Abstract

The study aimed to characterize food insecurity, nutritional status, and eating habits of people affected by leprosy. This is a descriptive cross-sectional study based on a census population. We evaluated 276 cases, reported in the Notifiable Diseases Information System, between 2001 and 2014, in the municipalities of Vitória da Conquista and Tremedal, in the state of Bahia. Food insecurity was estimated according to the Brazilian Food Insecurity Scale. We collected weight and height measurements, meal frequency, and household, socioeconomic, psychosocial and clinical variables. The prevalence of food insecurity was 41.0% among the study population - 28.3% mild, 8.0% moderate and 4.7% severe. Overweight/obesity was estimated in 60.1% of the study participants, and excessive salt intake was reported by 8.6%. Beans and red meat were the most regularly consumed foods; there was low consumption of milk, raw and cooked vegetables, and fruits. This population presented high food insecurity prevalence, inadequate eating habits and nutritional status, reflecting nutritional vulnerability. The insertion of nutritional assistance in the leprosy control programmes is recommended, to improve health care.

Food and nutrition security; Nutritional status; Food habits; Leprosy

Introduction

Neglected Tropical Diseases (NTDs) prevail in vulnerable populations, contributing to poverty, inequality and social exclusion¹1. Adams J, Gurney KA, Pendlebury D. Thomson Reuters Global Research Report Neglected Tropical Diseases 2012.. The NTD leprosy is a chronic bacterial disease²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358. of compulsory notification, and still poses a serious public health problem in endemic areas³3. Penna MLF, Oliveira MLVDR, Penna GO. The epidemiological behaviour of leprosy in Brazil. Leprosy Review 2009; 80:332-344..

The disease is transmitted through the respiratory tract and occurs through intimate and prolonged interaction of people mainly with multibacillary disease and with untreated people⁴4. Alencar CHM, Ramos Júnior AN, de Sena Neto AS, Murto C, Alencar MJ, Barbosa JC, Heukelbach J. Diagnóstico da hanseníase fora do município de residência: uma abordagem espacial, 2001 a 2009. Cad Saude Publica 2012; 28(9):1685-1698.. It primarily affects skin and nerves, which can cause neurological, motor, ophthalmological and stigmatizing sequelae⁵5. Fonseca MS, Garcia MR. Aspectos psicossociais em hanseníase. In: Alves ED, Ferreira TL, Ferreira IN, organizadores. Hanseníase: avanços e desafios. Brasília: NESPROM; 2014. p. 373-388.. It is diagnosed via clinical history, dermatoneurological examination and smear test, performed to confirm the initial evaluation⁶6. Lyon S, Grossi MAF. Diagnóstico de Tratamento da Hanseníase. In: Alves ED, Ferreira TL, Ferreira IN, organizadores. Hanseníase: avanços e desafios. Brasília: NESPROM; 2014. p. 141-170.. Treatment consists of multidrug therapy based on the combination of three drugs (dapsone, rifampicin and clofazimine), and therapeutic schemes vary according to the operational, paucibacillary and multibacillary classification and patient’s age⁷7. World Health Organization (WHO). WHO Expert Committee on Leprosy: eighth report. Geneva; WHO; 2012.. Leprosy-affected people may also show acute inflammatory conditions, triggered by recurrence and/or disease severity, the so-called leprosy reactions⁸8. Teixeira MAG, Silveira VM, França ER. Características epidemiológicas e clínicas das reações hansênicas em indivíduos paucibacilares e multibacilares, atendidos em dois centros de referência para hanseníase, na Cidade de Recife, Estado de Pernambuco. Rev Soc Bras Med Trop 2010; 43(3):287-292.. These reactions have a significant disabling and stigma generating potential²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.,⁹9. Monteiro LD, Alencar CH, Barbosa JC, Novaes CCBS, Silva RCPS, Heukelbach J. Pós-alta de hanseníase: limitação de atividade e participação social em área hiperendêmica do Norte do Brasil. Rev Bras Epidemiol 2014; 17(1):91-104..

