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Instituto de Nutricion y Tecnologia de los Alimentos (INTA), Universidad de Chile, Santiago, Chile
2To whom correspondence and reprint requests should be addressed at Universidad de Chile, Instituto de Nutricion y Tecnologia de los Alimentos (INTA), Casilla 138-11, Santiago, Chile. E-mail: uauy{at}uchile.cl.
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ABSTRACT |
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 TOP ABSTRACT OBESITY TRENDS IN LATIN...OLD AND NEW CONDITIONING...REFERENCES |
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KEY WORDS: • obesity • Latin America • aboriginal population • diabetes • supplementary feeding programs
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OBESITY TRENDS IN LATIN AMERICA |
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TOPABSTRACTOBESITY TRENDS IN LATIN...OLD AND NEW CONDITIONING...REFERENCES |
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illustrates the trends in causes of death by disease categories in
Guatemala, Mexico, Chile and Uruguay (1)
. These data give
a clear indication of how death from infections is on the decline while
death from noncommunicable chronic disease is on the rise. Guatemala
has recently initiated the transition while Mexico is clearly in the
midst of the process. Chile has recently finished the period of rapid
change while Uruguay can be considered to be in the posttransition
phase. In the absence of systematically collected data on distribution
of causes of death, these categories serve as a proxy indicator of type
of malnutrition present at the population level. As obesity rises,
deaths from cardiovascular disease and cancer also increase;
conversely, if death from infection predominates, malnutrition tends to
be high and obesity low.
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reviewed DHS surveys
conducted since 1982 and evaluated the prevalence of obesity in women
and children. The mean value for obesity in women for the eight
countries evaluated was 8–10%. Table 1
summarizes results for five countries using a BMI cutoff of 
30
kg/m2 according to WHO or a BMI index of 27.3 following USA Hanes I (3)
. The lowest prevalence was
found in Honduras while the highest is found in Bolivia and Peru,
depending on cutoff point defined. In the case of children under 5 y of age a weight-for-height > 1 SD was considered as
overweight, and > 2 SD as obesity. The lowest figures
are found in Bolivia while the highest are found in the Dominican
Republic. An increasing prevalence of obesity in women was found in
countries with higher per capita income and in those with lower rates
of stunting in children. A recent PAHO/WHO publication on obesity in
Latin America (4)
revealed an increasing trend for obesity
as countries emerge from poverty, especially in urban areas. In
contrast, in middle income countries, obesity tends to decline as
income increases; this is especially so in women.
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, and B
for women and men
(5
,6
). Similar trends are observed for Costa
Rica, Barbados and other Caribbean countries. A study by Sichieri et
al. (7)
using a BMI 30 found 4. 8% obesity for
men and 11.7% in Brazilian adult women. In Costa Rica the prevalence
of overweight in 1996 was 45.9% using a BMI 25
(8)
. Atalah (9)
in Santiago, Chile, reports a
prevalence of 20.5% in men and 30% in women in 1993 using a BMI of 27
as a cutoff limit. Sinha (10)
from Barbados reports a
prevalence of obesity of 16% in men and 38% in women in 1981 using a
BMI 27, indicating that for the Caribbean, obesity rates in
1995 were 7–20% for men and 22–48% for women.
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demonstrate in a cross-sectional study of adults
older than 35 y of age a higher prevalence in urban areas relative
to rural areas. Trends demonstrate a progressive rise in obesity rates,
especially in urban women; rates of increase are highly variable
between and within countries (12)
. In general as income
increases so does the prevalence of obesity; dietary changes and
progressive inactivity are considered the crucial contributory factors
that explain this rise. |
OLD AND NEW CONDITIONING FACTORS FOR OBESITY |
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TOPABSTRACTOBESITY TRENDS IN LATIN...OLD AND NEW CONDITIONING...REFERENCES |
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The nutrition transition brings about significant dietary changes as presented by Popkin et al. in this same issue. Increases in total fat, animal protein and fat consumption are the most prominent. As income increases in transitional countries, so does the consumption of high fat foods, including industrially processed hydrogenated fats. Processed foods are usually more expensive in the rural areas, whereas the converse is true for natural foods such as grains, fruits and vegetables. Progressive urbanization and the mass media may contribute to the shift in diet of rural migrants who abandon their staple plant food–based diets, favoring processed foods and animal food products. These factors affect children and adolescents as well. If the change in diet is accompanied by a sedentary lifestyle and physical inactivity, the combination is perfect to trigger increasing adiposity. Energy balance and fat stores strictly follow the laws of thermodynamics, whether people are urban or rural, rich or poor. The end result is a progressive rise in overweight and obesity, especially in low income groups who improve their income and buy high fat/high carbohydrate energy-dense foods. Sweet and salty high fat foods show marked consumer preference in the urban supermarket; intake of these foods increases to the detriment of grains, fruits and vegetables. On a positive note, recent trends demonstrate that high income countries are reducing the consumption of fat, possibly in response to the existence of public health–based dietary guidelines.
