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Ciência & Saúde Coletiva

versão impressa ISSN 1413-8123versão On-line ISSN 1678-4561

Ciênc. saúde coletiva vol.24 no.7 Rio de Janeiro jul. 2019  Epub 22-Jul-2019 


Nutritional aspects of people affected by leprosy, between 2001 and 2014, in semi-arid Brazilian municipalities

Camila Silveira Silva Teixeira1

Danielle Souto de Medeiros2

Carlos Henrique Alencar1

Alberto Novaes Ramos Júnior1

Jorg Heukelbach1

1 Departamento de Saúde Comunitária, Faculdade de Medicina, Universidade Federal do Ceará. R. Professor Costa Mendes 1608/Bloco Didático/ 5º andar, Bairro Rodolfo Teófilo. 60460-140 Fortaleza CE Brasil.

2 Instituto Multidisciplinar em Saúde, Universidade Federal da Bahia. Vitória da Conquista BA Brasil.


The study aimed to characterize food insecurity, nutritional status, and eating habits of people affected by leprosy. This is a descriptive cross-sectional study based on a census population. We evaluated 276 cases, reported in the Notifiable Diseases Information System, between 2001 and 2014, in the municipalities of Vitória da Conquista and Tremedal, in the state of Bahia. Food insecurity was estimated according to the Brazilian Food Insecurity Scale. We collected weight and height measurements, meal frequency, and household, socioeconomic, psychosocial and clinical variables. The prevalence of food insecurity was 41.0% among the study population - 28.3% mild, 8.0% moderate and 4.7% severe. Overweight/obesity was estimated in 60.1% of the study participants, and excessive salt intake was reported by 8.6%. Beans and red meat were the most regularly consumed foods; there was low consumption of milk, raw and cooked vegetables, and fruits. This population presented high food insecurity prevalence, inadequate eating habits and nutritional status, reflecting nutritional vulnerability. The insertion of nutritional assistance in the leprosy control programmes is recommended, to improve health care.

Key words: Food and nutrition security; Nutritional status; Food habits; Leprosy


Neglected Tropical Diseases (NTDs) prevail in vulnerable populations, contributing to poverty, inequality and social exclusion1. The NTD leprosy is a chronic bacterial disease2 of compulsory notification, and still poses a serious public health problem in endemic areas3.

The disease is transmitted through the respiratory tract and occurs through intimate and prolonged interaction of people mainly with multibacillary disease and with untreated people4. It primarily affects skin and nerves, which can cause neurological, motor, ophthalmological and stigmatizing sequelae5. It is diagnosed via clinical history, dermatoneurological examination and smear test, performed to confirm the initial evaluation6. Treatment consists of multidrug therapy based on the combination of three drugs (dapsone, rifampicin and clofazimine), and therapeutic schemes vary according to the operational, paucibacillary and multibacillary classification and patient’s age7. Leprosy-affected people may also show acute inflammatory conditions, triggered by recurrence and/or disease severity, the so-called leprosy reactions8. These reactions have a significant disabling and stigma generating potential2,9.

In Brazil, leprosy is a highly endemic disease, and most cases are distributed in the Midwest, North and Northeast regions10. In the state of Bahia, the municipalities Vitória da Conquista and Tremedal are characterized as highly endemic and hyperendemic municipalities, respectively10, and show typical socioeconomic and health characteristics that contribute to their vulnerability.

The complex social determination of leprosy is reflected from social inequalities11 and populations in a greater context of vulnerability, such as indigenous and quilombola groups, and low-income population strata. These populations generally have a higher prevalence of food insecurity (FI), in many cases with greater severity12-15. The state of FI is perceived when there is no assurance of regular and permanent access to quality, nutritional and healthy food in sufficient quantity, which may also compromise access to other basic needs16. Access to food can be interrupted by political, socioeconomic and demographic determinants, which affects the multifactorial profile and the vast complexity of FI17.