In Brazil, leprosy is a highly endemic disease, and most cases are distributed in the Midwest, North and Northeast regions¹⁰10. Brasil. Ministério da Saúde (MS). Departamento de Informática do SUS – DATASUS 2016. Sala de Apoio à Gestão Estratégica – SAGE. Situação de Saúde. Indicadores de Morbidade: Hanseníase; 2016 [serial na internet] [acessado 2017 Jan 25]. Disponível em: http://datasus.saude.gov.br/informacoes-de-saude.
http://datasus.saude.gov.br/informacoes-... . In the state of Bahia, the municipalities Vitória da Conquista and Tremedal are characterized as highly endemic and hyperendemic municipalities, respectively¹⁰10. Brasil. Ministério da Saúde (MS). Departamento de Informática do SUS – DATASUS 2016. Sala de Apoio à Gestão Estratégica – SAGE. Situação de Saúde. Indicadores de Morbidade: Hanseníase; 2016 [serial na internet] [acessado 2017 Jan 25]. Disponível em: http://datasus.saude.gov.br/informacoes-de-saude.
http://datasus.saude.gov.br/informacoes-... , and show typical socioeconomic and health characteristics that contribute to their vulnerability.

The complex social determination of leprosy is reflected from social inequalities¹¹11. Ayres JA, Paiva BSR, Duarte MTC, Berti HW. Repercussões da hanseníase no cotidiano de pacientes: vulnerabilidade e solidariedade. Rev Min de Enferm 2012; 16(1):56-62. and populations in a greater context of vulnerability, such as indigenous and quilombola groups, and low-income population strata. These populations generally have a higher prevalence of food insecurity (FI), in many cases with greater severity¹²12. Facchini LA, Nunes BP, Motta JVS, Tomasi E, Silva SM, Thumé E, Silveira DS, Siqueira FV, Dilélio AS, Saes MO, Miranda VIA, Volz PM, Osório A, Fassa AG. Insegurança alimentar no Nordeste e Sul do Brasil: magnitude, fatores associados e padrões de renda per capita para redução das iniquidades. Cad Saude Publica 2014; 30(1):161-174.

13. Mondini L, Rosa TE, Gubert MB, Sato GS, Benício MHD’A. Insegurança alimentar e fatores sociodemográficos associados nas áreas urbana e rural do Brasil. Informações Econômicas 2011; 41(2):52-60.

14. Monego ET, Peixoto MRG, Cordeiro MM, Costa RM. (In) segurança alimentar de comunidades quilombolas do Tocantins. Segur Aliment Nutr 2010; 17(1):37-47.-¹⁵15. Souza NN, Dias MM, Sperandio N, Franceschini SCC, Priore SE. Perfil socioeconômico e insegurança alimentar e nutricional de famílias beneficiárias do Programa Bolsa Família no município de Viçosa, Estado de Minas Gerais, Brasil, em 2011: um estudo epidemiológico transversal. Epidemiol Serv Saúde 2012; 21(4):655-662.. The state of FI is perceived when there is no assurance of regular and permanent access to quality, nutritional and healthy food in sufficient quantity, which may also compromise access to other basic needs¹⁶16. Segall-Corrêa AM, Marin-León L. A segurança alimentar no Brasil: Proposição e usos da Escala Brasileira de Insegurança Alimentar (EBIA) de 2003 a 2009. Segur Aliment Nutr 2009; 16(2):1-19.. Access to food can be interrupted by political, socioeconomic and demographic determinants, which affects the multifactorial profile and the vast complexity of FI¹⁷17. Hoffmann R. Brasil, 2013: mais segurança alimentar. Segur Aliment Nutr 2014; 21(2):422-436..

Food restriction in socially vulnerable groups may result in impaired nutritional quality of eating habits¹⁸18. Navas R, Kanikadan AYS, Santos KMP, Garavello MEPE. Transição alimentar em comunidade quilombola no litoral sul de São Paulo. Rev NERA 2015; 18(27):138-155.. The financial conditions of access to food and the influence of a Western diet based on industrialized foods are factors that can directly contribute to these modifications and lead to a worse nutritional status¹⁹19. Tardido AP, Falcão MC. O impacto da modernização na transição nutricional e obesidade. Rev Bras Nutr Clin 2006; 21(2):117-124..

