Community and International Nutrition

Obesity in Latin American Women and Children1,2,3

Reynaldo Martorell,4 Laura Kettel Khan,* Morgen L. Hughes and
Laurence M. Grummer-Strawn*
Department of International Health, The Rollins School of Public Health of Emory University, Atlanta, Georgia
30322 and *Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta,
Georgia 30341

ABSTRACT National surveys conducted since 1982 were used to assess maternal and child obesity in Latin
American and Caribbean countries and in U.S. residents of Mexican descent. Obesity in women, a body mass
index (BMI) ¢30 kg/m2, was 3% in Haiti, 8–10% in eight Latin American countries and 29% in Mexican Americans.
Median BMI for Latin American women were near or above the 50th percentile of the general U.S. population;
values exceeded the 75th percentile in the case of Mexican Americans. The prevalence of overweight (ú1 SD
above mean weight-for-height) in children 1–5 y of age ranged from 6% in Haiti to 24% in Peru among 13
countries. Overweight occurred in 24% of Mexican-American children. Prevalences of overweight in children and
of obesity in women were greater in urban areas and in households of higher socioeconomic status. Overweight
in children increased with higher maternal education; however, in some countries, obesity in women decreased
with higher education. No general pattern of change over time was observed in eight countries in overweight in
children. Obesity in women increased in the three countries with such data and in Mexican-American women and
children. There was a tendency for greater national incomes to be associated with greater obesity levels in women
and with lower levels of stunting in children. Levels of obesity in the region indicate a public health concern,
particularly among women, considering that studies have identified mortality and morbidity risks associated with
obesity in adults. J. Nutr. 128: 1464–1473, 1998.

KEY WORDS: • overweight • obesity • Latin America and Caribbean • Mexican Americans

Undernutrition remains the nutrition problem of greatest
concern in developing countries. However, there is increased
recognition, particularly in Latin America, that dietary pat-
terns and lifestyles are changing dramatically, and that as a
result, chronic and degenerative diseases are becoming im-
portant public health concerns (Monteiro et al. 1995, Popkin
1994, Sinha 1995, Walker 1995). These changes are occurring
at a time when undernutrition levels, although reduced over
the years, still afflict large sectors of the population (Adminis-
trative Committee on Coordination/Sub-Committee on Nutri-
tion 1992 and 1997).
Popkin (1994) notes that authors have emphasized the de-
mographic (i.e., from high fertility and high childhood mortal-
ity to low fertility and low childhood mortality) and epidemio-
logic (i.e., shift in causes of mortality from infections to
chronic diseases) changes occurring in many developing coun-
tries while neglecting what he calls the concurrent ‘‘nutrition
transition.’’ The latter includes adoption of ‘‘Western’’ diets
(i.e., high in saturated fats, sugar and refined foods) and in-
1
Presented in preliminary form at the XI Congreso de la Sociedad Latinoamer-
icana de Nutrición, November 9–15, 1997, Guatemala City, Guatemala.
2
Supported by the Food and Nutrition Program of the Pan American Health
Organization and by the World Bank.
3 5
The costs of publication of this article were defrayed in part by the payment
of page charges. This article must therefore be hereby marked ‘‘advertisement’’
in accordance with 18 USC section 1734 solely to indicate this fact.
4
To whom correspondence should be addressed.
creases in levels of fatness and obesity. In addition to diet,
reduced levels of physical activity, increased use of alcohol
and tobacco and increased stress, particularly in the rapidly
growing cities of developing countries, are among the determi-
nants of obesity and other chronic and degenerative diseases.
Obesity is increasingly recognized as a growing problem
in Latin America. Using national survey data from Brazil,
researchers have shown that obesity increased between 1974
and 1989 in adults (Monteiro et al. 1995, Sichieri et al. 1994)
but not in children (Monteiro et al. 1995). Defining obesity
as a body mass index (BMI)5 ¢30 kg/m2, prevalences increased
from 2.5 to 4.8% in men and from 6.9 to 11.7% in women
(Sichieri et al. 1994). Obesity increased with family income
in children (Monteiro et al. 1995) and adults (Monteiro et al.
1995, Sichieri et al. 1994). However, the relationship between
adult obesity and income was nonlinear; at low and middle
income levels, obesity increased with income but at high levels
the pattern was reversed, just as in developed countries (Mon-
teiro et al. 1995). Results from the 1988 National Nutrition
Survey of Mexico suggest that obesity in women was as com-
mon in Mexico as in the United States in the 1970s (Hernan-
dez et al. 1996). Approximately 17% of Mexican women aged
Abbreviations used: BMI, body mass index; DHS, Demographic and Health
Surveys; GNP, gross national product; NCHS, National Center for Health Statis-
tics; NHANES, National Health and Nutrition Examination Survey; PI, poverty
index; SES, socioeconomic status.

0022-3166/98 $3.00 q 1998 American Society for Nutritional Sciences.

Manuscript received 4 February 1998. Initial review completed 13 March 1998. Revision accepted 5 June 1998.

