Maria Cecília Formoso Assunção

Atenção primária em diabetes no Sul do Brasil: estrutura, processo e resultado

OBJETIVO: Descrever e avaliar a estrutura, o processo e o resultado do cuidado do paciente diabetico atendido em nivel primario de atencao a saude em Pelotas, RS. METODOS: O delineamento foi transversal. Foram estudados todos os 32 postos de saude e 61 medicos que atendem pacientes diabeticos nesses locais. Foi identificada uma amostra de 378 pacientes que tiveram consulta medica nos postos. Os pacientes foram entrevistados em casa, e sua glicemia capilar, pressao arterial e indice de massa corporal foram avaliados e comparados a padroes. Componentes da estrutura e do processo de atendimento foram comparados a padroes recomendados ao manejo de pacientes diabeticos. RESULTADOS: A maioria dos servicos carece de aproximadamente todos os requerimentos minimos. A afericao da pressao arterial foi o item do exame fisico mais relatado na visita inicial. Como plano de tratamento na consulta inicial, cerca de 85% dos medicos relataram prescrever dieta, e 72% exercicio fisico. Todos os medicos relataram solicitar glicemia de jejum, e 60% hemoglobina glicosilada na monitorizacao laboratorial dos pacientes. O controle da doenca variou de 6% a 11%, conforme os diferentes parâmetros utilizados. CONCLUSOES: A rede publica de saude esta deficiente, mas existe potencial de melhoria dos tres aspectos (estrutura, processo e resultado) atraves de treinamento em servico e seguimento de normas-padrao.

Anemia em menores de seis anos: estudo de base populacional em Pelotas, RS

OBJETIVO: Analisar a prevalencia de anemia em criancas menores de seis anos, em uma amostra probabilistica de area urbana. METODOS: Foi realizado estudo com criancas de zero a cinco anos de idade, na cidade de Pelotas, RS, em 2004. Foram coletadas informacoes sobre caracteristicas demograficas, socioeconomicas, antropometricas, de morbidade e sobre alimentacao, por meio de questionario aplicado as maes ou responsaveis. As criancas foram pesadas e medidas. A concentracao de hemoglobina foi medida com hemoglobinometro portatil, HemoCue e anemia foi definida como valores de hemoglobina <11 g/dL. A associacao entre anemia e preditores foi expressa como razao de prevalencia. Foi realizada analise multivariada por regressao de Poisson a partir de um modelo conceitual, considerando o efeito do delineamento do estudo. RESULTADOS: Foram identificadas 534 criancas e as perdas e recusas totalizaram 27 criancas (5,1%). A prevalencia de anemia foi 30,2% (IC 95%: 23,5%;37,0%). Na analise multivariada, somente idade e renda familiar permaneceram significativamente associadas com anemia. CONCLUSOES: A anemia foi, em grande parte, socialmente determinada na populacao estudada. Intervencoes com o objetivo de combate-la devem ser delineadas para amenizar esta condicao em curto prazo e direcionadas para populacoes menos favorecidas economicamente.

O Mestrado do Programa de Pós-graduação em Epidemiologia da UFPel baseado em consórcio de pesquisa: uma experiência inovadora

O Programa de Pos-graduacao em Epidemiologia da UFPel realizou um intenso trabalho de auto-avaliacao para resolver problemas identificados com seu curso de mestrado. O resultado foi a introducao de uma estrutura curricular baseada em dois pilares. De um lado, disciplinas de cunho teorico, fornecendo a base da formacao do mestrando; de outro, disciplinas de cunho pratico, onde os alunos trabalham coletivamente a construcao de seu projeto de pesquisa, passando pela escolha de um tema, revisao da literatura, definicao de objetivos e da metodologia. Esse esforco conjunto culmina na realizacao de um trabalho de campo unico, na forma de um estudo transversal de base populacional, em que todos os mestrandos participam de maneira integral, obtendo dados para sua dissertacao. Essa estrategia tem garantido a formacao de mestres em epidemiologia com forte base teorica e com experiencia de preparacao e conducao de um trabalho de campo. Alem disso, tem sido possivel manter um tempo de titulacao abaixo de 24 meses. Cerca de 80% dos egressos tem publicado pelo menos um artigo baseado em seu mestrado. Destas publicacoes, quase 90% tem se dado em periodicos classificados como Internacional-A no Qualis da Capes.