Food restriction in socially vulnerable groups may result in impaired nutritional quality of eating habits18. The financial conditions of access to food and the influence of a Western diet based on industrialized foods are factors that can directly contribute to these modifications and lead to a worse nutritional status19.

Assuming that leprosy-affected people are subject to greater vulnerability, the assessment of FI, food consumption and nutritional status may reveal health inequities and the need to improve nutritional care. Considering the disease’s sequels, such as physical disabilities, neurological impairments, reactive episodes, stigma, prejudice and poverty, this approach is of particular importance. In addition, few studies address nutritional aspects in the context of leprosy.

This study aimed to characterize food insecurity, nutritional status and eating habits of people affected by leprosy, between 2001 and 2014, in two municipalities in the southwestern part of Bahia State.


Study design and location

This is a cross-sectional study performed as part of the so-called IntegraHans - North/Northeast (N/NE) study: Health care for leprosy in highly endemic areas in the states of Rondônia, Tocantins and Bahia: an integrated approach to operational, epidemiological (space-time), clinical and psychosocial aspects. The present data were collected in the two municipalities of Vitória da Conquista and Tremedal in Bahia State.

Study population

In this census, we included all cases of leprosy (reference cases) reported in the Brazilian Notifiable Diseases Information System (SINAN) of the Ministry of Health (MS) in the period 2001-2014, living in these two municipalities.

Data sources and collection

The application of structured questionnaires, clinical evaluation and collection in medical records (clinical profile of the reference case) occurred between October 2014 and August 2015. Interviews were conducted using questionnaires and scales, based on nationally and internationally validated tools20-22.

The following variables were used to describe the study population: municipality; rural/urban area; type of house construction; water supply; waste disposal; proportion og residents < 18 years; number of residents; Bolsa Família Program (PBF) Family Grant benefit; ethnicity/skin color; schooling; work status. A socio-economic score was obtained by the total sum of goods and household utensils owned – color TV, radio, bathroom, automobile, monthly wage house cleaner, washing machine, video/DVD, refrigerator and freezer – and adapted to the Brazilian Economic Classification Criterion23.

The psychosocial and clinical description were performed as follows: limited activity – due to deformities caused by leprosy and other neuropathies; restricted social participation – restrictions related to leprosy, disabilities or other stigmatizing conditions; quality of life in dermatology – impaired quality of life related to dermatosis caused by leprosy; operational classification – based on the number of skin lesions and nerve injuries; occurrence of leprosy reactions; permanent physical disability.

FI was calculated according to the Brazilian Food Insecurity Scale (EBIA)16,17. One point was assigned for “yes” and zero for “no” and “don’t know” answers. At least one “yes” response defined the state of FI, categorized at different levels (mild, moderate and severe), in households with and without residents under 18 years of age24.

We interviewed the heads of the families, provided that they were at least 18 years of age and able to respond. If they were unavailable, the reference cases were interviewed. In households with more than one reported leprosy case, the first reported case was interviewed. In the case of absence, families were visited up to three times.

The anthropometric evaluation was performed according to the recommendations of the Technical Norms of the Food and Nutrition Surveillance System25. The body mass index (BMI) for adults and the elderly was classified, as low weight (< 18.5 kg/m2; ≤ 22.0 kg/m2), eutrophy (≥ 18.5 and < 25.0 kg/m2; > 22.0 and < 27.0 kg/m2), overweight (≥ 25.0 and < 30.0 kg/m2; ≥ 27.0 kg / m2) and obesity (≥ 30.0 kg/m2)26-28.

Food consumption was estimated from the individual Food Frequency Questionnaire (FFQ), based on a tool used by the National Health Survey29. The frequency of intake (0-5 days or more per week) of 17 foods, food groups or preparations, such as: excess of animal fats, soft drinks, soft drinks, sweets, fast food, meat (red and white), milk, beans, vegetables (raw and cooked), fruits and fruit juice. Salt intake was obtained by response to daily consumption options as very high, high, adequate, low or very low.

