Elard Koch

Impact of parity on anthropometric measures of obesity controlling by multiple confounders: a cross-sectional study in Chilean women

Aim: To find out whether there is an association between parity and obesity, evaluated through body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) in Chilean women after controlling for sociodemographic characteristics, health risk and gynaeco-obstetric factors. Design: Cross-sectional study, using baseline data of the San Francisco Project. Setting: San Francisco de Mostazal, located in the central region of Chile, 6512 Chilean-Hispanic women (Spanish heritage with a variable indigenous component). Methods: A weighted random sample of 508 women who had their first pregnancy inside the primary child-bearing ages. Data were collected between 1997 and 1999. Statistical associations between parity and different anthropometric measurements of adiposity in multiple linear (MLnR) and logistic regression models (MLtR) were evaluated. Results: In MLnR a modest parity-related increment in BMI and practically null increment in WC, WHR and WHtR was observed. Covariates that showed a statistically significant association with anthropometric measures of adiposity were age, low education, marital status, employment, smoking, smoking cessation, hypertension, diabetes, dyslipidaemia, parent’s obesity, menarche and fetal macrosomia. Crude odds ratio (OR) showed a strong association between parity and anthropometric markers of obesity. Nevertheless, after adjustments in MLtR models, the association remained only for BMI. All the measures of abdominal obesity related to parous women showed OR smaller than 1 (95% confidence intervals 0.57 to 0.96). Conclusions: Parity modestly influences BMI, but does not seem to be related to WC, WHR and WHtR after controlling by confounders. Parity can increase adiposity but not necessarily following an abdominal pattern.

Overcoming Barriers in the Management of Hypertension: The Experience of the Cardiovascular Health Program in Chilean Primary Health Care Centers

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

A landmark for popperian epidemiology: refutation of the randomised Aldactone evaluation study

In 1999 a great multi-site clinical trial known as the randomised Aldactone evaluation study (RALES) showed that the use of spironolactone importantly reduced complications attributable to chronic heart failure without major negative side effects. Recently, RALES has been questioned by a large scale observational study in the Ontario population. In contrast with predictions, the complications and mortality increased dramatically because of hyperkalaemia, reaching dimensions that from a public health perspective are comparable to an epidemic. This review analyses both researches in the light of Karl Popper’s science theory applying the modus tollens syllogism to the reality proposed by the main empirical enunciations that ensue from its epidemiological designs. RALES is deductively refuted because of the non-fulfillment of auxiliary assumptions that would act as reciprocal potential falsifiers in both studies, taking the logical form of a bi-conditional argument of the type: (a) P-then-Q and (b) Q-if-XP, XP being a set of potential falsifiers of Q as part of the explicit falsity content of P. From this popperian model, implications for clinical research are discussed.

Desigualdad educacional y socioeconómica como determinante de mortalidad en Chile: análisis de sobrevida en la cohorte del proyecto San Francisco

In thisprospective cohort study, a random sample of 920 subjects, living in San Francisco de Mostazal, Chile,aged more than 20 years (395 males) was examined for the first time in 1997-1999 and re-examinedin 2005-2006. All had information about economic household income and level of education. A Coxregression model was used to evaluate the association between mortality and socioeconomic measures.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: A natural experiment in 32 mexican states

Objective To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Design Population-based natural experiment. Setting and data sources Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Main outcomes Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Independent variables Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. Main results Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=−0.061 to −1.100), skilled attendance at birth (β=−0.032 to −0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=−0.566 to −0.962), clean water (β=−0.048 to −0.730), sanitation (β=−0.052 to −0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=−14.329) and MMRAO (β=−1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R2) 51–88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. Conclusions Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Influencia de factores psicosociales en la adherencia al tratamiento farmacológico antihipertensivo: Resultados de una cohorte del Programa de Salud Cardiovascular de la Región Metropolitana, Chile

Background: Inadequate blood pressure control in hypertensive patients remains a persistent health problem in Chile and worldwide. Poor adherence to antihypertensive drug therapy is one of the frequently cited factors. Objectives: To determine the influence of psychosocial factors in the adherence to drug therapy in hypertensive patients followed through a Cardiovascular Health Program (CHP) that provides free access to primary care centers located in the Metropolitan Region of Santiago, Chile. Methods: Cross sectional study. A randomized sample of 513 hypertensive patients (30 to 68 years) was obtained from a universe of 1.484 patients. Adherence to treatment was determined by the Morisky-Green-Levine test. Demographic, socioeconomic and average values of blood pressure were recorded. Validated questionnaires were utilized to assess the patient-physician relationship, awareness of being hypertensive, patient perception of social support, family cohesion, patient self-health assessment and symptoms of emotional stress and depression. Results: The drug therapy adherence was 36.6%, higher in women (38.4% vs 28.9%; p<0.001). After multivariate analysis, absence of adherence was associated with male gender (OR: 1.76 [95% CI 1.21 – 2.56]), low education (OR: 1.72 [95% CI 1.18 to 2.53]), inadequate patient-physician relationship (OR: 1.56 [95% CI 1.13 to 2.27]), and high level of emotional stress and depression (OR: 1.93 [95% CI 1.27 to 2.94]). Conclusions: Our study highlights the influence of inadequate patient-physician relation, high level of emotional stress and depression, low education level and income and male gender in the lack of adherence to antihypertensive drug therapy in hypertensive patients followed throughout the CHP.

Women's education level, contraceptive use and maternal mortality estimates.

As part of the Millennium Development Goals proposed by the United Nations, research on maternal mortality estimates and the determinants that positively influence maternal health outcomes is key for adequate evidence-based public health interventions. In the case of maternal death statistics, accuracy of estimating methods strongly depends on the quality of official records and, when unavailable, on the variables used in the predictive model, e.g. total fertility rate (TFR), percentage of childbirth delivery by skilled attendants, women’s education level, and per capita income, among others. Thus, a thorough evaluation of the reliability of estimated maternal mortality statistics is warranted before drawing any causal inference. In this regard, a recent report by Ahmed et al. provided the largest global estimate of the possible effect of contraceptive use on maternal mortality reduction and concluded that the ‘use of contraception is a substantial and effective primary

Estatura, factores de riesgo cardiovascular y riesgo de mortalidad en adultos: Proyecto San Francisco, Chile

Resumen:Antecedentes: Una relacion inversa entre estatura y riesgo de mortalidad ha sido establecida en estudios prospectivos de paises desarrollados. Sin embargo, di-cha asociacion practicamente permanece inexplorada en sociedades latinoamericanas en rapida transicion economica y epidemiologica. Diseno: De un universo de 11.600 adultos vi-viendo en el centro urbano de Mostazal, Chile, se realizo un estudio de cohorte prospectivo de una muestra aleatoria ponderada de 795 sujetos segui-dos durante 8 anos. Metodo: Desde 1997 a 1999 se evaluo la estatura (percentiles 50 y 75 por sexo), hipertension, diabetes, dislipidemia, obesidad, tabaquismo, consumo de alco-hol y antecedentes hereditarios de enfermedad cardio-vascular. El riesgo relativo de mortalidad por cualquier causa fue estimado a traves de modelos de regresion de Cox ajustando por edad, sexo, factores de riesgo, educacion e ingreso. Resultados: Se observo una relacion inversa entre la estatura adulta y los factores de riesgo cardiovascu-lar. En el modelo completamente ajustado el riesgo de mortalidad por cualquier causa asociado a la estatura fue 0,75 (IC 95% 0,66 – 0,85; p tendencia <0,001). Los factores de riesgo cardiovascular tradicionales solo explicaron 22% de la asociacion inversa estable-cida entre estatura y mortalidad.