Rafael Monge-Rojas

Prevalence of overweight and obesity among Costa Rican elementary school children

OBJECTIVE Given that excessive body weight during childhood influences the development of several chronic diseases in adulthood, this study was conducted to determine the prevalence of overweight and obesity in urban and rural Costa Rican elementary school children. METHODS The study was carried out from July 2000 to April 2001. A total of 1 718 students ages 7-12 were selected from 34 schools in the capital city of San José and in other nearby urban and rural areas. Both younger children (ones aged 7 through 9 years) and older children (ones aged 10 through 12 years) with a body mass index (BMI) at or above the sex-specific 85th percentile were considered overweight. The younger children were classified as being obese if their triceps skinfold was greater than or equal to the 85th percentile for age and sex using the percentiles by age for children in the United States of America as normative standards. The older children were considered obese if they had a BMI at or above the sex-specific 85th percentile and both the triceps and subscapular skinfold thickness at or above the 90th percentile. RESULTS The prevalence of overweight was 34.5%. Children aged 7-9, boys, children from urban areas, and children of a higher socioeconomic status had a higher prevalence of overweight. The prevalence of obesity was 26.2%. A higher prevalence of obesity was found among children aged 7-9, boys, children from urban areas, and children of middle socioeconomic status. CONCLUSIONS Given the high prevalence of obesity that we found in the Costa Rican children, primary and secondary prevention measures are needed in order to reduce the proportion of deaths due to chronic nontransmissible diseases among Costa Rican adults in the coming decades.

Barriers to and Motivators for Healthful Eating as Perceived by Rural and Urban Costa Rican Adolescents

OBJECTIVE To assess the perceptions of rural and urban Costa Rican adolescents about their diet and the factors they consider significant to healthful eating. DESIGN Data were collected in focus group discussions. PARTICIPANTS The study sample included 108 male and female adolescents aged 12 to 18 years. Adolescents were recruited among 7th to 11th grade students interested in taking part in the study. SETTING Two urban and one rural high school in San José, Costa Rica. PHENOMENA OF INTEREST Diet perceptions and barriers to and motivators for healthful eating. ANALYSIS Data were reviewed for emerging themes, and themes were coded applying content analysis procedures. The conceptual model for understanding adolescent eating behavior, proposed by Story and colleagues, served as the framework for this study. RESULTS Factors perceived as barriers to adopting healthful eating practices included unavailability of healthful food in the school environment, inadequate food choices within the family diet, and the peer-group notion among males and females that healthful eating by males is effeminate. Factors perceived as motivators included improving the nutritional quality of foods available at school, adoption of healthful eating practices by the entire family, and healthful eating becoming a peer-group social norm. CONCLUSIONS AND IMPLICATIONS This study suggests that the family, peer group, and school environment are potential targets for nutrition interventions for Costa Rican adolescents, but further studies are needed to confirm this conclusion. Future studies should explore in depth the factors associated with the familys eating pattern and the influence of adolescent socialization patterns (particularly male) in the establishment of a healthful diet.

Components of the Metabolic Syndrome among a Sample of Overweight and Obese Costa Rican Schoolchildren

