DE CICLO VITAL A CURSO DE VIDA Un cambio epistemológico Chilean Health Ministry Public Health Subsecretary DIPRECE Vital Cycle Departament APEC HOW DOES CHILE APROACH AGING From Vital Cycle to Course of life. An Epistemologic change Dra. Sylvia Santander Rigollet Jefa del Departamento de Ciclo Vital Sylvia.santander@minsal.cl Noviembre de 2011

Adolescentes and Jóvenes 25% Adultos mayores 12/04/2017 2010 Población General 17.094.275 millones Niños 14% Adolescentes and Jóvenes 25% Adultos mayores 65 *Población 9,2% 2010 12,1% 2020 16,9% 2030 (INE) Latin American Country Largo¡e and narrow and extremly diverssity 2010 General population 17.094.275 million 2020 estimate population 18.549.095 million Adolescents and Young people 25% of population 2010, 20,5% in 2020 65 and more years populations 5%- 1980; 9,2% 2010 12,1% 2020 16,9% 2030 (INE) http://siteresources.worldbank.org/INTLAC/Images/CHL30715.jpg

- Disminuye el riesgo de morir a toda edad 1. CHILE - Experimenta una transición demográfica, - Disminuye el riesgo de morir a toda edad - Aumenta el porcentaje de adultos mayores. Fuente: DEIS Minsal, PNUD 2009 -Demografic transition - Being near to be a developed country Influent on epidemiologic indicators Increasing mortality secundary to non transmisible illness, associated with prevenible risk factors, so we can forsee them. Increasing the external causes of mortality like self murder, murderous, and accidents, were the numbers are alarming numbers, specially in adolescents and olf people Dicreases the risk of dieing in all ages

12/04/2017 En Chile: Cambio Demográfico 1. Aumenta la expectativa de vida 2. Decrece la tasa de fecundidad In Chile the evolution of the hope of life is important, so we can see that in the 1990 this hope was 55 years, The expectations of life at birth In 2009 this expectives changes to 81 for men and 85 women (INE, 2009). In the other grafic we can see that there is an important change too, in the Global fecundity rate. This rate was 5,49 chidren for woman in 1955 and in the 2011 this rate is 1.9 children per woman, lower than the rate nedded to change population. Chile, after Cuba has the lower rate of fecundity on L.A Why does irt happens : it could be many explanations for this for example: 1. Important incresse of education coverture in all population 2. Access for Using Contraceptives in all populations that ask for them (Family planning programs in public polities ) 3. Important cultural changes specially those concerning with gender roles conceptions. 4. Increse of Women incorporation to labour market In 2009, life expectancy at birth in Chile stood at 78.2 years, slightly below the OECD average of 79.5 years. Tasa Global de fecundidad : 5,49 hijos por mujer en 1955. 1,9 hijos por mujer 2011, mas baja que la tasa necesaria para el recambio de la población Expectativa de vida al nacer: 55 (1999) 81 los hombres, 85 las mujeres (INE, 2009)

12/04/2017 CHILE: INDICADORES DEMOGRAFICOS Pirámide poblacional (1990-2000-2010-2020) Changes in the population pyramid, from a pyramidal pyramid (many child and adolescents on the base, and less old people on the top), This changes to a bellform pyramid on the 2020, with decresing of child and adolescents on the base and increasing of olderst on the top . Range to rechange populatin is 1,9 minor than what we need (2,1). In this actual deomografic situation. We have a demografic bonus, it means that the active economical population is bigger than the number non active economical population) (child and oldest people) Cambios en la pirámide de población, desde piramidal (donde hay mas niños, que población adulta y adulta mayor ) a una pirámide campaniforme , en que decrese la población de niños y adolecentes y aumentan los adultos mayores . Rango de recambiio es 1,9 menor que lo que se necesita para el recambio (2,1)

