Socio-economic factors related to premature death from colorectal cancer in Santiago de Chile, 2014-2018: a cross-sectional study.

OBJECTIVES: In Chile, colorectal cancer (CRC) is the fourth cause of death by cancer. Few studies have evaluated the role of contextual and individual socio-economic variables associated with premature death by CRC (<70 years). We analyzed the association between socio-economic factors (at individual and contextual levels) and premature death from CRC in Santiago de Chile. STUDY DESIGN: This was a cross-sectional study. METHODS: We analyzed deaths from CRC between 2014 and 2018 using data published by the Ministry of Health. Individual predictors were sex, marital status, and educational level. Contextual variable included the Social Priority Index (SPI) of the commune where the deceased lived. The association was assessed through multilevel logistic regression models. RESULTS: During the period, 4762 deaths occurred (51.7% women); 39.3% were premature. At the individual level, male sex (odds ratio [OR] 1.36; 95% confidence interval [CI] 1.20-1.53) and single marital status (OR 1.45; 95% CI 1.24-1.68) were associated with premature death from CRC. Primary or lower education was a protective factor (OR 0.53; 95% CI 0.47-0.60). At the contextual level, communes with a higher SPI were three times more at risk than those with a lower SPI (OR 3.13; 95% CI 2.15-4.57). CONCLUSIONS: This study showed that individual and contextual socio-economic variables are related to premature death from CRC. Residing in communes with greater socio-economic vulnerability was associated with greater risk. To reduce this gap, it is urgent to design and implement structural policies to reduce social inequities and improve access to health care.

Socio-economic inequalities in the effect of public policies and the COVID-19 pandemic on exclusive breastfeeding in Chile.

OBJECTIVE: To assess the impact of the addition of 12 maternity leave (ML) weeks (2011), a pay for performance (P4P) exclusive breastfeeding (EBF) promotion strategy (2015), and the COVID-19 pandemic in EBF inequalities in Chile. STUDY DESIGN: Interrupted time-series analyses (ITSAs). METHODS: Aggregated national EBF data by municipality and month were collected from 2009 to 2020. We assess the impact of the three events in EBF inequalities using two procedures: 1. ITSA stratified by municipal SES quintiles (Q1-Q5); 2. Calculating the EBF slope index of inequality (SII). RESULTS: The EBF prevalence was higher in lower SES municipalities before and after the three time-events. No impact in EBF inequalities was observed after the extended ML. The P4P strategy increased EBF at six months in all SES quintiles (effect size between 4% and 5%), but in a higher level in poorer municipalities (SII: -0.36% and -1.05%). During COVID-19, wealthier municipalities showed a slightly higher EBF at six months prevalence (SII: 1.44%). CONCLUSION: The null impact of the extended ML in EBF inequalities could be explained by a low access to ML among affiliated to the public health system (20%). The P4P strategy includes multiple interventions that seemed effective in increasing EBF across all SES quintiles, but further in lower quintiles. The restrictions in healthcare access in poorer municipalities could explain EBF inequalities during COVID-19.

Trends and predictors of birth weight in Chilean children.

OBJECTIVES: Birth weight is an important public health indicator that reflects fetal health conditions and predicts future health. Identifying the most important factors related to birth weight would help defining preventive health strategies for both mothers and children. The objectives of this study are i. to describe, using a large birth database from a Chilean hospital, the trend of birth weight during 2002-2015, and ii. to determine factors during prenatal care associated with low and high birth weight. STUDY DESIGN: This study is a secondary analysis of all single birth records at a Chilean Hospital in the southeast district of Santiago, Chile, during 2002-2015 (N = 78,931). METHODS: Sociodemographic information, clinical and obstetric history, lifestyle, and anthropometric variables were evaluated as potential predictors. Birth weight was categorized into five groups as per percentiles of weight as per gestational age. Data were extracted from clinical records. We used classification and regression tree methodology and logistic regression. RESULTS: The average birth weight for the period was 3316 g (SD 566), with little variation across time. Preterm births increased from 7% in 2002 to 10% in 2015, and births >40 weeks decreased from 10.7% in 2002 to 4.4% in 2015. The percentages of small and large for gestational age changed from 10.9% and 12.7% in 2002 to 9.9% and 13.9% in 2015, respectively. The predictors included in the optimal tree were body mass index, gestational weight gain, pre-eclampsia, and gestational diabetes. We found that women with a pregestational body mass index <28 kg/m2, gestational weight gain <17 kg, and preeclampsia had a probability of 41% of having a small for gestational age neonate. Conversely, women with a body mass index ≥28 kg/m2, gestational weight gain ≥17 kg, and gestational diabetes had a probability of 44% of having a large for gestational age neonate. CONCLUSIONS: This study showed that the most important variables explaining birth weight are those related to maternal nutritional status. Thus, the strategies to promote a normal birth weight should aim for a normal maternal weight at the beginning of pregnancy, gestational weight gain within the recommendations, and prevention of gestational diabetes and pre-eclampsia.

Gestational weight gain recommendations for Chilean women: a mathematical optimization approach.

