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Carlos Augusto Monteiro: From privation to excess of food

MIGUEL BOYAYANBrazilian society has lived through rapid and radical transformations in the field of nutrition over the last few decades. From hunger, which was the concern of the migrant Northeasterners up until the decade of the 1970’s, the country also began to live with the spectacle of obesity that threatens even the poorest classes of the population. The fifty- seven-year-old epidemiologist doctor Carlos Augusto Monteiro, has been dedicating himself for three decades to studying the so called phenomenon of “nutritional transition” in Brazil. He has been searching to understand the causes and identify the implications for the perfecting of public policies in the area of food, nutrition and health. To a large extent, having been able to count upon the research and publications of this researcher, Brazil is now being accorded the condition, recognized by the World Health organization (WHO), of being one of the countries in the world that has been improving its documentation and analysis on the phenomenon of nutritional transition.

A full professor at the Nutrition Department of the Public Health Faculty of USP and the scientific coordinator of the Epidemiological Studies Center in Nutrition and Health (Nupens), during the 1990’s, professor Monteiro led a FAPESP thematic project carried out by a team of epidemiologists, demographers, economists, sociologists and specialists in various areas of public health, concerning the characteristics and nature of the changes in the profile of the health and nutrition of the Brazilian population during the second half of the 20th century. The project was rounded off with the book Velhos e novos males da saúde no Brasil: a evolução do país e de suas doenças [Old and new health maladies in Brazil: the evolution of the country and its illnesses], which won the Jabuti Award for literature in 1995. Since 1997 professor Monteiro has been co-directing a task force of the International Union of Nutritional Sciences about nutritional transition and, in this function, dedicated himself in particular to unveiling the relationships existing between poverty and obesity in the developing countries.

Recently the researcher was at the epicenter of a polemic situation with the federal government by reason of a publication from the Brazilian Institute of Geography and Statistics (IBGE), according to which obesity has become a public health problem in the country that is much more serious than hunger, a scourge restricted to a few spots in the semi-arid Northeast. The publication, which had massive publicity, was produced by a team of researchers and technicians from the IBGE and the Ministry of Health, under the Monteiro’s leadership. The work was even criticized by the President of the Republic himself, who saw in the survey a challenge to the priority of his government in combating hunger. Monteiro has remained serene, but does not dodge the polemic situation. “I’m praying to common sense that Brazil isn’t a country that suffers from illnesses due to shortage, due to absolute misery. But when you objectively examine the evidence, you see that it’s not quite that way. Public opinion, unfortunately, doesn’t always lie on the side of scientific knowledge”, he says.

Married, a father of two daughters, and a grandfather with four grandchildren, r  Monteiro is not one of those doctors who nails down something and does the opposite in his personal life. He looks after his eating habits, likes to exercise frequently and underlines the importance of professors setting good examples for their students. Some time ago, when he was head of the Nutrition Department for the first time, he decided to create a smoke-free working zone, which was quickly followed by the other departments. “It seems like something of little importance, but it’s not. The professor exercises an important influence and it needs to be coherent It’s not acceptable that a public health professor smokes in corridors or munches sandwiches and drinks sodas in the middle of a lecture”, he says.

What is the specter of hunger in Brazil?
The WHO considers that the chronic deficiency of energy in a population acquires the connotation of a public health problem when the proportion of thin adults, or that is to say, with a body mass index below 18.5 kilograms per meter to the square (Kg/m2), is higher than 5%. Percentages of thin individuals between 5% and 10% must be seen as a signal of alert and they justify monitoring, while percentages up to 5% are normal and correspond to the fraction of thin people who normally exist in whatever population. The average percentage of thin individuals in the adult Brazilian population, according to estimates of the national anthropometric inquiry carried out by the IBGE in 2003, is some 4%, which does not place the chronic deficiency of energy as a public health problem in the country as a whole. Situations that justify monitoring the problem (6 to 7% of thin individuals) were found by the IBGE in the rural areas of the Northeast region, and in a general manner, among very low-income families, less than a quarter of a minimum salary per capita. Happily, in not a single region or income band were situations found in which the chronic deficiency of energy would represent an unquestionable problem of public health. A comparison of the 2003 inquiry with previous IBGE inquiries carried out in the decades of the 1970’s and 1980’s indicates a tendency of a drop in chronic energy deficiency and allows for the projection of a future close to the virtual elimination of the problem throughout all of the national territory. Although the problem still exists in the semi-arid Northeast and among the poorest families, the Brazilian situation today has nothing to do with that found, for example, in Haiti, Ethiopia or India, where 20%, 30% and up to 50% of adult individuals show clear signs of chronic energy deficiency.

