the 85th percentile, or a BMI of ~27 kg/m2, of the distribution found in women measured in the 1976-80 Second National Health and Nutrition Examination Survey (NHANES). The Ministry of Public Health of Costa Rica reported increases at the national level in the prevalence of obesity (25 BMI) between 1982 and 1996 of 34.6-45.9% (Ministerio de Salud 1997). National surveys in different Caribbean countries found that 7-20% of males and 22-48% of females >15 y of age exceeded 120% of reference weight for height, or a BMI of ~27 kg/m2 (Sinha 1995). In addition, serial data from Barbados showed increases in the prevalence of obesity from 7 to 16% in males and 33 to 38% in females between 1969 and 1981 (Sinha 1995).
). In Santiago, Chile, the prevalence of obesity, defined as >120% of reference weight for height, was 20% in men and 30% in women (Atalah 1993). Although socioeconomic status (SES) was unrelated to obesity in men, it was related negatively in women such that levels were ~10% for high SES and 40% for low SES. There was also an interaction with stature; the highest prevalence of obesity was found among low SES women of short stature, nearly 50% (Atalah 1993). In a study of school children from Santiago, the prevalence of obesity, defined as >120% of reference weight for height, was 8.9% and increased as a function of income (Ivanovic et al. 1987). In an urban community from Trinidad, Beckles et al. (1985) found that obesity, defined as a BMI 30, was greater in women than in men and greatest among those of African descent. Obesity was present in 8, 7 and 4% in men of African, mixed and Indian ancestry, respectively; in women, the values were 32, 29 and 25%, respectively.
METHODS
Abstract
Introduction
Methods
Results
Discussion
References
View this table:
Table 1.
National nutrition and health surveys included in this study1
) using the Anthropometric Software Package Tutorial Guide and Handbook (Jordan 1990). Records with height-for-age, weight-for-age, or weight-for-height Z-scores > +5 or < 
5 were excluded from the analyses. Populations <5000 were designated as "rural" and those above as "urban" in the DHS datasets; similar criteria were applied to non-DHS datasets. Maternal education was coded as low (primary school or less) and high (at least 1 y of secondary schooling). An index of socioeconomic status (SES) was calculated for individual families in each dataset based on amenities (e.g., electricity or water), possessions (e.g., radio, television or bicycle) and characteristics of the home (e.g., type of floor or roof). The calculation was particular to each country and thus, the socioeconomic index is not valid across countries; rather, it reflects relative socioeconomic status within each country. The poverty index in the datasets from the United States was generated by NCHS and is a continuous variable based on income, estimates of living costs appropriate for the area of residence and date of measurement, and family composition. A poverty index (PI) 1.0 implies that the family should be able to meet its basic needs; a PI <1 was used as the definition of low SES.
30 kg/m2. Also, estimates were provided using the definition of 27.3 kg/m2 to facilitate comparison with the literature and for grades 1, 2 and 3 of obesity as defined by WHO (1990 and 1995) (1 = 25.0-29.9, 2 = 30.0-39.9 and 3 = 40 kg/m2).
30 BMI) in women but on overweight (>1 SD) in children because the prevalence of obesity (>2 SD) in children was low and statistical power consequently poor. Odds ratios for overweight or obesity (0 = No, 1 = Yes) were estimated in multivariate logistic regressions that included area of residence (0 = rural, 1 = urban), SES (0 = low, 1 = medium or high) and education (0 = none or primary, 1 = secondary or higher) as independent variables. In analyses of overweight in children, gender (0 = male, 1 = female) and age in months were included as additional covariates. In analyses of obesity in women, age and age squared were included in the models because these provided a better fit than age alone. Multivariate analyses were restricted to the most recent national survey when countries had more than one survey. Statistical significance was defined as P < 0.05.
RESULTS
Abstract
Introduction
Methods
Results
Discussion
References
30 BMI) was lowest for Haitian (2.6%) and greatest for Mexican-American women (28.7%). The range in the prevalence of obesity was 5-40% when a BMI 27.3 kg/m2 was used as the criterion for obesity. Defining obesity as a BMI 25 kg/m2, as in the WHO classification, led to large numbers of women being classified as obese, specifically, over one third of Latin American women and more than one half of Mexican-American women.
View this table:
Table 2.
Age and anthropometric characteristics of Latin American and Caribbean women 15-49 y old
, which is based on data from the first (1971-1973) and second (1976-1980) National Health and Nutrition Examination Surveys (NHANES). Medians for all countries, with the exception of Haiti, were near or above the 50th percentile of the U.S. distribution. Mexican American women had medians that were closer to the 75th percentile, whereas medians for Haitian women were closer to the 25th percentile.