Envejecimiento de la población 12/04/2017 El desarrollo de la medicina ha permitido un avance sin precedente del control de la mortalidad como de la natalidad, lo que provoca una reducción del crecimiento de la población y un envejecimiento de ésta. En esta transición demográfica y epidemiológica, las enfermedades infecciosas son reemplazadas por las enfermedades no transmisibles, habitualmente crónicas, que empeoran con los años y que están relacionadas con estilos de vida. Aging is a process, present in all human beings; begins at birth and ends with death. Is a process of gradual adaptation. Differ in different species, individuals and periods of life, so the forms of ageing are as many as there are individuals, and people become more different with age, (genetic reasons), and the environment“ (Dulcey-Ruiz & Uribe Valdivieso, 2002) In the field of health, the consequences of this population aging are specially marked. In this demographic and epidemiological transition, infectious diseases are replaced by non-infectious, usually Chronicles, linked to certain lifestyles and that occur preferentially at advanced ages. (WHO, 2002) * (World Population Ageing 1950–2050, 2002 The process of demographic transition in Latin America had a faster pace in compare with the pace on which they had developed. This was due to the pre-existence of after World War II medical and health development, which allowed an improvement without precedent for the control of mortality and fertility later. Latin American countries have undergone profound demographic transformations, whose main features are: reduction of population growth and the ageing of structures by age.

12/04/2017 Envejecimiento en el mundo - En 2009, la población mundial estimada de más de 60 años ascendía a 737 millones de personas. - Se estima que en 2050, los mayores de 60 serán 2 billones de personas. - El porcentaje de adultos mayores es más y aumenta más en los países desarrollados.

Tiene indicadores epidemiológicos de país desarrollado. 2. CHILE Tiene indicadores epidemiológicos de país desarrollado. Aumenta la mortalidad y morbilidad secundaria a enfermedades transmisibles asociadas a factores de riesgo previsibles (ECNT) y a causas externas, (accidentes, asesinatos y suicidios) Fuente: DEIS Minsal, PNUD 2009 -Demografic transition - Being near to be a developed country Influent on epidemiologic indicators Increasing mortality secundary to non transmisible illness, associated with prevenible risk factors, so we can forsee them. Increasing the external causes of mortality like self murder, murderous, and accidents, were the numbers are alarming numbers, specially in adolescents and olf people Dicreases the risk of dieing in all ages

CHILE: Tasas de mortalidad comparando mujeres y hombres 12/04/2017 CHILE: Tasas de mortalidad comparando mujeres y hombres ambos sexos Hombres mujeres   Muertes Rango (**) muerte rango(**) Muerte 2005 86.102 5,3 46,369 5,8 39,733 4,8 2006 85.639 5,2 45.987 5,7 39,652 2007 93.000 5,6 49,753 6,1 43,247 2008 90.168 5,4 48,588 5,9 41,58 4,9 2009 91.965 49.608 42.357 5,0 These are the mortality rate in Chile compairing men and women The general rate in 5,4 per 1.000 per one thousand population. If we compare men and women rate of mortality, men has nearly one point mayor rate than women (0,9) Definición de tasa de mortalidad The mortality rate is an indicator reflecting the number of deaths per 1,000 inhabitants in a population at a certain period of time (usually one year). It is usual to refer to this demographic as crude mortality rate or simply mortality index. The mortality rate is inversely linked to life expectancy at the time of birth: to increased life expectancy, child mortality rate. A higher than developed countries mortality rate in developing countries. Is usually considered that the mortality rate is high if it exceeds 30%; moderate if it falls between 15% and 30%; and low if it is below 15%. Worldwide, malnutrition-related mortality is the primary responsibility of the highest mortality rates. In developed countries, on the other hand, the main causes of mortality are tumors, diseases of the circulatory system and diseases of the r system... *Tasa por 1.000 hbts. Fuente: (DEIS 2011) Depto Ciclo Vital.

CHILE: Tasas de mortalidad en 2009 12/04/2017 CHILE: Tasas de mortalidad en 2009   Muertes Hombres Mujeres Nº tasa * Enfermedades isquémicas del corazón 4.408 53,1 2.891 34,1 Enfermedades cerebro vasculares 3.961 47,7 4.169 49,2 Cirrosis y otras enfermedades hepáticas 2.970 35,8 1.198 14,2 Tumores estomacales malignos 2.235 26,9 1.115 13,2 Neumonía 1.759 21,2 1.757 20,8 Próstata y tumores malignos 1.753 20,9 0,0 Suicidios 1.724 424 5,0 Enfermedades respiratorias crónicas 1.581 19,2 1.350 15,9 Diabetes mellitus 1.598 19,1 1.655 19,5 VIH/Sida 365 4,4 70 0,8 Todas las causas 49.608 6,0 42.357 Fuente: DEIS-MINSAL, 2009. Tasa de mortalidad por todas las causas por 1.000 We start last year (2010) Planing or National Health Survey 2009-2010. For that the first tthat we do was the state of art of epidemiologic rates in all ages. . Added to this we have the results of the NATIONAL SURVEY OF HEALTH 2009-2010, THAT ADD INFORMTION ABOUT HEALTH AND RISK FACTORS. If you look at this slide you can see the same situation reviewed before BUT ON deceases. In most of the deceases that we see here The rate for men is higger in compare with women If you look this and add the antecedent of five years al least less of hope of life for men, one of the focus to board health in a conception of “course of life”, Would be to start thinking of early preventive actions for men health  