Assuming that leprosy-affected people are subject to greater vulnerability, the assessment of FI, food consumption and nutritional status may reveal health inequities and the need to improve nutritional care. Considering the disease’s sequels, such as physical disabilities, neurological impairments, reactive episodes, stigma, prejudice and poverty, this approach is of particular importance. In addition, few studies address nutritional aspects in the context of leprosy.

This study aimed to characterize food insecurity, nutritional status and eating habits of people affected by leprosy, between 2001 and 2014, in two municipalities in the southwestern part of Bahia State.

Methodology

Study design and location

This is a cross-sectional study performed as part of the so-called IntegraHans - North/Northeast (N/NE) study: Health care for leprosy in highly endemic areas in the states of Rondônia, Tocantins and Bahia: an integrated approach to operational, epidemiological (space-time), clinical and psychosocial aspects. The present data were collected in the two municipalities of Vitória da Conquista and Tremedal in Bahia State.

Study population

In this census, we included all cases of leprosy (reference cases) reported in the Brazilian Notifiable Diseases Information System (SINAN) of the Ministry of Health (MS) in the period 2001-2014, living in these two municipalities.

Data sources and collection

The application of structured questionnaires, clinical evaluation and collection in medical records (clinical profile of the reference case) occurred between October 2014 and August 2015. Interviews were conducted using questionnaires and scales, based on nationally and internationally validated tools²⁰20. Scale, SALSA. Users Manual. 2010 [acessado 2012 Fev 5]. Disponível em: http://www.ilep.org.uk/fileadmin/uploads/Documents/Infolep_Documents/Salsa/SALSA_manual_v1.1pdf.pdf.
http://www.ilep.org.uk/fileadmin/uploads...

21. Participation Scale Users. 2005 [acessado 2012 Fev 21]. Disponível em: http://www.leprastichting.nl/assets/infolep/Participation%20Scale%20Users%20Manual%20v.4.6.pdf.
http://www.leprastichting.nl/assets/info... -²²22. Finlay AY, Khan G. Dermatology Life Quality Index (DLQI) - a simple practical measure for routine clinical use. Clinl Experimental Dermatol 1994; 19(3):210-216..

The following variables were used to describe the study population: municipality; rural/urban area; type of house construction; water supply; waste disposal; proportion og residents < 18 years; number of residents; Bolsa Família Program (PBF) Family Grant benefit; ethnicity/skin color; schooling; work status. A socio-economic score was obtained by the total sum of goods and household utensils owned – color TV, radio, bathroom, automobile, monthly wage house cleaner, washing machine, video/DVD, refrigerator and freezer – and adapted to the Brazilian Economic Classification Criterion²³23. Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de classificação econômica Brasil 2014 [serial na internet] [acessado 2016 Jan 12]. Disponível em: http://www.abep.org/criterio-brasil
http://www.abep.org/criterio-brasil... .

The psychosocial and clinical description were performed as follows: limited activity – due to deformities caused by leprosy and other neuropathies; restricted social participation – restrictions related to leprosy, disabilities or other stigmatizing conditions; quality of life in dermatology – impaired quality of life related to dermatosis caused by leprosy; operational classification – based on the number of skin lesions and nerve injuries; occurrence of leprosy reactions; permanent physical disability.

FI was calculated according to the Brazilian Food Insecurity Scale (EBIA)¹⁶16. Segall-Corrêa AM, Marin-León L. A segurança alimentar no Brasil: Proposição e usos da Escala Brasileira de Insegurança Alimentar (EBIA) de 2003 a 2009. Segur Aliment Nutr 2009; 16(2):1-19.,¹⁷17. Hoffmann R. Brasil, 2013: mais segurança alimentar. Segur Aliment Nutr 2014; 21(2):422-436.. One point was assigned for “yes” and zero for “no” and “don’t know” answers. At least one “yes” response defined the state of FI, categorized at different levels (mild, moderate and severe), in households with and without residents under 18 years of age²⁴24. Instituto Brasileiro de Geografia e Estatística (IGBE). Pesquisa Nacional por Amostra de Domicílios: segurança alimentar 2013. Rio de Janeiro: IBGE; 2014..

