María Luisa Garmendia

Structural responses to the obesity and non-communicable diseases epidemic: the Chilean Law of Food Labeling and Advertising

In 12 July 2012, the Chilean Senate approved the Law of Food Labeling and Advertising, resulting from the joint efforts of a group of health professionals, researchers and legislators who proposed a regulatory framework in support of healthy diets and active living. Its goal was to curb the ongoing epidemic increase of obesity and non‐communicable diseases. Two actions included: (i) improving point of food purchase consumer information by incorporating easy‐to‐understand front‐of‐packages labeling and specific messages addressing critical nutrients, and (ii) decreasing childrens exposure to unhealthy foods by restricting marketing, advertising and sales. We summarize the work related to the laws release and discuss the conclusions reached by the various expert committees that were convened by the Ministry of Health to guide the development of the regulatory norms. Throughout the process, the food industry has overtly expressed its disagreement with the regulatory effort. The final content of the regulatory norms is still pending; however there are suggestions that its implementation will be delayed and might be modified based on the industry lobbying actions. These lessons should contribute to show the need of anticipating and addressing potential barriers to obesity‐prevention policy implementation, particularly with respect to the role of the private sector.

The Alcohol Use Disorders Identification Test (AUDIT) as a screening instrument for adolescents

BACKGROUND The Alcohol Use Disorders Identification Test (AUDIT) is an international screening instrument extensively employed in adult target groups. However, there is scarce information on screening with the AUDIT in adolescent populations. The purpose of this study was to determine the cut-off point for hazardous, harmful, and dependent alcohol use through the validation of the AUDIT in a Chilean adolescent sample. METHODS The original English version of the AUDIT was translated into Spanish, using the procedure recommended by the World Health Organization. The text was then back-translated and sent to one of the original authors (Thomas Babor), who approved the translation. Students attending public schools in Santiago, Chile, self-administered the AUDIT, and those older than 15 years completed the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), which served as a gold standard. Between 1 and 4 weeks after the CIDI-SAM, participants answered a second AUDIT. RESULTS A total of 42 female and 53 male adolescents (mean age: 15.9 [SD=1.2]) completed the AUDIT, with a mean score of 4.3. Reliability according to Cronbachs alpha was 0.83. Test-retest correlation was also satisfactory (intra-class correlation 0.81 [95% CI 0.73-0.87]). Analysis of the receiver operating characteristic (ROC) curve yielded cut-off points for hazardous, harmful, and dependent alcohol use of 3, 5, and 7 points, respectively. CONCLUSIONS The Chilean version of the AUDIT is a valid and reliable tool for identifying adolescents with hazardous, harmful, and dependent alcohol use. The suggested cut-off points make screening with the AUDIT more accurate for adolescent populations.

Addressing malnutrition while avoiding obesity: minding the balance

Latin America has experienced rapid demographic, epidemiological and nutrition changes that have successfully contributed to decreasing undernutrition, but concomitantly have resulted in an increase of obesity and associated conditions; in this paper we propose that policies to address undernutrition have not adapted at a sufficiently rapid pace to address the emerging challenges. Taking Chile as an example we show that health promotion policies, implemented only when the obesity epidemic was well advanced, have succeeded in establishing effective regulatory frameworks and in implementing national large-scale programs for treatment; however, they have been insufficient in preventing obesity. The main lessons learned are: (1) Failure to monitor existing malnutrition programs for changing needs and true effectiveness can have unintended consequences. (2) Institutions and professionals working in nutrition and health need to assess changing scenarios and redefine their priorities for action accordingly. (3) There is a need to provide updated information to decision makers, program planners and to the population at large on how to promote and achieve healthy food consumption and active living considering local context. Timely policies and interventions to address these issues may contribute to the prevention of the obesity epidemic in transitional countries, particularly among low socioeconomic groups.

Assessment of the alcohol use disorders identification test (AUDIT) to detect problem drinkers