Problemas prevalentes de salud 12/04/2017 Sexo Nivel educacional (años de escolaridad) Problemas prevalentes de salud Total Nacional % hombres % mujeres < 8 años % 8 a 12 > 12 años % Tasa diaria de adultos fumando 41 44 37 25,6 41,3 50 Consumo de alcohol (consumo del último mes) 57,6 69,5 46,4 42 57 72 Obesidad 25 19,0 31,0 35,5 19 Sobrepeso 38 45,3 33,6 37,2 43 Síndrome metabólico 35,3 41,7 31 47,8 32,7 26,4 Hipertensión arterial 27 29 51,1 22,8 16,7 Diabetes 9 8,0 10 21 7 6 Colesterol alto 39 34 Triglicéridos 31,2 35,6 27,1 35 33 Riesgo cardiovascular 16 12 28 Sedentarismo 89 84 93 96,9 88,6 82,2 Síntomas depresivos 17,2 8,5 25,7 20,8 18,4 11,8 Adults smoking daily rate In Chile (2009) was 41% OECD average (22.3%). Sweden, Iceland, the United States and Canada (less than 17%) Obesity rates increased in all OECD countries. In Chile, among adults was 25.1% in 2009. United States (33.8% in 2008) Canada (24.2% in 2008). The average for the OECD countries with measured data was 21.0% in 2009. Obesity’s growing prevalence foreshadows increases in the occurrence of health problems (such as diabetes and cardiovascular diseases), and higher health care costs in the future. Hight weight in Chiles is on 38% of the population, and is higher on men population Alcohol consumer of the last month in Chile is 57,6% , higher on men population For more information on OECD's work on Chile, please visit www.oecd.org/chile.

- Un país en vías de desarrollo según su ingreso per cápita. 3. CHILE - Un país en vías de desarrollo según su ingreso per cápita. Fuente: DEIS Minsal, PNUD 2009 -Demografic transition - Being near to be a developed country Influent on epidemiologic indicators Increasing mortality secundary to non transmisible illness, associated with prevenible risk factors, so we can forsee them. Increasing the external causes of mortality like self murder, murderous, and accidents, were the numbers are alarming numbers, specially in adolescents and olf people Dicreases the risk of dieing in all ages

Alto, medio y bajo GDP (PPP) ingreso per cápita (Banco Mundial 2005-2010) 12/04/2017 Rank País Ingresos US$ Año 1  Qatar 90,950 2009 2  Luxembourg 89,626 2010 3  United Arab Emirates 57,473 5  Singapore 56,794 7  Kuwait 48,403 2007 8  United States 47,084 53  Argentina 15,794 54  México 15,224 55  Chile 15,026 178  Liberia 405 179  Burundi 399 180  Congo, Democratic R 335

- Con grandes progresos en los indicadores 3. CHILE - Con grandes progresos en los indicadores de salud en los últimos años. - Con grandes inequidades que también están presentes en salud. Fuente: DEIS Minsal, PNUD 2009 -Demografic transition - Being near to be a developed country Influent on epidemiologic indicators Increasing mortality secundary to non transmisible illness, associated with prevenible risk factors, so we can forsee them. Increasing the external causes of mortality like self murder, murderous, and accidents, were the numbers are alarming numbers, specially in adolescents and olf people Dicreases the risk of dieing in all ages

