Risk factors for cardiovascular disease in Brazil: Time trends and current status
Marcia C. de Oliveira Otto,
14 Feb 2014
As in other emerging economies, chronic conditions such cardiovascular disease (CVD) and diabetes have emerged as the major causes of mortality in Brazil, accounting for 37% of deaths in the country. Although there has been a considerable reduction of smoking and physical inactivity, the epidemiological transition in Brazil is marked by trends toward unhealthy diet patterns and a poor cardio-metabolic profile. This is characterised by increased consumption of processed foods, as well as a higher prevalence of overweight individuals, obesity, impaired fasting glucose and diabetes, potentially reversing the decline in CVD mortality in the medium- to long-term.
Brazil has recently experienced political and economic changes that have greatly influenced its demography, social structure and lifestyle. As mortality and fertility rates decreased over the past 40 years, life expectancy in Brazil has increased from 52 to 73 years of age; the proportion of people living in urban settings has increased from 55% to 80%; and the percentage of Brazilians with higher education (≥ 10 years of formal schooling) has nearly doubled . The modern Brazilian population is predominantly non-white, older and has a greater proportion of middle class inhabitants compared to 1970 . As in other emerging economies, chronic conditions such cardiovascular disease (CVD) and diabetes have emerged as the major causes of mortality in Brazil, accounting for 37% of deaths in the country [3, 4]. Improvements in health care quality and access over the past two decades have successfully contributed to the reduction of CVD mortality ; however, current trends in lifestyle and metabolic risk factors show a shift toward unhealthy dietary patterns and poor metabolic health. This may reverse the decline in CVD mortality in the medium- to long-term. Understanding time trends and the current status of modifiable risk factors relevant to cardio-metabolic health may provide relevant information to inform strategies focused on disease prevention in Brazil.
Increasing income and the availability of highly processed foods in Brazil, among other factors, have influenced the dietary patterns in the country, particularly in urban environments. Between 1999 and 2009, the household income per capita in Brazil increased by 25% [2, 5], which paralleled an increase in dining out . Between 1974 and 2009, there was a 15% decrease in energy intake from rice, and a 33% decrease in energy from beans, two of the major traditional food staples in the country [7-9] (Figure 1). Similarly, a considerable decrease in mean energy intake from vegetables (27%) and fish (20%) were observed during the same period. There was, however, a substantial increase in energy intake from less healthy foods such as processed meat (102%) and ready-to-eat meals (250%) (Fig.1). Data from the same study suggests that diet patterns differ according to income levels. As purchasing power increases, Brazilians tend to consume less rice, beans and fish, and more red meat, processed meat and ready-to-eat meals . Higher income levels were also associated with higher consumption of vegetables, fruit and fruit juices, dairy products and alcohol  (Fig 2). Overall, time trends and analysis by income levels are consistent with a transition to lower consumption of traditional Brazilians foods and higher consumption of industrialised foods, as well as increased consumption of vegetables and fruits among Brazilians in higher income strata.
Figure 1: Energy intake from different foods in Brazil, 1974-2009 (Source: Levi-Costa et al., 2005 and Levy et al., 2012 [7, 9])
Figure 2: Energy intake from selected foods by income levels in Brazil (2002-2003)( Source: Levi-Costa, 2005)
High body-mass index and obesity
Consistent with a worldwide trend, the prevalence of overweight and obesity has increased considerably in Brazil in recent decades. Results from surveys using anthropometric measurements in a nationally representative sample showed an over 2 fold increase in the prevalence of overweight (from 18.5% to 50.1%) and a 4-fold increase in the prevalence of obesity (2.8% in 1975 to 12.4% in 2008) among adult men between 1975 and 2008. During the same period, the prevalence of overweight in adult Brazilian women increased from 28.7% to 48%, while the prevalence of obesity in women doubled [6, 10]. A study evaluating income-specific trends reported that changes in the prevalence of obesity in Brazil between 1975 and 1989 were 66% higher in men in the lower quintile of family income, compared to those in the highest quintile . Consistent with the changes observed in adults, one third of Brazilian children between 5-9 years of age were overweight in 2008, with 17% obese boys and 12% obese girls  (see Figure 3). Excessive adiposity is higher in children living in urban areas, as well as in the southeast, the region with the highest population density in the country. On the other hand, between 1974 and 2009, childhood under nutrition assessed as low height for age decreased from 29% to 7% in boys and from 27% to 6% among girls 5-9 years of age [6, 10].
Figure 3: Prevalence of overweight and obesity among Brazilian children 5-9 years of age 1974-2009, source: Melo et al. 2010
Very few studies have reported lipid levels in the Brazilian population. According to a recent report from the World Health Organization, the prevalence of high total cholesterol levels (≥5.28 mmol/L) among Brazilian adults in 2008 was approximately 43%, with no major differences between men and women . Data from 1980 to 2008 showed no major changes in the mean total cholesterol levels over the years, which suggests that recent improvements in health care have not affected hypercholesteromia levels in the country . In a study which included over 1,500 children 7-14 years of age living in the large city of Campinas, the prevalence of high total cholesterol was 11% among girls and 8% among boys. Compared to boys, girls had higher mean triglycerides and a total HDL-C ratio , which is a predictor of cardiovascular disease risk in adult populations.
