Prevalence and determinants of obesity and dietary habits among adults in rural area, Chile

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1 Prevlence nd determinnts of obesity nd dietry hbits mong dults in rurl re, Chile Miho Nozue 1, Miki Miyoshi 1, Junko Okumur 1, Hugo Snchez 2, Jun Andreu 3, Chushi Kuroiw 1, * 1 Deprtment of Helth Policy nd Plnning, School of Interntionl Helth, the University of Tokyo, Jpn; 2 Institute of Nutrition nd Food Technology. University of Chile, Sntigo, Chile; 3 University of Ctolic, Chile. SUMMARY This study ws undertken to exmine the prevlence of obesity nd its determinnts mong dults in rurl re of Chile. A community-bsed cross-sectionl study ws conducted in April-June 2004 in Sn Crlos (8th region). Height, weight, nd wist nd hip circumferences were mesured for 603 dults (femle 447, mle 156) ged yers, nd dt on socio-economic fctors, dietry intke, nd dietry hbits were obtined by questionnire interviews. The prevlence of obese individuls ws 45.2% mong femles nd 30.1% mong mles, wheres tht of overweight individuls ws higher mong mles thn femles. Obesity ws ssocited with socio-economic fctors for femles but not for mles. With regrd to diet, different ptterns between femles nd mles were observed in terms of frequency of food intke, s well s in dietry hbits. Our findings of high prevlence of obese/overweight individuls, together with the chrcteristics of their diets including chnges in the cooking process, suggest tht nutrition trnsition is underwy in rurl regions s well. Approprite interventions, therefore, should be introduced to control obesity mong women nd to enhnce helth wreness mong men throughout the country. Key Words: Obesity, overweight, socio-economic, nutrition trnsition, Chile Introduction Obesity is known to be the most significnt nutritionl disorder in developed countries. There re estimted to be 1 billion overweight dults, of which t lest 300 million re obese, worldwide (1). Being obese or overweight is regrded s mjor risk for serious lifestyle-relted diseses, including Dibetes Mellitus (DM), hypertension, nd crdiovsculr diseses. Moreover, dditionl burdens of obesity on the limited ntionl helth budget cnnot be ignored (e.g % in the US) (2,3). The problem of obesity is now emerging in developing countries s well, where *Correspondence to: Deprtment of Helth Policy nd Plnning, School of Interntionl Helth, University of Tokyo, Hongo Bunkyo-ku, Tokyo , Jpn; e-mil: ckuroiw@m.u-tokyo.c.jp Received September 25, 2007 Accepted November 17, mlnutrition nd infectious diseses used to be the most serious problems. As country chieves economic development, the diet nd physicl ctivity ptterns of its citizens chnge gretly. This phenomenon, observed in countries with economies in trnsition, is known s nutrition trnsition (4). Like other countries in Ltin Americ, Chile is undergoing nutrition trnsition (5). A nutrition trnsition is defined s chnge in diet nd lifestyles, leding to significnt impct on the nutritionl sttus of the popultion. Dietry chnges include the incresed consumption of ft, sugr, nd niml food products nd decresed cerel nd fiber intke (6-8). Likewise, chnges in diet, from trditionl to Western one, nd in physicl ctivity ptterns hve resulted in the incresed prevlence of obesity nd lifestyle-relted diseses in Chile (9,10). In light of these circumstnces, the Ministry of Helth strted to invest in the control of obesity for children nd pregnnt women in 1998 (11)

2 BioScience Trends 2007;1(3): Article nd lter for dults in 1999 (12). And yet the country s obesity rtes remin high. According to the ltest Ntionl Helth Survey, the prevlence of overweight individuls ws 33% for femles nd 43% for mles, nd tht of obese individuls ws 27% nd 19%, respectively (13). So fr, studies on the obesity of dults in this country hve tended to concentrte on urbn res like the metropolitn Sntigo re nd dt on other provinces including rurl res re scrce. This study therefore, ims to exmine the prevlence of obesity nd investigte its determinnts nd dietry hbits mong dults in rurl Chile. Mterils nd methods A community-bsed cross-sectionl study ws undertken from April to June 2004 in Sn Crlos in the Ñuble Province of the 8th region (of totl 13 regions) in Chile. The 8th region is locted km south from Sntigo (popultion: 6,061,185), nd Sn Crlos is in the northern