Chronic energy deficiency and hunger? That’s to say they are the same thing?
Chronic energy deficiency is the modality of nutritional disturbance that gets closest to what the majority of people call hunger, with the advantage that we have objective indicators for its diagnosis within a population. Sometimes one uses the term hunger as synonymous with poverty, of the non-access of people to the basic necessities. Rather than helping, I believe that this free use of the word hunger confuses things and equates the problem to those who don’t have enough to eat, which, happily, are few and far between in the Brazil of today, and those who do not have adequate housing, sanitation, health assistance and quality of education. Unfortunately, there are still lots of these people around.

And what is the specter of obesity in Brazil?
Among men the trajectory of obesity is explosive throughout the country, with increases of 50% every fifteen years. Among women, the greatest increase occurred in the 70’s and 80’s, observed a certain stability in the 1990’s, except in the northeast region and among low income families, in which female obesity continued to rise. No matter what, in both sexes, four out of every ten adults in the country suffer from being overweight. Obesity is already the second highest factor that kills and causes illnesses in Brazil. It lies only behind that of the alcohol consumption. The same IBGE inquiry of 2003 revealed a substantial increase in the saturated fats level in the eating habits of Brazilian, the maintenance of our absurdly high levels of sugar consumption and a geometrical increase in the consumption of processed foods rich in fat, salt and sugar, including biscuits, snacks, soft drinks and ready made meals. These factors are consistent with the highlighted role of obesity towards hypertension and high cholesterol in the profile of illnesses and mortality in the country.

The IBGE study in which you yourself participated, which showed that obesity in Brazil is a much more serious public health hazard than that of hunger, was criticized by the President of the Republic. What is your evaluation of the incident?
Many voices were raised for and against this survey. In all of my experience as a researcher, I can’t remember another survey having caused such major repercussions. One part of the polemic situation I put down to the fact that many declarations and opinions about the survey were made by people who apparently had not consulted the publication, but in truth they reacted to the declarations and opinions of others who as well had not read the publication. The other part of the confusion I attribute to the fact that the results revealed by the survey run contrary to a superficial vision, shall we say, of the true sanitary condition of the country. According to this vision, the greatest health problems of the Brazilian population originate from illnesses associated with shortage, with absolute poverty, whilst the problems relative to excess consumption, such as obesity, belong exclusively to the better off social classes. Anyhow, I believe that the IBGE survey fed, in a healthy manner, the debate surrounding Brazilian reality.

The reaction didn’t come from public opinion. It came from the government that has as its banner the fight against hunger…
The government’s reaction wasn’t homogenous. There were, yes, comments that tried to discredit the IBGE survey or at least the obvious implications that it brought with it, but there were also thoughtful and imbued reactions of a constructive nature. One needs to consider that the current government was elected having “combating hunger and poverty” as one of its largest if not the largest campaign slogan and also one has to take into account that the leading political party in the government has a long and recognized tradition in the fight involving social issues. All of this produces the idea of a certain infallibility of this government in everything that is referred to as the “social area”. It’s only that social policies are not made just by good intentions, there needs to be correct, unbiased diagnoses and analyses of the problems one intends to correct.

