Third International 5 A Day Symposium
Berlin, January 14-15, 2003

The burden of nutrition-related non-communicable diseases in the developing world is shifting to the poor!

Carlos Monteiro
School of Public Health, University of Sao Paulo

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
1- Some definitions …
2- Conceptual framework
3- Empirical evidence
4- Policy implications

"NCDs are chronic,"
NCDs are chronic, non-infectious diseases. They include cardiovascular diseases, cancers, obesity, diabetes and other endocrine disorders, respiratory diseases, digestive diseases, bone diseases, mental diseases, etc.
NR-NCDs are NCDs whose causality involves nutritional risk factors, particularly unbalanced diets, sedentary life-style, and obesity. They include obesity itself, most CVDs, some cancers, diabetes, dyslipidaemia, musculoskeletal diseases,etc.

THE SOCIAL DISTRIBUTION OF NR-NCDs IN THE DEVELOPING COUNTRIES
2- Conceptual framework

DETERMINANTS OF OBESITY AND OTHER NR-NCDs

DETERMINANTS OF OBESITY AND OTHER NR-NCDs

DETERMINANTS OF OBESITY AND OTHER NR-NCDs

DETERMINANTS OF OBESITY AND OTHER NR-NCDs

THE SOCIAL DISTRIBUTION OF NR-NCDs IN THE DEVELOPING COUNTRIES
The social distribution of obesity and other NR-NCDs in a society essentially reflects differences in the physical, economic and socio-cultural environment surrounding the poor and the rich, but these differences are dynamic and dependent on the society stage of economic development.

The dynamic link between economic development, environment and social distribution of NR-NCDs.
The empirical question we intend to answer here is:
at what stage of economic development (and/or economic  globalization) the poor and the rich start to be equally exposed to obesity and other NR-NCDs and at what stage the burden shifts toward the poor?

THE SOCIAL DISTRIBUTION OF NR-NCDs IN THE DEVELOPING COUNTRIES
3- Empirical evidence

THE SOCIAL DISTRIBUTION OF NR-NCDs IN THE DEVELOPING COUNTRIES
Data sources:  anthropometric national surveys* of women at reproductive ages
(n=157, 844) conducted from 1992 to 2000 in 37 developing countries of Africa, Asia and Latin America
* Macro-DHS, World Bank-LSMS, Mexico and China Health and Nutrition Surveys

THE SOCIAL DISTRIBUTION OF NR-NCDs IN THE DEVELOPING COUNTRIES
Analyses:
a) country age-adjusted prevalence of obesity by SES (country-specific women education quartiles)
b) pattern of association between obesity and SES according to the country per capita GNP
c) predicted prevalence of obesity by SES at different GNP levels

WOMEN’S OBESITY AND SES
Sub-Saharan Africa: 1992-1999

WOMEN’S OBESITY AND SES
Sub-Saharan Africa: 1992-1999

WOMEN’S OBESITY AND SES
 Southeast/South/East Asia: 1996-1999

WOMEN’S OBESITY AND SES
  Central Asia: 1996-1999

WOMEN’S OBESITY AND SES
  Middle East: 1992-1998

WOMEN’S OBESITY AND SES
  Latin America and Caribbean: 1995-2000

"Pattern of association between obesity..."
Pattern of association between obesity and SES according to the country per capita GNP

WOMEN’S OBESITY AND SES AT DIFFERENT LEVEL OF ECONOMIC DEVELOPMENT (1992-2000)

"Predicted prevalence of obesity by..."
Predicted prevalence of obesity by SES at different GNP levels in a model with an interaction term between individual SES and country GNP level.

PREDICTED PREVALENCE OF WOMEN’S OBESITY BY  SES AT DIFFERENT LEVEL OF
ECONOMIC DEVELOPMENT (1992-2000)

OBESITY AND INEQUITIES IN HEALTH
IN THE DEVELOPING WORLD
   In sum: cross-sectional studies undertaken in the 90’s indicate that only at earlier stages of economic development the poor are protected against obesity and at intermediate stages (GNP per capita from US$ 1,500) the risk of obesity is actually higher for the poor than for the rich.

OBESITY AND INEQUITIES IN HEALTH
IN THE DEVELOPING WORLD
    But, due to the cross-sectional nature of the analyses, the hypothesis of the shifting of obesity toward the poor was not directly tested - this requires comparable cross-sectional surveys on obesity and SES repeated over time in the same population.

THE SHIFTING OF OBESITY TOWARD THE POOREST WOMEN
Southeastern  Brazil: 1975-1997

THE SHIFTING OF MALE OBESITY TOWARD THE MIDDLE INCOME GROUPS
Southeastern  Brazil: 1975-1997

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
4- Policy implications

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
4- Policy implications
The equity issue
Targeting of interventions
The content of interventions

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
The equity issue
Fighting obesity and other NR-NCDs in the developing world will contribute to reduce  inequities in health in some countries and to prevent them in others.

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
Targeting of interventions
Public policies to fight obesity and other NR-NCDs in the developing world will fail if they don’t effectively  reach the poor.

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
The content of interventions
To reduce or prevent obesity and other NR-NCDs and the inequities in health generated by them it is essential to narrow  the gap between the poor and the rich concerning not only the information needed to decide for healthier behaviours but also the environment that makes possible the adoption of these behaviours.

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
Example of physical  environment constraints to promote the consumption of fruits and vegetables among the poor in Brazil.

FRUITS AND VEGETABLES:
     a typical upper middle class selling point  in Sao Paulo city

Slide 35

Slide 36

FRUITS AND VEGETABLES:
     a typical lower middle class selling point  in Sao Paulo city

Slide 38

Slide 39

THE SOCIAL DISTRIBUTION OF NR-NCDs
 IN THE DEVELOPING COUNTRIES
Example of economic environment constraints to promote the consumption of fruits and vegetables among the poor in Brazil

RELATIVE CONSUMPTION OF FRUITS AND VEGETABLES BY INCOME DECILES
 Brazil  1997

FAMILY FOOD BUDGET SPENT WITH
FRUITS AND VEGETABLES.
Brazil  1997

FAMILY INCOME  SPENT WITH
FRUITS AND VEGETABLES.
Brazil 1997

COST PER CALORY OF SELECTED FOOD
 GROUPS FOR THE FIRST INCOME DECILE .
Brazil 1997