1464

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 OBESITY IN LATIN AMERICA
12–49 y exceeded the 85th percentile, or a BMI of Ç27 kg/
m2, of the distribution found in women measured in the 1976–
80 Second National Health and Nutrition Examination Sur-
vey (NHANES). The Ministry of Public Health of Costa Rica
reported increases at the national level in the prevalence of
obesity (¢25 BMI) between 1982 and 1996 of 34.6–45.9%
(Ministerio de Salud 1997). National surveys in different Ca-
ribbean countries found that 7–20% of males and 22–48% of
females ú15 y of age exceeded 120% of reference weight for
height, or a BMI of Ç27 kg/m2 (Sinha 1995). In addition,
serial data from Barbados showed increases in the prevalence
of obesity from 7 to 16% in males and 33 to 38% in females
between 1969 and 1981 (Sinha 1995).
Results from studies of selected samples complement those
from national surveys. In Costa Rica, 14% of men in a rural
area exceeded 130% of reference weight for height (i.e., a BMI
of Ç30 kg/m2) compared with 21% in an urban area; in
women, the corresponding values were 33 and 39% (Campos
et al. 1992). In Santiago, Chile, the prevalence of obesity,
defined as ú120% of reference weight for height, was 20% in
men and 30% in women (Atalah 1993). Although socioeco-
nomic status (SES) was unrelated to obesity in men, it was
related negatively in women such that levels were Ç10% for
high SES and 40% for low SES. There was also an interaction
with stature; the highest prevalence of obesity was found
among low SES women of short stature, nearly 50% (Atalah
1993). In a study of school children from Santiago, the preva-
lence of obesity, defined as ú120% of reference weight for
height, was 8.9% and increased as a function of income (Iva-
novic et al. 1987). In an urban community from Trinidad,
Beckles et al. (1985) found that obesity, defined as a BMI
¢30, was greater in women than in men and greatest among
those of African descent. Obesity was present in 8, 7 and 4%
in men of African, mixed and Indian ancestry, respectively;
in women, the values were 32, 29 and 25%, respectively.
The above results suggest that obesity is a problem in Latin
America, particularly in women. However, varying definitions
of obesity and different age ranges of the subjects studied make
cross-country comparisons difficult. Also, estimates of obesity
have been reported for only a few of the many national nutri-
tion surveys that have been carried out in the region. This
omission reflects the fact that most surveys have been used
to provide information about undernutrition in women and
children. The scarcity of information on men and school age
children also reflects the focus of most nutrition surveys on
women and young children.
It is important for policy makers to have accurate informa-
tion not only about the level of obesity at the country level,
but about how values vary across subgroups of the population
as defined on the basis of region, urban/rural residence, levels
of education and socioeconomic status. Also useful to policy
makers is information about changes in the extent of obesity
over time.
The primary objective of this study is to estimate preva-
lences of obesity in women and children from Latin American
countries based on national survey data collected since 1982.
Uniform definitions of overweight and obesity are used to
facilitate comparison across countries. A second objective is
to investigate how obesity varies by area of residence, socioeco-
nomic level and education. A third objective is to estimate
trends in obesity.
METHODS
National nutrition surveys from Latin America and the Caribbean
collected since 1982 were the focus of study. These surveys typically
/ 4W43$$5038 08-04-98 14:06:35
1465
contain height and weight information for children õ5 y of age,
sometimes for women of reproductive age (15–49 y) and almost never
for men. Most surveys used were collected by the Demographic and
Health Surveys (DHS/IRD, 1992) program, which has assisted coun-
tries since 1984 in conducting national surveys on fertility, family
planning, and maternal and child health (Institute for Resource De-
velopment/MACRO International 1990). In these surveys, women
of childbearing age were interviewed or measured with the use of
standard survey instruments; the areas of data collection were family
planning knowledge, attitudes and practices; maternal and child
health; nutritional status of women and their children; and social
and economic background indicators (Institute for Resource Develop-
ment/MACRO International 1990). DHS surveys are available to
investigators through the World Wide Web [http://www.macroint.-
com/dhs/].
We used 16 DHS data sets from 9 Latin American and Caribbean
countries, data from 8 other national nutrition and health surveys
from 5 Latin American countries, and data from Mexican Americans
(i.e., persons of Mexican origin living in the United States) who
were included in two national nutrition and health surveys from the
United States (Table 1). All 26 data sets included anthropometric
data for children but only 14 data sets contained anthropometric data
for women (Table 1). Information about Mexican Americans was
included for comparison because this population, of Latin American
origin, has a diet and a lifestyle characteristic of an industrialized
country. Not all national surveys carried out in Latin America since
1982 were accessible to us. However, those included constitute the
largest compilation ever assembled to assess the extent of obesity in
Latin America and the Caribbean.
The variables of interest in women were height, weight, age, fam-
ily, socioeconomic status, residence (urban or rural) and education.
Only records with complete data for all variables were used. The age
range in women was restricted to between 15 and 49 y, the focus of
virtually all available national surveys. Pregnant women were ex-
cluded. Children 12–60 mo of age were selected for study, but some
surveys provided data only for children 12–36 mo. Anthropometric
Z-scores were computed for children relative to the WHO/National
Center for Health Statistics (NCHS) reference population (Dibley
et al. 1987) using the Anthropometric Software Package Tutorial
Guide and Handbook (Jordan 1990). Records with height-for-age,
weight-for-age, or weight-for-height Z-scores ú /5 or õ 05 were
excluded from the analyses. Populations õ5000 were designated as
‘‘rural’’ and those above as ‘‘urban’’ in the DHS datasets; similar
criteria were applied to non-DHS datasets. Maternal education was
coded as low (primary school or less) and high (at least 1 y of second-
ary schooling). An index of socioeconomic status (SES) was calcu-
lated for individual families in each dataset based on amenities (e.g.,
electricity or water), possessions (e.g., radio, television or bicycle)
and characteristics of the home (e.g., type of floor or roof). The
calculation was particular to each country and thus, the socioeco-
nomic index is not valid across countries; rather, it reflects relative
socioeconomic status within each country. The poverty index in the
datasets from the United States was generated by NCHS and is a
continuous variable based on income, estimates of living costs appro-
priate for the area of residence and date of measurement, and family
composition. A poverty index (PI) ¢1.0 implies that the family
should be able to meet its basic needs; a PI õ1 was used as the
definition of low SES.
Obesity in children was defined as weight-for-height Z-scores ú2
SD as recommended by WHO (1995). In addition, overweight in
children was defined as a Z-score value ú1 SD above the WHO/
NCHS mean weight-for-height. Wasting and stunting were defined
as Z-scores õ2 SD below the reference mean for weight for height and
height, respectively. By definition, Ç15.9% of cases in the reference
population were overweight and Ç2.3% were obese. Obesity in
women was defined as a BMI ¢30 kg/m2. Also, estimates were pro-
vided using the definition of ¢27.3 kg/m2 to facilitate comparison
with the literature and for grades 1, 2 and 3 of obesity as defined by
WHO (1990 and 1995) (1 Å 25.0–29.9, 2 Å 30.0–39.9 and 3
Å ¢40 kg/m2).
Sample weights were used in all cases where applicable. The analy-
ses of relationships between relative weight and SES, education and
area of residence focused on obesity (¢30 BMI) in women but on
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1466 MARTORELL ET AL.

TABLE 1
National nutrition and health surveys included in this study1

Survey Country Year

Demographic and Health Survey Bolivia 1989, 19942

Brazil 1896, 19962
Colombia 1986, 19952
Dominican Republic 1986, 1991,2, 19962
Guatemala 1987, 19952
Haiti 1994–19952
Paraguay 1990
Peru 1992,2 19962
Trinidad and Tobago 1987
Hispanic Health and Nutrition Examination Survey United States 1982–19842,3
Living Standard Measurement Nicaragua 1993–1994
Micronutrient Survey Honduras 19962
National Epidemiology and Family Health Survey Honduras 1991–1992
National Family Health Survey El Salvador 1993
National Health and Nutrition Survey Brazil 19892
National Nutrition Survey El Salvador 1988
Honduras 1987
Mexico 19872
Third National Health and Nutrition Examination Survey United States 1988–19942,3