CHILE: Progresos sanitarios de los últimos 50 años These graphics ilustrates only some of the social and sanitarian gains in the last 50 years: For example The infant mortality rate in Chile, has fallen (decreased greatly over the past decades specialy that related with malnutrition =0,4% (2005). - 7.5 deaths per 1 000 live births in 2008. - OECD average of 4.4. ODM Propose is 6.8. The same happens with Maternal mortality, 17 x100.000 birth ODM propose 12 9,9x100.000 . The increse of the treatment of no potable water, and the increse in child inmunization coverture near to 90%, the important reduction of poverty and extreme poverty population, are the most important Sanitarian advances that explain our GENERAL presents health indicators, ARE THE POSIBLE BEST BUYS . Chile is a country that has had a strong public health tradition, reflected in more Than 50 years of development of important public politics; in the fiftys contributed very significantly (a lot), to decreased (to the reduction ) child malnutrition and child mortality. This actions place us in a strong apposittion or as regional leader position, on regional health public policy, with a very important responsibility General mortality 5,1 x 1.000 population Child Mortality 7,5 x 1.000 birth Maternal Mortality 1,65 x 10.000 birth (17 x100.000) Goal for decade 1,2 x 10.000 birth no complete Maternal mortality x Abortion 0,2 x10.000 birth Goal for decade 0,25 2000-2010 complete Adolescent maternal mortality : 0,0 2009 DEIS References : DEIS .MINSAL. www.minsal.cl For a thousand (1.000) one hundred thousand (100.000) live births or born alive 10.000 ten thousand population 100.000 one hundred thousand population Goal for decade and ODM 6,8 x 1.000 no complete   Fuente: www.minsal.cl o www.mideplan.cl Mortalidad infantil 7,5x 1.000 materna 17X100.000 Gradual reducción de la pobreza Casen 2009

CHILE: Indicadores de equidad 12/04/2017 CHILE: Indicadores de equidad Encuesta Casen 2006 13,7 % población bajo la línea de la pobreza Encuesta Casen 2009 15,1% población bajo la línea de la pobreza Casen 2009 Indigentes= 634.328 (3,7%) Gente pobre =2.564.032 (11,4%) Población bajo la línea de la pobreza son con mas frecuencia niños mujeres y adultos mayores Now I will show you, some equity indicators in Chile 2011. In the Casen survey 2006 two thousand and six (2006) 13,7% of the population was below the line of poverty, in the same INQUIRY 2009 two thousand and nine these numbers increased to 15,1% of the population below the line of poverty. This number includes poor people : 11,4% = 2.564.032 and indigent people 3,7% (634.328) The population below the line of poverty, are almost always child, adolescents, women, old people or inmigrants If you look this % as % i think is no sufficiently clear to imagine what does it mean. I like to put this in number and tell you that it means that there are near 3 million people below the line of poverty in CHILE, And our country is not an exception, because this is happening in many developed countries at this moment, and of course in those countries we named like low income countries. In Latinoamérica this situation is most frecuently. Thats what I say is only for YOU TO THINK OF THIS is not as a particular problem of a particular country, but think of this as a global and generaliced problem in the world

CHILE: Coeficiente Gini - 0,55 Este índice que mide la desigualdad y las brechas entre los ricos y los pobres del mundo, sitúa a Chile entre los países con mayor inequidad. Germany 0,283 China 0,47 Brasil 0,579 Japan 0,249 EE.UU. 0,445 Chile 0,55 Denmark 0,247 Rusia 0,39 México 0,546 Italy 0,36 Argentina 0,542 France 0,327 Namibia (mayor inequidad) 0,707 Spain The gini index is an equality index (meassure the global distributives terms whithout separated urban and rural population); Indicates us the social and economic differences between poorest and richest, Its value is between the range 0-1; being greater inequality in indexes more close to one and less inequality when the Gini value is near zero OTHER: Being major the inequity in indexes nearer to one and minor the inequity when the value of Gini is near to cero. Gini coeficient Rate 0 to 1. More inequity if the number is close to 1. Minor inequity if When the number is close to 0  In this slide we can see the different countries and their social gap Gini. Chile could be compared in this indicator with Argentina, México and Brasil all of them with Gini number near to 1 (0,5 or more) China, USA , Rusia , Italy, France and Spain are better numbers, (0,4) but if we think that all this countries are developed countries, the diference is not very important. But to really compare this index we have to kwow the per capita income The countries in this slide where the gap is near the best are Germany, JAPAN, Denmark and Suecia (0.2) NEAR TO 0 Denmark has the best situation of equality Fuente: Informe Desarrollo Humano PNUD 2009

