Cardiovascular risk factors among Ecuadorian adolescents : a school-based health promotion intervention

Non-communicable diseases (NCDs) are the leading cause of death worldwide. More than 80% of deaths from cardiovascular diseases (CVD) and diabetes occur in low- and middle-income countries (LMICs). Identifying and understanding the distribution of risk factors is key to developing effective population intervention programs to prevent NCDs. These preventive strategies should start in youth. In Ecuador diabetes mellitus, hypertension, stroke, ischemic heart disease and heart failure rank high on a list of the ten leading causes of death in the general population. Furthermore, overweight and obesity are prevalent risk factors among adolescents. This thesis aims to: (i) explore the distribution of CVD risk factors with a major focus on diet among adolescents living in urban and rural settings from different socio-economic backgrounds, (ii) analyze the effect on dietary intake, body mass index (BMI), waist circumference and blood pressure of a school-based health promotion intervention, (iii) describe the process evaluation (PE) of the school-based health promotion intervention and, (iv) link the PE data with the intervention effect. To accomplish these objectives, two main activities were performed. A cross-sectional survey among 779 adolescents 10-16 years old from an urban and rural area in Ecuador was performed. The research aimed to identify the prevalence of metabolic CVD risk factors and the dietary intake of the target group. Dyslipidemia, abdominal obesity, high blood cholesterol and overweight were the most prevalent risk factors. The diet of this group of adolescents was carbohydrate based, rich in refined cereals, added sugar and processed foods consumed mainly in snacks. Consumption of fruit, vegetables, fish and oilseeds were very low. An estimated 18% of the adolescents reported skipping breakfast. Differences in dietary intake between urban and rural adolescents were small. Diets high in refined carbohydrates were associated with higher plasma glucose levels, while diets with high fat and low fiber content were correlated with increased levels of low density lipoprotein (LDL) and total blood cholesterol concentrations. The cross-sectional data was combined with theoretical approaches to design a culturally appropriate evidence and theory-based health promotion intervention. A pair matched cluster randomized controlled trial was implemented among 1430 adolescents attending 20 schools in Cuenca-Ecuador during 28 months from 2009-2012, 10 schools were allocated to the intervention group and the remaining ten to the control group. The program aimed to improve dietary intake, physical activity, sedentary behavior and physical fitness (primary outcomes) and reduce BMI, waist circumference and blood pressure (secondary outcomes). The intervention strategies combined the implementation of an individual classroom-based component with an environment-based component along the ten intervention schools. The individual-based component involved the implementation of an educational tool-kit, whilst, the environment-based component consisted in the delivery of educational workshops for parents and food-tuck shop staff. The normal standard curriculum was followed in the control schools. A detailed PE was also conducted. At the end of the intervention, data from 1079 adolescents from the 20 schools originally contacted was available for analysis. The program effectively increased fruit and vegetable intake and decreased added sugar and processed food intake during snacks. The intervention was also effective in decreasing waist circumference and blood pressure in favor of the intervention group. The effect on dietary intake was not moderated by the socioeconomic status or the weight or the age of the participants. However, the effect on waist circumference was higher among younger and overweight-obese adolescents. The program was correctly implemented and well received by the target audiences i.e. adolescents, teachers, parents and food-tuck shop staff. Dose, reach and fidelity were high with the exception of parental reach (only 15%). Barriers for program implementation were the difficulty to attach the program to the school curriculum, the low parental reach and, the resistance to a decrease in portion size served in the food-tuck shops. Although still below the nutritional recommendations, the combined effect of the intervention on several individual risk factors is encouraging and promising. It suggests that school-based interventions can address various risk factors simultaneously in adolescents from LMICs. This thesis provides new evidence for the prevention of NCDs among adolescents from LMICs

Cardiovascular risk among 6-8-year-old children living in urban and rural communities in Ecuador: A cross-sectional analysis