1 All surveys contain child anthropometry data.

2 Also contains maternal anthropometry data.
3 Data for Mexican Americans only.

overweight (ú1 SD) in children because the prevalence of obesity
(ú2 SD) in children was low and statistical power consequently poor.
Odds ratios for overweight or obesity (0 Å No, 1 Å Yes) were esti-
mated in multivariate logistic regressions that included area of resi-
dence (0 Å rural, 1 Å urban), SES (0 Å low, 1 Å medium or high)
and education (0 Å none or primary, 1 Å secondary or higher) as
independent variables. In analyses of overweight in children, gender
(0 Å male, 1 Å female) and age in months were included as additional
covariates. In analyses of obesity in women, age and age squared were
included in the models because these provided a better fit than age
alone. Multivariate analyses were restricted to the most recent na-
tional survey when countries had more than one survey. Statistical
significance was defined as P õ 0.05.
Trends for overweight in children were estimated for eight Latin
American countries and for Mexican Americans. In two countries,
Guatemala and Colombia, children 12–36 mo of age were measured
in the first survey and children 12–60 mo of age were measured in
the second survey. Restricting the second survey to 12–36 mo pro-
vided similar results to those for 12–60 mo, reflecting that overweight
prevalences are similar over the 12- to 60-mo range. Unfortunately,
trends in obesity in women could be estimated only for three Latin
American countries and for Mexican Americans.
Finally, analyses were carried out at the country level to explore
whether overweight and obesity varied by the level of child stunting
or the gross national product (GNP) per capita in 1992. Information
about national incomes was obtained from the State of the World’s
Children, 1995 (UNICEF 1995).
RESULTS
Obesity among women. Sample sizes, age and anthropo-
metric characteristics of the women are given in Table 2.
Mean ages were very similar across surveys, but body sizes
varied markedly. Women from Guatemala, Peru and Bolivia
were very short in comparison to women from Haiti and the
U.S. Mean BMI were between 23 and 25 kg/m2 for all but
Mexican Americans who were the heaviest at 27.1 kg/m2 and
Haitian women who were the leanest at 21.2 kg/m2. Similarly,
the extent of obesity (¢30 BMI) was lowest for Haitian (2.6%)
and greatest for Mexican-American women (28.7%). The
range in the prevalence of obesity was 5–40% when a BMI
¢27.3 kg/m2 was used as the criterion for obesity. Defining
/ 4W43$$5038 08-04-98 14:06:35
obesity as a BMI ¢25 kg/m2, as in the WHO classification,
led to large numbers of women being classified as obese, spe-
cifically, over one third of Latin American women and more
than one half of Mexican-American women.
Median BMI values at various ages for each sample are
plotted in Figure 1 relative to the U.S. distribution published
by Frisancho (1990), which is based on data from the first
(1971–1973) and second (1976–1980) National Health and
Nutrition Examination Surveys (NHANES). Medians for all
countries, with the exception of Haiti, were near or above the
50th percentile of the U.S. distribution. Mexican American
women had medians that were closer to the 75th percentile,
whereas medians for Haitian women were closer to the 25th
percentile.
The percentage of obese (BMI ¢30) women is given in
Table 3 by area of residence, SES, and educational level. The
risk of obesity (BMI ¢30) by category of the social variables
is given in Table 4. Results from unadjusted models (see Table
4, footnote 1) indicate that obesity was 1.5–4 times more
common in urban areas except in Brazil, Colombia, Mexico
and the U.S. where obesity rates were similar in urban and
rural areas. High SES and obesity covaried in all samples ex-
cept among Mexican and Mexican-American women where
SES bore no relationship to obesity. Better education was asso-
ciated with greater obesity in Haiti, Guatemala and Peru, some
of the poorest countries, but there was no relationship in Bo-
livia, Colombia, the Dominican Republic, Honduras and in
Mexican Americans; in Brazil and Mexico, there was more
obesity in poorly educated women. Multivariate models atten-
uated the associations, particularly for education. Controlling
for area of residence and SES, there was a tendency for higher
prevalences of obesity in poorly educated women except in
Haiti and Guatemala where more education was associated
with increased obesity. Urban residency and high SES were
strongly and independently related to greater levels of obesity
in most countries. Only in Mexican Americans were all three
social variables unrelated to obesity levels.
Overweight and obesity in children. Sample sizes, age, and
anthropometric characteristics are given for children in Table
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 OBESITY IN LATIN AMERICA 1467

TABLE 2
Age and anthropometric characteristics of Latin American and Caribbean women 15–49 y old

Obesity Obesity Obesity

Body Obese Obese grade 1 grade 2 grade 3
Sample mass (¢27.3 (¢30 (25.0– (30.0– (¢40
Country (year) size Age1 Weight1 Height1 index1 BMI) BMI) 29.9 BMI) 39.9 BMI) BMI)

y kg cm (kg/m2) %

Bolivia (1994) 2347 28.6 (7.0) 55.4 (9.3) 151.0 (5.8) 24.3 (3.7) 16.8 7.6 26.2 7.1 0.5
Brazil (1996) 3158 28.2 (6.5) 58.6 (11.1) 156.3 (6.5) 24.0 (4.3) 19.8 9.7 25.0 9.3 0.4
Colombia (1995) 3319 28.3 (6.7) 58.4 (10.1) 154.5 (6.0) 24.5 (4.0) 21.6 9.2 31.4 8.9 0.3
Dominican
Republic (1996) 7356 28.9 (9.6) 59.8 (12.5) 156.8 (6.4) 24.3 (4.9) 23.3 12.1 26.0 11.3 0.8
Guatemala (1995) 4978 28.9 (7.2) 53.1 (10.1) 148.1 (6.3) 24.2 (3.9) 17.9 8.0 26.2 7.5 0.4
Haiti (1994/1995) 1896 30.1 (7.5) 53.2 (9.3) 158.4 (7.0) 21.2 (3.4) 5.2 2.6 8.9 2.6 0.0
Honduras (1996) 885 30.0 (8.2) 54.4 (12.2) 152.1 (6.3) 23.5 (4.7) 18.7 7.8 23.8 7.3 0.5
Mexico (1987) 3681 28.9 (8.7) 57.7 (10.5) 156.2 (5.5) 23.7 (4.3) 20.0 10.4 23.1 9.8 0.6
Peru (1996) 10747 29.5 (6.8) 56.7 (8.8) 150.4 (5.6) 25.1 (3.6) 22.8 9.4 35.5 9.0 0.4
United States2
(1988–1994) 1404 29.4 (10.8) 67.7 (17.1) 158.1 (6.6) 27.1 (6.7) 39.9 28.7 26.5 24.5 4.1

1 Means (SD).
2 Data for Mexican-American women only.

5. Stunting was pronounced in several countries, whereas wast-
ing was less common. The country with the greatest proportion
of stunted children was Guatemala (56%); the highest propor-
tion of wasted children was observed in Haiti (8%). The per-
centage of overweight children (Z score ú 1 for weight-for-
height) or obese (Z score ú 2) was highest in Mexican Ameri-
cans and lowest in Honduras and Haiti. The samples with
higher rates of obesity than the 2.3% value found in the refer-
ence population were the U.S. Mexican Americans (7.4%),
Peru (4.7%), the Dominican Republic (4.6%), Brazil (4.1%),
Mexico (3.9%) and Paraguay (2.7%).
The percentage of overweight children is given in Table 6
by area of residence, SES, maternal education and gender. As
in the case of women, the risk of overweight is given by cate-
gory of each social variable in Table 7. In general, social
variables were not as strongly related to relative body mass in
children as they were in women. Urban residency, high SES
and greater maternal education were associated with greater
risk of overweight in children in most countries.
There was a tendency for obesity to be 10–20% more com-
mon in girls than in boys, but this was significant only in the
Dominican Republic, Guatemala and Peru (Table 7).

