Impact of the change of the Atalah standard cut-off point to classify underweight nutritional status during pregnancy

ABSTRACT Chile, and several Latin American countries, use the Atalah standard to assess nutritional status during pregnancy. However, this standard (underweight: pre-pregnancy body mass index (BMI)<20 kg/m2 and normal weight: pre-pregnancy BMI= 20-24.9 kg/m2) differ from those recommended by the US Institute of Medicine (IOM2009) (underweight: BMI<18.5 kg/m2 and normal weight: 18.5-24.9 kg/m2). Using a large population database from a Chilean public hospital, we compared the prevalence of underweight and normal weight at the beginning of pregnancy with Atalah and IOM2009 standards. Additionally, we evaluated the performance of both standards in detecting adverse neonatal outcomes and gestational weight gain. Methods: Data from clinical records of single birth pregnancies (n= 59,476) at the Sótero del Río Hospital, between 2003-2012 were collected. We compared 1. nutritional status, 2. proportion of excessive gestational weight gain, 3. association between nutritional status and neonatal outcomes (large/small for gestational age, low birth weight, preterm birth and macrosomia), using logistic regression models, and 4. Sensitivity, specificity, and predictive values to predict adverse neonatal outcomes per nutritional status. Results: Pre-pregnancy underweight decreased from 8.6% to 2.5% and women with BMI between 18.5-19.9kg/m2, who exceeded the recommended gestational weight gain increased from 32.7% to 49.2% when using IOM2009 instead of Atalah. Both standards showed low sensitivity, but the IOM2009 cut-off points showed better specificity for identifying healthy newborns. Conclusion: The cut-off points recommended by the IOM2009 better identify the prevalence of underweight and normal weight during pregnancy without increasing neonatal risk. This study supports the recent change of the Ministry of Health in adopting the WHO cut-off points during pregnancy.

RESUMEN Chile y diversos países Latinoaméricanos utilizan el estándar de Atalah para evaluar el estado nutricional (EN) durante el embarazo. Sin embargo, los puntos de corte de este estándar (bajo peso, BP: índice de masa corporal pre-gestacional (IMC)<20 kg/m2 y normal, NP: IMC pregestacional= 20-24,9 kg/m2) difieren de los recomendados por el Instituto de Medicina de EE.UU. (IOM2009) (BP: BMI<18.5kg/m2 and NP: 18,5-24,9 kg/m2). Con datos obtenidos desde el Hospital Sótero del Río, nosotros evaluamos la prevalencia de BP y NP al comienzo del embarazo con los estándares de Atalah e IOM2009. Adicionalmente, nosotros comparamos el comportamiento de ambos estándares en detectar resultados neonatales (RN) adversos y en la clasificación de la ganancia de peso gestacional (GPG). Métodos: Se obtuvieron datos de embarazos simples entre 2003-2012, (n= 59.476). Nosotros comparamos: 1. Prevalencia de EN, 2. Proporción de excesiva GPG, 3. Asociación entre EN y RN, usando modelos de regresión logística, y 4. Sensibilidad, especificidad y valores predictivos para predecir RN según EN. Resultados: La prevalencia de BP pregestacional disminuyó de 8,6% a 2,5% y las mujeres con IMC entre 18,5-19,9 kg/m2 que excedieron la GPG recomendada, incrementaron desde 33% a 50% cuando se utilizó el estándar IOM2009 en vez de Atalah. Ambos estándares mostraron baja sensibilidad, pero IOM2009 mostró mejor especificidad para identificar recién nacidos saludables. Conclusión: Estandar IOM2009 identifica con mayor precisión la prevalencia de BP y NP durante la gestación sin incrementar el riesgo neonatal. Este estudio respalda el reciente cambio del MINSAL al adoptar los puntos de corte de la OMS durante el embarazo.

Tendencia y causas de la mortalidad materna en Chile de 1990 a 2018

Background: Previous studies have shown a decrease in the maternal mortality (MM) rates in Chile, with a trend towards stability since 2001. However, some of its associated causes such as high blood pressure, obesity, or maternal age, have increased in the last years. Aim: To describe the trend and characteristics of MM in Chile between 1990 and 2018. Material and Methods: MM rates were calculated using death records available at the website of the Department of Health Statistics of the Ministry of Health, using the codes 630 to 679 of the International Classification Diseases (ICD)-9 (630-679) and O00-O99 from ICD-10. Live births were obtained from vital statistics of the National Statistics Institute (INE). The age at the time of death and the causes were recorded. Polynomial and Prais-Winsten modelings were applied. Results: There were 1,728 maternal deaths with an overall rate for the period of 23 / 100,000 live births. An inflection of the trend was observed in 2003, with a decrease between 1990-2003 and an increase between 2004-2018. While in the 1990-2003 period all age groups decreased their rate, in 2004-2018 it increased significantly in the 20-34 age group. Concerning the causes, "other obstetric conditions not classified elsewhere" showed a steady upward trend, particularly the late maternal deaths or deaths from sequelae of obstetric causes (O96-O97). Conclusions: MM rates increased in Chile in recent years, mainly due to the increase in women aged 20 to 34 years and in causes referred to as "other obstetric conditions not classified elsewhere." It is possible that changes in risk factors and in the registries could explain this increase.

