Exploring DSM-5 ADHD criteria beyond young adulthood: phenomenology, psychometric properties and prevalence in a large three-decade birth cohort

BACKGROUND

There are still uncertainties on the psychometric validity of the DSM-5 attention deficit hyperactivity disorder (ADHD) criteria for its use in the adult population. We aim to describe the adult ADHD phenotype, to test the psychometric properties of the DSM-5 ADHD criteria, and to calculate the resulting prevalence in a population-based sample in their thirties.

METHOD

A cross-sectional evaluation using the DSM-5 ADHD criteria was carried out in 3574 individuals from the 1982 Pelotas Birth Cohort. Through receiver operator curve, latent and regression analyses, we obtained parameters on construct and discriminant validity. Still, prevalence rates were calculated for different sets of criteria.

RESULTS

The latent analysis suggested that the adult ADHD phenotype is constituted mainly by inattentive symptoms. Also, inattention symptoms were the symptoms most associated with impairment. The best cut-off for diagnosis was four symptoms, but sensitivity and specificity for this cut-off was low. ADHD prevalence rates were 2.1% for DSM-5 ADHD criteria and 5.8% for ADHD disregarding age-of-onset criterion.

CONCLUSIONS

The bi-dimensional ADHD structure proposed by the DSM demonstrated both construct and discriminant validity problems when used in the adult population, since inattention is a much more relevant feature in the adult phenotype. The use of the DSM-5 criteria results in a higher prevalence of ADHD when compared to those obtained by DSM-IV, and prevalence would increase almost threefold when considering current ADHD syndrome. These findings suggest a need for further refinement of the criteria for its use in the adult population.

Prenatal care and child growth and schooling in four low- and medium-income countries

BACKGROUND

The effectiveness of prenatal care for improving birth and subsequent child outcomes in low-income countries remains controversial, with much of the evidence to date coming from high-income countries and focused on early-life outcomes. We examined associations between prenatal care visits and birth weight, height-for-age at 24 months and attained schooling in four low- and middle-income countries.

METHODS

We pooled data from prospective birth-cohort studies from Brazil, Guatemala, Philippines and South Africa. We created a prenatal care utilization index based on the number and timing of prenatal visits. Associations were examined between this index and birth weight, height-for-age at 24 months, and highest attained schooling grade until adulthood.

RESULTS

Among 7203 individuals in the analysis, 68.9% (Philippines) to 96.7% (South Africa) had at least one prenatal care visit, with most having at least four visits. Over 40% of Brazilians and Guatemalans had their first prenatal visit in the first trimester, but fewer Filipinos (13.9%) and South Africans (19.8%) did so. Prenatal care utilization was not significantly associated with birth weight (p>0.05 in pooled data). Each unit increase in the prenatal care utilization index was associated with 0.09 (95% CI 0.04 to 0.15) higher height-for-age z-score at 24 months and with 0.26 (95% CI 0.17 to 0.35) higher schooling grades attained. Although there was some heterogeneity and greater imprecision across sites, the results were qualitatively similar among the four different populations.

CONCLUSIONS

While not related to birth weight, prenatal care utilization was associated with important outcomes later in life, specifically higher height-for-age at 24 months and higher attained school grades. These results suggest the relevance of prenatal care visits for human capital outcomes important over the lifecycle.

Distribution of Glycated Haemoglobin According to Early-Life and Contemporary Characteristics in Adolescents and Adults without Diabetes: The 1982 and 1993 Pelotas Birth Cohorts

Aim

Glycated haemoglobin (HbA_1c), a marker of glucose control in individuals with diabetes mellitus, is also related with the incidence of cardiometabolic risk in populations free of disease. The aim of this study was to describe the distribution of HbA_1c levels according to early-life and contemporary factors in adolescents and adults without diabetes mellitus.

Methods

HbA_1c was measured in adults aged 30 years and adolescents aged 18 years who are participants in the 1982 and 1993 Pelotas Birth Cohorts, respectively. Bivariate and multivariate analyses were performed to describe the HbA_1c mean values according to early-life and contemporary characteristics collected prospectively since birth.

Results

The distribution of the HbA_1c was approximately normal in both cohorts, with a mean (SD) 5.10% (0.43) in the 1982 cohort, and 4.89% (0.50) in the 1993 cohort. HbA_1c mean levels were significantly higher in individuals self-reported as black/brown skin color compared to those self-reported as white in both cohorts. Parental history of diabetes was associated with higher HbA_1c mean in adults, while stunting at one year old presented an inverse relation with the outcome in adolescents. No other early and contemporary factors were associated with HbA_1c levels in adults or adolescents.

Conclusions

We found a consistent relationship between HbA_1c and skin color in both cohorts. Further research is needed to understand the role of genomic ancestry on levels of HbA_1c concentrations which may inform policies and preventive actions for diabetes mellitus and cardiometabolic risk.

Body size dynamics in young adults: 8-year follow up of cohorts in Brazil and Thailand

Increase in body size has appeared as an epidemic in Western countries and is now rapidly emerging in low- and middle-income countries, contributing to the rise in non-communicable diseases worldwide. Brazil and Thailand have gone through similar economic and health transitions, and this unique comparative study investigates changes in body size (body mass index) in relation to socioeconomic status in two cohorts of similar age followed from 2004/2005 to 2012/2013. At 20-24 years of age, Pelotas cohort members had a much higher prevalence of overweight and obesity (20.7 and 8.6%) than the Thai cohort (6.0 and 1.7%); these proportions rose to 34.6% and 22.9% vs 15.8% and 5.1%, respectively, in their early 30s. An association between a higher socioeconomic status and increase in overweight and obesity was observed among males; but an inverse pattern was noted for females in both cohorts and remained statistically significant after 8 years of follow up. Our comparative longitudinal analyses highlight the relationship between two middle-income settings facing rapid increases in body size (2-3 fold increase in the rate of overweight and obesity). Long-term follow up and a lifecourse approach for effective prevention of obesity will minimize adverse health burdens in later life.

Childhood stunting and the metabolic syndrome components in young adults from a Brazilian birth cohort study

BACKGROUND/OBJECTIVES

The aim of this study was to investigate the association between stunting in the second year of life and metabolic syndrome components in early adulthood among subjects who have been prospectively followed-up since birth, in a city in Southern Brazil.

SUBJECTS/METHODS

In 1984, we attempted to follow-up the entire cohort; the subjects were examined and their mothers interviewed. Stunting was defined by a length-for-age Z-score 2 s.d. or more below the mean, in accordance with the World Health Organization reference. Between 2004 and 2005, we again tried to follow the entire cohort; during this period the subjects were evaluated for the following metabolic syndrome components: high-density lipoprotein (HDL) cholesterol, triglycerides, random blood glucose, waist circumference and systolic and diastolic blood pressure. Family income at the time of the baby's birth, asset index, mother's education, mother's smoking during pregnancy and duration of breastfeeding were considered possible confounders. Linear regression was used in the unadjusted and adjusted analyses.

RESULTS

Among men, stunting was inversely associated with triglycerides (β=-11.90, confidence interval (CI)=-22.33 to -1.48) and waist circumference (β=-4.29, CI=-5.62 to -2.97), whereas for women stunting was negatively related to HDL-cholesterol (β=-4.50, CI=-6.47 to -2.52), triglycerides (β=-9.61, CI=-17.66 to -1.56) and waist circumference (β=-1.14, CI=-4.22 to -1.02). However, after controlling for confounding variables, these associations vanished.

CONCLUSIONS

The findings suggest that stunting in childhood is not associated with metabolic syndrome components in young adults.

[Evolution of overweight and obesity into adulthood, Pelotas, Rio Grande do Sul State, Brazil, 1982-2012]

This study assessed the prevalence of overweight and obesity in adolescence and adulthood among subjects enrolled in the 1982 Pelotas Birth Cohort, Rio Grande do Sul State, Brazil, according to social and demographic characteristics. In 1982, hospital births in Pelotas were identified and all live born infants (n = 5,914) were examined and have been followed since. The data were collected at 15, 18, 23, and 30 years of age. In women, prevalence of overweight increased from 23.6% at 15 years to 52.4% at 30 years of age, while obesity increased from 6.6% to 23.8%. In men, overweight increased from 22.9% to 62.9%, and obesity from 7.5% to 22.1%. Overweight and obesity increased more among individuals of both sexes with lower socioeconomic status, which can lead to more inequality in the occurrence of chronic diseases.

Anemia among indigenous women in Brazil: findings from the First National Survey of Indigenous People's Health and Nutrition

BACKGROUND

Anemia is recognized as a major public health problem that disproportionately affects vulnerable populations. Indigenous women of reproductive age in Brazil are thought to be at high risk, but lack of nationwide data limits knowledge about the burden of disease and its main determinants. This study aimed to assess the prevalence of anemia and associated factors in this population using data from The First National Survey of Indigenous People's Health and Nutrition in Brazil.