FIGURE 1 Median body mass index of women 15–49 y old relative to the 25th, 50th and 75th percentiles (dashed lines) of the distribution in
the first and second National Health and Nutrition Examination Surveys (Frisancho 1990). The sample for the United States includes data for Mexican-
American children only.

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1468 MARTORELL ET AL.

TABLE 3
Percentage of obese [body mass index (BMI) ¢30] women from Latin America and the Caribbean and denominator by area of
residence, socioeconomic status (SES) and educational level1

SES Educational level

Area of residence
Medium or None or Secondary or
Country (year) Urban Rural Low high primary higher

Bolivia (1994) 9.8 5.1 1.9 9.8 7.4 8.0

1286 1061 681 1666 1410 937
Brazil (1996) 9.9 8.9 16.0 10.4 11.0 8.8
2440 718 609 2549 1408 1750
Colombia (1995) 9.2 9.1 6.0 9.8 9.9 8.7
2258 1061 502 2817 1527 1792
Dominican Republic (1996) 13.4 9.6 6.6 12.8 13.8 10.0
4450 2906 1038 6318 4501 2855
Guatemala (1995) 12.9 5.2 2.3 9.2 7.1 13.1
1302 3676 1010 3968 4457 521
Haiti (1994/1995) 4.8 1.4 1.1 3.2 1.5 9.5
782 1114 455 1441 1617 279
Honduras (1996) 13.0 4.8 0.4 9.6 8.1 6.6
406 479 171 714 698 187
Mexico (1987) 10.0 10.4 11.0 10.1 15.8 5.4
285 3396 1010 2671 1790 1891
Peru (1996) 12.1 4.6 3.1 11.2 8.2 10.4
6075 4672 2983 7764 5466 5281
United States2 (1988–1994) 27.1 31.0 29.5 28.1 35.5 27.0
807 597 567 837 312 1092

1 Percentages reflect sample weighting.

2 Data for Mexican-American women only.

Trends in obesity and overweight. Repeated surveys for
women were available for only four samples. Prevalences of
obesity (BMI ¢30) increased in all. In Brazil, values increased
from 7.6 to 9.2% between 1989 and 1996; small increases were
also observed in Peru between 1992 and 1996, 8.8–9.4%.
Greater increases occurred between 1991 and 1996 in the
Dominican Republic, 7.3–12.1%. Among Mexican Ameri-
cans, the increase in obesity from 1982–1984 to 1988–1994
was large, from 19.5 to 28.7%. More information is available
from repeated surveys for children. The percentage of over-
weight is plotted in Figure 2 for countries with data for more
than one survey. Overweight increased in Mexican Americans,
but the pattern was mixed for Latin American countries; some
reported increases and other decreases.
Relationship with stunting and national incomes. At the
national level, there was a significant relationship between the
level of overweight in children and per capita GNP (r Å 0.53,
P Å 0.05, n Å 14); however, excluding the data point for
Mexican Americans (identified as U.S. in the figures), an out-
lier in terms of income, reduced the correlation to 0.11

TABLE 4
Odds ratios for obesity [body mass index ¢ 30] (BMI); 0 Å nonobese, 1 Å obese] among women from Latin America and the
Caribbean as a function of area of residence, socioeconomic status (SES) and educational level

Unadjusted models1 Multivariate models2

Educational level Educational level

Area of residence SES (0 Å none/primary, Area of residence SES (0 Å none/primary,
(0 Å rural, (0 Å low, 1 Å secondary/ (0 Å rural, (0 Å low, 1 Å secondary/
Country (year) 1 Å urban) 1 Å med/high) higher) 1 Å urban) 1 Å med/high) higher)

Bolivia (1994) 2.15*** 6.12*** 1.30 1.39† 5.44*** 0.84

Brazil (1996) 1.15 1.80** 0.81† 1.04 2.03** 0.71**
Colombia (1995) 1.06 1.71** 0.93 0.96 1.90** 0.83
Dominican Republic (1996) 1.53*** 2.07*** 0.82** 1.53*** 1.86*** 0.68***
Guatemala (1995) 2.87*** 4.43*** 2.12*** 2.27*** 3.06*** 1.29†
Haiti (1994/1995) 3.99*** 3.77** 10.01*** 1.94† 1.57 6.82***
Honduras (1996) 2.97*** 28.89** 0.79 2.71*** 23.66** 0.43*
Mexico (1987) 0.93 0.90 0.59*** 0.84 1.00 0.58***
Peru (1996) 3.08*** 4.17*** 1.67*** 2.08*** 2.51*** 1.00
Unites States3 (1988–1994) 0.84 0.84 0.92 0.85 0.87 0.95

1 Unadjusted models include only age and age squared as covariates.

2 Multivariate models include age, age squared, area of residence, SES and educational level.
3 Data for Mexican-American women only.
† P õ 0.10; *P õ 0.05; **P õ 0.01; ***P õ 0.001.

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 OBESITY IN LATIN AMERICA 1469

TABLE 5
Age and anthropometric characteristics of Latin American children

Age Height/ Weight/ Weight/

range Sample age Z- age Z- height Z- % % % over- %
Country (year) (mo) size Age (mo)1 score1 score1 score1 wasting2 stunting2 weight2 obese2

