Svetoslav Handjiev, Daniella Popova

Bulgarian Association for the Study of Obesity,
Sofia, Bulgaria

Obesity and related metabolic diseases are some of the most important health problems in Bulgaria. About 8 million people now live in Bulgaria. More than 4 million are overweight or obese. 47% of the whole Bulgarian population weigh above the norm (BMI>25 kg/m2), including 1,250 000 people (15.6%) with BMl>27.3 kg/m2 (600,000 men and 650,000 women) and 860,000 people (10.8%) with BMI>30 kg/m2. 

To this number 100,000 children have been added (10% of the students of the age 7-14 years), the total number of the overweight persons in Bulgaria (7-84 yrs) being 3,750,000 persons. 330 000 persons of this group are with BMI>32.3 kg/m2 (142% relative body mass), whose obesity has to be characterized as massive (Figure 1, Figure 2). 

A recent epidemiological study in 19 representative settlements in two districts of Bulgaria (Bourgas and Dobritch) among 5245 non-selected subjects (2198 men and 3047 women aged from 18 to 87 years) has been performed. Data on nutrition, metabolic and cardiovascular diseases, as well as data of measuring obesity have been collected according to the WHO Expert Group's recommendations. Overweight and obesity (BMI over 25 kg/m2) have amounted to, on average, 73.75% among all examined persons. The previous epidemiological study in the same districts in 1972 showed a frequency of obesity in only 22.6% of the population (Figure 3). In another recent epidemiological study among 4400 transport workers, the results showed 65.8% of them to be obese (Table 1).

There are 250,000 diabetics (mostly obese) in the general Bulgarian population (Table 2). About 1 million are hyperlipoproteinemic; the number of patients having arterial hypertension and ischemic heart disease is also great. Unfortunately, the highest cerebrovascular disease mortality in the world and also rather high cardiovascular disease mortality, both closely related to obesity have been recorded in Bulgaria. 

According to the latest statistical data, cardiovascular mortality has increased to 61.5% of total mortality in the Bulgarian population. lschemic heart disease and cerebrovascular disease mortality alone, make up 37-46% of total mortality. In absolute terms, 43,000-46,000 people per year die of myocardial infarction or stroke. Neoplasm mortality is 13.9-14.4% of total mortality.

A study of eating habits has confirmed the role of diet in the development of obesity. More than one half of the obese persons have relatively overfat nutrition (mean fat intake: 108 g/d), as well as higher consumption of bread, pasta and baked products instead of meat and milk products (which are considered expensive), and low intake of vegetables and fruits. Irregular nutrition and late evening eating as well as a sedentary lifestyle are rather frequent in obese people, and chronic stress factors, including negative psychosocial influences, financial and economic crisis, are frequently seen.

The unhealthy eating habits of the Bulgarian people occupy a central position among the other important risk determinants. During the post-war period, the consumption of a number of foodstuffs has increased several times, as follows: 

• animal fats - over 200%
• fats (in general)- 250%
• sugar- 500%
• pork - 700%. 

The specific features of the Bulgarian "nutrition model" also comprise: high consumption of bread (first place among the developed countries and second in the world) and pickles, accompanied by an insufficient consumption of fruit and vegetables (only 50% of the necessary norm). The salt consumption per person per day is 15-17 grams. Sugar consumption has increased to 35 kg per year and fat consumption to 23.4 kg per year. Comparison to international norms has made it clear that Bulgaria is among the countries with the highest energy intake (predominantly as to calories of vegetable origin), the highest rate of increase of animal fats in the diet, accompanied by a very low consumption of vitamin A (Table 3).

In the period from 1952-1990, the general mean personal alcohol equivalent increased 3.3 times, from 4.25 to 14 litres per year; sweetened drinks - 7 times, and beer - 12 times. Among 145 countries, Bulgaria occupies the seventh position as to the consumption of alcoholic beverages. Nowadays 1.2 million people systematically consume alcohol.

The public and physicians know the importance of obesity as a disease and as a cardiovascular risk factor but in general medical practice this problem has been underestimated. Fifteen years ago our National program for Treatment of Obesity was established. Now the creation of a new program, suitable to changed conditions is forthcoming. 

Health insurance in our country has not been established yet. The metabolic clinic of the medical university, some groups of departments of nutrition and dietetics, outpatient units, some special sanatoria and prophylactoria have carried out the diagnosis, treatment and prevention of obesity in Bulgaria. 