View larger version (23K):
[in a new window]
Fig 1.
Median body mass index of women 15-49 y old relative to the 25th, 50th and 75th percentiles (dashed lines) of the distribution in the first and second National Health and Nutrition Examination Surveys (Frisancho 1990 ). The sample for the United States includes data for Mexican-American children only.
30) women is given in Table 3 by area of residence, SES, and educational level. The risk of obesity (BMI 30) by category of the social variables is given in Table 4. Results from unadjusted models (see Table 4, footnote 1) indicate that obesity was 1.5-4 times more common in urban areas except in Brazil, Colombia, Mexico and the U.S. where obesity rates were similar in urban and rural areas. High SES and obesity covaried in all samples except among Mexican and Mexican-American women where SES bore no relationship to obesity. Better education was associated with greater obesity in Haiti, Guatemala and Peru, some of the poorest countries, but there was no relationship in Bolivia, Colombia, the Dominican Republic, Honduras and in Mexican Americans; in Brazil and Mexico, there was more obesity in poorly educated women. Multivariate models attenuated the associations, particularly for education. Controlling for area of residence and SES, there was a tendency for higher prevalences of obesity in poorly educated women except in Haiti and Guatemala where more education was associated with increased obesity. Urban residency and high SES were strongly and independently related to greater levels of obesity in most countries. Only in Mexican Americans were all three social variables unrelated to obesity levels.
View this table:
Table 3.
Percentage of obese [body mass index (BMI) 30] women from Latin America and the Caribbean and denominator by area of residence, socioeconomic status (SES) and educational level1
View this table:
Table 4.
Odds ratios for obesity [body mass index 30] (BMI); 0 = nonobese, 1 = obese] among women from Latin America and the Caribbean as a function of area of residence, socioeconomic status (SES) and educational level
View this table:
Table 5.
Age and anthropometric characteristics of Latin American children
View this table:
Table 6.
Percentage of overweight (>1 SD) children from Latin America and the Caribbean and denominator by area of residence, socioeconomic status (SES), maternal education and gender1
View this table:
Table 7.
Odds ratios for overweight (>1 SD; 0 = nonoverweight, 1 = overweight) among children from Latin America and the Caribbean as a function of area of residence, socioeconomic status (SES) and maternal education
30) increased in all. In Brazil, values increased from 7.6 to 9.2% between 1989 and 1996; small increases were also observed in Peru between 1992 and 1996, 8.8-9.4%. Greater increases occurred between 1991 and 1996 in the Dominican Republic, 7.3-12.1%. Among Mexican Americans, the increase in obesity from 1982-1984 to 1988-1994 was large, from 19.5 to 28.7%. More information is available from repeated surveys for children. The percentage of overweight is plotted in Figure 2 for countries with data for more than one survey. Overweight increased in Mexican Americans, but the pattern was mixed for Latin American countries; some reported increases and other decreases.
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[in a new window]
Fig 2.
Trends in overweight (weight-for-height Z-score > 1.00) among children (>12 mo). The sample for the United States includes data for Mexican-American children only.
0.53, P = 0.05, n = 14), even after excluding Mexican Americans (r = 0.61, P = 0.03, n = 13). The relationship between the percentage of children stunted and the percentage of children overweight was negative but not significant (r = 0.45, P = 0.11, n = 14); excluding Mexican Americans gave similar results (r = 0.29, P = 0.34, n = 13).
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[in a new window]
Fig 3.
Relationship between overweight (weight-for-height Z-score > 1.00) among young Latin American children and gross national product (GNP) per capita. When the United States (Mexican-American data only) is included in the analysis, r = 0.53, P = 0.05.
0.66, P = 0.04, n = 10); the correlation coefficient was of similar magnitude but not significant after excluding Mexican Americans (r = 0.55, P = 0.12, n = 9).
View larger version (16K):
[in a new window]
Fig 4.
Relationship between obesity (BMI 30) among Latin American women of reproductive age (15-49 y) and gross national product (GNP) per capita. When the United States (Mexican-American data only) is excluded from the analysis, r = 0.95, P = 0.0001.
