Abstract

The aim of the present study was to investigate the prevalence of excess weight and associated factors in women of reproductive age living in a low-income community. A cross-sectional study was conducted with a sample of 663 women 15 to 49 years of age residing in the neighborhood of Coelhos in the city of Recife, Brazil. Body mass index (BMI)-for-age was used to classify the nutritional status of the adolescents (15 to 19 years of age), adopting Z-score of ≥+1 for the definition of overweight. For the adults, BMI≥25.0 kg/m² was considered indicative of overweight. Socioeconomic, demographic and reproductive variables were analyzed as possible factors associated with overweight. The prevalence of excess weight was found in two thirds of the sample. The results of the Poisson multiple regression analysis showed a significantly higher prevalence of excess weight with the advance in age, among those with a younger menarche age, those who had three or more pregnancies, those living with their partner and those self-declared black or white. Multiparity was the only factor associated with excess weight that could be modified, which underscores the importance of prenatal and family planning services to its prevention and control.

Key words:
Poverty areas; Body Mass Index; Overweight; Menarche; Pregnancy

Introduction

Excess weight is a public health problem that affects a large portion of the adult population throughout the world¹1 World Health Organization (WHO). Global status report on noncommunicable diseases 2014. Genebra: WHO; 2014.^,22 World Health Organization (WHO). Prevalence of overweight among adults, ages 18+, 1975-2016 (age standardized estimate) Both sexes: 2016 [Internet]. [acessado 2018 dez 23]. Disponível em: http://gamapserver.who.int/gho/interactive_charts/ncd/risk_factors/overweight/atlas.html.
http://gamapserver.who.int/gho/interacti... as well as a significant percentage of women of reproductive age¹1 World Health Organization (WHO). Global status report on noncommunicable diseases 2014. Genebra: WHO; 2014.^,33 World Health Organization (WHO). Prevalence of overweight, ages 18+, 2016 (age standardized estimate) female [Internet]. [acessado 2018 dez 23]. Disponível em: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_Overweight_2016_Female.png.
http://gamapserver.who.int/mapLibrary/Fi...

4 Instituto Brasileiro de Geografia e Estatística (IBGE). Estudo Nacional de Despesa Familiar - ENDEF. Dados preliminares. Consumo alimentar, antropometria. Rio de Janeiro: IBGE; 1977.^-55 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: MS; 2018.. Comparing data from the Brazilian National Family Expenses Study (1974-1975), which was the first Brazilian survey on food consumption, family expenses and nutritional status in a representative sample of the population, to data from the Surveillance of Risk and Protection Factors for Chronic Diseases (2017), excess weight among women nearly doubled, going from 28.7% to 51.2%⁴4 Instituto Brasileiro de Geografia e Estatística (IBGE). Estudo Nacional de Despesa Familiar - ENDEF. Dados preliminares. Consumo alimentar, antropometria. Rio de Janeiro: IBGE; 1977.^,55 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: MS; 2018..

Excess weight is a multifactor condition secondary to excessive food intake and the inadequate burning of calories. This process is triggered by genetic, biological, social and environmental factors, particularly inadequate dietary practices and a low level of physical activity⁶6 Costa EC, Lira PIC, Oliveira JS, Menezes RCE, Tavares FCLP, Batista Filho M. Evolução do excesso de peso e fatores associados em mulheres de 10 a 49 anos em Pernambuco, Nordeste, Brasil. Rev Nutr 2014; 27(5):513-524.

7 Andrade RG, Chaves OC, Costa DAS, Andrade ACS, Bispo S, Felicissimo MF, Friche AAL, Proietti FA, Xavier CC, Caiaffa WT. Overweight in men and women among urban area residents: individual factors and socioeconomic context. Cad Saude Publica 2015; 31(S11):148-158.