METHODS

Data were collected from Indigenous women between 15 and 49 years old based on a nationwide sample of villages. The outcomes of interest were hemoglobin levels (g/dL) and anemia (< 12 g/dL for nonpregnant and < 11 g/dL for pregnant women). Multilevel models were used to explore associations with contextual (village) and individual (household/woman) level variables.

RESULTS

Based on data for 6692 Indigenous women, the nationwide mean hemoglobin level was 12.39 g/dL (95% CI: 12.29-12.50). Anemia prevalence was high (33.0%; 95% CI: 30.40-35.61%) and showed pronounced regional disparities. No village-level characteristics were associated with anemia or hemoglobin levels in the multilevel model. Even after controlling for upper level variables, socioeconomic status, parity, body mass index, and having been treated for malaria were associated with anemia and hemoglobin levels.

CONCLUSION

The prevalence of anemia in Brazilian Indigenous women was 12% greater than the national estimates for women of reproductive age. Anemia prevalence and mean hemoglobin levels among Indigenous women appear to be partly explained by some previously recognized risk factors, such as socioeconomic status, body mass index, and malaria; however, part of the variability in these outcomes remains unexplained. Knowledge of health status and its potential determinants is essential to guide public policies aimed at controlling anemia burden in Indigenous communities.

Secular trends in smoking during pregnancy according to income and ethnic group: four population-based perinatal surveys in a Brazilian city

OBJECTIVES

To assess socioeconomic and ethnic inequalities in smoking during pregnancy over three decades (1982-2011).

SETTING

Population-based study in Pelotas City, Brazil.

PARTICIPANTS

All urban women giving birth in the city hospitals in 1982 (5909), 1993 (5223) and 2004 (4201), plus all urban and rural women delivering from January 2011 to April 2012 (6275).

PRIMARY OUTCOME

Self-reported smoking during pregnancy.

RESULTS

The prevalence of smoking during pregnancy fell from 35.7% in 1982 to 21.0% in 2011. In each survey, prevalence decreased with increasing income (p<0.001). In the poorest quintile, smoking fell by 27.4% in the period studied compared to 67.1% in the wealthiest quintile. In all surveys, prevalence was lower among white women than among those who classified themselves as black or brown (p<0.001). Over time, smoking declined by 50.0% among the former and 30.7% among the latter. Absolute and relative inequalities both increased over time.

CONCLUSIONS

The reduction in smoking during pregnancy was primarily due to a decline among white, high-income women. Further efforts are needed to reduce smoking among all population groups.

Is there a causal role for homocysteine concentration in blood pressure? A Mendelian randomization study

BACKGROUND

An understanding of whether homocysteine is a cause or a marker of increased blood pressure is relevant because blood homocysteine can be effectively lowered by safe and inexpensive interventions (e.g., vitamin B-6, B-9, and B-12 supplementation).

OBJECTIVE

The aim was to assess the causal influence of homocysteine on systolic and diastolic blood pressure (SBP and DBP, respectively) in adults with the use of Mendelian randomization (MR).

DESIGN

Data from the 1982 Pelotas Birth Cohort (Brazil) were used. A total of 4297 subjects were evaluated in 2004-2005 (mean age: 22.8 y). The association of homocysteine concentration with SBP and DBP was assessed by conventional ordinary least-squares (OLS) linear regression and 2-stage least-squares (2SLS) regression (MR analysis). The single nucleotide polymorphism (SNP) methylenetetrahydrofolate reductase (MTHFR) C677T (rs1801133) was used as proxy for homocysteine concentration. We also applied MR to data from the International Consortium for Blood Pressure (ICBP) genomewide association studies (>69,000 participants) using rs1801133 and additional homocysteine-associated SNPs as instruments.

RESULTS

In OLS regression, a 1-SD unit increase in log homocysteine concentration was associated with an increase of 0.9 (95% CI: 0.4, 1.4) mm Hg in SBP and of 1.0 (95% CI: 0.6, 1.4) mm Hg in DBP. In 2SLS regression, for the same increase in homocysteine, the coefficients were -1.8 mm Hg for SBP (95% CI: -3.9, 0.4 mm Hg; P = 0.01) and 0.1 mm Hg for DBP (95% CI: -1.5, 1.7 mm Hg; P = 0.24). In the MR analysis of ICBP data, homocysteine concentration was not associated with SBP (β = 0.6 mm Hg for each 1-SD unit increase in log homocysteine; 95% CI: -0.8, 1.9 mm Hg) but was positively associated with DBP (β = 1.1 mm Hg; 95% CI: 0.2, 1.9 mm Hg). The association of genetically increased homocysteine with DBP was not consistent across different SNPs.

CONCLUSION

Overall, the present findings do not corroborate the hypothesis that homocysteine has a causal role in blood pressure, especially in SBP.

Genomic Ancestry, Self-Rated Health and Its Association with Mortality in an Admixed Population: 10 Year Follow-Up of the Bambui-Epigen (Brazil) Cohort Study of Ageing

Background

Self-rated health (SRH) has strong predictive value for mortality in different contexts and cultures, but there is inconsistent evidence on ethnoracial disparities in SRH in Latin America, possibly due to the complexity surrounding ethnoracial self-classification.

Materials/Methods

We used 370,539 Single Nucleotide Polymorphisms (SNPs) to examine the association between individual genomic proportions of African, European and Native American ancestry, and ethnoracial self-classification, with baseline and 10-year SRH trajectories in 1,311 community dwelling older Brazilians. We also examined whether genomic ancestry and ethnoracial self-classification affect the predictive value of SRH for subsequent mortality.

Results

European ancestry predominated among participants, followed by African and Native American (median = 84.0%, 9.6% and 5.3%, respectively); the prevalence of Non-White (Mixed and Black) was 39.8%. Persons at higher levels of African and Native American genomic ancestry, and those self-identified as Non-White, were more likely to report poor health than other groups, even after controlling for socioeconomic conditions and an array of self-reported and objective physical health measures. Increased risks for mortality associated with worse SRH trajectories were strong and remarkably similar (hazard ratio ~3) across all genomic ancestry and ethno-racial groups.

Conclusions

Our results demonstrated for the first time that higher levels of African and Native American genomic ancestry—and the inverse for European ancestry—were strongly correlated with worse SRH in a Latin American admixed population. Both genomic ancestry and ethnoracial self-classification did not modify the strong association between baseline SRH or SRH trajectory, and subsequent mortality.

Promotion of Weight Gain in Early Childhood Does Not Increase Metabolic Risk in Adolescents: A 15-Year Follow-Up of a Cluster-Randomized Controlled Trial

BACKGROUND

A rapid gain in weight for length may put children at a higher risk of noncommunicable diseases later in life.

OBJECTIVE

The objective of this study was to assess the long-term effects of nutrition counseling delivered in the first 2 y of life in Pelotas, a city in Southern Brazil.

METHODS

The original cluster-randomized controlled trial was conducted in 1998. Nutrition counseling (breastfeeding promotion and increased intake of micronutrient-rich and energy-dense foods) was delivered to mothers of children aged 0-17.9 mo attending primary care. Six months later, weight gain was higher in the intervention group than in the control group for children ≥12 mo of age at enrollment. In 2013 (mean age 15 y), assessments included anthropometric measurements, body composition (air-displacement plethysmography), body shape (3-dimensional photonic scan), and plasma total, LDL, and HDL cholesterol, triglycerides, C-reactive protein, and glucose.

RESULTS

A total of 363 of the 424 original participants were assessed. An a priori decision was made to prioritize analyses of subjects aged 12-17.9 mo at enrollment (51 from the intervention group and 45 from the control group). In this subgroup, boys in the intervention group were [mean (95% CI)] 3.4 (0.8, 6.0) cm taller than those in the control group. Systolic blood pressure tended to be 5.2 (-0.8, 11.1) mm Hg higher in male subjects from the intervention group than in those in the control group. Lipid profiles tended to be healthier in the intervention group. The plasma total cholesterol concentration was -17.8 (-29.8, -5.7) mg/dL lower in boys in the intervention group than in those in the control group. The total-to-HDL cholesterol ratio and triglyceride concentration in the girls in the intervention group were -0.4 (-0.6, -0.1) and -26.3 (-46.3, -6.3) mg/dL, respectively, lower than in the control group. There was no difference between the groups in terms of body composition.

CONCLUSIONS

Promotion of weight gain in children between 12.0-17.9 mo of age was not associated with higher metabolic risk 15 y later. On the contrary, there was some evidence of reduced metabolic risk in the intervention group.