OBJECTIVES: We examined if the guidelines for gestational weight gain (GWG) proposed by the Institute of Medicine (IOM) are the most suitable for Chilean women. STUDY DESIGN: Secondary analysis of records of single full-term births at the Dr. Sótero del Río Hospital, Santiago, Chile, during 2003-2012 (n = 62,579). METHODS: From clinical records, we obtained data regarding maternal age, height, prepregnancy and at delivery weights, pathologies during pregnancy such as gestational diabetes (GDM) and pre-eclampsia, gestational age at delivery, and number of infants born small for gestational age (SGA) and large for gestational age (LGA). We formulated a mathematical model (MM) to determine the GWG range that maximizes the likelihood of a healthy pregnancy (HP) if the recommendation is followed. We defined an HP as one where the mother has no complications such as pre-eclampsia, GDM, SGA, or LGA. RESULTS: Forty-six percent of women had prepregnancy overweight or obesity. The prevalence of GDM, pre-eclampsia, SGA, and LGA were 3%, 1.2%, 9%, and 12%, respectively. An HP was present in 76% of pregnancies, 79% in the underweight group, 79% in normal weight group, 74% in the overweight group, and 67% in obese women. The GWG recommendations given by the MM (14-20 kg for underweight, 6-20 kg for normal weight, 9-11 kg for overweight, and 6-7 kg for obese) led to higher probabilities of achieving an HP than the ones obtained with the IOM recommendations. CONCLUSION: The adoption of GWG recommendations based on characteristics of the Chilean population might lead to better short- and long-term health results for pregnant women.

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.

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 (ß: 5.10 (95% confidence interval (CI): 4.29-5.91)), higher glucose (ß: 1.02 (1.00-1.03)), insulin resistance (ß Homeostatic Model Assessment: 1.06 (1.03-1.09)), triglycerides (ß: 10.37 (4.01-6.73)) and adverse metabolic score (ß: 0.30 (0.02-0.37)). Associations decreased significantly if adiposity was added to the models (i.e. ß WC: 0.85 (0.33-1.38)) and, to a lesser extent, when adipokines (i.e. ß WC: 0.73 (0.14-1.32)) and skeletal maturation (i.e. ß 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.

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 children's exposure to unhealthy foods by restricting marketing, advertising and sales. We summarize the work related to the law's 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.

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

OBJECTIVES: The 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 PARTICIPANTS: Using 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). MEASUREMENTS: Using 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. RESULTS: Adherence 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. CONCLUSION: In 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.

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.

Increasing crude and adjusted mortality rates for colorectal cancer in a developing South American country.

AIM: Colorectal cancer (CRC) is a major cause of cancer death worldwide. We examined temporal trends in death rates from colorectal cancer in Chile from 1983 to 2008. METHOD: We analysed the mortality database in Chile from 1983 to 2008. Cases were selected using ICD-9/10 codes. We calculated mortality rates per 100,000 inhabitants according to sex, age group and type of cancer - colon (CC) or rectal (RC). The rates were adjusted by a direct method using the WHO-2000 standard population. Time trends were assessed with Prais-Winsten regression models. RESULTS: There were 26,250 deaths from CRC (75.7% for CC). There was a higher frequency of deaths from CC (57.6%) in women than in men, who had a higher frequency of deaths from RC (51.3%). The crude CC mortality rate increased by 116% (from 3.6 to 7.8), while the overall RC rate increased by 71% (from 1.4 to 2.4). After adjusting for age, a significant increase in mortality rate was found for CC (coefficient 0.09, 95% CI 0.08-0.11, P < 0.001) and RC (coefficient 0.02, 95% CI 0.009-0.04, P = 0.002) in men. In women, this increase was significant for CC (coefficient 0.03, 95% CI 0.005-0.05; P = 0.02), but not for RC (coefficient -0.007, 95% CI -0.02 to 0.005, P = 0.23). CONCLUSION: The crude mortality rate from CRC has doubled in Chile in this period. After adjustment of mortality rates, it appears that much of this increase is due to the aging population. However, part of this increase could be explained by other factors.

Malignant melanoma mortality rates in Chile (1988-98).

BACKGROUND: Malignant melanoma (MM) mortality has increased in the Caucasian population many fold over the past several decades. In this study, we analyzed the Chilean-specific, age-adjusted MM mortality rates per 100,000 population during the decade 1988-98 in order to establish changes in that period. METHODS: We analyzed all death certificates from the Chilean Death Registry Office (1988-98) and retrieved the deaths attributed to MM. The data were categorized according to sex and age group. The annual age-adjusted and sex-specific rates of MM mortality per 100,000 population were calculated. RESULTS: Chilean MM mortality rates increased by 14% between 1988 and 1998. The relative risk for males vs. females was 1.3 with a tendency to rise, showing an increase of 30%. The relative risk of dying from MM in Chile increased linearly with age. An individual of 75 years or older had a 44.24 times greater risk of dying of MM than an individual in the 0-44-year age group. The rates in the > 75-year age group also showed a tendency to rise over the decade, with an increase of 64% (1988-98). CONCLUSIONS: The Chilean MM mortality rates are lower than the world standardized rates. The total Chilean MM mortality rates showed an increase over the decade 1988-98, mainly due to MM mortality in males. The MM mortality in Chilean females was lower than that in males, and was unchanged over the decade; this is in agreement with the results reported in other countries. This is one of the first studies of MM mortality in the Chilean population. The results are important when the geographic location of Chile is considered.