8 Peña M, Bacallao J. Obesity and Poverty a New Public Health Challenge. Washington, D.C.: PAHO; 2000.

9 Bezerra IN, Sichieri R. Sobrepeso e Obesidade: Um Problema de Saúde Pública. In: Taddei JAAC, Lang RMF, Logo-Silva G, Toloni MHA. Nutrição em Saúde Pública. Rio de Janeiro: Rubio; 2011.^-1010 Wanderley EN, Ferreira VA. Obesidade: uma perspectiva plural. Cien Saude Colet 2010; 5(1):185-194.. The major associated biological factors related to the female reproductive cycle are age at menarche and number of pregnancies¹⁰10 Wanderley EN, Ferreira VA. Obesidade: uma perspectiva plural. Cien Saude Colet 2010; 5(1):185-194.

11 Kac G, Velasquez-Melendez G, Valente JG. Menarca, gravidez precoce e obesidade em mulheres brasileiras selecionadas em um Centro de Saúde de Belo Horizonte, Minas Gerais, Brasil. Cad Saude Publica 2003; 6(S1):S111-S118.

12 Teichmann L, Olinto MTA, Costa JSD, Ziegler D. Fatores de risco associados ao sobrepeso e a obesidade em mulheres de São Leopoldo, RS. Rev Bras Epidemiol 2006; 9(3):360-367.

13 Nast M, Oliveira A, Rauber F, Vitolo MR. Ganho de peso excessivo na gestação é fator de risco para o excesso de peso em mulheres. Rev Bras Ginecol Obstet 2013; 35(1):536-540.^-1414 Forte CC, Bernardi JR, Goldani MZ, Bosa VL. Relação entre a retenção de peso nos primeiros três meses pós-parto com ganho de peso e ingestão alimentar durante a gestação. Rev Bras Saude Matern Infant 2015; 15(3):279-287..

With regard to socioeconomic and demographic aspects, few studies have been conducted to analyze the increase in excess weight in the context of poverty, especially among women living in low-income communities, who are more vulnerable to social determinants of changes in weight¹⁵15 Ferreira VA, Magalhães R. Obesidade e pobreza: o aparente paradoxo. Um estudo com mulheres da Favela da Rocinha, Rio de Janeiro, Brasil. Cad Saude Publica 2005; 21(6):1976-1800.

16 Ferreira VA, Magalhães R. O corpo cúmplice da vida: considerações a partir dos depoimentos de mulheres obesas de uma favela carioca. Cien Saude Colet 2006; 11(2):483-490.^-1717 Ferreira VA, Silva AE, Rodrigues CAA, Nunes NLA, Vigato TC, Magalhães R. Desigualdade, pobreza e obesidade. Cien Saude Colet 2010; 15(1):1423-1432.. In this scenario of social inequity, the hypothesis has been put forth that weight gain stems an inability to afford the maintenance of a healthy diet¹⁷17 Ferreira VA, Silva AE, Rodrigues CAA, Nunes NLA, Vigato TC, Magalhães R. Desigualdade, pobreza e obesidade. Cien Saude Colet 2010; 15(1):1423-1432.. This hypothesis encompasses all contexts in which women are found and involves a combination of unfavorable socioeconomic, environmental and biological conditions, the interrelations of which favor the occurrence of excess weight.

Therefore, the aim of the present study was to evaluate the prevalence of excess weight and associated factors in women of reproductive age residing in a low-income community in the city of Recife, Brazil.

Methods

A cross-sectional study was conducted involving women of reproductive age residing in the neighborhood of Coelhos in the city of Recife, using data from the “Health, Nutrition and Health Services in a Low-Income Population of Recife: a baseline study”. This community has a population of approximately 7,633 residents in 2,322 households, with a mean monthly household income of R$ 898.41. Women are the head of the household in 53.6% of homes. The literacy rate is 87.7% among the population aged 10 years or older and the mean number of residents per home is 3.6¹⁸18 Prefeitura de Recife. Caracterização socioeconômica da comunidade dos Coelhos, Recife-PE [Internet]. [acessado 2018 jun 09]. Disponível em: http://www2.recife.pe.gov.br/servico/coelhos.
http://www2.recife.pe.gov.br/servico/coe... . Primary health care is offered by two Family Health Units.