Breastfeeding and intelligence: a systematic review and meta-analysis

AIM

This study was aimed at systematically reviewing evidence of the association between breastfeeding and performance in intelligence tests.

METHODS

Two independent searches were carried out using Medline, LILACS, SCIELO and Web of Science. Studies restricted to infants and those where estimates were not adjusted for stimulation or interaction at home were excluded. Fixed- and random-effects models were used to pool the effect estimates, and a random-effects regression was used to assess potential sources of heterogeneity.

RESULTS

We included 17 studies with 18 estimates of the relationship between breastfeeding and performance in intelligence tests. In a random-effects model, breastfed subjects achieved a higher IQ [mean difference: 3.44 points (95% confidence interval: 2.30; 4.58)]. We found no evidence of publication bias. Studies that controlled for maternal IQ showed a smaller benefit from breastfeeding [mean difference 2.62 points (95% confidence interval: 1.25; 3.98)]. In the meta-regression, none of the study characteristics explained the heterogeneity among the studies.

CONCLUSION

Breastfeeding is related to improved performance in intelligence tests. A positive effect of breastfeeding on cognition was also observed in a randomised trial. This suggests that the association is causal.

Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: a systematic review and meta-analysis

AIM

To systematically review the evidence on the associations between breastfeeding and overweight/obesity, blood pressure, total cholesterol and type 2 diabetes.

METHODS

Two independent literature searches were carried out using the MEDLINE, LILACS, SCIELO and Web of Science databases. Studies restricted to infants and those without an internal comparison group were excluded. Fixed- and random-effects models were used to pool the estimates.

RESULTS

Breastfed subjects were less likely to be considered obese/overweight [pooled odds ratio: 0.74 (95% confidence interval (CI): 0.70; 0.78)] (n = 113). Among the 11 high-quality studies, the association was smaller [pooled odds ratio: 0.87 (95%CI: 0.76; 0.99)]. Total cholesterol (n = 46) was independent of breastfeeding [pooled mean difference: -0.01 mmol/L (95%CI: -0.05; 0.02)]. Systolic blood pressure (n = 43) was lower among breastfed subjects [mean difference: -0.80 (95%CI: -1.17; -0.43)], but no association was observed among larger studies, and for diastolic blood pressure (n = 38) [mean difference: -0.24 (95%CI: -0.50; 0.02)]. For type 2 diabetes (n = 11), the odds ratio was lower among those subjects who had been breastfed [pooled odds ratio: 0.65 (95%CI: 0.49; 0.86)].

CONCLUSION

Breastfeeding decreased the odds of type 2 diabetes and based on high-quality studies, decreased by 13% the odds of overweight/obesity. No associations were found for total cholesterol or blood pressure.

Effect of breastfeeding promotion interventions on child growth: a systematic review and meta-analysis

AIM

To update a previous systematic review and meta-analyses about the effect of breastfeeding promotion interventions on child growth.

METHODS

Studies evaluating the effect of any type of breastfeeding promotion intervention on child weight, length (or height) and weight/height (or BMI) were screened. Papers published between 2006 and 2014 were checked using the following databases: PubMed/MEDLINE, Embase, Cochrane Database of Systematic Reviews, Lilacs and SciELO.

RESULTS

Sixteen studies were added to 19 other studies identified in the previous review, resulting in 35 studies. Meta-analyses of studies reporting on mean weight, length, weight/length or BMI showed that the interventions had no impact on weight or length/height z scores [pooled effect: 0.03 (95% confidence interval: -0.06;0.12) and 0.03 (95% confidence interval: -0.02;0.08), respectively] and had a modest, but significant, reduction in body mass index/weight-for-height z scores [z score mean difference: -0.06 (95% confidence interval: -0.12;0.00)], which was limited to studies from low- and high-incomes settings. For all three outcomes, there was important heterogeneity among studies, which should be taken into account when interpreting the results.

CONCLUSION

Breastfeeding promotion interventions were not associated with significant changes in weight or length, but led to a modest, albeit significant, reduction in body mass index/weight-for-height z scores.

High Blood Pressure among Students in Public and Private Schools in Maceió, Brazil

The prevalence of hypertension in childhood is increasing, and investigation of its distribution is important for planning timely interventions. This study assessed the prevalence of high blood pressure (HBP) and associated factors in students between 9 and 11 years of age enrolled in public and private schools in Maceió, Brazil. A cross-sectional study was performed in a probabilistic sample of students (10.3 ± 0.5 years). The students were selected from a systematic sampling of 80 schools (40 public and 40 private). To maintain similar proportions of students existing in public and private schools in Maceió, 21 and 14 students were randomly selected from each public and private school, respectively. The prevalence ratio (PR) was estimated using Poisson regression. A total of 1,338 students were evaluated (800 from public schools and 538 from private schools). No differences were observed between school types in terms of student age and gender (p > 0.05). The prevalence of obesity (19.9% vs. 9.0%; PR = 2.2; 95% CI = 1.67-2.92) and hypertension (21.2% vs. 11.4%; PR = 1.86; 95% CI = 1.45-2.40) were higher in private schools. The association between high blood pressure and type of school (public or private) remained statistically significant even after adjustment for obesity (PR = 1.53; 95% CI = 1.19-1.97).

IN CONCLUSION

(a) students from private schools have higher socioeconomic status, BMI, and HBP prevalence compared to those of public school; (b) among the evaluated students, the prevalence of obesity only partially explained the higher prevalence of high blood pressure among students from private schools. Other factors related to lifestyle of children from private schools may explain the higher prevalence of HBP. This results show the need to implement measures to promote healthy lifestyles in the school environment, since children with HBP are more likely to become hypertensive adults. Therefore, early detection and intervention in children with HBP is an important action for the prevention of hypertension in adulthood.

Gestational age and newborn size according to parental social mobility: an intergenerational cohort study

Background

We examined the associations between socioeconomic trajectories from birth to adulthood and gestational age and birth size in the next generation, using linked data from two population-based birth cohorts carried out in a Brazilian city. By comparing socioeconomic trajectories of mothers and fathers, we attempted to identify-specific effects of maternal and paternal socioeconomic trajectory on offspring birth weight, birth length, head circumference and gestational age at birth.

Methods

2 population-based birth cohort studies were carried out in 1982 and 2004 in Pelotas (Brazil); 156 mothers and 110 fathers from the earlier cohort had children in 2004. Gestational age and birth length, weight and head circumference were measured. Analyses were carried out separately for mothers and fathers. Mediation analyses assessed the role of birth weight and adult body mass index (BMI).

Results

Among mothers, but not for fathers, childhood poverty was strongly associated with smaller size in the next generation (about 400 g in weight and 1.5 cm in height) and shorter gestations (about 2 weeks). Adult poverty did not play a role. For mothers, the associations with gestational age, birth length and weight—but not with head circumference—persisted after adjusting for maternal birth weight and for the height and weight of the grandmother. Maternal birth weight did not mediate the observed associations, but high maternal BMI in adulthood was partly responsible for the association with gestational age.

Conclusions

Strong effects of early poverty on gestational age and birth size in the next generation were observed among mothers, but not among fathers. These findings suggest a specific maternal effect of socioeconomic trajectory, and in particular of early poverty on offspring size and duration of pregnancy.

Consumption of ultra-processed foods and their impact on the diet of young adults

OBJECTIVE To evaluate the consumption of ultra-processed foods, its associated factors, and its influence on nutrient intake in young adults. METHODS In 2004-2005, the individuals belonging to the Pelotas birth cohort of 1982 were identified for a home interview. A total of 4,297 individuals were interviewed and 4,202 individuals were included in the study (follow-up rate of 77.4%). Diet was assessed using a questionnaire on dietary intake and the percentage of daily caloric intake attributed to ultra-processed foods as well as the intake of macro- and micronutrients were estimated. The association between cohort characteristics and the consumption of ultra-processed foods was assessed using linear regression. Analysis of variance and Pearson's Chi-square test were used to evaluate the association between the quintiles of the consumption of ultra-processed food, nutrient intake and adequacy of nutrient intake, respectively. RESULTS The consumption of ultra-processed foods corresponded to 51.2% of the total caloric intake. The consumption of ultra-processed foods was higher among women, individuals with higher education, and individuals who were never poor and eutrophic. The increased consumption of ultra-processed foods was positively correlated with the consumption of fat, cholesterol, sodium, iron, calcium, and calories (p < 0.001) and was negatively correlated with the consumption of carbohydrates, protein, and dietary fiber (p < 0.001). CONCLUSIONS The high consumption of ultra-processed foods and its positive correlation with the intake of sodium, cholesterol, and fats underscores the need to perform interventions aimed at decreasing the intake of this food group.

