Morbid obesity in a developing country: the Chilean experience

813Bulletin of the World Health Organization | October 2008, 86 (10) Morbid obesity in a developing country: the Chilean experience Claudia Bambs,a Jaime Cerda b & Alex Escalona c Perspectives a Department of Cardiovascular Diseases, Pontificia Universidad Católica de Chile, Santiago, Chile. b Department of Public Health, Pontificia Universidad Católica de Chile, Santiago, Chile. c Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile. Correspondence to Claudia Bambs (e-mail: cbambs@med.puc.cl). doi:10.2471/BLT.07.048785 (Submitted: 18 October 2007 – Revised version received: 27 November 2007 – Accepted: 9 December 2008 – Published online: 30 May 2008 ) Introduction Chile is a country of 16 million people of whom 88% live in an urban setting. Life expectancy is 78.3 years, gross na- tional income per capita is US$ 4360 and 13.7% of the population lives be- low the national poverty line. Health conditions in Chile have changed strik- ingly in the past 50 years. In a brief period of time, Chile has undergone major demographic, epidemiological and nutritional transitions. The pro- portion of malnutrition among chil- dren aged less than 6 years decreased from 37% to 2.9% in the period 1960–2000;1 in contrast, the preva- lence of obesity today reaches 20% among 4-year-old children.2 Between 1987 and 2000, the prevalence of undernourished pregnant women de- creased from 26.0% to 14.1%; while obesity among them increased from 12.9% to 32.7%.3 Progressive industri- alization and urbanization has occurred in Chile during the second half of the 20th century. This has been associ- ated with changes in lifestyle towards unhealthy dietary and physical activity patterns. In many developing coun- tries like Chile, there has been a rapid shift in diet to increased consump- tion of high energy-dense foods and caloric beverages, animal-source foods, and caloric sweeteners added to many other foods. Between 1980 and 1998, the average daily per capita calorie con- sumption increased from 2.667 kcal per 11.159 J (21% fat) to 2.844 kcal per 11.899 J (28% fat).3 This dietary pattern, together with a sedentary life- style, has been widely associated with obesity. Comorbidities associated with obesity In 2003, a National Health Survey showed that prevalence of overweight, non-morbid obesity and morbid obe- sity was 37.8%, 21.9% and 1.3%, respectively.4 Obesity prevalence was significantly higher among people with a lower educational level (odds ratio, OR: 1.5) and the prevalence of morbid obesity was six times higher in low socioeconomic groups.4 Comorbidities associated with obesity are also preva- lent among the general population: low concentrations of high-density lipo- protein cholesterol (39.3%), hyperten- sion (33.7%), hypercholesterolaemia (35.4%), hypertriglyceridaemia (27.0%) and type 2 diabetes (6.3%). The preva- lence of metabolic syndrome was 22.6%. Moreover, the prevalence of a sedentary lifestyle among Chileans is extremely high (89.4%). There are approximately 205 000 people with morbid obesity, most of them suffering its consequences and needing expen- sive health care. Preliminary data from the Surgical Treatment of Obesity pro- gramme conducted by Hospital Clínico Universidad Católica showed a high prevalence of cardiovascular risk factors among young obese subjects (with an average age of 37 years). Often the same individual had two or more risk factors and 10% of the subjects were rated as a high global cardiovascular risk, accord- ing to the Framingham Risk Score.5 Bariatric surgery There is strong evidence that non- surgical treatment among subjects with severe or morbid obesity is insufficient. On the contrary, bariatric surgery, spe- cifically gastric bypass, achieves good long-term results including weight-loss maintenance, reduction of comorbidi- ties and improvement of quality of life. In terms of mortality, bariatric surgery is associated with an 89% reduction in the relative risk of death as well as an 82% reduction of cardiovascular events among morbidly obese patients.6 Increasing demand for treatment of morbid obesity and the limitation of conventional therapies to accomplish and maintain substantial weight loss, promoted the creation in the mid- 1980s of surgical groups in Chile dedi- cated to bariatric procedures, most of them located in university centres.7 In the past 5 years, bariatric surgery has experienced an explosive development in Chile. During this time, 10 university and private medical centres