What’s your evaluation concerning the Zero Hunger Program?
At the beginning, centered on the food donation campaigns, on a parade of celebrities and on ideas that difficult to label, such as the demand for invoices as evidence of spending on food by the benefited families, it was in fact very weak. But the direction that the program took afterwards, emphasizing the transfer of income to families below the poverty line and giving incentive to the attendance of children at school and accompanying health through basic health clinics, was without doubt positive. Clearly these actions are directed basically to combat poverty and not hunger. But is poverty in the country sufficiently important for us to tolerate semantic impropriety?

Does combating hunger not include the food distribution?
As I have just mentioned, there are still regions with signs of chronic energy deficiency, mainly in the semi-arid region of the northeast. There the supply of food is unstable due to the question of drought and of an archaic economic structure, very much different from the rest of the country. There is as well the difficult and complex situation of the indigenous communities of the country. Eventually, in situations of cyclic emergency, you really have to think about assistance, in distributing food quickly and efficiently. The country will need to have these regional monitoring systems operating on the availability and consumption of food – which we don’t yet have – since hunger, when it occurs, is devastating and cannot wait. But it’s clear that the definite solution for these regions is not to distribute food. It’s to remove the causes that determine the problem, basically through instruments of local development.

Government authorities refer to a supposed fat hunger, which contemplates an association between obesity and starvation. Does this exist?
Yet again another example of semantic impropriety. This argument can’t be sustained. In Brazil, at least for now, the typical food of the poorest sector of the population is rice, beans, a vegetable and a little meat. The bean, for example, is an excellent food, relatively cheap, a source of proteins, micronutrients and fiber, and has nothing to do with obesity, on the contrary. From the point of view of the risk of obesity, the poor in Brazil, in general, tend to feed themselves better than the rich, since they consume less fats and less processed foods, which habitually have a high energetic density. However, this picture is different in the developed countries, where intense industrialization of food production cheapened the cost of feeding and turned processed foods more accessible than natural foods. We must be attentive, since this same situation could well occur in the future here in Brazil.

Why then the overreaction towards the hunger problem?
I believe that the political scientist could better reply to this question, but I’ll risk it and say that the dramatization of hunger and the fact that it mobilizes society more than poverty are elements that merit consideration.

Are there social policies that could be sacrificed through the super evaluation of the hunger problem?
Recently expressive resources were allocated in the Ministry of Health’s budget for the government’s program of income transfer. The argument used was that, through combating poverty, we’re combating hunger and thus we’re improving peoples’ health. But the Brazilian reality doesn’t correspond to this simplistic rational and, in fact, it’s highly probable that direct investments into the basic health network and in environmental sanitation would offer returns to the population’s health that are much greater than those associated with the transfer of income.

What’s the risk of looking only at hunger in a country in which obesity is advancing?
When you create a program of income transfer, or when the economy grows, people expand their capacity of consumption. What are they going to consume more? Studies have carried out concerning the relationship between income and food consumption indicate that it is highly probable that families of very low income will buy more food and that they will improve the nutritional quality of their food, diversify their diet and above all increase the meager consumption of products of animal origin, such as meat and milk products. These changes could improve the nutritional conditions and health of these people, in particular their young aged children. But the same thing can’t be said for families with incomes even below the point that were part of the clientele of the programs of income transfer, but not so low.

Why not?
Among these families the increase in consumption of products of animal origin could easily lead to an excess of the consumption of fats, in particular of fats that are prejudicial to health, the saturated fats. Also it’s highly probable that the consumption of processed foods will increase among these families that in general are of high calorific value, rich in fat, salt and poor in fiber and micronutrients. As well it’s probable that an increase in the consumption of alcoholic drinks and the quantity of cigarettes consumed by smokers will be observed. The habit of smoking in the country is concentrating itself more and more in the poorest segments of the population. In summation, there’s no security that the final effect of increasing the purchasing power of relative segments of the Brazilian population will result in an improvement in their nutritional and health conditions. Clearly an increase in the purchasing power of the population of low income could well produce more positive results for their conditions of nutrition and health, but we need to count upon more actions in the area on information and nutritional education of the population and also with fiscal and regulatory measures that make health foods such as fruit and horticultural products, for example, more accessible and lower the attraction of the less healthy foodstuffs.

