The Problem of Overweight and Obesity

Brazil is a country located in South America with territorial area of 3,287,673

square miles with population around 182 million ( (U.S. Department of State, 2005). It is

the fifth-largest country in the world whether by geographical area or by population. The

official language in Brazil is Portuguese and it is the only country in the region speaking

Portuguese. It is a tropical country where 61.9% of its land is consists of forest (Central

Intelligence Agency, 2016). Brazil is a Catholic dominated country where approximately

74 percent of the population defined themselves as Roman Catholic although their

adherence such as attending Mass are quite low (U.S. Department of State, 2005).

Regarding the economic condition of Brazil, it is the largest economy in Latin

America, it is also projected to be the fifth country with largest economy in the world

with GDP growth second only to China (Blankfeld, 2010). Brazil underwent a drastic

urbanization period from 1970 where there is an increase of more than 100% of urban

population in the country, table 1 below depicts the growth of urbanization in Brazil.

Table 1

Brazil: Relative distribution for the urban population (%), according to the cities’ size.

It is interesting to compare the increasing rate of urbanization and nutritional

transition that happened in Brazil at the same time. Batista and Rissin (2003) stated that

there was a fast decrease in the prevalence of childhood malnutrition and a faster increase

in cases of adult overweight/obesity. This signifies that even though urbanization in some

way solve the problem of underweight but its impact toward obesity cannot be

underestimated. Batista and Rissin (2003) also concluded that obesity rates was doubled

or tripled in adult men and women at the end of the study. Figure 1 below describes the

nutritional transition that happened Brazil from 1975 until 2009.

Figure 1

Nutritional transition in Brazil: Geographic and temporal trends

The increasing trend of obesity did end in 1996 but it continually increased until

the 21st century. In 1975 only 19% of Brazillian men and 29% of Brazilian women were

overweight; as the time passed by those number have increased drastically where in 2009

from the total population 54% men and 48% of women are overweight. Senthilingam

(2014) stated that 4,750 extra-wide seats were provided in the football stadium during the

world’s cup to accommodate the increasing number of obese people in the country. It

should be noted that obesity is considered as a disability hence public facilities must

provide the needs of the obese. Senthilingam (2014) also stated that there is an increasing

number of bariatric surgery, and also a surgeon stated that he operated five to 10 persons

per week.

The problem of childhood obesity is increasing also in Brazil this will someday

exacerbate cases of obesity among adults in the future. Arbex, Rocha, Aizenberg, and

Ciruzzi (2014) stated that one in every three children between five and nine years of age

was overweight. Cases of obesity among children has risen from 3.7% to 21.7% in 34

years, indicating a six-fold increase. The government should prioritize this issue since it

signifies there are several factors that influence children’s lifestyle that contributes to the

rise of obesity cases among the children.

Obesity should not be considered as a simple problem that can be solved with

simple solution. Its consequences on one’s health should not be underestimated because it

may causes premature death, noncommunicable diseases, and also influenced the

disability-adjusted life year in a country. Malta and Silva (2012) stated that in 1930, 46%

of all deaths in Brazlillian state capitals were caused by infectious diseases, but it has

changed by 2007 where this number has fallen to 10%. The opposite happened to the

cases of cardiovascular diseases where it increased from 11% in 1930 to 31% in the year

of 2007 (Malta, D. C., & da Silva, J. B., 2012)

Determinants of Obesity

The state of one’s health does not influenced by only one single factor. World

Health Organization (WHO) (2016) stated that there are many factors working together

that affect one’s health whether in individual or community setting. Many times various

individual blames sickness or disease due to indecision to improve their lifestyle but

WHO (2016) stated that our health are influenced by our residence, genetics, our income,

level of education, social interaction, and family as well. There are three determinants of

obesity that will be discuss in this paper, those determinants are psychosocial,

behavioral/lifestyle, and environmental.

Psychosocial determinants. Obesity is not an instantaneous incident where one

woke up in the morning and all of a sudden discovered his/her body is obese. It is a

chronic condition started early on in life. Several factors that influenced from pregnancy

or infancy are high birth weight, rapid growth in infancy, maternal smoking during

pregnancy, and lack of breastfeeding (Sharma, M. & Ickes, M., 2008) . As a child grows

up there are many different psychosocial determinants that influenced their lifestyle

which often times are related to food intake.