Cardiovascular diseases have their origins in childhood. At least 20% of children and adolescents in Latin America are overweight or obese. However, little is known regarding the cardiovascular risk of young children living in the region. This paper aims to identify associations between socio-demographics, adiposity, and dietary intake with cardiometabolic risk among children between 6- and 8-years old living in urban and rural Andean regions of Ecuador. A cross-sectional study was conducted among 267 children attending elementary schools between February and August 2018. Sociodemographic data were collected using a structured interview. Bodyweight, height, and waist circumference were measured in duplicate; blood samples were taken after overnight fasting to determine blood lipids, hepatic enzymes, and adipokines; food intake data was assessed by two 24-h recalls administered to the guardians. Associations between cardiometabolic risk (i.e., blood lipids, hepatic enzymes, and adipokines) with sociodemographic characteristics, dietary intake, and waist circumference were tested using multiple hierarchical regression models. Twenty-nine percent of the children were overweight or obese, 12% had low HDL levels, and over 18% had high levels of LDL and triglycerides. Children living in the urban region had lower levels of HDL (β−4.07 mg/dL; 95% CI: −7.00; −1.15; P = 0.007) but higher levels of LDL cholesterol (β 8.52 mg/dL; 95% CI: 1.38; 15.66; P = 0.019). Hepatic enzymes were also higher among urban children (SGOT: β% 22.13; 95% CI: 17.33; 26.93; P < 0.001; SGPT: β 0.84 U/L; 95% CI: 0.09; 1.59; P = 0.028). Leptin blood levels were higher (β% 29.27; 95% CI: 3.57; 54.97; P = 0.026), meanwhile adiponectin plasma concentrations were lower among urban children (β%−103.24; 95% CI: −58.9; −147.58; P = < 0.001). Fiber intake was inversely associated with total cholesterol (β−9.27 mg/dL; 95% CI –18.09; −0.45; P = 0.040) and LDL cholesterol blood levels (β−9.99 mg/dL; 95% CI: −18.22; −1.75; P = 0.018). Our findings demonstrate that young children are at high cardiovascular risk; if no actions are taken, the burden of non-communicable diseases will be substantial. The differences in risk between rural and urban areas are evident; urbanization might predispose children to a different reality and, in most cases, result in poor habits

Grupos focales : Guía metodológica en el contexto escolar ecuatoriano

Los grupos focales son una herramienta ampliamente utilizada en la investigación cualitativa, consisten en la aplicación de una entrevista con preguntas abiertas y semiestructuradas dirigidas a grupos pequeños acerca de un tema específico de indagación (Escobar y Bonilla-Jiménez, 2009). Esta técnica revela procesos, respuestas culturales, emocionales y cognitivas, así como motivaciones, actitudes y opiniones que normalmente no saldrían a la luz en la recopilación de datos cuantitativos (Elliott, Gruer, Farrow, Henderson y Cowan, 1996; Houghton, Durkin y Carroll, 1995; Kennedy, Kools y Krueger, 2001). En el proceso se da importancia tanto a las respuestas de los participantes como a las interacciones y la dinámica social que existen dentro del grupo (Noaks y Wincup, 2004). Los estándares de grupos focales se han desarrollado en torno a la población adulta. Para adaptar la técnica a grupos infantiles, se debe considerar que los factores cognitivos, lingüísticos, sociales y psicológicos difieren en la niñez y en la adultez (Macnaghten, 2017). Quizá por ello, la realización de grupos focales en niños es escasa. Las investigaciones disponibles realizadas con niños suelen incluir pocos grupos focales o no son llevadas a cabo por profesionales expertos en el desarrollo infantil (Irwin y Johnson, 2005) reduciendo la capacidad de contrastar y verificar los resultados. El objetivo del presente estudio es describir y evaluar el proceso de aplicación de grupos focales con niños de la zona Andina y Amazónica del Ecuador.Facultad de Humanidades y Ciencias de la Educació

Two years of school-based intervention program could improve the physical fitness among Ecuadorian adolescents at health risk : subgroups analysis from a cluster-randomized trial

