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Symposium: Obesity in Developing Countries:

Biological and Ecological Factors

Obesity Trends in Latin America: Transiting from Under- to Overweight1


Ricardo Uauy,2 Cecilia Albala and Juliana Kain
Instituto de Nutricion y Tecnologia de los Alimentos (INTA), Universidad de Chile, Santiago, Chile

ABSTRACT Latin America is undergoing a rapid demographic and nutritional transition. A recent WHO/PAHO
survey on obesity in the region revealed an increasing trend in obesity as countries emerge from poverty, especially
in urban areas. In contrast, in middle income countries, obesity tends to decline as income increases; this is
especially so in women. Dietary changes and increasing inactivity are considered the crucial contributory factors
that explain this rise. The end result is a progressive rise in overweight and obesity, especially in low income groups
who improve their income and buy high fat/high carbohydrate energy-dense foods. Intake of these foods increases
to the detriment of grains, fruits and vegetables. Most aboriginal populations of the Americas have changed their
diet and physical activity patterns to fit an industrialized country model. They now derive most of their diet from
Western foods and live sedentary and physically inactive lives. Under these circumstances they develop high rates

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of obesity, insulin resistance and type 2 diabetes. Supplementary feeding programs are common in the region; the
number of beneficiaries significantly exceeds the malnourished. Weight-for-age definition of undernutrition without
assessment of length will overestimate the dimension of malnutrition and neglect the identification of stunted
overweight children. Providing food to low income stunted populations may be beneficial for some, although it may
be detrimental for others, inducing obesity especially in urban areas. Defining the right combination of foods/
nutrients, education and lifestyle interventions that are required to optimize nutrition and health is a present
imperative. J. Nutr. 131: 893S– 899S, 2001.

KEY WORDS: ● obesity ● Latin America ● aboriginal population ● diabetes


● supplementary feeding programs

OBESITY TRENDS IN LATIN AMERICA as a proxy indicator of type of malnutrition present at the
population level. As obesity rises, deaths from cardiovascular
Latin America is undergoing a rapid demographic and disease and cancer also increase; conversely, if death from
nutritional transition. Significant changes in the causes of infection predominates, malnutrition tends to be high and
death have occurred over a relatively short period of time. As obesity low.
an example of this, Figure 1 illustrates the trends in causes of Information on obesity trends in Latin America is limited
death by disease categories in Guatemala, Mexico, Chile and to specific country data for selected countries and to data of
Uruguay (1). These data give a clear indication of how death women of reproductive age and children under 5 y of age
from infections is on the decline while death from noncom- obtained from the Demographic and Health Surveys Institute
municable chronic disease is on the rise. Guatemala has re- for Resource Development (DHS/IRD). Martorell et al. (2)
cently initiated the transition while Mexico is clearly in the reviewed DHS surveys conducted since 1982 and evaluated
midst of the process. Chile has recently finished the period of the prevalence of obesity in women and children. The mean
rapid change while Uruguay can be considered to be in the value for obesity in women for the eight countries evaluated
posttransition phase. In the absence of systematically collected was 8 –10%. Table 1 summarizes results for five countries using
data on distribution of causes of death, these categories serve a BMI cutoff of ⱖ 30 kg/m2 according to WHO or a BMI index
of ⱖ 27.3 following USA Hanes I (3). The lowest prevalence
was found in Honduras while the highest is found in Bolivia
1
Presented as part of the symposium “Obesity in Developing Countries: and Peru, depending on cutoff point defined. In the case of
Biological and Ecological Factors” given at the Experimental Biology 2000 meet-
ing held in San Diego, CA on April 15–19, 2000. This symposium was sponsored children under 5 y of age a weight-for-height ⬎ 1 SD was
by the American Society for Nutritional Sciences and was supported in part by an considered as overweight, and ⬎ 2 SD as obesity. The lowest
educational grant from Monsanto Company. Symposium proceedings are pub- figures are found in Bolivia while the highest are found in the
lished as a supplement to The Journal of Nutrition. Guest editors for the sympo-
sium publication were Benjamin Caballero, Center for Human Nutrition, Johns Dominican Republic. An increasing prevalence of obesity in
Hopkins University, Baltimore, MD and Najat Mokhtar, Ibn Tofaı̈l University, women was found in countries with higher per capita income
Kenitra, Morocco. and in those with lower rates of stunting in children. A recent
2
To whom correspondence and reprint requests should be addressed at
Universidad de Chile, Instituto de Nutricion y Tecnologia de los Alimentos (INTA), PAHO/WHO publication on obesity in Latin America (4)
Casilla 138-11, Santiago, Chile. E-mail: uauy@uchile.cl. revealed an increasing trend for obesity as countries emerge

