(introduction...)

Antonio Berdasco

Department of Human Growth and Development, J. Trigo School of Medicine, Institute of Medical Sciences, Havana, Cuba

An anthropometric study was carried out on 31 662 male and female adults from 20 to 60 years of age, living in Cuba's 14 provinces. Measurements were taken utilizing the methods and equipment recommended by the UN International Biological Programme. Weight/height, body mass index (BMI), Rohrer, Sheldon, Ponderal and Benn indices were registered as well as their correlation with height, weight and fat folds in order to obtain the suitable index for nutritional evaluation. The BMI was selected as the most appropriate and its values were recorded by sex, age, dwelling, educational level and type of occupation. The cut-off points of 'normal' BMI values were determined. Their range, based exclusively on anthropometric data, in general coincided with those defined by international actuarial data. The distribution of BMI values was very similar to that of developed countries with more overweight than underweight individuals, particularly in females. Rural populations were lighter than those in urban communities and had more underweight subjects. Lower educational levels were directly related to higher percentages of chronic energy deficiency (CED) in women; in men, there was no defined trend. On the contrary, in men CED was slightly more related to jobs that required light effort; in women there was no defined trend. Finally, a model of action against malnutrition is proposed.

Introduction

There are several nutritional problems in adults. In developed countries (Miller & Stephens, 1987) obesity is the most frequent and constitutes a health problem that has been discussed and analysed in terms of definition, possible causes, diagnosis, impact on health and longevity. Such issues must be investigated to better understand the causes of obesity, and how to facilitate its prevention (National Institute of Health, 1985).

The other side of the problem is the high incidence of undernutrition in developing countries. Undernutrition, especially if it is severe, is linked with many physiological, behavioural, sociological and economic problems. Consequently, it is very important to select the best tool to estimate its real incidence in an easy and effective way. This is a first step before taking action to solve such an enormous social and health problem facing the world's population, especially in developing countries.

To know the desirable or 'normal' physical characteristics of adults is very useful in determining the nutritional condition and health status of a group of people. Weight has been the most widely used and when relating to height and sex it has increased value as a tool in nutritional studies. The best weight/height index is the one having the lowest correlation with height and the highest with weight (Lee, Kolonel & Hinds, 1981; Miccozzi et al., 1986). Although not uniform, higher correlations are found between BMI and weight/height index with weight or fat folds than with height. (Keys et al., 1972; Frisancho & Flegel, 1982; Miccozzi et al., 1986.)

In our country, national studies on growth and development (Jordan, 1979; Berdasco et al., 1991) have yielded adequate data on both children and adults to allow appropriate analyses. The study of the children's parents in the sample of the second national growth and development Cuban study of 1982, yielded data on Cuban adults of both sexes from 20 to 60 years of age. This allowed us to examine other anthropometric variables as well as the weight/height indices of these individuals.

We decided to analyse characteristics that change with age, the style of life and the environmental conditions. It is important to determine which environmental differences affect adult anthropometry. In Cuba, as in the case of children and adults of many countries (Eveleth & Tanner, 1976; Bielicki, 1986), individuals from rural areas are usually found to be less physically developed. Differences between adults performing physical work of varying intensity are also expected. Lastly, differences in the relationship of physical characteristics to educational level are important. This might not only reflect the degree of training for jobs differing in their physical requirements but also the graded effects of different cultural levels with different nutritional knowledge, aesthetic concepts etc. Understanding these relationships may affect public policies aimed at achieving or maintaining optimum patterns of physical development.

Another reason why the study of adults in Cuba, and especially adults aged 20-60 years of age is necessary, is that this age group comprises the country's basic productive and service sector of the population, that is, 46.9% of the total as shown in the 1981 National Census (Comitstatal de Estadisticas, 1984). In this paper, we shall limit our analysis to the variations in BMI, and particularly low BMIs in relation to the sex, age, height, dwelling, educational level and physical working activity linked to occupation. We shall also estimate the cut-off points of 'normality' for our population.