Social-economic status are one of the prominent factors that influenced one’s

weight. Stein, Weinberger-Litman, and Latzer (2014) stated that there is an inverse

relationship between socio-economic status and obesity among adults in both the

industrialized and non-industrialized nations. Brazil is categorized as a developing

country with GDP of $2.417 trillion and inflation rate of 9.0% (The World Bank, 2016).

It is one of the fastest growing economy in the world where there was a

significant economic and social progress between 2003 and 2014. The reforms brought

by the government was able to help 29 million people out of poverty and significantly

reduced inequality in the country (The World Bank, 2016). Nevertheless the progress has

reached stalemate since 2015.

Monteiro, Conde, and Popkin (20 07) stated that from 1975-1989, the obesity

rates among men increased by 92% while the rates among women increased by 63%.

This period reflected that obesity tends to influenced more among men compared to

women. From 1989-2003 there was not much change of obesity rates among the female

population but it increased by 26% among women in the 2 lower income quintiles and

decreased by 10% among women in the 3 higher income quintiles. Table 2 and 3 below

presents the changes in age-adjusted obesity prevalence rates, by income quintiles among

men and women in Brazil.

The study by Monteiro, Conde, and Popkin (2007) concluded that burden of

obesity is changing from the middle-upper class toward the poor. This phenomenon is

occurring not only in women but men as well even though there is a more rapid increase

among the women. It is interesting to note also that there is a declining cases of obesity in

Brazil among the higher income groups where 1989 obesity prevalence rate of women

among the highest income was 12.7%; then in 2003 it was decreasing into 11.5% which

is a reduction of 1.5% in 14 years. Even though the reduction was not truly large yet it

signifies an important fact that fight against obesity is not unwinnable.

TABLE 2—

Changes Over Time in Obesity Prevalence Rates Among Women, by Income Level: Brazil, 1975, 1989, and 2003

Obesity Prevalence

Rate, %

Age-Adjusted Prevalence Ratio

(95% CI)

Family Income

Quintile

1975 1989 2003 1975–1989 1989–2003a

First (lowest) 2.6 8.9 11.2 3.27*

(2.64, 4.06)

1.36*

(1.14, 1.62)

Second 5.7 11.7 13.5 1.97

(1.65, 2.34)

1.17

(0.99, 1.39)

Third 8.8 14.8 13.5 1.65

(1.40, 1.94)

0.87

(0.73, 1.03)

Fourth 11.0 14.3 14.1 1.30

(1.10, 1.52)

0.92

(0.77, 1.10)

Fifth (highest) 8.6 12.7 11.5 1.42

(1.23, 1.65)

0.90

(0.76, 1.07)

Total 7.4 12.4 13.0 1.63

(1.47, 1.80)

1.03

(0.95, 1.12)

TABLE 3—

Changes Over Time in Obesity Prevalence Rates Among Men, by Income Level: Brazil, 1975, 1989, and 2003

OBESITY PREVALENCE RATE,

%

AGE-ADJUSTED PREVALENCE RATIO (95%

CI)

FAMILY INCOME

QUINTILE

1975 1989 2003 1975–1989 1989–2003

FIRST (LOWEST)0.5 1.7 4.1 3.19*

(1.98, 5.15)

2.50*

(1.68, 3.72)

SECOND1.4 3.3 8.0 2.37

(1.64, 3.42)

2.45

(1.76, 3.42)

THIRD2.2 4.6 8.6 2.10

(1.55, 2.84)

1.83

(1.36, 2.45)

FOURTH3.7 7.7 10.5 2.10

(1.70, 2.56)

1.31

(1.06, 1.62)

FIFTH (HIGHEST)5.5 8.5 12.8 1.53

(1.28, 1.82)

1.45

(1.21, 1.74)

TOTAL 2.7 5.1 8.8 1.92 (1.62,

2.27)

1.70 (1.48,

1.95)

Another important psychosocial determinant that influence obesity is education.