Project profile: a multicenter study on breast cancer in young women in Latin America (PRECAMA study) / Perfil de Proyecto: Un estudio multicéntrico sobre el cáncer de mama en mujeres jóvenes en América Latina (estudio PRECAMA)

Abstract: Objective: To describe the rationale and the methodology of a multicenter project to study the etiology of breast cancer in young Latin American women. Materials and methods: The International Agency for Research on Cancer has established an international collaborative population-based case-control study in four countries in Latin America: Chile, Colombia, Costa Rica, and Mexico (the PRECAMA study). Standardized methodologies were developed to collect information on reproductive variables, lifestyle, anthropometry, diet, clinical and pathological data, and biological specimens. The study will be extended to other countries in the region. Conclusion: PRECAMA is unique in its multidisciplinary approach that combines genetics, genomics, and metabolomics with lifestyle factors. The data generated through this project will be instrumental to identify major risk factors for molecular subtypes of breast cancer in young women, which will be important for prevention and targeted screening programs in Latin America.

Resumen: Objetivo: Describir la justificación y la metodología para el establecimiento de un proyecto multicéntrico sobre el cáncer de mama en mujeres jóvenes de América Latina. Material y métodos: La Agencia Internacional para la Investigación del Cáncer (IARC) ha establecido un estudio colaborativo internacional de casos y controles con base poblacional en cuatro países de América Latina: Chile, Colombia, Costa Rica y México (el estudio PRECAMA). Se han desarrollado metodologías estandarizadas para recolectar información sobre variables reproductivas, estilos de vida, antropometría y dieta, datos clínicos y patológicos y muestras biológicas. Conclusión: PRECAMA es único en su enfoque multidisciplinario. Los datos generados a través de este proyecto serán fundamentales para identificar los principales factores de riesgo del cáncer de mama en mujeres jóvenes. Los hallazgos serán relevantes para la prevención y los programas de detección oportuna en América Latina, con beneficios clínicos inmediatos.

Obesidad en mujeres chilenas en edad fértil / Prevalence of obesity among Chilean women in childbearing ages

Background: Women in childbearing ages (WCBA) represent a strategic intervention group to reverse the global trend of increasing obesity. Aim: To conduct a review of studies reporting obesity prevalence in WCBA in Chile in the last 25 years. Material and Methods: To describe obesity prevalence, we used three approaches, namely qualitative review of studies describing obesity prevalence in WCBA and a comparative study of the prevalence of obesity, overweight, abdominal and morbid obesity in WCBA from 2003 and 2009-10 National Health Surveys (ENS). Finally, nutrition status trends of pregnant women in the period 1987-2013 were plotted. Results: According to ENS, obesity prevalence exceeded 20% and excess weight 50%, both in 2003 and 2009-10 surveys. We found seven population studies, being difficult to compare them due to the heterogeneity of obesity definitions, design, and populations. Population studies showed that the prevalence of obesity increases along with age. The higher prevalence of obesity in WCBA aged 20 to 43 years was found in the city of San Carlos in 2007 (35.5%). The lowest was found in female university students, ranging from 0% to 5.9%. Obesity in pregnant women increased from 12.9% to 32.2% in the period 1987-2004 and from 20.3% to 26.3% in the period 2005-2013. Conclusions: There is a high and increasing prevalence of obesity among women in childbearing age, whether pregnant or not-pregnant.

Prevención secundaria post infarto agudo de miocardio en hospitales públicos: implementación y resultados de las garantías GES / Universal health coverage and accomplishment of secondary prevention goals among patients with acute myocardial infarction