Cross-Sectional and Prospective Associations between Physical Activity and C-Reactive Protein in Males

Background

There is conflicting evidence about the association between physical activity and inflammatory markers. Few prospective studies are available, particularly from low and middle-income countries. This study was aimed at assessing the cross-sectional and prospective associations between physical activity and C-reactive protein (CRP) levels in males belonging to the 1982 Pelotas (Brazil) Birth Cohort Study.

Methods

The sample comprised 2,213 males followed up at the ages of 18 and 23 years. We performed high sensitivity CRP assays; we used a cut-off of 3 mg/L in categorical analyses. We measured physical activity by self-report at ages 18 and 23 years. Body mass index and waist circumference were studies as possible mediators.

Results

CRP levels above the 3mg/L cut-off were found in 13.3% (95%CI: 11.7; 14.8) of the individuals. We found no evidence for an association between physical activity (leisure-time or all-domains) and either continuous (geometrical mean) or categorical CRP. We confirmed these null findings in (a) prospective and cross-sectional analyses; (b) trajectories analyses.

Conclusions

There was no association between CRP levels and physical activity levels in early adulthood in a large birth cohort. Little variability in CRP at this early age is the likely explanation for these null findings.

Protective effect of breastfeeding against overweight can be detected as early as the second year of life: a study of children from one of the most socially-deprived areas of Brazil

Millions of children live in Brazil's semi-arid region, one of the most socially-deprived areas of the country, where undernutrition co-exists with obesity as a consequence of the nutrition transition. There is evidence that childhood obesity predisposes adult obesity and, thus, that obesity should be prevented as early as possible. Some studies have shown that breastfeeding is a protective factor against overweight and obesity while other studies have not found this association. There have been few studies on this association in developing countries and of children below two years of age. The present study aimed to investigate whether children exposed to exclusive breastfeeding for ≥ 6 months showed a lower prevalence of overweight in the second year of life, based on a probability sample of 2,209 children (aged 12 to 24 months). The dependent variable was overweight, defined as weight-for-length z-scores of >2, based on the WHO 2006 standard while the independent variable was exclusive breastfeeding (≥ 6 months). The prevalence ratio (PR) and its 95% CI were estimated using Poisson regression with robust adjustment of variance. After adjusting for potential confounding factors (socioeconomic, demographic and health-related variables), children on exclusive breastfeeding for ≥ 6 months showed a lower prevalence of overweight (5.7% vs 9.1%, PR 0.62, 95% CI 0.45-0.89). It was found that exclusive breastfeeding for six months or more is a protective factor against overweight in children in the second year of life living in the Brazilian semi-arid region.

Diarrhea and health inequity among Indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition

BACKGROUND

Globally, diarrhea is the second leading cause of death among children under five. In Brazil, mortality due to diarrhea underwent a significant reduction in recent decades principally due to expansion of the primary healthcare network, use of oral rehydration therapy, reduced child undernutrition, and improved access to safe drinking water. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first survey based on a nationwide representative sample to study the prevalence of diarrhea and associated factors among Indigenous children in the country.

METHODS

The survey assessed the health and nutritional status of Indigenous children < 5 years of age based on a representative sample of major Brazilian geopolitical regions. A stratified probabilistic sampling was carried out for Indigenous villages. Within villages, children < 5 years of age in sampled households were included in the study. Interviews were based on a seven day recall period. Prevalence rates of acute diarrhea were calculated for independent variables and hierarchical multivariable analyses were conducted to assess associations.

RESULTS

Information on diarrhea was obtained for 5,828 children (95.1% of the total sample). The overall prevalence of diarrhea was 23.5%. Regional differences were observed, with the highest rate being in the North (38.1%). Higher risk of diarrhea was observed among younger children and those who had less maternal schooling, lower household socioeconomic status, undernutrition (weight-for-age deficit), presence of another child with diarrhea in the household, and occurrence of upper respiratory infection.

CONCLUSIONS

According to results of the First National Survey of Indigenous People's Health and Nutrition, almost a quarter of Indigenous children throughout the country had diarrhea during the previous week. This prevalence is substantially higher than that documented in 2006 for Brazilian children < 5 years generally (9.4%). Due to its exceedingly multicausal nature, the set of associated variables that remained associated with child diarrhea in the final multivariable model provide an excellent reflection of the diverse social and health inequities faced by Indigenous peoples in contemporary Brazil.

African ancestry, lung function and the effect of genetics

African-Americans have smaller lung function compared with European-Americans. The aim of this study was to disentangle the contribution of genetics from other variables on lung function.

A cohort was followed from birth to 30 years of age in Brazil. Several variables were collected: genomic analysis based on DNA; forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) obtained by spirometry; height measured by anthropometrists; and thorax circumference evaluated by photonic scanner. Crude and adjusted linear regression models were calculated according to African ancestry.

The sample comprised 2869 participants out of 3701 members of the cohort. Males with higher African ancestry by DNA analysis had a smaller FEV₁ (−0.13 L, 95% CI −0.23– −0.03 L) and FVC (−0.21 L, 95% CI −0.32– −0.09 L) compared with those with less African ancestry, having accounted for height, sitting to standing height ratio and other confounders. Similar effects were seen in females.

After adjustment, ancestry remained significantly associated with lung function, but the large effect of adjustment for confounding among males (but not females) does not allow us to exclude the possibility that residual confounding may still account for these findings.

Smaller lung function is related to African ancestry but adjustments for confounders reduced the effect sizeshttp://ow.ly/Iq0Ve

Body size dissatisfaction among young adults from the 1982 Pelotas birth cohort

BACKGROUND/OBJECTIVES

To identify the prevalence and factors associated with body dissatisfaction.

SUBJECTS/METHODS

Birth cohort study investigating 4100 subjects (2187 men and 1913 women) aged between 22 and 23 years who answered questionnaires, including the body satisfaction Stunkard Scale were included in the study; they were weighed and measured. Multinomial logistic regression was used in the crude and adjusted analyses.

RESULTS

The prevalence of body dissatisfaction was 64% (95% CI, 62.7-65.6); 42% (95% CI, 40.6-43.6) of the subjects reported feeling larger than the desired body size, and 22% (95% CI, 20.7-23.3) reported feeling smaller than desired. Underweight subjects, subjects with less schooling, poor and sedentary male subjects with low psychological well-being and female subjects who were already mothers were more likely to express body dissatisfaction, perceiving their body as smaller than the desirable body size. The prevalence of body dissatisfaction was also high among overweight subjects, subjects with a high socioeconomic status and married female subjects, who perceived their body size as too large. Minor psychiatric disorders were associated with body dissatisfaction in all subjects, regardless of perceiving themselves as larger or smaller than the desired body size. Most women perceived themselves as larger, but similar proportions of men perceived themselves as too small or too large.

CONCLUSIONS

Body dissatisfaction was observed among men and women with normal weight, but it was more evident in the obese individuals. Regardless of the nutritional status, both men and women should be appropriately counseled because body size perception can lead to unhealthy behaviors in relation to diet and physical activity.

The association of maternal age with birthweight and gestational age: a cross-cohort comparison

BACKGROUND

We examined the associations of maternal age with low birthweight (LBW) and preterm birth in four cohorts from a middle- and a high-income country, where the patterning of maternal age by socio-economic position (SEP) is likely to differ.

METHODS

Population-based birth cohort studies were carried out in the city of Pelotas, Brazil in 1982, 1993, and 2004, and in Avon, UK in 1991 [Avon Longitudinal Study of Parents and Children (ALSPAC)]. Adjustment for multiple indicators of SEP were applied.

RESULTS

Low SEP was associated with younger age at childbearing in all cohorts, but the magnitudes of these associations were stronger in ALSPAC. Inverse associations of SEP with LBW and preterm birth were observed in all cohorts. U-shaped associations were observed between maternal age and odds of LBW in all cohorts. After adjustment for SEP, increased odds of LBW for young mothers (<20 years) attenuated to the null but remained or increased for older mothers (≥ 35 years). Very young (<16 years) maternal age was also associated with both outcomes even after full SEP adjustment. SEP adjusted odds ratio of having a LBW infant in women <16 years and ≥ 35 years, compared with 25-29 years, were 1.48 [95% confidence interval (CI) 1.00, 2.20] and 1.66 [95% CI 1.36, 2.02], respectively. The corresponding results for preterm birth were 1.80 [95% CI 1.23, 2.64)] and 1.38 [95% CI 1.15, 1.67], respectively.

CONCLUSION

Confounding by SEP explains much of the excess risk of LBW and preterm among babies born to teenage mothers as a whole, but not for mothers aged <16 or ≥ 35 years. Given that the proportion of women becoming pregnant at <16 years is smaller than for those ≥ 35 years, the population burden is greater for older age.