Demográficos y epidemiológicos, los 12/04/2017 CHILE: - País en una transición demográfica, con aumento sostenido de población adulta mayor - Indicadores Epidemiológicos cercanos a los de los países de la OCDE, con tasas crecientes de E. crónicas.. - Importante inequidad Implicancias para los programas de salud del depto de Ciclo Vital del Minsal Sitúa nuestro trabajo en un punto de vista distinto, desde la lógica de ciclo vital a la de “Curso de vida”, poniendo el foco en los cambios Demográficos y epidemiológicos, los determinantes sociales y la equidad, basándose en modelos sistémicos e integrales. I think, that the first we must do when we want to propose to install the Course of life concept in Public health actions in Chile, is to ask us for the effect or the impact of the health estrategics implemented in the diferents moments of vital cicle. The key is to proyect on our vision the way that they will afect people involved in the future. Situated us to work with a different point view,from “Cicle of life” to“Course of life” focusing - - Demographic and Epidemiological situation -Social determinants and Equity focus -Sistemic and Integral theoric Models

De Ciclo de Vida a Curso de Vida 12/04/2017 De Ciclo de Vida a Curso de Vida El concepto Curso de Vida no es nuevo. En la primera mitad del siglo veinte, la mayoría de los modelos de salud pública consideraban que las experiencias tempranas de la vida determinaban la salud adulta. En los ’80, basado en mayor evidencia científica, los estudios de cohortes indicaban que los riesgos de muchas muertes no reportadas, como las causadas por enfermedades Cardio- vasculares o diabetes, no eran atribuibles a los factores de riesgo de la adultez sino que se habían iniciado en la niñez o adolescencia, y eventualmente antes: durante el desarrollo fetal. Ben-Shlomo & Kuh, 2002). *(Bao, Srinivasan, Valdez, Greenlund, Wattigney, & Berenson, 1997),

Modelos que justifican el cambio de Ciclo de Vida a Curso de Vida - La programación como modelo etiológico de la enfermedad. - La hipótesis del origen fetal de la enfermedad en la adultez, (Barker, 1999). - La evidencia emergente indica que los nuevos factores de riesgo pueden actuar a lo largo de las generaciones, lo que resulta en aumento del riesgo cardiovascular en niños. (Sterne & Smith, 2001) - Estas investigaciones científicas dan soporte a la necesidad de integrar el concepto Curso de Vida como el marco que permite entender cómo interactúan los determinantes de la salud, cómo afectan la salud de las personas a lo largo de toda la vida y cómo pueden incluso afectar a las futuras generaciones. Estamos hablando entonces de un cambio Epistemológico 12/04/2017

Alteraciones en la nutrición fetal y efectos a largo plazo: ¿algo más que una hipótesis? J.M. Moreno Villares et al. Unidad de Nutrición Clínica. Madrid

Diferencias epidemiológicas a lo largo del curso de vida - El desarrollo embrionario o fetal temprano, es desde el inicio un período crítico, sentándose aquí las bases de la fundación del bienestar físico y mental de los seres humanos. Puede predecir lo que pasará con la persona a lo largo de su vida. Vivir la etapa embrionaria y fetal, así como la primera infancia, en ambientes adversos puede gatillar tempranamente patologías tales como obesidad, sobrepeso, hipertensión y diabetes que aparecerán en la adultez. Este fenómeno es explicado por modelos epidemiológicos ecológicos y sociales (*). : If we think how can the first 9 month of pregnancy could affects the rest of your life, we start seeing people since before the early stages of pregnancy. Embrionary and Fetal, and/or early infance adverse enviroment, are related with some early programmed pathologics, like Obesity, overweight, High-tension, Diabetes, that will appear in adults * This pfenomenon is explained by ecological and social epidemiological models. The most important benefits in one age group could be those that appears after an interventions improve in an earlier age. We need interventions improved en several moments along the life to allow better results and acumulative effects. There are risks and benefits intergenerations that be essential to abord the risk in all the groups of ages. There are Critical periods in the course of life (*) Barker (1986) Rose (1964) and Forsdahl (1977)