BACKGROUND AUDIT is a self-reported questionnaire used to detect problem drinkers. It must be translated into Spanish and validated in order to be used in Chile. AIM To assess the validity of a Chilean version of the AUDIT questionnaire. MATERIAL AND METHODS The English version of the questionnaire was translated into Spanish and adapted to the Chilean cultural environment. Using the Delphi method, an expert group examined the text and then decided on which would be the definitive version. This test was translated to English again and was approved by one of the original authors. It was then applied to 93 subjects aged 37 +/- 12 years (60% males) consulting at a primary health care center These subjects also answered the Composite International Diagnostic Interview (CIDI), version 2.1 that was used as the gold standard for the diagnosis of hazardous drinking and alcohol dependence. Cronbach alpha and test-retest validity were analyzed. Sensitivity and specificity were determined using receiver operating (ROC) curves. RESULTS The internal consistency of AUDIT was 0.93, its test re-tests reliability was 0.97 (95% confidence intervals 0.96-0.98). Using a cutoff point of 6 for hazardous consumption, its sensitivity and specificity were 83% and 88%, respectively. The figures for dependence and harmful consumption, using a cutoff point of 9, were 87% and 85%, respectively. CONCLUSIONS AUDIT is a valid questionnaire to detect problem drinkers.

Early adiposity rebound is associated with metabolic risk in 7-year-old children

Background:Early adiposity rebound (AR <5 years) has been consistently associated with increased obesity risk, but its relationship with metabolic markers is less clear; in addition, the biologic mechanisms involved in these associations have not been established.Objective:The objective of this study was to assess the association between timing of AR and metabolic status at age 7 years, evaluating the potential role of adiposity, adipose functionality and skeletal maturation in this association.Design:We estimated the age of AR from the body mass index (BMI) trajectories from 0 to 7 years in 910 children from the Growth and Obesity Chilean Cohort Study (GOCS). At 7 years, we measured waist circumference (WC) and blood glucose, insulin, triglycerides and high-density lipoprotein-cholesterol levels and constructed a metabolic risk score. We also measured percent fat mass (adiposity), plasma concentrations of leptin and adiponectin (adipose functionality) and bone age using wrist ultrasound (skeletal maturation).Results:We found that 44% of the children had an AR <5 years. Earlier AR was associated with larger WC (β: 5.10 (95% confidence interval (CI): 4.29–5.91)), higher glucose (β: 1.02 (1.00–1.03)), insulin resistance (β Homeostatic Model Assessment: 1.06 (1.03–1.09)), triglycerides (β: 10.37 (4.01–6.73)) and adverse metabolic score (β: 0.30 (0.02–0.37)). Associations decreased significantly if adiposity was added to the models (i.e. β WC: 0.85 (0.33–1.38)) and, to a lesser extent, when adipokines (i.e. β WC: 0.73 (0.14–1.32)) and skeletal maturation (i.e. β WC: 0.65 (0.10–1.20)) were added.Conclusion:In GOCS children, AR at a younger age predicts higher metabolic risk at 7 years; these associations are mostly explained by increased adiposity, but adipose dysfunction and accelerated skeletal maturation also have a role.

Valores normativos de resistencia a la insulina mediante HOMA-IR en adultos mayores de Santiago de Chile

Background: The homeostasis assessment model for insulin resistance (HOMA-IR) estimates insulin resistance using basal insulin and glucose values and has a good concordance with values obtained with the euglycemic clamp. However it has a high variability that depends on environmental, genetic and physiologic factors. Therefore it is imperative to establish normal HOMA values in different populations. Aim: To report HOMA-IR values in Chilean elderly subjects and to determine the best cutoff point to diagnose insulin resistance. Material and methods: Cross sectional study of 1003 subjects older than 60 years of whom 803 (71% women) did not have diabetes. In 154 subjects, an oral glucose tolerance test was also performed. Insulin resistance (IR) was defined as the HOMA value corresponding to percentile 75 of subjects without over or underweight. The behavior of HOMA-IR in metabolic syndrome was studied and receiver operating curves (ROC) were calculated, using glucose intolerance defined as a blood glucose over 140 mg/dl and hyperinsulinemia, defined as a serum insulin over 60 ∝U/ml, two hours after the glucose load. Results: Median HOMA-IR values were 1.7. Percentile 75 in subjects without obesity or underweight was 2.57. The area under the ROC curve, when comparing HOMA-IR with glucose intolerance and hyperinsulinemia, was 0.8 (95% confidence values 0.72-0.87), with HOMA-IR values ranging from 2.04 to 2.33. Conclusions: HOMA-IR is a useful method to determine insulin resistance in epidemiological studies. The HOMA-IR cutoff point for insulin resistance defined in this population was 2.6 (Rev Med Chile 2009; 137: 1409-16). (Key words: Aged, Diabetes mellitus, Hyperinsulinism, Insulin resistance)

Adherence to a physical activity intervention among older adults in a post-transitional middle income country: a quantitative and qualitative analysis