Prevalence of high blood pressure in 122,053 adolescents: a systematic review and meta-regression

Several studies have reported high prevalence of risk factors for cardiovascular disease in adolescents. To perform: i) systematically review the literature on the prevalence of high blood pressure (HBP) in adolescents; ii) analyze the possible methodological factors associated with HBP; and iii) compare the prevalence between developed and developing countries. We revised 10 electronic databases up to August 11, 2013. Only original articles using international diagnosis of HBP were considered. The pooled prevalence's of HBP were estimated by random effects. Meta-regression analysis was used to identify the sources of heterogeneity across studies. Fifty-five studies met the inclusion criteria and total of 122,053 adolescents included. The pooled-prevalence of HBP was 11.2%, 13% for boys, and 9.6% for girls (P < 0.01). Method of measurement of BP and year in which the survey was conducted were associated with heterogeneity in the estimates of HBP among boys. The data indicate that HBP is higher among boys than girls, and that the method of measurement plays an important role in the overall heterogeneity of HBP value distributions, particularly in boys.

Parental childhood growth and offspring birthweight: pooled analyses from four birth cohorts in low and middle income countries

Objective

Associations between parental and offspring size at birth are well established, but the relative importance of parental growth at different ages as predictors of offspring birthweight is less certain. Here we model parental birthweight and postnatal conditional growth in specific age periods as predictors of offspring birthweight.

Methods

We analyzed data from 3,392 adults participating in four prospective birth cohorts and 5,506 of their offspring.

Results

There was no significant heterogeneity by study site or offspring sex. 1SD increase in maternal birthweight was associated with offspring birthweight increases of 102 g, 1SD in maternal length growth 0–2 year with 46 g, and 1SD in maternal height growth Mid-childhood (MC)-adulthood with 27 g. Maternal relative weight measures were associated with 24 g offspring birth weight increases (2 year- MC) and 49 g for MC-adulthood period but not with earlier relative weight 0–2 year. For fathers, birthweight, and linear/length growth from 0–2 year were associated with increases of 57 and 56 g in offspring birthweight, respectively but not thereafter.

Conclusions

Maternal and paternal birthweight and growth from birth to 2 year each predict offspring birthweight. Maternal growth from MC-adulthood, relative weight from 2-MC and MC-adulthood also predict offspring birthweight. These findings suggest that shared genes and/or adequate nutrition during early life for both parents may confer benefits to the next generation, and highlight the importance of maternal height and weight prior to conception. The stronger matrilineal than patrilineal relationships with offspring birth weight are consistent with the hypothesis that improving the early growth conditions of young females can improve birth outcomes in the next generation. Am. J. Hum. Biol. 27:99–105, 2015. © 2014 The Authors American Journal of Human Biology Published by Wiley Periodicals, Inc.

[Prevalence of preterm birth according to birth weight group: a systematic review]

OBJECTIVE

To estimate the prevalence of preterm birth by categories of birth weight, and to obtain an equation to correct the estimates.

METHODS

Systematic review of the Brazilian literature published from 1990 to 2012, to identify studies with primary collection of data on birth weight and gestational age. Twelve studies were selected and contributed for tabulations of preterm prevalence according to 100 g birth weight categories. These results were combined using sex-specific fractional polynomial equations and the resulting curves were compared with results from the Live Birth Information System for the years 2000, 2005, 2010 and 2011.

RESULTS

For all birth weight categories, preterm prevalence estimates based on primary studies had a higher prevalence than those of the the Live Birth Information System. The prevalence reported by the Live Birth Information System was of 7.2% in 2010, about 38.0% lower than the estimated prevalence of 11.7% obtained with the correctional equation.

CONCLUSIONS

Information reported by the Live Birth Information System on preterm prevalence does not reflect the true magnitude of the problem in Brazil, and should not be used without the correction factors proposed in the present analyses.

Physical activity throughout adolescence and bone mineral density in early adulthood: the 1993 Pelotas (Brazil) Birth Cohort Study

Association between three physical activity (PA) measurements throughout adolescence and bone density at 18 years of age was investigated. PA was associated with both lumbar spine and femoral neck bone mineral density (BMD) in early adulthood independent of type of PA used in the analysis. The results were more consistent in boys.

INTRODUCTION

This study amis to evaluate if PA during adolescence could influence BMD later in life.

METHODS

A population-based birth cohort study was carried out. PA was assessed at 11 and 15 years of age by questionnaire and included sports performed while BMD (lumbar spine and femoral neck) was measured by dual-energy X-ray absorptiometry at 18 years. A peak strain score was generated based on ground reaction forces of different PA. PA was measured as peak strain score, peak strain score multiplied by minutes/week and minutes/week. Unadjusted and adjusted analyses were performed using linear regression.

RESULTS

Overall, 3,811 adolescents were studied (1,866 boys and 1,945 girls). The peak strain score at 11 and 15 years was associated with lumbar and femoral neck BMD at 18 years in boys. Among girls, high-impact PA at 11 years was positively associated with lumbar and femoral BMD (p = 0.01; p < 0.001). After adjusted analysis, weekly minutes of PA at 11 years were not associated with lumbar spine but were associated with femoral neck BMD (p < 0.001); at 15 years, weekly minutes of PA were positively associated with BMD at both sites. Regardless of PA status at 11 years of age, attaining the recommendations of PA (300 min/week) at 15 years appears to be important for BMD at 18 years in both sites in boys and girls. The results Appeared to be more consistent in boys.

CONCLUSIONS

PA during adolescence was positively associated with both lumbar spine and femoral neck BMD in early adulthood independent of type of PA used in the analysis.

Treatment outcomes in tuberculosis patients with diabetes: a polytomous analysis using Brazilian surveillance system

BACKGROUND

The impact of non-communicable diseases on tuberculosis incidence has received significant attention. It has been suggested that the risk of tuberculosis is higher among subjects with diabetes and these subjects also has poor TB treatment outcomes.This study was aimed at assessing the socio-demographic and clinical factors that may influence different outcome of TB in patients with DM (TB-DM) identified in the Brazilian national database from 2001 to 2011.

METHODS

TB-DM cases reported in the Brazilian information system were identified and compared.Covariates associated with the outcomes of interest (cure, default, deaths, and development of TB MDR) were included in a hierarchical regression model.

RESULTS

TB-DM cases increased from 380/100,000/year in 2001 to 6,150/100,000/year in 2011. Some of the main associations found are pointed. The odds of default was higher among those in the age group 20-39 years (OR = 2.07, 95%CI 1.32-3.24); alcoholics (OR = 2.17, 95%CI 1.86-2.54), and HIV/AIDS (OR = 2.16, 95%CI 1.70-2.74);positive monitoring smear (OR = 1.94, 95%CI 1.55-2.43); prior default (OR = 5.41, 95%CI 4.47-6.54), and unknown type of treatment (OR = 3.33, 95%CI 1.54-7.22). The odds of death was greater for subjects ≥60 years old (OR = 2.74, 95%CI 1.74-4.29); institutionalized in shelter (OR = 2.69, 95%CI 1.07-6.77); alcoholics (OR = 2.70, 95%CI 2.27-3.22); HIV/AIDS (OR = 2.87, 95%CI 2.13-3.86); pulmonary+extrapulmonary TB (OR = 2.49, 95%CI 1.79-3.46); with unknown type of treatment (OR = 14.12, 95%CI 7.04-28.32).Development of MDR TB was more related to relapse (OR = 9.60, 95%CI 6.07-15.14);previous default (OR = 17.13, 95%CI 9.58-30.63); and transfer of treatment center (OR = 7.87, 95%CI 4.74-13.07).

CONCLUSIONS

Older subjects and those with comorbidities and with a previous treatment of TB had poorest outcomes. TB control program in Brazil will need to expand efforts to focus on treatment of TB-DM patients to improve their cure rates in order to achieve the goals of tuberculosis elimination.

Physical activity from adolescence to young adulthood and bone mineral density in young adults from the 1982 Pelotas (Brazil) Birth Cohort

OBJECTIVE

To evaluate a prospective association between physical activity (PA) and bone mineral density (BMD) in young adults.

METHOD

Total body (TB), lumbar spine (LS) and femoral neck (FN) BMD were measured in participants from the 1982 Pelotas Birth Cohort by dual-energy X-ray absorptiometry at 30 y. PA was evaluated at 15, 18 (males) and 23 y.

RESULTS

3454 young adults were scanned (DXA) at least at one anatomical site. In males, PA at 15 y was associated with LS density (β=0.061 g/cm(2); 95% confidence interval (CI): 0.015; 0.108). A positive dose-response effect was found for the association between PA at 18 y and BMD. Males in the two highest quartiles of PA at 23 y had significantly greater BMD at all anatomical sites than males in the lowest quartile. We observed greater BMD at 30 y in boys who were active at least in one of the assessments (18 or 23 y) compared to inactive boys at both ages. Females in the highest quartile of PA at 23 y showed greater FN density at 30 y (β=0.020; 95%CI: 0.001; 0.039).