Recent data from several urban centers including data obtained in
Santiago, Chile, demonstrate that television viewing and a child’s
preference for certain TV commercials has a direct relationship with
snack food consumption and other food purchased by children at school
(13)
. The relative contribution of dietary change vs.
physical inactivity in determining the increasing rates of obesity in
children in transitional societies cannot be quantified in a precise
manner. Furthermore, attempting to do this would be futile, because
preventive strategies should address both. Recommendations to prevent
obesity are presently integrating dietary advice, increasing physical
activity and weight monitoring. The challenge of preventing obesity is
yet to be tackled effectively in urban societies.
Although Chile has no national system to monitor the nutritional status
in adults, there are data representative of the city of Santiago, where
40% of the population lives. In two surveys on risk factors for
chronic diseases carried out in the population over 15 y of age,
obesity increased from 6% to 11% and from 14% to 24% in men and
women, respectively, over a 4-y period
(14
,15
). Obesity increased with age, was more
prevalent in women than in men and was higher in women of low
socioeconomic level. In another study carried out in a representative
sample in urban Valparaiso, Chile (25–64 y of age) in 1997, obesity
prevalence was also high and had a similar distribution to that found
in Santiago (16)
. Changes in the diet and sedentarism are
the most probable causes of the increasing trend of obesity in Chile.
Dietary patterns in Chile have changed rapidly, becoming closer to the
"Western diet," high in saturated fat with decreased consumption of
grains and other fiber-rich foods (5)
. A recent
analysis of a National Household Survey on Food Expenditure
(17)
demonstrated that the principal components of food
expenditure among the poor are bread, meat and soft drinks. A study on
food consumption carried out in Santiago in 1995 demonstrated that 70%
of adults consumed less than two fruits and 59% consumed less than two
portions of vegetables per day (18)
. On the other hand,
sedentarism is high in Chile and has increased with the progress of
urbanization. In 1970 three quarters of the population lived in urban
areas; for 1997 this figure is 87%. The number of cars increased from
363,150 in 1970 to 1,969,128 in 1997. TV sets numbered 12,170 in 1970,
increasing to > 2 million in 1997 (19)
. A recent
study carried out in Santiago demonstrated that 90% of school-age
children watch television during weekdays, and of these 20% watch for
more than 3 h daily (5)
. For Metropolitan Santiago in
1988, 55% of men and 77.4% of women performed less than two 15-min
periods of exercise per week, while in 1992 these figures increased to
57.8% in men and to 80.1% in women (20)
. In Valparaiso
for 1997, > 90% of adult women were inactive during their leisure
time, which for the low socioeconomic group was 97% (16)
.
Lifestyle changes of aboriginal populations and obesity
Obesity has a complex etiology, resulting from the combined
effects of genes, environment, lifestyle and their interactions.
Although the genetic background is crucial to explain the
susceptibility to most chronic diseases, the modernization and
urbanization process affecting aboriginal populations has brought about
major changes that are most likely contributing to the high prevalence
of obesity and diabetes reported (21)
. Most aboriginal
populations today have changed their diet and physical activity
patterns to fit an industrialized country model. They now derive their
diet completely or in large part from Western foods and live sedentary
and physically inactive lives. Under these circumstances they develop
high rates of obesity, insulin resistance and type 2 diabetes
(22
,23
).
The Chilean population is formed by a mixture of Amerindian native
groups and descendants of several European migrants. The Mapuche
population, the major aboriginal group in Chile, are descendants of
Asian migrations that settled in the southern part of the central
valley of Chile and extended to Patagonia, both sides of the Andes. A
self-assessment questionnaire on ethnicity included in the 1992
Chilean census among people older than 14 y (24)
indicated that close to 10% of Chileans identify themselves as
"Mapuche." Economic and social changes have forced a great number
of Mapuche to migrate from their original rural conditions in the South
of Chile to large urban centers, such as Santiago and its surroundings.