Background: In 2005, acute myocardial infarction (AMI) was included in a universal health plan (GES) to reduce inequity in care and optimize its diagnosis and treatment. Aim: To evaluate the effect of GES in risk factor control and therapeutic management among patients with AMI. Material and Methods: A survey was conducted in 2008-2009 in six public hospitals. Patients were identified from a hospital based registry of AMI and evaluated one year later with laboratory tests and an interview. Results: The registry enrolled 534 patients with ST and non ST segment elevation myocardial infarction. Of these, 416 patients aged 63 ± 12 years (25% women) were evaluated one year later. Eighty three percent were evaluated by a cardiologist and 37% by a general practitioner. Twenty two percent were evaluated by a nurse and 22% by a nutritionist. At the moment of the interview, 9% smoked, 78% were overweight or obese, 24% performed moderate or vigorous physical activity ≥ 150 min/week, 60% had systolic pressure > 130 mmHg and 63% a diastolic pressure > 80 mmHg. In 30%, LDL cholesterol was > 100 mg/dl and in 43%, triglycerides were > 150 mm/dl. Twenty two percent were diabetic and among them, 52% had a glycosilated hemoglobin > 7%. Forty five percent of non-diabetic patients had a fasting glucose > 100 mg/dl. Ninety three percent were in treatment with aspirin, 86% with statins, 66% with b-blockers, and 73% with angiotensin converting enzyme inhibitors or angiotensin receptor blockers and 20% with clopidogrel. Conclusions: Despite the high proportion of patients in treatment with evidence-based therapy, many do not achieve the targets for risk factor control with the new health care model.

Obesidad y cáncer en Chile: estimación de las fracciones atribuibles poblacionales / Obesity and cancer in Chile: Estimation of population attributable fractions

Background: Obesity is a risk factor for the development of certain types of cancer. Aim: To estimate the proportion of cancers potentially attributable to obesity in men and women in Chile based on the calculation of population attributable fractions (PAF %). Material and Methods: Cancer sites studied were those where obesity is a known risk factor based on the updated World Cancer Research Fund (WCRF) analysis. Namely, colorectal, endometrium, esophagus, breast, pancreas, kidney and gallbladder cancers were analyzed. Overall and specific PAFs% were calculated for cancer sites and sex from known estimates of relative risk and national prevalence of overweight and obesity. Results: The overall estimates of cancer PAF% for obesity were approximately 20%, without differences between men and women. Highest cancer PAFs% were for endometrial (47%) in women, and esophageal (35%) and pancreatic (31%) in men. The largest sex differences in PAFs% were for gallbladder (higher in women) and colorectal (higher in men). Results are closer to those reported from developed countries (USA and United Kingdom) than those from developing countries (Brasil, China). Conclusions: In Chile about 20% of all cancers could be prevented by obesity prevention and control strategies.

Detección de virus linfotrópico de células T humano-I/II en pacientes con enfermedades de transmisión sexual de Santiago / Human T-lymphotropic virus I/II detection in Chilean patients from Sexually Transmitted Diseases clinics

Background: The human T-lymphotropic virus I (HTLV-I) causes spastic para-paresis and adult T-cell leukemia/lymphoma. It can be sexually transmitted and is highly prevalent in Central and South America. Aim: To study HTLV-I/IIprevalence in serum samples obtained from two Sexually Transmitted Diseases (STD) clinics. Material and Methods: Two hundred serum samples were randomly chosen from two reference STD centers of Santiago. The presence of specific HTLV I/II antibodies was detected by indirect immunofluorescence. Results: The analyzed samples came from participants aged 14 to 70 years. Forty nine percent were women and 76% were heterosexual. Only one of the 200 samples was positive (0.5%) and it came from a 70 year-old woman, housewife, with a stable single partner, a history of recurrent genital ulcers, VDRL (-) and positive serology for herpes simplex virus. Conclusions: The prevalence of HTLV-I found in this group is similar to that demonstrated in other populations in Chile, except for aboriginal populations, and similar to international STD studies. Our data is consistent with the low transmissibility by sexual contact.

Análisis de la tendencia de la mortalidad por cirrosis hepática en Chile: Años 1990 a 2007 / Mortality trend from liver cirrhosis in Chile from 1990 to 2007

Background: There is a worldwide tendency towards a reduction in the rates of deaths due to cirrhosis. In Chile, a decrease in the number of hospital admissions due to this disease has been recorded. Aim: To assess general characteristics and temporal evolution of liver cirrhosis mortality in Chile between 1990 and 2007. Material and Methods: National death records and population databases were reviewed. Crude and age-adjusted mortality rates for alcoholic and non-alcoholic cirrhosis were calculated, evaluating their evolution in the study period and the relative risk by gender. Results: In the study period, 44,894 deaths caused by cirrhosis were recorded. Mortality rate was 16.6 deaths per 100,000 inhabitants. 54 percent of deaths were attributed to non-alcoholic cirrhosis. There was a reduction in mortality rates for both types of cirrhosis. Males accounted for 83 and 65 percent of deaths caused by alcoholic and non-alcoholic cirrhosis, respectively. The figures for relative risk of death were 5 and 1.9, respectively. Conclusions: Alcoholic cirrhosis was the preponderant cause among liver cirrhosis deaths. A decrease in mortality rates was observed in the study period. Improvements in disease treatment and control could possibly explain this trend.

