María Lazo-Porras

A Multiethnic Study of Pre-Diabetes and Diabetes in LMIC.

BACKGROUND Diabetes mellitus is one of the leading causes of death and disability worldwide. Approximately three-quarters of people with diabetes live in low- and middle-income countries, and these countries are projected to experience the greatest increase in diabetes burden. OBJECTIVES We sought to compare the prevalence, awareness, treatment, and control of diabetes in 3 urban and periurban regions: the Southern Cone of Latin America and Peru, South Asia, and South Africa. In addition, we examined the relationship between diabetes and pre-diabetes with known cardiovascular and metabolic risk factors. METHODS A total of 26,680 participants (mean age, 47.7 ± 14.0 years; 45.9% male) were enrolled in 4 sites (Southern Cone of Latin America = 7,524; Peru = 3,601; South Asia = 11,907; South Africa = 1,099). Detailed demographic, anthropometric, and biochemical data were collected. Diabetes and pre-diabetes were defined as a fasting plasma glucose ≥126 mg/dl and 100 to 125 mg/dl, respectively. Diabetes control was defined as fasting plasma glucose <130 mg/dl. RESULTS The prevalence of diabetes and pre-diabetes was 14.0% (95% confidence interval [CI]: 13.2% to 14.8%) and 17.8% (95% CI: 17.0% to 18.7%) in the Southern Cone of Latin America, 9.8% (95% CI: 8.8% to 10.9%) and 17.1% (95% CI: 15.9% to 18.5%) in Peru, 19.0% (95% CI: 18.4% to 19.8%) and 24.0% (95% CI: 23.2% to 24.7%) in South Asia, and 13.8% (95% CI: 11.9% to 16.0%) and 9.9% (95% CI: 8.3% to 11.8%) in South Africa. The age- and sex-specific prevalence of diabetes and pre-diabetes for all countries increased with age (p < 0.001). In the Southern Cone of Latin America, Peru, and South Africa the prevalence of pre-diabetes rose sharply at 35 to 44 years. In South Asia, the sharpest rise in pre-diabetes prevalence occurred younger at 25 to 34 years. The prevalence of diabetes rose sharply at 45 to 54 years in the Southern Cone of Latin America, Peru, and South Africa, and at 35 to 44 years in South Asia. Diabetes and pre-diabetes prevalence increased with body mass index. South Asians had the highest prevalence of diabetes and pre-diabetes for any body mass index and normal-weight South Asians had a higher prevalence of diabetes and pre-diabetes than overweight and obese individuals from other regions. Across all regions, only 79.8% of persons with diabetes were aware of their diagnosis, of these only 78.2% were receiving treatment, and only 36.6% were able to attain glycemic control. CONCLUSIONS The prevalence of diabetes and pre-diabetes is alarmingly high among urban and periurban populations in Latin America, South Asia, and South Africa. Even more alarming is the propensity for South Asians to develop diabetes and pre-diabetes at a younger age and lower body mass index compared with individuals from other low and middle income countries. It is concerning that one-fifth of all people with diabetes were unaware of their diagnosis and that only two-thirds of those under treatment were able to attain glycemic control. Health systems and policy makers must make concerted efforts to improve diabetes prevention, detection, and control to prevent long-term consequences.

Low HDL cholesterol as a cardiovascular risk factor in rural, urban, and rural-urban migrants: PERU MIGRANT cohort study

Introduction Whilst the relationship between lipids and cardiovascular mortality has been well studied and appears to be controversial, very little has been explored in the context of rural-to-urban migration in low-resource settings. Objective Determine the profile and related factors for HDL-c patterns (isolated and non-isolated low HDL-c) in three population-based groups according to their migration status, and determine the effect of HDL-c patterns on the rates of cardiovascular outcomes (i.e. non-fatal stroke and non-fatal myocardial infarction) and mortality. Methods Cross-sectional and 5-year longitudinal data from the PERU MIGRANT study, designed to assess the effect of migration on cardiovascular risk profiles and mortality in Peru. Two different analyses were performed: first, we estimated prevalence and associated factors with isolated and non-isolated low HDL-c at baseline. Second, using longitudinal information, relative risk ratios (RRR) of composite outcomes of mortality, non-fatal stroke and non-fatal myocardial infarction were calculated according to HDL-c levels at baseline. Results Data from 988 participants, rural (n = 201), rural-to-urban migrants (n = 589), and urban (n = 199) groups, was analysed. Low HDL-c was present in 56.5% (95%CI: 53.4%–59.6%) without differences by study groups. Isolated low HDL-c was found in 36.5% (95%CI: 33.5–39.5%), with differences between study groups. In multivariable analysis, urban group (vs. rural), female gender, overweight and obesity were independently associated with isolated low HDL-c. Only female gender, overweight and obesity were associated with non-isolated low HDL-c. Longitudinal analyses showed that non-isolated low HDL-c increased the risk of negative cardiovascular outcomes (RRR = 3.46; 95%CI: 1.23–9.74). Conclusions Isolated low HDL-c was the most common dyslipidaemia in the study population and was more frequent in rural subjects. Non-isolated low HDL-c increased three-to fourfold the 5-year risk of cardiovascular outcomes.

Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries

Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control.

Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries—A Systematic Review

OBJECTIVE The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation. RESEARCH DESIGN AND METHODS Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences. RESULTS Most LMIC guidelines were inadequate in terms of applicability, clarity, and dissemination plan as well as socioeconomic and ethical-legal contextualization. LMIC guidelines targeted mainly health care providers, with only a few including patients (7%), payers (11%), and policy makers (18%) as their target audiences. Compared with HIC guidelines, the spectrum of DM clinical care addressed by LMIC guidelines was narrow. Most guidelines from the LMIC complied with less than half of the IOM standards, with 12% of the LMIC guidelines satisfying at least four IOM criteria as opposed to 60% of the HIC guidelines (P < 0.001). CONCLUSIONS A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.

Resilience in Vulnerable Populations With Type 2 Diabetes Mellitus and Hypertension: A Systematic Review and Meta-analysis

BACKGROUND Patients with chronic conditions and limited access to health care experience stressful challenges resulting from the burden of managing both their conditions and their daily life demands. Resilience provides a mechanism of adapting to stressful experiences. We conducted a systematic review and meta-analysis to synthesize the evidence about interventions to enhance resiliency in managing hypertension or type 2 diabetes in vulnerable populations and to assess the efficacy of these interventions on clinical outcomes. METHODS We searched multiple databases from early inception through February 2015 including randomized controlled trials that enrolled patients with type 2 diabetes or hypertension. All interventions that targeted resilience in vulnerable populations were included. Data were synthesized to describe the characteristics and efficacy of resiliency interventions. We pooled the total effects by calculating standardized mean difference using the random-effects model. RESULTS The final search yielded 17 studies. All studies were conducted in the United States and generally targeted minority participants. Resiliency interventions used diverse strategies; discussion groups or workshops were the most common approach. CONCLUSIONS Interventions aimed at enhancing the resiliency of patients from vulnerable groups are diverse. Outcomes were not fully conclusive. There was some evidence that resiliency interventions had a positive effect on hemoglobin A1C levels but not blood pressure. The incorporation of resiliency-oriented interventions into the arsenal of preventing and managing chronic conditions appears to be an opportunity that remains to be better investigated and exploited, and there is need to pursue further understanding of the core components of any intervention that claims to enhance resilience.

Evaluation of cognitive impairment in elderly population with hypertension from a low-resource setting: Agreement and bias between screening tools

Introduction The evaluation of cognitive impairment in adulthood merits attention in societies in transition and especially in people with chronic diseases. Screening tools available for clinical practice and epidemiological studies have been designed in high-income but not in resource-constrained settings. The aim of this study was to assess the agreement and bias of three common tools used for screening of cognitive impairment in people with hypertension: the modified Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and the Leganés Cognitive Test (LCT). Methods A cross-sectional study enrolling participants with hypertension from a semi-urban area in Peru was performed. The three screening tools for cognitive impairment were applied on three consecutive days. The prevalence of cognitive impairment was calculated for each test. Pearsons correlation coefficients, Bland-Altman plots, and Kappa statistics were used to assess agreement and bias between screening tools. Results We evaluated 139 participants, mean age 76.5 years (SD ± 6.9), 56.1% females. Cognitive impairment was found in 28.1% of individuals using LCT, 63.3% using MMSE, and 100% using MoCA. Correlation coefficients ranged from 0.501 between LCT and MoCA, to 0.698 between MMSE and MoCA. Bland-Altman plots confirmed bias between screening tests. The agreement between MMSE and LCT was 60.4%, between MMSE and MoCA was 63.3%, and between MoCA and LCT was 28.1%. Conclusions Three of the most commonly used screening tests to evaluate cognitive impairment showed major discrepancies in a resource-constrained setting, signaling towards a sorely need to develop and validate appropriate tools.