Background: Adolescents with overweight and poor physical fitness have an increased likelihood of developing cardiovascular diseases during adulthood. In Ecuador, a health promotion program improved the muscular strength and speed-agility, and reduced the decline of the moderate-to-vigorous physical activity of adolescents after 28 months. We performed a sub-group analysis to assess the differential effect of this intervention in overweight and low-fit adolescents. Methods: We performed a cluster-randomized pair matched trial in schools located in Cuenca–Ecuador. In total 20 schools (clusters) were pair matched, and 1440 adolescents of grade 8 and 9 (mean age of 12.3 and 13.3 years respectively) participated in the trial. For the purposes of the subgroup analysis, the adolescents were classified into groups according to their weight status (body mass index) and aerobic capacity (scores in the 20 m shuttle run and FITNESSGRAM standards) at baseline. Primary outcomes included physical fitness (vertical jump, speed shuttle run) and physical activity (proportion of students achieving over 60 min of moderate–to-vigorous physical activity/day). For these primary outcomes, we stratified analysis by weight (underweight, normal BMI and overweight/ obese) and fitness (fit and low fitness) groups. Mixed linear regression models were used to assess the intervention effect. Results: The prevalence of overweight/obesity, underweight and poor physical fitness was 20.3 %, 5.8 % and 84.8 % respectively. A higher intervention effect was observed for speed shuttle run in overweight (β = −1.85 s, P = 0.04) adolescents compared to underweight (β = −1.66 s, P = 0.5) or normal weight (β = −0.35 s, P = 0.6) peers. The intervention effect on vertical jump was higher in adolescents with poor physical fitness (β = 3.71 cm, P = 0.005) compared to their fit peers (β = 1.28 cm, P = 0.4). The proportion of students achieving over 60 min of moderate-to-vigorous physical activity/ day was not significantly different according to weight or fitness status. Conclusion: Comprehensive school-based interventions that aim to improve diet and physical activity could improve speed and strength aspects of physical fitness in low-fit and overweight/obese adolescents

Tuberculose disseminada em doentes idosos: relato de caso: Disseminated tuberculosis in an aged patient: case report

A tuberculose extrapulmonar é causada por Mycobacterium Tuberculosis em órgãos fora do pulmão, e está principalmente relacionada com a imunossupressão, geralmente secundária ao vírus da imunodeficiência humana, embora haja pacientes que desenvolvem a doença sem relação com o supracitado. Esta patologia deve-se à disseminação hematogênica ou linfática do bacilo devido à infecção anterior, ou reativação de um foco latente, com envolvimento subsequente de outro órgão, como a pleura, sistema nervoso central, gânglios linfáticos, pele, entre outros. O presente caso é de um paciente masculino de 77 anos, com história de diabete mellitus tipo II, sem tratamento, que apresentou um quadro clínico de 5 meses de evolução, apresentando lesões cutâneas, mais súbita perda de peso, há 2 meses apresentou tosse intensa, o esfregaço da expectoração foi negativo, no entanto, foi possível identificar um aumento da perda de peso do paciente e um aumento do tamanho do gânglio linfático cervical, razão pela qual foi realizada uma biópsia do gânglio linfático, que relatou tuberculose extrapulmonar

Avances terapeúticos en atrofia muscular espinal

Antecedentes. La atrofia muscular espinal es una patología neurológica degenerativa hereditaria. Causa una degeneración paulatina de las motoneuronas de la asta anterior medular, también conocida como enfermedad de primera motoneurona. Como resultado, se genera debilidad y atrofia muscular progresiva. Afecta a 1 infante por cada 10000 nacidos vivos, por lo cual, es catalogado como una causa relevante de morbi-mortalidad infantil. A pesar de no existir cura actualmente, los medicamentos más conocidos son el nusinersen y el onasemnogén abaparvovec, actuando a nivel genético en el tratamiento de la enfermedad. Metodología. El presente estudio es una revisión tipo Scoping Reviw con metodología PICO y PRISMA utilizando la base de datos PUBMED a través de descriptores bibliográficos con la utilización de palabras clave aplicando criterios de elegibilidad de inclusión y exclusión. Objetivo. Detallar los nuevos avances terapéuticos para el manejo de la atrofia muscular espinal. Discusión y Resultados. Con un total de 17 artículos seleccionados se demostró que las nuevas opciones terapéuticas enriquecen las opciones médicas para tratar esta enfermedad, con menores costos y resultados exitosos a largo plazo. Conclusión. Es una de las enfermedades genéticas con más alta tasa de mortalidad alrededor del mundo. Un diagnóstico precoz mejora notablemente el pronóstico del paciente y permite tomar la decisión adecuada frente al tratamiento, asegurando la eficacia del mismo

