Food Perceptions and Dietary Changes for Chronic Condition Management in Rural Peru: Insights for Health Promotion.

Peru is undergoing a nutrition transition and, at the country level, it faces a double burden of disease where several different conditions require dietary changes to maintain a healthy life and prevent complications. Through semistructured interviews in rural Peru with people affected by three infectious and noninfectious chronic conditions (type 2 diabetes, hypertension, and neurocysticercosis), their relatives, and focus group discussions with community members, we analyzed their perspectives on the value of food and the challenges of dietary changes due to medical diagnosis. The findings show the various ways in which people from rural northern Peru conceptualize good (buena alimentación) and bad (mala alimentación) food, and that food choices are based on life-long learning, experience, exposure, and availability. In the context of poverty, required changes are not only related to what people recognize as healthy food, such as fruits and vegetables, but also of work, family, trust, taste, as well as affordability and accessibility of foods. In this paper we discuss the complexity of introducing dietary changes in poor rural communities whose perspectives on food are poorly understood and rarely taken into consideration by health professionals when promoting behavior change

Parents' Perceptions about Salt Consumption in Urban Areas of Peru: Formative Research for a Social Marketing Strategy.

BACKGROUND: Salt intakes in Latin America currently double the World Health Organization's recommendation of 5 g/day. Various strategies to reduce the population's salt consumption, such as raising awareness using social marketing, have been recommended. This study identified parents' perceptions of salt consumption to inform a social marketing strategy focused on urban areas in Peru. METHODS: Using a sequential exploratory methods design, parents of pre-school children, of high and low socioeconomic status, provided qualitative data in the form of interviews and focus groups. Following this, quantitative data was obtained via questionnaires, which were sent to all parents. The information was analyzed jointly. RESULTS: 296 people (mean age 35.4, 82% women) participated, 64 in the qualitative and 232 in the quantitative phase of the study. Qualitative data from the first phase revealed that the majority of mothers were in charge of cooking, and female participants expressed that cooking was "their duty" as housewives. The qualitative phase also revealed that despite the majority of the participants considered their salt intake as adequate, half of them mentioned that they have tried to reduce salt consumption, and the change in the flavor of the food was stated as the most difficult challenge to continue with such practice. Quantitative data showed that 67% of participants would be willing to reduce their salt intake, and 79.7% recognized that high salt intake causes hypertension. In total, 84% of participants reaffirmed that mothers were in charge of cooking. There were no salient differences in terms of responses provided by participants from high versus low socioeconomic groups. CONCLUSIONS: The results point towards the identification of women as a potential target-audience of a social marketing strategy to promote reductions in salt intake in their families and, therefore, a gender-responsive social marketing intervention is recommended

Integration of a Technology-Based Mental Health Screening Program Into Routine Practices of Primary Health Care Services in Peru (The Allillanchu Project): Development and Implementation.

BACKGROUND: Despite their high prevalence and significant burden, mental disorders such as depression remain largely underdiagnosed and undertreated. OBJECTIVE: The aim of the Allillanchu Project was to design, develop, and test an intervention to promote early detection, opportune referral, and access to treatment of patients with mental disorders attending public primary health care (PHC) services in Lima, Peru. METHODS: The project had a multiphase design: formative study, development of intervention components, and implementation. The intervention combined three strategies: training of PHC providers (PHCPs), task shifting the detection and referral of mental disorders, and a mobile health (mHealth) component comprising a screening app followed by motivational and reminder short message service (SMS) to identify at-risk patients. The intervention was implemented by 22 PHCPs from five health centers, working in antenatal care, tuberculosis, chronic diseases, and HIV or AIDS services. RESULTS: Over a period of 9 weeks, from September 2015 to November 2015, 733 patients were screened by the 22 PHCPs during routine consultations, and 762 screening were completed in total. The chronic diseases (49.9%, 380/762) and antenatal care services (36.7%, 380/762) had the higher number of screenings. Time constraints and workload were the main barriers to implementing the screening, whereas the use of technology, training, and supervision of the PHCPs by the research team were identified as facilitators. Of the 733 patients, 21.7% (159/733) screened positively and were advised to seek specialized care. Out of the 159 patients with a positive screening result, 127 had a follow-up interview, 72.4% (92/127) reported seeking specialized care, and 55.1% (70/127) stated seeing a specialist. Both patients and PHCPs recognized the utility of the screening and identified some key challenges to its wider implementation. CONCLUSIONS: The use of a screening app supported by training and supervision is feasible and uncovers a high prevalence of unidentified psychological symptoms in primary care. To increase its sustainability and utility, this procedure can be incorporated into the routine practices of existing health care services, following tailoring to the resources and features of each service. The early detection of psychological symptoms by a PHCP within a regular consultation, followed by adequate advice and support, can lead to a significant percentage of patients accessing specialized care and reducing the treatment gap of mental disorders

Lessons learned about co-creation: developing a complex intervention in rural Peru.