Background The term “pediatric metabolic syndrome” includes a cluster of cardiovascular risk factors such as insulin resistance, dyslipidemia (including increased triglycerides and decreased HDL cholesterol), hypertension, and obesity in children. No studies have been performed on this syndrome in a pediatric population in Costa Rica. Objective To establish the prevalence of metabolic syndrome and its components in 8- to 10-year old prepuberal overweight and obese schoolchildren. Methods This cross-sectional survey was conducted in 214 overweight and obese boys and girls, aged 8 to 10 years, who were selected from six urban schools from San José, Costa Rica. Anthropometric measurements and determinations of blood glucose, insulin, triglycerides, total cholesterol, HDL cholesterol, and high-sensitivity C-reactive protein (hs-CRP) were performed. The home-ostasis model assessment of insulin resistance (HOMA-IR) index and the Castelli index were calculated to assess insulin resistance and cardiovascular risk, respectively. Social and lifestyle variables were obtained through validated questionnaires. Results A total of 110 boys and 104 girls participated in this study; 37.9% of them were overweight and 62.1% were obese. Compared with boys, girls were more sedentary and had higher insulin levels (16.05 ± 10.45 μIU/mL vs. 12.72 ± 7.63 μIU/mL, p = .008), body fat (36.5% vs. 30.9%, p < .001), and HOMA-IR indexes (3.5 ± 2.4 vs. 2.8 ± 1.7, p = .014) but lower HDL cholesterol (0.99 ± 0.23 mmol/L vs. 1.08 ± 0.27 mmol/L, p = .009). Obese children had significantly higher mean serum concentrations of insulin, hs-CRP, and triglycerides and higher insulin resistance (estimated by HOMA-IR) than overweight children, but lower mean serum levels of HDL cholesterol. The prevalence of metabolic syndrome in the study population was 5.6%. Other risk factors for developing cardiovascular disease and type 2 diabetes had high prevalence rates among the children: sedentarism (40.6%), family history of type 2 diabetes (73.3%), high LDL cholesterol levels (≥ 2.84 mmol/L) (57.0%), hyperinsulinemia (> 10.5 μIU/mL) (59.8%), insulin resistance (estimated by HOMA-IR ≥ 2.4) (55.1%), and total cholesterol (> 4.39 mmol/L) (60.7%). Children with metabolic syndrome had significantly higher body mass indexes, glucose levels, and triglyceride levels and lower HDL cholesterol levels than children without metabolic syndrome. Insulin had a very strong positive correlation with HOMA-IR values (r = 0.982), and hs-CRP had a mild positive correlation with body mass index (r = 0.296) and body fat (r = 0.320). Conclusions This study reported a prevalence of 5.6% of metabolic syndrome among a sample of Costa Rican overweight and obese prepuberal children. Lifestyle interventions focusing on weight reduction and increasing physical activities should be promoted by education and health authorities in order to avoid the early development and onset of type 2 diabetes and atherosclerosis in childhood.

Saturated and Cis- and Trans-Unsaturated Fatty Acids Intake in Rural and Urban Costa Rican Adolescents

Objective: The purpose of this study is to determine whether intake of saturated fatty acids and cis- and trans-unsaturated fatty acids is associated with an urban compared to a rural lifestyle, and whether these associations are responsible for differences in plasma lipid concentrations. Methods: Two hundred seventy-five adolescents, aged 12 to 19 years, living in rural and urban areas of San José, Costa Rica, were included in the study. All participants completed three-day food records, provided a fasting blood sample, and carried out a modified Harvard Step Test. Results: Compared to rural, urban adolescents reported higher intakes of energy-adjusted individual and total saturated fatty acids, total n-3, total n-6 (p < 0.05). Compared to rural, urban adolescents had higher intake of 18:1 (3.65 vs. 3.25, p = 0.0001) and 18:2 (0.62 vs. 0.80, p = 0.001) trans fatty acids, as well as lower intake of carbohydrate (p < 0.05). Palm shortening was the main source of saturated fat (32%), and partially hydrogenated soybean oil used for cooking was the main source of n-3 fatty acids (33%), n-6 fatty acids (33%) and trans fatty acids (34%). Compared to rural, urban adolescents had lower systolic and diastolic blood pressure and higher plasma HDL cholesterol concentration (44 vs. 40 mg/dL, p < 0.0001), but were more likely to be sedentary (68% vs. 57%, p < 0.0001). Among environmental factors, higher carbohydrate intake was a significant determinant of a lower HDL cholesterol (β coeff = −1.45, p = 0.04), while lauric and myristic fatty acids correlated with increased LDL cholesterol (β coeff = 3.6, 1.7, p < 0.05). Conclusions:A diet containing less carbohydrate and less saturated fatty acids contributes to a more beneficial lipid profile in Costa Rican adolescents, but a trend towards high trans fatty acids intake, particularly in the urban area is worrisome given the well-known adverse effects of trans fatty acids.

La violencia física, psicológica, emocional y sexual durante el embarazo: riesgo reproductivo predictor de bajo peso al nacer en Costa Rica

OBJECTIVE To determine the prevalence of physical, psychological, emotional, and sexual violence during pregnancy and the association that that violence has with low birthweight. METHODS For 118 women who gave birth between September 1998 and November 1999 we explored the violence that they had suffered during their pregnancy. All the women were residents of Finca San Juan, a low-income urban settlement in the Rincón Grande de Pavas section of San José, Costa Rica. We used a previously validated questionnaire with closed questions. A multiple linear regression model was used to adjust the average weights of the newborns according to the characteristics of the mother: age, years of schooling, marital status, desire for the pregnancy, harmful habits (smoking, drinking alcohol), number of previous pregnancies and childbirths, birth interval, physical stature, total increase in weight during the pregnancy, and illnesses during the gestation. A logistic regression model was used to measure the direct effect of violence on low birthweight, and a nonparametric method was used to calculate the attributable fraction among the exposed women. RESULTS The newborns of the mothers who suffered acts of violence weighed on average 449.4 g less that the newborns of the women who had not been exposed to acts of violence (P < 0.001). The mothers who suffered acts of violence were three times as likely to have a newborn with low birthweight (95% confidence interval: 1.39 to 8.10). The variables that were most closely associated with low birthweight were violence suffered by the mother (direct association) and the mothers weight gain during pregnancy (inverse relation). CONCLUSIONS Our results indicate the need to investigate this subject more deeply, to train health workers concerning violence toward women as a reproductive-risk factor, and to form groups of experts on this subject to develop specialized protocols for the early identification of pregnant women subject to violence.