Simple random sampling without replacement was performed. To ensure the representativeness of the sample, households were selected by a random drawing method with probability proportional to the estimate of the total number of women 15 and 49 years of age residing in the study location.

The sample size was calculated considering the prevalence of excess weight reported in a previous study⁶6 Costa EC, Lira PIC, Oliveira JS, Menezes RCE, Tavares FCLP, Batista Filho M. Evolução do excesso de peso e fatores associados em mulheres de 10 a 49 anos em Pernambuco, Nordeste, Brasil. Rev Nutr 2014; 27(5):513-524. (41.7% among women of reproductive age). Establishing a 5% maximum margin of error and 95% confidence interval, the total sample was estimated to be 374 adolescents and adults. Adopting the data obtained by Pinheiro et al.¹⁹19 Pinheiro MM, Oliveira JS, Leal VS, Lira PIC Souza NP, Campos FACS. Prevalência do excesso de peso e fatores associados em mulheres em idade reprodutiva no Nordeste do Brasil. Rev Nutr 2016; 29(5):679-689. who found a percentage of 54.0% of overweight in women between 15 and 49 years of age with menarche over 13 years of age and 67.7% of overweight among those with menarche 13 years of age or younger, a power of the study of 80.0%, confidence interval of 95.0% and a ratio of 1:3 among exposed women: unexposed we obtained a total sample estimate of 572 women (143 exposed:429 unexposed). The sample was increased by 16.0% to compensate for possible dropouts, resulting in a minimum sample of 663 women.

The eligibility criteria for inclusion of women in the study were: age between 15 and 49 years and living in the community of Coelhos. Women who, at the time of data collection, had not presented the menarche, were pregnant, and those with cognitive impairment that impeded answering the questionnaires and those with a physical limitation that prevented anthropometric evaluation were excluded from the study.

The dependent variable was nutritional status, which was assessed based on body mass index for age (BMI/A) in adolescents and BMI in adults. The independent variables were categorized as follows: economic class (B1/B2/C1; C2; D/E); age group (15-19; 20-35; 36-49 years); self-declared skin color (brown, yellow and indigenous; black; white); schooling (≤eight; ≥nine years of study); conjugal status (with partner; without partner); formal employment (no; yes); head of household (no; yes); beneficiary of Family Grant Program (no; yes); age at menarche (<12; ≥12 years); number of pregnancies (nulliparous; 1-2; ≥3); and screening for common mental disorders using the classification proposed by Mari and Williams²⁰20 Mari JJ, Williams PA. Validity Study of a Psychiatric Screening Questionnaire (SRQ-20) in Primary Care in the city of São Paulo. Br J Psychiatry 1986; 148:23-26. (<8 points=no; ≥8 points=yes).

Family information and anthropometric data were collected in the participants’ households between June and December 2014 by a trained fieldwork team. Weight was determined using an electronic scale (Model MEA-03200/Plenna) with a capacity of 150 kg and sensitivity of 100 g. Height was measured using a portable stadiometer (Alturaexata® Ltd.) with a capacity of 213 cm and precision of 1 mm. Weight and height were determined in accordance with the techniques proposed by Lohman et al.²¹21 Lohman TG, Roche AF, Martorell R. Anthropometric standardization reference manual. Toronto: Abridged; 1991. in duplicate followed by the calculation of the mean. To ensure consistency, the measurements were repeated if differences were larger than 100 g for weight and 0.5 cm for height and the mean of the two closest values was used.

