Luciana Bertoldi Nucci

Nutritional status of pregnant women: prevalence and associated pregnancy outcomes

INTRODUCTION Although obesity is well recognized as a current public health problem, its prevalence and impact among pregnant women have been less investigated in Brazil. The objective of the study was to evaluate the impact of pre-obesity and obesity among pregnant women, describing its prevalence and risk factors, and their association with adverse pregnancy outcomes. METHODS A cohort of 5,564 pregnant women, aged 20 years or more, enrolled at approximately 20 to 28 weeks of pregnancy, seen in prenatal public clinics of six state capitals in Brazil were followed up, between 1991 and 1995. Prepregnancy weight, age, educational level and parity were obtained from a standard questionnaire. Height was measured in duplicate and the interviewer assigned the skin color. Nutritional status was defined using body mass index (BMI), according to World Health Organization (WHO) criteria. Odds ratios and 95% confidence interval were calculated using logistic regression. RESULTS Age-adjusted prevalences (and 95% CI) based on prepregnancy weight were: underweight 5.7% (5.1%-6.3%), overweight 19.2% (18.1%-20.3%), and obesity 5.5% (4.9%-6.2%). Obesity was more frequently observed in older black women, with a lower educational level and multiparous. Obese women had higher frequencies of gestational diabetes, macrosomia, hypertensive disorders, and lower risk of microsomia. CONCLUSIONS Overweight nutritional status (obesity and pre-obesity) was seen in 25% of adult pregnant women and it was associated with increased risk for several adverse pregnancy outcomes, such as gestational diabetes and pre-eclampsia.

Assessment of weight gain during pregnancy in general prenatal care services in Brazil

Obesity is an emerging major health risk for women around the world. In this regard, little attention has been given to pregnancy, a moment of risk not only for major weight gain in these women, but also for macrosomia in their offspring. The objective of this study is to evaluate weight gain during pregnancy. Data pertains to a cohort of pregnant women attending general prenatal care clinics in six state capitals in Brazil, from 1991 to 1995. We studied women aged 20 years and over with singleton pregnancies and no diagnosis of diabetes outside pregnancy, enrolled at approximately 20 - 28 weeks of gestation. According to the Institute of Medicine criteria, 38% (95%CI: 36-40%) of the women studied gained less and 29% (95%CI: 28-31%) had more than the recommended total weight gain. These proportions vary according to pre-pregnancy nutritional status. Given the increasing epidemic of obesity, the high prevalence of overweight and obesity in Brazilian women prior to pregnancy, and the lack of achievement of recommended weight gain during pregnancy, more effective means of managing weight gain during pregnancy are necessary.

Fasting Plasma Glucose Is a Useful Test for the Detection of Gestational Diabetes

OBJECTIVE To evaluate fasting plasma glucose as a screening test for states of gestational diabetes. RESEARCH DESIGN AND METHODS Baseline data of a cohort conducted in general prenatal care units in Brazil, enrolling 5,579 women aged ≥ 20 years with gestational ages of 24–28 weeks at the time of testing and no previous diagnosis of diabetes. A standardized 2-h 75-g oral glucose tolerance test was performed in 5,010 women. Gestational diabetes and its subcategories—diabetes and impaired glucose tolerance—were defined according to the 1994 World Health Organization panel recommendations. We evaluated screening properties of calculated sensitivity and specificity for fasting plasma glucose with receiver operator characteristic curves. RESULTS For detection of the subcategory diabetes, a fasting plasma glucose of 89 mg/dl jointly maximizes sensitivity (88%) and specificity (78%), identifying 22% of the women as test-positive. For detection of impaired glucose tolerance, a value of 85 mg/dl jointly maximizes sensitivity and specificity (68%), identifying as test-positive 35% of the women. Lowering the cut point to 81 mg/dl increases sensitivity to 81%, but decreases specificity to 54%, labeling as test-positive 49% of the women. CONCLUSIONS Fasting plasma glucose is a useful test for the screening of both subcategories of gestational diabetes, a threshold of 85 mg/dl being an acceptable option. Effective screening for the subcategory diabetes can be achieved using a cut point of 89 mg/dl. If greater emphasis is placed on the detection of impaired glucose tolerance, a lower value, 81 mg/dl, may be needed.