We interviewed the heads of the families, provided that they were at least 18 years of age and able to respond. If they were unavailable, the reference cases were interviewed. In households with more than one reported leprosy case, the first reported case was interviewed. In the case of absence, families were visited up to three times.

The anthropometric evaluation was performed according to the recommendations of the Technical Norms of the Food and Nutrition Surveillance System²⁵25. Brasil. Ministério da Saúde (MS). Orientações para a coleta e análise de dados antropométricos em serviços de saúde: Norma Técnica do Sistema de Vigilância Alimentar e Nutricional. Brasília: MS; 2011.. The body mass index (BMI) for adults and the elderly was classified, as low weight (< 18.5 kg/m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.; ≤ 22.0 kg/m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.), eutrophy (≥ 18.5 and < 25.0 kg/m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.; > 22.0 and < 27.0 kg/m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.), overweight (≥ 25.0 and < 30.0 kg/m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.; ≥ 27.0 kg / m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.) and obesity (≥ 30.0 kg/m²2. Barbosa JC, Ramos Júnior AN, Alencar OM, Pinto MSP, Castro CGJ. Atenção pós-alta em hanseníase no Sistema Único de Saúde: aspectos relativos ao acesso na região Nordeste. Cad Saúde Coletiva 2014; 22:351-358.)²⁶26. World Health Organization (WHO). Physical status: use and interpretation of anthropometry. Genova: WHO; 1995.

27. World Health Organization (WHO). Obesity: preventing and managing the global epidemic. Geneva: WHO; 2000.-²⁸28. The Nutrition Screening Initiative. Incorporating nutrition screening and interventions into medical practice: a monograph for physicians. Washington D.C. US: American Academy of Family Physicians, The American Dietetic Association, National Council on Aging Inc; 1994..

Food consumption was estimated from the individual Food Frequency Questionnaire (FFQ), based on a tool used by the National Health Survey²⁹29. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2008. Rio de Janeiro: IBGE; 2009.. The frequency of intake (0-5 days or more per week) of 17 foods, food groups or preparations, such as: excess of animal fats, soft drinks, soft drinks, sweets, fast food, meat (red and white), milk, beans, vegetables (raw and cooked), fruits and fruit juice. Salt intake was obtained by response to daily consumption options as very high, high, adequate, low or very low.

Regular intake was described considering the intake of food on five or more days per week. Among proteins, we considered the intake of red meat and chicken on three or more days, and fish, on one or more days per week as regular consumption. To evaluate the excessive consumption of salt, categories were considered as high and very high²⁹29. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2008. Rio de Janeiro: IBGE; 2009..

Data review and ethical aspects

We present relative frequencies of the collected variables. Pearson’s chi-squared test (uncorrected), Fisher’s exact test (for categories with expected number of observations < 5) and linear trends (for variables with 3 or more categories) were applied. All tests had a significance level of 5%. The Stata program, version 15.0 (Stata Corporation, College Station, USA) was used for data analysis.

The Ethical Review Board of the Federal University of Ceará approved this study, according to Resolution Nº 466/12 of the National Health Council³⁰30. Brasil. Ministério da Saúde. Conselho Nacional de Saúde. Resolução nº 466, de 12 de dezembro de 2012. Diário Oficial da União 2012; 12 dez..

Results

A total of 643 cases was identified in the city of Vitória da Conquista, and 51 cases in Tremedal, totaling a target population of 694. Most of the cases had already been released from multidrug therapy. We evaluated a total of 319 reference cases, namely, 272 from Vitória da Conquista and 47 from Tremedal. The proportion of 45.0% (312) of not evaluated individuals, included refusal (1.3%); death (9.3%); address change (30.1%); wrong address (40.1%); no approach after three attempts (14.7%); and not attending evaluation (4.5%). 21 cases did not meet the inclusion criteria and 22 cases refused to answer the questions of the FI tool, resulting in a study population of 276 individuals (Figure 1).