Bolivia (1994) 12–35 1866 23.3 (6.8) 01.4 (1.4) 01.0 (1.2) 00.1 (1.1) 4.7 33.9 13.1 2.1
Brazil (1996) 12–59 3165 35.4 (13.6) 00.5 (1.3) 00.3 (1.2) 0.1 (1.0) 2.0 11.3 14.7 4.1
Colombia (1995) 12–59 3600 34.8 (13.6) 01.0 (1.1) 00.7 (1.0) 0.0 (0.9) 1.5 17.0 12.2 1.8
Dominican Republic (1996) 12–59 2984 34.9 (13.4) 00.6 (1.2) 00.4 (1.2) 0.1 (1.0) 1.2 11.5 15.3 4.6
El Salvador (1993) 12–59 2887 34.7 (15.5) 01.3 (1.3) 00.9 (1.1) 00.1 (1.0) 1.6 25.9 9.5 1.7
Guatemala (1995) 12–59 6477 34.6 (13.3) 02.1 (1.2) 01.4 (1.0) 00.2 (1.0) 3.5 56.1 10.0 2.0
Haiti (1994/1995) 12–59 2079 35.0 (14.1) 01.5 (1.5) 01.4 (1.2) 00.6 (1.1) 8.2 36.6 5.7 1.4
Honduras (1996) 12.1–60 1329 35.3 (14.4) 01.6 (1.4) 01.2 (1.1) 00.3 (0.9) 1.1 36.9 3.7 1.4
Mexico (1987) 12–59 5286 35.3 (14.8) 01.0 (1.7) 00.8 (1.3) 00.2 (1.3) 6.4 25.5 14.5 3.9
Nicaragua (1993/1994) 12–59 2581 35.4 (15.9) 01.3 (1.5) 00.8 (1.3) 0.0 (1.1) 2.1 28.2 12.1 2.2
Paraguay (1990) 12–59 2824 35.0 (13.4) 00.8 (1.2) 00.3 (1.0) 0.3 (0.8) 0.3 15.0 17.1 2.7
Peru (1996) 12–59 11796 35.5 (13.3) 01.3 (1.3) 00.5 (1.1) 0.4 (0.9) 1.1 29.2 23.9 4.7
Trinidad and Tobago (1987) 12–36 616 24.0 (7.3) 00.2 (1.1) 00.5 (1.2) 00.4 (1.0) 3.7 4.5 8.9 1.9
United States3 (1988–1994) 12–60 1359 36.2 (14.0) 0.1 (1.0) 0.3 (1.2) 0.4 (1.1) 0.4 1.9 23.7 7.4

1 Mean (SD).
2 Wasting defined as õ2 SD below the reference mean for weight for height; stunting defined as õ2 SD below the reference mean for height for
age; overweight defined as ú1 and obese as ú2 SD above the reference mean for weight for height.
3 Data for Mexican-American children only.

(P Å 0.72, n Å 13; Fig. 3). The relationship between percent- between the percentage of children stunted and the percentage
age of children stunted and GNP was negative and significant of children overweight was negative but not significant (r
(r Å 00.53, P Å 0.05, n Å 14), even after excluding Mexican Å 00.45, P Å 0.11, n Å 14); excluding Mexican Americans
Americans (r Å 00.61, P Å 0.03, n Å 13). The relationship gave similar results (r Å 00.29, P Å 0.34, n Å 13).

TABLE 6
Percentage of overweight (ú1 SD) children from Latin America and the Caribbean and denominator by area of residence,
socioeconomic status (SES), maternal education and gender1

SES Maternal education

Area of residence Gender
Medium None or Secondary
Country (year) Urban Rural Low or high primary or higher Male Female

Bolivia (1994) 15.3 10.6 10.2 14.1 12.1 14.5 12.3 13.9
983 883 553 1313 1133 733 942 924
Brazil (1996) 15.9 10.8 9.6 15.9 11.9 17.1 13.9 15.5
2366 799 731 2434 1544 1621 1631 1534
Colombia (1995) 13.9 9.4 6.6 13.4 10.9 13.6 11.5 13.0
2281 1319 637 2963 1817 1783 1812 1788
Dominican Republic (1996) 19.3 10.1 6.4 17.1 13.2 18.7 14.1 16.7
1540 1444 689 2295 1984 1000 1539 1445
El Salvador (1993) 10.8 8.4 6.7 12.0 7.8 14.0 9.0 10.1
1365 1522 1348 1539 2118 769 1465 1422
Guatemala (1995) 12.5 8.7 7.6 10.5 9.5 12.8 8.7 11.3
1532 4945 1363 5114 5926 551 3258 3219
Haiti (1994/1995) 6.8 5.2 5.6 5.7 5.5 7.2 5.4 6.0
748 1331 494 1585 1818 261 1048 1031
Honduras (1996) 8.5 3.1 2.0 5.9 4.5 8.2 5.3 4.8
598 731 277 1052 1107 222 692 637
Mexico (1987) 15.7 14.2 11.6 15.2 13.4 17.2 13.9 15.2
905 4381 766 4520 3560 1726 2715 2571
Nicaragua (1993/1994) 14.9 9.2 9.9 13.4 10.9 15.4 11.1 13.2
1295 1286 981 1600 1898 683 1299 1282
Paraguay (1990) 17.9 16.6 15.3 17.7 17.2 17.0 17.0 17.3
1055 1769 827 1997 2237 587 1464 1360
Peru (1996) 28.0 17.3 15.6 26.5 20.0 27.7 22.8 24.9
6315 5481 3591 8205 6497 5299 5891 5905
Trinidad and Tobago (1987) 11.2 7.5 8.4 9.1 8.1 9.9 11.1 7.0
241 375 119 497 322 294 288 328
United States2 (1988–1994) 24.4 22.5 25.6 21.7 26.9 22.4 24.4 23.0
863 496 742 617 404 955 673 686

1 Percentages reflect sample weighting.

2 Data are for Mexican-American children only.

/ 4W43$$5038 08-04-98 14:06:35 nutra LP: J Nut October

1470 MARTORELL ET AL.

TABLE 7
Odds ratios for overweight (ú1 SD; 0 Å nonoverweight, 1 Å overweight) among children from Latin America and the Caribbean as
a function of area of residence, socioeconomic status (SES) and maternal education

Unadjusted models1 Multivariate models2

Maternal Maternal
education education
Area of SES (0 Å none/ Area of SES (0 Å none/
residence (0 Å low, primary, 1 Å residence (0 Å low, primary, 1 Å Gender3
(0 Å rural, 1 Å med/ secondary/ (0 Å rural, 1 Å med/ secondary/ (0 Å male,
Country (year) 1 Å urban) high) higher) 1 Å urban) high) higher) 1 Å female)

Bolivia (1994) 1.54** 1.45* 1.23 1.44* 1.16 1.01 1.15

Brazil (1996) 1.57*** 1.79*** 1.53*** 1.21 1.45* 1.33** 1.14
Colombia (1995) 1.56*** 2.19*** 1.30** 1.27† 1.88*** 1.03 1.16
Dominican Republic (1996) 2.14*** 3.05*** 1.52*** 1.69*** 2.18*** 1.14 1.23*
El Salvador (1993) 1.32* 1.91*** 1.92*** 0.88 1.66*** 1.61*** 1.13
Guatemala (1995) 1.50*** 1.44** 1.39** 1.38*** 1.26† 1.13** 1.35***
Haiti (1994/1995) 1.33 1.02 1.36 1.32 0.88 1.24 1.13
Honduras (1996) 2.94*** 3.08** 1.89* 2.43*** 2.12† 1.22 0.95
Mexico (1987) 1.13 1.36** 1.34*** 1.25* 1.30** 1.32*** 1.12
Nicaragua (1993/1994) 1.72*** 1.40** 1.50*** 1.62*** 0.97 1.25† 1.21†
Paraguay (1990) 1.10 1.19 0.98 1.07 1.19 0.91 1.02
Peru (1996) 1.85*** 1.94*** 1.54*** 1.46*** 1.39*** 1.17** 1.12*
Trinidad and Tobago (1987) 1.61† 1.13 1.24 1.58*** 1.05* 1.17 0.60†
United States4 (1988–1994) 1.12 0.80† 0.78† 1.12 0.84 0.83 0.93

1 Unadjusted models include only age and gender as covariates.

2 Multivariate models include age, gender, area of residence, SES, and maternal education.
3 Odds ratios for gender for multivariate models; these are similar to those from unadjusted models.
4 Data for Mexican-American young children only.
† p õ 0.10; *P õ 0.05; **P õ 0.01; ***P õ 0.001.

