Can mothers rely on the Brazilian health system for their deliveries? An assessment of use of the public system and out-of-pocket expenditure in the 2004 Pelotas Birth Cohort Study, Brazil

<p>Abstract</p> <p>Background</p> <p>In a country where comprehensive free health care is provided via a public health system (SUS), an unexpected high frequency of catastrophic out-of-pocket expenditure has been described. We studied how deliveries were financed among mothers of a birth cohort and whether they were an important source of household out-of-pocket expenditure.</p> <p>Methods</p> <p>All deliveries occurring in the city of Pelotas, Brazil, during 2004, were recruited for a birth cohort study. All mothers were interviewed just after birth and three months later. Comprehensive data on the pregnancy, delivery, birth conditions and newborn health were collected, along with detailed information on expenses related to the delivery.</p> <p>Results</p> <p>The majority of the deliveries (81%) were financed by the public health system, a proportion that increased to more than 95% among the 40% poorest mothers. Less than 1% of these mothers reported some out-of-pocket expenditure. Even among those mothers covered by a private health plan, nearly 50% of births were financed by the SUS. Among the 20% richest, a third of the deliveries were paid by the SUS, 50% by private health plans and 17% by direct payment.</p> <p>Conclusion</p> <p>The public health system offered services in quantity and quality enough to attract even beneficiaries of private health plans and spared mothers from the poorest strata of the population of practically any expense.</p

First-food systems transformations and the ultra-processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption

The inappropriate marketing and aggressive promotion of breastmilk substitutes (BMS) undermines breastfeeding and harms child and maternal health in all country contexts. Although a global milk formula ‘sales boom’ is reportedly underway, few studies have investigated its dynamics and determinants. This study takes two steps. First, it describes trends and patterns in global formula sales volumes (apparent consumption), by country income and region. Data are reported for 77 countries, for the years 2005–19, and for the standard (0–6 months), follow‐up (7‐12 m), toddler (13‐36 m), and special (0‐6 m) categories. Second, it draws from the literature to understand how transformations underway in first‐food systems – those that provision foods for children aged 0–36 months – explain the global transition to higher formula diets. Total world formula sales grew by 115% between 2005 and 2019, from 3.5 to 7.4 kg/child, led by highly‐populated middle‐income countries. Growth was rapid in South East and East Asia, especially in China, which now accounts for one third of world sales. This transition is linked with factors that generate demand for BMS, including rising incomes, urbanisation, the changing nature of woman's work, social norms, media influences and medicalisation. It also reflects the globalization of the baby food industry and its supply chains, including the increasing intensity and sophistication of its marketing practices. Policy and regulatory frameworks designed to protect, promote and support breastfeeding are partially or completely inadequate in the majority of countries, hence supporting industry expansion over child nutrition. The results raise serious concern for global child and maternal health

Obesity-induced hypoadiponectinaemia: the opposite influences of central and peripheral fat compartments