ObjectivesThe effectiveness of community level interventions depends to a great extent on adherence. Currently, information on factors related to adherence in older adults from developing countries is scarce. Our aim was to identify factors associated to adherence to a physical activity intervention in older adults from a post-transitional middle income country.Design, setting and participantsUsing a combination of quantitative and qualitative methods we studied 996 older Chilean subjects (65–67.9 years at baseline) with low to medium socioeconomic status from 10 health centers randomized to receive a physical activity intervention as part of the CENEX cluster trial (ISRCTN48153354).MeasurementsUsing a multilevel regression model, the relationship between adherence (defined a priori as attendance at a minimum of 24 physical activity classes spread over at least 12 months) and individual, intervention-related and contextual factors was evaluated. We also conducted 40 semi-structured interviews with older adults (n=36) and instructors (n=4). Transcripts of the interviews were analyzed using content analysis to identify barriers and facilitators to adherence.ResultsAdherence to physical activity intervention was 42.6% (CI 95% 39.5 to 45.6). Depression, diabetes mellitus, percentage of impoverished households and rate of arrests for violent crimes in the neighborhood predicted less adherence (p<0.05) while being retired, participation in physical activity prior to the intervention, and green areas per habitant were positively associated with adherence (p<0.05). The qualitative interviews identified three primary barriers to adherence: current health problems, lack of time due to commitments for caring for family members, and being employed, and two primary facilitators to adherence: the health benefits attributed to the intervention and the opportunity the classes provided for social interaction with others.ConclusionIn order to enhance effectiveness of community exercise interventions, strategies to improve participation should be targeted to older adults from deprived areas and those with psychological and medical conditions.

Nutrition status of children in Latin America

The prevalence of overweight and obesity is rapidly increasing among Latin American children, posing challenges for current healthcare systems and increasing the risk for a wide range of diseases. To understand the factors contributing to childhood obesity in Latin America, this paper reviews the current nutrition status and physical activity situation, the disparities between and within countries and the potential challenges for ensuring adequate nutrition and physical activity. Across the region, children face a dual burden of undernutrition and excess weight. While efforts to address undernutrition have made marked improvements, childhood obesity is on the rise as a result of diets that favour energy‐dense, nutrient‐poor foods and the adoption of a sedentary lifestyle. Over the last decade, changes in socioeconomic conditions, urbanization, retail foods and public transportation have all contributed to childhood obesity in the region. Additional research and research capacity are needed to address this growing epidemic, particularly with respect to designing, implementing and evaluating the impact of evidence‐based obesity prevention interventions.

Alarming weight gain in women of a post-transitional country

OBJECTIVE In post-transitional countries, obesity disproportionally affects women. Longitudinal studies can detect high-risk groups in whom to target actions. We investigated the magnitude and velocity of BMI changes in Chilean women of reproductive age and evaluated whether these trends vary in specific groups. DESIGN Longitudinal study. We measured weight and height in 2007 (baseline) and again in 2010 (follow-up); we estimated change in BMI (weight/height2) within the 3-year period and assessed its relationship with age, years of education and parity, collected at baseline and follow-up using a questionnaire. SETTING Population-based cohort of low- to middle-income Chilean women. SUBJECTS Seven hundred and sixty-one women of reproductive age (mean 32·0 (sd 7·0) years), mothers of children who participate in the Growth and Obesity Cohort Study (GOCS). RESULTS At baseline, 61 % of women had BMI ≥ 25·0 kg/m2. After 3 years, women gained on average 2·6 kg and obesity (BMI ≥ 30·0 kg/m2) increased by 23 % (12 % new obesity cases). Women with normal nutritional status gained more BMI than obese women (1·4 v. 0·6 kg/m2, P < 0·001). An increase in parity was positively associated with BMI change, independently of age, nutritional status and education (P < 0·05). Age and education were not associated with BMI change after controlling for other factors (P > 0·05). CONCLUSIONS In Chile, a post-transitional country, we observed an alarming increase in obesity among women of reproductive age. Our results indicate that in this population actions need to be targeted at all women irrespective of their nutritional status. A key component of these policies should be avoiding excessive weight gain during pregnancy.

Importancia del apoyo social en la permanencia de la abstinencia del consumo de drogas

We studied 306 subjects that were treated in drug addiction centers, financed by the NationalCouncil for Drug Control (CONACE). At discharge, social and demographic data were recordedand the Medical Outcomes Study (MOS) questionnaire was given to evaluate social support.Subjects that achieved abstinence at the moment of discharge were contacted six months laterand interrogated about eventual drug consumption thereafter.