Diferencias epidemiológicas a lo largo del curso de vida Otro período crítico es la adolescencia, pues la mayoría de los problemas en esta etapa se relacionan con conductas modificables que pueden impactar fuertemente en la etapa siguiente de la vida. Existe una ventana de oportunidades para desarrollar intervenciones promocionales y preventivas en salud en esta etapa. Los beneficios mas importantes presentes en un grupo de edad, pueden ser aquellos que aparecen despues de una intervención implementada en una edad temprana, por lo que necesitamos aumentar las intervenciones en diferentes momentos de la vida para lograr mejores resultados y efectos acumulativos. : If we think how can the first 9 month of pregnancy could affects the rest of your life, we start seeing people since before the early stages of pregnancy. Embrionary and Fetal, and/or early infance adverse enviroment, are related with some early programmed pathologics, like Obesity, overweight, High-tension, Diabetes, that will appear in adults * This pfenomenon is explained by ecological and social epidemiological models. The most important benefits in one age group could be those that appears after an interventions improve in an earlier age. We need interventions improved en several moments along the life to allow better results and acumulative effects. There are risks and benefits intergenerations that be essential to abord the risk in all the groups of ages. There are Critical periods in the course of life (*) Barker (1986) Rose (1964) and Forsdahl (1977)

Marco conceptual de la teoría de Barker Durán P. Nutrición temprana y enfermedades en la edad adulta: acerca de la "hipótesis de Barker“ Arch. argent. pediatr. v.102 n.1 Buenos Aires ene./feb. 2004

Ciclo de Vida y Curso de Vida 12/04/2017 Son conceptos complementarios, pero que tienen diferentes implicancias políticas. El enfoque por ciclo de vida sugiere ver los programas de salud en bloques o estadios: embarazo, niñez, adolescencia, adultez y adultez mayor. Cada ciclo tiene un principio y un fin. Es, por tanto, un concepto operativo, útil para definir donde pueden medirse los indicadores. Es un modo transversal de aproximación En oposición, hemos comenzado a usar el concepto curso de vida –entendido como trayectoria- períodos latentes y efectos acumulativos, que explican la vida como un continuo integrado, en el que todas las etapas están imbricadas y hay efectos acumulativos de etapa en etapa. Así, el curso de vida provee un marco conceptual que permite entender cómo múltiples determinantes de la salud interactúan a lo largo de la vida y entre generaciones para producir resultados en salud. La experiencia y exposiciones de hoy determinan la salud del mañana.

Principales estadios del Ciclo de Vida 12/04/2017 Período prenatal Embarazo Período neonatal Birth 7 days Early neonatal Period Prekinder 28 days Death Aeging 1 year Let us turn to the life cycle framework , what is it and how can it be used. This slide describes the lifecycle--the main stages of life. The lifecycle starts with birth, is divided into infancy within which there is a neonatal period of up to 28 days ( and an early neonatal, first week of life). It is followed by the rest of the childhood years, then the school age period of life, early adolescence, adulthood and aging. The reproductive period covers adolescence and adulthood. Why a life “cycle” and not just a life “span”? The lifecycle comes full circle when the reproductive period of a women results in pregnancy and child birth. The concept of a lifecycle emphasizes the intergenerational effects of social policy and spending. For example, the education, health and nutritional status of a woman--before and during pregnancy--are key determinants for the health and nutritional outcomes of her infant--including the survival of the newborn. Adults Años preescolares 20 years 5 years Período reproductivo 10 years Niñez Adolescencia Años escolares

Each circuit turn around changes tha pattern Incorporate previous elements especially those who afected on Critical and sensible periods The influences superpose each other (be above) So we need longitudinal meassures In Chile we propose a Cohorte study to meassure effects of social politics and public heath polities on health (like Chile crece contigo) We need to meassure Trayectorys of life

Pre Concep- cional Prenatal Parto y Atención Puerperio Recién Nacido Cuidado Neonatal Precoz Infancia Adolescente Mujer Adulta Mujer Adulta Mayor Evaluar riesgo reproductivo Ingreso precoz Acompaña- Miento Preparación parto y crianza Detección riesgo biosico- Social (depresión, drogadicción, alcoholismo Visita Domiciliaria Integral Atención personalizada Detección oportuna de patología Apego temprano Auto cuidado Detección respuesta y seguimiento riesgo psicosocial (depresión, drogadicción, alcoholismo) Atención integral del RN Lactancia Materna Detección precoz de patología Vinculo madre-padre-hijo Visita Domiciliaria a madres y niños de riesgo Control salud integral Vacunación Alimentación adecuada Estimulación Control de salud integral Prevención consumo de alcohol, tabaco y drogas Prevención de transmisión ITS Prevención embarazo adolescente Vigilancia del estado nutricional Fomentar la reducción del consumo de tabaco Detección precoz y tratamiento oportuno de las pacientes con riesgo de cáncer cervicouterino,mama y vesícula Mejorar calidad de vida Diagnóstico y tratamiento oportuno de la depresión Detección de morbilidad ginecológica Riesgo preconcepcional Riesgo Obstétrico – y perinatal

