Excess mortality associated with COVID-19 in Brazil: 2020-2021.

OBJECTIVE: To evaluate excess mortality in Brazil from January 2020 to April 2021, according to the primary causes of death registered in the Brazilian Mortality Information System (MIS). METHODS: Cross-sectional study with data extracted from the MIS. Excess deaths were examined by the primary cause of death according to 11 grouped causes. Autoregressive models used mortality data from 2015 to 2019 to predict expected deaths from January 2020 to April 2021. Excess deaths were calculated as the difference between the observed and the expected number of deaths. RESULTS: Total excess deaths of 370 055 were observed in the studied period, corresponding to a ratio of observed to expected of 1.14 in 2020 and 1.40 in 2021. Excess deaths were seen in three groups: symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified; other diseases of the respiratory system and coronavirus infection, unspecified site. CONCLUSIONS: The excess mortality in Brazil in these 16 months was 1.20 times greater than the previous year. The increase in not elsewhere classified causes and causes of death associated to COVID-19 indicate caution about the negative balance for some causes. Furthermore, the inequalities of mortality reporting systems in low- and middle-income countries in relation to underestimation of mortality still need to be addressed.

Obesity and inequities in health in the developing world.

OBJECTIVE: To update the social distribution of women's obesity in the developing world and, in particular, to identify the specific level of economic development at which, if any, women's obesity in the developing world starts to fuel inequities in health. DESIGN: Multilevel logistic regression analyses applied to anthropometric and socioeconomic data collected by nationally representative cross-sectional surveys conducted from 1992 to 2000 in 37 developing countries within a wide range of world regions and stages of economic development (gross national product (GNP) from 190 to 4440 US dollars per capita). SUBJECTS: : In total, 148 579 nonpregnant women aged 20-49 y. MEASUREMENTS: Body mass index to assess obesity status; quartiles of years of education to assess woman's socioeconomic status (SES), and GNP per capita to assess country's stage of economic development. RESULTS: Belonging to the lower SES group confers strong protection against obesity in low-income economies, but it is a systematic risk factor for the disease in upper-middle income developing economies. A multilevel logistic model-including an interaction term between the country's GNP and each woman's SES-indicates that obesity starts to fuel health inequities in the developing world when the GNP reaches a value of about 2500 US dollars per capita. CONCLUSIONS: For most upper-middle income economies and part of the lower-middle income economies, obesity among adult women is already a relevant booster of health inequities and, in the absence of concerted national public actions to prevent obesity, economic growth will greatly expand the list of developing countries where this situation occurs.

Intestinal parasitic infections in young children in São Paulo, Brazil: prevalences, temporal trends and associations with physical growth.

The prevalences of intestinal parasitic infections were investigated, between 1995 and 1996, in a household-based sample of 1044 children aged <5 years who lived in the city of São Paulo, Brazil. Only 10.7% of the children were infected, the most prevalent parasites being Giardia duodenalis (5.5%), Ascaris lumbricoides (4.4%) and Trichuris trichiura (1.0%). A comparison between these data and results from two previous population-based surveys, completed in São Paulo in 1974 and 1985, revealed a dramatic decrease in the prevalence of intestinal helminths in this age-group, with less marked changes in the prevalence of Giardia, over the two past decades. Despite the low prevalence of malnutrition (2.4% of stunting and 0.6% of wasting) and intestinal parasites in this population, there was a significant association (P=0.05, after controlling for potential confounding variables) between helminth (but not Giardia) infection and height. The helminth-infected children had a mean height-for-age z-score of-0.412 [95% confidence interval (CI)=-0.637--0.186], compared with one of 0.015 (CI=-0.049-0.079) for the non-infected children. No significant relationship between intestinal parasitic infection and children's weight was detected. In conclusion, a small but significant negative relationship between intestinal helminthic infections and children's growth was detected in an urban environment with low prevalences of both intestinal parasitic infection and malnutrition.

Independent effects of income and education on the risk of obesity in the Brazilian adult population.

With a view to assess the independent effects of income and education on the risk of obesity we studied cross-sectional randomly selected samples of the adult population (20 y and over) living in 1996/97 in the less (northeastern) and the more (southeastern) developed region of Brazil (1971 and 2588 northeastern and 2289 and 2549 southeastern men and women, respectively). Independent effects of income and education on obesity (BMI > or = 30 kg/m(2)) were assessed through logistic regression analyses that controlled for age, ethnicity, household setting (urban or rural) and either education or income. The risk of obesity in men strongly increased with income in the two regions. The level of education did not influence the risk of male obesity in the less developed region but, in the more developed one, better-educated men had slightly less chance to be obese. In the less developed region obesity in women was strongly associated with both income (direct association) and education (inverse association). In the more developed region only the women's education influenced the risk of obesity, and the association between the two variables was inverse and strong as in the less developed region. Findings from this study reveal a scenario that is far from what has been generally admitted for the social distribution of obesity in the developing countries. They indicate that in transition societies income tends to be a risk factor for obesity, whereas education tends to be protective and that both gender and level of economic development are relevant modifiers of the influence exerted by these variables.

Shifting obesity trends in Brazil.