HYPERTENSIVE DISORDERS IN PREGNANCY: FREQUENCY AND ASSOCIATED FACTORS IN A COHORT OF BRAZILIAN WOMEN

Objective. To evaluate the frequency of and risk factors associated with hypertensive disorders in general antenatal care in five distinct areas of Brazil. Methods. We performed a cohort study of 4892 women enrolled in midpregnancy from 1991 to 1995. Patients were queried at enrollment about hypertension prior to pregnancy. Medical diagnoses of hypertensive disorders in pregnancy were abstracted from patient records. Hypertensive disorders in pregnancy were classified according to recommendations of the American College of Obstetrics and Gynecology (ACOG). Results. Of 4892 women studied, 367 (7.5%) presented hypertensive disorders, 113 (2.3%) being preeclampsia/eclampsia and 198 (4.0%) chronic hypertension. Frequencies of superimposed preeclampsia/eclampsia and transitory hypertension were 0.5% and 0.7%, respectively. Greater brachial arm circumference was strongly associated both with preeclampsia/eclampsia and with chronic hypertension (threefold difference across extreme quartiles, p ≤0.001). In adjusted analyses, being older, black, and obese were important and statistically significant risk factors for chronic hypertension. Similarly, nulliparity was a statistically significant risk factor for preeclampsia/eclampsia, and tendencies toward increased risk were seen for older, black, and obese women in adjusted analyses. Preeclampsia/eclampsia and chronic hypertension were notably less frequent in Manaus, although regional differences were statistically significant only for chronic hypertension. Conclusions. Hypertensive disorders commonly complicate pregnancy in Brazilian women. Risk factors for these disorders appear similar to those reported in other countries. Use of an inappropriately sized cuff to measure blood pressure may result in many false-positive diagnoses in more obese women. The considerably lower frequency of hypertensive disorders found in Manaus, in the Amazon region, warrants further study.

Waist circumference in the prediction of obesity-related adverse pregnancy outcomes

The aim of this study is to evaluate the diagnostic properties of waist circumference in the prediction of obesity-related gestational outcomes. Pregnant women 20 years or older were consecutively enrolled in six Brazilian State capitals from 1991 to 1995. Weight, height, and waist circumference were measured and an oral glucose tolerance test was performed. Patients were followed through childbirth by chart review. Diagnostic performance for the different outcomes, as measured by area under the receiver operating characteristic (ROC) curve, was estimated through logistic regression. Areas under the ROC curve (95%CI) for waist circumference were 0.621(0.589-0.652) for gestational diabetes, 0.640 (0.588-0.692) for preeclampsia, and 0.645(0.617-0.673) for macrosomia. These areas were similar to those for BMI (p > 0.05). A waist circumference of 82 cm jointly maximized sensitivity (63%) and specificity (57%). Cutoff points of 23 kg/m(2) for pre-pregnancy BMI and 26 kg/m(2) for BMI at enrollment produced similar diagnostic properties. In conclusion, waist circumference predicts obesity-related adverse pregnancy outcomes at least as well as BMI.

Fatores associados ao fumo em gestantes avaliadas em cidades brasileiras

OBJETIVO: Avaliar a correlacao dos fatores sociodemograficos e estilo de vida com o habito de fumar em gestantes atendidas em hospitais. METODOS: O delineamento foi o de um estudo transversal. A amostra foi composta por 5.539 gestantes atendidas em ambulatorios de pre-natal em hospitais publicos credenciados nas cidades de Manaus, Fortaleza, Salvador, Rio de Janeiro, Sao Paulo e Porto Alegre, entre 1991 e 1995. A selecao foi consecutiva para todas as gestantes com 20 anos ou mais de idade, excetuando-se aquelas com diabetes previa a gestacao. Foram realizadas medidas antropometricas e entrevistas entre a 21a e a 28a semanas da gravidez. Por meio de um questionario padronizado, considerou-se como fumante quem informou fumar um ou mais cigarros por dia, como ex-fumante quem informou ter fumado mais de um cigarro por dia e ter cessado, e nao fumantes quem informou nunca ter fumado um ou mais cigarros por dia. RESULTADOS: O habito de fumar na gestacao associou-se a baixa escolaridade (RC=2,13; IC 95%: 1,76-2,57) e paridade (RC=1,84; IC 95%: 1,53-2,21). Para o aumento da idade da gestante e uso de bebidas alcoolicas tambem foram observadas associacoes positivas com o fumo na gestacao. Nao foi observada nenhuma associacao significativa entre cor da pele e situacao ocupacional com fumo na gestacao. Um efeito protetor foi observado para mulheres casadas ou com companheiro (RC=0,55; IC 95%: 0,42-0,72). Entre as cidades, tomando Manaus como referencia, Porto Alegre apresentou o maior risco para fumo na gestacao (RC=5,00; IC 95%: 3,35-7,38), seguida de Sao Paulo (RC=3,42; IC 95%: 2,25-5,20), Rio de Janeiro (RC=2,53; IC 95%: 1,65-3,88) e Fortaleza (RC=2,56; IC95%: 1,74-3,78). CONCLUSOES: Os achados sao semelhantes aqueles descritos na literatura com relacao a escolaridade, paridade e situacao conjugal. Entretanto, nenhuma associacao com a cor da pele foi observada na analise multivariada. As ex-fumantes mostraram caracteristicas sociodemograficas mais proximas das nao fumantes do que das fumantes.