Most respondents were from the urban area of Vitória da Conquista, Afro-Brazilians and with elementary school education. The evaluation of clinical and psychosocial characteristics showed that 47.5% had some limited activity, 25.8% had restricted social participation, 36.0% had a dermatological effect on quality of life and 75.4% had permanent physical disabilities (Table 1).

FI was found in 41.0% of the total population, estimated at 39.4% of the population of Vitória da Conquista and 51.4% Tremedal (Figure 2). Overweight/obesity was found in 60.1% of the total population. In Vitória da Conquista and Tremedal, overweight/obesity was estimated at 62.0% and 46.7%, respectively. No statistically significant differences were found between the two municipalities (Figure 2).

There was excessive salt consumption in 8.6% of the total population. The evaluation of regular food consumption showed that beans and red meat were the most consumed foods regularly and there was low intake of milk, vegetables (raw and cooked) and fruits (Table 2).

Discussion

This study demonstrated a high prevalence of FI and overweight/obesity, in addition to unsatisfactory consumption of healthy food in people affected by leprosy. This result points to nutritional vulnerability that may have been affected by the clinical and psychosocial consequences of leprosy, progression and treatment difficulties in the state of Bahia.

The prevalence and degrees of FI encountered were higher than in the general Brazilian population (22.6%)²⁴24. Instituto Brasileiro de Geografia e Estatística (IGBE). Pesquisa Nacional por Amostra de Domicílios: segurança alimentar 2013. Rio de Janeiro: IBGE; 2014.. The municipality of Vitória da Conquista had similar values to the Northeast region (38.1%) and the state of Bahia (37.8%)²⁴24. Instituto Brasileiro de Geografia e Estatística (IGBE). Pesquisa Nacional por Amostra de Domicílios: segurança alimentar 2013. Rio de Janeiro: IBGE; 2014.. Among people in the municipality of Tremedal, FI was higher. In a study by Saboia and Santos³¹31. Sabóia RCB, Santos MM. Prevalência de insegurança alimentar e fatores associados em domicílios cobertos pela Estratégia Saúde da Família em Teresina, Piauí, 2012-2013. Epidemiol Serv Saúde 2015; 24(4):749-758. including families from a peripheral area of the city of Teresina-Piauí, 65.0% of households presented any degree of FI. Pérez-Zepeda et al.³²32. Pérez-Zepeda MU, Castrejón-Pérez RC, Wynne-Bannister E, Garcia-Penã C. Frailty and food insecurity in older adults. Public Health Nutr 2016; 19(15):2844-2849., evaluating communities of the elderly by the National Health and Nutrition Survey of Mexico, found that 73.7% of families lived with FI. A study by Pardilla et al.³³33. Pardilla M, Prasad D, Suratkar S, Gittelsohn J. High levels of household food insecurity on the Navajo Nation. Public Health Nutr 2013; 17(1):58-65. demonstrated that 76.7% of the Navajo Nation Indians in the U.S, had an FI situation. The prevalence of mild FI was higher than in Brazil (14.8%), the Northeast region (23.6%) and Bahia (21.8%). When frequencies of moderate and severe FI were evaluated, they were higher than in Brazil, 4.6% and 3.2%, respectively. Tremedal had a prevalence of moderate and severe FI also higher than in the Northeast (8.9% and 5.6%) and Bahia (9.4% and 6.6%)²⁴24. Instituto Brasileiro de Geografia e Estatística (IGBE). Pesquisa Nacional por Amostra de Domicílios: segurança alimentar 2013. Rio de Janeiro: IBGE; 2014..