Monteiro, Conde, and Popkin (2001) concluded that educational attainment did not have

a significant influence to the risk of obesity among male in less developed region but in

the more developed region, men with higher educational attainment had slightly less

chance to be obese. Different results came up among the women, in the less and more

developed region obesity was strongly associated with education (inverse association).

This signifies that education tends to be a protective factor of obesity among both men

and women. Table 4 below summarizes the findings of Monteiro, Conde, and Popkin

(2001).

As it has been mentioned before that obesity is a multifactorial problem. It does

not arises because of one causes. Psychosocial factors have been attributed to contribute

towards the increasing cases of obesity. Hence, it is necessary for every health promoter

to investigate further on psychosocial determinants in one’s population in order to

understand the problem of obesity in community.

TABLE 4—

Quartiles of family income and education in the northeastern and southeastern adult population of Brazil

Behavioral/Lifestyle determinants. Lifestyle is a broad term that usually used to

describe a particular way of living (Merriam-Webster, 2016). It covers daily activities

such as diet, physical activity, duration of sleep, spirituality, and many other things which

we do every day. Diet or eating habit is one of the most prominent determinants,

Swinburn, Caterson, Seidell, and James (2004) stated that high intake of dietary non-

starch polysaccharides and fiber is a protective factor toward obesity and high intake of

energy-dense, micronutrient-poor foods and sugar-sweetened soft drinks and fruit juices

increases the risk of obesity.

Each nation or culture has their own uniqueness on eating behaviors or diet.

Monteiro and Cannon (2012) stated that analyses of household food expenditure surveys

in Brazil for the past 40 years shows that it retains many long-established food systems

and dietary patterns. In other words, Brazilian still has a strong cultural ties to their

traditional diet. Camoriano (2014) stated that culture has an important place in shaping

dietary pattern of Brazilian. One of the most important part of their diet is almoco or

lunch. It is the largest, most significant meal of the day and it has an important part in the

relationship of family (Camoriano, 2014).

The staple food includes rice, beans, and manioc or the root of cassava; these

foods usually are cooked by various methods of preparation and addition of seeds, oils,

herbs, spices, and leaves. Usually meat, fish and other animal products are eaten in small

amounts on a daily basis or as part of a feast (Monteiro, C. A., & Cannon, G., 2012).

Camoriano (2014) considered that traditional Brazilian eating pattern has always been

high in salt, fat and sugar, and low in vegetable and fruit consumption. This is true

because Portugues had a very strong influence on preservation of animal food by the

means of salting hence introducing a high salt intake among the Brazilian. High sugar

intake is inevitable because Brazil has been the world’s largest sugar producer for

centuries. Montairo and Cannon (2012) noted also that tropical fruits is commonly

consumed at breakfast or as desserts but there is a low consumption of green vegetables

especially among the poor population.

It is interesting to note that many things have change since the urbanization of

Brazil in 1970. Urbanization comes together with globalization where transnational food

companies introduced many kinds of processed food in the country. Monteiro and

Cannon (2012) argued that traditional long-established food systems and dietary patterns

are being displaced in Brazil by ultra-processed products made by transnational food

corporation. One of the example on the effectiveness of Transnational companies in

marketing their product is the establishment of floating supermarket as depicted in picture

1 below. This floating supermarket travels to remote part of Brazil and marketed Nestle

products, hence introducing processed food for the indigenous population.

Picture 1 and 2

Nestle Floating Supermarket

The floating supermarket was projected to reach over 800,000 customers in the

Brazilian Amazon River. Nestle (2010) considered it is a service to the population of the

Amazon, and it offers more than 300 Nestle brands such as ninho, maggi, nescafe which

was aimed for low-income customers. It was designed also to develop a different trading

channel which offer access to Nutrition, health and wellness to the remote communities

(Nestlé, 2010).

The nutritional transition that is happening in Brazil maybe one of the cause of

increasing cases of obesity throughout the country. Cunha, de Almeida, Sichieri, and

Pereira (2010) identified three different kinds of diet on a low-income neighbourhood in

Rio de Janeiro metropolitan area. Those diets are mixed patter which consisted of cereals,

fish and shrimp, vegetables, roots, fruits, eggs, meat and caffeinated beverages; a western

pattern which consisted of fast foods, soft drink, juices, cakes, cookies, milk and dairy,

sweets and snacks; The last diet is traditional pattern, which included rice, beans, bread,

sugar, fats, and salad dressings.