Valores normativos de resistencia a la insulina mediante HOMA-IR en adultos mayores de Santiago de Chile / Homeostasis model assessment (HOMA) values in Chilean elderly subjects

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 percent 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 µU/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 percent 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 thi spopulation was 2.6.

Validez y confiabilidad de la versión chilena del Alcohol Use Disorders Identification Test (AUDIT) / 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 percent 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 percent confidence intervals 0.96-0.98). Using a cutoff point of 6 for hazardous consumption, its sensitivity and specificity were 83 percent and 88 percent, respectively. The figures for dependence and harmful consumption, using a cutoff point of 9, were 87 percent and 85 percent, respectively. Conclusions: AUDIT is a valid questionnaire to detect problem drinkers.

Importancia del apoyo social en la permanencia de la abstinencia del consumo de drogas / Social support as a protective factor of recurrence after drug addiction treatment

Lack of social support can be one of the factors that influences recurrences of drug consumption after treatment of addictions. Aim: To assess the role of social support in maintaining drug abstinence after treatment. Material and methods: We studied 306 subjects that were treated in drug addiction centers, financed by the National Council for Drug Control (CONACE). At discharge, social and demographic data were recorded and 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 later and interrogated about eventual drug consumption thereafter. Results: One hundred fifty three (76 percent male, aged 32 ± 10 years) of 197 abstinent subjects at discharge, were located six months later. Of these, 108 (71 percent) were not consuming drugs. On univariate analysis, social support had a protective effect against recurrence of drug consumption (OR - 0.98; CI 95 percent = 0.96-0.99). This effect remained significant after adjusting for age, sex, occupational situation, mental health self-assessment, family history of alcohol and drug consumption, type of drug treatment and type of discharge as confounding variables (OR = 0.97; CI 95 percent = 0.94-0.99). Conclusions: These data provide evidence that social support protects against recurrence into drug consumption at ¡east up to six months. Long-term effects should be evaluated.

Análisis factorial: una aplicación en el cuestionario de salud general de Goldberg, versión de 12 preguntas / Factor analysis: an application of the 12-item version of the Goldberg

Objetivo: Explorar la estructura factorial del cuestionario de Salud General de Goldberg, versión de 12 preguntas en escala Likert, en personas que egresaron de programas de tratamiento y rehabilitación por problemas derivados del consumo de drogas en centros de tratamiento de Chile. Material y Método: Se llevó a cabo un estudio descriptivo transversal en una muestra de 306 personas que completaron el cuestionario de Salud General. Se evaluó la confiabilidad del instrumento a través del análisis de su consistencia interna. Se realizó un análisis factorial confirmatorio por extracción de componentes principales con rotación varimax. Resultado: El promedio de edad fue de 30 años con un 80% de hombres. Se obtuvo un coeficiente de alpha de Cronbach de 0,902. Empleando el score de 0 a 36 puntos, el promedio del puntaje total en el Cuestionario de Salud General de Goldberg fue de 8,5, con una desviación estándar de 7,1. El análisis factorial confirmó la bidimensionalidad del instrumento, con la existencia de dos factores latentes que, en conjunto, explicaron 60 por ciento de la varianza total. Conclusiones: Este estudio mostró una alta confiabilidad y una estructura factorial similar a la encontrada en estudios de otras poblaciones. Dados su carácter autoadministrado y rapidez en su llenado, es recomendable considerar su uso en la evaluación de la autopercepción del estado de salud mental en usuarios que consultan por problemas derivados del consumo de drogas.

Purpose: To explore the factor structure of the 12-item version of the Goldberg General Health Questionnaire with Likert scoring, within persons discharged from treatment and rehabilitation programs for drug abuse related problems, in Chilean care centers. Material and Methods: A cross-sectional descriptive study was carried out on a sample of 306 persons who completed the General Health questionnaire. The reliability of the instrument was assessed through an internal consistency analysis. A confirmatory factor analysis was carried out through extraction of the principal components with varimax rotation. Results: The mean age was 30; among the study population 80% were male. The Cronbach’s alpha coefficient was 0,902. Using a 0 to 36 points score, the mean total score in the General Health Questionnaire was 8,5 with a standard deviation of 7,1. The factor analysis confirmed the bidimensionality of the instrument, and the existence of two latent factors, which together accounted for 60 percent of the total variance. Conclusions: The present study showed a high level of reliability and a similar factor structure to that found in studies within other populations. In view of its self-administered character and the promptness to complete it, the use of the questionnaire is strongly recommended for the assessment of self- perception of the mental health status within persons consulting for drug abuse related disorders.