prt of the region (popultion: 50,139) (14,15). About 44% of the popultion is engged in griculture, minly frming nd cultivting whet (15). Out of totl of 78 districts, the centrl district nd 13 suburb districts were chosen for this study to represent the diverse geogrphicl chrcteristics of Sn Crlos. All households in ech district were visited individully by interviewers who fully explined the study objective nd procedures, nd then one person ged yers per household, excluding pregnnt nd lctting women, ws chosen, upon receipt of consent, to prticipte. A totl of 603 dults (447 femles nd 156 mles) were recruited. During the household visits, nthropometric mesurements were tken for ll 603 dults. Height ws mesured to the nerest 0.1 cm using portble stdiometer (Sec 214, Sec, Germny). Weight ws mesured using digitl bthroom scle (Sec 880, Sec, Germny) with cpcity of 200 kg 100 g. All of the smpled dults were weighed brefoot wering light clothing. In order to ssess ftness of ech study subject, Body Mss Index (BMI) ws clculted s weight (kg) divided by height squred (m 2 ), nd subjects were ctegorized into four groups: underweight (< 18.5 kg/m 2 ), norml ( kg/m 2 ), overweight ( kg/m 2 ), nd obese ( 30 kg/m 2 ) (16). Using plstic tpe mesure, wist nd hip circumferences were lso mesured s n independent indictor of viscerl obesity. An individul is considered t risk of obesity when women hve wist circumference greter thn 88 cm nd men hve one greter thn 102 cm (16). The wist to hip rtio ws clculted by dividing the wist circumference by the hip circumference, nd study subjects with rtio greter thn 1.0 were considered t risk. Pregnnt nd lctting women were excluded from the smpling. Socio-economic nd behviorl (e.g. ge, residence, mritl sttus, occuption, eduction, income) were obtined by the interviews using the structured questionnires. Residence ws ctegorized s suburb ( popultion < 2,000 or popultion of with less thn 50% of those working in industries/service ) or centrl ( popultion 2,000 or popultion of with more thn 50% of those working in industries/service ). The minimum monthly wge in Chile (120,000 pesos) ws used to clssify income levels. This study used the frequency of exercise s vrible to estimte n individul s physicl ctivity level. A food frequency questionnire (FFQ) ws used to obtin dietry dt. The frequency of mjor food items consumed during the pst yer ws included in order to investigte the chrcteristics nd hbits of prticipnts diets. Dietry hbits were sked to investigte the fctors ffecting their food intke. A focus group discussion ws held with 12 housewives s prticipnts in order to obtin informtion on dietry chnges. All of the dt were entered nd nlyzed with SPSS version Softwre clled Minut ws used to clculte nutrition composition, which ws derived from the Chilen food composition tble of the Institute of Nutrition nd Food Technology (INTA) (17). Univrite nlyses were performed to exmine the ssocition between BMI nd socio-economic nd behviorl chrcteristics nd food intke. In t-test, χ 2 test, nd F-test cut-off of 0.05 ws used s the level of sttisticl significnce. All subjects gve informed consent, nd the study protocol ws pproved by the ethicl committee of the University of Tokyo nd the University of Chile nd the Chilen Ministry of Helth s helth council for the 8th region. Results Tble 1 shows socio-economic chrcteristics of study subjects. Distributions of ge, residence, nd mritl sttus mong femles nd mles were lmost the sme. Types of occuption differed, however, with more mles thn femles being employed. Other occuptions include vendor, student, nd unemployed. Income mens the totl monthly income of the fmily, which ws higher mong the fmilies of mle respondents thn of femle respondents (Medin: 130,000 pesos vs. 115,000 pesos; p = 0.002). The proportion of study subjects who were illiterte or hd primry level (1-8 yers) ws higher mong femles (46.1%) thn mles (35.9%). The prevlence of overweight or obese individuls ws 38.5% nd 45.2% for femles, nd 51.3% nd 30.1% for mles, respectively (Tble 2). There ws significnt difference between femles nd mles (p = 0.009) in the distribution of BMI. The proportion of overweight individuls ws higher mong mles 141