performed 4040 gastric bypass procedures (36% laparoscopic) and 896 gastric bandings, with an overall mortality rate of gastric bypass of 0.32%. Postoperative com- plication rates and re-operation rates are similar to those reported in devel- oped countries. Three surgical groups – Hospital Clínico Universidad Católica, Hospital Clínico Universidad de Chile and Integramédica/Hospital San Juan de Dios – have led to the expansion of bariatric surgery in Chile, performing 77% of gastric bypasses in the past 5 years.7 This reveals that bariatric sur- gery is now concentrated in a few sur- gical groups, mostly from the private health sector. Facing the burden of obesity Has the Chilean health sector drawn up multisectorial strategies to fight against 814 Bulletin of the World Health Organization | October 2008, 86 (10) Perspectives Morbid obesity in Chile Claudia Bambs et al. References Monckeberg B. Prevención de la desnutrición en Chile experiencia vivida por 1. un actor y espectador [Prevention of undernutrition in Chile, experience lived by an actor and spectator]. Rev Chil Nutr 2003;30 (supp. 1):160-76. Kain BJ, Lera ML, Rojas PJ, Uauy DR. Obesidad en preescolares de la Región 2. Metropolitana de Chile. [Obesity among preschool children of Santiago, Chile]. Rev Med Chil 2007;135:63-70. PMID:17369985 Albala3. C, Vio F, Kain J, Uauy R. Nutrition transition in Chile: determinants and consequences. Public Health Nutr 2002;5 1A;123-8. PMID:12027274 doi:10.1079/PHN2001283 National4. Population Health Survey (ENS 2003). Santiago: Ministerio de Salud de Chile; 2004. Available from: http://epi.minsal.cl/epi/html/invest/ENS/ InformeFinalENS.pdf [accessed on 26 May 2008]. Framingham Heart Study5. . Bethesda, MD: National Heart Lung and Blood Institute; 2008. Available from: http://www.nhlbi.nih.gov/about/framingham [accessed on 26 May 2008]. Christou NV, Sampalis J, Liberman M, Look D, Auger S, McLean AP, et al. 6. Surgery decreases long-term mortality, morbidity and health care use in morbidly obese patients. Ann Surg 2004;240:416-24. PMID:15319713 doi:10.1097/01.sla.0000137343.63376.19 Csendes7. A, Maluenda F. Mortality of bariatric surgery. Experience in 10 Chilean institutions. Rev. Rev Chil Cirugía 2006;58:208-12. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S0718-4026200600 0300009&lng=en&nrm=iso&tlng=en [accessed on 29 May 2008]. Carrasco F, Klaassen J, Papaprieto K, Reyes E, Rodríguez L, Csendes A, et al. 8. A proposal of guidelines for surgical management of obesity. Rev Med Chil 2005;133:699-706. PMID:16075135 Letelier LM, Bedregal P. Health reform in Chile. 9. Lancet 2006;368:2197-8. PMID:17189018 doi:10.1016/S0140-6736(06)69875-9 obesity? In 2004, a group of Chilean ex- perts wrote specific recommendations for patient management and the forma- tion of reference centres for the surgical treatment of obesity.8 In addition, a health reform is underway that includes 56 health conditions to be covered by a new law that guarantees access to health care, opportunity, quality and financial protection for every citizen.9 Even though some comorbidities of obesity, such as essential hypertension and type 2 diabetes, have been considered in this bill, obesity itself has not. Considering that obesity is a disease on its own, is a recognized risk factor for multiple ill- nesses and affects a greater proportion of people in lower socioeconomic groups, it seems reasonable to consider it a public health priority to assure integral treat- ment of this complex disease among the entire population. A few public hospitals are trying to perform bariatric surgery in Chile, however, this procedure is in direct competition with other digestive- system surgeries such as gastric cancer and cholelitiasis, both of which are highly prevalent diseases in our country that are included in the new bill. This situation means that there are extensive waiting lists for bariatric surgery. Trends demonstrate a progressive rise in obesity rates among all age groups in Chile. Together with the implementation of primary preven- tion strategies to face this problem integrally, it seems reasonable that mul- tidisciplinary treatments that include surgical alternatives should be available for all morbidly obese patients, with no distinction made between the public and the private sectors. We hope that the Chilean experience may be useful for other developing countries experienc- ing accelerated transitional processes in order to face this challenging public health problem holistically. ■ Competing interests: None declared.