DISCUSSION
Abstract
Introduction
Methods
Results
Discussion
References
30 kg/m2, is extreme. Yet we find that with the exception of Haiti, where only 3% of women were obese, the prevalence of obesity was between 8 and 10% in eight other Latin American countries that we studied. Some define obesity as a body mass index 27.3 kg/m2 in women and 27.8 kg/m2 in men, equivalent to ~120% of desirable weight according to 1983 Metropolitan Life Insurance Company height and weight tables (Kuczmarski et al. 1994, Solomon and Manson 1997). If we use the criterion of obesity in women of a BMI 27.3 and exclude Haiti, between 17 and 23% of women were obese in Latin America. Using the WHO criteria, which considers grade 1 of obesity to begin at a BMI of 25 kg/m2, prevalences of obesity (total of grades 1, 2 and 3) in Latin American countries other than Haiti were 34-49%.
). Authors of a review of studies that adjusted for effects of smoking and underlying disease concluded that optimal weights in terms of mortality are well below the commonly used cut-off points of a BMI 27.3 kg/m2 for women and 27.8 kg/m2 for men (Solomon and Manson 1997). Using American Cancer Society data, analyses show that mortality for both men and women begins to rise among individuals with a BMI of 22-25 kg/m2 (Stevens et al. 1998). Thus, the criteria of a BMI 30 and a BMI 27.3 identify only the extreme groups at risk.
). We found that nearly 29% of Mexican-American women were obese (BMI 30) in the 1988-1994 survey, and that this represented an increase over the prevalence of 20% found in the 1982-1984 survey. Mexican Americans receive special emphasis in U.S. surveys because they are the largest Hispanic minority. Cuban Americans and Puerto Ricans living in the U.S. were also included in the Hispanic Health and Nutrition Examination Survey of 1982-1984. Obesity was found to be high and similar in all three groups (Pawson et al. 1991). Centralized obesity, usually identified through high waist-to-hip ratios or through measures of greater fat deposition in the trunk vs. the extremities, was greater in Mexican Americans than among non-Hispanic whites (Kaplowitz et al. 1989). Central accumulation of fat has been found to be adversely related to morbidity and mortality outcomes (Solomon and Manson 1994). The Latin American surveys analyzed did not contain measures of relative fat deposition, and this remains an issue for further research.
) also indicate increasing levels of obesity among women. Additional surveys are required to examine whether obesity levels are also rising in men and in other countries. The high prevalences found in Mexican Americans, furthest along in the nutrition transition, suggest that a high priority should be assigned to monitoring obesity levels in Latin America.
). Although BMI correlates well with measures of adiposity, it is not as reliable a measure of fatness in children as it is in adults (Troiano and Flegal 1998). Racial and ethnic variation in these dimensions, for example, body proportions, may also affect the interpretation of weight-for-height indices (Martorell et al. 1987, WHO 1995).
, Serdula et al. 1993, Whitaker et al. 1997). In a literature review, Serdula et al. (1993) found that the risk of adult obesity was 2.0-2.6 times greater in obese preschool children than in nonobese preschool children. Among school-age children later examined as adults, the corresponding range in risk ratios was 3.9-6.5.
found that young adult obesity was associated with child obesity (defined as >85 percentile) at 3-5 y of age but not at 1-2 y of age. However, these relationships were considerably stronger in older children. Also, the risk of adult obesity was increased when the mother or father of the obese child was also obese.
). Correlations between BMI measured at 12-42 mo of age and later during adolescence (7-14 y) or adulthood (18-26 y) were ~0.3. At ~5 y of age, the correlations between childhood and adolescent or adult BMI were ~0.4-0.5.
). Despite the availability of serial data for several countries, we could not discern a clear pattern of change in overweight in Latin American children. Finally, we call attention to the need for information from national surveys on school-age children, a group not generally included, in whom overweight and obesity would be a clearer concern than among preschool children.
for different income levels of the Brazilian population fits this expected pattern (see introduction).
30) among women were between 8 and 10% in all countries except Haiti. These statistics suggest an already existing public health concern. Although the prevalences of overweight and obesity in children approached or exceeded that in the U.S. reference population (Dibley et al. 1987) in a few countries, most countries had low values. Because uncertainty remains about the significance of overweight in children <5 y of age, it is unclear what level of concern to express about the results reported here.
). Achieving behavior change that leads to reduced obesity has proven difficult in the United States and elsewhere; even when success occurs, programmatic lessons must be made applicable to each Latin American country. These are difficult issues that warrant urgent discussion among researchers, public health practitioners and policy makers.
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FOOTNOTES |
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Manuscript received 4 February 1998. Initial reviews completed 13 March 1998. Revision accepted 5 June 1998.
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ACKNOWLEDGMENTS |
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Helpful comments are acknowledged from Wilma Freire and Manuel Peña of PAHO and from Kenneth Resnicow, Richard Levinson and Dirk Schroeder of Emory University.
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LITERATURE CITED |
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Abstract
Introduction
Methods
Results
Discussion
References
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