Barriers to and Suggestions for a Healthful, Active Lifestyle as Perceived by Rural and Urban Costa Rican Adolescents

OBJECTIVE To assess the perceptions of rural and urban Costa Rican adolescents regarding which barriers and motivators affect their adoption of an active lifestyle. DESIGN Data were collected in focus group discussions. PARTICIPANTS 108 male and female adolescents aged 12 to 18 from the 7th to 11th grades. SETTING Two urban and 1 rural high school in San José, Costa Rica. PHENOMENA OF INTEREST Active lifestyle; barriers and motivators for active life. ANALYSIS Data were reviewed for emerging themes, and themes were coded using content analysis procedures. RESULTS Major barriers: (a) physical education curriculum was focused on competitive sports; (b) lack of facilities in the school and community environments; (c) family did not provide good role models and reinforced the socially expected gender roles. Key motivators: (a) changed the physical education curriculum to focus on leisure and recreational activities; (b) increased the availability of facilities both in the school and in the community; and (c) provided a strong social support network. CONCLUSIONS AND IMPLICATIONS The school, community, and family environments are potential targets for physical activity interventions for adolescents. Future studies should explore in depth the influence of adolescent socialization patterns (particularly for females) in the establishment of an active lifestyle.

Impact of WHO recommendations to eliminate industrial trans-fatty acids from the food supply in Latin America and the Caribbean

BACKGROUND The World Health Organization (WHO) has deemed that there is enough evidence to recommend the elimination of industrially produced trans-fatty acids (TFA) from the food supply. This article evaluates government-led public health strategies in countries in Latin America and the Caribbean (LAC), and factors perceived to affect following WHOs recommendation to eliminate industrially produced TFA. METHODS Descriptive, prospective multiple case studies integrated data from open-ended questionnaires to representatives of ministries of health, and systematic review of internal and publicly available documents in 13 LAC countries. FINDINGS Overall, government efforts to follow WHO recommendations have not been well co-ordinated throughout the region. Evidence for this includes the lack of standardization of TFA definitions. For example, some countries exclude naturally occurring TFA from the definitions, whereas others leave the option open to their inclusion. As a consequence, the criteria for trans-free nutrient claims and labelling requirements are inconsistent across the region. Government-led strategies varied from banning or limiting TFA content in the food supply to voluntary labelling of TFA. The identified challenges to the implementation of policies to reduce TFA include the shortage of information on TFA content of diets and foods, consumer unawareness of TFA and lack of monitoring and surveillance. The identified enabling factors were intersectoral collaboration with industry, mandatory labelling regulation and international and national visibility of the topic, which facilitated reduction of TFA content. INTERPRETATION A co-ordinated effort is required to achieve virtual elimination of all TFA in the region, as recommended by WHO. Standardization of the definition of TFA across the region would facilitate regulation, consumer education efforts and monitoring and surveillance efforts. Simultaneously, countries need to determine their level of exposure to TFA through the implementation of small surveys to assess blood TFA levels using blood spots, and the evaluation of TFA in fat sources that are commonly used.

Genetic, dietary, and other lifestyle determinants of serum homocysteine levels in young adults in Costa Rica