$\textbf{Background and Aims:}$ The substantial reduction in adiponectin concentration among obese individuals seems to depend on fat distribution and is a marker of metabolic and adipose tissue dysfunction. We aimed to: (i) address whether abdominal fat from different compartments (visceral, deep subcutaneous abdominal and superficial subcutaneous abdominal) and gluteofemoral fat are independently associated with blood adiponectin concentration; and (ii) investigate whether abdominal (proxied by waist circumference) and gluteofemoral fat (proxied by hip circumference) accumulation causally determine blood adiponectin concentration. $\textbf{Methods:}$ To investigate the independent association of abdominal and gluteofemoral fat with adiponectin concentration, we used multivariable regression and data from 30-year-old adults from the 1982 Pelotas Birth Cohort ($n$ = 2,743). To assess the causal role of abdominal and gluteofemoral fat accumulation on adiponectin concentration, we used Mendelian randomization and data from two consortia of genome-wide association studies—the GIANT ($n$ > 210 000) and ADIPOGen consortia ($n$ = 29 347). $\textbf{Results:}$ In the multivariable regression analysis, all abdominal fat depots were negatively associated with adiponectin concentration, specially visceral abdominal fat [men: $\beta$ = -0.24 standard unit of log adiponectin per standard unit increase in abdominal fat; 95% confidence interval (CI) = -0.31, -0.18; $P$ = 8*10$^{-13}$; women: $\beta$ = -0.31; 95% CI = -0.36, -0.25; $P$ = 7*10$^{-27}$), whereas gluteofemoral fat was positively associated with adiponectin concentration (men: $\beta$ = 0.13 standard unit of log adiponectin per standard unit increase in gluteofemoral fat; 95% CI = 0.03, 0.22; $P$ = 0.008; women: $\beta$ = 0.24; 95% CI = 0.17, 0.31; $P$ = 7*10$^{-11}$). In the Mendelian randomization analysis, genetically-predicted waist circumference was inversely related to blood adiponectin concentration ($\beta$ = -0.27 standard unit of log adiponectin per standard unit increase in waist circumference; 95% CI = -0.36, -0.19; $P$ = 2*10$^{-11}$), whereas genetically-predicted hip circumference was positively associated with blood adiponectin concentration ($\beta$ = 0.17 standard unit of log adiponectin per standard unit increase in hip circumference; 95% CI = 0.11, 0.24; $P$ = 1*10$^{-7}$). $\textbf{Conclusions:}$ These results support the hypotheses that there is a complex interplay between body fat distribution and circulating adiponectin concentration, and that whereas obesity-induced hypoadiponectinaemia seems to be primarily attributed to abdominal fat accumulation, gluteofemoral fat accumulation is likely to exert a protective effect.The study ‘Pelotas Birth Cohort, 1982’ is conducted by Postgraduate Program in Epidemiology at Universidade Federal de Pelotas with the collaboration of the Brazilian Public Health Association (ABRASCO). From 2004 to 2013, the Wellcome Trust supported the 1982 birth cohort study. The International Development Research Center, World Health Organization, Overseas Development Administration, European Union, National Support Program for Centers of Excellence (PRONEX), the Brazilian National Research Council (CNPq) and the Brazilian Ministry of Health supported previous phases of the study. M.C.B. receives financial support from the Brazilian National Research Council (CNPq) [144749/2014-9, 201498/2014-6 (Science Without Borders Program), and 163291/2015-2] and Coordenac¸~ao de Aperfeic¸oamento de Pessoal de Nıvel Superior (CAPES). K.K.O. is supported by the Medical Research Council [Unit Programme numbers MC_UU_12015/1 and MC_UU_12015/2]

Focus and coverage of Bolsa Família Program in the Pelotas 2004 birth cohort

ABSTRACT OBJECTIVE To describe the focalization and coverage of Bolsa Família Program among the families of children who are part of the 2004 Pelotas birth cohort (2004 cohort). METHODS The data used derives from the integration of information from the 2004 cohort and the Cadastro Único para Programas Sociais do Governo Federal (CadÚnico &#8211; Register for Social Programs of the Federal Government), in the 2004-2010 period. We estimated the program coverage (percentage of eligible people who receive the benefit) and its focus (proportion of eligible people among the beneficiaries). We used two criteria to define eligibility: the per capita household income reported in the cohort follow-ups and belonging to the 20% poorest families according to the National Economic Indicator (IEN), an asset index. RESULTS Between 2004 and 2010, the proportion of families in the cohort that received the benefit increased from 11% to 34%. We observed an increase in all wealth quintiles. In 2010, by income and wealth quintiles (IEN), 62%-72% of the families were beneficiaries among the 20% poorest people, 2%-5% among the 20% richest people, and about 30% of families of the intermediate quintile. According to household income (minus the benefit) 29% of families were eligible in 2004 and 16% in 2010. By the same criteria, the coverage of the program increased from 43% in 2004 to 71% in 2010. In the same period, by the wealth criterion (IEN), coverage increased from 29% to 63%. The focalization of the program decreased from 78% in 2004 to 32% in 2010 according to income, and remained constant (37%) according to the IEN. CONCLUSIONS Among the families of the 2004 cohort, there was a significant increase in the program coverage, from its inception until 2010, when it was near 70%. The focus of the program was below 40% in 2010, indicating that more than half of the beneficiaries did not belong to the target population

Role of Adiponectin in Coronary Heart Disease Risk: A Mendelian Randomization Study