0022-3166/01 $3.00 © 2001 American Society for Nutritional Sciences.

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FIGURE 1 Trends in relative contri-


bution of cause of death in four Latin
American countries from 1970 to 1995.
Guatemala preepidemiologic transition,
Mexico undergoing rapid change, Chile
early posttransition and Uruguay post-
transition. (Data from Ref. 1.)

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from poverty, especially in urban areas. In contrast, in middle Lerman Garber et al. (11) demonstrate in a cross-sectional
income countries, obesity tends to decline as income increases; study of adults older than 35 y of age a higher prevalence in
this is especially so in women. urban areas relative to rural areas. Trends demonstrate a pro-
Selected country data demonstrate increasing rates for obe- gressive rise in obesity rates, especially in urban women; rates
sity in adults (BMI ⬎ 30) over the past two decades for Brazil of increase are highly variable between and within countries
and the past decade in Chile; this is depicted in Figure 2A, (12). In general as income increases so does the prevalence of
and B for women and men (5,6). Similar trends are observed obesity; dietary changes and progressive inactivity are consid-
for Costa Rica, Barbados and other Caribbean countries. A ered the crucial contributory factors that explain this rise.
study by Sichieri et al. (7) using a BMI ⱖ 30 found 4. 8%
obesity for men and 11.7% in Brazilian adult women. In Costa OLD AND NEW CONDITIONING FACTORS
Rica the prevalence of overweight in 1996 was 45.9% using a FOR OBESITY
BMI ⱖ 25 (8). Atalah (9) in Santiago, Chile, reports a
prevalence of 20.5% in men and 30% in women in 1993 using Lifestyle changes in the general population
a BMI of 27 as a cutoff limit. Sinha (10) from Barbados reports
a prevalence of obesity of 16% in men and 38% in women in The nutrition transition brings about significant dietary
1981 using a BMI ⱖ 27, indicating that for the Caribbean, changes as presented by Popkin et al. in this same issue.
obesity rates in 1995 were 7–20% for men and 22– 48% for Increases in total fat, animal protein and fat consumption are
women. the most prominent. As income increases in transitional coun-
In this current issue Monteiro reports regional data within tries, so does the consumption of high fat foods, including
Brazil, which demonstrates the interaction between educa- industrially processed hydrogenated fats. Processed foods are
tional level, urban/rural residence and socioeconomic level in usually more expensive in the rural areas, whereas the con-
defining obesity trends over the past two decades. In Mexico verse is true for natural foods such as grains, fruits and vege-
tables. Progressive urbanization and the mass media may con-
tribute to the shift in diet of rural migrants who abandon their
staple plant food– based diets, favoring processed foods and
TABLE 1 animal food products. These factors affect children and ado-
Prevalence of obesity in women and children lescents as well. If the change in diet is accompanied by a
in Latin America1
sedentary lifestyle and physical inactivity, the combination is
perfect to trigger increasing adiposity. Energy balance and fat
% Children stores strictly follow the laws of thermodynamics, whether
weight-for-height % Women BMI people are urban or rural, rich or poor. The end result is a
progressive rise in overweight and obesity, especially in low
Country (year) ⬎1 SD ⬎2 SD ⬎ 27.3 ⬎ 30 income groups who improve their income and buy high fat/
high carbohydrate energy-dense foods. Sweet and salty high fat
Bolivia (1994) 13.1 2.1 16.8 7.6 foods show marked consumer preference in the urban super-
Colombia (1995) 21.6 9.2 12.2 1.8
Peru (1996) 22.8 9.4 23.9 4.7
market; intake of these foods increases to the detriment of
Honduras (1996) 18.7 7.8 3.7 1.4 grains, fruits and vegetables. On a positive note, recent trends
Dominican Republic (1996) 23.3 12.1 15.3 4.6 demonstrate that high income countries are reducing the
consumption of fat, possibly in response to the existence of
1 From Ref. 2 [Martorell et al. (1998)]. public health– based dietary guidelines.
OBESITY IN LATIN AMERICA 895S