Regular intake was described considering the intake of food on five or more days per week. Among proteins, we considered the intake of red meat and chicken on three or more days, and fish, on one or more days per week as regular consumption. To evaluate the excessive consumption of salt, categories were considered as high and very high29.

Data review and ethical aspects

We present relative frequencies of the collected variables. Pearson’s chi-squared test (uncorrected), Fisher’s exact test (for categories with expected number of observations < 5) and linear trends (for variables with 3 or more categories) were applied. All tests had a significance level of 5%. The Stata program, version 15.0 (Stata Corporation, College Station, USA) was used for data analysis.

The Ethical Review Board of the Federal University of Ceará approved this study, according to Resolution Nº 466/12 of the National Health Council30.


A total of 643 cases was identified in the city of Vitória da Conquista, and 51 cases in Tremedal, totaling a target population of 694. Most of the cases had already been released from multidrug therapy. We evaluated a total of 319 reference cases, namely, 272 from Vitória da Conquista and 47 from Tremedal. The proportion of 45.0% (312) of not evaluated individuals, included refusal (1.3%); death (9.3%); address change (30.1%); wrong address (40.1%); no approach after three attempts (14.7%); and not attending evaluation (4.5%). 21 cases did not meet the inclusion criteria and 22 cases refused to answer the questions of the FI tool, resulting in a study population of 276 individuals (Figure 1).

Figure 1 Flowchart of study population to investigate nutritional aspects in people affected by leprosy in the municipalities of Vitória da Conquista and Tremedal. IntegraHans - N / NE, Bahia, 2015. 

Most respondents were from the urban area of Vitória da Conquista, Afro-Brazilians and with elementary school education. The evaluation of clinical and psychosocial characteristics showed that 47.5% had some limited activity, 25.8% had restricted social participation, 36.0% had a dermatological effect on quality of life and 75.4% had permanent physical disabilities (Table 1).

Table 1 Characteristics of population studied (n* = 276). IntegraHans – N/NE, Bahia, 2015. 

Variables n* % IC95%
Vitória da Conquista 241 87.3 82.8-90.8
Tremedal 35 12.7 9.2-17.2
Residence area
Urban 161 61.5 55.4-67.2
Rural 101 38.5 32.8-44.6
Household external walls
With coating 213 81.3 76.7-85.6
Without coating 49 18.7 14.4-23.9
Water supply
General water distribution network 202 77.1 71.6-81.8
Well. spring. rainwater. water truck’s water 60 22.9 18.2-28.4
Waste disposal
Cleaning services 190 72.5 66.8-77.6
Burned. Buried. Thrown into wasteland 72 27.5 22.4-33.2
Dwellers < 18 years
No 134 48.5 42.7-54.5
Yes 142 51.5 45.5-57.3
Number of residents
Up to 2 79 30.2 24.9-36.0
3 or 4 119 45.4 39.4-51.5
5 and over 64 24.4 19.6-30.0
PBF Benefit
No 196 74.2 68.6-79.2
Yes 68 25.8 20.8-31.4
Household assets score
1st tertile 80 30.5 25.2-36.4
2nd tertile 93 35.5 29.9-41.5
3rd tertile 89 34.0 28.4-40.0
Other 53 20.0 15.6-25.3
Afro-Brazilian /Pardo-Brazilian 212 80.0 74.7-84.4
Secondary school/Higher Education (incomplete/complete) 49 18.6 14.3-23.8
Elementary School (incomplete/complete) 136 51.7 45.6-57.7
Did not go to school 78 29.7 24.4-35.5
Work status
Working 100 37.7 32.1-43.8
Pension/benefít 116 43.8 37.9-49.8
Never worked/idle 49 18.5 14.2-23.7
Limited activity
No limitation 128 52.5 46.1-58.7
Some limitation 116 47.5 41.3-53.9
Restricted social participation
No restriction 181 74.2 68.3-79.3
Some restriction 63 25.8 20.7-31.7
Quality of life in dermatology
No effect 155 64.0 57.7-69.9
Some effects 87 36.0 30.1-42.2
Operational classification
Paucibacillary 71 31.3 25.5-37.6
Multibacillary 156 68.7 62.4-74.5
Reactive episode
No 130 50.8 44.6-56.9
Yes 126 49.2 43.1-55.4
Physical disability
No 63 24.6 19.7-30.3
Yes 193 75.4 69.7-80.3

* Absolute frequency (information not available in all cases).