Towards sustainable partnerships in global health: The case of the CRONICAS Centre of Excellence in Chronic Diseases in Peru

Human capital requires opportunities to develop and capacity to overcome challenges, together with an enabling environment that fosters critical and disruptive innovation. Exploring such features is necessary to establish the foundation of solid long-term partnerships. In this paper we describe the experience of the CRONICAS Centre of Excellence in Chronic Diseases, based at Universidad Peruana Cayetano Heredia in Lima, Peru, as a case study for fostering meaningful and sustainable partnerships for international collaborative research. The CRONICAS Centre of Excellence in Chronic Diseases was established in 2009 with the following Mission: “We support the development of young researchers and collaboration with national and international institutions. Our motivation is to improve population’s health through high quality research.” The Centre’s identity is embedded in its core values — generosity, innovation, integrity, and quality— and its trajectory is a result of various interactions between multiple individuals, collaborators, teams, and institutions, which together with the challenges confronted, enables us to make an objective assessment of the partnership we would like to pursue, nurture and support. We do not intend to provide a single example of a successful partnership, but in contrast, to highlight what can be translated into opportunities to be faced by research groups based in low- and middle-income countries, and how these encounters can provide a strong platform for fruitful and sustainable partnerships. In defiant contexts, partnerships require to be nurtured and sustained. Acknowledging that all partnerships are not and should not be the same, we also need to learn from the evolution of such relationships, its key successes, hurdles and failures to contribute to the promotion of a culture of global solidarity where mutual goals, mutual gains, as well as mutual responsibilities are the norm. In so doing, we will all contribute to instil a new culture where expectations, roles and interactions among individuals and their teams are horizontal, the true nature of partnerships.Abstract (Spanish)Además de la necesidad de contar con un ambiente proactivo que impulse la innovación crítica y disruptiva, el capital humano requiere tanto de oportunidades para su desarrollo como de capacidades para asumir y sobreponerse a retos. Explorar dichas características permitirá establecer las bases para asociaciones (en Inglés partnerships) sólidas y duraderas. En este artículo se describe la experiencia de CRONICAS Centro de Excelencia en Enfermedades Crónicas de la Universidad Peruana Cayetano Heredia en Lima, Perú, como un caso de promoción de asociaciones valiosas y sostenibles para el desarrollo de investigaciones colaborativas a nivel internacional. La Misión de CRONICAS Centro de Excelencia en Enfermedades Crónicas, establecido en el año 2009, indica que “Apostamos por la formación de jóvenes investigadores y la colaboración con instituciones locales e internacionales. Nuestra motivación es mejorar la salud de la población a través de investigación de alta calidad”. La identidad del Centro se refleja en sus valores, —generosidad, innovación, integridad y calidad— y la trayectoria del mismo es el reflejo de múltiples interacciones entre individuos, colaboradores, equipos e instituciones. Sumadas a los retos afrontados, este recorrido se traduce en experiencias concretas que alimentan una evaluación objetiva apuntando a definir un perfil o tipo de asociaciones que ameritan alimentarse y protegerse. No se pretende brindar ejemplos de un perfil particular de asociación exitosa, sino, al contrario, resaltar y transmitir potenciales oportunidades para otros grupos de investigación también ubicados en países de ingresos bajos y medios, y cómo dichas experiencias pueden proveer de una amplia plataforma que permita la generación de asociaciones fructíferas y sostenibles. En contextos con limitaciones y retos cotidianos, las asociaciones requieren ser amamantadas, cuidadas y sostenidas. El reconocer que las distintas asociaciones no son ni deberían ser idénticas entre ellas nos permite aprender de la evolución de las mismas, de sus éxitos y sus obstáculos, así como de sus fallas. Esto se traduciría ulteriormente en la promoción de una cultura de solidaridad global en donde los objetivos comunes junto con los beneficios comunes, de la mano de las responsabilidades comunes, sean la norma. De esta manera, todas las partes y actores involucrados contribuyen a instilar una nueva cultura de horizontalidad a nivel de expectativas, roles e interacciones entre individuos y sus equipos, es decir la verdadera naturaleza de un partnership.