drinks. A study on food consumption carried out in Santiago


in 1995 demonstrated that 70% of adults consumed less than
two fruits and 59% consumed less than two portions of vege-
tables per day (18). On the other hand, sedentarism is high in
Chile and has increased with the progress of urbanization. In
1970 three quarters of the population lived in urban areas; for
1997 this figure is 87%. The number of cars increased from
363,150 in 1970 to 1,969,128 in 1997. TV sets numbered
12,170 in 1970, increasing to ⬎ 2 million in 1997 (19). A
recent study carried out in Santiago demonstrated that 90% of
school-age children watch television during weekdays, and of
these 20% watch for more than 3 h daily (5). For Metropolitan
Santiago in 1988, 55% of men and 77.4% of women performed
less than two 15-min periods of exercise per week, while in
1992 these figures increased to 57.8% in men and to 80.1% in
women (20). In Valparaiso for 1997, ⬎ 90% of adult women
were inactive during their leisure time, which for the low
socioeconomic group was 97% (16).

Lifestyle changes of aboriginal populations and obesity


Obesity has a complex etiology, resulting from the com-
bined effects of genes, environment, lifestyle and their inter-

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actions. Although the genetic background is crucial to explain
the susceptibility to most chronic diseases, the modernization
and urbanization process affecting aboriginal populations has
brought about major changes that are most likely contributing
FIGURE 2 Change in the prevalence of obesity (BMI ⬎ 30 kg/m2 ) to the high prevalence of obesity and diabetes reported (21).
in Brazil (A) and Chile (B) for adult women and men. (Data from Refs. 2 Most aboriginal populations today have changed their diet and
and 5.) physical activity patterns to fit an industrialized country
model. They now derive their diet completely or in large part
from Western foods and live sedentary and physically inactive
Recent data from several urban centers including data lives. Under these circumstances they develop high rates of
obtained in Santiago, Chile, demonstrate that television view- obesity, insulin resistance and type 2 diabetes (22,23).
ing and a child’s preference for certain TV commercials has a The Chilean population is formed by a mixture of Amer-
direct relationship with snack food consumption and other indian native groups and descendants of several European
food purchased by children at school (13). The relative con- migrants. The Mapuche population, the major aboriginal
tribution of dietary change vs. physical inactivity in determin- group in Chile, are descendants of Asian migrations that
ing the increasing rates of obesity in children in transitional settled in the southern part of the central valley of Chile and
societies cannot be quantified in a precise manner. Further- extended to Patagonia, both sides of the Andes. A self-assess-
more, attempting to do this would be futile, because preven- ment questionnaire on ethnicity included in the 1992 Chilean
tive strategies should address both. Recommendations to pre- census among people older than 14 y (24) indicated that close
vent obesity are presently integrating dietary advice, to 10% of Chileans identify themselves as “Mapuche.” Eco-
increasing physical activity and weight monitoring. The chal- nomic and social changes have forced a great number of
lenge of preventing obesity is yet to be tackled effectively in Mapuche to migrate from their original rural conditions in the
urban societies. South of Chile to large urban centers, such as Santiago and its
Although Chile has no national system to monitor the surroundings. Nowadays, nearly one third of the Mapuche live
nutritional status in adults, there are data representative of the in urban centers (24). In 1985 a high prevalence of obesity,
city of Santiago, where 40% of the population lives. In two close to 40% in the rural Mapuche population was found.
surveys on risk factors for chronic diseases carried out in the However, this ethnic group had a very low prevalence of type
population over 15 y of age, obesity increased from 6% to 11% 2 diabetes, ⬍ 1% (25). The prevalence of risk factors for
and from 14% to 24% in men and women, respectively, over chronic diseases has increased dramatically in Chile over the