Relationships with obesity in women were stronger. Obesity DISCUSSION

in women was related significantly to GNP (r Å 0.95, P
õ 0.001, n Å 10) but not after excluding Mexican Americans
(r Å 0.51, P Å 0.16, n Å 9; Fig. 4). The percentage of obesity
in women was negatively related to the percentage of children
stunted (r Å 00.66, P Å 0.04, n Å 10); the correlation coeffi-
cient was of similar magnitude but not significant after exclud-
ing Mexican Americans (r Å 00.55, P Å 0.12, n Å 9).
Women of reproductive age. The definition of obesity em-
phasized in this report, a BMI ¢30 kg/m2, is extreme. Yet we
find that with the exception of Haiti, where only 3% of women
were obese, the prevalence of obesity was between 8 and 10%
in eight other Latin American countries that we studied. Some
define obesity as a body mass index ¢27.3 kg/m2 in women

FIGURE 2 Trends in overweight (weight-for-height Z-score ú 1.00) among children (ú12 mo). The sample for the United States includes data
for Mexican-American children only.

/ 4W43$$5038 08-04-98 14:06:35 nutra LP: J Nut October

 OBESITY IN LATIN AMERICA
FIGURE 3 Relationship between overweight (weight-for-height Z-
score ú 1.00) among young Latin American children and gross national
product (GNP) per capita. When the United States (Mexican-American
data only) is included in the analysis, r Å 0.53, P Å 0.05.
and ¢27.8 kg/m2 in men, equivalent to Ç120% of desirable
weight according to 1983 Metropolitan Life Insurance Com-
pany height and weight tables (Kuczmarski et al. 1994, Solo-
mon and Manson 1997). If we use the criterion of obesity in
women of a BMI ¢27.3 and exclude Haiti, between 17 and
23% of women were obese in Latin America. Using the WHO
criteria, which considers grade 1 of obesity to begin at a BMI
of 25 kg/m2, prevalences of obesity (total of grades 1, 2 and
3) in Latin American countries other than Haiti were 34–
49%.
There is reason to be concerned about the levels of obesity
found in Latin American women. Overwhelming evidence
links obesity to a number of diseases, including diabetes melli-
tus, hypertension, dyslipidemia and ischemic heart disease; ad-
ditionally, a relationship is found with all-cause mortality (Sol-
omon and Manson 1997). Authors of a review of studies that
adjusted for effects of smoking and underlying disease con-
cluded that optimal weights in terms of mortality are well
below the commonly used cut-off points of a BMI ¢27.3 kg/
m2 for women and ¢27.8 kg/m2 for men (Solomon and Man-
son 1997). Using American Cancer Society data, analyses
show that mortality for both men and women begins to rise
among individuals with a BMI of 22–25 kg/m2 (Stevens et al.
1998). Thus, the criteria of a BMI ¢30 and a BMI ¢27.3
identify only the extreme groups at risk.
Mexican-American and African-American women are
among the heaviest in the United States (Kuczmarski et al.
1994). We found that nearly 29% of Mexican-American
women were obese (BMI ¢30) in the 1988–1994 survey, and
that this represented an increase over the prevalence of 20%
found in the 1982–1984 survey. Mexican Americans receive
special emphasis in U.S. surveys because they are the largest
Hispanic minority. Cuban Americans and Puerto Ricans living
in the U.S. were also included in the Hispanic Health and
Nutrition Examination Survey of 1982–1984. Obesity was
found to be high and similar in all three groups (Pawson et
al. 1991). Centralized obesity, usually identified through high
waist-to-hip ratios or through measures of greater fat deposition
in the trunk vs. the extremities, was greater in Mexican Ameri-
cans than among non-Hispanic whites (Kaplowitz et al. 1989).
Central accumulation of fat has been found to be adversely
related to morbidity and mortality outcomes (Solomon and
Manson 1994). The Latin American surveys analyzed did not
contain measures of relative fat deposition, and this remains
an issue for further research.
Trends in obesity were available only for Brazil, Peru and
/ 4W43$$5038 08-04-98 14:06:35
1471
the Dominican Republic. Levels of obesity in women increased
in all three countries. Other data from Costa Rica (Ministerio
de Salud 1997) and Barbados (Sinha 1995) also indicate in-
creasing levels of obesity among women. Additional surveys
are required to examine whether obesity levels are also rising
in men and in other countries. The high prevalences found in
Mexican Americans, furthest along in the nutrition transition,
suggest that a high priority should be assigned to monitoring
obesity levels in Latin America.
Children. Measuring obesity or overweight in children is
difficult because body proportions, bone mass, and the ratio
of lean-to-fat tissue changes during growth and maturation
(Troiano and Flegal 1998). Although BMI correlates well with
measures of adiposity, it is not as reliable a measure of fatness
in children as it is in adults (Troiano and Flegal 1998). Racial
and ethnic variation in these dimensions, for example, body
proportions, may also affect the interpretation of weight-for-
height indices (Martorell et al. 1987, WHO 1995).
An important question is the degree to which weight for
height predicts BMI in adulthood. Most of the studies to date
used BMI as the weight-for-height variable in childhood and
found that its predictive power was a function of age (Guo et
al. 1994, Serdula et al. 1993, Whitaker et al. 1997). In a
literature review, Serdula et al. (1993) found that the risk of
adult obesity was 2.0–2.6 times greater in obese preschool
children than in nonobese preschool children. Among school-
age children later examined as adults, the corresponding range
in risk ratios was 3.9–6.5.
Whitaker et al. (1997) found that young adult obesity was
associated with child obesity (defined as ú85 percentile) at
3–5 y of age but not at 1–2 y of age. However, these relation-
ships were considerably stronger in older children. Also, the
risk of adult obesity was increased when the mother or father
of the obese child was also obese.
Tracking in BMI also occurs in subjects from rural Guate-
mala (Schroeder and Martorell 1998). Correlations between
BMI measured at 12–42 mo of age and later during adoles-
cence (7–14 y) or adulthood (18–26 y) were Ç0.3. At Ç5 y
of age, the correlations between childhood and adolescent or
adult BMI were Ç0.4–0.5.
The levels of overweight and obesity found in Latin Ameri-
can children are lower than those in the United States today
but approach those of the WHO/NCHS reference population,
which are more reflective of conditions in the U.S. up to the
mid-1970s (Dibley et al. 1987). Despite the availability of
FIGURE 4 Relationship between obesity (BMI ¢30) among Latin
American women of reproductive age (15–49 y) and gross national
product (GNP) per capita. When the United States (Mexican-American
data only) is excluded from the analysis, r Å 0.95, P Å 0.0001.
nutra LP: J Nut October
1472 MARTORELL ET AL.
serial data for several countries, we could not discern a clear
pattern of change in overweight in Latin American children.
Finally, we call attention to the need for information from
national surveys on school-age children, a group not generally
included, in whom overweight and obesity would be a clearer
concern than among preschool children.
Obesity and social factors. In their review of the world
literature on the relationship between obesity and SES, Sobol
and Stunkard (1989) found that the prevalence of obesity in
adults and children increased with rising wealth in developing
societies. In developed societies, in contrast, prevalence is
lower with greater income, at least among women. Thus, devel-
oping countries in transition to greater wealth should be found
along a continuum that begins with a positive relationship
between obesity and SES in the poorest countries, to no rela-
tionship in those with middle incomes, to a negative relation-
ship in those with the greatest wealth. The pattern of relation-
ships between income and obesity described by Monteiro et
al. (1995) for different income levels of the Brazilian popula-
tion fits this expected pattern (see introduction).
Unfortunately, almost all of the surveys we analyzed lacked
measures of income. Furthermore, the socioeconomic indices
we calculated were specific to the country and relied on relative
wealth based on amenities, possessions and home characteris-
tics. Educational attainment of women and area of residence
were used as additional social variables. Despite the limitations
of our studies, the findings should still be of interest to scholars
trying to describe the relationship between SES or income and
obesity or overweight. We found that, in general, the patterns
of relationships among children were those expected for poor,
developing countries. Overweight in children tended to be
greater in urban areas, in families of higher SES and in house-
holds with higher maternal education. Relationships were
much stronger and more complex in women compared with
children. Obesity in women was more common in urban areas
in the poorest countries and was unrelated to area of residence
in the richest two (i.e., Brazil and Mexico) and in Colombia.
SES was related positively and significantly to obesity in
women in all Latin American and Caribbean countries except
Mexico. Controlling for SES and residence, obesity was more
common in women with higher education only in Haiti and
Guatemala, two very poor countries; in all other countries,
there was a tendency for more obesity in women with lower
education. On the other hand, no significant relationships
were observed between social variables and obesity in Mexi-
can-American women. In the context of the United States,
the Mexican-American population is of low socioeconomic
status and has one of the highest levels of obesity.
One limitation is that some countries show great variations
in wealth by region, and these analyses do not investigate
regional differences. Brazil and Mexico are perhaps the best
examples of countries with much intracountry variation.
Grouping countries as single entities, as we did, probably masks
patterns of relationships between social variables and obesity.
We wish to emphasize that obesity in women is less com-
mon, but is not rare, in rural areas and in poor households
and that there is a strong tendency for obesity to be more
common in poorly educated women. Because poor and rural
households represent significant proportions of the total popu-
lation, large numbers of obese women and children are found
among them. For example, on average, about a third of obese
women in Latin America come from rural areas. The social
mapping of obesity should be examined at the country level,
including examination by region, when contemplating possible
programs and policies. Even the limited information presented
here indicates that educational campaigns should be designed
/ 4W43$$5038 08-04-98 14:06:35
to meet the needs of a broad range of income and education
levels. In countries such as Brazil and Mexico, obesity can no
longer be dismissed as a condition of the elite, but viewed
rather as a concern of the disadvantaged.
Relationships with stunting and GNP. The analyses at
country level were limited by low statistical power such that
most relationships examined were not significant, particularly
after excluding the data for the U.S. In general, the results
suggest that greater national incomes are associated with
greater obesity levels in women and lower levels of stunting
in children. Also, there was a tendency for greater levels of
stunting in children to be associated with less obesity in
women and in children. These results are consistent with our
initial expectation that increased national wealth would be
associated with less undernutrition and greater obesity.
The results reviewed have important policy implications.
Prevalences of obesity (BMI ¢30) among women were be-
tween 8 and 10% in all countries except Haiti. These statistics
suggest an already existing public health concern. Although
the prevalences of overweight and obesity in children ap-
proached or exceeded that in the U.S. reference population
(Dibley et al. 1987) in a few countries, most countries had
low values. Because uncertainty remains about the significance
of overweight in children õ5 y of age, it is unclear what level
of concern to express about the results reported here.
Tackling the problems of overweight and obesity poses
enormous challenges for Latin American countries. First, many
of these countries still have high levels of undernutrition and
it is imperative that this issue remain a priority. In addition,
Latin American countries are not prepared institutionally to
deal with problems of diet and chronic disease. Professionals
assigned to diet and chronic disease within ministries of public
health are rare, even in countries where these problems are
large relative to those of undernutrition. Finally, consensus is
lacking about how to address diet and health problems in
developed countries (Blackburn and Kanders 1994). Achiev-
ing behavior change that leads to reduced obesity has proven
difficult in the United States and elsewhere; even when success
occurs, programmatic lessons must be made applicable to each
Latin American country. These are difficult issues that warrant
urgent discussion among researchers, public health prac-
titioners and policy makers.
ACKNOWLEDGMENTS