High fasting glucose and diabetes
In a multi-centre study conducted in 1988 which included over 20,000 participants ages 30-69 years old living in 9 large cities in Brazil, the prevalence of each type II diabetes and impaired glucose tolerance was approximately 8% . Nearly 46% of diabetes cases had not been diagnosed before, and 23% of previously diagnosed cases were untreated. The study showed no major differences in age-adjusted diabetes prevalence across sex, race or social-economic status categories . Two cross-sectional studies which included participants of similar ages have subsequently been conducted in two large cities located in the state of Sao Paulo. In 1997, in Ribeirao Preto the prevalence of diabetes and impaired fasting was 12% and 8% respectively . A study conducted in Sao Carlos in 2007 reported 13.5% of participants having diabetes and 5% having impaired fasting glucose levels . The prevalence of metabolic disorders among obese participants in Ribeirao Preto was over two times greater compared to the non-obese participants. In addition, the proportion of undiagnosed diabetes was 60% greater in obese participants compared to non-obese adults . The lack of recent national data on metabolic risk factors including blood lipids and fasting plasma glucose level by sex, age and geographic location is a major limitation to the understanding of the potential impact these variables have on cardio-metabolic mortality and morbidity.
Time and regional trends on hypertension (blood pressure >140/90 mmHg) in Brazil were recently reported in a systematic review including data from over 120,000 participants in cross-sectional and cohort studies . Combining data from studies published in different decades, investigators estimated the prevalence of hypertension as 36% in the 1980’s, 33% in the1990’s and 29% in the 2000’s . Although the authors suggested a trend toward a lower prevalence of hypertension in Brazil, there are limitations to the generalisation of early estimates that might prevent such a straightforward conclusion. In fact, results from a survey including adults living in 27 Brazilian state capitals reported a 3% increase in the prevalence of self-reported hypertension between 2006 and 2009 among men and women [17, 18]. The high prevalence of hypertension in Brazil and its potential impact on cardiovascular health suggests the need for appropriate measures to reduce the prevalence of this important CVD risk factor in the country.
Smoking and physical activity
Brazil was one of the first countries to implement national anti-tobacco policies. Pricing policies implemented between 1991 and 1993 lead to nearly 80% increase in the price of tobacco products, and a subsequent 20% reduction on tobacco use. A study using national household survey data reported age-adjusted smoking prevalence decreased from 35% in 1989  to 12.1% in 2012. In addition, the average daily number of cigarettes consumed by adults in Brazil decreased from 13.3 to 11.6 . The reduction in cigarette smoking consumption was similar across sex, living conditions (urban vs rural), education and income levels, which suggests a significant impact of anti-tobacco policies across different strata of society.
Although there has been a considerable reduction in work-related physical activity due to the use of modern technology in the work place , data from cross-sectional surveys in 27 state capitals showed a rise in physical activity in the country. In 2012, 35% of Brazilians met the WHO guidelines for physical activity (≥150 min/week of moderate to vigorous activity), an almost 2-fold increase compared to the estimates in 2006. In cross-sectional surveys including over 2,000 adults living in Sao Paulo city showed an increased prevalence of people meeting WHO guidelines for physical activity from 16% in 2002 to 61.5 % in 2008 . Improvements in physical activity levels were similar among men and women, and interestingly, the greatest change was observed among those in low income categories . According to the authors, changes in physical activity levels were largely influenced by the implementation of “Agita Brasil”, a national program to promote physical activity in 1997. Overall, improvements on national smoking prevalence and physical activity levels in large cities following implementation of health policies support the important role of population strategies to change behaviour.
Although there has been a considerable reduction of smoking and physical inactivity, the epidemiological transition in Brazil is marked by trends toward unhealthy diet patterns and a poor cardio-metabolic profile. This is characterised by increased consumption of processed foods, as well as a higher prevalence of overweight individuals, obesity, impaired fasting glucose and diabetes. Consistent with suboptimal lifestyle and health care management, recent data shows that 29% of Brazilian adults have hypertension and 43% have hypercholesteromia. In 2011, the Brazilian Ministry of Health launched a national plan to reduce the incidence of non-communicable chronic diseases, with focus on physical activity, tobacco control, food guidance and policy, treatment of diabetes and hypertension, cancer screening, and overall access to health care . Increasing engagement of other segments of the Brazilian society such as the media, the food industry, the service sector and education are necessary to the long term success of this strategy. In addition, the development of epidemiologic studies prospectively assessing relevant risk factors and their impact on health in different groups, including underserved populations, is essential to measure the effectiveness of this initiative, as well as to help design specific interventions for the prevention of cardio-metabolic disease in Brazil.
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