OBJECTIVE: To describe secular trends in obesity in various settings and socio-economic groups of the adult population of Brazil. METHODS: Trend analysis of the prevalence of obesity in adults aged over 20 y (body mass index >/=30.0 kg/m2) applied to anthropometric and socio-economic data collected by three comparable household surveys undertaken in the two most populated Brazilian regions in 1975 (n=95,062), 1989 (n=15,585) and 1997 (n=10,680). RESULTS: While previous trends (1975-1989) showed increasing obesity prevalence for all population groups except for men in rural areas, recent trends (1989-1997) have pointed to a much more complex picture where increases in obesity tend to be more intense in men than in women, in rural than in urban settings and in poorer than in richer families. Particularly notable was the fact that, in the recent period, obesity was actually reduced for women belonging to the upper income groups, especially in urban settings. CONCLUSION: Earlier obesity trends in Brazil entirely agree with what has been described for both developed and developing countries where reliable secular trend information exists, but the 1989-1997 trend of a substantial reduction in the prevalence of obesity among upper income urban women (12.8-9.2%, or a 28% reduction), is unique in a developing country and, indeed, up to now has only been detected in Scandinavian populations. It is speculated that this declining obesity trend may be a result of an intense mass media work focused on combating a sedentary life style and promoting better food habits.

[Evolution of maternal and child health care in São Paulo (1984-1996)]. / Evolução da assistência materno-infantil na cidade de São Paulo (1984-1996).

OBJECTIVE: Two consecutive household surveys undertaken in mid-80s and mid-90s in the city of S. Paulo, Brazil, made possible to establish time trends of several child health determinants and indicators as well as to analyse the relationships among them. The study intends to report trends in maternal and child health care. METHODS: Random samples of the population aged from zero to 59 months were studied: 1,016 children in the period of 1984-85 and 1,280 children in 1995-96. Both surveys investigated three components of maternal and child health care: prenatal care, delivery and newborn care and routine health care provided to children up to five years of age (including development follow-up and vaccination). RESULTS: Favourable changes seen in the period between the two surveys were the continuing universal birth coverage, significant increase in rooming-in in maternity hospitals and the number of routine visits for babies in their first year of life and, particularly, the universal outreach of the DPT, measles and tuberculosis vaccinations. Unfavourable trends were seen regarding the slight and clearly insufficient growth of prenatal care, the still high percentage (of near 50%) of cesarean sections, and the limited routine visits for children after their first year of age. CONCLUSIONS: Estimates in the same period for the outreach of maternal and child health care in other urban areas of Brazil reinforce the unsatisfactory trends of the prenatal care in S. Paulo. Favourable comparisons are only seen regarding the outreach of child vaccination. The influence that changes in the maternal and child health care provided in the city may have exerted on several child health indicators is examined in subsequent articles.

[Secular trends in postanal growth in the city of São Paulo, Brazil (1974-1996)]. / Tendência secular do crescimento pósnatal na cidade de São Paulo (1974-1996).

OBJECTIVE: Data from three household surveys undertaken in the city of S. Paulo, Brazil, from mid-80s to mid-90s allow to characterize and analyse secular trends in infant and child linear growth. METHODS: In the three surveys, random population samples aged from zero to 59 months (1,008 children in the period of 1974-75; 1,016 in 1984-85 and 1,280 in 1995-96) were studied. Recumbent length was obtained from children up to 24 months of age and then stature was recorded. The international growth standard was used to evaluate the child's height according to age and sex. For the study of the social distribution of growth status, tertiles of the per capita family income was taken into account in each survey. For the study of the determinants of secular trends, hierarchical causal models, multivariate regression analyses and calculations analogous to the ones used to assess population attributable risks were applied. RESULTS/CONCLUSIONS: In the period of 22 years covered by the three surveys, the secular trend of child growth in S. Paulo City showed a positive, continuous and apparently uniform curve. It was equivalent to a total average gain of 0.650 z scores of the international growth reference, or near 2.3 cm at the age of 30 months. The higher gain was observed among the third poorest fraction of the population--3.3 cm--and the lower gain--1.7 cm--among the third richest. Positive changes in distal determinants (family income and maternal schooling) and intermediate determinants (housing, sanitation, access to health services and reproductive past history) of child growth explained substantially part of the improvements seen from the mid-80s to mid-90s.

[Secular trends in malnutrition and obesity among children in the city of São Paulo, Brazil (1974-1996)]. / Tendência secular da desnutrição e da obesidade na infância na cidade de São Paulo (1974-1996).

OBJECTIVE: Data from three household surveys undertaken in the city of S. Paulo, Brazil, from mid-80s to mid-90s allow to characterize and analyse secular trends in malnutrition and obesity among infants and children. METHODS: The three surveys included random population samples aged from zero to 59 months (1,008 children in the period of 1974-75; 1,016 in 1984-85 and 1,280 in 1995-96). The malnourished status was diagnosed when height-for-age and/or weight-for-height indices were below two standard deviation of the mean values expected according to the international growth reference. The obesity status was determined when weight-for-height indices fell two standard deviations above the reference. The study of the social distribution of malnutrition and obesity in each survey took into account tertiles of the per capita family income. For the study of the determinants of secular trends, hierarchical causal models, multivariate regression analyses and calculations analogous to the ones used to assess population attributable risks were applied. RESULTS/CONCLUSIONS: In the period of 22 years covered by the three surveys, child malnutrition was controlled in the city and became relatively rare even among the poorest families. The risk of obesity remained low and restricted to the richest families. Positive changes in distal (family income and maternal schooling) and intermediate determinants (sanitation, access to heath services and reproductive past history) of child nutritional status substantially explained part of the decline in the prevalence of malnutrition seen in the mid-80s to mid-90s.