The nutritional status of the adolescents was evaluated based on BMI/A expressed in z-scores using the AnthroPlus program, version 3.2.2. The cutoff points established by the WHO were considered²²22 World Health Organization (WHO). AnthroPlus for personal computers. Manual: Software for assessing growth of the world's children and adolescents. Genebra: WHO; 2009.: <-2 z-scores=underweight; ≥-2 and <+1 z-score=ideal range; ≥+1 and <+2 z-scores=overweight; ≥+2 z-scores=obesity. For the statistical analysis, two categories were created: without excess weight (those categorized as underweight and in the ideal range) and with excess weight (overweight and obesity).

For the adults (20 to 49 years of age), nutritional status was evaluated based on the BMI using the WHO classification²³23 World Health Organization (WHO). Physical status: The use and interpretation of anthropometry. WHO Technical Report Series No. 854. Genebra: WHO; 1995.: <18.5 kg/m²=underweight; 18.5 to 24.9 kg/m²=ideal range; 25.0 to 29.9 kg/m²=overweight; and ≥30.0 kg/m²=obesity. Two categories were created for statistical analysis, similar to those used in the evaluation of the nutritional status of adolescents.

The economic class of the families was determined using the Brazilian Economic Classification Criteria established by the Brazilian Association of Research Firms²⁴24 Associação Brasileira de Empresas de Pesquisa (ABEP). Critério de classificação econômica Brasil. São Paulo, 2014 [Internet]. [acessado 2018 nov 26]. Disponível em: http://www.abep.org/novo/default.aspx.
http://www.abep.org/novo/default.aspx... . This classification involves a point attribution system based on the number of consumer goods and schooling of the head of the family. The sum of these points determines economic class, which is categorized from highest to lowest as A1, A2, B1, B2, C1, C2, D and E.

Screening for common mental disorders was performed using the Self-Reporting Questionnaire (SQR-20) developed by the WHO²⁵25 World Health Organization (WHO). A User´s guide to the self reporting questionnaire (SQR /compiled by Beusenberg M, Orley J) [Internet]. Genebra: WHO; 1994. [acessado 2018 jun 17]. Disponível em: http://www.who.int/iris/handle/10665/61113. and validated for the Brazilian population²⁰20 Mari JJ, Williams PA. Validity Study of a Psychiatric Screening Questionnaire (SRQ-20) in Primary Care in the city of São Paulo. Br J Psychiatry 1986; 148:23-26.. This instrument is composed of 20 questions. The total score ranges from 0 to 20 points, with a higher score denoting a greater probability of traits of depression and anxiety.

The questionnaires created with pre-coded closed-ended questions were revised throughout the data collection process. The data were entered into the database twice and checked for consistency using the Data Compare command of Epi-Info 3.5.4 for Windows.

The bivariate analyses were performed with the aid of the Statistical Package for the Social Sciences, version 13.0 (SPSS Inc., Chicago, IL, USA) to determine associations between the independent variables and outcome using Pearson’s chi-square test. Variables with a p-value<0.20 in the bivariate analyses were incorporated into the multiple Poisson regression analysis.

Crude and adjusted prevalence ratios (PR) were estimated with respective 95% confidence intervals (CI) using STATA 7.0 (Stata, Texas, USA). The independent variables were incorporated into the regression models in blocks using a previously established hierarchical conceptual model, beginning with Block I (economic class, age, self-declared skin color and conjugal status), followed by Block II (age at menarche and number of pregnancies).

This study received approval from the Human Research Ethics Committee of the Instituto de Medicina Integral Professor Fernando Figueira (IMIP). The statement of informed consent²⁶26 Brasil. Conselho Nacional De Saúde (CNS). Resolução nº 196, de 10 de outubro de 1996. Diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. Diário Oficial da União 1996;16 out. was signed by all participants older than 18 years of age and legal guardians of the participants less than 18 years of age.

Results

Table 1 displays the nutritional status of the participants based on BMI. Excess weight was identified in two thirds of the sample (66.3%). The proportion of overweight was discretely higher (35.7%) than the proportion of obesity (30.6%).