RATIONALE: Hypoadiponectinemia correlates with several coronary heart disease (CHD) risk factors. However, it is unknown whether adiponectin is causally implicated in CHD pathogenesis. OBJECTIVE: We aimed to investigate the causal effect of adiponectin on CHD risk. METHODS AND RESULTS: We undertook a Mendelian randomization study using data from genome-wide association studies consortia. We used the ADIPOGen consortium to identify genetic variants that could be used as instrumental variables for the effect of adiponectin. Data on the association of these genetic variants with CHD risk were obtained from CARDIoGRAM (22 233 CHD cases and 64 762 controls of European ancestry) and from CARDIoGRAMplusC4D Metabochip (63 746 cases and 130 681 controls; ≈ 91% of European ancestry) consortia. Data on the association of genetic variants with adiponectin levels and with CHD were combined to estimate the influence of blood adiponectin on CHD risk. In the conservative approach (restricted to using variants within the adiponectin gene as instrumental variables), each 1 U increase in log blood adiponectin concentration was associated with an odds ratio for CHD of 0.83 (95% confidence interval, 0.68–1.01) in CARDIoGRAM and 0.97 (95% confidence interval, 0.84–1.12) in CARDIoGRAMplusC4D Metabochip. Findings from the liberal approach (including variants in any locus across the genome) indicated a protective effect of adiponectin that was attenuated to the null after adjustment for known CHD predictors. CONCLUSIONS: Overall, our findings do not support a causal role of adiponectin levels in CHD pathogenesis

Obesity-induced hypoadiponectinaemia: the opposite influences of central and peripheral fat compartments

$\textbf{Background and Aims:}$ The substantial reduction in adiponectin concentration among obese individuals seems to depend on fat distribution and is a marker of metabolic and adipose tissue dysfunction. We aimed to: (i) address whether abdominal fat from different compartments (visceral, deep subcutaneous abdominal and superficial subcutaneous abdominal) and gluteofemoral fat are independently associated with blood adiponectin concentration; and (ii) investigate whether abdominal (proxied by waist circumference) and gluteofemoral fat (proxied by hip circumference) accumulation causally determine blood adiponectin concentration. $\textbf{Methods:}$ To investigate the independent association of abdominal and gluteofemoral fat with adiponectin concentration, we used multivariable regression and data from 30-year-old adults from the 1982 Pelotas Birth Cohort ($n$ = 2,743). To assess the causal role of abdominal and gluteofemoral fat accumulation on adiponectin concentration, we used Mendelian randomization and data from two consortia of genome-wide association studies—the GIANT ($n$ > 210 000) and ADIPOGen consortia ($n$ = 29 347). $\textbf{Results:}$ In the multivariable regression analysis, all abdominal fat depots were negatively associated with adiponectin concentration, specially visceral abdominal fat [men: $\beta$ = -0.24 standard unit of log adiponectin per standard unit increase in abdominal fat; 95% confidence interval (CI) = -0.31, -0.18; $P$ = 8*10$^{-13}$; women: $\beta$ = -0.31; 95% CI = -0.36, -0.25; $P$ = 7*10$^{-27}$), whereas gluteofemoral fat was positively associated with adiponectin concentration (men: $\beta$ = 0.13 standard unit of log adiponectin per standard unit increase in gluteofemoral fat; 95% CI = 0.03, 0.22; $P$ = 0.008; women: $\beta$ = 0.24; 95% CI = 0.17, 0.31; $P$ = 7*10$^{-11}$). In the Mendelian randomization analysis, genetically-predicted waist circumference was inversely related to blood adiponectin concentration ($\beta$ = -0.27 standard unit of log adiponectin per standard unit increase in waist circumference; 95% CI = -0.36, -0.19; $P$ = 2*10$^{-11}$), whereas genetically-predicted hip circumference was positively associated with blood adiponectin concentration ($\beta$ = 0.17 standard unit of log adiponectin per standard unit increase in hip circumference; 95% CI = 0.11, 0.24; $P$ = 1*10$^{-7}$). $\textbf{Conclusions:}$ These results support the hypotheses that there is a complex interplay between body fat distribution and circulating adiponectin concentration, and that whereas obesity-induced hypoadiponectinaemia seems to be primarily attributed to abdominal fat accumulation, gluteofemoral fat accumulation is likely to exert a protective effect.The study ‘Pelotas Birth Cohort, 1982’ is conducted by Postgraduate Program in Epidemiology at Universidade Federal de Pelotas with the collaboration of the Brazilian Public Health Association (ABRASCO). From 2004 to 2013, the Wellcome Trust supported the 1982 birth cohort study. The International Development Research Center, World Health Organization, Overseas Development Administration, European Union, National Support Program for Centers of Excellence (PRONEX), the Brazilian National Research Council (CNPq) and the Brazilian Ministry of Health supported previous phases of the study. M.C.B. receives financial support from the Brazilian National Research Council (CNPq) [144749/2014-9, 201498/2014-6 (Science Without Borders Program), and 163291/2015-2] and Coordenac¸~ao de Aperfeic¸oamento de Pessoal de Nıvel Superior (CAPES). K.K.O. is supported by the Medical Research Council [Unit Programme numbers MC_UU_12015/1 and MC_UU_12015/2]

Body shape and size in 6-year old children: assessment by three-dimensional photonic scanning.