Methods

Subjects

The parents of the subjects selected for the sample of the second growth and development study (Berdasco et al., 1991) were the subjects of this survey. After cleaning the data, the total number of adults was 31 662, of whom 11912 were males and 19 750 were females. This difference in the numbers was probably due to the better attendance of mothers for their appointments.

Field work

The adults attended the measuring centres where they were weighed, and had their height, upper arm circumference, triceps and subscapular fat-folds measured. The survey was undertaken by eight measuring teams (two anthropometrists each) working simultaneously from May to December 1982. Individuals living in the country's 14 provinces were measured.

In order to assure the best possible quality in the primary data, anthropometrists were trained in the same measuring procedures utilized in the first national growth and development study (Jordan, 1979), namely, those recommended by UN International Biological Programme (Weiner & Laurie, 1969). The quality of the measurements was also guaranteed through technical supervision by the investigators, and two quality control sessions. In this way, a correct application of measuring techniques was assured and consequently, consistent and uniform measurements were obtained. The adults were measured without shoes and with the lightest clothing possible (underwear and trousers or skirt) from which their nude weight could be estimated as 1 kg less than the recorded weight.

Criteria to define urban or rural dwelling

The basic definitions of the 1981 Cuban Population and Housing Census were used (Comitstatal de Estadisticas, 1984).

Urban dwellings were categorized as:

(a) all places with a population of 2000 or more inhabitants;

(b) all places with a population of 500 to 2000 inhabitants with electricity and three or more facilities such as an aqueduct, paved streets, a sewerage system, medical services and an educational centre; or

(c) all places with a population of 200 to 500 inhabitants with electricity and all of the five facilities listed in (b).

All places with a population of less than 200 inhabitants were considered rural. This category also included places with a population between 200 and 2000 inhabitants and without the facilities available in urban places.

Classification criteria related to educational level

Adults were classified into the following four groups based on the last grade passed:

Group 1: 12th or over (high school graduates, university graduates or students)
Group 2: 9th to 11th (junior high school graduates)
Group 3: 6th to 8th (junior high school not completed; elementary school graduates)
Group 4: 6th grades (elementary school not completed).

Classification criteria related to the type of occupation

Occupation was recorded by questioning the subjects at an interview. They were then classified as follows:

Group 1: Production and service workers (moderate to intense physical activity)
Group 2: Professional, technical and administrative workers (light physical activity)
Group 3: Agricultural workers and small farm workers (mainly intense physical activity)
Group 4: Housewives and students.

Data processing

After cleaning the data, the following indices were calculated: weight/height, Rohrer, Sheldon, Ponderal, Benn (data not shown except for BMI). Correlations were established (Pearson's linear correlation coefficients) with weight, height, triceps fat-fold, subscapular fat-fold and the sum of both fat-folds.

Percentiles 3, 10, 25, 50, 75, 90, 97 of BMI were estimated for each year of age, by sex and by sex and place of dwelling i.e. urban and rural. Calculations were also made by 10 year groups categorized by sex and by sex and place of dwelling. Classification of the BMI was also carried out with the cut-off points proposed by James, Ferro-Luzzi & Waterlow (1988) for CED:

CED 3 BMI <16.0
CED 2 BMI 16.0-16.9
CED 1 BMI 17.0-18.4.

To this classification were added the following categories:

Underweight BMI 18.5-19.9
Normal BMI 20.0-24.9
Obese 1 BMI 25.0-29.9
Obese 2 BMI 30.0-39.9
Obese 3 BMI 240.0.

These groupings were used to classify BMI by 10 year intervals and by sex, sex and place of dwelling, sex and educational level, sex and occupation, sex and height (where the shortest < percentile 3, and the tallest were > percentile 97). Another classification was also made by percentiles of BMI and height by sex. Finally, the cut-off points of 'normal' BMI for the Cuban population were estimated by the percentage distribution of individuals by category of fat-folds in relation to the BMI groups and by sex and two age groups, 20-39 and 40-59 years. More detailed information of the data processing may be found elsewhere (Berdasco & Romero, 1992).

Results

Correlation analysis of the various weight-for-height indices with weight, height, triceps and subscapular fat-folds and with the sum of both, showed that the Quetelet index or BMI was the one that at each year of age, tended to have the highest correlations with weight, fat-folds and their sum, and lower correlations with height (data not shown).

The percentile values of BMI for either sex showed that the median for men was between 22.2 and 23.7 and for women between 22.4 and 25.5. More than 97% of men had BMI >18.0 and almost the same proportion of women were >17.0 (Table 1).

With the data supplied by the distribution tables of individuals by categories of fat-folds according to the BMI categories, cut-off points for BMI were selected (Table 2). The distribution of individuals in relation to the agreed figures (Tables 3 and 4) showed, for the whole group, that over 50% of men and a little over 40% of women fell into a normal BMI range. Very small percentages, especially of men, were classified as CED. In the obese classification, however, there was a considerable number of individuals (a little over 30% of the men and nearly 40% of the women). A higher percentage of urban adults of both sexes showed obese BMI values, while the rural population in general had the lower BMI categories (Table 5).

Table 1. Body mass index values in the Cuban adult population

		Percentiles
Age groups (years)	n	3	10	25	50	75	90	97
Males
20-39	2907	18.0	19.2	20.5	22.2	24.6	27.2	29.7
30-39	4518	18.3	19.7	21.2	23.4	26.1	28.7	31.3
40-49	2741	18.4	19.8	21.5	23.7	26.5	29.0	31.8
50-59	1189	17.9	19.4	21.1	23.3	26.3	:28.6	31.5
Females
20-29	7447	16.9	18.2	20.0	22.4	25.6	28.9	32.9
30-39	7233	17.4	19.1	21.3	24.1	27.4	31.1	34.9
40-49	3189	17.5	19.7	22.1	25.4	28.8	32.4	36.1
50-59	839	16.8	19.3	22.3	25.5	29.7	33.3	37.1

Table 2. The 'normality' body mass index of values specified by cut-off points (COP)

Age (years) groups	Males		Females
	Low COP	High COP	Low COP	High COP
20-39	21.0	25.4	20.6	26.6
40-59	21.5	26.5	22.2	28.9

Table 3. Distribution of individuals by body mass index (BMI): males

		CED 3 BMI <16		CED 2 BMI 16-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³25
Age groups (years)	n	n	%	n	%	n	%	n	%	n	%	n	%
20-29	2907	3	0.1	19	0.7	132	4.5	386	13.3	1740	59.9	627	21.6
30-39	4518	9	0.2	22	0.5	150	3.3	396	8.8	2428	53.7	1513	33.5
40-49	2741	4	0.1	19	0.7	75	2.7	211	7.7	1396	50.9	1036	37.8
50-59	1189	2	0.2	10	0.8	46	3.9	123	10.3	602	50.6	406	34.1
20-59	11355	18	0.2	70	0.6	403	3.6	1116	9.8	6166	54.3	3582	31.5

Table 4. Distribution of individuals by body mass index (BMI): females

Age groups (years)		CED 3 BMI <16		CED 2 BMI I6-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³25
	n	n	%	n	%	n	%	n	%	n	%	n	%
20-29	7447	62	0.8	185	2.5	680	9.1	962	12.9	3444	46.2	2114	28.4
30-39	7233	46	0.6	101	1.4	377	5.2	642	8.9	2963	41.0	3104	42.9
40-49	3189	34	1.1	27	0.8	119	3.7	200	6.3	1106	34.7	1703	53.4
50-59	839	11	1.3	16	1.9	33	3.9	53	6.3	280	33.4	446	53.2
20-59	18708	153	0.8	329	1.8	1209	6.5	1857	9.9	7793	41.7	7367	39.4

Table 5. Distribution of individuals by body mass index (BMI) and place of residence

Age group: 20-59 years		CED 3 BMI <16		CED 2 BMI 16-16.9		CED 1 BM I17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³25
	n	n	%	n	%	n	%	n	%	n	%	n	%
Males
Urban	7565	13	0.2	50	0.7	257	3.4	677	8.9	3841	50.8	2727	36.0
Rural	3786	5	0.1	20	0.5	146	3.9	438	11.6	2323	61.4	854	22.6
Females
Urban	12974	89	0.7	188	1.5	712	5.5	1198	9.2	5363	41.3	5424	41.8
Rural	5727	64	1.1	141	2.5	497	8.7	657	11.5	2425	42.3	1943	33.9

In men, there was no relation between educational level and percentages of CED 1, 2, 3, nor in those classified as underweight. In the normal BMI category the percentages of men were inversely proportional to their educational level. In the obese classification, the values followed the same trend as the educational level (Table 6). In women, percentages for CED classification as well as for underweight followed an inverse trend with the educational level. In the normal BMI range there were higher percentages in the higher educational groups but obesity had no relation to the educational level (Table 7).

As for occupation, the percentages of men classified as CED or underweight were slightly higher in those who did light physical work. Obesity was much more prevalent in the office worker than in the farm workers (Table 8). The highest proportions of underweight and CED women were found in agricultural workers and housewives. There was no relation between the physical effort required by the occupation and the percentages of individuals in the normal BMI and obese groups (Table 9).

The shortest men tended to have BMIs shifted to the right (higher) compared with tallest men. There was a similar shift in the shortest compared with the tallest women (Tables 10 and 11).

Table 6. Distribution of individuals by body mass index (BMI) and educational level in men aged 20-59 years

Educational levela		CED 3 BMI<16		CED 2 BMI 216-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³25
	n	n	%	n	%	n	%	n	%	n	%	n	%
1	1623	2	0.1	15	0.9	60	3.7	123	7.6	785	46.7	663	41.0
2	2728	5	0.2	12	0.4	92	3.4	273	10.0	1395	51.1	951	34.9
3	4643	7	0.2	24	0.5	159	3.4	440	9.5	2623	56.5	1390	29.9
4	2280	4	0.2	18	0.8	88	3.9	271	11.9	1345	59.0	554	24.3

^aGroups:
1, high school graduates, university graduates
2, junior high school graduates
3, junior high school not completed, elementary school graduates
4, elementary school not completed.

Table 7. Distribution of individuals by body mass index (BMI) and educational level in women aged 20-59 years

Educational groupa		CED 3 BMI<16		CED 2 BMI 16-16.9		CED I BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³25
	n	n	%	n	%	n	%	n	%	n	%	n	%
1	1888	6	0.3	18	1.0	95	5.0	161	8.5	862	45.7	746	39.5
2	4089	26	0.6	61	1.5	249	6.1	399	9.8	1793	43.9	1561	38.2
3	7870	60	0.8	138	1.8	517	6.6	770	9.8	3220	40.9	3165	40.2
4	4786	60	1.3	111	2.3	340	7.1	520	10.9	1886	39.4	1869	39.0

^aGroups: see Table 6.

Table 8. Distribution of individuals by body mass index (BMI) and occupation in men aged 20-59 years

Occupational groupa		CED 3 BMI<16		CED 2 BMI 16-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Norma BMI 20-24.9		Obese 1-2-3 BMI ³25
	n	n	%	n	%	n	%	n	%	n	%	n	%
1	5833	13	0.2	36	0.6	197	3.4	576	9.9	3109	53.3	1902	32.6
2	2724	3	0.1	17	0.6	104	3.8	220	8.1	1334	49.0	1046	38.4
3	]963	-	-	9	0.5	71	3.6	240	12.2	1286	65.5	357	18.2

^aGroups:
1, service and production workers (except agriculture)
2, office workers
3, rural and small farm workers.

Table 9. Distribution of individuals by body mass index (BMI) and occupation in women aged 20-59 years

Occupational groupa		CED 3 BMI<16		CED 2 BMI 16-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³25
	n	n	%	n	%	n	%	n	%	n	%	n	%
1	2839	22	0.8	36	1.3	105	3.7	242	8.5	1136	40.0	1298	45.7
2	4079	18	0.4	46	1.1	202	5.0	341	8.4	1772	43.4	1700	41.7
3	620	8	1.3	15	2.4	46	7.4	65	10.5	289	46.6	197	31.8
4	10992	105	1.0	229	2.1	848	7.7	1195	10.9	4510	41.0	4105	37.3

^aGroups:
1, service and production workers (except agriculture)
2, office workers
3, rural and small farm workers
4, housewives and students.

Table 10. Distribution of shortest and tallest individuals by body mass index (BMI): in men aged 20-59 years

Height group		CED 3 BMI<16		CED 2 BMI 16-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³ 25
	n	n	%	n	%	n	%	n	%	n	%	n	%
Shortest ± 3rd percentile	318	-	-	-	-	10	3.1	21	6.6	160	50.3	127	39.9
Tallest ± 97th percentile	315	1	0.3	7	2.2	23	7.3	28	8.9	161	51.1	95	30.2

Table 11. Distribution of shortest and tallest individuals by body mass index (BMI): in women aged 20-59 years

Height group		CED 3 BMI<16		CED 2 BMI 16-16.9		CED 1 BMI 17-18.4		Underweight BMI 18.5-19.9		Normal BMI 20-24.9		Obese 1-2-3 BMI ³ 25
	n	n	%	n	%	n	%	n	%	n	%	n	%
Shortest ± 3rd percentile	531	5	0.9	7	1.3	25	4.7	52	9.8	205	38.6	237	44.6
Tallest ± 97th percentile	509	8	1.6	8	1.6	43	8.5	46	9.0	222	43.6	182	35.7

Discussion

The results obtained in this study pointed to BMI as the best index among those examined to evaluate the nutritional condition of adults 20-59 years old in our country. This coincides with what was stated in the conference on 'Implications of obesity on health', organized by the US National Health Institutes (1985). It also coincides with the criteria proposed by, for example, Keys et al. (1972), Cronk & Roche (1982) and Frisancho & Flagel (1982).

The BMI values of the Cuban population had a distribution similar to those of developed countries with a greater tendency towards overweight and obesity than to low weight, especially in females (Table 1).

The range of BMI values considered appropriate for our population and based exclusively on anthropometric data (Table 2) coincided, except in the oldest women group, with those mentioned by Bray & Gray (1988) who based this choice of cut-off points on lower mortality recorded data with either classification (Tables 3 and 4). Only a very small percentage of adults is classified by CED, particularly men. It should be noted that James, Ferro-Luzzi & Waterlow (1988) indicate that those classified as CED 2 with physical activity levels (PAL) 21.4 (4-5 h or more of standing activity) would be shifted to CED 1, and those in CED 1 with PAL values 21.4 would be changed to low weight. It should be inferred that the individuals in this study, because they were almost all workers, expected to spend at least 4-5 h standing -including housewives. They should therefore have a PAL >1.4, for which a reclassification would have to be made starting with group 2 of CED.

Rural individuals were lighter than urban adults (Table 5) as has been found in children and in other adults (Eveleth & Tanner, 1991; Bielicki, 1986). They had higher percentages of individuals classified as CED and underweight. But despite this, rural adults have a higher percentage of normal adults than the urban population because of the smaller proportion of obese individuals in the rural area. Rural women have a higher proportion with CED than the men, even if the men seem to have a higher sensitivity, in terms of BMI, to their environment. In other cultures the apparent lack of environmentally related differences between men and their low response to change may be masked by the preferential treatment that men usually receive in terms of more food and other benefits. This is not the case in Cuba.

Educational level was related to BMI values although its influence was not the same on both sexes (Tables 6 and 7). In men, higher educational levels were linked to greater obesity but in women this was not so. Lower educational levels were related to higher CED percentages in women, but there was not a defined trend in men.

As far as the physical activity demands of work were concerned (Tables 8 and 9) men engaged in light activity were prone to obesity. In women the highest percentages with CED were found in agricultural workers and housewives.

Different findings from ours were reported by Sonne-Holm et al. (1986) and Braddon et al. (1986) who found a relationship between high obesity levels and lower educational and occupational levels. Likewise, Seidell et al. (1986) found (in both men and women) that obesity was inversely related to educational level. Power & Moynihan (1988) too, in the cohort study of British children born between 3 and 9 March 1958, noted that when they were adults there was a direct relation between obesity prevalences and lower socio-economic status.

Lew & Garfinkel (1979) reported weight-for-height data in the study of the American Cancer Society. Having calculated the BMI from these data, it must be concluded that individuals of either sex with higher educational levels have the highest percentage of normal BMI values. Poorly educated men had the highest proportion of both the overweight and underweight. Women with a lower educational level also had higher overweight percentages.

Most of the information that we have about the relationship between morbidity or mortality and BMI values has been gathered in developed countries. The extreme BMI values are associated with high morbidity and mortality but extrapolated; these conclusions applied to populations of developing countries may not be appropriate. In developing countries, the issue is malnutrition and this may enhance morbidity and mortality. Where there is a high proportion of adults with CED low levels of all kinds of resources, including food, may be responsible.

These relationships need to be recognized because actions to solve or paliate the malnutrition is difficult. Nevertheless the issues must be faced because the health of millions and future generations in Asia, Africa and Latin America is at risk. Selecting a tool such as the BMI and choosing appropriate cut-off points is not enough: government and international organizations have to respond with aid and programmes to combat the problem.

Conclusions

1. BMI is an appropriate index for the nutritional assessment of individuals and easy to obtain.

2. Obesity rather than CED is the most important problem of malnutrition in the Cuban population.

3. Obesity seems to be linked to an inappropriate lifestyle and CED to poor living.

4. A rural location seems to be more important than educational level or occupational category in determining CED.

5. Good cut-off points of normality can be obtained linking BMI values with fat-folds values.

6. BMI cut-off points proposed by James et al. (1988) without PAL estimation are adequate for the epidemiological analysis of CED.

7. The finding of malnutrition must be followed by actions to solve or alleviate this health problem.

Recommendations

Studies in developing countries' populations have shown (James et al., 1988; Shetty & James, 1994; Ferro-Luzzi, Franklin & James, 1992) that as BMI values fall below 18.5 by low productive efficiency and a gradual reduction in socially desirable and leisure activities, this limits the opportunity for a decent quality of life. Based on our own data in Cuba and on research from developing countries (James et al., 1988) we suggest, from an epidemiological and clinical point of view, the following actions:

High values of BMI

>30.0 Action Priority I
Clinical evaluation
Health education
Lifestyle modifications
Dietetic control

25.1-30.0 Action Priority II

Periodical clinical supervision and control
Health education
Lifestyle modifications (?)

Normal values of BMI
18.5-25.0 No Action

Low values of BMI
17.0-18.4 Action Priority III

Periodical clinical evaluation and control
Health education Lifestyle modifications

16.0-16.9 Action Priority II

Clinical evaluation
Food supplementation (?)
Improved living conditions
Health education
<16.0 Action Priority I
Clinical evaluation
Food supplementation
Improved living conditions
Health education.

Acknowledgements - We appreciate very much the work done by Lic. J. M. Romero who processed all the adult data, the revision of the English version of this work done by Professor J. R. Jordan, the typewriting of the manuscript by Mrs A. Soler and Lic. D. Mesa.

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Discussion

Shetty: You conclude that BMI is the best index. How did that compare with the Benn index? Your population is really obese in Cuba. Is there an increase in the risk of heart disease with obesity in Cuba?

Berdasco: All the indices were examined and we found BMI was easier to obtain and use. For coronary heart disease, we are fighting against a sedentary lifestyle. By next year we may have some data on morbidity in obesity.

Durnin: I am concerned that you think action is necessary with BMI between 17 and 18.4. If resources are limited I think action, including lifestyle modification in this group, would be a low priority.