Table 2 displays the sociodemographic, reproductive and behavioral characteristics of the sample. More than half of the participants belonged to economic classes B1/B2 and C1/C2 (66.4%) and had more than eight years of schooling (64.6%). Half of the sample was between 20 and 35 years of age (50.5%), 40.6% lived with a partner, 30.6% were the head of the household and 62.0% were beneficiaries of the Family Grant Program. The percentages of women with excess weight were significantly higher with the increase in age, among those self-declared black or white, those who lived with a partner, those who reported having their menarche prior to 12 years of age and those who had three or more pregnancies.

Table 3 displays the results of the simple and multiple Poisson regression analyses of the sociodemographic and reproductive variables associated with excess weight in the sample. The adjusted PRs were significantly higher with the advance in age, among participants self-declared black or white, among those who lived with a partner, among those who reported the occurrence of the menarche prior to 12 years of age and those with three or more pregnancies.

Discussion

This study was conducted in a low-income community in the city of Recife, Brazil, to investigate the prevalence of excess weight and associated factors in women of reproductive age. The findings reveal that two thirds of the women had excess weight, which was associated with the advance in age, skin color, conjugal status, age at the first menstrual episode and the number of pregnancies.

The high prevalence of excess weight in the present sample confirms that this is a problem in the female population, as demonstrated in data published by the WHO¹1 World Health Organization (WHO). Global status report on noncommunicable diseases 2014. Genebra: WHO; 2014.. Other data in the literature also corroborate our results²⁷27 Ferreira VA, Magalhães R. Obesidade entre os pobres no Brasil: a vulnerabilidade feminina. Cien Saude Colet 2011; 16(4):2279-2287.

28 Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa nacional de saúde: 2013: ciclos de vida: Brasil e grandes regiões/IBGE, Coordenação de Trabalho e Rendimento. Rio de Janeiro: IBGE; 2015.^-2929 Gigante DP, França GVA, Sardinha LMV, Iser BPM, Meléndez GV. Temporal variation in the prevalence of weight and obesity excess in adults: Brazil, 2006 to 2009. Rev Bras Epidemiol 2011; 14(1):157-165..

The prevalence of excess weight in the population studied is further evidence of the epidemic of obesity in emerging countries, such as Brazil. This growing trend was also reported in two population-based studies conducted in the state of Pernambuco (northeastern Brazil) in 1997 and 2006⁶6 Costa EC, Lira PIC, Oliveira JS, Menezes RCE, Tavares FCLP, Batista Filho M. Evolução do excesso de peso e fatores associados em mulheres de 10 a 49 anos em Pernambuco, Nordeste, Brasil. Rev Nutr 2014; 27(5):513-524.. The same was also found on the national level through the VIGITEL Telephone Inquiry conducted with the female population in capital cities, with rates of 38.8% in 2006²⁹29 Gigante DP, França GVA, Sardinha LMV, Iser BPM, Meléndez GV. Temporal variation in the prevalence of weight and obesity excess in adults: Brazil, 2006 to 2009. Rev Bras Epidemiol 2011; 14(1):157-165. and 51.2% in 2017⁵5 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: MS; 2018.. The prevalence of excess weight in women has increased in developed countries, such as the United States (63.2%), United Kingdom (58.9%) and Canada (58.5%)³3 World Health Organization (WHO). Prevalence of overweight, ages 18+, 2016 (age standardized estimate) female [Internet]. [acessado 2018 dez 23]. Disponível em: http://gamapserver.who.int/mapLibrary/Files/Maps/Global_Overweight_2016_Female.png.
http://gamapserver.who.int/mapLibrary/Fi... , as well as developing countries, such as Chile (61%)³⁰30 Garmendia ML, Alonso FT, Kain J, Uauy R, Corvalan C. Alarming weight gain in women of a post-transitional country. Public Health Nutr 2013; 17(3):667-673. and Jamaica (62%)³¹31 Kanguru L, McCaw-Binns A, Bell J, Yonger-Coleman N, Wilks R, Hussein J. The burden of obesity in women of reproductive age and in pregnancy in a middle-income setting: A population based study from Jamaica. PLoS One 2017; 12(12):e0188677..