Studies with other vulnerable populations showed similar results, such as Fachinni et al.¹²12. Facchini LA, Nunes BP, Motta JVS, Tomasi E, Silva SM, Thumé E, Silveira DS, Siqueira FV, Dilélio AS, Saes MO, Miranda VIA, Volz PM, Osório A, Fassa AG. Insegurança alimentar no Nordeste e Sul do Brasil: magnitude, fatores associados e padrões de renda per capita para redução das iniquidades. Cad Saude Publica 2014; 30(1):161-174., that showed high prevalences of mild (31.3%), moderate (13.4%) and severe (9.5%) FI, higher than the respective prevalence rates (19.8%, 4.7% and 2.8%) of the southern region. Rosa et al.³⁴34. Rosa TEDC, Mondini L, Gubert MB, Sato GS, Benício MHD’A. Segurança alimentar em domicílios chefiados por idosos. Rev Bras Geriatr Gerontol 2012; 15(1):69-77., evaluating families headed by elderly people, showed that FI was more prevalent in the North and Northeast of the country, where levels of moderate or severe FI were perceived in more than 1/4 of the households. A study by Anschau et al.³⁵35. Anshau FR, Matsuo T, Segall-Corrêa AM. Food insecurity among recipients of government assistance. Rev Nutr 2012; 25(2):177-189. with families benefiting from Income Transfer Programs in Toledo, Paraná, showed that 44.9% of these patients had mild FI, 23.8% had moderate FI and 5.9% severe FI.

In this study, people affected by leprosy had unfavorable economic and social conditions. Vitória da Conquista had one of the fastest growing GDPs in the Southwest region of Bahia and, in the last census, had the mean standard of the Municipal Human Development Index (MHDI) (0.678)³⁶36. Bahia. Superintendência de Estudos Econômicos e Sociais (SEI). Estatística – Territórios – Bahia 2015 [internet] [acessado 2016 Abr 04]. Disponível em: http://www.sei.ba.gov.br/
http://www.sei.ba.gov.br/... . Despite this, the studied population had a homogeneous distribution among the tertiles of assets’ score, which shows that a significant portion of these people still survived in poor conditions.

On the other hand, Tremedal is a small municipality with an MHDI of 0.528, which represents low development, and relies on the linkage to federal government social programs, especially for investments in education, health, basic sanitation and infrastructure sectors³⁶36. Bahia. Superintendência de Estudos Econômicos e Sociais (SEI). Estatística – Territórios – Bahia 2015 [internet] [acessado 2016 Abr 04]. Disponível em: http://www.sei.ba.gov.br/
http://www.sei.ba.gov.br/... . In this municipality, almost all families were from rural areas, with poorer housing conditions, which adds greater vulnerability to the occurrence of FI, when compared to urban populations¹³13. Mondini L, Rosa TE, Gubert MB, Sato GS, Benício MHD’A. Insegurança alimentar e fatores sociodemográficos associados nas áreas urbana e rural do Brasil. Informações Econômicas 2011; 41(2):52-60.,³⁷37. Hoffmann R. Determinantes da insegurança alimentar no Brasil em 2004 e 2009. Segur Aliment Nutr 2013; 20(2):219-235..

The evaluation of nutritional status evidenced a high prevalence of overweight / obesity. The highest prevalence of overweight / obesity was also found in the Brazilian population (63.8%)³⁸38. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa de Orçamentos Familiares 2008-2009. Rio de Janeiro: IBGE; 2011. and is typical of the nutritional transition process that occurred in the country in recent decades. A similar result was found by Bruschi et al.³⁹39. Bruschi KR, Labrêa MGA, Eidt LM. Avaliação do estado nutricional e do consumo alimentar de pacientes com hanseníase do Ambulatório de Dermatologia Sanitária. Hansen Int 2011; 36(2):53-61., with cured individuals and leprosy patients undergoing treatment in a dermatology outpatient clinic in Porto Alegre, Rio Grande do Sul, where 71.8% were diagnosed as overweight / obese.

The nutritional transition is a process characterized by changes in diet and body composition of the population, which had an impact on the increase of morbimortality rates. The traditional food standard based on a higher consumption of grains and cereals, was gradually replaced by foods of low nutritional quality, poor in fiber, rich in fats and sugars, as well as by processed and ultra-processed foods¹⁹19. Tardido AP, Falcão MC. O impacto da modernização na transição nutricional e obesidade. Rev Bras Nutr Clin 2006; 21(2):117-124..

While there are no specific nutritional recommendations for leprosy, good nutrition is fundamental to improving nutritional status in any health condition. In the case of people who have had leprosy, an adequate diet is a protective factor based on improved immunity and quality of life, minimizing relapses and reactions⁴⁰40. Silva CPG, Miyazaki COM. Hanseníase e a Nutrição: uma revisão da literatura. Hansen Int 2012; 37(2):69-74..

The FFA evidenced excessive salt intake, especially among Tremedal dwellers, who had a prevalence higher than that found in the Brazilian population (14.2%). The values of regular consumption of red meat and chicken fat were higher than those found in the Brazilian population (37.2%) and in the Northeast (29.7%)⁴¹41. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013. Rio de Janeiro: IBGE; 2014..

A study on the accumulated behavioral factors for cardiovascular diseases (CVD) in southern Brazil demonstrated that the habit of regularly consuming excess salt and the availability of unhealthy food markers were factors associated with the predisposition and development of CVD⁴²42. Muniz LC, Schneider BC, Silva ICM, Matijasevich A, Santos IS. Fatores de risco comportamentais acumulados para doenças cardiovasculares no sul do Brasil. Rev Saude Publica 2012; 46(3):534-542.. In a study of dietary risk for CVD in people with type 2 diabetes mellitus, Mann⁴³43. Mann JI. Diet and risk of coronary heart disease and type 2 diabetes. Lancet 2002; 360(9335):783-789. demonstrated that regular consumption of animal fats, high intake of saturated fats and food sources of cholesterol were associated with increased risk of coronary disease and other CVDs. The results of this study indicate that the behavior and eating habits found can damagingly contribute to poor diet and be considered additional risk factors for these populations.

On the other hand, beans, considered the marker food of a healthy diet, were most regularly consumed among the populations studied, higher than the result of the Brazilian population (71.9%)⁴¹41. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional de Saúde 2013. Rio de Janeiro: IBGE; 2014.. A study by Montenegro et al.⁴⁴44. Montenegro RMN, Molina MDC, Moreira MM, Zandonade E. Avaliação nutricional e alimentar de pacientes portadores de hanseníase tratados em unidades de saúde da grande Vitória, Estado do Espírito Santo. Rev Soc Bras Med Trop 2010; 44(2):228-231. evidenced bean consumption similar to that found in this study (81.8%) in leprosy patients treated at a Health facility in Vitória, Espírito Santo. Beans have a high nutritional value, are rich in nutrients (proteins, iron, folic acid and other essential) and become an important food substitute when there is no regular intake of animal proteins⁴⁵45. Brasil. Ministério da Saúde (MS). Guia alimentar para a população brasileira. Brasília: MS; 2014.. Culturally, consumption of this food is routine for these populations, and, perhaps because of this, has been high.

The independent evaluation of regular fruit and vegetable intake (raw and cooked) showed low consumption. Montenegro et al.⁴⁴44. Montenegro RMN, Molina MDC, Moreira MM, Zandonade E. Avaliação nutricional e alimentar de pacientes portadores de hanseníase tratados em unidades de saúde da grande Vitória, Estado do Espírito Santo. Rev Soc Bras Med Trop 2010; 44(2):228-231. showed that fruit intake was only 41.1% and that of vegetables of 57.0% among people affected by leprosy.

Tardido and Falcão¹⁹19. Tardido AP, Falcão MC. O impacto da modernização na transição nutricional e obesidade. Rev Bras Nutr Clin 2006; 21(2):117-124. showed that the purchase of these foods was directly associated to the high cost of the diet, since they have a higher cost when compared to others. Families who are more socially and economically vulnerable may have less access to these food groups and, consequently, have greater use of calory-dense foods.