Pulmonary function and physical performance outcomes with preoperative physical therapy in upper abdominal surgery: a randomized controlled trial

Objective: Investigation of the effects of preoperative physical therapy on pulmonary function and physical performance before and after upper abdominal surgery. Design: Non-blind randomized controlled trial. Setting: Tertiary public hospital and private university, São Paulo state, Brazil. Subjects: Thirty-two patients undergoing abdominal surgery. Interventions: Patients were randomly assigned to receive physical therapy, with respiratory and global exercises, 2–3 weeks before surgery (treatment group; n = 16) or await operation without engaging in practicing (control group; n = 16). After surgery, a physical therapy protocol was administered to all subjects until the seventh postoperative day. Main measures: Pulmonary function outcome variables were inspiratory and expiratory strength, respiratory muscle endurance and spirometry, and physical performance outcome variables were the functional independence measure and 6-minute walk test distance. Any postoperative pulmonary complications were recorded. Results: There were no between-group differences at randomization. In the preoperative period, patients in the intervention group had higher inspiratory strength and respiratory muscle endurance than controls (88 cmH2O versus 64 cmH2O and 28 cmH2O versus 23 cmH2O, respectively; P <0 0.05). On the seventh postoperative day, in addition to inspiratory force and respiratory muscle endurance, the intervention group showed better results than controls in the functional independence measure score (118 versus 95) and 6-minute walk test distance (368.5 m versus 223 m), all P <0 0.05. Postoperative pulmonary complications occurred in 11 patients in the control group and five in the intervention group (P = 0.03). Conclusion: Preoperative physical therapy improved pulmonary function and physical performance in the pre- and postoperative periods among patients undergoing upper abdominal surgery.

Initial impact and cost of a nationwide population screening campaign for diabetes in Brazil: A follow up study

BackgroundIn 2001 Brazilian citizens aged 40 or older were invited to participate in a nationwide population screening program for diabetes. Capillary glucose screening tests and procedures for diagnostic confirmation were offered through the national healthcare system, diagnostic priority being given according to the severity of screening results. The objective of this study is to evaluate the initial impact of the program.MethodsPositive testing was defined by a fasting capillary glucose ≥ 100 mg/dL or casual glucose ≥ 140 mg/dL. All test results were tabulated locally and aggregate data by gender and clinical categories were sent to the Ministry of Health. To analyze individual characteristics of screening tests performed, a stratified random sample of 90,106 tests was drawn. To describe the actions taken for positive screenees, a random sub-sample of 4,906 positive screenees was actively followed up through home interviews.Main outcome measures considered were the number of diabetes cases diagnosed and cost per case detected and incorporated into healthcare.ResultsOf 22,069,905 screening tests performed, we estimate that 3,417,106 (95% CI 3.1 – 3.7 million) were positive and that 346,168 (290,454 – 401,852) new cases were diagnosed (10.1% of positives), 319,157 (92.2%) of these being incorporated into healthcare. The number of screening tests needed to detect one case of diabetes was 64. As many cases of untreated but previously known diabetes were also linked to healthcare providers during the Campaign, the estimated number needed screen to incorporate one case into the healthcare system was 58. Total screening and diagnostic costs were US

A nationwide population screening program for diabetes in Brazil

26.19 million, the cost per diabetes case diagnosed being US

Spatial distribution of the risk of dengue fever in southeast Brazil, 2006-2007

76. Results were especially sensitive to proportion of individuals returning for diagnostic confirmation.ConclusionThis nationwide population-based screening program, conducted through primary healthcare services, demonstrates the feasibility, within the context of an organized national healthcare system, of screening campaigns for chronic diseases. Although overall costs were significant, cost per new case diagnosed was lower than previously reported. However, cost-effectiveness analysis based on more clinically significant outcomes needs to be conducted before this screening approach can be recommended in other settings.