A Conceptual Framework for Healthy Eating Behavior in Ecuadorian Adolescents: A Qualitative Study

Objective: The objective of this study was to identify factors influencing eating behavior of Ecuadorian adolescents - from the perspective of parents, school staff and adolescents - to develop a conceptual framework for adolescents’ eating behavior. Study design: Twenty focus groups (N = 144 participants) were conducted separately with adolescents aged 11–15 y (n (focus groups) = 12, N (participants) = 80), parents (n = 4, N = 32) and school staff (n = 4, N = 32) in rural and urban Ecuador. A semi-structured questioning route was developed based on the ‘Attitude, Social influences and Self-efficacy’ model and the socio-ecological model to assess the relevance of behavioral and environmental factors in low- and middle-income countries. Two researchers independently analyzed verbatim transcripts for emerging themes, using deductive thematic content analysis. Data were analyzed using NVivo 8. Results: All groups recognized the importance of eating healthily and key individual factors in Ecuadorian adolescents’ food choices were: financial autonomy, food safety perceptions, lack of self-control, habit strength, taste preferences and perceived peer norms. Environmental factors included the poor nutritional quality of food and its easy access at school. In their home and family environment, time and convenience completed the picture as barriers to eating healthily. Participants acknowledged the impact of the changing socio-cultural environment on adolescents’ eating patterns. Availability of healthy food at home and financial constraints differed between settings and socio-economic groups. Conclusion: Our findings endorse the importance of investigating behavioral and environmental factors that influence and mediate healthy dietary behavior prior to intervention development. Several culture-specific factors emerged that were incorporated into a conceptual framework for developing health promotion interventions in Ecuador

Status and trends of physical activity surveillance, policy, and research in 164 countries: Findings from the Global Observatory for Physical Activity—GoPA! 2015 and 2020 Surveys

BACKGROUND: Physical activity (PA) surveillance, policy, and research efforts need to be periodically appraised to gain insight into national and global capacities for PA promotion. The aim of this paper was to assess the status and trends in PA surveillance, policy, and research in 164 countries. METHODS: We used data from the Global Observatory for Physical Activity (GoPA!) 2015 and 2020 surveys. Comprehensive searches were performed for each country to determine the level of development of their PA surveillance, policy, and research, and the findings were verified by the GoPA! Country Contacts. Trends were analyzed based on the data available for both survey years. RESULTS: The global 5-year progress in all 3 indicators was modest, with most countries either improving or staying at the same level. PA surveillance, policy, and research improved or remained at a high level in 48.1%, 40.6%, and 42.1% of the countries, respectively. PA surveillance, policy, and research scores decreased or remained at a low level in 8.3%, 15.8%, and 28.6% of the countries, respectively. The highest capacity for PA promotion was found in Europe, the lowest in Africa and low- and lower-middle-income countries. Although a large percentage of the world's population benefit from at least some PA policy, surveillance, and research efforts in their countries, 49.6 million people are without PA surveillance, 629.4 million people are without PA policy, and 108.7 million live in countries without any PA research output. A total of 6.3 billion people or 88.2% of the world's population live in countries where PA promotion capacity should be significantly improved. CONCLUSION: Despite PA is essential for health, there are large inequalities between countries and world regions in their capacity to promote PA. Coordinated efforts are needed to reduce the inequalities and improve the global capacity for PA promotion