Inadequate glycaemic control in LMIC: health system failures in Peru.

Photo: Socios en Salud, Sucursal Peru ©SES 2014. Worldwide, 80% of patients with diabetes reside in low- and middle-income countries (LMICs). These patients are at higher risk of having inadequate glycaemic control and developing serious complications from their diabetes when compared with patients from high-income countries.1 There are multiple causes explaining poor outcomes, one being the failure of healthcare systems to adapt to the necessary challenges of managing patients with chronic diseases. In Peru’s highly fragmented health system, most patients use free or low-cost public health services. In comparison with private healthcare services, those using the public healthcare system report lower satisfaction rates and longer waiting times. Nevertheless, it seems that neither public nor private health systems provide adequate diabetes prevention and management services.2 …

Perspectives, Decision Making, and Final Mode of Delivery in Pregnant Women With a Previous C-Section in a General Hospital in Peru: Prospective Analysis

Objective: Explore the perspectives, decision-making process, and final mode of delivery among pregnant women with a previous C-section (Cesarean section) in a general public sector hospital in Lima, Peru. Methods: A qualitative prospective study using semistructured interviews at two time points in the outpatient obstetrics and gynecology clinic of a public sector, university-affiliated reference hospital in Lima, Peru. Seventeen adult pregnant women with a prior C-section who were deemed by their attending obstetrician to be candidates for a trial of labor were interviewed. The first interview was between 37 and 38 weeks of pregnancy, and the second interview was 24 to 48 hours after delivery. Main outcome measures: Predelivery decision-making process and final mode of delivery. Results: Among the 17 participants, about half (9) of the participants stated that the physician explained that they had two approaches for delivery, a trial of labor after C-section (TOLAC) or elective repeated C-section (ERCD). Two women stated that their respective providers explained only one option, either an ERCD or TOLAC. However, 6 women did not receive any information from their providers about their delivery options. Of the 10 participants that decided TOLAC, 8 ended up having a C-section, and of the 7 patients that had planned an ERCD, 1 ended up having a vaginal delivery. Conclusion: Many participants affirmed that they made the decision about their approach of delivery. However, most of the participants that decided a TOLAC ended up having a C-section because of complications during the final weeks of pregnancy or during labor.

Urbanization, mainly rurality, but not altitude is associated with dyslipidemia profiles

Background Geographical and environmental features such as urbanization and altitude may influence individuals lipid profiles because of the diversity of human-environment interactions including lifestyles. Objective To characterize the association between altitude and urbanization and lipid profile among Peruvian adults aged ≥35 years. Methods Cross-sectional analysis of the CRONICAS Cohort Study. The outcomes of interest were 6 dyslipidemia traits: hypertriglyceridemia, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol (HDL-c), nonisolated low HDL-c, isolated low HDL-c, and high non-HDL-c. The exposures of interest were urbanization level (highly urban, urban, semi-urban, and rural) and altitude (high altitude vs sea level). Prevalence ratios (PRs) and 95% confidence intervals (95% CIs) were calculated using Poisson regression models with robust variance adjusting for potential confounders. Results Data from 3037 individuals, 48.5% males, mean age of 55.6 (standard deviation ±12.7) years, were analyzed. The most common dyslipidemia pattern was high non-HDL-c with a prevalence of 88.0% (95% CI: 84.9%–90.7%) in the rural area and 96.0% (95% CI: 94.5%–97.1%) in the semi-urban area. Relative to the highly urban area, living in rural areas was associated with a lower prevalence of hypertriglyceridemia (PR = 0.75; 95% CI: 0.56–0.99) and high non-HDL-c (PR = 0.96; 95% CI: 0.93–0.99), whereas living in semi-urban areas was associated with higher prevalence high low-density lipoprotein cholesterol (PR = 1.37; 95% CI: 1.11–1.67). Compared with sea level areas, high-altitude areas had lower prevalence of high non-HDL-c (PR = 0.97; 95% CI: 0.95–0.99). Conclusion Urbanization but not altitude was associated to several dyslipidemia traits, with the exception of high non-HDL-c in high altitude settings.