a 4-y period (14,15). Obesity increased with age, was more past three decades, in that lifestyle changes and rapid urban-
prevalent in women than in men and was higher in women of ization have occurred. In fact, 15% of adult Chilean men and
low socioeconomic level. In another study carried out in a 23% of women are now obese (14). Considering these
representative sample in urban Valparaiso, Chile (25– 64 y of changes, we explored whether Mapuche living in large cities
age) in 1997, obesity prevalence was also high and had a like Santiago had also experienced a rise in the metabolic
similar distribution to that found in Santiago (16). Changes in complications of obesity.
the diet and sedentarism are the most probable causes of the Our studies over the past 5 y have examined the effect of
increasing trend of obesity in Chile. genetic differences on the prevalence of obesity, glucose in-
Dietary patterns in Chile have changed rapidly, becoming tolerance and leptin levels in groups with different ethnic
closer to the “Western diet,” high in saturated fat with de- backgrounds. Mapuche of rural areas preserving ethnical and
creased consumption of grains and other fiber-rich foods (5). A cultural distinctive characteristics were compared to Cauca-
recent analysis of a National Household Survey on Food sian subjects (Spanish heritage) from the general population of
Expenditure (17) demonstrated that the principal components Santiago (26). We found that BMI, gender and insulin were
of food expenditure among the poor are bread, meat and soft independently associated to leptin levels in Caucasians,
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whereas for the Mapuche group, only BMI was associated to dietary factors and gene/environment interactions may deter-
leptin after controlling for gender and insulin. The comparison mine a potential epigenetic effect. However, the low preva-
of plasma leptin levels adjusted for BMI, gender and age lence of type 2 diabetes in Aymara and rural Mapuche subjects
showed significant ethnic differences. Mean concentration of (30) is in sharp contrast to the high prevalence of this con-
plasma leptin in Caucasian individuals was approximately dition in most aboriginal groups in North America, including
twofold higher compared to that of Mapuche subjects. Fasting the Pima from Arizona and Mexican-American minorities in
insulin levels adjusted for age, gender and BMI, indicative of the United States (21,32). Although the distribution of BMI
glucose sensitivity, were also significantly higher in Cauca- observed in the Aymara is similar to that in the general
sians. Only 4.1% of rural Mapuche were classified as diabetics, population of urban Santiago, mean values of insulin resis-
compared to 9.8% observed in urban Mapuche and 5.3% in tance, determined by HOMA, indicate improved glucose tol-
the Caucasian population of Santiago. Glucose intolerance erance in the Aymara subjects (30). Low mean values of
was identified in 3.4% of the rural and in 6.1% of the urban HOMA-IR and insulin levels in Aymara subjects could be in
Mapuche. Our study also revealed a higher prevalence of part a consequence of their high level of physical activity and
obesity (P ⬍ 0.05) in urban Mapuche compared to that in their traditional high complex carbohydrate diet. The preva-
rural natives. Moreover, these data suggest that the change in lence of diabetes in the rural Aymara population who live in
environment may increase disease susceptibility beyond that high altitudes in the north of Chile is lower than the preva-
observed in Caucasian populations. The early report of a low lence in the urban Caucasian population of Santiago, Chile,
prevalence of diabetes in the presence of high rates of obesity and much lower than the prevalence in other Amerindian
in the Mapuche was not upheld by our recent studies, suggest- groups from North America. Prevalence of diabetes in this
ing that aboriginal populations lose their protection from the Aymara population is similar to, or slightly lower than, the
metabolic complications of obesity as they undergo urbaniza- prevalence reported for the rural Mapuche population. Both
tion and lifestyle, including dietary changes (27). Table 2 populations have preserved a rural physically active lifestyle
summarizes these findings. and have maintained their traditional diet (30).