Traumatic dental injuries in primary dentition: epidemiological study among preschool children in South Brazil

AIM To estimate the prevalence of traumatic injury in primary dentition among children aged 12-71 months old, as well as to evaluate the distribution of traumatic injuries, type of trauma and associated factors. MATERIAL AND METHODS After the research project approval by the Ethics Research Committee, a cross-sectional study was carried out including 571 preschool children--both from public and private schools--in the city of Pelotas, Southern Brazil. Data were collected by means of anterior teeth examination, and by the administration of a structured questionnaire to parents. The classification proposed by Andreasen & Andreasen was used, and crown discoloration and fistula were added to this criterion. RESULTS AND CONCLUSIONS The prevalence of dental trauma was 36.6% (95% CI 32.7-40.5), with no significant differences between boys and girls. Trauma were more frequent among older children (P = 0.001). No associations were found for maternal schooling, income and type of school. The most frequent trauma was enamel fracture, and the most affected tooth was number 61. A significant statistical association was observed between the presence of dental trauma during clinical examination and parental report of trauma occurrence. The percentage of parents who looked for dental treatment was higher among children from private schools (P = 0.001). The most frequent place of occurrence was home, and the most frequently reported etiology was childs own-height fall. CONCLUSIONS Dental trauma in primary teeth is characterized as an accident that occurs due to the childrens development stage, even when they are cared for by mothers of higher schooling and income. Parents should search for assistance right after trauma occurrence to minimize sequelae.

Hábitos alimentares de escolares adolescentes de Pelotas, Brasil

OBJETIVO: Descrever a frequencia com que escolares adolescentes de Pelotas (RS) estao seguindo as recomendacoes nacionais para uma alimentacao saudavel. METODOS: Estudo transversal aninhado a um estudo longitudinal em 2004, incluindo adolescentes de 13 e 14 anos matriculados em 32 escolas publicas de Pelotas (RS). A amostra incluiu 2.209 adolescentes. Para avaliacao da frequencia de consumo alimentar, foi utilizado questionario proposto pelo Instituto Nacional do Câncer. Foram construidos desfechos baseados nos dez passos para a alimentacao saudavel propostos pelo Ministerio da Saude do Brasil. RESULTADOS: Os habitos alimentares saudaveis mais frequentes foram o consumo diario de feijao e leite, relatado por cerca de metade dos adolescentes. Quase metade dos jovens referiu ingerir batata frita e salgadinhos no maximo uma vez por semana. Verificou-se consumo adequado de alimentos conservados e enlatados em 44,6% dos adolescentes. Pouco menos da metade dos jovens (43,6%) nunca colocava sal adicional na comida. Quanto ao consumo de doces e outros alimentos ricos em acucar, constatou-se que aproximadamente um terco deles consumia bolos ou biscoitos no maximo duas vezes por semana. CONCLUSAO: Verificou-se baixa frequencia de habitos alimentares saudaveis em todos os subgrupos estudados, sendo a frequencia mais baixa entre jovens de maior nivel socioeconomico e entre as meninas. O habito alimentar que apresentou mais baixa frequencia - 5,3% dos adolescentes - foi o consumo de frutas e verduras cinco ou mais vezes por dia. Politicas publicas de promocao da saude voltadas a melhoria da alimentacao e nutricao dos adolescentes sao necessarias e urgentes.

Efeito da fortificação de farinhas com ferro sobre anemia em pré-escolares, Pelotas, RS

OBJECTIVE Iron fortification of flour has been sanctioned by the Brazilian government since 2004. The objective of the study was to assess the impact of flour fortification on hemoglobin level in children under six. METHODS A time-series study was carried out in Pelotas, southern Brazil, consisting of three assessments at a 12-month interval. In May 2004, before flour fortification, hemoglobin measurements were obtained in a probabilistic sample of 453 children. Twelve and 24 months later, samples of 923 and 863 children were studied, respectively. RESULTS The three groups studied were comparable in terms of demographic and socioeconomic characteristics. At baseline, mean hemoglobin was 11.3 +/- 2.8 g/dL. In the post-fortification period, means were 11.2 +/- 2.8 (at 12 months) and 11.3 +/- 2.5 g/dL (at 24 months), with no statistically significant difference among the three time periods studied (p=0.16). CONCLUSIONS Fortification had no effect on hemoglobin levels of the children studied. This finding could be partially due to inadequate flour intake and/or low bioavailability of dietary iron.

Agreement between Self-Reported Smoking and Cotinine Concentration in Adolescents : A Validation Study in Brazil

PURPOSE To validate self-reported data on smoking in adolescents in comparison with cotinine concentration. METHODS Two thousand two hundred nine seventh- and eighth-grade students from 32 public schools in Pelotas, Brazil. Adolescents were contacted twice--before and after an educational intervention--and samples of urine for cotinine analyses were taken. In this paper, only data from the baseline phase are presented. High-performance liquid chromatography was used for cotinine analysis. Two cutoff points for cotinine were used: 10 ng/mL and 30 ng/mL. Two self-reported smoking variables were used: at least one cigarette smoked in the previous 30 days; and daily smoking. RESULTS The self-reported prevalence of smoking in the previous 30 days was 7.4%, and 0.9% of the adolescents reported to be daily smokers. Those who reported smoking in the previous 30 days presented mean cotinine values 10 times greater than those who reported to be nonsmokers. Using a cutoff of 10 ng/mL for cotinine, sensitivity of self-reported smoking was 16.3% (95% confidence interval [CI] 11.7; 20.9) and specificity was 93.6% (95% CI 92.8; 95.0). Using a cutoff of 30 ng/mL, sensitivity was 22.6% (95% CI 15.6; 29.6) and specificity was 93.7% (95% CI 92.6; 94.8). CONCLUSIONS Self-reported smoking presents low agreement with cotinine concentration, suggesting that adolescents underestimate tobacco consumption.