Cunha, et al. (2010) concluded that traditional dietary pattern was inversely

associated with BMI and waist circumference among females; while a positive

association between western eating pattern and waist circumference among women.

Furthermore, a diet based on rice and beans may provide protective role against weight

gain in women.

Physical activity is another problem that influenced obesity in Brazil.

Senthilingam (2014) stated that 14% of the population cycle or walk to work/school, 34%

are active in their free time, 15% are not active, and 25% are watching TV three hours

per day. This result signified that most of the students going to school or college or

university either used public transportation or their own car or motorcycle. Duncan, S.,

Duncan, E., Fernandes, Buonani, Bastos, Segatto, Codogno, Gomes, and Freitas (2011)

concluded that compared with those who were driven to school by car, the odds of

overweight/obesity were 0.72, 0.61, and 0.59 times lower in participants who bussed,

cycled, and walked to school respectively. This signifies that most of the population have

high risk toward obesity since only 14% are walking or cycling to school.

Findings of Duncan et al. (2011) highlighted also that the odds of

overweight/obesity were 1.64 and 1.94 times higher for those who spent 1-2 and >2

hours/day on the computer compared to those who did not use computer at all. One more

additional factor often forgotten, parental support towards a good physical activity. It is

an important matter because those with one parent involved in sport showed 1.25 times

greater odds of overweight/obesity than those with no sporting parents. Children who

have one or both parents actively supporting their physical activity showed 1.67 and 1.63

greater odds of overweight/obesity than those who received no encouragement from

parents.

Environmental. Our environment also plays an important part in determining our

weight. Harvard school of public health (2016) stated that our choices are shaped by the

complex world in which we live – by the kind of food our parents make available at

home, by how far we live from the nearest supermarket or fast food restaurant, even by

the ways that government support farmers. As it has been discussed previously that the

transnational food companies are aggressively looking for customers in Brazil. Bruha

(2014) stated that even though the economy is in stagnation but the supermarket industry

is still reaching their tenth consecutive year of growing revenue especially since the

government decided not to put a negative impact on the prices and exempted various

items of the basic needs from tax as an effort to slows down inflation (Bruha, 2014).

The growth of supermarket chains in Brazil also mirrors fast food industry. Lewis

and Jelmayer (2015) stated that there are many U.S. restaurant chains which are looking

for expansion in the country despite of slowing down of economy. These companies are

trying to take advantage for the down market while many of their local competitors are

facing bankruptcy. It was estimated that more than 100 million people have an attraction

for brands coming from U.S (Lewis, J. T. & Jelmayer, R., 2015).

It is important to note that Brazil is the fourth largest foodservice sector in the

world. Its value reach US$146 billion in 2012 where cafes/bars and fullservice

restaurants dominated marketvalue and follows by fast food with compound annual

growth rate of 15.0% (Agriculture and Agri-Food Canada, 2014). This signifies that fast

food industry has a segment in the market and it is also popular because of their

increasing market value since 2008 as reflected in table 5 below.

In regards of outlets distribution, cafes/bars have 406,696 outlets in the country

while second place is owned by street stalls with 334,710 and fast food is in the third

place with 156,787 outlets spread in the country (Agriculture and Agri-Food Canada,

2014). Even though fast food industry does not have as many outlets as cafes/bars but

their numbers should not be underestimated since it is growing rapidly as the years

passed by. Furthermore, the fast food industry is being dominated by foreign companies.

Table 6 below depicts the outlets and transactions of Brazil foodservice by subsector in

2012.

Table 5

Market value and growth of brazil foodservice by subsector, historic, current process, fixed by 2012 exchange rates

Table 6

Outlets and transactions of Brazil foodservice by subsector, 2012

Cafes/Bars is the largest subsector in Brazilian foodservice industry. But it has the

lowest CAGR with only 8.7% from 2013 to 2017 because of Dry law that limited the

consumption of alcohol. Street stalls/kosk are popular with their ice cream products, the

two top companies which hold 75% of the market share in chained street stall/kiosk

subsector are McDonald Corp and Brazil Fast food Corp, but the independent street stall

is still the majority which owns 99% of total outlets (Agriculture and Agri-Food Canada,

2014).

The 5 top companies of fast food in Brazil are McDonald’s Corp, Al Saraiva,

Doctor’s Association, Inc. (Subway), Brazil Fast Food Corp (Bob’s, and Burger King

Holding Inc. The increasing number of new shopping centers opened in Brazil

contributed to the rapid increase of fast food outlets in the country. Table 7 below depicts

the top 10 companies in Brazil consumer foodservice.

Even though Fast food is still the third largest seller in terms of foodservice but its

impact upon the population should not be underestimated. The importance of providing

healthy foods for the population should be the main priority of the government. This

topic will be discussed further in the intervention section of this paper.

Table 7

Top 10 companies in brazil consumer foodservice

Obesity Prevention and Treatment

The Brazilian constitution of 1988 considered health as citizen’s right and

obligation of the state. Health system in Brazil is called Sistema Unico de Saude (SUS), it

is an universal health. In other words it offer free service for its citizen, a preventive and

ccurative care in 26 states. It also decentralizes healthcare service in the country and

encourage community participation in decision making (Jaime, P. C., Silva, A. C. F.,

Gentil, P. C., Claro, R. M., & Monteiro, C. A., 2013).

Buss (n.d.) stated that Brazil has adopted the WHO Global strategy on diet,

physical activity and health as a measure to prevent obesity. Brazil also has created an

inter-ministerial commission to define and implement national strategy in 2004 and in

March 2006 Brazil started the implementation of the National Policy on Health

promotion and on Prevention and Control of Chronic Non-Communicable Diseases.

Brazilian Government also has published Food Guide which is called Guia

Alimentar para a População Brasileira in 2005 and released also the 2nd Edition in 2014.

It was written that in order to be healthy, people need to follow 10 simple steps:

1. Make natural or minimally processed foods the basis of your diet

Natural or minimally processed foods, in great variety, and mainly of plant origin,

are the basis for diets that are nutritionally balanced, delicious, culturally appropriate, and

supportive of socially and environmentally sustainable food systems. Variety means

foods of all types – cereals, legumes, roots, tubers, vegetables, fruits, nuts, milk, eggs,

meat – and diversity within each type – such as beans and lentils, rice and corn, potato

and cassava, tomatoes and squash, orange and banana, chicken and fish.

2. Use oils, fats, salt, and sugar in small amounts when seasoning and cooking

natural or minimally processed foods and to create culinary preparations

As long as they are used in moderation in dishes and meals based on natural or

minimally processed foods, oils, fats, salt, and sugar contribute to diverse and delicious

diets without making them nutritionally unbalanced.

3. Limit consumption of processed foods

The ingredients and methods used in the manufacture of processed foods – such

as vegetables in brine, fruits in syrup, cheeses and breads – unfavourably alter the

nutritional composition of the foods from which they are derived. In small amounts,

processed foods can be used as ingredients in dishes and meals based on natural or

minimally processed foods.

4. Avoid consumption of ultra-processed foods

Because of their ingredients, ultra-processed foods such as salty fatty packaged

snacks, soft drinks, sweetened breakfast cereals, and instant noodles, are nutritionally

unbalanced. As a result of their formulation and presentation, they tend to be consumed

in excess, and displace natural or minimally processed foods. Their means of production,

distribution, marketing, and consumption damage culture, social life, and the

environment.

5. Eat regularly and carefully in appropriate environments and, whenever possible,

in company

Make your daily meals at regular times. Avoid snacking between meals. Eat

slowly and enjoy what you are eating, without engaging in another activity. Eat in clean,

comfortable and quiet places, where there is no pressure to consume unlimited amounts

of food. Whenever possible, eat in company, with family, friends, or colleagues: this

increases the enjoyment of food and encourages eating regularly, attentively, and in

appropriate environments. Share household activities that precede or succeed the

consumption of meals.

6. Shop in places that offer a variety of natural or minimally processed foods

Shop in supermarkets and municipal and farmers markets, or buy directly from

producers or other places, that sell varieties of natural or minimally processed foods.

Prefer vegetables and fruits that are locally grown in season. Whenever possible, buy

organic and agro-ecological based foods, preferably directly from the producers.

7. Develop, exercise and share cooking skills

If you have cooking skills, develop them and share them, especially with boys and

girls. If you do not have these skills – men as well as women – acquire them. Learn from

and talk with people who know how to cook. Ask family, friends, and colleagues for

recipes, read books, check the internet, and eventually take courses. Start cooking!

8. Plan your time to make food and eating important in your life

Plan the food shopping, organise your domestic stores, and decide on meals in

advance. Share with family members the responsibility for all activities related to meals.

Make the preparation and eating of meals privileged times of conviviality and pleasure.

Assess how you live so as to give proper time for food and eating

9.Out of home, prefer places that serve freshly made meals

Eat in places that serve fresh meals at good prices. Self-service restaurants and

canteens that serve food buffet-style charged by weight are good choices. Avoid fast food

chains.

10. Be wary of food advertising and marketing

The purpose of advertising is to increase product sales, and not to inform or

educate people. Be critical and teach children to be critical of all forms of food

advertising and marketing.

Interventions and Best Practices

Healthy school lunch program. Jaime at al. (2013) stated that lunch programme

in Brazil is one of the oldest in the world. The lunch programme aimed to teach good

eating hubits, supplements sudents’ diets, and improve students’ nutritional status and

leaning capacity. When it started, purchase food was in the form of dehydrated or

prepackaged form which was unhealthy. Nevertheless Government introduced a new

legislation in 2001 that at least 70% of the funds must be spent of basic foods. Each

municipal must use at least 30% of their meal funds to buy food from local family farms.

School health program. This program is a result of collaboration between the

education and health ministries. It aimed to assess student’s health and nutritional status,

health promotion and disease prevention. It encouraged teachers who collaborate together

with local primary healthcare services. The program was implemented in 2012 in 44.8%

of all municipalities in Brazil where it involved more than 56,000 school and 15,000

family health teams. The result was magnificent as more than 8.2 million public school

students participated in the program (Jaime, P. C., Silva, A. C. F., Gentil, P. C., Claro, R.

M., & Monteiro, C. A., 2013).

Family Health Strategy Team. It is a part of the SUS healthcare system where a

team consists of family medical doctor, a nurse, a nurse’s assistant and community health

agent visited different household in the community. This team is an important work in the

primary and secondary prevention. Currently, Brazil has around 30,000 teams situated

around the country where population coverage of this team reached until 96.1%. There

are 230,000 community health agents involved countrywide to do health promotion,

disease prevention, and rehabilitation (Health Ministry of Bazil, 2016).

Promotion of physical activity in the community. In the SUS healthcare

system, the government encouraged municipalities to build infrastructure in parks,

squares, and streets near health care centers. Government also provide equipment and

qualified professionals to guide the community about physical activities (Hallal, P. C.,

Tenorio, M. C. M., Tassitano, R. M., et al., 2010). Academia de Cidade is one of the

successful program in Brazil. It is a health promotion policy in Brazil which focuses on

physical activity, leisure, and healthy eating and curently it has 30,000 participants in 19

“polos” or settings. It includes aerobic and dance classes, and organized jogging groups,

and diet orientation sessions for healthy problems and those with hypertension, obesity,

diabetes, and heart disease.

Conclusion

Even though the prevalence of obesity in Brazil is still high, the Government is

effectively working to curb obesity cases in the country. Brazilian Government should be

recommended for introducing several prevention awareness programs and intervening in

municipal level by providing necessary funding and human resources. It is interesting to

note that a reduction of obesity happened from 1970 to 1990 among the middle to upper

class population and I believe that it is possible to repeat the same phenomenon in the

futures. The government has introduced a system that encouraged inter-ministerial

collaboration that works but they should have maintained the same program especially in

the face of financial problem that currently happened in Brazil.

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