Throughout the whole year; 6 specialized centres, situated in resort settlements, have been working for the treatment and rehabilitation of obesity and related diseases in Bulgaria. Three of the centres (Baitchik, Albena and Kiten) are on the Black sea coast. One is near a mineralwater spring, and another is in the Rhodopes mountains (Figure 4).

The basis of treatment in these facilities is a dietary regimen (1400 kcal/daily; 99 g proteins, 56 g fats and 120 g carbohydrates) and a heavy regimen of physical activity. 

The applied training regime consists of physical exercise, sports, hiking, excursions and therapeutic dancing. This last is probably the "Bulgarian contribution" to the treatment of obesity; by leading to an increase psychological well-being, the dancing brings about the desired energy expenditure without the awareness of the patient. The mean daily energy expenditure is 2873 kcal. Since 1972, international symposia on obesity have taken place near these sanatoria, the last one (the 5th) in 1995. postgraduate courses for physicians, health professionals and diet specialists are also currently organized there. In order to help obesity management in Bulgaria many new low-calorie healthy nutritive products enriched with biologically active substances have been prepared. Their favourable dietary effect (a significant decrease in body weight and serum lipids) after a dietary treatment with low-energy diets (1200-1400 kcal/d) including these products for a period of 20-30 days, in a lot of clinical studies, was established.

But in our present economic conditions there are real production and marketing difficulties in putting these products on the market. Body fat regain in obese and postobese individuals in one year follow-ups after a short (one month) clinical treatment of obesity is quite frequent In fact, it occurs in 70% of all cases. There are numerous reasons for this state of affairs. Some of the most important factors are: insufficient education, the impossible expense of anorexic drugs and of an optimal diet, weak self-control and inadequate medical supervision of the maintenance of weight loss caused by a systemic lack of sufficient financial support that exists in the management of obesity.

The trend of increasing obesity is evident. Management and prevention of obesity in Bulgaria are very important factors in the current state of health of people in the country, and they both need special public and professional intervention and international attention.

The incidence of obesity-related metabolic and cardiovascular diseases has also increased in recent years. The frequency of hypertension has increased 1.6 times since 1964. There have been about 1.5 million hypertensive individuals in Bulgaria and 1 million of them have blood pressure >160/95 mm Hg. Nowadays, 225,000 people are not aware of their disease and 481,000 people suffering from hypertension either do not treat their disease at all or their therapy is a non-systematic one.

As far as the serum cholesterol level is concerned, 840,000 people (aged 10-69) have levels above 6.50 mmol/l and 310 000 people are have levels at 7.50 mmol/l or higher.

Only 13-14% of the male population over 35 years of age and 10.11 % of the female population take physical exercise regularly. The high rate of the combined risk factors is a characteristic feature of the Bulgarian risk constellation, and this rate is being thoroughly studied.

In view of the peculiarities of the ,,risk profile" of Bulgarians, the large number of unhealthy habits, factors and circumstances, a number of epidemiological hypotheses have been suggested in recent years to explain the ,,acceleration of atherosclerosis" in Bulgaria, which is much more evidently expressed in Bulgaria in comparison with other developed countries. They have tried to explain the high mortality rate from cardiovascular and cerebrovascular diseases, the abrupt rise in the death rate among the male and rural population. Whatever the epidemiology, we have come to express this syndrome as the ,,rejuvenation of mortality."

Conclusions:

1. Obesity and related diseases represent a great social and medical problem in Bulgaria. Nearly half of the people over the age of 15 are overweight or obese.

2. The economic and political crisis in our country with continuously rising inflation, leads to unhealthy nutrition. There is a prevailing consumption of relatively cheaper bread and pasta and a decrease in the consumption of the more expensive milk, yoghurt, cheese, meat, eggs and fish products, as well as of fresh fruits and vegetables which worsens all parameters of metabolism and cardiovascular system in obese patients.

3. The treatment of obesity takes place in clinical and ambulatory conditions, as well as in specialized centres in resort settlements. The basis of treatment is a hypocaloric normoprotein diet, enriched by biologically-active substances and high-physical-activity regimes (including sports, dance therapy etc.). 

4. The creation of a new program, suitable to the changed conditions, is forthcoming.
 
 

References:

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