Nutritional status of the adult population in Niterói, Rio de Janeiro, Brazil: the Nutrition, Physical Activity, and Health Survey - PDF

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ARTIGO ARTICLE 1867 Nutritional status of the adult population in Niterói, Rio de Janeiro, Brazil: the Nutrition, Physical Activity, and Health Survey Estado nutricional da população adulta de Niterói,

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ARTIGO ARTICLE 1867 Nutritional status of the adult population in Niterói, Rio de Janeiro, Brazil: the Nutrition, Physical Activity, and Health Survey Estado nutricional da população adulta de Niterói, Rio de Janeiro, Brasil: resultados da Pesquisa de Nutrição, Atividade Física e Saúde Francine Moreira Bossan 1 Luiz Antonio dos Anjos 1,2 Mauricio Teixeira Leite de Vasconcellos 3 Vivian Wahrlich 1 Abstract Introduction 1 Departamento de Nutrição Social, Universidade Federal Fluminense, Niterói, Brasil. 2 Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. 3 Escola Nacional de Ciências Estatísticas, Fundação Instituto Brasileiro de Geografia e Estatística, Rio de Janeiro, Brasil. Correspondence L. A. Anjos Laboratório de Avaliação Nutricional e Funcional, Departamento de Nutrição Social, Universidade Federal Fluminense. C. P , Rio de Janeiro, RJ , Brasil. A household survey was conducted to assess the nutritional status of the adult population in Niterói, Rio de Janeiro, Brazil. In the selected households, all adults ( 20 years) had their body mass and stature measured. Body mass index (BMI) was used to determine the nutritional status according to the World Health Organization classification. The population estimates showed low prevalence of underweight (BMI 18.5kg/m2), while 45.8% of women and 49.6% of men were overweight/obese (BMI 25kg/m2). Obesity prevalence varied from 5.6% to 19.3% in men and from 9.6% to 21.3% in women, according to age. The prevalence of overweight/obesity was not associated with income (in either men and women) or schooling (in men), but there was an inverse relationship between schooling and overweight/obesity in women. The prevalence of underweight decreased with increasing mean income in the census enumeration area. The authors conclude that overweight/obesity is the most prevalent nutritional disorder in both men and women in Niterói. This pattern resembles recent results for the adult population in Southeast Brazil as a whole, where Niterói is located. Nutritional Status; Anthropometry; Adult; Population Studies in Public Health; Nutrition Surveys Excess body mass (pre-obesity and obesity) is now one of the most serious public health problems in various countries, especially the developed ones, where obesity prevalence varies from 10% to 50% of the adult population 1. Obesity is a risk factor for several chronic diseases such as systemic arterial hypertension, type 2 diabetes, and dyslipidemias, among others, the treatment of which greatly increases health sector expenditures 1. Increased obesity prevalence in various countries has mainly accompanied socioeconomic development, population growth, internal migration, technological development, and cultural changes leading to a significant increase in energy intake associated with a possible decrease in physical activity level by the population 2. Thus, the decreased prevalence of underweight and increased obesity prevalence in these countries has been referred to as nutrition transition, now characterizing not only the developed countries, but also many societies that view themselves as mirroring the development of the Northern Hemispheric countries, particularly the United States culture 3. The Brazilian Institute of Geography and Statistics (Fundação Instituto Brasileiro de Geografia e Estatística IBGE), conducted four major nationwide surveys on the population s nutritional profile. These surveys allowed monitoring the nutritional status of Brazilians from 1974 to 1868 Bossan FM et al. 2003, in addition to revealing the principal aspects leading to the modification of the population s nutritional profile over time. At the beginning of the study period the population showed a high prevalence of undernutrition, especially among children in the Northeast region. However, over the years, the prevalence of undernutrition decreased, while there was a progressive increase in the prevalence of excess body mass, especially among men in the Southeast and also in the poorest areas of the country, thus characterizing a nutrition transition in the national population 4. In 15 years ( ), the prevalence of underweight in children decreased by 60% and the low prevalence of obesity remained stable in this same age bracket. During this same period, underweight in adults also decreased, while obesity prevalence nearly doubled. For the population of the Northeast and Southeast of Brazil, from 1989 to 1997 there was an increase in obesity prevalence that was greatest among the poor population, particularly women 5. More recent data show that from 1989 to 2003 the prevalence of excess body mass (pre-obesity and obesity) stabilized among women. Among men, the prevalence of both pre-obesity and obesity continued to increase, especially in the South, Southeast, and Central West of the country in all age brackets and all income fifths 6. Despite the lack of historical data, the nutrition transition in the Brazilian population has been explained by changes in the dietary model, which has become rich in fat, processed foods, and sugar, with low fiber intake, in addition to a possible association with decreased physical activity 6. Knowing that obesity is due to an imbalance between food intake and energy expenditure, resulting in positive energy balance, knowledge of individual daily physical activity and food intake is important to prevent and control obesity 5. Meanwhile, despite the high prevalence of excess body mass in the Brazilian population, undernutrition is still observed (although at low rates), especially among women and children in the poorest areas 7. Both excess body fat and lack of fat pose risks to individual health, so that knowing the population s nutritional status is important not only to characterize it but also to plan the prevention and treatment of nutritional disorders and detect the diseases associated with them. The current study aimed to evaluate anthropometric nutritional status and analyze it according to gender, age, and census enumeration area (CEA) mean income in the adult population in Niterói, Rio de Janeiro, Brazil, to determine this population s nutritional profile and compare it to data for Brazil as a whole and particularly the Southeast Region of the country, based on data from the Nutrition, Physical Activity, and Health Survey (PNAFS). Material and methods The PNAFS was a household survey conducted from January to December 2003, based on a three-stage probabilistic sample of households and adults ( 20 years). In the first stage, 110 CEAs in Niterói were systematically selected, with probability proportional to the number of permanent private households observed in the 2000 Population Census 8. Prior to selection, the CEAs were ordered from lowest to highest according to the head-of-household s mean nominal monthly income, thus implicitly stratifying the CEA by mean income and ensuring the selection of CEA from all income levels. In the second stage, 16 households were selected in each CEA with equal probability, using an inverse sampling procedure analogous to that applied in the World Health Survey in Brazil 9, leading to a sample size of 1,760 households. The CEA listing from the 2000 Population Census 8 served as a frame for selection of households in the 110 CEA selected in the first stage, and the ordinal numbers for the households in the lists were selected to establish the order of the visits. The households were then visited in the order pre-established in the selection, the results of each visit were recorded in an appropriate data collection instrument, and the visits ended when the 16th interview had been obtained in the given CEA, obeying the eligibility criteria set for the PNAFS, which included agreement to answer the interview by an eligible resident adult ( 20 years), as described below. In the third stage, one adult was selected in each household interviewed, assigning equal probability to all the adult residents in that household. The present analysis used secondstage data from the sample selection, i.e., data obtained from the household interview. However, the third stage is mentioned here because the household had to have at least one eligible adult (healthy in the sense of not presenting any disease that might interfere in metabolism, not on a diet, and not on any medication that could alter the heart rate). Thus, the third stage represents a household selection bias, since households could only participate in the survey if they had at least one eligible (healthy) adult. While the household selection bias with healthy adults could not be corrected, the distribution bias by gender and age in Niterói s population, common in any household survey, could indeed be NUTRITIONAL STATUS OF AN URBAN ADULT POPULATION 1869 corrected by calibrating the sample weights. The sample weight was calculated as the product of inverse selection probabilities in each stage and was calibrated according to the technique known as the Integrated Household Weighting System, which ensures the consistency of the estimates for population totals available for post-strata, in this case comprised according to gender and age bracket 10. On the day of the interview, the head-of-household signed a free informed consent form and answered a standardized questionnaire prepared to collect both coded information on the survey area and household as well as individual and family data. All residents were survey targets vis-à-vis the head-of-household (for the family composition), gender, age, and education as expressed by the number of complete years of schooling, which was grouped in five levels (0; 4; 4-8; 8-12; 12). For each household adult, the survey obtained: body mass (kg), stature (cm), physiological condition (if pregnant or nursing), and basic demographic data. The Institutional Review Board of the Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, approved all the research procedures. In the household, body mass (accurate to 0.1kg) was measured once using a previously calibrated electronic scale (Soehnle, Murrhardt, Germany; Seca, Birmingham, UK). Individuals were weighed barefoot and with as little clothing as possible, usually in the morning. Stature was measured twice as per Lohman et al. 11, with a portable stadiometer (Seca) attached to a wall. Subjects were positioned against the wall barefoot, with their feet together, arms hanging at their sides, and head, heels, and buttocks leaning against the wall. Subjects were asked to fix their gaze on a horizontal plane (Frankfort line) and breathe in, then breathe out and hold their breath. The stadiometer ruler was slid up to the top of the subject s head and the reading was done at the same level. Various attempts were made to obtain data from all the household residents, returning to the household at different times and on different days whenever necessary. Data from pregnant or nursing women, individuals with missing limbs or limbs in casts, or who were wearing shoes at the time of the measurement were not computed in the current study s analysis. Based on the resulting body mass and stature measurements, we calculated the body mass index (BMI) by dividing body mass (kg) by stature squared (m2), with stature based on the mean of the two measurements, to determine nutritional status according to the classification proposed by the expert committee of the World Health Organization (WHO) in The nomenclature of this classification differs from that previously suggested by the WHO itself 12, since it classifies BMI from 25 to 30kg/m2 as pre-obesity. Under the new nomenclature, BMI 30kg/m2 is called obesity with three different levels. The current study refers to excess body mass as BMI 25kg/m2, thus including pre-obesity and obesity. The data analysis was descriptive (means, standard errors of the means SEM, minimum and maximum values, 95% confidence intervals 95%CI) for all the continuous variables. Prevalence of nutritional status according to gender, age, and income was based on the WHO classifications of BMI. All analyses used SAS (SAS Institute, Cary, USA) version 8.1 for PC. All the results in this study are estimates of means, SEM, and 95%CI, using the SAS surveymeans procedure, based on sample weights and the structural information in the sample design. Results While obtaining 16 interviews per CEA, 7,527 addresses were visited, selected from the 2000 population CEA listing 8, of which 465 households no longer existed (demolished or only in occasional usage), 1,835 could not be visited (locations with access closed off either by the drug traffic or by building superintendents who did not allow entry into gated housing areas, in addition to households under construction), 378 were vacant, and 4,849 were occupied and accessible. Of the latter, 675 did not have any eligible adults, 24 refused to participate in the study before it was possible to determine whether there were adults residing in the household, and 2,402 households with adult residents refused to participate. Thus, 1,748 households were interviewed, so that there was a loss of 12 households among the planned total of 1,760 households. In a traditional sample design, to obtain the 16 interviews, a sample size of 69 households would need to be defined ( 7,527 households/110 CEAs). However, the number of households interviewed here per CEA varied from 17 to 188: fewer than 50 interviews each were done in 68 CEAs, 50 to 67 interviews in 30 tracts, and 71 to 188 interviews in only 12 CEAs. The 1,748 interviewed households had 5,745 current residents, with a mean of 3.3 individuals per household. Of the 4,180 adults interviewed, several visits to the households allowed locating 3,096 adults and measuring their body mass and stature (1,941 women and 1,155 men), corresponding to a loss of anthropometric infor- 1870 Bossan FM et al. mation for some 34% of the adults, which was corrected by the sample weight calibration procedure, such that the observed sub-sample was representative of the 324,671 adults residing in Niterói. Participants age varied from 20.0 to 96.7 years, and mean body mass (± SEM) was 63.1kg (± 0.42kg) for women and 75.3kg (± 0.54kg) for men (Table 1). Mean BMI for men and women was slightly above the cutoff point for pre-obesity. In fact, 30.4% of women and 35.5% of men were classified as pre-obese (25 BMI 30kg/m2) and 15.4 and 14.1%, respectively, as obese (BMI 30kg/m2; Tables 2 and 3). When separating the data by age bracket, 12.5% of women in their twenties were underweight, but this rate decreased over the decades and increased slightly again after 70 years of age (Table 2). For pre-obesity, prevalence increased with age until leveling off around 60. Obesity prevalence also showed an important increase over the years, leveling off around