What type of public policy would have the power to combat the problem of obesity?
In the first instance we need to recognize that the control of the advance of obesity is extremely complex and needs actions that run from agricultural modifications, which will make possible a greater offer of healthy foods, to changes in urban planning capable of stimulating the regular practice of physical activities in towns and cities. Fiscal measures that would make healthy foods more accessible and less accessible to non-healthy foods are indispensable, as well as regulatory measures that discipline the limits for marketing foods, completely prohibiting marketing directed towards children. A permanent and systematic effort to educate and to awaken the conscience of people about the importance of healthy foods and of the fight against an inactive lifestyle are obviously essential. In short, one can control obesity by supporting, protecting and promoting practices of  healthy living.

Which countries have managed to solve this equation?
There are very successful examples in developed countries that have managed to invert the growth of obesity or even to prevent it coming about as a public health problem. In the first case we have the example of Finland and in the second case the examples of Japan and South Korea. The parallel with the reduction in smoking conquered in the face of courageous public policies by various countries, including Brazil, is inevitable. In the decade of the 1960’s, more than half of the Brazilian male population were smokers. At the end of the 1980’s, when Brazil started systematic efforts to control smoking in the country, smokers were still around 40%, but now we know that only one in every four or five adults continues to smoke. It’s alleged very often that the economic power of the food industry is very great, but isn’t that of the tobacco industry just the same? Anyhow, starting from last year we have an important ally in the fight to control obesity and other chronic illnesses associated with non-healthy foods and an inactive lifestyle. This is the World Health Organization’s program named Global Strategy on Diet, Physical Activity and Health, which was discussed over various years by the scientific community and national governments, and finally approved by the World Health Assembly in May of 2004. The major advance within this strategy, which was strongly fought against by the United States and by other sectors opposing it from within the food industry, in particular sugar producers, is in admitting that information about more healthy choices concerning foods must be accompanied by government actions about the environment that makes these choices possible and easier, including fiscal and regulatory measures, which may not be appreciated by the economic sectors that profit from the consumption of non-healthy foods.

The IBGE research showed another reality: obesity advances, but there are sections of the population, such as middle class women, who are less fat than they were during the 1980’s, thus showing a rare example of an inversion of this tendency. To what do you attribute this?
Brazil is a country that is incredibly permeable to changes. At the same time that we were incorporating determined inadequate habits, non-healthy lifestyles, people were also taking in positive messages. This appears to have occurred with Brazilian women who have an educational background of high school or above. The 2003 survey provided evidence that throughout the country, with the exception of the northeast region, obesity among middle class women had stopped rising and had even begun to decline. The available data didn’t make it possible to know the reasons for this tendency, which as yet hasn’t been described in any other developing country. Anyhow t, in the male Brazilian population there’s no signal of the damping down of the growth of obesity within any of the social classes.

It’s said that the “Girl from Ipanema” is getting fat, as was suggested in the polemic article in the newspaper, The New York Times. Is this an injustice…
Completely absurd! Perhaps it was the Girl from Bangu (lower income neighborhood in Rio de Janeiro) , but certainly not the one from Ipanema.

 If hunger suffered a drastic reduction in Brazil during the decade of 1970, infant malnutrition was only diminished more recently, in the decades of the 80’s and 90’s. Why?
Malnutrition of the adult is in a general manner a problem of shortage, of the absolute lack of food. You only have hunger when misery is extreme. If the adult has food, even living in an unfavorable habitat, it will be difficult for him to show clinical signs of malnutrition. The increase in family income brought about by the growth in the Brazilian economy during the decade of the 1970’s was decisive in reducing the proportion of the adult population exposed to malnutrition. However, infant malnutrition has other determining factors as well as family income. In particular one can highlight the exposure of children to episodes of infectious illnesses that end up undermining the child’s nutritional state. And the main factors for the prevention of these illnesses – environment sanitation, basic health assistance and the educational level of the mothers – have only recently reached the poorest strata of the Brazilian population.