Nowadays, nearly one third of the Mapuche live in urban centers
(24)
. In 1985 a high prevalence of obesity, close to
40% in the rural Mapuche population was found. However, this ethnic
group had a very low prevalence of type 2 diabetes, < 1%
(25)
. The prevalence of risk factors for chronic diseases
has increased dramatically in Chile over the past three decades, in
that lifestyle changes and rapid urbanization have occurred. In fact,
15% of adult Chilean men and 23% of women are now obese
(14)
. Considering these changes, we explored whether
Mapuche living in large cities like Santiago had also experienced a
rise in the metabolic complications of obesity.
Our studies over the past 5 y have examined the effect of genetic
differences on the prevalence of obesity, glucose intolerance and
leptin levels in groups with different ethnic backgrounds. Mapuche of
rural areas preserving ethnical and cultural distinctive
characteristics were compared to Caucasian subjects (Spanish heritage)
from the general population of Santiago (26)
. We found
that BMI, gender and insulin were independently associated to leptin
levels in Caucasians, whereas for the Mapuche group, only BMI was
associated to leptin after controlling for gender and insulin. The
comparison of plasma leptin levels adjusted for BMI, gender and age
showed significant ethnic differences. Mean concentration of plasma
leptin in Caucasian individuals was approximately twofold higher
compared to that of Mapuche subjects. Fasting insulin levels adjusted
for age, gender and BMI, indicative of glucose sensitivity, were also
significantly higher in Caucasians. Only 4.1% of rural Mapuche were
classified as diabetics, compared to 9.8% observed in urban Mapuche
and 5.3% in the Caucasian population of Santiago. Glucose intolerance
was identified in 3.4% of the rural and in 6.1% of the urban Mapuche.
Our study also revealed a higher prevalence of obesity (P
< 0.05) in urban Mapuche compared to that in rural natives.
Moreover, these data suggest that the change in environment may
increase disease susceptibility beyond that observed in Caucasian
populations. The early report of a low prevalence of diabetes in the
presence of high rates of obesity in the Mapuche was not upheld by our
recent studies, suggesting that aboriginal populations lose their
protection from the metabolic complications of obesity as they undergo
urbanization and lifestyle, including dietary changes
(27)
. Table 2
summarizes these findings.
|
,29
). Moreover, the Aymara rural
population has not experienced a massive shift from their traditional
ways of living to a modern Western lifestyle. According to the
self-identification questionnaire of the 1992 census only 0.5% of
Chileans older than 14 y were Aymara (24)
. Studies
conducted in the early 1970s revealed an absence of clinically
recognizable diabetes in a large sample of rural Aymara subjects living
in their natural ecosystem. Our most recent study of the Aymara
conducted in 1997, in a sample of 78 men and 118 women older than
19 y of age, found a prevalence of diabetes of only 1.0%,
adjusted for age, and 3.5% glucose intolerance. The low prevalence
estimated in the present study is concordant with previous observations
(30)
.
The difference in prevalence of obesity and diabetes between Aymara and
Mapuche populations or other indigenous population of the Americas is
difficult to interpret. Multiple dietary factors and gene/environment
interactions may determine a potential epigenetic effect. However, the
low prevalence of type 2 diabetes in Aymara and rural Mapuche subjects
(30)
is in sharp contrast to the high prevalence of this
condition in most aboriginal groups in North America, including the
Pima from Arizona and Mexican-American minorities in the United
States (21
,32
). Although the distribution of
BMI observed in the Aymara is similar to that in the general population
of urban Santiago, mean values of insulin resistance, determined by
HOMA, indicate improved glucose tolerance in the Aymara subjects
(30)
. Low mean values of HOMA-IR and insulin
levels in Aymara subjects could be in part a consequence of their high
level of physical activity and their traditional high complex
carbohydrate diet. The prevalence of diabetes in the rural Aymara
population who live in high altitudes in the north of Chile is lower
than the prevalence in the urban Caucasian population of Santiago,
Chile, and much lower than the prevalence in other Amerindian groups
from North America. Prevalence of diabetes in this Aymara population is
similar to, or slightly lower than, the prevalence reported for the
rural Mapuche population. Both populations have preserved a rural
physically active lifestyle and have maintained their traditional diet
(30)
.
Nutrition interventions programs: from stunting and underweight to overweight and obesity
Supplementary feeding programs are a fact of life for most
countries in the region. A recent Food and Agriculture
Organization survey with data from 19 Latin American countries found
that over 20% of the population—or approximately 83 million people
out of an estimated 414 million in these countries—receive some level
of food assistance benefits from nutrition-related programs
(33)
. In contrast, the number of malnourished in the study
countries was 10 million, that is, 12% of total beneficiaries. The
explanation for this phenomenon is that nutrition programs have evolved
beyond the immediate needs of the malnourished and have become part of
social economic benefit demanded by populations living under poverty.
