In Portugal some studies have shown trends in growth, under and over nutrition during the second half of the XX century (Gama 2002; De Castro et al. 1998; Meira 1953;
24 Meira 1956; Wennberg 1988). The secular trend observed in Portugal showed significant socioeconomic changes that improved quality of life reflected into decreasing of menarche age and increasing average height (Barreto 2000; Padez & Rocha 2003; Padez 2003b). While both changes are the result of genetic and environmental variables (Padez & Rocha 2003; Tanner 1992), the increment on the average height was not sufficient and the Portuguese are still the shortest Europeans (Garcia & Quintana-Domeque 2007; Padez 2002). A positive pattern in the Portuguese Lisbon male population (Lacerda 1904; Padez & Johnson 1999) showed increments of 1.8 cm and 1.5 cm respectively (De Castro et al. 1998; Sobral 1988). Consequently children from higher SES and urban settings were taller and heavier (Caninas 2002; Carmona da Mota 1990) while adults from poorer regions of Portugal were shorter (Sobral 1988). The same was observed in conscripts living in the dictatorship period (Sobral 1990) and more recently children from Madeira island (Freitas et al. 2007). The period of 1961-1966 was especially favourable for economic, political and social conditions allowing the Portuguese to grow more in length. Moreover, the entry to the European Union (1986) and the democratic period increased the average height by 2.9 cm/decade (Padez & Johnson 1999; Padez 2002). While rising height was associated with better living conditions regional differences became less expressive in 1996 (Padez & Johnson 1999). In the 1990’s father’s higher educational level was positively related with their children’s height followed by maternal academic level and area (Fragoso 1998). Simultaneously a marked positive trend in weight (Padez & Johnson 1999)(Cardoso & Padez 2009) was also found. Portuguese adolescents grew 1.8cm/decade (boys) and 2.1 cm (females) but also gained 6 kg (Coelho-e-Silva & Malina 2003) in Portugal and the Azores islands (Sobral & Coelho-e-Silva 2001). In spite of significant socioeconomic changes the country has the highest European obesity rates (Lobstein & Frelut 2003; Cattaneo et al. 2010) exceeding 30% and 31.8% in OW/OB along with deep social disparities (Padez et al. 2004; Padez et al. 2005; Padez 2003a; Branca et al. 2007; Ferrão et al. 2013). Moreover the last National Study of Childhood Obesity conducted in 2009, showed a prevalence of 37.9% for overweight (OW) and 15.3% for obesity (OB) in 6-8 year old school children (Rito et al. 2012). A study showed that 20. 1% of under 6 year old boys were OW/OB and 27.3% of the girls
25 (Rito 2006). In the older children (6-10 years) the percentages for OW/OB ranged from 5.3 to 13.2% in boys and 6.4 to 12.6% for girls. The adolescents born in the 90s presented with 11.3% boys and 9.2% girls being obese, according to CDC references (Centre for Disease Control,(Kuczmarski et al. 2002)). Recently, in 2008, 1 in 3 Portuguese children aged 6 to 8 years was overweight showing a similar trend of southern European countries (Rito et al. 2012). The findings quantified the underweight, overweight and obesity according to the IOTF standards, as 4.8%, 28.1% and 8.9% respectively. Interestingly the islands, Azores and Madeira, show a higher concentration of OW/OB children while the south of Portugal exhibits lower rates. Furthermore in 2012 rising excessive weight among pre-schoolers marked a north- south pattern (Wijnhoven et al. 2013) and showed the highest European values (26.8% and 28.5% for Portuguese boys and girls, respectively) for overweight and obesity (7.9% and 9.3%). Back in 2007, Moreira presented a review on OW/OB prevalence rates in Portuguese children. The paper covered studies from 1999 to 2006, different regions of the country, different age ranges with only one presenting national data (Padez et al. 2004). Table 2.2 summarises some of the main conclusions. Starting from 2 to 6 years (Mira 2006) and going to 10-15 years (Sardinha et al. 1999) the common standard used was the IOTF criteria (International Obesity Task Force). On the following age range (6-10 years) obesity rates showed variations from 5.3 to 13.2% in boys and 6.4 to 12.6% for girls. Nevertheless the single study with a pubertal population (Ramos & Barros 2005) born in the 90s showed incidences of obesity of 11.3% in boys and 9.2% in girls, even though using a different growth standard (CDC, Centre for Disease Control, (Kuczmarski et al. 2002)). Despite the difficulties to compare data from different age ranges, locations and different criteria, the main conclusion of the paper was that OW/OB represented more than a third of the young population (30%), an altogether alarming fact.
Consequently the same tendency was observed by Padez and collaborators in a national study of 7 to 9 years old attending public teaching Institutions (4511 in total)(Padez et al. 2009). Similar to other southwest European countries these are only exceeded by Italian children (Binkin et al. 2010).
26 Table 2. 2. Summary of studies on over nutrition in children and adolescents conducted in Portugal.
The actual values presented are that 31.5% of the children are OW/OB and 11.3% obese (using IOTF standards). As expected girls presented higher values (33.7%) while boys accounted for almost a third (29.4%).
In Table 2.3 overweight and obesity classification are presented according to the two different cut off points. Values are slightly higher for IOTF cut off points on overweight for boys and girls.
Table 2. 3. Values found for over nutrition in a review paper in Portuguese children 2-10 years (Antunes & Moreira 2011).
Overweight Obesity
Standards Boys Girls Boys Girls
CDC 9.1-27.4% 13.4-26.5 % 5.9-19.8% 6.1-21.3%
IOTF 29.6% 31.4% 10.6% 13.1%
However for obesity, on the higher end of the spectrum, IOTF cut off points show lower rates for boys and girls. One of the recent review studies on over nutrition in Portugal (Antunes & Moreira 2011), as shown in Table 2.3, reports higher overweight for IOTF on both sexes and lower rates for obesity. The CDC standards were commonly used in studies with children younger than 10 years.
Reference Region Sample Age range
(years) Prevalence girls (%) Prevalence boys (%) Standards used (Vaz de Almeida et al. 1999) Continent 1000 >= 15 BMI≤19.9: 8% 20≥BMI≤24.9: 50% 25≥BMI≤29.9: 33% BMI≥30:9% Garrow 1981 Castro et al.(1996;1998) Continent 2383 20 BMI>25kg/m2: 18% BMI>27kg/m2: 6.4%
Mira 2006 Coimbra 408 2-6 --- OW: 20.6 %
OB: 7.8 % IOTF Rito 2006 (Rito 2006) Coimbra 2361 3-5 OW: 20.4% OB: 6.9% OW: 13.6% OB: 6.5% IOTF Sardinha 1999 Lisbon 328 10-15 44.8 27.3 BF
Padez et al 2004 Continent 4511 7-9 OW: 19.1%
OB: 10.3% OW: 21.4% OB: 12.3% IOTF Ramos and Barros 2005 Porto 2023 13-14 OW: 16.9% OB: 11.3% OW: 16% OB: 9.2% CDC Bingham et al 2013 Continent 17136 3-10 OW: 17.7% OB: 7.5% OW: 21.7% OB: 8.9% IOTF Notes: OW: overweight; OB: Obesity; IOTF: International obesity task force; CDC : Centre for Disease Control, BF: body fat % defined in Sardinha et al 1999 for obesity BF >25% in boys and >30% in girls citing Williams et al 1992; Garrow 1981
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