Sugar Consumption and Changes in Dental Caries from Childhood to Adolescence

There are no prospective studies investigating the effects of sugar-related feeding practices on changes in dental caries from early childhood to young adulthood. The aim of this study was to assess whether sugar-related feeding practices affect dental caries between the ages of 6 and 18 y. This birth cohort study was initiated in 1993 in Pelotas, Brazil. There were 3 dental clinical assessments; at ages 6 y (n = 359), 12 y (n = 339), and 18 y (n = 307). Sugar-related feeding practices were assessed at ages 4, 15, and 18 y. Covariates included sex and life course variables, such as family income, breast-feeding, mother’s education, regularity of dental visit, and child’s toothbrushing habits. Group-based trajectory analysis was performed to characterize trajectories of time-varying independent variables that had at least 3 time points. We fitted a generalized linear mixed model assuming negative binomial distribution with log link function on 3-time repeated dental caries assessments. One in 5 participants was classified as “high” sugar consumers, and nearly 40% were “upward consumers.” “Low consumers” accounted for >40% of the sample. High and upward sugar consumers had higher dental caries prevalence and mean DMFT in all cohort waves when compared with low sugar consumers. Caries occurred at a relatively constant rate over the period of study, but in all sugar consumption groups, the increment of dental caries was slightly higher between ages 6 and 12 y than between 12 and 18 y. Adjusted analysis showed that dental caries increment ratio between ages 6 and 18 y was 20% and 66% higher in upward and high sugar consumer groups as compared with low consumers. The higher the sugar consumption along the life course, the higher the dental caries increment. Even the low level of sugar consumption was related to dental caries, despite the use of fluoride.

Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues.

Background Maternal nutrition interventions are efficacious in improving birth outcomes. It is important to demonstrate that if delivered in field conditions they produce improvements in health and nutrition. Objective Analyses of scaling-up of five program implemented in several countries. These include micronutrient supplementation, food fortification, food supplements, nutrition education and counseling, and conditional cash transfers (as a platform for delivering interventions). Evidence on impact and cost-effectiveness is assessed, especially on achieving high, equitable, and sustained coverage, and reasons for success or failure Methods Systematic review of articles on large-scale programs in several databases. Two separate reviewers carried out independent searches. A separate review of the gray literature was carried out including websites of the most important organizations leading with these programs. With Google Scholar a detailed review of the 100 most frequently cited references on each of the five above topics was conducted. Results Food fortification programs: iron and folic acid fortification were less successful than salt iodization initiatives, as the latter attracted more advocacy. Micronutrient supplementation programs: Nicaragua and Nepal achieved good coverage. Key elements of success are antenatal care coverage, ensuring availability of tablets, and improving compliance. Integrated nutrition programs in India, Bangladesh, and Madagascar with food supplementation and/or behavioral change interventions report improved coverage and behaviors, but achievements are below targets. The Mexican conditional cash transfer program provides a good example of use of this platform to deliver maternal nutritional interventions. Conclusions Programs differ in complexity, and key elements for success vary with the type of program and the context in which they operate. Special attention must be given to equity, as even with improved overall coverage and impact inequalities may even be increased. Finally, much greater investments are needed in independent monitoring and evaluation.

Maternal Anthropometry Is Associated with the Body Mass Index and Waist:Height Ratio of Offspring at 23 Years of Age

Obesity is considered a public health problem worldwide. Evidence from epidemiologic studies has shown that early undernutrition may be a determinant of obesity later in life. Longitudinal studies are scarce in the setting of low- and middle-income countries. In Pelotas, southern Brazil, a birth cohort has been followed since 1982. Between 2004 and 2005, 4297 members of this cohort were interviewed. The aim of this study is to describe the association between maternal anthropometry and offspring BMI and waist:height ratio (WHtR) at 23 y of age in individuals from the 1982 Pelotas birth cohort. Independent variables included maternal prepregnancy BMI and maternal height, obtained in 1982. The BMI and WHtR of the offspring at 23 y of age were the outcomes. The analysis was stratified by sex and restricted to those cohort members belonging to the lower income group. Multivariable linear regression was adjusted for potential confounding or mediating factors according to a hierarchical framework. For each unit of maternal prepregnancy BMI, the offspring BMI increased 0.65 and 0.63 kg/m(2) in men and women, respectively (P < 0.001). Maternal prepregnancy BMI was directly associated with offspring WHtR in both sexes (P < 0.001). On the other hand, maternal height was not associated with offspring BMI or WHtR. In conclusion, our study suggests that maternal anthropometry is associated with the offspring BMI and WHtR at 23 y of age.