3 Tble 1. Chrcteristics of study subjects (51.3%) thn femles (38.5%), though obese individuls were more prevlent mong femles (45.2%) thn mles (30.1%). The proportion of femles with wist circumference t risk ws higher thn mles (65.1%, 22.4%; p < 0.001), though the reverse trend ws observed in terms of wist-to-hip rtio (7.8%, 16.0%; p = 0.003). Tbles 3 nd 4 show the prevlence of obesity 142 Femle Mle (n = 447) (n = 156) n (%) n (%) Age, yers (17.2) 33 (21.2) (23.7) 39 (25.0) (31.6) 40 (25.6) (27.5) 44 (28.2) Residence Suburb 170 (38.0) 54 (34.6) Centrl 277 (62.0) 102 (65.4) Mritl sttus Mrried 260 (58.2) 96 (61.5) Single 91 (20.4) 36 (23.1) Widowed 26 (5.8) 1 (0.7) Seprted 31 (6.9) 8 (5.1) Living together 39 (8.7) 13 (8.3) No nswer 0 (0.0) 2 (1.3) Occuption Frmer 1 (0.2) 26 (16.7) Housewife 264 (59.1) 0 (0.0) Employee 78 (17.4) 68 (43.6) Other 104 (23.3) 62 (39.7) Eduction Illiterte 14 (3.1) 4 (2.6) Primry 192 (43.0) 52 (33.3) Secondry 173 (38.7) 60 (38.5) High schoolor university 68 (15.2) 24 (15.4) No nswer 0 (0.0) 16 (10.2) Medin (Inter- Medin (Interqurtile rnge) qurtile rnge) Income, pesos ( ) ( ) b US$1 = 608 pesos (April 2004); b Mnn-Whitney test, p < Tble 2. Anthropometric chrcteristics of study subjects Femle Mle (n = 447) (n = 156) n (%) n (%) BMI Underweight 1 (0.2) 0 (0.0)** Norml 72 (16.1) 29 (18.6) Overweight 172 (38.5) 80 (51.3) Obese 202 (45.2) 47 (30.1) Wist circumference Norml 156 (34.9) 121 (77.6)*** At risk b 291 (65.1) 35 (22.4) Wist to hip rtio Norml 412 (92.2) 131 (84.0)** At risk c 35 (7.8) 25 (16.0) Men (SD) Men (SD) Height, cm (6.4) (7.1)*** Weight, kg 71.2 (12.8) 78.6 (12.2)*** Wist circumference, cm 93.2 (12.8) 94.1 (10.3) Only one femle ws underweight nd she ws not included in the χ 2 test; b 88 cm for femles nd 102 cm for mles; c 1.0 for femles nd mles. * p < 0.05; ** p < 0.01; *** p < mong femles nd mles, respectively, ccording to socio-economic nd behviorl chrcteristics. Only one femle ws underweight (Tble 2), hence her dt were excluded from the nlysis in Tble 3. Age, residence, mritl sttus, eduction, income, smoking, nd prity were ssocited with obesity for femles (p < 0.05 for ech), wheres only ge (p < 0.001) nd smoking (p < 0.05) were significnt fctors for mles. Regrdless of gender, older persons were more likely to be obese thn younger ones. Obese individuls were more prevlent in suburb (54.7%) thn centrl (39.5%) res mong femles, though no geogrphicl difference ws observed mong mles in this rurl region. Subjects who were illiterte or hd primry school eduction were more likely to be obese thn those with higher eduction ( 9 yers) (femle: 54.9% vs. 37.1%; p < 0.001, mle: 39.3% vs. 22.6%; p = 0.088). Among the fmilies of femle subjects, those with low incomes (< 120,000 pesos) hd higher prevlence of obesity (49.3%) thn those with high incomes ( 120,000 pesos) (39.8%) (p = 0.007). Prity ws lso significnt fctor, nd women who hd delivered three or more times hd higher proportion of obesity (54.0%) in comprison to those who delivered fewer thn three times (once or twice 40.9%, never 24.0%; p < 0.001). Next, the ssocition between obesity nd behviorl fctors ws exmined. The proportion of obese individuls ws the highest for those who hd never smoked or hd stopped smoking mong femles (50.3%). With regrd to physicl ctivity, rther smll proportion of study subjects in ll BMI ctegories exercised for 30 min more thn three times per week. There ws no sttisticlly significnt ssocition between physicl ctivity level nd obesity. The men frequency of intke per week for selected food items is listed in Tbles 5 nd 6 by BMI nd gender. There ws no significnt difference in food frequency between BMIs. Intke of bred, pottoes, vegetbles, nd fruit ws more frequent, followed by rice, beef, chicken, mrgrine, juice, nd crbonted drinks for both genders. The intke of fish, sefood, mushrooms, nd lcohol ws low. The men frequency of intke of beef nd chicken ws more thn once week, but the men frequency of intke of fish ws less thn once week regrdless of gender. For mles, intke of juice nd crbonted drinks ws two or three times week, but intke of milk ws two times week. Although dt re not shown in the tbles, comprison of femles nd mles indicted tht intke of bred, pottoes, cheese, pork, mutton, processed met, eggs, crbonted drinks, nd lcohol ws more frequent for mles thn femles (p < 0.05 for ech), while femles consumed yogurt, seweed, fruit, nd jm more frequently thn mles (p < 0.05 for ech). Dietry hbits were lso sked in this study (Tble 7 nd 8). More thn 70% of the subjects took brekfst everydy, nd more thn 80% of the norml femles nd overweight mles did so. Regrdless of gender, there