CONCLUSIONES Bases para construir Políticas de salud deben ser: Considerar la trayectoria de la salud a lo largo del curso de la vida. 2. Preguntárse acerca del impacto que tendrán en el futuro las estrategias implementadas em diferentes momentos de la vida. 3. Pensar la vejez bajo el prisma de los derechos humanos y la equidad. Integrar estándares y planes específicos que promuevan estilos de vida saludables e intervenciones preventivas en salud en toda etapa de la vida, y siempre con visión de largo plazo. 5. Incluir el desafío de una longevidad sana y una muerte digna. 6. Fortaler el rol de la autoridad sanitaria para guiar adecuadamente las intervenciones en salud. 7. Administrarlos recursos humanos, los sistemas de información y las prioridades de investigación.

CONCLUSIONES 12/04/2017 - Los cambios demográficos con incremento progresivo de la población de adultos mayores y el aumento de las ECNT, nos plantean un complejo desafío para el futuro, por el fuerte aumento del gasto en salud. - Actualmente el mayor gasto en enfermedades en Chile se relaciona con aquellas relacionadas con enfermedades crónicas, iniciándose muchas de ellas en el período embrionario o en la infancia, por lo que es perentorio implementar estrategias preventivas a lo largo del curso de vida. - Los indicadores generales de salud son mas malos en las poblaciones mas pobres, siendo la brecha entre pobres y ricos aun enorme. La EQUIDAD es por lo tanto uno de los principales problemas a considerar al desarrollar políticas públicas en CHILE. Health interventions in Chile have been suffiently affective, in decreasing woman and child mortality and in diclining child malnutrition. But, health results are worse in the poorest populations , because the gap betwen poor and rich is still enormous in our country, specially amoungst children, women and the elderly Then, the biggest future challenges are to overcome health inequities, considering social determinants in our clinical and public health focuses Epidemiologic socialeconomic and sociodemografic informations support this. Is very important to consider epidemilogical and demographic changes, but is important too, to include human right focus, specially gender and etnics non discrimination, and of course, considering social determinants and equity in all our politics.  The most important challanges in chile is to change the point of view from vital cicle to course of life, trying to dicrease the social gap, and considering the equity as one of the central topics that we have to consider and relave on course of life when we think on public health politics.

Ha tenido una posición de líder regional en políticas CONCLUSIONES 12/04/2017 - Nuestro país ha tenido una fuerte tradición de salud pública, disminuyendo la mortalidad materna e infantil y disminuyendo la malnutrición. Ha tenido una posición de líder regional en políticas de salud pública, siendo esto una gran responsabilidad. Uno de los mas importantes desafíos en Chile es el de pensar la salud como una prioridad, en especial en la intervenciones de promoción y prevención en salud a lo largo del curso de vida. - Es relevante pensar que invertir en salud es un imperativo ético, pero también un imperativo económico, siendo la mejor opción de inversión para alcanzar el desarrollo del pais. Health interventions in Chile have been suffiently affective, in decreasing woman and child mortality and in diclining child malnutrition. But, health results are worse in the poorest populations , because the gap betwen poor and rich is still enormous in our country, specially amoungst children, women and the elderly Then, the biggest future challenges are to overcome health inequities, considering social determinants in our clinical and public health focuses Epidemiologic socialeconomic and sociodemografic informations support this. Is very important to consider epidemilogical and demographic changes, but is important too, to include human right focus, specially gender and etnics non discrimination, and of course, considering social determinants and equity in all our politics.  The most important challanges in chile is to change the point of view from vital cicle to course of life, trying to dicrease the social gap, and considering the equity as one of the central topics that we have to consider and relave on course of life when we think on public health politics.

DE CICLO VITAL A CURSO DE VIDA Un cambio epistemológico Chilean Health Ministry Public Health Subsecretary DIPRECE Vital Cycle Departament APEC HOW DOES CHILE APROACH AGING From Vital Cycle to Course of life. An Epistemologic change Dra. Sylvia Santander Rigollet Jefa del Departamento de Ciclo Vital Sylvia.santander@minsal.cl Noviembre de 2011