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In contrast to the Mapuche, the Aymara living isolated in
the north of Chile, in the Bolivian and Peruvian highlands, Nutrition interventions programs: from stunting and
have mostly preserved their nomadic primitive agricultural underweight to overweight and obesity
and cultural traditions. They speak their native language and
are dependent on subsistence agriculture for most of their Supplementary feeding programs are a fact of life for most
survival. They consume a traditional diet composed of indig- countries in the region. A recent Food and Agriculture Orga-
enous crops such as potatoes, quinoa (a local legume) and nization survey with data from 19 Latin American countries
some barley. Animal husbandry (domesticated llamas, alpacas found that over 20% of the population— or approximately 83
and sheep) is their main economic activity (28,29). Moreover, million people out of an estimated 414 million in these coun-
the Aymara rural population has not experienced a massive tries—receive some level of food assistance benefits from nu-
shift from their traditional ways of living to a modern Western trition-related programs (33). In contrast, the number of mal-
lifestyle. According to the self-identification questionnaire of nourished in the study countries was 10 million, that is, 12%
the 1992 census only 0.5% of Chileans older than 14 y were of total beneficiaries. The explanation for this phenomenon is
Aymara (24). Studies conducted in the early 1970s revealed that nutrition programs have evolved beyond the immediate
an absence of clinically recognizable diabetes in a large sample needs of the malnourished and have become part of social
of rural Aymara subjects living in their natural ecosystem. Our economic benefit demanded by populations living under pov-
most recent study of the Aymara conducted in 1997, in a erty. Despite the obvious benefits (namely the significant
sample of 78 men and 118 women older than 19 y of age, reductions in underweight and wasting that have occurred in
found a prevalence of diabetes of only 1.0%, adjusted for age, most countries), these programs have the potential to affect
and 3.5% glucose intolerance. The low prevalence estimated the trends in obesity rates. Also, stunting remains a problem in
in the present study is concordant with previous observations this region. In this setting providing food supplements may be
(30). beneficial for some, although it may be detrimental for others.
The difference in prevalence of obesity and diabetes be- Careful selection of beneficiaries of food assistance programs
tween Aymara and Mapuche populations or other indigenous and determining the right combination of nutrients/foods,
population of the Americas is difficult to interpret. Multiple education and lifestyle interventions, required to optimize

TABLE 2
Obesity and metabolic complications in aboriginal and Caucasian populations in Chile according
to gender and rural/urban condition

Rural Aymara 11 Rural Mapuche 22 Urban Mapuche 22 Urban Caucasian 33

Men Women Men Women Men Women Men Women

BMI ⬍ 25 53 43.1 34 24.7 17.9 14.6 40 40


BMI 25–29.9 34 33.8 51 43.2 53.8 30.1 44 37
BMI ⬎ 29.9 13 23.1 15 32.1 28.3 44.7 16 23
Diabetes 1.3 1.7 3.2 4.5 9.8 6.0 4 3.8
Impaired glucose tolerance 2.6 4.3 4.2 3.1 7.3 4.8 — —