CONCLUSIONS

A physically active pattern is important to BMD across the first three decades of life. Potential beneficial effects of PA were not entirely lost with advancing age in male young adults.

Relationship Between Periodontal Disease and Obesity: The Role of Life-Course Events

Periodontal disease is ranked among the 10 most prevalent chronic diseases worldwide, and is considered a major public health problem. Its etiology has been associated with local and general conditions that could interfere in the host immune response. Obesity, like periodontal disease, has emerged as a prevalent chronic disease in high-, low- and medium-income countries, recognized as risk factor for cardiovascular disease and cancer. A relationship between periodontal health and obesity may exist, but the mechanism that would explain this association remains unclear. Life-course epidemiology could be a useful instrument to investigate a casual association between early exposures and later outcomes, being appropriate for understanding the establishment of chronic conditions. This approach comprehends different theories, considering the time, the duration and the intensity of early exposition, and its impact on the development of chronic diseases in later life. Thus, the aim of this study is to hypothesize the different life-course epidemiology theories to explain the possible association between periodontal health and nutritional status in adulthood.

Birth status, child growth, and adult outcomes in low- and middle-income countries

OBJECTIVE

To assess the impact of being born preterm or small for gestational age (SGA) on several adult outcomes.

STUDY DESIGN

We analyzed data for 4518 adult participants in 5 birth cohorts from Brazil, Guatemala, India, the Philippines, and South Africa.

RESULTS

In the study population, 12.8% of males and 11.9% of females were born preterm, and 26.8% of males and 22.4% of females were born term but SGA. Adults born preterm were 1.11 cm shorter (95% CI, 0.57-1.65 cm), and those born term but SGA were 2.35 cm shorter (95% CI, 1.93-2.77 cm) compared with those born at term and appropriate size for gestational age. Blood pressure and blood glucose level did not differ by birth category. Compared with those born term and at appropriate size for gestational age, schooling attainment was 0.44 years lower (95% CI, 0.17-0.71 years) in those born preterm and 0.41 years lower (95% CI, 0.20-0.62 years) in those born term but SGA.

CONCLUSION

Being born preterm or term but SGA is associated with persistent deficits in adult height and schooling, but is not related to blood pressure or blood glucose level in low- and middle-income settings. Increased postnatal growth is associated with gains in height and schooling regardless of birth status, but not with increases in blood pressure or blood glucose level.

Associated factors for accelerated growth in childhood: a systematic review

Several studies have shown that accelerated growth in the postnatal period is critical for the development of chronic diseases. The term catch-up has been used for the accelerated growth of children who have suffered some sort of restriction of nutrition or oxygen supply. However, accelerated growth has been observed among children who have an appropriate birth weight for their gestational age (AGA) and with no apparent morbidity. Therefore, this systematic review was carried out on the associated factors of accelerated growth, or catch-up, using the Medline/Pubmed database. Only cohort studies written in Portuguese, English or Spanish, with children between zero and 12 years old who presented accelerated growth or catch-up as the outcome were included. Out of the 2,155 articles found, 9 were selected. There is no uniformity in the operational definition of accelerated growth, or in the concept of catch-up. According to this review, accelerated growth is associated with primiparity, maternal smoking during pregnancy, lower birth weight, and early weaning. The main limitations in the available literature are the high number of follow-up losses and the lack of control for confounding factors. The determinants of accelerated growth still need to be studied further, especially among AGA children.

Birth by caesarean section and prevalence of risk factors for non-communicable diseases in young adults: a birth cohort study

Background

Conflicting findings on the risk of obesity among subjects born by caesarean section have been published. Caesarean section should also increase the risk of obesity related cardiovascular risk factors if type of delivery is associated with obesity later in life. This study was aimed at assessing the effect of type of delivery on metabolic cardiovascular risk factors in early adulthood.

Methodology and Principal Findings

In 1982, maternity hospitals in Pelotas, southern Brazil, were visited and those livebirths whose family lived in the urban area of the city have been followed. In 2000, when male subjects undertook the Army entrance examination (n=2200), fat mass and fat free mass were estimated through bioimpedance. In 2004–2005, we attempted to follow the whole cohort (n=4297), and the following outcomes were studied: blood pressure; HDL cholesterol; triglycerides; random blood glucose, C-reactive protein, waist circumference and body mass index. The estimates were adjusted for the following confounders: family income at birth; maternal schooling; household assets index in childhood; maternal skin color; birth order; maternal age; maternal prepregnancy weight; maternal height; maternal smoking during pregnancy; birthweight and family income at early adulthood.

Results

In the crude analyses, blood pressure (systolic, diastolic and mean arterial pressure) and body mass index were higher among subjects who were delivered through caesarean section. After controlling for confounders, systolic blood pressure was 1.15 mmHg (95% confidence interval: 0.05; 2.25) higher among subjects delivered by caesarean section, and BMI 0.40 kg/m² (95% confidence interval: 0.08; 0.71). After controlling for BMI the effect on systolic blood pressure dropped to 0.60 mmHg (95% confidence interval: -0.47; 1.67). Fat mass at 18 years of age was also higher among subjects born by caesarean section.

Conclusion

Caesarean section was associated with a small increased in systolic blood pressure, body mass index and fat mass.

Prevalence and patterns of multimorbidity among tuberculosis patients in Brazil: a cross-sectional study

Introduction

The number of subjects with tuberculosis (TB) presenting with co-occurrence of multiple chronic medical conditions, or multimorbidity (MM) is increasing in Brazil. This manuscript aimed to characterize subjects with TB, according to their MM status and to analyse factors associated with TB treatment outcomes.

Methods

This is a cross-sectional study that included 39,881 TB subjects reported in Brazil, in 2011. MM were defined as any (two or more) occurrence of chronic medical conditions in a TB patient (TB–MM). Data analysis was performed by hierarchical logistic regression models comparing TBMM with those with only TB.

Results

Of the reported TB cases in 2011, 454 (1.14%) had MM. The subjects in the age group 40–59 years (OR: 17.89; 95% CI, 5.71-56.03) and those ≥ 60 years (OR: 44.11; 95% CI, 14.09-138.06) were more likely to develop TB–MM. The TB–MM subjects were less likely to be male (OR: 0.63; 95% CI, 0.52-0.76), institutionalized (OR: 0.59; 95% CI, 0.23-0.80) and live in rural areas (OR: 0.63; 95% CI, 0.42-0.95). Death from causes other than TB was higher among TB–MM subjects (OR: 1.76; 95% CI, 1.36-2.28). Of 454 TB–MM subjects 302 (66.5%) were cured and 152 (33.5%) were not cured. The odds of not being cured was 1.55 (95% CI, 1.04-2.32) among males, 2.85 (95% CI, 1.12-7.28) among institutionalized subjects, and 3.93 (IC 95%, 1.86-8.30) among those who were infected with HIV. TB retreatment after previous abandonment (OR: 7.53; 95% CI, 2.58-21.97) and transfer from a treatment site (OR: 2.76; 95% CI, 1.20-6.38) were higher for subjects not cured compared to those who were cured.

Conclusions

While TB is well recognized to be a disease engendered by social inequity, we found that even among TB patients, those who have MM have greater inequity in terms of socioeconomic status and adverse clinical outcomes. Addressing the problem of TB and TB–MM requires a multisectorial approach that includes health and social service organizations.

Infant feeding and school attainment in five cohorts from low- and middle-income countries

BACKGROUND

Performance in intelligence tests tends to be higher among individuals breastfed as infants, but little is known about the association between breastfeeding and achieved schooling. We assessed the association of infant feeding with school achievement in five cohorts from low- and middle-income countries. Unlike high-income country settings where most previous studies come from, breastfeeding is not positively associated with socioeconomic position in our cohorts, thus reducing the likelihood of a spurious positive association.

METHODOLOGY AND PRINCIPAL FINDINGS

Participants included 10,082 young adults from five birth cohorts (Brazil, India, Guatemala, the Philippines, and South Africa). The exposures variables were whether the subject was ever breastfed, total duration of breastfeeding, and age at introduction of complementary foods. We adjusted the estimates for age at follow up, sex, maternal age, smoking during pregnancy, birthweight and socioeconomic position at birth. The key outcome was the highest grade achieved at school. In unadjusted analyses, the association between ever breastfeeding and schooling was positive in Brazil, inverse in the Philippines, and null in South Africa; in adjusted analyses, these associations were attenuated. In Brazil, schooling was highest among individuals breastfed for 3-12 months whereas in the Philippines duration of breastfeeding was inversely associated with schooling; and null associations were observed in South Africa and Guatemala. These associations were attenuated in adjusted models. Late introduction of solid foods was associated with lower schooling achievement in Brazil and South Africa.