Background: Co-creation is the process of involving stakeholders in the development of interventions. Although co-creation is becoming more widespread, reports of the process and lessons learned are scarce.Objective: To describe the process and lessons learned from using the COHESION manual, a co-creation methodology to develop interventions aimed at the improvement of diagnosis and/or management of chronic diseases at the primary healthcare level in a low-resource setting in Peru.Methods: Observational study to describe the use of the COHESION manual 'Moving from Research to Interventions: The COHESION Model' developed for a multi-country project in low- and middle-income countries for co-creation and the adaptations needed to customize it to the local context of rural communities in northern Peru.Results: The actual process of co-creation in Peru included co-creation-related questions in the formative research; an initial consultation with stakeholders at the micro, meso, and macro levels (e.g. community members, health workers, and policy-makers); the analysis of the collected data; a second consultation with each stakeholder group; the prioritization of intervention options; and finally the design of a theory of change for all activities included in the complex intervention. The complex intervention included: 1) offer training in specific diseases and soft skills to health workers, 2) create radio programs that promote chronic disease prevention and management plus empower patients to ask questions during their visits to primary health care (PHC) facilities, and 3) provide a small grant to the PHC for infrastructure improvement. Small adaptations to the COHESION manual were necessary for this co-creation process.Conclusion: This study provides a practical example of the process of co-creating complex interventions to increase access and quality of health care in a low-resource setting. The process, components, challenges and opportunities identified could be useful for other researchers who want to co-create interventions with beneficiaries in similar settings

In silico Analyses of Immune System Protein Interactome Network, Single-Cell RNA Sequencing of Human Tissues, and Artificial Neural Networks Reveal Potential Therapeutic Targets for Drug Repurposing Against COVID-19

Background: There is pressing urgency to identify therapeutic targets and drugs that allow treating COVID-19 patients effectively.Methods: We performed in silico analyses of immune system protein interactome network, single-cell RNA sequencing of human tissues, and artificial neural networks to reveal potential therapeutic targets for drug repurposing against COVID-19.Results: We screened 1,584 high-confidence immune system proteins in ACE2 and TMPRSS2 co-expressing cells, finding 25 potential therapeutic targets significantly overexpressed in nasal goblet secretory cells, lung type II pneumocytes, and ileal absorptive enterocytes of patients with several immunopathologies. Then, we performed fully connected deep neural networks to find the best multitask classification model to predict the activity of 10,672 drugs, obtaining several approved drugs, compounds under investigation, and experimental compounds with the highest area under the receiver operating characteristics.Conclusion: After being effectively analyzed in clinical trials, these drugs can be considered for treatment of severe COVID-19 patients. Scripts can be downloaded at

Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal and Peru.

Different methodological approaches for implementation research in global health focusing on how interventions are developed, implemented and evaluated are needed. In this paper, we detail the approach developed and implemented in the COmmunity HEalth System InnovatiON (COHESION) Project, a global health project aimed at strengthening health systems in Mozambique, Nepal and Peru. This project developed innovative formative research at policy, health system and community levels to gain a comprehensive understanding of the barriers, enablers, needs and lessons for the management of chronic disease using non-communicable and neglected tropical diseases as tracer conditions. After formative research, COHESION adopted a co-creation approach in the planning of interventions. The approach included two interactions with each type of stakeholder at policy, health system and community level in each country which aimed to develop interventions to improve the delivery of care of the tracer conditions. Diverse tools and methods were used in order to prioritise interventions based on support, resources and impact. Additionally, a COHESION score that assessed feasibility, sustainability and scaling up was used to select three potential interventions. Next steps for the COHESION Project are to further detail and develop the interventions propositioned through this process. Besides providing some useful tools and methods, this work also highlights the challenges and lessons learned from such an approach

Rising rural body-mass index is the main driver of the global obesity epidemic in adults

Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities(.)(1,2) This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity(3-6). Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.Peer reviewe

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

Summary Background Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents. Methods For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5–19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence. Findings We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9–10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes—gaining too little height, too much weight for their height compared with children in other countries, or both—occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls. Interpretation The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: A pooled analysis of 1018 population-based measurement studies with 88.6 million participants

© The Author(s) 2018. Background: Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure. Methods: We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probittransformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure. Results: In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the highincome Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association. Conclusions: Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries(1,2). However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world(3) and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health(4,5). However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular riskchanged from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.Peer reviewe