4 BioScience Trends 2007;1(3): Article Tble 3. Prevlence of obesity ccording to socio-economic nd behviorl chrcteristics (femles) Norml Overweight Obese (n = 72) (n = 172) (n = 202) Age, yers < (23.1) 92 (41.6) 78 (35.3)*** (9.3) 80 (35.6) 124 (55.1) Residence Suburb 17 (10.0) 60 (35.3) 93 (54.7)** Centrl 55 (19.9) 112 (40.6) 109 (39.5) Mritl sttus Mrried 36 (13.8) 101 (38.9) 123 (47.3)* Single 25 (27.8) 30 (33.3) 35 (38.9) Widowed 4 (15.4) 14 (53.8) 8 (30.8) Seprted 1 (3.2) 14 (45.2) 16 (51.6) Living together 6 (15.4) 13 (33.3) 20 (51.3) Occuption Frmer 0 (0.0) 0 (0.0) 1 (100.0) Housewife 35 (13.2) 105 (39.8) 124 ( 47.0) Employee 20 (25.6) 31 (39.8) 27 (34.6) Other 17 (16.5) 36 (35.0) 50 (48.5) Eduction Primry 18 (8.7) 75 (36.4) 113 (54.9)*** Secondry 54 (22.5) 97 (40.4) 89 (37.1) Income, pesos < (11.8) 105 (38.9) 133 (49.3)** (22.9) 62 (37.3) 66 (39.8) Smoking Everydy 19 (22.6) 36 (42.9) 29 (34.5)** Sometimes 13 (25.0) 22 (42.3) 17 (32.7) Don t smoke, quit 40 (12.9) 114 (36.8) 156 (50.3) Exercise b Yes 7 (16.7) 19 (45.2) 16 (38.1) No 65 (16.1) 153 (38.0) 185 (45.9) Prity 0 20 (40.0) 18 (36.0) 12 (24.0)*** (15.5) 79 (43.6) 74 (40.9) 3 24 (11.2) 75 (34.9) 116 (53.9) US$1 = 608 pesos (April 2004); b More thn 3 times week, more thn 30 min; * p < 0.05; ** p < 0.01; *** p < Tble 4. Prevlence of obesity ccording to socio-economic nd behviorl chrcteristics (mles) Norml Overweight Obese (n = 29) (n = 80) (n = 47) Age, yers < (26.6) 42 (53.2) 16 (20.2)** 43 8 (10.4) 38 (49.3) 31 (40.3) Residence Suburb 10 (18.5) 28 (51.9) 16 (29.6) Centrl 19 (18.6) 52 (51.0) 31 (30.4) Mritl sttus Mrried 14 (14.6) 49 (51.0) 33 (34.4) Single 12 (33.3) 17 (47.2) 7 (19.5) Widowed 0 (0.0) 0 (0.0) 1 (100.0) Seprted 1 (12.5) 7 (87.5) 0 (0.0) Living together 2 (15.4) 6 (46.1) 5 (38.5) Occuption Frmer 6 (23.1) 12 (46.1) 8 (30.8) Housewife 0 (0.0) 0 (0.0) 0 (0.0) Employee 10 (12.8) 35 (55.3) 23 (31.9) Other 13 (30.6) 33 (44.4) 16 (25.0) Eduction Primry 8 (14.3) 26 (46.4) 22 (39.3) Secondry 19 (22.6) 46 (54.8) 19 (22.6) Income, pesos < (23.3) 35 (47.9) 21 (28.8) (15.4) 44 (56.4) 22 (28.2) Smoking Everydy 6 (21.4) 18 (64.3) 4 (14.3)* Sometimes 9 (31.0) 9 (31.0) 11 (38.0) Don t smoke, quit 14 (14.6) 52 (54.2) 30 (31.2) Exercise b Yes 2 (12.5) 8 (50.0) 6 (37.5) No 27 (19.4) 72 (51.8) 40 (28.8) US$1 = 608 pesos (April 2004); b More thn 3 times week, more thn 30 min; * p < 0.05; ** p < ws no sttisticlly significnt ssocition between eting out for lunch/dinner or hving snck nd BMI. The percentge of individuls who te out for lunch nd dinner ws higher mong mles thn femles but there ws n opposite trend regrding hving sncks. Dietry hbits were closely ssocited with fctors ffecting food purchses: regrdless of gender, the most importnt fctor for the present purchse ws found to be price, 143

5 Tble 5. Men (SD) of food frequency per week ccording to BMI (femles) Norml Overweight Obese (n = 72) (n = 171) (n = 202) Cerels Bred 6.6 (1.3) 6.8 (1.1) 6.9 (0.7) Noodles 1.8 (1.2) 1.8 (1.1) 1.9 (1.3) Rice 2.1 (1.0) 2.2 (1.0) 2.4 (1.3) Pottoes 3.6 (2.1) 4.0 (2.1) 4.4 (2.1) * Legumes 1.3 (0.9) 1.5 (0.8) 1.4 (0.8) Diry products Milk 2.8 (2.8) 2.4 (2.7) 2.4 (2.8) Yogurt 1.7 (2.0) 1.6 (1.9) 1.3 (1.8) Unripe cheese 1.2 (1.5) 1.3 (1.6) 1.1 (1.5) Cheese 2.0 (1.8) 1.6 (1.6) 1.4 (1.4) Met Beef 2.1 (1.5) 2.1 (1.5) 2.1 (1.6) Pork 0.9 (0.8) 1.2 (0.9) 1.2 (0.9) Mutton 0.2 (0.4) 0.1 (0.3) 0.1 (0.4) Chicken 1.8 (0.9) 2.0 (1.2) 2.0 (1.3) Other (rbbit, wild bird) 0.2 (0.4) 0.2 (0.5) 0.3 (0.6) Viscer 0.3 (0.4) b 0.5 (0.6) b * 0.5 (0.7) * Processed met 1.5 (1.3) 1.4 (1.2) 1.4 (1.3) Eggs 2.1 (1.5) 1.8 (1.3) 1.9 (1.7) Fish nd sefood Fish 0.7 (0.5) 0.8 (0.6) 0.8 (0.7) Cnned fish 1.1 (0.7) 1.2 (0.8) 1.2 (0.9) Sefood 0.2 (0.5) 0.4 (0.6) 0.3 (0.5) Seweed 0.4 (0.9) 0.4 (0.7) 0.4 (0.6) Vegetbles nd fruits Vegetbles 5.6 (2.3) 6.0 (1.9) 5.8 (2.1) Mushrooms 0.1 (0.3) 0.1 (0.4) 0.1 (0.3) Fruit 4.9 (2.5) 5.4 (2.2) 5.5 (2.2) Fts nd oils Butter 1.2 (2.3) 1.2 (2.3) 1.2 (2.4) Mrgrine 2.7 (2.9) 2.6 (2.9) 2.2 (2.6) Myonnise 1.3 (1.6) 1.2 (1.2) 1.0 (1.2) Sugr nd sweets Jm 2.4 (2.2) 2.3 (2.1) 1.8 (2.0) Sweets 2.8 (2.6) b 2.0 (2.2) b * 1.7 (2.3) ** Beverges Juice 2.6 (2.9) 2.1 (2.7) 1.9 (2.6) Crbonted