Is the Brazilian leading an inactive lifestyle?
In a survey that we made starting from another IBGE study carried out in the country during 1997, we showed that only 3% of adults follow the recommendations of doing physical exercise at least thirty minutes daily during the majority of the days of the week. Although in other countries, above all the developed countries, there are more people exercising, one can’t say that the country is a champion in sedentariness because one part of the population has jobs that demand spending energy regularly and intensely. Starting from a monitoring system via telephone interviews, which we’re testing at the moment in various capital cities of the country, we estimate that in the city of Sao Paulo the proportion of people completely sedentary, or that is to say who don’t do, with minimum regularity, any type of moderate or intensive physical exercise, goes beyond 50%. And, in the case of women, there’s an inverse relationship with their educational background, or that is to say,  the lower their educational background, the more frequent their sedentariness. This inverse relationship offers an interesting clue for understanding why the prevalence of obesity in poorer women supplants by two or three times the same prevalence in women who are better off. The study on standards and reasons for physical activity in the population is one of the major priorities for research into public health in the country.

And what can be done?
Well, the size and complexity of the nutritional problems in a society such as the Brazilian society are so large that at times it’s difficult to convince the formulators of public policies and those who take the decisions that it’s worthwhile investing in this area. As I said before, consistent actions in the area of the promotion of healthy foods are essentially, along with those that combine information and motivation with changes in the environment that allow for the choice of healthy options. At the end of 2004 we carried out a relatively simple experiment in a very poor community in the district of Grajaú, in the southern zone of the city of Sao Paulo. Firstly we carried out a field study that documented the poorness of this community in relation to the commercialization of healthy foods. The options for buying food that we found were practically restricted to small stores that sold processed food, such as rice, macaroni, tinned sardines and hot dogs. Fresh products, such as fruit and vegetables, were rare and when they existed were of very poor quality and highly priced. Next, we studied over a period of one month the standard of purchases and consumption of foods within a sample of families. The first part of the intervention that we implemented in the community consisted in offering to half of the selected families, information about feeding, nutrition and health and cookery classes that taught the preparation of healthy meals making more use of fruit, vegetables and legumes. In the second part of the intervention, extended to all of the families, we established a “portable store” that went around the streets of the community three times per week for four weeks selling fruit and fresh horticultural produce that were of good quality, having been purchases at the Ceagesp market. The evaluation of the impact of the intervention, which is still ongoing, indicates an increase of around 20% in the consumption of fruit and horticultural produce only with the educational activities and motivation and a 50% increase with the families who received full intervention. We’re carrying out this study with financing from the CNPq on research into food safety.

Do you yourself view the future with optimism?
A difficult question. For example, in the case of deficiencies in the supply of healthy foods and in the degree of information given to the population, I believe that the solution isn’t so difficult and will depend, above all, on the clear-sightedness of municipal governments and of the allocation of public investments. There’re other measures that can equally be taken that are going on in various Brazilian municipalities, such as the improvement in the nutritional quality of foods and the restriction of the sale of unhealthy foods in school canteens. But there’re other measures of public policy, equally necessary, which have found greater resistance in society and over which we have made very little advance. For example, measures that restrict the publicizing of non-healthy foods and totally prohibit propaganda on the television directed specifically at children, along the lines of that which has already been done in various other developed countries. There’s a project that has been lying dormant for some time in the Federal Senate, sponsored by senator Tião Viana, from the PT party of Acre State, whose approval could be an important sign of the concern of Brazilian parliamentarians and of the government with the process of nutritional transition through which our country is passing.