years and decreasing slightly in the year group (Table 2). Men of all ages showed a low prevalence of underweight, with a downward trend beginning in the twenties (Table 3). Pre-obesity increased markedly with increasing age, with a slight decrease in the year bracket, increasing again above 70. Obesity prevalence increased in the twenties and thirties and remained stable until 70, when it showed a slight decrease (Table 3). Women showed a decrease in the prevalence of underweight with increasing mean income, while excess body mass did not display any evident trend (Table 4). For men, the prevalence Table 1 Means, standards errors of the means (SEM), minimums, maximums, and 95% confidence intervals (95%CI) for body measurements in the adult female and male population ( 20 years) in Niterói, Rio de Janeiro, Brazil. Mean SEM Minimum Maximum 95%CI Women Body mass (kg) Stature (cm) Body mass index (kg/m2) Men Body mass (kg) Stature (cm) Body mass index (kg/m2) Table 2 Percent distribution of the adult female population ( 20 years) in Niterói, Rio de Janeiro, Brazil, according to the classification of nutritional status proposed by the World Health Organization in , by age bracket. Age bracket N Body mass index (kg/m2) (years) Underweight Adequate Pre-obesity Obesity I Obesity II Obesity III , , , , , , Total 178, NUTRITIONAL STATUS OF AN URBAN ADULT POPULATION 1871 Table 3 Percent distribution of the adult male population ( 20 years) in Niterói, Rio de Janeiro, Brazil, according to the classification of nutritional status proposed by the World Health Organization in , by age bracket. Age bracket N Body mass index (kg/m2) (years) Underweight Adequate Pre-obesity Obesity I Obesity II Obesity III , , , , , , Total 145, Table 4 Percent distribution of the adult female population ( 20 years) in Niterói, Rio de Janeiro, Brazil, according to the classification of nutritional status proposed by the World Health Organization in , by mean income fifths of the census enumeration areas (CEA). CEA mean N Body mass index (kg/m2) income fifths* Underweight Adequate Pre-obesity Obesity I Obesity II Obesity III 1 36, , , , , Total 178, * According to the aggregate file by CEA in the 2000 Population Census 8, the four quintiles that demarcate the CEA mean income fifths were: R$ ; R$ 1,118.21; R$ 1,750.99; and R$ 2, The mean income in each fifth corresponds, respectively, to: R$ ; R$ ; R$ 1,582.74; R$ 2,594.56; and R$ 3, of underweight was low and tended to decrease even further with increasing mean income (Table 5). Prevalence of excess body mass tended to increase with the increase in mean income, but leveled off in the third income fifth, with a slight drop in the fourth and highest fifths. As for schooling, women showed an important decrease in the prevalence of excess body mass as their schooling increased, from nearly 60% for those with primary education to some 32% at the university level (Figure 1). Data for men did not vary strikingly according to schooling, except for higher excess body mass in men with more schooling (Figure 2). Discussion Two points contributed to the increase in noninterviews in the PNAFS: (1) the increasing difficulty in conducting household surveys in large Brazilian cities, especially for studies adhering to ethical principles and requiring free informed consent by interviewees and (2) the use of the 2000 Population Census lists 8, which were somewhat outdated at the time of the PNAFS but made the project feasible to the extent that they reduced the costs (one fewer step prior to data collection) and allowed inverse sampling. Use of this procedure to select households reduced the losses to interviews to only 12 households out of 1872 Bossan FM et al. Table 5 Percent distribution of the adult male population ( 20 years) in Niterói, Rio de Janeiro, Brazil, according to the classification of nutritional status proposed by the World Health Organization in , by mean income fifths of the census enumeration ares (CEA). CEA mean N Body mass index (kg/m2) income fifths * Underweight Adequate Pre-obesity Obesity I Obesity II Obesity III 1 30, , , , , Total 145, * According to the aggregate file by CEA in the 2000 Population Census 8, the four quintiles that demarcate the CEA mean income fifths were: R$ ; R$ 1,118.21; R$ 1,750.99; and R$ 2, The mean income in each fifth corresponds, respectively, to: R$ ; R$ ; R$ 1,582.74; R$ 2,594.56; and R$ 3, Figure 1 Percent distribution of the adult female population ( 20 years) in Niterói, Rio de Janeiro, Brazil, according to the classification of nutritional status proposed by the World Health Organization in , by level of schooling. 100% Obesity Pre-obesity 80% Adquate Underweight 60% 40% 20% 0% Schooling (years) NUTRITIONAL STATUS OF AN URBAN ADULT POPULATION 1873 Figure 2 Percent distribution of the adult male population ( 20 years) in Niterói, Rio de Janeiro, Brazil, according to the classification of nutritional status proposed by the World Health Organization in , by level of schooling. 100% Obesity P
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