drinks 2.5 (2.3) 2.2 (2.0) 2.4 (2.4) Alcohol 0.5 (0.8) 0.5 (0.8) 0.3 (0.7) Significnt between norml nd obese; b Significnt between norml nd overweight; Bonferroni correction following ANOVA * p < 0.05; ** p < followed by freshness (though not significntly different, obese femle subjects tended to choose price more thn subjects with other BMIs). With regrd to fctors ffecting future purchses, reltively high proportion of prticipnts nswered nutrition. Since price ws quoted s the most significnt fctor for food purchses, verge food prices were surveyed t three mrkets in Sn Crlos (Tble 9). During the focus group discussion, the prticipnts discussed the differences in pst nd present diets. They stted tht they hd consumed milk, soup, legumes, nd fruits during their childhood while they mentioned tht their ltest children consumed yogurt, sweets, french fries, nd hot dogs. Overll, the cooking process ws lso found to hve chnged, with fried now being fvored over boiling/cooking (e.g. french fries vs. boiled pottoes). A question bout when nd how dietry ptterns hve chnged received the following responses: Our diet chnged s technology dvnced, nd then redy-mde nd processed food begn to pper on the mrket. 144 Since TV sets hve incresed, we hd more chnces to et the foods dvertised in commercils. Sometimes my children prefer to hve the foods shown on TV rther thn the mels I cook. Discussion Although there re mny studies on obesity in Chile, little is known bout rurl res, especilly with respect to the influences of socio-economic nd dietry fctors. This study confirmed the high prevlence of obesity in rurl province of Chile (femle: 45.2%, mle: 30.1%), finding it to be much higher thn ntionl verge (femle 27%, mle 19%). Femles hd higher proportion of obesity thn mles, especilly in suburb res. Similr results were found in severl Ltin Americn countries like Brzil nd Peru nd two previous studies of the Chilen cities of Sntigo nd Vlpriso (18). One of the possible explntions for femles being more likely to be obese is biologicl differences (19). Humns crry number of genes

6 BioScience Trends 2007;1(3): Article Tble 6. Men (SD) of food frequency per week ccording to BMI (mles) Norml Overweight Obese (n = 29) (n = 80) (n = 47) Cerels Bred 7.0 (0.0) 6.9 (0.6) 6.8 (0.8) Noodles 1.9 (1.1) 2.0 (1.1) 1.7 (1.2) Rice 2.2 (1.1) 2.6 (1.3) c 1.9 (1.1) c ** Pottoes 4.3 (2.2) 4.8 (2.2) 4.5 (2.4) Legumes 1.2 (0.7) 1.5 (0.9) 1.3 (0.8) Diry products Milk 2.3 (2.6) 2.2 (2.5) 2.0 (2.5) Yogurt 1.1 (1.2) 1.0 (1.4) 1.0 (1.6) Unripe cheese 0.8 (1.0) 1.2 (1.5) 1.1 (1.4) Cheese 2.5 (2.2) 1.8 (1.9) 1.9 (1.6) Met Beef 1.4 (1.0) b 2.4 (1.7) b ** 2.3 (1.8) Pork 1.0 (0.8) 1.5 (1.3) 1.5 (0.9) Mutton 0.3 (0.5) 0.2 (0.4) 0.4 (0.8) Chicken 1.9 (1.2) 2.0 (1.3) 1.6 (0.7) Other (rbbit, wild bird) 0.3 (0.5) 0.5 (1.0) 0.3 (0.8) Viscer 0.4 (0.5) 0.5 (0.6) 0.4 (0.5) Processed met 2.0 (1.4) 1.8 (1.6) 1.7 (1.5) Eggs 1.8 (1.2) 2.4 (1.5) 2.4 (1.9) Fish nd sefood Fish 0.9 (0.4) 0.9 (0.5) 0.7 (0.5) Cnned fish 1.4 (1.2) 1.2 (0.9) 1.2 (0.9) Sefood 0.2 (0.4) 0.4 (0.5) 0.3 (0.5) Seweed 0.3 (0.5) 0.4 (0.6) 0.2 (0.4) Vegetbles nd fruits Vegetbles 5.2 (2.4) 5.9 (2.0) 5.8 (2.2) Mushrooms 0.0 (0.2) 0.2 (0.4) 0.2 (0.6) Fruit 4.5 (2.6) 4.9 (2.3) 5.0 (2.5) Fts nd oils Butter 0.9 (1.6) 1.6 (1.7) 1.5 (2.4) Mrgrine 2.7 (2.7) 2.4 (2.8) 2.5 (2.8) Myonnise 1.6 (1.8) 1.2 (1.6) 1.0 (1.3) Sugr nd sweets Jm 1.3 (1.1) 1.8 (1.9) 1.7 (2.0) Sweets 2.1 (2.6) 1.5 (2.2) 1.3 (2.0) Beverges Juice 3.4 (2.8) 2.3 (2.6) 2.5 (2.9) Crbonted drinks 3.4 (2.4) 3.6 (2.7) 3.0 (2.5) Alcohol 0.8 (0.6) 1.0 (1.4) 0.9 (1.1) b Significnt between norml nd overweight; c Significnt between overweight nd obese; Bonferroni correction following ANOVA ** p < Tble 7. Prevlence of obesity ccording to dietry hbits (femles) Norml Overweight Obese (n = 72) (n = 172) (n = 202) Brekfst Don t et 6 (8.3) 6 (3.5) 8 (4.0) Sometimes 7 (9.7) 35 (20.6) 45 (22.4) Everydy 59 (82.0) 129 (75.9) 148 (73.6) Et out for lunch, no. of times 0 38 (52.8) 89 (52.7) 113 (55.9) < 3 27 (37.5) 62 (36.7) 67 (33.2) 4 7 (9.7) 18 (10.6) 22 (10.9) Et out for dinner, no. of times b 0 40 (55.6) 123 (71.6) 153 (76.1)** < 3 26 (36.1) 46 (26.7) 43 (21.4) 4 6 (8.3) 3 (1.7) 5 (2.5) Hve snck, no. of times c 0 37 (51.4) 82 (47.7) 114 (56.4) 1 35 (48.6) 90 (52.3) 88 (43.6) Hve you herd of dietry fiber? Yes 58 (80.6) 131 (76.2) 151 (74.8) No 14 (19.4) 41 (23.8) 51 (25.2) Wht do you think is most Price 34 (16.8) 59 (29.2) 109 (63.7) importnt when buy food? Freshness 12 (11.0) 49 (45.0) 48 (28.1) Nutrition 1 (16.7) 1 (16.7) 4 (2.3) Other 2 (6.4) 19 (61.3) 10 (5.9) In the future, wht will be most Price 19 (38.8) 38 (29.7) 70 (40.2) importnt for you when buy food? Freshness 14 (28.6) 43 (33.6) 46 (26.4) Nutrition 11 (22.4) 28 (21.9) 42 (24.2) Other 5 (10.2) 19 (14.8) 16 (9.2) Frequency of eting out for lunch per week; b Frequency of eting out for dinner per week; c Frequency of hving sncks per dy; ** p <

