Maria João Gregório

Promoting health equity in European children: Design and methodology of the prospective EPHE (Epode for the Promotion of Health Equity) evaluation study

BackgroundReducing health inequalities is a top priority of the public health agendas in Europe. The EPHE project aims to analyse the added value of a community-based interventional programme based on EPODE methodology, adapted for the reduction of socio-economic inequalities in childhood obesity. The interventions that will be implemented by this project focus on four energy balance-related behaviours (fruit and vegetable consumption, tap water intake, physical inactivity, sleep duration) and their determinants. This article presents the design of the effect evaluation of the EPHE project.Methods/DesignThis is a prospective two-year follow-up evaluation study, which will collect data on the energy balance-related behaviours and potential environmental determinants of 6–8 year olds, depending on the socio-economic status of the parents. For this purpose a parental self-reported questionnaire is constructed. This assesses the socio-economic status of the parents (5 items) and the dietary (12 items), sedentary (2 items) and sleeping (4 items) behaviour of the child. Alongside potential family-environmental determinants are assessed. The EPHE parental questionnaire will be disseminated in schools of a selected medium-sized city in seven European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands).DiscussionThis study will evaluate the effects of the EPHE community-based interventional programmes. Furthermore, it will provide evidence for children’s specific energy balance-related behaviours and family environmental determinants related to socio-economic inequalities, in seven European countries.

Food Insecurity Is Associated with Low Adherence to the Mediterranean Diet and Adverse Health Conditions in Portuguese Adults

Background Food insecurity is a limited or uncertain access to the adequate food and is a significant public health problem. We aimed to assess determinants of food insecurity and the corresponding health impact in Portugal, a southern European country that faced a severe economic crisis. Methods Data were derived from the Epidemiology of Chronic Diseases Cohort Study (EpiDoC), a population-based cohort of 10,661 individuals that were representative of the Portuguese adult population and followed since 2011. A cross-sectional analysis of the third wave of evaluation (EpiDoC 3) was performed between 2015 and 2016. Food insecurity was assessed with the household food insecurity psychometric scale. Socioeconomic, demographic, lifestyle, adherence to Mediterranean diet (MD), self-reported non-communicable disease, health-related quality of life (HRQoL) (EQ-5D-3L), physical function (HAQ score), and health resource consumption information was also collected. Results The estimated proportion of food insecurity was 19.3% among a total of 5,653 participants. Food insecure households had low adherence to the MD (OR = 0.44; 95% IC 0.31–0.62). In addition, diabetes (OR = 1.69; 95% IC 1.20–2.40), rheumatic disease (OR = 1.67; 95% IC 1.07–2.60), and depression symptoms (OR = 1.50; 95% IC 1.09–2.06) were independently associated with food insecurity. On average, food insecure households had a lower HRQoL (OR = 0.18; 95% IC 0.11–0.31) and a higher disability (OR = 2.59; 95% IC 2.04–3.29). A significantly higher proportion of food insecure households reported being hospitalized (OR = 1.57; 95% IC 1.18–2.07) and had more public hospital medical appointments (OR = 1.48; 95% IC 1.12–1.94) in the previous 12 months. Conclusion We found that food insecurity is highly prevalent in Portugal. Food insecurity was associated with low adherence to the MD, non-communicable chronic diseases, lower quality of life, and higher health resource consumption. Therefore, this study provides valuable insight into the relationship between food security and the diet and health of the population during an economic crisis.

Inequities in energy-balance related behaviours and family environmental determinants in European children: baseline results of the prospective EPHE evaluation study

BackgroundTackling inequalities in overweight, obesity and related determinants has become a top priority for the European research and policy agendas. Although it has been established that such inequalities accumulate from early childhood onward, they have not been studied extensively in children. The current article discusses the results of an explorative analysis for the identification of inequalities in behaviours and their determinants between groups with high and low socio-economic status.MethodsThis study is part of the Epode for the Promotion of Health Equity (EPHE) evaluation study, the overall aim of which is to assess the impact and sustainability of EPODE methodology to diminish inequalities in childhood obesity and overweight. Seven community-based programmes from different European countries (Belgium, Bulgaria, France, Greece, Portugal, Romania, The Netherlands) participate in the EPHE study. In each of the communities, children aged 6–8 years participated, resulting in a total sample of 1266 children and their families. A parental self-administrated questionnaire was disseminated in order to assess the socio-economic status of the household, selected energy balance-related behaviours (1. fruit and vegetable consumption; 2. soft drink/ fruit juices and water consumption; 3. screen time and 4. sleep duration) of the children and associated family environmental determinants. The Mann–Whitney U test and Pearson’s chi-square test were used to test differences between the low and high education groups. The country-specific median was chosen as the cut-off point to determine the educational level, given the different average educational level in every country.ResultsChildren with mothers of relatively high educational level consumed fruits and vegetables more frequently than their peers of low socio-economic status. The latter group of children had a higher intake of fruit juices and/or soft drinks and had higher screen time. Parental rules and home availability were consistently different between the two socio-economic groups in our study in all countries. However we did not find a common pattern for all behaviours and the variability across the countries was large.ConclusionsOur findings are indicative of socio-economic inequalities in our samples, although the variability across the countries was large. The effectiveness of interventions aimed at chancing parental rules and behaviour on health inequalities should be studied.

Ações de alimentação e nutrição e sua interface com segurança alimentar e nutricional: uma comparação entre Brasil e Portugal

Abstract This paper aims to compare food and nutrition actions related to foodsecurity (FS) in Brazil and Portugal, keeping in mind that several countries have established guidelines to guarantee adequate food. Both nations are experiencing a reduction in fertility rates, increased life expectancy, and a high prevalence of non-communicable diseases. In Bra-zil, 30.2% of households live in food insecurity; in Portugal, even without estimating food insecurity, 18.0% of its inhabitants are at risk for poverty. The National Food and Nutrition Policy is the current Brazilian document which seeks to ensure univer-sal access to food. Portugal, due to its inclusion in the European Union, is guided by the Second WHO European Action Plan for Food and Nutrition Policy as well as by the Portuguese National Health Plan, which has been updated periodically. Guided by the intersectoral approach, these countries share actions related to FS, such as combating obesity, preventing nutritional deficiences and promoting nutrition education in schools, whereas, specifically in Brazil, some strategies also combat malnutrition and, in Portugal, are linked to industry and the production of safe food. With relation to FS, some distinctions were seen: FS is more widely discussed by Brazilian policies, while this subject is implied in several food and nutrition actions in Portugal. Keywords: Health Public Policy; Food Security; Nu -trition Programs; Brazil; Portugal.

Time and regional perspectives of food insecurity during the economic crisis in Portugal, 2011-2013

Food insecurity (FI) has received much attention in recent years, even in high-income countries, due to the increasing trend of poverty and social inequalities indicators, as a result of the global financial crisis. The establishment of a monitoring system of FI becomes a priority for food and nutrition policies. Our study aims to evaluate FI trends during the economic crisis in Portugal and to identify regional disparities throughout the country. Data derived from three surveys conducted by the Portuguese Directorate-General of Health, concerning FI of the Portuguese population, during the period that Portugal was under the International Monetary Fund financial assistance program (2011‐2013). Data were collected by face-to-face interviews and FI was evaluated using a psychometric scale. Logistic regression models were used to identify regional disparities in FI. The prevalence of FI was relatively unchanged at national and regional levels, during the analysis period. Data from 2013 indicates a high prevalence of FI (50.7%), including 33.4% for low FI, 10.1% for moderate FI and 7.2% for severe FI. Disparities according health region were also found for household FI. Algarve, Lisboa and Vale do Tejo were the two regions with the highest levels of FI, even after controlling for other socioeconomic variables. High levels of FI found in Portugal and the different regional profiles suggest the need for regional strategies, in particu

Common Evaluations of Disease Activity in Rheumatoid Arthritis Reach Discordant Classifications across Different Populations

Objectives The classification of disease activity states in rheumatoid arthritis (RA) can be achieved through disease activity indices, such as the Disease Activity Score in 28 joints erythrocyte sedimentation rate (DAS28-ESR), the Simplified Disease Activity Index (SDAI), and the Clinical Disease Activity Index (CDAI). Subjective measurements, such as patient reported outcomes have been incorporated into several of these indices alongside more objective assessments, such as increases in the ESR and C-reactive protein. Moreover, while they use similar criteria, different indices weight these criteria to different extents. Therefore, the classifications based on each evaluation may not always be the same. We aim to compare the performance of the three indices and their individual components in two different populations. Methods Data from Dutch and Portuguese adherent centers were extracted from the METEOR database, a multinational collaboration on RA. We included a total of 24,605 visits from Dutch centers (from 5,870 patients) and 20,120 visits from Portuguese centers (from 3,185 patients). We compared the disease activity states as evaluated by the DAS28-ESR, CDAI, and SDAI across the two populations. In addition, we analyzed the individual components of each evaluation, including their respective contributions to the outcome, in each population. Results We found significant differences in the disease activity states classified with the DAS28-ESR between the two populations. SDAI and CDAI had more congruous results. While the proportion of visits to Dutch and Portuguese centers that were classified as “in remission” was very similar between the CDAI and SDAI, the DAS28-ESR gave discordant results. Dutch patients had lower ESRs, which is more heavily weighted in the DAS28-ESR. In addition, even though the mean physicians’ global assessment values did not vary significantly for Dutch vs Portuguese physicians, we found that doctors at Portuguese centers overall scored the physician’s global assessment lower than Dutch physicians for patient visits classified by disease activity state. Conclusion While the CDAI and SDAI assigned disease activity states that were largely similar, the DAS28-ESR was often discordant across the two populations. Moreover, we found that physicians, more than patients, evaluated disease activity differently among the Portuguese and Dutch populations.

Dietary Patterns Characterized by High Meat Consumption Are Associated with Other Unhealthy Life Styles and Depression Symptoms

Objective We aimed to identify dietary patterns (DPs) of Portuguese adults, to assess their socioeconomic, demographic, lifestyle determinants, and to identify their impact on health. Design EpiDoC 2 study included 10,153 Portuguese adults from the EpiDoC Cohort, a population-based study. In this study, trained research assistants using computer-assisted telephone interview collected socioeconomic, demographic, dietary, lifestyles, and health information from March 2013 to July 2015. Cluster analysis was performed, based on questions regarding the number of meals, weekly frequency of soup consumption, vegetables, fruit, meat, fish, dairy products, and daily water intake. Factors associated with DP were identified through logistic regression models. Results Two DPs were identified: the “meat dietary pattern” and the “fruit & vegetables dietary pattern.” After multivariable adjustment, women (OR = 0.52; p < 0.001), older adults (OR = 0.97; p < 0.001), and individuals with more years of education (OR = 0.96; p = 0.025) were less likely to adopt the “meat dietary pattern,” while individuals in a situation of job insecurity/unemployment (OR = 1.49; p = 0.013), Azores island residents (OR = 1.40; p = 0.026), current smoking (OR = 1.58; p = 0.001), daily alcohol intake (OR = 1.46; p = 0.023), and physically inactive (OR = 1.86; p < 0.001) were positively and significantly associated with “meat dietary pattern.” Moreover, individuals with depression symptoms (OR = 1.50; p = 0.018) and the ones who did lower number of medical appointments in the previous year (OR = 0.98; p = 0.025) were less likely to report this DP. Conclusion Our results suggest that unhealthy DPs (meat DP) are part of a lifestyle behavior that includes physical inactivity, smoking habits, and alcohol consumption. Moreover, depression symptoms are also associated with unhealthy DPs.

Inequalities in energy-balance related behaviours and family environmental determinants in European children: changes and sustainability within the EPHE evaluation study

BackgroundIncreasing social inequalities in health across Europe are widening the gap between low and high socio-economic groups, notably in the prevalence of obesity. Public health interventions may result in differential effects across population groups. Therefore, the EPHE (EPODE for the Promotion of Health Equity) project analysed the added value of community-based programmes, based on the EPODE (Ensemble Prévenons l’Obésité Des Enfants-Together Let’s Prevent Obesity) model, to reduce socio-economic inequalities in energy balance-related behaviours of children and their family-environmental related determinants in seven European communities. This study presents the changes between baseline and follow-up after the one-year interventions and their sustainability one year after.MethodsThis is a prospective study with a one school-year intervention, followed by one year of follow-up. In all, 1266 children (age 6-8 years) and their families from different socio-economic backgrounds were recruited at baseline. For 1062 children, information was available after one year (T1) and for 921 children after two years (T2). A self-reported questionnaire was completed by the parents to examine the children’s energy balance-related behaviours and family- environmental determinants. Socio-economic status was defined by the educational level of the mother. The Wilcoxon signed-rank test for paired data was used to test the differences between baseline and intermediate, and between intermediate and final, measurements for each of the socio-economic status groups.ResultsPost-intervention effects in energy-balance related behaviours showed the following improvements among the low socio-economic status groups: increased fruit consumption (Netherlands), decreased fruit juices amount consumed (Romania) and decreased TV time on weekdays (Belgium). Whereas in only the latter case the behavioural change was accompanied with an improvement in a family-environmental determinant (monitoring the time the child watches TV), other improvements in parental rules and practices related to soft drinks/fruit juices and TV exposure were observed. A few of those effects were sustainable, notably in the case of Belgium.ConclusionsInequalities in obesity-related behaviours could be potentially reduced when implementing community-based interventions, tailored to inequality gaps and using the EPODE methodology. Within-group changes varied widely, whereas monitoring of interventions and process evaluation are crucial to understand the observed results.

Food Insecurity in Older Adults: Results From the Epidemiology of Chronic Diseases Cohort Study 3

Introduction: The public health problem of food insecurity also affects the elderly population. This study aimed to estimate the prevalence of household food insecurity and its associations with chronic disease and health-related quality of life characteristics in individuals ≥65 years of age living in the community in Portugal. Methods: The data were collected from the Epidemiology of Chronic Diseases Cohort Study 3 (EpiDoC3)—Promoting Food Security Study (2015–2016), which was the third evaluation wave of the EpiDoC and represented the Portuguese adult population. Food insecurity was assessed using a psychometric scale adapted from the Brazilian Food Insecurity Scale. The data on sociodemographic variables, chronic disease, and management of chronic disease were self-reported. Health-related quality of life were assessed using the European Quality of Life Survey (version validated for the Portuguese population). Logistic regression models were used to determine crude and adjusted odds ratios (for age group, gender, region, and education). The dependent variable was the perceived level of food security. Results: Among older adults, 23% were living in a food-insecure household. The odds of living in a food-insecure household were higher for individuals in the 70–74 years age group (odds ratio (OR) = 1.405, 95% confidence interval (CI) 1.392–1.417), females (OR = 1.545, 95% CI 1.534–1.556), those with less education (OR = 3.355, 95% CI 3.306–3.404), low income (OR = 4,150, 95% CI 4.091–4.210), and those reporting it was very difficult to live with the current income (OR = 16.665, 95% CI 16.482–16.851). The odds of having a chronic disease were also greater among individuals living in food-insecure households: diabetes mellitus (OR = 1.832, 95% CI 1.818–1.846), pulmonary diseases (OR = 1.628, 95% CI 1.606–1.651), cardiac disease (OR = 1.329, 95% CI 1.319–1.340), obesity (OR = 1.493, 95% CI 1.477–1.508), those who reduced their frequency of medical visits (OR = 4.381, 95% CI 4.334–4.428), and who stopped taking medication due to economic difficulties (OR = 5.477, 95% CI 5.422–5.532). Older adults in food-insecure households had lower health-related quality of life (OR = 0.212, 95% CI 0.210–0.214). Conclusions: Our findings indicated that food insecurity was significantly associated with economic factors, higher values for prevalence of chronic diseases, poor management of chronic diseases, and decreased health-related quality of life in older adults living in the community.

Anxiety and Depression in the Portuguese Older Adults: Prevalence and Associated Factors

Anxiety and depression in the elderly individuals have been studied around the world, and some authors consider them among the most serious problems faced by modern societies. With recent economic crisis—very important in Southern European countries—isolation, loneliness, and exclusion of the active society, mental problems are probably raising and associated with distinct factors. In this cross-sectional analysis, nested in a longitudinal population-based cohort study, we analyze anxiety and depression prevalence, and their related factors, in a representative cohort of Portuguese seniors. We used data retrieved from second wave of follow-up of EpiDoC Cohort—EpiDoC 2 study, which is composed by 10,661 adults, representative of adult Portuguese population. This study included all ≥65 years old EpiDoC 2 study participants, who responded to Hospital Anxiety and Depression Scale (HADS), n = 1,680. Sociodemographic, lifestyles, self-reported non-communicable diseases, health-related quality of life (EQ-5D-3D), physical function (HAQ), and health resources consumption data were collected. Anxiety and depression were assessed with HADS. Anxiety and depression prevalence were estimated. Multivariable logistic regression was used to assess anxiety and depression score determinants. The estimated prevalence of anxiety among Portuguese elderly is 9.6% and depression is 11.8%. Seniors with anxiety and seniors with depression have a higher probability to self-report higher levels of physical disability (OR = 3.10; 96% CI 2.12–4.52; OR = 3.08, 95% CI 2.29–4.14, respectively) and lower levels of quality of life (OR = 0.03, 95% CI 0.01–0.09; OR = 0.03, 95% CI 0.01–0.06, respectively). Female gender (OR = 2.77, 95% CI 1.53–5.00), low educational level (OR = 2.30, 95% CI 1.22–4.36), allergic (OR = 2.02, 95% CI 1.14–3.55), and rheumatic disease (OR = 2.92, 95% CI 1.74–4.90) were significantly and independently associated with the presence of anxiety symptoms. Physical inactivity (OR = 1.64, 95% CI 1.11–2.42) and low educational level (OR = 2.40, 95% CI 1.41–4.09) were significantly and independently associated with depression symptoms. Subjects that reported to drink alcohol daily or occasionally were negatively associated with depression symptoms. Anxiety and depression are frequent among Portuguese elderly. These prevalence rates suggest that preventing mental illness in senior population is a crucial need. A well-designed prevention strategy might have an effective action in raising the well-being of elderly.