95% confidence interval.

FI was found in 41.0% of the total population, estimated at 39.4% of the population of Vitória da Conquista and 51.4% Tremedal (Figure 2). Overweight/obesity was found in 60.1% of the total population. In Vitória da Conquista and Tremedal, overweight/obesity was estimated at 62.0% and 46.7%, respectively. No statistically significant differences were found between the two municipalities (Figure 2).

* Information was not available in all cases, due to population composition process and interview losses. p-value calculated through Pearson’s chi-square or Fisher’s exact test to compare municipalities.

Figure 2 Prevalence of FI and nutritional status of people affected by leprosy (n*=276). IntegraHans - N/NE, Bahia, 2015. 

There was excessive salt consumption in 8.6% of the total population. The evaluation of regular food consumption showed that beans and red meat were the most consumed foods regularly and there was low intake of milk, vegetables (raw and cooked) and fruits (Table 2).

Table 2 Regular food intake (n* = 276). IntegraHans - N/NE, Bahia, 2015. 

Food Regular Intake† (n) Regular Intake (%) CI95%||
Excess meat fat 111 41.6 35.8-47.6
Soft drinks 41 15.4 11.5-20.2
Sweetened soft drink 40 15.0 11.2-19.8
Sweets 68 25.6 20.7-31.2
Snacks (fast food) 8 3.0 1.5-5.9
Red meat 193 72.3 66.6-77.4
Chicken 26 9.7 6.7-13.9
Milk 86 32.3 26.9-38.2
Leite 104 39.0 33.2-45.0
Bean 226 84.6 79.8-88.5
Vegetables 121 45.3 39.4-51.4
Raw vegetables 87 32.8 27.4-38.8
Cooked vegetables 90 33.8 28.4-39.8
Fruits 117 44.0 38.1-50.0
Fruit juice 77 28.8 23.7-35.6

* Information was not available in all cases due to interview losses. Frequency ≥ 5 days. Frequency ≥ 3 days. § Frequency ≥ 1 day. || 95% confidence interval.


This study demonstrated a high prevalence of FI and overweight/obesity, in addition to unsatisfactory consumption of healthy food in people affected by leprosy. This result points to nutritional vulnerability that may have been affected by the clinical and psychosocial consequences of leprosy, progression and treatment difficulties in the state of Bahia.

The prevalence and degrees of FI encountered were higher than in the general Brazilian population (22.6%)24. The municipality of Vitória da Conquista had similar values to the Northeast region (38.1%) and the state of Bahia (37.8%)24. Among people in the municipality of Tremedal, FI was higher. In a study by Saboia and Santos31 including families from a peripheral area of the city of Teresina-Piauí, 65.0% of households presented any degree of FI. Pérez-Zepeda et al.32, evaluating communities of the elderly by the National Health and Nutrition Survey of Mexico, found that 73.7% of families lived with FI. A study by Pardilla et al.33 demonstrated that 76.7% of the Navajo Nation Indians in the U.S, had an FI situation. The prevalence of mild FI was higher than in Brazil (14.8%), the Northeast region (23.6%) and Bahia (21.8%). When frequencies of moderate and severe FI were evaluated, they were higher than in Brazil, 4.6% and 3.2%, respectively. Tremedal had a prevalence of moderate and severe FI also higher than in the Northeast (8.9% and 5.6%) and Bahia (9.4% and 6.6%)24.

Studies with other vulnerable populations showed similar results, such as Fachinni et al.12, that showed high prevalences of mild (31.3%), moderate (13.4%) and severe (9.5%) FI, higher than the respective prevalence rates (19.8%, 4.7% and 2.8%) of the southern region. Rosa et al.34, evaluating families headed by elderly people, showed that FI was more prevalent in the North and Northeast of the country, where levels of moderate or severe FI were perceived in more than 1/4 of the households. A study by Anschau et al.35 with families benefiting from Income Transfer Programs in Toledo, Paraná, showed that 44.9% of these patients had mild FI, 23.8% had moderate FI and 5.9% severe FI.

In this study, people affected by leprosy had unfavorable economic and social conditions. Vitória da Conquista had one of the fastest growing GDPs in the Southwest region of Bahia and, in the last census, had the mean standard of the Municipal Human Development Index (MHDI) (0.678)36. Despite this, the studied population had a homogeneous distribution among the tertiles of assets’ score, which shows that a significant portion of these people still survived in poor conditions.

On the other hand, Tremedal is a small municipality with an MHDI of 0.528, which represents low development, and relies on the linkage to federal government social programs, especially for investments in education, health, basic sanitation and infrastructure sectors36. In this municipality, almost all families were from rural areas, with poorer housing conditions, which adds greater vulnerability to the occurrence of FI, when compared to urban populations13,37.

The evaluation of nutritional status evidenced a high prevalence of overweight / obesity. The highest prevalence of overweight / obesity was also found in the Brazilian population (63.8%)38 and is typical of the nutritional transition process that occurred in the country in recent decades. A similar result was found by Bruschi et al.39, with cured individuals and leprosy patients undergoing treatment in a dermatology outpatient clinic in Porto Alegre, Rio Grande do Sul, where 71.8% were diagnosed as overweight / obese.

The nutritional transition is a process characterized by changes in diet and body composition of the population, which had an impact on the increase of morbimortality rates. The traditional food standard based on a higher consumption of grains and cereals, was gradually replaced by foods of low nutritional quality, poor in fiber, rich in fats and sugars, as well as by processed and ultra-processed foods19.

While there are no specific nutritional recommendations for leprosy, good nutrition is fundamental to improving nutritional status in any health condition. In the case of people who have had leprosy, an adequate diet is a protective factor based on improved immunity and quality of life, minimizing relapses and reactions40.

The FFA evidenced excessive salt intake, especially among Tremedal dwellers, who had a prevalence higher than that found in the Brazilian population (14.2%). The values of regular consumption of red meat and chicken fat were higher than those found in the Brazilian population (37.2%) and in the Northeast (29.7%)41.

A study on the accumulated behavioral factors for cardiovascular diseases (CVD) in southern Brazil demonstrated that the habit of regularly consuming excess salt and the availability of unhealthy food markers were factors associated with the predisposition and development of CVD42. In a study of dietary risk for CVD in people with type 2 diabetes mellitus, Mann43 demonstrated that regular consumption of animal fats, high intake of saturated fats and food sources of cholesterol were associated with increased risk of coronary disease and other CVDs. The results of this study indicate that the behavior and eating habits found can damagingly contribute to poor diet and be considered additional risk factors for these populations.

On the other hand, beans, considered the marker food of a healthy diet, were most regularly consumed among the populations studied, higher than the result of the Brazilian population (71.9%)41. A study by Montenegro et al.44 evidenced bean consumption similar to that found in this study (81.8%) in leprosy patients treated at a Health facility in Vitória, Espírito Santo. Beans have a high nutritional value, are rich in nutrients (proteins, iron, folic acid and other essential) and become an important food substitute when there is no regular intake of animal proteins45. Culturally, consumption of this food is routine for these populations, and, perhaps because of this, has been high.

The independent evaluation of regular fruit and vegetable intake (raw and cooked) showed low consumption. Montenegro et al.44 showed that fruit intake was only 41.1% and that of vegetables of 57.0% among people affected by leprosy.

Tardido and Falcão19 showed that the purchase of these foods was directly associated to the high cost of the diet, since they have a higher cost when compared to others. Families who are more socially and economically vulnerable may have less access to these food groups and, consequently, have greater use of calory-dense foods.

A case-control study on people with leprosy residing in an endemic area of Bangladesh identified an association between leprosy and conditions of low total caloric intake, lower variety and lack of food stocks in the households, suggesting a greater probability of developing the disease46. Due to the greater vulnerability of these people, the consumption of healthy foods may have been compromised. Among the populations of the municipalities studied, about half had some limited activity and approximately one third had a restricted social participation. In view of the disabling nature of the disease, daily life activities and social participation of people under study are aspects that may have affected working conditions, income generation and other means of food acquisition.

Ayres et al.11 evaluated the repercussions of leprosy in the daily life of patients at a PHC facility in Botucatu, São Paulo and observed that these people suffered impairments in their work capacity and, consequently, restriction in own and family subsistence. Monteiro et al.9 evidenced that in a hyperendemic municipality of the Northern Region of Brazil, functional limitation was one of the factors that overly affected the performance of activities and restricted social participation of people who were discharged from leprosy, focusing on the health conditions of these people. In this study, we observed a relevant proportion of people who were retired and/or who received some type of benefit. However, other variables indicated that these populations still lived in conditions of social and economic vulnerability.

The population of this study evidenced specific features, corroborating their programmatic and individual vulnerability. In terms of health, Tremedal is a municipality assisted by the Regional Health Center of the Southwest, based in Vitória da Conquista, and until 2009, leprosy care services were centralized, hindering the timely diagnosis and widening comprehensive care gaps in both municipalities47.

While comprehensive care for these people was effective, services such as nutritional care were not planned, since the multi-professional team did not include nutritionists. Such evidence reveals the possibility of iniquities such as FI, poor eating habits and inadequate nutritional status.

This study has some limitations. The composition of the population may have been biased by situations such as the lack of consistency of secondary data found in SINAN-MS. Selection bias may have occurred due to an incomplete database. The territorial extension of the mainly rural municipalities generated difficulties during fieldwork. To minimize participation bias, up to three direct attempts and/or telephone contacts were made. In addition, due to mobility difficulties of the case, care was performed through home visits. In spite of these potential limitations, we highlight the representativeness of the study population.


The population had a high prevalence of FI associated with an inadequate nutritional status and food habits. The patterns observed reflect the social and economic context and the varying degrees of social and human development. Physical, social and psychological impacts associated with leprosy over time may affect living and health conditions, favoring household’s food vulnerability in the family context, perpetuating the cycle of poverty.

Nutritional care should be cross-sectional with regard to public leprosy control policies, as a way of providing care to leprosy-affected people; the poor eating habits and the nutritional state compromise further worsen the health conditions. An integration with Primary Health Care is required, as well as the inclusion of nutritionists within the context of Family Health Support Centers.


We wish to thank the Foundation Coordination for the Improvement of Higher Education Personnel (CAPES), the Regional Health Center for the Southwest of Bahia, the Municipal Health Secretariats of Vitória da Conquista and Tremedal, families and people affected by leprosy, interviewers and Primary Health Care professionals, fundamental to the implementation of this work. JH is Class 1 research fellow at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq/Brazil).


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Received: January 10, 2017; Revised: October 03, 2017; Accepted: October 05, 2017


The authors CSS Teixeira, DS Medeiros and J Heukelbach participated in the conception of the study, its implementation and data collection. Teixeira CSS and Medeiros DS, Alencar CH, Ramos Júnior AN and Heukelbach J, participated in writing the article, analyzing and interpreting the results. The authors Teixeira CSS, DS Medeiros, CH Alencar, AN Ramos Júnior and J Heukelbach made the relevant critical analysis of the intellectual content. In addition to the contributions already cited, the authors CSS Teixeira, DS Medeiros and J Heukelbach were responsible for all aspects of the work, ensuring the accuracy and integrity of any part of the work. All authors read and approved the final version of this manuscript.

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