7 Tble 8. Prevlence of obesity ccording to dietry hbits (mles) Norml Overweight Obese (n = 29) (n = 80) (n = 47) Brekfst Don t et 3 (10.7) 3 (3.8) 4 (8.7) Sometimes 4 (14.3) 11 (13.9) 6 (13.0) Everydy 21 (75.0) 65 (82.3) 36 (78.3) Et out for lunch, no. of times 0 6 (20.7) 40 (51.9) 23 (50.0)* < 3 20 (69.0) 25 (32.5) 17 (37.0) 4 3 (10.3) 12 (15.6) 6 (13.0) Et out for dinner, no. of times b 0 8 (27.6) 56 (71.8) 32 (71.1) < 3 17 (58.6) 16 (20.5) 9 (20.0) 4 4 (13.8) 6 (7.7) 4 (8.9) Hve snck, no. of times c 0 17 (58.6) 52 (65.0) 32 (68.1) 1 12 (41.4) 28 (35.0) 15 (31.9) Hve you herd of dietry fiber? Yes 23 (79.3) 49 (62.0) 28 (60.9) No 6 (20.7) 30 (38.0) 18 (39.1) Wht do you think is most Price 9 (56.3) 28 (59.6) 13 (56.6) importnt when buy food? Freshness 6 (37.5) 14 (29.8) 5 (21.7) Nutrition 0 (0.0) 1 (2.1) 0 (0.0) Other 1 (6.2) 4 (8.5) 5 (21.7) In the future, wht will be most Price 7 (43.8) 19 (40.4) 9 (37.5) importnt for you when buy food? Freshness 5 (31.3) 15 (31.9) 6 (25.0) Nutrition 1 (6.2) 8 (17.0) 5 (20.8) Other 3 (18.7) 5 (10.7) 4 (16.7) Frequency of eting out for lunch per week; b Frequency of eting out for dinner per week; c Frequency of hving sncks per dy; * p < Tble 9. List of mrket food prices Food Unit Price (pesos) Cerels Bred 1 kg 580 Noodles 1 kg 598 Rice 1 kg 687 Pottoes 1 kg 100 Bens 1 kg 980 Diry products Milk 1 L 490 Powdered Milk 130 g + wter (L) = 1 L 375 Low ft powdered milk 130 g + wter (L) = 1 L 408 Yogurt 165 g 117 Low ft yogurt 165 g 190 Unripe cheese 250 g 695 Cheese 250 g 555 Met nd eggs Beef 1 kg 2406 Pork 1 kg 1352 Chicken 1 kg 1015 Susge 1 dozen 804 Eggs 1 dozen 680 Fish nd sefood Fish 1 kg 2390 Cnned fish 425 g 463 Sefood (with shell) 1 kg 650 Cnned sefood 110 g 805 Vegetbles 1 kg Fruits 1 kg Fts nd oils Butter 250 g 662 Mrgrine 250 g 479 Low ft mrgrine 250 g 500 Myonnise 250 g 308 Low ft myonnise 250 g 411 Sweets Jm 250 g 374 Low sugr jm 250 g 376 Beverges Powdered juice 45 g + wter (L) = 1 L 116 Low sugr juice 45 g + wter (L) = 1 L 116 Crbonted drinks 1 L 330 Low clorie crbonted drinks 1 L 338 Visits were mde to three supermrkets in Sn Crlos; The price is the verge of the three supermrkets; US$1 = 608 pesos (April 2004). relted to body size, nd environmentl fctors would lso ffect the phenotypic expression of these genes (20). Another importnt determinnt of obesity of femles ws prity. This finding ws comptible to study by 146 Bstin et l. (21), which showed tht the risk of being obese in lter life would increse ccording to the number of children one hd. One of the interesting findings of the current study

8 BioScience Trends 2007;1(3): Article is tht there ws significnt ssocition between BMI nd some socio-economic fctors for femles (Tble 3) but not for mles (Tble 4). A similr trend ws observed in previous study (22). In the current study, mles hd fewer restrictions on ccess to food, with more chnces to et out for dinner; they were probbly influenced less by socio-economic fctors thn femles. Peñ et l. suggested tht the ssocition between obesity nd socio-economic chrcteristics my be influenced by culturl nd socil bckground, though in most cses this is not redily pprent (7). In ptrirchl society, the intr-household food distribution my be in fvor of mles. Contrry to generl understnding, subjects with lower level of physicl ctivity were not necessrily obese in this study. The proportion of those who exercised for more thn 30 min three times or more per week ws 9.7% (58/600), nd thus it ws quite difficult to mke the sttisticl comprison. Moreover, this study did not mesure ctul energy expenditure, so cution is needed when interpreting the results. A Ntionl Helth Survey noted tht the proportion of persons with low level of physicl ctivity ws quite high (13). Enhncing wreness of the