OBJECTIVE Elevated serum total homocysteine (tHcy) is considered an independent risk factor for cardiovascular disease. The objective of this study was to develop the first-ever information on the prevalence of hyperhomocysteinemia and its determinants in a population in Costa Rica. METHODS A cross-sectional study was conducted to determine serum levels of tHcy, vitamin B(12), folate, and creatinine, as well as the presence of the genotype TT for the methylenetetrahydrofolate reductase (MTHFR) enzyme. Additionally, dietary vitamin intakes and other lifestyle risk factors were assessed. A total of 399 Costa Rican adults from the central valley of the country (where the capital city, San José, is located), aged 20 to 40 years, participated in this study in the year 2000. Analyses of variance were performed for continuous variables, and the chi-square test was used for categorical data. Spearman correlation tests were calculated to determine associations between variables. Three linear regression analyses and one binary logistic model were developed in order to determine the predictors for homocysteine levels in the population studied. RESULTS The overall prevalence of hyperhomocysteinemia (>15 micromol/L) in the population was 6%, 31% of the population were in the range of 10 to 15 micromol/L, 29% had the genotype TT for the enzyme MTHFR, 18% presented a vitamin B(12) deficiency (<165 pmol/L), and none of the persons had low serum folate levels (<7.0 nmol/L). No significant associations were found between tHcy and age, smoking, consuming alcohol, or dietary vitamin intake. CONCLUSIONS Only serum vitamin B(12) levels and the genotype TT of the enzyme MTHFR were considered significant predictors of high serum tHcy levels in the Costa Rica population studied.

Insulin Resistance and Impaired Glucose Tolerance in Overweight and Obese Costa Rican Schoolchildren

Background Worldwide obesity has become an unprecedented public health challenge. In addition, a notable increase in the risk of insulin resistance and type 2 diabetes mellitus has emerged. In Costa Rica, there are no epidemiological data to establish the prevalence of type 2 diabetes in the pediatric population. However, information from the Endocrinology Department of the Childrens National Hospital indicates an increased number of cases in the last 2 to 3 years. Objective To determine the prevalence of insulin resistance and impaired glucose tolerance in overweight and obese schoolchildren. Methods This cross-sectional study was conducted among 214 healthy 8- to 10-year-old children from urban schools of San José, Costa Rica. Anthropometric measurements and blood determinations of glucose, insulin, proinsulin, glycosylated hemoglobin, C-peptide, and leptin were performed. Indexes were calculated to assess insulin resistance. Information on social and lifestyle variables was obtained from questionnaires, and acanthosis nigricans was certified by a physician. Statistical analysis was performed with SPSS software for Windows, version 10.0. Results The prevalence of type 2 diabetes mellitus was very low (0.5%) in the studied population. However, hyperinsulinemia and impaired glucose tolerance were present in 20.6% and 6.5% of the subjects, respectively. On the basis of the Fasting Glucose-to-Insulin Resistance Ratio (FGIR), 46.7% of the children showed insulin resistance. Girls and obese children (body mass index ≥ 95th percentile) were more likely to have higher serum insulin levels and insulin resistance than boys and over-weight children (BMI ≥ 85th percentile). Compared with the lowest quintile, children in the highest quintile of body-fat tissue had higher insulin resistance but had similar serum concentrations of glucose, C-peptide, and proinsulin. Positive family histories of type 2 diabetes mellitus and sedentarism (73.7% and 40.7%, respectively) were highly prevalent among overweight and obese children. Conclusions The prevalence of impaired glucose tolerance and insulin resistance in obese children indicates a worrisome trend in the incidence of type 2 diabetes in Costa Rica. Strategies for weight reduction, obesity prevention, and promotion of healthy lifestyles are necessary to prevent the onset of type 2 diabetes during childhood and adolescence.

Influence of sensory and cultural perceptions of white rice, brown rice and beans by Costa Rican adults in their dietary choices ☆

Little is known about the distinct perceptions towards rice and beans that may shape the consumption of these main staple foods among Costa Ricans. We aimed to identify barriers and motivators that could change the current staple into a healthier one, and assess the sensory perceptions of these foods in this population. Focus group discussions and sensory tastings of 8 traditional white or brown rice and beans preparations were conducted in 98 Costa Ricans, aged 40-65 years. Traditional habits and family support emerged as the two main drivers for current consumption. Consuming similar amounts of rice and beans, as well as unfamiliarity with brown rice, are habits engrained in the Costa Rican culture, and are reinforced in the family and community environment. Suggested strategies for consuming more brown rice and more beans included introducing them during childhood, disseminating information of their health benefits that take into account the importance of tradition, lowering the cost, increasing availability, engaging women as agents of change and for brown rice masking the perceived unpleasant sensory characteristics by incorporating them into mixed dishes. Plain brown rice received the lowest mean hedonic liking scores. The preparations rated highest for pleasant were the beans: rice 1:1 ratio regardless of the type of rice. This study identified novel strategies to motivate Costa Rican adults to adapt their food choices into healthier ones within their cultural and sensory acceptability.