Helpful comments are acknowledged from Wilma Freire and Man-
uel Peña of PAHO and from Kenneth Resnicow, Richard Levinson
and Dirk Schroeder of Emory University.
LITERATURE CITED
Administrative Committee on Coordination/Sub-Committee on Nutrition (1992)
Second Report on the World Nutrition Situation. Volume I, Global and Re-
gional Results. ACC/SCN, Geneva, Switzerland.
Administrative Committee on Coordination/Sub-Committee on Nutrition (1997)
Update on the Nutrition Situation 1996. Summary of Results for the Third
Report on the World Nutrition Situation. ACC/SCN, Geneva, Switzerland.
Atalah, E. (1993) Análisis de la situación nutricional de la población de Santi-
ago. Rev. Méd. Chile 121: 819–826.
Beckles, G.L.A., Miller, G. J., Alexis, S. D., Price, S.G.L., Kirkwood, B. R., Carson,
D. C. & Byam, N.T.A. (1985) Obesity in women in an urban Trinidadian
community. Prevalence and associated characteristics. Int. J. Obes. 9: 127–
135.
Blackburn, G. L. & Kanders, B. S., eds. (1994) Obesity: Pathophysiology, Psy-
chology and Treatment. Chapman & Hall, New York, NY.
Campos, H., Mata, L., Siles, X., Vives, M., Ordovas, J. M. & Schaefer, E. J. (1992)
Prevalence of cardiovascular risk factors in rural and urban Costa Rica. Circu-
lation 85: 648–658.
DHS/IRD (1992) Demographic and Health Surveys. Country Publication Se-
ries. Institute of Resource Development, Columbia, MD.
Dibley, M. J., Goldsby, J. B., Staehling, N. W. & Trowbridge, F. L. (1987) Devel-
nutra LP: J Nut October
 OBESITY IN LATIN AMERICA
opment of normalized curves for the international growth reference: historical
and technical considerations. Am. J. Clin. Nutr. 46: 749–762.
Frisancho, A. R. (1990) Anthropometric Standards for the Assessment of
Growth and Nutritional Status. University of Michigan Press, Ann Arbor, MI.
Guo, S. S., Roche, A. F., Chumlea, W. C., Gardner, J. D. & Siervogel, R. M.
(1994) The predictive value of childhood body mass index values for over-
weight at age 35 y. Am. J. Clin. Nutr. 59: 810–819.
Hernández, B., Peterson, K., Sobol, A., Rivera, J., Sepúlveda, J. & Lezana, M. A.
(1996) Sobrepeso en mujeres de 12 a 49 años y niños menores de cinco
años en México. Salud Pública de México 38: 178–188.
Institute of Resource Development/MACRO International (1990) Model ‘‘B’’
Questionnaire with Commentary for Low Contraceptive Prevalence Countries.
DHS-II Basic Documentation, no. 2. Institute for Resource Development, Co-
lumbia, MD.
Ivanovic, D., Ivanovic, R. & Buitron, C. (1987) Nutritional status, birth weight
and breast feeding of elementary first grade Chilean students. Nutr. Rep. Int.
36: 1347–1361.
Jordan, M. D. (1990) Anthropometric Software Package Tutorial Guide and
Handbook. The Centers for Disease Control, Center for Health Promotion and
Education, Division of Nutrition, Statistics Branch, Atlanta, GA.
Kaplowitz, H., Martorell, R. & Mendoza, F. S. (1989) Fatness and fat distribu-
tion in Mexican-American children and youths from the Hispanic Health and
Nutrition Examination Survey. Am. J. Hum. Biol. 1: 631–648.
Kuczmarski, R. J., Flegal, K. M., Campbell, S. M. & Johnson, C. L. (1994) In-
creasing prevalence of overweight among U.S. adults: the National Health
and Nutrition Examination Surveys, 1960 to 1991. J. Am. Med. Assoc. 272:
205–211.
Martorell, R., Mendoza, F. S., Castillo, R. O., Pawson, I. G. & Budge, C. C. (1987)
Short and plump physique of Mexican-American children. Am. J. Phys. An-
thropol. 73: 475–487.
Ministerio de Salud (1997) Encuesta Nacional de Nutrición, 1996,
AntropometrıB a. San José, Costa Rica.
Monteiro, C. A., Mondini, L., Medeiros de Souza, A. L. & Popkin, B. M. (1995)
The nutrition transition in Brazil. Eur. J. Clin. Nutr. 49: 105–113.
National Center for Health Statistics (NCHS) (1985) Plan and operation of the
Hispanic Health and Nutrition Examination Survey, 1982–84. Vital Health Sta-
tistics 1: 19 [DHHS Publication (PHS) 85-1321].
National Center for Health Statistics (NCHS) (1994) Plan and operation of the
/ 4W43$$5038 08-04-98 14:06:35
1473
Third National Health and Nutrition Examination Survey, 1988–94. Vital Health
Statistics 1: 32 [DHHS Publication (PHS) 94-1308].
Pawson, I. G., Martorell, R. & Mendoza, F. E. (1991) Prevalence of overweight
and obesity in U.S. Hispanic populations. Am. J. Clin. Nutr. 53: 1522S–1528S.
Popkin, B. M. (1994) The nutrition transition in low income countries: an
emerging crisis. Nutr. Rev. 52: 285–298.
Schroeder, D. G. & Martorell, R. (1998) Fatness and body mass index from
birth to young adulthood in a rural Guatemalan population. In: The Assess-
ment of Childhood and Adolescent Obesity. Results of an International Obe-
sity Task Force Workshop. Am. J. Clin. Nutr. (suppl.) (in press).
Serdula, M. K., Ivery, D., Coates, R. J., Freedman, D. S., Williamson, D. F. & Byers,
T. (1993) Do obese children become obese adults? A review of the litera-
ture. Prev. Med. 22: 167–177.
Sichieri, R., Coitinho, D. C., MarıB lia, L. M., Recine, E. & Everhart, J. E. (1994)
High temporal, geographic, and income variation in body mass index among
adults in Brazil. Am. J. Public Health 84: 793–798.
Sinha, D. P. (1995) Changing patterns of food, nutrition and health in the Carib-
bean. Nutr. Res. 15: 899–938.
Sobal, J. & Stunkard, A. J. (1989) Socioeconomic status and obesity: a review
of literature. Am. Psych. Assoc. 105: 260–275.
Solomon, C. G. & Manson, J. E. (1997) Obesity and mortality: a review of the
epidemiologic data. Am. J. Clin. Nutr. 66: 1044S–1050S.
Stevens, J., Cai, J., Pamuk, E. R., Williamson, D. F., Thun, M. J. & Wood, J. L.
(1998) The effect of age on the association between body-mass index and
mortality. N. Engl. J. Med. 338: 1–7.
Troiano, R. P. & Flegal, K. M. (1998) Overweight children and adolescents: de-
scription, epidemiology and demographics. Pediatrics 101: 497–504.
UNICEF (1995) The State of the World’s Children. Oxford University Press,
New York, NY.
Walker, A.R.P. (1995) Nutrition-related diseases in Southern Africa: with special
reference to urban African populations in transition. Nutr. Res. 15: 1053–1095.
Whitaker, R. C., Wright, J. A., Pepe, M. S., Seidel, K. D. & Dietz, W. H. (1997)
Predicting obesity in young adulthood from childhood and parental obesity.
N. Engl. J. Med. 337: 869–873.
World Health Organization (1990) Diet, Nutrition, and the Prevention of Chronic
Disease: Report of a WHO Study Group. World Health Organization Technical
Report Series no. 797, pp. 69–72. WHO, Geneva, Switzerland.
World Health Organization (1995) Physical Status: The Use and Interpretation
of Anthropometry: Report of a WHO Expert Committee. World Health Organi-
zation Technical Report Series no. 854. WHO, Geneva, Switzerland.
nutra LP: J Nut October