CONCLUSION

Measures of breastfeeding are not consistently related to schooling achievement in contemporary cohorts of young adults in lower and middle-income countries.

Maternal height and child growth patterns

OBJECTIVE

To examine associations between maternal height and child growth during 4 developmental periods: intrauterine, birth to age 2 years, age 2 years to mid-childhood (MC), and MC to adulthood.

STUDY DESIGN

Pooled analysis of maternal height and offspring growth using 7630 mother-child pairs from 5 birth cohorts (Brazil, Guatemala, India, the Philippines, and South Africa). We used conditional height measures that control for collinearity in height across periods. We estimated associations between maternal height and offspring growth using multivariate regression models adjusted for household income, child sex, birth order, and study site.

RESULTS

Maternal height was associated with birth weight and with both height and conditional height at each age examined. The strongest associations with conditional heights were for adulthood and 2 years of age. A 1-cm increase in maternal height predicted a 0.024 (95% CI: 0.021-0.028) SD increase in offspring birth weight, a 0.037 (95% CI: 0.033-0.040) SD increase in conditional height at 2 years, a 0.025 (95% CI: 0.021-0.029 SD increase in conditional height in MC, and a 0.044 (95% CI: 0.040-0.048) SD increase in conditional height in adulthood. Short mothers (<150.1 cm) were more likely to have a child who was stunted at 2 years (prevalence ratio = 3.20 (95% CI: 2.80-3.60) and as an adult (prevalence ratio = 4.74, (95% CI: 4.13-5.44). There was no evidence of heterogeneity by site or sex.

CONCLUSION

Maternal height influences offspring linear growth over the growing period. These influences likely include genetic and non-genetic factors, including nutrition-related intergenerational influences on growth that prevent the attainment of genetic height potential in low- and middle-income countries.

Haplotype TGTG from SNP 45T/G and 276G/T of the adiponectin gene contributes to risk of polycystic ovary syndrome

BACKGROUND

Haplotypes of adiponectin gene single nucleotide polymorphisms (SNP) might be related to metabolic disorders.

AIM

To assess whether the prevalence of SNP 45T/G and 276G/T of the adiponectin gene and their haplotypes differ between polycystic ovary syndrome (PCOS) and non-hirsute cycling controls and to investigate the relationship between these haplotypes and risk factors for cardiovascular disease.

SUBJECTS AND METHODS

In this case-control study, 80 women with PCOS and 1500 non-hirsute controls with regular cycles underwent clinical and laboratory measurements. Genotype distribution was analyzed by conventional PCR-restriction fragment length polymorphism.

RESULTS

Compared to controls, PCOS women had greater body mass index (BMI) (31.0±7.9 kg/m² vs 23.4±4.6 kg/m²; p<0.001), waist circumference (92.2±18.8 cm vs 74.5±10.2 cm; p<0.001), and systolic and diastolic blood pressure (124.6±19.9 vs 111.5±13.0 mmHg and 79.2±12.5 vs 71.8±10.6 mmHg; p<0.025), as well as a worse lipid profile (p<0.007), even after adjustment for age and BMI. Genotype distribution was similar in PCOS and controls (45T/G: p=0.399; 276G/T: p=0.135). Six haplotypes were inferred and their frequencies differed significantly between the groups (p=0.001). The TGTG haplotype was more frequent in PCOS than controls (41.3 vs 18.9%). In PCOS, the GG genotype for SNP 276 (p=0.031) and the TGTG haplotype (p=0.023) were associated with higher systolic blood pressure vs other genotypes and haplotypes. Body composition, glucose, insulin, and lipid profile were similar across genotypes and haplotypes in both groups.

CONCLUSIONS

Haplotype TGTG from adiponectin gene variants 45T/G and 276G/T is related to susceptibility to PCOS, and might be associated with increased blood pressure in PCOS.

Prevalence of anemia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition

BACKGROUND

Anemia is the most prevalent nutritional deficiency globally, affecting about a quarter of the world population. In Brazil, about one-fifth of children under five years of age are anemic. Previous case studies indicate prevalence rates much higher among indigenous peoples in the country. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first survey based on a nationwide representative sample to study the prevalence of anemia and associated factors among indigenous children in Brazil.

METHODS

The survey assessed the health and nutritional status of indigenous children < 5 years of age based on a representative sample of major Brazilian geopolitical regions. A stratified probabilistic sampling was carried out for indigenous villages. Within villages, children < 5 years of age in sampled households were included in the study. Prevalence rates of anemia were calculated for independent variables and hierarchical multivariate analysis were conducted to assess associations.

RESULTS

Evaluation of hemoglobin levels was conducted for 5,397 children (88.1% of the total sample). The overall prevalence of anemia was 51.2%. Higher risk of presenting anemia was documented for boys, lower maternal schooling, lower household socioeconomic status, poorer sanitary conditions, presence of maternal anemia, and anthropometric deficits. Regional differences were observed, with the highest rate being observed in the North.

CONCLUSIONS

The prevalence rates of anemia in indigenous children were approximately double than those reported for non-indigenous Brazilian children in the same age group. Similarly notable differences in the occurrence of anemia in indigenous and non-indigenous children have been reported for other countries. Deeper knowledge about the etiology of anemia in indigenous children in Brazil is essential to its proper treatment and prevention.

Socio-demographic and clinical differences in subjects with tuberculosis with and without diabetes mellitus in Brazil--a multivariate analysis

BACKGROUND

Several studies have evaluated the relationship between diabetes mellitus (DM) and tuberculosis (TB), but the nature of this relationship is not fully understood. TB incidence may be influenced by immunosuppression from DM, but this association may be confounded by other clinical and socioeconomic factors. We aimed to assess socio-demographic and clinical differences in TB patients with and without DM.

METHODS

Using the Brazilian national surveillance system (SINAN), we compared 1,797 subjects with TB and DM with 29,275 subjects diagnosed with TB only in 2009. We performed multivariate analysis to identify factors associated with the presence of DM among TB patients.

RESULTS

Subjects with TB - DM were older; have initial positive sputum smear test (OR = 1.42, 95% CI 1.26-1.60), and were more likely to die from TB (OR = 1.44, 95% CI 1.03-2.01). They were less likely to have been institutionalized [in prison, shelter, orphanage, psychiatric hospital (OR = 0.74, 95% CI 0.60-0.93)]; developed extra pulmonary TB (OR = 0.62, 95% CI 0.51-0.75) and to return to TB treatment after abandonment (OR = 0.66, 95% CI 0.51-0.86).

CONCLUSIONS

Prevalence of NCD continues to rise in developing countries, especially with the rise of elderly population, the prevention and treatment of infectious diseases will be urgent. DM and TB represent a critical intersection between communicable and non-communicable diseases in these countries and the effect of DM on TB incidence and outcomes provide numerous opportunities for collaboration and management of these complex diseases in the national public health programs.

Nutritional status of indigenous children: findings from the First National Survey of Indigenous People's Health and Nutrition in Brazil

INTRODUCTION

The prevalence of undernutrition, which is closely associated with socioeconomic and sanitation conditions, is often higher among indigenous than non-indigenous children in many countries. In Brazil, in spite of overall reductions in the prevalence of undernutrition in recent decades, the nutritional situation of indigenous children remains worrying. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first study to evaluate a nationwide representative sample of indigenous peoples. This paper presents findings from this study on the nutritional status of indigenous children < 5 years of age in Brazil.

METHODS

A multi-stage sampling was employed to obtain a representative sample of the indigenous population residing in villages in four Brazilian regions (North, Northeast, Central-West, and Southeast/South). Initially, a stratified probabilistic sampling was carried out for indigenous villages located in these regions. Households in sampled villages were selected by census or systematic sampling depending on the village population. The survey evaluated the health and nutritional status of children < 5 years, in addition to interviewing mothers or caretakers.

RESULTS

Height and weight measurements were taken of 6,050 and 6,075 children, respectively. Prevalence rates of stunting, underweight, and wasting were 25.7%, 5.9%, and 1.3%, respectively. Even after controlling for confounding, the prevalence rates of underweight and stunting were higher among children in the North region, in low socioeconomic status households, in households with poorer sanitary conditions, with anemic mothers, with low birthweight, and who were hospitalized during the prior 6 months. A protective effect of breastfeeding for underweight was observed for children under 12 months.