Age stands out among the factors associated with excess weight, as the advance in age was accompanied by an increase in the prevalence of the outcome. Similar results are described in previous studies¹²12 Teichmann L, Olinto MTA, Costa JSD, Ziegler D. Fatores de risco associados ao sobrepeso e a obesidade em mulheres de São Leopoldo, RS. Rev Bras Epidemiol 2006; 9(3):360-367.^,3232 Correia LL, Silveira DMI, Silva AC, Campos JS, Machado MMT, Rocha HAL, Cunha AJLA, Lindsay AC. Prevalência e determinantes de obesidade e sobrepeso em mulheres em idade reprodutiva residentes na região semiárida do Brasil. Cien Saude Colet 2011; 16(1):133-145.^,3333 Malta DC, Santos MA, Andrade SS, Oliveira TP, Stopa SR, Oliveira MM, Jaime P. Tendência temporal dos indicadores de excesso de peso em adultos nas capitais brasileiras, 2006-2013. Cien Saude Colet 2016; 21(4):1061-1069.. The high prevalence of excess weight in older women likely occurs due to the greater accumulation of fat over the years due the reduction in the metabolism³⁴34 Pinho CPS, Diniz AS, Arruda IKG, Batista Filho M, Coelho PC, Sequeira LAS, Lira PIC. Prevalência e fatores associados à obesidade abdominal em indivíduos na faixa etária de 25 a 59 anos do Estado de Pernambuco, Brasil. Cad Saude Publica 2012; 29(2):313-324. and decrease in the level of physical activity.

White and black skin color was also associated with excess weight. This finding is in contradiction with data described in the literature. A telephone survey involving the population of adults and seniors found a greater susceptibility to excess weight only in black women³⁵35 Gigante DP, Moura EC, Sardinha LMV. Prevalence of overweight and obesity and associated factors, Brazil, 2006. Rev Saude Publica 2009; 43(S2):83-89.. In contrast, a study conducted in northeastern Brazil found no significant association between excess weight and skin color⁶6 Costa EC, Lira PIC, Oliveira JS, Menezes RCE, Tavares FCLP, Batista Filho M. Evolução do excesso de peso e fatores associados em mulheres de 10 a 49 anos em Pernambuco, Nordeste, Brasil. Rev Nutr 2014; 27(5):513-524.. This divergence may be due to the fact that skin color was self-declared, which may have led to the occurrence of a misclassification.

Living with a partner was another demographic variable associated with excess weight in the present sample. This result is in agreement with data described in two national studies conducted with secondary data from the 2006³⁵35 Gigante DP, Moura EC, Sardinha LMV. Prevalence of overweight and obesity and associated factors, Brazil, 2006. Rev Saude Publica 2009; 43(S2):83-89. and 2008³⁶36 Sá NNB, Moura EC. Excesso de peso: determinantes sociodemográficos e comportamentais em adultos, Brasil, 2008. Cad Saude Publica 2011; 27(7):1380-1392. VIGITEL surveys as well as a study conducted in the United States with 20 years of data from the National Longitudinal Study of Youth³⁷37 Teachman J. Body weight, marital status, and changes in marital status. J Fam Issues 2016; 37(1):74-96.. Individuals with a stable conjugal life are more likely to have company at meals and may therefore have the habit of eating more regularly and/or having more high-calorie foods, favoring an increase in weight. Another possible explanation is that couples in a stable relationship may be less concerned with their body weight due to the fact that they are not seeking a partner³⁸38 Averett S, Sikora A, Argys L. For better for worse: Relationship status and body mass index. Econ Hum Biol 2008; 6(3):330-349..