Despite the obvious benefits (namely the significant reductions in
underweight and wasting that have occurred in most countries), these
programs have the potential to affect the trends in obesity rates.
Also, stunting remains a problem in this region. In this setting
providing food supplements may be beneficial for some, although it may
be detrimental for others. Careful selection of beneficiaries of food
assistance programs and determining the right combination of
nutrients/foods, education and lifestyle interventions, required to
optimize nutrition and health at each stage of the life cycle, is a
problem that cannot be avoided (33)
.
Chile is often presented as a paradigm of the success of supplementary
feeding programs. Indeed, the association between the presence of these
massive interventions and the decline in malnutrition in all age groups
is there. Unfortunately, these programs may be also contributing to the
rising prevalence in obesity (34)
. Specific examples will
be given in an effort to show the impact that these assistance programs
may have on the prevalence in obesity and to signal the road ahead for
other countries undergoing the rapid nutrition transition.
The Chilean supplementary feeding program or "Programa Nacional de Alimentación Complementaria" (PNAC) began in the 1920s as a public milk distribution program for working mothers. It was built into the workers’ social security legislation in 1937 as part of preventive health to protect working class families. The PNAC was significantly strengthened in the 1950s with the creation of the National Health Service (NHS), which provides universal health protection and health services for insured workers and the indigent population. The existence of the PNAC is secured by law and financed by direct contribution of private and public employees and employers. In terms of beneficiaries it has the largest coverage, presently approximately 1.2 million children under 6 y and 200,000 pregnant women. This corresponds to approximately 80% of the national population of infants under 2 y and 70% of preschool children, pregnant and nursing mothers.
The main objectives of the PNAC are: to promote normal growth and
development in children from conception through 6 y of age by
providing food supplements to the mother during pregnancy and
lactation, and to the child from birth to 6 y of age; to protect
mother’s health during pregnancy and lactation; to promote breast
feeding by providing supplements to mothers during pregnancy and
lactation; to prevent low birth weight related to maternal
malnutrition; to prevent infant and childhood malnutrition among the
beneficiaries of the NHS; and to improve coverage of primary health
care activities, thus providing an incentive for beneficiaries to
attend regular check-ups (35)
. Within the activities
of the PNAC the enhanced program was specifically designed for the
early control of undernutrition. The calorie contribution provided by
this program varies from 100% of the requirement for infants of 5 mo
old to 30% for children between 2 and 6 y of age. The protein
contribution is considerably higher, 180 and 58%, respectively.
Table 3
provides the results of a controlled evaluation conducted by Kain et
al. (35)
in a group of 1149 infants in which
weight-for-length Z-score categorization on entry into the
program was compared to the corresponding Z-score upon
discharge, 12 mo later. As noted from the data on admission, 93 of 1149
infants had a weight for length below -1 Z, while at the
end of a year of receiving the benefit, only 7 remained in that
condition. On the other hand, the number of infants who exceeded +1
Z increased from 0 to 117. Those who were within ±1
Z remained basically unchanged, that is, went from 1056 to
1025. The changes observed in the group in terms of length-for-age are
depicted in Figure 3
; a control group was obtained from nonparticipants in the enhanced PNAC
program matched for age and growth indices (36)
. The data
from participants and control infants were analyzed according to
stunted (below -1 Z length for age) or nonstunted
(length-for-age > -1 Z). As noted, both control and
enhanced PNAC stunted groups experienced a small nonsignificant gain in
length-for-age. Infants who were not stunted exhibited no change in
length Z-score during the year-long evaluation. In
summary, the benefit of improving mild underweight in 86 infants was
offset by increasing the number of overweight infants by 117. The
evidence from length-for-age Z-score suggests that even the
stunted exhibited no gain from the program as compared to a control
group that did not receive the benefit. Moreover, presently the
significance of being mildly underweight should be reassessed in light
of the emergence of a new paradigm of growth, in which more is not
necessarily better. What is clear from this evaluation is that, if
stunted or normal children are provided additional food, they will gain
weight to exceed the median reference value.
|
|
.
