Excess body weight, particularly obesity, increased in the population of Sao Paulo from 2003 to 2015, especially in female adolescents and adults. In general, the prevalence increased 31% from 2003 to 2008, and 126% from 2003 to 2015. If this pattern does not change, more than three-quarters of the population will have excess body weight by 2030. Those with higher chance of having both overweight and obesity were adults, those with higher income, and former smokers.
The prevalence of obesity for the total population in ISA-Capital in 2015 (19.2, 95% CI = 17.8, 20.6%) was similar to the observed in Sao Paulo in VIGITEL 2016 (18.1, 95% CI = 16.2, 20.0%) [17], despite the aforementioned differences between the studies designs: the telephone interviews in people aged 18 years old or more in VIGITEL versus the household interviews in people aged 12 years old or more in ISA-Capital. The frequency of obesity is comparable to other Brazilian State capitals with diverse populations and characteristics, such as Curitiba (18.9%), Boa Vista (18.7%), and Macapá (17.7%) [17]. However, these cities present higher prevalence of both excess body weight and obesity in men, while in Sao Paulo men have higher rates of excess body weight while women have higher rates of obesity. This pattern is consistent with the observed in developed countries over time [1]. The observed differences across the cities suggest that environmental factors, such as urbanization, physical, economic and social contexts, and food environment [10, 36,37,38], could play an important role regarding sex differences in obesity.
The prevalence of obesity in the city of São Paulo in 2015 among female adolescents (11.2%; 95% CI: 8.4, 14.7%) is similar to countries such as Australia (11.2%; 95% CI: 6.4, 17.0%), Turkey (10.9%; 95% CI: 4.0, 20.8%), and Uruguay (11.5%; 95% CI: 3.4, 23.1%) and among male adolescents (7.6%; 95% CI: 5.5, 10.3%), it is similar to Colombia (7.5%; 95% CI: 3.0, 14.0%), Switzerland (7.0%; 95% CI: 3.5, 11.8%), and Kazakhstan (7.8%; 95% CI: 1.5, 19.0%) [39]. The prevalence among adult women (22.3%; 95% CI: 19.9, 24.8%) is similar to the observed in European countries such as France (22%; 95% CI: 16.2, 28.3%), Portugal (22.1%; 95% CI: 16.3, 28.4%), Spain (23.8%; 95% CI: 18.7, 29.0%), and Romania (22.5%; 95% CI: 16.7, 29.1%) [39]. Among adult men (18.6%; 95% CI: 15.8, 21.7%), the prevalence is comparable to Colombia (18.3%; 95% CI: 12.9, 24.2%), Panama (18.5%; 95% CI: 12.5, 25.5%), and Russia (18.9%; 95% CI: 14.0, 24.5%) [39]. Among older adults, the prevalence of obesity is similar to the observed in Austria (21.3%), Belgium (20.4%), France (20.8%), and Spain (20.9%), considering both sex [40].
In 2015, 30% of the population of Sao Paulo was overweight, with the highest prevalence for adults (36%), especially men (42%), similar to countries such as Spain (42.1%), Germany (42.4%), and Portugal (42.9%) [1]. Although a lot of attention is given to obesity, overweight is also an important public health issue, since the risk of death continuously increases for adults with BMI above 25 kg/m2. A study of 67.8 million individuals worldwide showed that 40% of deaths and 38% of the disability-adjusted life years (DALYs) related to high BMI occurred among non-obese individuals, indicating that a significant proportion of the total burden would be missed by focusing exclusively on obese individuals [4]. In addition, since weight gain is usually a gradual process caused by small changes in energy balance over time, for individuals to become obese they must first be overweight during a period of their lives, and this time may be a good opportunity for prevention [41, 42].
The younger population is also a significant target for prevention. Children and adolescents with excess body weight are more likely to have several health problems in their present and future lives, such as chronic diseases (e.g., asthma), cardiovascular risk factors (e.g., high blood pressure), and poor mental health (e.g., low self-esteem) [20, 41]. Obese adolescents are five times more likely to become obese adults, which increases the potential for morbidity and premature mortality across the life [43]. In the present study, the prevalence of overweight in adolescents from 12 to 19 years old was 19% and they were 43% more likely to have excess body weight compared to older adults. In spite of the lack of change in overweight prevalence across the years, obesity increased significantly, especially in girls. Studies conducted in Brazil observed that, compared to boys, girls are less physically active [44], have more sedentary leisure time [45], skip breakfast more frequently [46], and consume more sugar and sweet food [47], besides the sex disparities in fat metabolism, fat storage, and puberty [48, 49], which are possible explanations for the observed differences.
Another important factor associated with both excess body weight and obesity in the present study was smoking status. Similar to our findings, a study with 499,504 adults from 31 to 69 years-old observed that current smokers were less likely to be obese than never smokers (OR = 0.83; 95% CI: 0.81, 0.86) and former smokers were more likely to be obese than both current smokers (OR = 1.33; 95% CI: 1.30, 1.37) and never smokers (OR = 1.14; 95% CI: 1.12, 1.15), however this association varied according to age, sex, and amount smoked [11]. Several factors may be related to this association, such as the belief that smoking is an effective way of reducing body weight, change in food preference, lower dietary energy intake, higher energy expenditure, or modifications in the metabolism of calories [11]. Between 1990 and 2015, Brazil recorded a sustained progress in tobacco control, the single most important preventable factor for death and illness, with a reduction of 56% in smoking prevalence [50, 51]. However, despite the increasing frequency of non-smokers observed from 2003 to 2015 in the present study, Sao Paulo remains one of the State capitals in the country with the highest tobacco use [17]. Our results show that, compared to non-smokers, current smokers were less likely to have excess body weight and former smokers presented 46% more chances of having excess body weight and obesity. Even though one of the main reasons cited for not trying to quit smoking is fear of weight gain, research shows that smoking cessation is associated with substantial health benefits, including improved insulin sensitivity even in the presence of weight gain [51]. Thus, policies and interventions focused on both smoking and diet could increase success rate in terms of smoking cessation and prevent weight gain.
Regarding socioeconomic status, excess body weight has increased at all levels of income during the past decades. Although the annual incremental rates indicate an increase in the incidence of obesity among the poorest men and women in Brazil, those with higher income present the highest rates, especially among men [15]. In the city of Sao Paulo, those who earn more than one minimum wage per person per month in the household are 14% more likely to have excess body weight and obesity. These findings may be associated with factors such as food environment, access and food security, as well as built environment and movement from physical to sedentary labor [10, 52]. In addition, studies have shown that education is inversely associated with excess body weight [9], but in the present study, this association was not statistically significant. Worldwide, the association between socioeconomic status and body weight is dependent on the level of economic development of the country [10]. Generally, the prevalence of obesity is positively associated with the initial stages of economic growth, as populations go through nutritional and lifestyle transitions with little access to education and health services. As income increases, some habits associated with obesity are adopted, such as television viewing, purchasing and consuming more fast food, convenience foods, and other high-energy and low-quality foods. However, when there is improved access to health services, education, exercise, and healthy food, as associated with behavioral changes, this association declines. Nevertheless, those factors remain limited. In Brazil, only the quartile of women with the highest income has a lower prevalence of overweight than the quartile with the lowest income [53].
Another social factor that has an important role in lifestyle and is also associated to excess body weight is marital status. In the present study, being single significantly reduced the chances of being overweight or obese compared to people who are married or have a common law partner. Similar results were observed in other populations, which had high rates of overweight or obesity relative to adults in other marital status groups, particularly among men [54,55,56]. On the other hand, research indicates that married adults were generally found to be healthier than adults in other marital status categories [55].
Taking these factors into account, the prediction models for excess body weight and obesity indicate that an important increase in their prevalence will occur in all age groups if the patterns observed in the latest surveys do not change. Secular trends estimate that 38% of adults will be overweight and 20% will be obese worldwide by 2030 [57]. As many aspects influence weight gain and the changes in environment in the population level are dynamic, the trends observed in this study may accelerate, stop, or slow. At the same time that some countries have been observing a slowing of increases in obesity prevalence [58, 59], others have reached extreme values, such as American Samoa, in Pacific Islands, where 75% of the general population is considered obese [60]. In USA, projections indicate that over 85% of adults will have excess body weight by 2030 [61]. Therefore, due to the rapid increase in prevalence of excess body weight in Sao Paulo observed in this 12-year period and the existing uncertainties when making predictions based on past data [62, 63], we highlight the need for continuous surveillance in order to enable the identification, implementation, and evaluation of evidence-based actions to face this public health problem.
Some limitations should be considered in interpreting the findings of the current study. First, the values for height and weight used to calculate the body mass index were self-reported by the individuals during the household interview, which could lead to underestimates of the population prevalence of overweight and obesity, especially if there is a propensity of over-reporting height and/or under-reporting weight. Although self-reported data may be subject to inaccuracies; they were validated in previous study with ISA-Capital population [30], which observed high intraclass correlation between self-reported and measured parameters for weight (r > 0,94) and BMI (r > 0,85). The agreement between measured and self-reported weight, height and BMI was good, as sensitivity was > 91% and specificity was > 83%. In general, the use of self-reported lifestyle habit variables is also vulnerable to biases, but many precautions were taken in the study design to minimize possible errors, such as the face-to-face interview held in the households, selection of qualified interviewers and training according to the standard operating procedures, besides periodical meetings between the interviewers and the coordinating staff to check if the procedures were being used accurately and to discuss doubts or potential problems. A second limitation is that we did not explore in detail the patterns of income during this period, but the profound economic crises that Brazil passed through the year of 2015 [64] may have had important influence on this association, as we observed an increase in the prevalence of people in the lowest income category in 2015. There is evidence that changes in socioeconomic position across life course influence excess body weight [65, 66], but future research is needed to explore this association in different contexts. A third limitation, is that due to the fact that overweight and obesity have multifactorial causes, many factors that could be associated to it, such as diet quality, energy intake, sleeping habits, sedentary behavior, psychosocial factors, gut microbiome, in-utero and physical environment, media and marketing exposure, and genetic and epigenetic variations [13, 14], could not be assessed in this analysis; however, as a complex issue, the association of evidences from multiple researches may help to elucidate this public health challenge. Finally, although we discussed many possible causes for the increases in obesity prevalence, it is important to observe that the cross-sectional design of the study precludes causal statements. Still, the survey design is adequate to properly answer the proposed objectives in this analysis: identification of individuals with a higher likelihood of disease occurrence for public health purposes [67].
Despite of the limitations, the present study represents the largest investigation of overweight and obesity in the city of São Paulo, with multiple time points and a sampling design that represents all the population aged 12 years and older living in households in the urban area of the city.