CONCLUSIONS

The elevated rate of stunting observed in indigenous children approximates that of non-indigenous Brazilians four decades ago, before major health reforms greatly reduced its occurrence nationwide. Prevalence rates of undernutrition were associated with socioeconomic variables including income, household goods, schooling, and access to sanitation services, among other variables. Providing important baseline data for future comparison, these findings further suggest the relevance of social, economic, and environmental factors at different scales (local, regional, and national) for the nutritional status of indigenous peoples.

The First National Survey of Indigenous People's Health and Nutrition in Brazil: rationale, methodology, and overview of results

Background

Although case studies indicate that indigenous peoples in Brazil often suffer from higher morbidity and mortality rates than the national population, they were not included systematically in any previous national health survey. Reported here for the first time, the First National Survey of Indigenous People’s Health and Nutrition in Brazil was conducted in 2008–2009 to obtain baseline information based on a nationwide representative sample. This paper presents the study’s rationale, design and methods, and selected results.

Methods

The survey sought to characterize nutritional status and other health measures in indigenous children less than 5 years of age and indigenous women from 14 to 49 years of age on the basis of a survey employing a representative probabilistic sample of the indigenous population residing in villages in Brazil, according to four major regions (North, Northeast, Central-West, and South/Southeast). Interviews, clinical measurements, and secondary data collection in the field addressed the major topics: nutritional status, prevalence of hypertension and diabetes mellitus in women, child hospitalization, prevalence of tuberculosis and malaria in women, access to health services and programs, and characteristics of the domestic economy and diet.

Results

The study obtained data for 113 villages (91.9% of the planned sample), 5,305 households (93.5%), 6,692 women (101.3%), and 6,128 children (93.1%). Multiple household variables followed a pattern of greater economic autonomy and lower socioeconomic status in the North as compared to other regions. For non-pregnant women, elevated prevalence rates were encountered for overweight (30.3%), obesity (15.8%), anemia (32.7%), and hypertension (13.2%). Among children, elevated prevalence rates were observed for height-for-age deficit (25.7%), anemia (51.2%), hospitalizations during the prior 12 months (19.3%), and diarrhea during the prior week (23.6%).

Conclusions

The clinical-epidemiological parameters evaluated for indigenous women point to the accentuated occurrence of nutrition transition in all regions of Brazil. Many outcomes also reflected a pattern whereby indigenous women’s and children’s health indicators were worse than those documented for the national Brazilian population, with important regional variations. Observed disparities in health indicators underscore that basic healthcare and sanitation services are not yet as widely available in Brazil’s indigenous communities as they are in the rest of the country.

Life-course evidence of birth weight effects on bone mass: systematic review and meta-analysis

A systematic review of the literature was performed in July 2011. Original papers based on longitudinal studies measuring spine, femoral neck, or total body bone mass by DXA were included (n = 17). Birth weight was positively associated with bone mass among children. The association was unclear among adolescents and weak among adults. This study aims to evaluate the association between birth weight and bone mass in future ages through a systematic review of literature and meta-analysis. A systematic review of the literature was performed in July 2011 in Medline, Web of Science and LILACS bases using key terms: ("birth size" OR "birth weight" OR birthweight OR prematurity OR premature OR "gestational age") AND (osteoporosis OR "bone mass" OR "bone density" OR "bone mineral density" OR "bone mineral content" OR "bone area") AND (longitudinal OR cohort). Original papers based on longitudinal studies measuring lumbar spine, femoral neck or total body bone mass by dual-emission X-ray absorptiometry (DXA) were included. A meta-analysis was performed using birth weight and bone mass density and/or content as continuous variables and adjusted for current height and/or weight. A total of 218 articles were retrieved from which 17 were selected and grouped into three categories according to age: studies with children; with adolescents and young adults, and studies with adults (older than 25). Five papers were included in the meta-analysis. Positive association between birth weight and bone mass was clear among children, unclear among adolescents, and weak among adults. The effect on bone mass content was stronger than those on body mass density regardless of age. Birth weight influences positively bone health in later life. Preventive health policies dealing with early-life modifiable risk factors, as birth weight, should be encouraged to attain an optimal peak bone mass as an strategy to decrease osteoporosis in the elderly.

Incidence of school failure according to baseline leisure-time physical activity practice: prospective study

PURPOSE

To evaluate the prospective association between leisure-time physical activity practice at 11 years of age and incidence of school failure from 11 to 15 years of age.

METHODS

The sample comprised >4,300 adolescents followed up from birth to 15 years of age participating in a birth cohort study in Pelotas, Brazil. The incidence of school failure from age 11 to 15 years was calculated by first excluding from the analyses all subjects who experienced a school failure before 11 years of age, and then categorizing as "positive" all those who reported repeating a grade at school from 11 to 15 years of age. Leisure-time physical activity was measured using a validated questionnaire.

RESULTS

The incidence of school failure was 47.9% among boys and 38.2% among girls. Adolescents in the top quartile of leisure-time physical activity practice at 11 years of age had a higher likelihood of school failure (OR: 1.36; 95% CI: 1.06, 1.75) compared with the least active adolescents. In adjusted analyses stratified by sex, boys in the top quartile of leisure-time physical activity practice at 11 years of age were also more likely to have failed at school from age 11 to 15 years (OR: 1.60; 95% CI: 1.09, 2.33).

CONCLUSIONS

Adolescents allocating >1,000 min/wk to leisure-time physical activity were more likely to experience a school failure from 11 to 15 years of age. Although this finding does not advocate against physical activity promotion, it indicates that excess time allocated to physical activity may jeopardize school performance among adolescents.

Life course association of maternal smoking during pregnancy and offspring's height: data from the 1993 Pelotas (Brazil) birth cohort

PURPOSE

To evaluate the effect of (1) maternal smoking during pregnancy; and (2) partner smoking on offspring's height in infancy, childhood, and adolescence.

METHODS

All hospital live births from 1993 (5,249) were identified, and these infants were followed up at several ages. Height for age, expressed as z-scores using the World Health Organization growth curves, was measured at all follow-up visits. Maternal smoking during pregnancy was collected retrospectively at birth and analyzed as number of cigarettes/day smoked categorized in four categories (never smoked, <10, 10-19, and ≥ 20 cigarettes/day). Partner smoking was analyzed as a dichotomous variable (No/Yes). Unadjusted and adjusted analyses were performed by use of linear regression.

RESULTS

The prevalence of self-reported maternal smoking during pregnancy was 33.5%. In the crude analysis, the number of cigarettes/day smoked by the mother during pregnancy negatively affected offspring's height in infancy, childhood, and adolescence. After adjustment for confounders and mediators, this association remained statistically significant, although the magnitude of the regression coefficients was reduced. Paternal smoking was not associated with offspring's height in the adjusted analyses.

CONCLUSIONS

In addition to the well-known harmful effects of smoking, maternal smoking during pregnancy negatively affects offspring's height. Public health policies aimed at continuing to reduce the prevalence of maternal smoking during pregnancy must be encouraged.

Trends in socioeconomic inequalities in anthropometric status in a population undergoing the nutritional transition: data from 1982, 1993 and 2004 Pelotas birth cohort studies

BACKGROUND

Socioeconomic inequalities in child nutrition may change rapidly over time, particularly in populations undergoing the nutrition transition. Yet, the few available studies are repeated cross-sectional surveys. By studying three prospective birth cohorts in the same city over a period of more than two decades, we describe secular trends in overweight and stunting at different ages, according to socioeconomic position.

METHODS

Population-based birth cohort studies were launched in the city of Pelotas (Brazil) in 1982, 1993 and 2004, with follow-up visits at twelve, 24 and 48 months. Children were weighed and measured at every visit. Z-scores of length/height-for-age and body mass index-for-age were calculated using the WHO Child Growth Standards. The slope and relative indices of inequality, based on family income quintiles, were estimated for each follow-up visit.

RESULTS

Between the 1982 and 2004 cohorts, stunting among four-year-olds declined (from 10.9% to 3.6%), while overweight increased (from 7.6% to 12.3%). In every visit, stunting prevalence was inversely related to income. Both absolute and relative inequalities declined over time; among four-year-olds stunting dropped from 26.0% in the 1982 cohort to 6.7% in the 2004 cohort in the poorest group, while in the richest group stunting prevalence dropped from 2.7% in 1982 to 1.1% in the 2004 cohort study. The secular trend towards increased overweight was evident for four-year-olds, in almost all socioeconomic groups, but not among one and two-year-olds. Among four-year old children, overweight prevalence increased in all income quintiles, by 130% in the middle-income group, 64% in the poorest and 41% in the richest group.

CONCLUSIONS

The decline in stunting is remarkable, but the increase in overweight among four-year olds - particularly among the poorest and the middle-income groups- requires concerted efforts to prevent the long term consequences of child overweight.