As demonstrated in Figure 4A
and B
this program has contributed most likely
to the notable decrease in stunting observed in the preschool
population during the past decade. The percentage of children below -1
SD in terms of weight-for-age and height-for-age has
dropped significantly, while those with mild under weight are < 5% of the total. Concomitantly over the same period (Fig. 4B
), we observe that mean weight for age has increased
progressively for 6-y-olds entering primary schools, more in girls than
in boys. We also evaluated the change in percentage of children over 2
Z in weight-for-length between March (school entrance) and
November (final month of school year) for each age group under JUNJI’s
program. We observed, as shown in Figure 5
, a rise in obesity rates during the school year, progressively higher
with each age cohort. Finally, we obtained retrospective data from 8086
children who had been measured every year under standardized conditions
to evaluate this cohort, mimicking a longitudinal follow-up
(38)
. This is summarized in Table 4
, demonstrating that at the time of entry into the program a total of
408 exceeded +2 Z in terms of weight-for-height, whereas
3 y later 1211 exceeded that limit. That is a threefold increase
in the number of obese children over a 3-y period. During this same
period, the number of overweight children (over +1 Z) went
from 1440 to 2160, that is, a 50% increase. On a more positive note
the program is presently adapting the food provided to the current
nutritional profile of the preschool population. Currently, sugar and
saturated fat content of the ration have been lowered, skimmed milk is
being provided and additional fresh fruits and vegetables have been
added, favoring the supply of calcium, micronutrients (iron and zinc)
and fiber (39)
.
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTOBESITY TRENDS IN LATIN...OLD AND NEW CONDITIONING...REFERENCES |
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 J. D. Piette, I. Lange, M. Issel, S. Campos, C. Bustamante, J. Sapag, F. Poblete, P. Tugwell, and A. M. O'Connor Use of telephone care in a cardiovascular disease management programme for type 2 diabetes patients in Santiago, Chile Chronic Illness, June 1, 2006; 2(2): 87 - 96. [Abstract] [PDF]
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M. Ramirez-Zea, B. Torun, R. Martorell, and A. D Stein Anthropometric predictors of body fat as measured by hydrostatic weighing in Guatemalan adults. Am. J. Clinical Nutrition, April 1, 2006; 83(4): 795 - 802. [Abstract] [Full Text] [PDF]
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 A. O. Carter, I. R. Hambleton, H. L. Broome, H. S. Fraser, and A. J. Hennis Prevalence and Risk Factors Associated With Obesity in the Elderly in Barbados J Aging Health, April 1, 2006; 18(2): 240 - 258. [Abstract] [PDF]
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E. K. Kabagambe, A. Baylin, E. Ruiz-Narvarez, X. Siles, and H. Campos Decreased Consumption of Dried Mature Beans Is Positively Associated with Urbanization and Nonfatal Acute Myocardial Infarction J. Nutr., July 1, 2005; 135(7): 1770 - 1775. [Abstract] [Full Text] [PDF]
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H. V. Kuhnlein, O. Receveur, R. Soueida, and G. M. Egeland Arctic Indigenous Peoples Experience the Nutrition Transition with Changing Dietary Patterns and Obesity J. Nutr., June 1, 2004; 134(6): 1447 - 1453. [Abstract] [Full Text] [PDF]
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 F. J Gomez-Perez, A. Perez-Monteverde, O. Nascimento, P. Aschner, M. Tagle, K. Fichtner, P. Subbiah, E. M Mutisya, For The Latin American Diabetic Neuropathy Study G, and B. Parsons Gabapentin for the treatment of painful diabetic neuropathy: dosing to achieve optimal clinical response The British Journal of Diabetes & Vascular Disease, May 1, 2004; 4(3): 173 - 178. [Abstract] [PDF]
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 I. M. Libman, M. Pietropaolo, S. A. Arslanian, R. E. LaPorte, and D. J. Becker Changing Prevalence of Overweight Children and Adolescents at Onset of Insulin-Treated Diabetes Diabetes Care, October 1, 2003; 26(10): 2871 - 2875. [Abstract] [Full Text] [PDF]
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A. Baylin, E. K. Kabagambe, A. Ascherio, D. Spiegelman, and H. Campos High 18:2 Trans-Fatty Acids in Adipose Tissue Are Associated with Increased Risk of Nonfatal Acute Myocardial Infarction in Costa Rican Adults J. Nutr., April 1, 2003; 133(4): 1186 - 1191. [Abstract] [Full Text] [PDF]
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A. Baylin, E. K Kabagambe, X. Siles, and H. Campos Adipose tissue biomarkers of fatty acid intake Am. J. Clinical Nutrition, October 1, 2002; 76(4): 750 - 757. [Abstract] [Full Text] [PDF]
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K. L. Tucker and S. Buranapin Nutrition and Aging in Developing Countries J. Nutr., September 1, 2001; 131(9): 2417S - 2423. [Abstract] [Full Text] [PDF]
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