The prevalence of excess weight was higher among the participants who had an early menarche. Similar findings have been described in other cross-sectional studies conducted in Brazil⁷7 Andrade RG, Chaves OC, Costa DAS, Andrade ACS, Bispo S, Felicissimo MF, Friche AAL, Proietti FA, Xavier CC, Caiaffa WT. Overweight in men and women among urban area residents: individual factors and socioeconomic context. Cad Saude Publica 2015; 31(S11):148-158.^,3232 Correia LL, Silveira DMI, Silva AC, Campos JS, Machado MMT, Rocha HAL, Cunha AJLA, Lindsay AC. Prevalência e determinantes de obesidade e sobrepeso em mulheres em idade reprodutiva residentes na região semiárida do Brasil. Cien Saude Colet 2011; 16(1):133-145. and Japan³⁹39 Sumi A, Iwase M, Nakamura U, Fujii H, Ohkuma T, Ide H, Jodai-Kitamura T, Komorita Y, Yoshinari M, Kitazono T. Impact of age at menarche on obesity and glycemic control in Japanese patients with type 2 diabetes: Fukuoka Diabetes Registry. J Diabetes Investig 2018; 9(5):1216-1223., indicating that an early menarche is a contributing factor to overweight and obesity in adulthood. The findings of previous studies conducted in northeastern Brazil also suggest that an early menarche is a precursor of excess weight in women in the states of Ceará³²32 Correia LL, Silveira DMI, Silva AC, Campos JS, Machado MMT, Rocha HAL, Cunha AJLA, Lindsay AC. Prevalência e determinantes de obesidade e sobrepeso em mulheres em idade reprodutiva residentes na região semiárida do Brasil. Cien Saude Colet 2011; 16(1):133-145. and Pernambuco¹⁹19 Pinheiro MM, Oliveira JS, Leal VS, Lira PIC Souza NP, Campos FACS. Prevalência do excesso de peso e fatores associados em mulheres em idade reprodutiva no Nordeste do Brasil. Rev Nutr 2016; 29(5):679-689.. Moreover, as study conducted in the state of Minas Gerais (southeastern Brazil) found that women who had an early menarche were threefold more likely to be obese¹²12 Teichmann L, Olinto MTA, Costa JSD, Ziegler D. Fatores de risco associados ao sobrepeso e a obesidade em mulheres de São Leopoldo, RS. Rev Bras Epidemiol 2006; 9(3):360-367.. However, it has been questioned whether an early menarche is the cause or consequence of excess weight. Longitudinal studies indicate that the early occurrence of menstruation may be due to a greater amount of adipose tissue in childhood, triggering the production of estrogen through androgen precursors of the adrenal gland and leading to early sexual maturation⁴⁰40 Benedet J, Lopes AS, Adami F, Hinnig PF, Vasconcelos FAG. Association of sexual maturation with excess body weight and height in children and adolescents. BMC Pediatr 2014; 14:72.^,4141 Solorzano CMB, McCartney CR. Obesity and the pubertal transition in girls and boys. Reprod 2010; 140(3):399-410..

The number of pregnancies was associated with excess weight, which is in agreement with data described in previous studies. Indeed, a greater number of pregnancies is considered a risk factor for obesity in women¹²12 Teichmann L, Olinto MTA, Costa JSD, Ziegler D. Fatores de risco associados ao sobrepeso e a obesidade em mulheres de São Leopoldo, RS. Rev Bras Epidemiol 2006; 9(3):360-367.^,4242 Castilho SD, Pinheiro CD, Bento CA, Barros-Filho AA, Cocetti M. Tendência secular da idade da menarca avaliada em relação ao índice de massa corporal. Arq Bras Endocrinol Metab 2012; 56(3):195-200.^,4343 Ferreira RAB, Benício MHD. Obesidade em mulheres brasileiras: associação com paridade e nível socioeconômico. Rev Panam Salud Publica 2015; 37(4/5):195-200.. This result is secondary to the excessive calorie intake that influences weight gain during pregnancy and the retention of excess weight in the postpartum period⁴³43 Ferreira RAB, Benício MHD. Obesidade em mulheres brasileiras: associação com paridade e nível socioeconômico. Rev Panam Salud Publica 2015; 37(4/5):195-200.