BACKGROUND: Body shape and size are typically described using measures such as body mass index (BMI) and waist circumference, which predict disease risks in adults. However, this approach may underestimate the true variability in childhood body shape and size. OBJECTIVE: To use a comprehensive three-dimensional photonic scan approach to describe variation in childhood body shape and size. SUBJECTS/METHODS: At age 6 years, 3350 children from the population-based 2004 Pelotas birth cohort study were assessed by three-dimensional photonic scanner, traditional anthropometry and dual X-ray absorptiometry. Principal component analysis (PCA) was performed on height and 24 photonic scan variables (circumferences, lengths/widths, volumes and surface areas). RESULTS: PCA identified four independent components of children's body shape and size, which we termed: Corpulence, Central:peripheral ratio, Height and arm lengths, and Shoulder diameter. Corpulence showed strong correlations with traditional anthropometric and body composition measures (r>0.90 with weight, BMI, waist circumference and fat mass; r>0.70 with height, lean mass and bone mass); in contrast, the other three components showed weak or moderate correlations with those measures (all r<0.45). There was no sex difference in Corpulence, but boys had higher Central:peripheral ratio, Height and arm lengths and Shoulder diameter values than girls. Furthermore, children with low birth weight had lower Corpulence and Height and arm lengths but higher Central:peripheral ratio and Shoulder diameter than other children. Children from high socio-economic position (SEP) families had higher Corpulence and Height and arm lengths than other children. Finally, white children had higher Corpulence and Central:peripheral ratio than mixed or black children. CONCLUSIONS: Comprehensive assessment by three-dimensional photonic scanning identified components of childhood body shape and size not captured by traditional anthropometry or body composition measures. Differences in these novel components by sex, birth weight, SEP and skin colour may indicate their potential relevance to disease risks.This article is based on data from the study ‘Pelotas Birth Cohort, 2004’ conducted by the Postgraduate Program in Epidemiology at Federal University of Pelotas, in collaboration with Brazilian Public Health Association (ABRASCO). The 2004 birth cohort study is supported by the Wellcome Trust through the scheme called ‘Major Awards for Latin America on Health Consequences of Population Change’. The World Health Organization, Brazilian National research Council (CNPq) and Brazilian Ministry of Health have supported previous phase of the study. LPS is supported by ‘Science without Borders’ Brazilian scheme under protocol number 201801/2014-0.This is the final version of the article. It first appeared from Nature Publishing Group via http://dx.doi.org/10.1038/ijo.2016.3

The influence of health expenditures on household impoverishment in Brazil

OBJECTIVE To analyze the variation in the proportion of households living below the poverty line in Brazil and the factors associated with their impoverishment. METHODS Income and expenditure data from the Household Budget Survey, which was conducted in Brazil between 2002-2003 (n = 48,470 households) and 2008-2009 (n = 55,970 households) with a national sample, were analyzed. Two cutoff points were used to define poverty. The first cutoff is a per capita monthly income below R$100.00 in 2002-2003 and R$140.00 in 2008-2009, as recommended by the Bolsa Família Program. The second, which is proposed by the World Bank and is adjusted for purchasing power parity, defines poverty as per capita income below US$2.34 and US$3.54 per day in 2002-2003 and 2008-2009, respectively. Logistic regression was used to identify the sociodemographic factors associated with the impoverishment of households. RESULTS After subtracting health expenditures, there was an increase in households living below the poverty line in Brazil. Using the World Bank poverty line, the increase in 2002-2003 and 2008-2009 was 2.6 percentage points (6.8%) and 2.3 percentage points (11.6%), respectively. Using the Bolsa Família Program poverty line, the increase was 1.6 (11.9%) and 1.3 (17.3%) percentage points, respectively. Expenditure on prescription drugs primarily contributed to the increase in poor households. According to the World Bank poverty line, the factors associated with impoverishment include a worse-off financial situation, a household headed by an individual with low education, the presence of children, and the absence of older adults. Using the Bolsa Família Program poverty line, the factors associated with impoverishment include a worse-off financial situation and the presence of children. CONCLUSIONS Health expenditures play an important role in the impoverishment of segments of the Brazilian population, especially among the most disadvantaged