1 From Ref. 30.


2 From Ref. 31.
3 From Ref. 16.
OBESITY IN LATIN AMERICA 897S

TABLE 3 the program was compared to the corresponding Z-score upon


discharge, 12 mo later. As noted from the data on admission,
Distribution of weight-for-length Z scores of infants receiving 93 of 1149 infants had a weight for length below ⫺1 Z, while
the enhanced complementary feeding program for 12 mo1 at the end of a year of receiving the benefit, only 7 remained
in that condition. On the other hand, the number of infants
Weight for length after 12 months in the who exceeded ⫹1 Z increased from 0 to 117. Those who were
program
within ⫾1 Z remained basically unchanged, that is, went from
Weight for length
on entry ⱕ ⫺1 ⫺1 to 0 ⬎ 0 to ⱕ 1 ⬎ ⫹1 Total 1056 to 1025. The changes observed in the group in terms of
length-for-age are depicted in Figure 3; a control group was
ⱕ ⫺1 2 65 23 3 93 obtained from nonparticipants in the enhanced PNAC pro-
⫺1 to 0 4 259 209 26 498 gram matched for age and growth indices (36). The data from
⬎ 0 to ⱕ ⫹1 1 151 318 88 558 participants and control infants were analyzed according to
⬎ ⫹1 0 0 0 0 0 stunted (below ⫺1 Z length for age) or nonstunted (length-
Total 7 475 550 117 1149
for-age ⬎ ⫺1 Z). As noted, both control and enhanced PNAC
1 From Ref. 35 [Kain et al. (1994)]. stunted groups experienced a small nonsignificant gain in
length-for-age. Infants who were not stunted exhibited no
change in length Z-score during the year-long evaluation. In
nutrition and health at each stage of the life cycle, is a problem summary, the benefit of improving mild underweight in 86
that cannot be avoided (33). infants was offset by increasing the number of overweight
Chile is often presented as a paradigm of the success of infants by 117. The evidence from length-for-age Z-score
supplementary feeding programs. Indeed, the association be- suggests that even the stunted exhibited no gain from the
tween the presence of these massive interventions and the program as compared to a control group that did not receive
decline in malnutrition in all age groups is there. Unfortu- the benefit. Moreover, presently the significance of being

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nately, these programs may be also contributing to the rising mildly underweight should be reassessed in light of the emer-
prevalence in obesity (34). Specific examples will be given in gence of a new paradigm of growth, in which more is not
an effort to show the impact that these assistance programs necessarily better. What is clear from this evaluation is that, if
may have on the prevalence in obesity and to signal the road stunted or normal children are provided additional food, they
ahead for other countries undergoing the rapid nutrition tran- will gain weight to exceed the median reference value.
sition. A separate example is drawn from the National Nursery
The Chilean supplementary feeding program or “Programa Schools Council Program (JUNJI). It was created in 1971
Nacional de Alimentación Complementaria” (PNAC) began under the Ministry of Education and provides child care as
in the 1920s as a public milk distribution program for working well as supplementary food for toddlers and preschoolers;
mothers. It was built into the workers’ social security legisla- coverage is close to 50% of those in need. It also provides
tion in 1937 as part of preventive health to protect working social assistance to the family when required. In 1998
class families. The PNAC was significantly strengthened in approximately 100,000 children under 5 y attended JUNJI.
the 1950s with the creation of the National Health Service Of those, 95% were preschoolers from 2 to 5 y of age, and
(NHS), which provides universal health protection and health the rest, infants under 2 y old. The food distributed covers
services for insured workers and the indigent population. The either 58% or 75% of the children’s daily caloric needs,
existence of the PNAC is secured by law and financed by depending on whether they attend for half or full day. The
direct contribution of private and public employees and em- calorie contribution is divided by age groups as follows:
ployers. In terms of beneficiaries it has the largest coverage, under 12 mo, 800 kcal; 12 to 24 mo, 950 kcal; 2 to 3 y, 1000
presently approximately 1.2 million children under 6 y and kcal; 3 to 5 y, 1150 kcal. If a nutritional deficit is detected,
200,000 pregnant women. This corresponds to approximately a reinforcement of 150 kcal/d is provided (37). As demon-
80% of the national population of infants under 2 y and 70% strated in Figure 4A and B this program has contributed
of preschool children, pregnant and nursing mothers. most likely to the notable decrease in stunting observed in
The main objectives of the PNAC are: to promote normal
growth and development in children from conception through
6 y of age by providing food supplements to the mother during
pregnancy and lactation, and to the child from birth to 6 y of
age; to protect mother’s health during pregnancy and lacta-
tion; to promote breast feeding by providing supplements to
mothers during pregnancy and lactation; to prevent low birth
weight related to maternal malnutrition; to prevent infant and
childhood malnutrition among the beneficiaries of the NHS;
and to improve coverage of primary health care activities, thus
providing an incentive for beneficiaries to attend regular
check-ups (35). Within the activities of the PNAC the en-
hanced program was specifically designed for the early control
of undernutrition. The calorie contribution provided by this
program varies from 100% of the requirement for infants of 5
mo old to 30% for children between 2 and 6 y of age. The
protein contribution is considerably higher, 180 and 58%, FIGURE 3 Change in length for age Z score on entry and after 12
respectively. mo of participation in enhanced supplementary feeding program in
Table 3 provides the results of a controlled evaluation stunted and nonstunted infants. A group matched by growth indices on
conducted by Kain et al. (35) in a group of 1149 infants in entry who did not receive the program served as controls. (Data from
which weight-for-length Z-score categorization on entry into Ref. 36.)
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TABLE 4
Distribution of weight-for-height Z scores of children
beneficiaries of JUNJI on entry and after 3 y of program1

Weight for height after 3 y of program


Weight for height
on entry ⱕ ⫹1 ⬎ ⫹1 to ⱕ ⫹2 ⬎ ⫹2 Total

ⱕ ⫹1 67.8% 24.1% 8.1% 6238


⬎ ⫹1 to ⱕ ⫹2 23.7% 42.5% 33.8% 1440
⬎ ⫹2 14.5% 26.0% 59.6% 408
Total 4715 2160 1211 8086

1 From Ref. 38 [Rojas and Uauy (1999)].

tering primary schools, more in girls than in boys. We also


evaluated the change in percentage of children over 2 Z in
weight-for-length between March (school entrance) and
November (final month of school year) for each age group
under JUNJI’s program. We observed, as shown in Figure 5,
a rise in obesity rates during the school year, progressively
higher with each age cohort. Finally, we obtained retro-

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spective data from 8086 children who had been measured
every year under standardized conditions to evaluate this
cohort, mimicking a longitudinal follow-up (38). This is
summarized in Table 4, demonstrating that at the time of
entry into the program a total of 408 exceeded ⫹2 Z in
terms of weight-for-height, whereas 3 y later 1211 exceeded
that limit. That is a threefold increase in the number of
FIGURE 4 (A) Change in percentage prevalence of nutritional def- obese children over a 3-y period. During this same period,
icit (⬍ ⫺1 SD; 39) in height for age, weight for age and weight for height the number of overweight children (over ⫹1 Z) went from
of preschool children during 1988 to 1996 in Chile; data derived from 1440 to 2160, that is, a 50% increase. On a more positive
census of children attending day care centers. (B). Change in mean Z note the program is presently adapting the food provided to
score weight for age (WHO reference) of 6-y-old children from 1987 to
the current nutritional profile of the preschool population.
1996 in Chile; data derived from census of children entering first grade.
Currently, sugar and saturated fat content of the ration
have been lowered, skimmed milk is being provided and
additional fresh fruits and vegetables have been added,
the preschool population during the past decade. The per- favoring the supply of calcium, micronutrients (iron and
centage of children below ⫺1 SD in terms of weight-for-age zinc) and fiber (39).
and height-for-age has dropped significantly, while those We conclude that Latin America is undergoing a rapid
with mild under weight are ⬍ 5% of the total. Concomi- nutritional transition with a progressive increase in the prev-
tantly over the same period (Fig. 4B), we observe that mean alence of obesity. The trends are most prominent among urban
weight for age has increased progressively for 6-y-olds en- poor women, although they affect both genders. The respon-
sible factors are changes in lifestyle and diet, which are similar
to those observed in industrialized societies. In addition the
protective environment of rural aboriginal populations has
been lost, demonstrating that these groups are possibly more
sensitive to the metabolic derangement associated with obe-
sity. Finally, we consider that nutrition intervention programs,
especially in stunted populations, have the potential for ag-
gravating the obesity epidemic. Weight-for-age definition of
undernutrition in children without assessment of length will
overestimate the dimension of malnutrition and neglect the
identification of stunted overweight children. As malnutrition
rates fall, the need to prevent overweight and obesity should
be considered of equal importance to the eradication of un-
dernutrition.

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