44 Jordão ISC, Kac G. Determinantes da retenção de peso pós-parto segundo a cor da pele em mulheres do Rio de Janeiro, Brasil. Rev Panam Salud Publica 2005; 18(6):403-411.

45 Harris HE, Ellison GTH. Do the changes in energy balance that occur during pregnancy predispose parous women to obesity. Nutr Res Rev 1997; 10(1):57-81.^-4646 Gunderson EP. Child bearing and obesity in women: weight before, during and after pregnancy. Obst Gynecol Clin North Am 2009; 36(2):317-334., which could last throughout life⁴⁷47 Siega-Riz, AM. A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: birthweight, fetal growth, and postpartum weight retention. Am J Obstet Gynecol 2009; 201(4):339.e1-14., especially among women with a larger number of children⁴²42 Castilho SD, Pinheiro CD, Bento CA, Barros-Filho AA, Cocetti M. Tendência secular da idade da menarca avaliada em relação ao índice de massa corporal. Arq Bras Endocrinol Metab 2012; 56(3):195-200..

Socioeconomic factors (economic class and schooling) were not associated with excess weight in the present study, possibly due to the fact that the sample was from a low-income community. In contrast, previous studies with greater representativeness of socioeconomic strata report a tendency toward a greater prevalence of excess weight in populations with less schooling and less purchasing power⁵5 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: MS; 2018.^,3232 Correia LL, Silveira DMI, Silva AC, Campos JS, Machado MMT, Rocha HAL, Cunha AJLA, Lindsay AC. Prevalência e determinantes de obesidade e sobrepeso em mulheres em idade reprodutiva residentes na região semiárida do Brasil. Cien Saude Colet 2011; 16(1):133-145.^,3333 Malta DC, Santos MA, Andrade SS, Oliveira TP, Stopa SR, Oliveira MM, Jaime P. Tendência temporal dos indicadores de excesso de peso em adultos nas capitais brasileiras, 2006-2013. Cien Saude Colet 2016; 21(4):1061-1069..

A major strength of the present study was the methodological care taken in selecting the participants through simple random sampling, which minimized the risk of selection bias. This study also has limitations that should be considered. The cross-sectional design does not enable the inference of cause-and-effect relations, which increases the risk of reverse causality. Moreover, memory bias is an inherent risk of studies involving the retrospective collection of information.

Conclusions

In the present study, two thirds of the population of women from a low-income community in Northeastern Brazil had excess weight, which was associated with demographic characteristics (age, skin color and living with a partner) and reproductive characteristics (early menarche and larger number of pregnancies). These results are similar to those found in representative samples of the region and country, demonstrating the pandemic of excess weight.

Multiparity was the only factor associated with overweight that could be modified, which underscores the importance of prenatal and family planning services to the prevention and control of excess weight, as a considerable number of women with this nutritional problem use these services.

The reduction in the prevalence of excess weight contributes to the control of chronic diseases, such as hypertension and type 2 diabetes. The increase in the prevalence of excess weight with the advance in age underscores the importance of educational actions regarding healthy eating habits and regular physical exercise among younger members of the population as a way to promote changes of behavior that favor a reduction in excess weight.

Acknowledgments

The authors are grateful to the Fundação de Amparo à Ciência e Tecnologia (FACEPE) for funding the study, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for awarding productivity grants to M Batista Filho, MC Lima and PIC Lira and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for awarding a master’s grant to L Dinegri.

References

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