A case-control study on people with leprosy residing in an endemic area of Bangladesh identified an association between leprosy and conditions of low total caloric intake, lower variety and lack of food stocks in the households, suggesting a greater probability of developing the disease⁴⁶46. Wagenaar I, Van Muiden L, Alam K, Bowers R, Hossain MA, Kispotta K, Richardus JH. Diet-Related Risk Factors for Leprosy: A Case-Control Study. PLoS Negl Trop Dis 2015; 9(5):1-15.. Due to the greater vulnerability of these people, the consumption of healthy foods may have been compromised. Among the populations of the municipalities studied, about half had some limited activity and approximately one third had a restricted social participation. In view of the disabling nature of the disease, daily life activities and social participation of people under study are aspects that may have affected working conditions, income generation and other means of food acquisition.

Ayres et al.¹¹11. Ayres JA, Paiva BSR, Duarte MTC, Berti HW. Repercussões da hanseníase no cotidiano de pacientes: vulnerabilidade e solidariedade. Rev Min de Enferm 2012; 16(1):56-62. evaluated the repercussions of leprosy in the daily life of patients at a PHC facility in Botucatu, São Paulo and observed that these people suffered impairments in their work capacity and, consequently, restriction in own and family subsistence. Monteiro et al.⁹9. Monteiro LD, Alencar CH, Barbosa JC, Novaes CCBS, Silva RCPS, Heukelbach J. Pós-alta de hanseníase: limitação de atividade e participação social em área hiperendêmica do Norte do Brasil. Rev Bras Epidemiol 2014; 17(1):91-104. evidenced that in a hyperendemic municipality of the Northern Region of Brazil, functional limitation was one of the factors that overly affected the performance of activities and restricted social participation of people who were discharged from leprosy, focusing on the health conditions of these people. In this study, we observed a relevant proportion of people who were retired and/or who received some type of benefit. However, other variables indicated that these populations still lived in conditions of social and economic vulnerability.

The population of this study evidenced specific features, corroborating their programmatic and individual vulnerability. In terms of health, Tremedal is a municipality assisted by the Regional Health Center of the Southwest, based in Vitória da Conquista, and until 2009, leprosy care services were centralized, hindering the timely diagnosis and widening comprehensive care gaps in both municipalities⁴⁷47. Bahia. Secretaria de Saúde do Estado. Regiões de saúde do estado da Bahia 2014 [serial na internet]. [acessado 2016 Dez 19]. Disponível em: www1.saude.ba.gov.br/mapa_bahia/
www1.saude.ba.gov.br/mapa_bahia/... .

While comprehensive care for these people was effective, services such as nutritional care were not planned, since the multi-professional team did not include nutritionists. Such evidence reveals the possibility of iniquities such as FI, poor eating habits and inadequate nutritional status.

This study has some limitations. The composition of the population may have been biased by situations such as the lack of consistency of secondary data found in SINAN-MS. Selection bias may have occurred due to an incomplete database. The territorial extension of the mainly rural municipalities generated difficulties during fieldwork. To minimize participation bias, up to three direct attempts and/or telephone contacts were made. In addition, due to mobility difficulties of the case, care was performed through home visits. In spite of these potential limitations, we highlight the representativeness of the study population.

Conclusions

The population had a high prevalence of FI associated with an inadequate nutritional status and food habits. The patterns observed reflect the social and economic context and the varying degrees of social and human development. Physical, social and psychological impacts associated with leprosy over time may affect living and health conditions, favoring household’s food vulnerability in the family context, perpetuating the cycle of poverty.

Nutritional care should be cross-sectional with regard to public leprosy control policies, as a way of providing care to leprosy-affected people; the poor eating habits and the nutritional state compromise further worsen the health conditions. An integration with Primary Health Care is required, as well as the inclusion of nutritionists within the context of Family Health Support Centers.

Acknowledgements

We wish to thank the Foundation Coordination for the Improvement of Higher Education Personnel (CAPES), the Regional Health Center for the Southwest of Bahia, the Municipal Health Secretariats of Vitória da Conquista and Tremedal, families and people affected by leprosy, interviewers and Primary Health Care professionals, fundamental to the implementation of this work. JH is Class 1 research fellow at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq/Brazil).

References

Publication Dates

History