importnce of incresing one s physicl ctivity is therefore crucil. With regrd to diet, no ssocition between frequency of food intke nd BMI ws found. The possibility of under-reporting of dietry intke of obese subjects ws noted in n erlier study (23), which might hve contributed to the obese subjects hving lower frequency of intke in sugr-rich foods such s sweets nd juice thn those with norml BMI. Another importnt finding in this study ws the possible ssocition between the fctors ffecting food purchses nd frequency of food intke. Comprison of the fctors ffecting present nd future food purchses indicted tht the highest proportion nswered price for both present nd future purchses, wheres those who nswered nutrition incresed for future purchses. This shows wreness of the importnce of nutrition mong the study popultion, though in ctulity individuls would plce priority on price. Obese femle subjects tended to ttch importnce to price for their present purchses. Chrcteristics of obese femle subjects like hving fmily nd income constrints might hve contributed this priority s well s decision of cooking process. These subjects re thus unble to plce priority on purchse spects besides price. Results for food frequency suggested the impct of price. Tble 9 shows the list of mrket food prices. Of course, the frequency of food intke is not simply due to price. The current dietry guideline in Chile recommends the intke of diry products nd fish (24). Compring fish nd met indictes people et more pork nd chicken (1352 pesos, 1015 pesos per 1 kg respectively) which is reltively cheper thn fish (2390 pesos per 1 kg), though beef is n exception (2406 pesos per 1 kg). Another food recommended in the dietry guideline is diry products including milk. For mles, the frequency of intke of milk ws bout two times week nd intke of juice nd crbonted drinks ws two or three times week. In terms of price, milk is more expensive thn juice nd crbonted drinks, nd low ft milk is even more expensive. Similr trends were observed in previous study where persons with low socio-economic sttus would consume only wht they could fford (25,26). Ironiclly, most of the foods ffordble to poor popultions tend to be energy-dense nd high-ft (27) nd the current study lso found tht food items recommended by dietry guidelines were rther expensive. An essentil spect to promoting helthy food choices is tht recommended foods do not increse the costs for the popultion. Combined with nutrition eduction, price controls s hve been reported in Muritius nd Finlnd my ply n importnt role, (28,29). The current study lso suggests tht in ddition to price the vilbility t the shop negtively ffects ccess to recommended foods (e.g. there were only three fish shops, while met ws vilble t mny shops). Since Chile is country bout 4000 km long from north to south, the crops cultivted nd livestock rised, s well s the vilbility of mrkets for other foods, my differ gretly by region. Estblishing re-specific strtegies, including the dietry guidelines, to control obesity nd relted diseses is therefore essentil. A good model for this my be the Jpnese Ministry of Helth, Lbor, nd Welfre s (former the Ministry of Helth nd Welfre) Helth Jpn 21 (Kenkou Nippon 21), which set out Jpnese public helth trgets for the yer 2010, s it employs different ims/strtegies by region (30). In conclusion, the current findings of high prevlence of obese/overweight individuls, together with the chrcteristics of their diets including chnges in the cooking process, suggest tht nutrition trnsition is underwy in rurl res s well. Although ssessing ctul chnges in BMI during the course of nutrition trnsition is difficult to do with cross-sectionl study, the findings of this study illustrte the significnce of obesity in the re studied. Ltin Americns re known to be more likely to hve greter body ft for the sme BMI thn whites in the US nd Europe nd therefore to hve higher likelihood of experiencing relted diseses t lower BMI levels (31). Although lower prevlence of obesity ws observed for mles, the high frequency of eting out must be curbed nd low wreness of dietry fiber must be remedied to prevent n increse in overweight individuls nd to enhnce helth wreness mong mles. In ddition, future nutrition policy should tke regionl difference into considertion nd should be estblished in collbortion with relevnt sectors (e.g. helth, eduction, griculture, 147

9 economic) s well s with the mss medi. Acknowledgements This study ws finncilly supported by the Foundtion for Totl Helth Promotion nd reserch fund from University of Tokyo. The uthors express their thnks to the stff of INTA, the municipl office, nd helth centers in Sn Crlos nd to field stff for their efforts in dt collection. Without their persistent efforts this work could not hve been completed. Ultimtely, uthors wish to express their deepest pprecition to the study prticipnts for their coopertion throughout the fieldwork. References 1. World Helth Orgniztion. Turning the tide of mlnutrition: Responding to the chllenge of the 21st century. Genev: WHO/NHD, Grrow JS. Obesity. In: Humn Nutrition nd Dietetics. 10th edition (Grrow JS, Jmes WPT, Rlph A, eds.). Churchill Livingstone, London, UK, 1999; pp Thompson D, Wolf AM. The medicl-cre cost burden of obesity. Obes Rev 2001; 2: World Helth Orgniztion. Diet, nutrition nd the prevention of chronic diseses: Report of Joint WHO/ FAO Expert Consulttion. WHO Technicl Report series 916. Genev: WHO, Pn Americn Helth Orgniztion/ World Helth Orgniztion. Obesity nd Poverty: A New public Helth Chllenge. In: A pending chllenge in Chile (Albl C, Vio F, eds.). PAHO/WHO, 2000; pp Vio F, Albl C. Obesidd en Chile: un mird epidemiológic: Obesidd: un desfío pendiente. University of Chile. 2000; pp Pn Americn Helth Orgniztion/ World Helth Orgniztion. Obesity nd Poverty: A New Public Helth Chllenge. In: Obesity mong the poor: An emerging problem in Ltin Americ nd the Cribben (Peñ M, Bcllo J, eds.). PAHO/WHO, 2000; pp Popkin BM. The nutrition trnsition nd obesity in the developing world. J Nutr 2001; 131(suppl): Uuy R, Albl C, Kin J. Obesity trends in Ltin Americ: Trnsiting from under-to overweight. Nutrition 2001; 131(suppl): Albl C, Vio F, Kin J, Uuy R. Nutrition trnsition in Chile: determinnts nd consequences. Public Helth Nutr 2002; 5: Ministry of Helth. Ntionl Bord for Helth Promotion (VIDA CHILE) Strtegic pln for helth promotion Gols for Chile, Ministry of Helth. Exmen de slud preventivo del dulto ESPA Chile, Ministry of Helth. Resultdos encuest de slud, Chile Chile, Ministry of Plnning. Indicdores de poblción (Año 2002). Internet site: Ingress communictions. midepln.cl (ccessed July 14, 2006). 15. Municipl Office of Sn Crlos. Pln de desrrollo comunl Sn Crlos. Chile, World Helth Orgniztion. Obesity: Preventing nd mnging the globl epidemic: Report of WHO Consulttion. WHO Technicl Report series 894. Genev: WHO, Jury G, Urteg C, Tibo M. Porciónes de intercmbio y composición químic de los limentos de l pirámide limentri chilen. Chile. INTA, University of Chile, Monteiro CA, Mour EC, Conde WL, Popkin BM. Socioeconomic sttus nd obesity in dult popultions of developing countries: review. Bull World Helth Orgn 2004; 82: Jmes PT. Obesity: The worldwide epidemic. Clin Dermtol 2004; 22: Brsh GS, Frooqi S, O Rhilly S. Genetics of bodyweight regultion. Nture 2000; 404: Bstin LA, West NA, Corcorn C, Munger RG. Number of children nd the risk of obesity in older women. Prev Med 2005; 40: Borders TF, Rohrer JE, Crdrelli KM. Gender-specific disprities in obesity. J Community Helth 2006; 31: Heimnn BL, Lissner L. Dietry underreporting by obese individuls is it specific or non-specific? British Medicine 1995; 311: Cstillo C, Uuy R, Atlh E. Guís de limentción pr l poblción Chilen. Sntigo: Ministry of Helth, Pn Americn Helth Orgniztion/ World Helth Orgniztion. Obesity nd Poverty: A New Public Helth Chllenge. In: Socionthropologicl spects of obesity in poverty (Aguirre P, eds.). PAHO/WHO, 2000; pp Food nd Agriculture Orgniztion. The nutrition trnsition nd obesity. Internet site: Ingress Communictions. obes2.htm (ccessed July 14, 2006). 27. Drewnowski A. Obesity nd the food environment. Dietry energy density nd diet costs. Am J Prev Med 2004; 27: Popkin BM. Urbniztion, lifestyle chnges nd the nutrition trnsition. Popul Dev Rev 1999; 19: Prttl R. Dietry chnges in Finlnd success stories nd future chllenges. Appetite 2003; 41: Ministry of Helth, Lbor nd Welfre. Kenkou Nippon 21. Internet site: Ingress Communictions. mhlw.go.jp/topics/kenko21_11/s0.html (ccessed July 14, 2006). 31. Popkin BM. An overview on the nutrition trnsition nd its helth implictions: the Bellgio meeting. Public Helth Nutr 2002; 5: