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1.  The association of birth order with later body mass index and blood pressure: a comparison between prospective cohort studies from the UK and Brazil 
Previous studies have found greater adiposity and cardiovascular risk in first born children. The causality of this association is not clear. Examining the association in diverse populations may lead to improved insight.
We examine the association between birth order and body mass index (BMI), systolic and diastolic blood pressure (SBP/DBP) in the 2004 Pelotas cohort from southern Brazil and the Avon Longitudinal Study of Parents and Children (ALSPAC) from Bristol, south west England, restricting analysis to families with two children in order to remove confounding by family size.
No consistent differences in BMI, SBP or DBP were observed comparing first and second born children. Within the Pelotas 2004 cohort, first born females were thinner, with lower SBP and DBP; e.g. mean difference in SBP comparing first with second born was -0.979 (95% confidence interval -2.901 to 0.943). In ALSPAC, first born females had higher BMI, SBP and DBP. In both cohorts, associations tended to be in the opposite direction in males, although no statistical evidence for gender interactions was found.
The findings do not support an association between birth order and BMI or blood pressure. Differences to previous studies may be explained by differences in populations and/or confounding by family size in previous studies.
PMCID: PMC4024316  PMID: 24097298
ALSPAC; birth order; blood pressure; body mass index; cardiovascular; obesity; Pelotas; siblings
2.  John Snow’s legacy: epidemiology without borders 
Lancet  2013;381(9874):1302-1311.
This Review provides abstracts from a meeting held at the London School of Hygiene and Tropical Medicine, on April 11–12, 2013, to celebrate the legacy of John Snow. They describe conventional and unconventional applications of epidemiological methods to problems ranging from diarrhoeal disease, mental health, cancer, and accident care, to education, poverty, financial networks, crime, and violence. Common themes appear throughout, including recognition of the importance of Snow’s example, the philosophical and practical implications of assessment of causality, and an emphasis on the evaluation of preventive, ameliorative, and curative interventions, in a wide variety of medical and societal examples. Almost all self-described epidemiologists nowadays work within the health arena, and this is the focus of most of the societies, journals, and courses that carry the name epidemiology. The range of applications evident in these contributions might encourage some of these institutions to consider broadening their remits. In so doing, they may contribute more directly to, and learn from, non-health-related areas that use the language and methods of epidemiology to address many important problems now facing the world.
PMCID: PMC3730273  PMID: 23582396
3.  Epidemiology and Public Health in 1906 England 
American journal of public health  2013;103(7):e17-e22.
In 1906 Arthur Newsholme linked artificial feeding and fatal diarrhea in infants aged one year and younger on the basis of two independent sources of information: mortality registration and a three-year (1903–1905) census of infants from Brighton, United Kingdom. Artificial feeding was more common in the infants who had died (89.3%) than in those in the survey (22.3%). However, boldly assuming the two data sources were nested, Newsholme computed the risks of fatal diarrhea: these were 48 times greater for infants fed fresh cow’s milk and 94 times greater for those fed condensed milk than for infants who were exclusively breast-fed. This mode of computing risks and risk ratios before the invention of the cohort study design was more innovative than was the usual investigation techniques of his contemporary epidemiologists. Newsholme’s conclusions were consistent with the current knowledge that breastfeeding protects against fatal diarrhea.
PMCID: PMC3682615  PMID: 23678939
4.  FEV1 Is a Better Predictor of Mortality than FVC: The PLATINO Cohort Study 
PLoS ONE  2014;9(10):e109732.
To determine whether the presence of chronic obstructive lung disease (COPD) and reduction of lung function parameters were predictors of mortality in a cohort.
Materials/Patients and Methods
Population based cohorts were followed in Montevideo, Santiago and Sao Paulo during 5, 6 and 9 years, respectively. Outcomes included all-cause, cardiovascular, respiratory and cancer mortality; exposures were COPD, forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). Cox regression was used for analyses. Sensitivity, specificity, positive and negative predictive values, receiver operator characteristics curves and Youden's index were calculated.
Main causes of death were cardiovascular, respiratory and cancer. Baseline COPD was associated with overall mortality (HR = 1.43 for FEV1/FVC
Answer to the Question
COPD and low FEV1 are important predictors for overall and cardiovascular mortality in Latin America.
PMCID: PMC4186841  PMID: 25285441
Background Low- and middle-income countries continue to experience a large burden of stunting; 148 million children were estimated to be stunted, around 30–40% of all children in 2011. In many of these countries, foetal growth restriction (FGR) is common, as is subsequent growth faltering in the first 2 years. Although there is agreement that stunting involves both prenatal and postnatal growth failure, the extent to which FGR contributes to stunting and other indicators of nutritional status is uncertain.
Methods Using extant longitudinal birth cohorts (n = 19) with data on birthweight, gestational age and child anthropometry (12–60 months), we estimated study-specific and pooled risk estimates of stunting, wasting and underweight by small-for-gestational age (SGA) and preterm birth.
Results We grouped children according to four combinations of SGA and gestational age: adequate size-for-gestational age (AGA) and preterm; SGA and term; SGA and preterm; and AGA and term (the reference group). Relative to AGA and term, the OR (95% confidence interval) for stunting associated with AGA and preterm, SGA and term, and SGA and preterm was 1.93 (1.71, 2.18), 2.43 (2.22, 2.66) and 4.51 (3.42, 5.93), respectively. A similar magnitude of risk was also observed for wasting and underweight. Low birthweight was associated with 2.5–3.5-fold higher odds of wasting, stunting and underweight. The population attributable risk for overall SGA for outcomes of childhood stunting and wasting was 20% and 30%, respectively.
Conclusions This analysis estimates that childhood undernutrition may have its origins in the foetal period, suggesting a need to intervene early, ideally during pregnancy, with interventions known to reduce FGR and preterm birth.
PMCID: PMC3816349  PMID: 23920141
Foetal growth restriction; preterm birth; stunting; wasting; childhood
BMC Pregnancy and Childbirth  2010;10(Suppl 1):S4.
The efficacious interventions identified in the previous article of this report will fail unless they are delivered at high and equitable coverage. This article discusses critical delivery constraints and strategies.
Barriers to scaling up interventions
Achieving universal coverage entails addressing major barriers at many levels. An overarching constraint is the lack of political will, resulting from the dearth of preterm birth and stillbirth data and the lack of visibility. Other barriers exist at the household and community levels, such as insufficient demand for interventions or sociocultural barriers; at the health services level, such as a lack of resources and trained healthcare providers; and at the health sector policy and management level, such as poorly functioning, centralized systems. Additional constraints involve weak governance and accountability, political instability, and challenges in the physical environment.
Strategies and examples
Scaling up maternal, newborn and child health interventions requires strengthening health systems, but there is also a role for focused, targeted interventions. Choosing a strategy involves identifying appropriate channels for reaching high coverage, which depends on many factors such as access to and attendance at healthcare facilities. Delivery channels vary, and may include facility- and community-based healthcare providers, mass media campaigns, and community-based approaches and marketing strategies. Issues related to scaling up are discussed in the context of four interventions that may be given to mothers at different stages throughout pregnancy or to newborns: (1) detection and treatment of syphilis; (2) emergency Cesarean section; (3) newborn resuscitation; and (4) kangaroo mother care. Systematic reviews of the literature and large-scale implementation studies are analyzed for each intervention.
Equitable and successful scale-up of preterm birth and stillbirth interventions will require addressing multiple barriers, and utilizing multiple delivery approaches and channels. Another important need is developing strategies to discontinue ineffective or harmful interventions. Preterm birth and stillbirth interventions must also be placed in the broader maternal, newborn and child health context to identify and prioritize those that will help improve several outcomes at the same time. The next article discusses advocacy challenges and opportunities.
PMCID: PMC2841777  PMID: 20233385
BMC Pregnancy and Childbirth  2010;10(Suppl 1):S7.
Preterm birth and stillbirth are complex local and global health problems requiring an interdisciplinary approach and an international commitment. Stakeholders developed recommendations for a Global Action Agenda (GAA) at the 2009 International Conference on Prematurity and Stillbirth. The primary goal of this GAA is to forge a collaborative effort toward achieving common goals to prevent preterm birth and stillbirth, and to improve related maternal, newborn, and child health outcomes.
Conference participants
GAPPS co-convened this four-day conference with the Bill & Melinda Gates Foundation, March of Dimes, PATH, Save the Children, UNICEF and the World Health Organization. Participants included about 200 leading international researchers, policymakers, health care practitioners and philanthropists. A near-final draft of this report was sent three weeks in advance to help co-chairs and participants prepare for workgroup discussions.
Global Action Agenda
Twelve thematic workgroups, composed of interdisciplinary experts, made recommendations on short-, intermediate-, and long-term milestones, and success metrics. Recommendations are based on the following themes: (1) advance discovery of the magnitude, causes and innovative solutions; (2) promote development and delivery of low-cost, proven interventions; (3) improve advocacy efforts to increase awareness that preterm birth and stillbirth are leading contributors to the global health burden; (4) increase resources for research and implementation; and (5) consider ethical and social justice implications throughout all efforts.
The conference provided an unprecedented opportunity for maternal, newborn and child health stakeholders to create a collaborative strategy for addressing preterm birth and stillbirth globally. Participants and others have already completed or launched work on key milestones identified in the GAA. Updates will be provided at
PMCID: PMC2841775  PMID: 20233388
BMC Pregnancy and Childbirth  2010;10(Suppl 1):S3.
Interventions directed toward mothers before and during pregnancy and childbirth may help reduce preterm births and stillbirths. Survival of preterm newborns may also be improved with interventions given during these times or soon after birth. This comprehensive review assesses existing interventions for low- and middle-income countries (LMICs).
Approximately 2,000 intervention studies were systematically evaluated through December 31, 2008. They addressed preterm birth or low birth weight; stillbirth or perinatal mortality; and management of preterm newborns. Out of 82 identified interventions, 49 were relevant to LMICs and had reasonable amounts of evidence, and therefore selected for in-depth reviews. Each was classified and assessed by the quality of available evidence and its potential to treat or prevent preterm birth and stillbirth. Impacts on other maternal, fetal, newborn or child health outcomes were also considered. Assessments were based on an adaptation of the Grades of Recommendation Assessment, Development and Evaluation criteria.
Most interventions require additional research to improve the quality of evidence. Others had little evidence of benefit and should be discontinued. The following are supported by moderate- to high-quality evidence and strongly recommended for LMICs:
• Two interventions prevent preterm births—smoking cessation and progesterone
• Eight interventions prevent stillbirths—balanced protein energy supplementation, screening and treatment of syphilis, intermittant presumptive treatment for malaria during pregnancy, insecticide-treated mosquito nets, birth preparedness, emergency obstetric care, cesarean section for breech presentation, and elective induction for post-term delivery
• Eleven interventions improve survival of preterm newborns—prophylactic steroids in preterm labor, antibiotics for PROM, vitamin K supplementation at delivery, case management of neonatal sepsis and pneumonia, delayed cord clamping, room air (vs. 100% oxygen) for resuscitation, hospital-based kangaroo mother care, early breastfeeding, thermal care, and surfactant therapy and application of continued distending pressure to the lungs for respiratory distress syndrome
The research paradigm for discovery science and intervention development must be balanced to address prevention as well as improve morbidity and mortality in all settings. This review also reveals significant gaps in current knowledge of interventions spanning the continuum of maternal and fetal outcomes, and the critical need to generate further high-quality evidence for promising interventions.
PMCID: PMC2841444  PMID: 20233384
Ethiopia has scaled up integrated community case management of childhood illness (iCCM) in most regions. We assessed the strength of iCCM implementation and the quality of care provided by health extension workers (HEWs). Data collectors observed HEWs' consultations with sick children and carried out gold standard re-examinations. Nearly all HEWs received training and supervision, and essential commodities were available. HEWs provided correct case management for 64% of children. The proportions of children correctly managed for pneumonia, diarrhea, and malnutrition were 72%, 79%, and 59%, respectively. Only 34% of children with severe illness were correctly managed. Health posts saw an average of 16 sick children in the previous 1 month. These results show that iCCM can be implemented at scale and that community-based HEWs can correctly manage multiple illnesses. However, to increase the chances of impact on child mortality, management of severe illness and use of iCCM services must be improved.
PMCID: PMC4125273  PMID: 24799369
International Journal of Epidemiology  2014;43(5):1437-1437f.
This is an update of the 2004 Pelotas Birth Cohort profile, originally published in 2011. In view of the high prevalence of overweight and mental health problems among Brazilian children, together with the availability of state-of-the-art equipment to assess body composition and diagnostic tests for mental health in childhood, the main outcomes measured in the fifth follow-up (mean age 6.8 years) included child body composition, mental health and cognitive ability. A total of 3722 (90.2%) of the original mothers/carers were interviewed and their children examined in a clinic where they underwent whole-body dual X-ray absorptiometry (DXA), air displacement plethysmography and a 3D photonic scan. Saliva samples for DNA were obtained. Clinical psychologists applied the Development and Well-Being Assessment questionnaire and the Wechsler Intelligence Scale for Children to all children. Results are being compared with those of the two earlier cohorts to assess the health effects of economic growth and full implementation of public policies aimed at reducing social inequalities in the past 30 years. For further information visit the programme website at []. Applications to use the data should be made by contacting 2004 cohort researchers and filling in the application form available at [].
PMCID: PMC4190519  PMID: 25063002
Global Health Action  2014;7:10.3402/gha.v7.23623.
From conception to 6 months of age, an infant is entirely dependent for its nutrition on the mother: via the placenta and then ideally via exclusive breastfeeding. This period of 15 months – about 500 days – is the most important and vulnerable in a child's life: it must be protected through policies supporting maternal nutrition and health. Those addressing nutritional status are discussed here.
Objective and design
This paper aims to summarize research on policies and programs to protect women's nutrition in order to improve birth outcomes in low- and middle-income countries, based on studies of efficacy from the literature, and on effectiveness, globally and in selected countries involving in-depth data collection in communities in Ethiopia, India and Northern Nigeria. Results of this research have been published in the academic literature (more than 30 papers). The conclusions now need to be advocated to policy-makers.
The priority problems addressed are: intrauterine growth restriction (IUGR), women's anemia, thinness, and stunting. The priority interventions that need to be widely expanded for women before and during pregnancy, are: supplementation with iron–folic acid or multiple micronutrients; expanding coverage of iodine fortification of salt particularly to remote areas and the poorest populations; targeted provision of balanced protein energy supplements when significant resources are available; reducing teenage pregnancies; increasing interpregnancy intervals through family planning programs; and building on conditional cash transfer programs, both to provide resources and as a platform for public education. All these have known efficacy but are of inadequate coverage and resourcing. The next steps are to overcome barriers to wide implementation, without which targets for maternal and child health and nutrition (e.g. by WHO) are unlikely to be met, especially in the poorest countries.
This agenda requires policy decisions both at Ministry and donor levels, and throughout the administrative system. Evidence-based interventions are established as a basis for these decisions, there are clear advocacy messages, and there are no scientific reasons for delay.
PMCID: PMC4049132  PMID: 24909407
maternal nutrition; women's health; intrauterine growth restriction; anemia; nutrition interventions
In this paper we update the profile of the 1993 Pelotas (Brazil) Birth Cohort Study, with emphasis on a shift of priority from maternal and child health research topics to four main categories of outcome variables, collected throughout adolescence: (i) mental health; (ii) body composition; (iii) risk factors for non-communicable diseases (NCDs); (iv) human capital. We were able to trace 81.3% (n = 4106) of the original cohort at 18 years of age. For the first time, the 18-years visit took place entirely on the university premises, in a clinic equipped with state-of-the-art equipment for the assessment of body composition. We welcome requests for data analyses from outside scientists. For more information, refer to our website ( or e-mail the corresponding author.
PMCID: PMC4121560  PMID: 24729426
Cadernos de saude publica  2010;26(10):1895-1903.
We evaluate the influence of demographic, socioeconomic, and maternal variables on the nutritional status of adolescents aged 11 years. We conducted a prospective cohort study including 4,452 adolescents born in Pelotas, Southern Brazil, in 1993, accounting for 87.5% of the original cohort. Nutritional status was evaluated based on World Health Organization criteria. Subjects were classified according to nutritional status into thin, normal, overweight and obese. Independent variables analyzed included skin color, socioeconomic status, maternal schooling, and maternal body mass index (BMI). Analyses were stratified by sex, and multivariable regression was performed using the multinomial logistic approach. Overall, 7% of adolescents were classified as thin, 11.6% as overweight, and 11.6% as obese. Among boys, thinness was inversely associated with maternal schooling and maternal BMI. Among girls, thinness was directly associated with maternal BMI. Overweight and obesity were directly associated with socioeconomic status and maternal BMI, the former showing the strongest association with nutritional status among adolescents.
PMCID: PMC3836176  PMID: 20963286
Nutritional Status; Adolescent; Cohort Studies
International journal of epidemiology  2013;42(5):10.1093/ije/dyt109.
Low- and middle-income countries continue to experience a large burden of stunting; 148 million children were estimated to be stunted, around 30–40% of all children in 2011. In many of these countries, foetal growth restriction (FGR) is common, as is subsequent growth faltering in the first 2 years. Although there is agreement that stunting involves both prenatal and postnatal growth failure, the extent to which FGR contributes to stunting and other indicators of nutritional status is uncertain.
Using extant longitudinal birth cohorts (n = 19) with data on birth-weight, gestational age and child anthropometry (12–60 months), we estimated study-specific and pooled risk estimates of stunting, wasting and underweight by small-for-gestational age (SGA) and preterm birth.
We grouped children according to four combinations of SGA and gestational age: adequate size-for-gestational age (AGA) and preterm; SGA and term; SGA and preterm; and AGA and term (the reference group). Relative to AGA and term, the OR (95% confidence interval) for stunting associated with AGA and preterm, SGA and term, and SGA and preterm was 1.93 (1.71, 2.18), 2.43 (2.22, 2.66) and 4.51 (3.42, 5.93), respectively. A similar magnitude of risk was also observed for wasting and underweight. Low birthweight was associated with 2.5–3.5-fold higher odds of wasting, stunting and underweight. The population attributable risk for overall SGA for outcomes of childhood stunting and wasting was 20% and 30%, respectively.
This analysis estimates that childhood undernutrition may have its origins in the foetal period, suggesting a need to intervene early, ideally during pregnancy, with interventions known to reduce FGR and preterm birth.
PMCID: PMC3816349  PMID: 23920141
Foetal growth restriction; preterm birth; stunting; wasting; childhood
BMC Medicine  2013;11:225.
The Millennium Development Goals have galvanized efforts to improve child survival (MDG-4) and maternal health (MDG-5). There has been important progress on both MDGs at global level, although it now appears that few countries will reach them by the target date of 2015. There are known and efficacious interventions to address most of the major causes of these deaths, but important gaps remain. The biggest challenge is to ensure that all women and children have access to life-saving interventions. Current levels of intervention coverage are too low, representing missed opportunities. Providing services at the community level is an important emerging priority, but preventing maternal and neonatal deaths also requires access to health facilities. Readers of the Medicine for Global Health collectiona in BMC Medicine are urged to make maternal and child health one of their key concerns, even if they work on other topics.
PMCID: PMC3852291  PMID: 24228742
Child survival; Child mortality; Maternal survival; Maternal health; Maternal mortality; Neonatal mortality; Nutrition; Millennium Development Goals
Lancet  2013;382(9890):417-425.
Babies with low birthweight (<2500 g) are at increased risk of early mortality. However, low birthweight includes babies born preterm and with fetal growth restriction, and not all these infants have a birthweight less than 2500 g. We estimated the neonatal and infant mortality associated with these two characteristics in low-income and middle-income countries.
For this pooled analysis, we searched all available studies and identified 20 cohorts (providing data for 2 015 019 livebirths) from Asia, Africa, and Latin America that recorded data for birthweight, gestational age, and vital statistics through 28 days of life. Study dates ranged from 1982 through to 2010. We calculated relative risks (RR) and risk differences (RD) for mortality associated with preterm birth (<32 weeks, 32 weeks to <34 weeks, 34 weeks to <37 weeks), small-for-gestational-age (SGA; babies with birthweight in the lowest third percentile and between the third and tenth percentile of a US reference population), and preterm and SGA combinations.
Pooled overall RRs for preterm were 6·82 (95% CI 3·56–13·07) for neonatal mortality and 2·50 (1·48–4·22) for post-neonatal mortality. Pooled RRs for babies who were SGA (with birthweight in the lowest tenth percentile of the reference population) were 1·83 (95% CI 1·34–2·50) for neonatal mortality and 1·90 (1·32–2·73) for post-neonatal mortality. The neonatal mortality risk of babies who were both preterm and SGA was higher than that of babies with either characteristic alone (15·42; 9·11–26·12).
Many babies in low-income and middle-income countries are SGA. Preterm birth affects a smaller number of neonates than does SGA, but is associated with a higher mortality risk. The mortality risks associated with both characteristics extend beyond the neonatal period. Differentiation of the burden and risk of babies born preterm and SGA rather than with low birthweight could guide prevention and management strategies to speed progress towards Millennium Development Goal 4—the reduction of child mortality.
Bill & Melinda Gates Foundation.
PMCID: PMC3796350  PMID: 23746775
Cadernos de saude publica  2010;26(10):1980-1989.
The aim of this prospective analysis was to describe the cumulative incidence of hospital admissions in the first year of life and between 1 and 11 years of age and to explore associated factors. Hospital admissions were collected through regular monitoring in the first year of life, and through maternal report on admissions between 1 and 11 years. Analyses were stratified by sex and adjusted for confounding factors. 18.1% of children were hospitalized in the first year of life, and 30.7% between ages 1 and 11 years. Among boys, hospital admission in the first year was associated with low family income, paternal smoking during pregnancy, preterm delivery, and low birthweight. Among girls, in addition to the variables described for boys, black/mixed skin color was also a risk factor for hospital admission. For admissions between 1 and 11 years of age, low family income and gestational age ≥ 37 weeks were found to be significant risk factors.
PMCID: PMC3795331  PMID: 20963296
Hospitalization; Adolescent; Child; Cohort Studies
Cadernos de saude publica  2010;26(10):1990-1999.
The aim of this study was to describe oral health follow-up studies nested in a birth cohort. A population-based birth cohort was launched in 1993 in Pelotas, Rio Grande do Sul State, Brazil. Two oral health follow-up studies were conducted at six (n = 359) and 12 (n = 339) years of age. A high response rate was observed at 12 years of age; 94.4% of the children examined at six years of age were restudied in 2005. The mean DMF-T index at age 12 was 1.2 (SD = 1.6) for the entire sample, ranging from 0.6 (SD = 1.1) for children that were caries-free at age six, 1.3 (SD = 1.5) for those with 1-3 carious teeth at six years, and 1.8 (SD = 1.8) for those with 4-19 carious teeth at six years (p < 0.01). The number of individuals with severe malocclusions at 12 years was proportional to the number of malocclusions at six years. Oral health problems in early adolescence were more prevalent in individuals with dental problems at six years of age.
PMCID: PMC3794421  PMID: 20963297
Oral Health; Cohort Studies; Child; Adolescent
Cadernos de saude publica  2010;26(10):1904-1911.
This study describes the food intake of adolescents participating in the 1993 birth cohort from Pelotas, Southern Brazil, according to socioeconomic position. We carried out a cross-sectional analysis of data collected in the 2004-2005 follow-up visit. Food intake in the previous year was evaluated using the Block questionnaire. Socioeconomic status was evaluated based on an assets index, divided into quintiles. Foods with the highest frequency of daily intake were white bread (83%), butter or margarine (74.6%), beans (66.4%) and milk (48.5%). Intake of butter or margarine, bread, and beans was more frequent among poorer adolescents, and the inverse was true for milk. Intake of fruits and vegetables was low in all socioeconomic strata, but particularly low among the poor. In early adolescence, all socioeconomic groups showed high consumption of foods rich in fat and low consumption of foods rich in fiber.
PMCID: PMC3794422  PMID: 20963287
Eating; Food Habits; Socioeconomic Factors; Adolescent; Cohort Studies
Public health nutrition  2010;14(1):150-159.
To identify dietary patterns among young adults and the relationships with socio-economic, demographic and lifestyle characteristics.
Population-based, cross-sectional analysis of a cohort study. Food intake was assessed by a frequency questionnaire, and dietary patterns were identified using principal components analysis.
Southern Brazil.
A total of 4202 men and women aged 23 years, who participated in the 1982 Pelotas Birth Cohort Study.
Five dietary patterns were identified: common Brazilian, processed food, vegetable/fruit, dairy/dessert and tubers/pasta. Subjects who had low own or maternal educational levels, low social position or who were always poor throughout life had high adherence to the common Brazilian dietary pattern. In contrast, the processed food pattern was more likely to be followed by those belonging to middle and high social position and who were never poor. Men and smokers showed high adherence to the processed food and common Brazilian dietary patterns. Vegetable/fruit pattern was more likely to be followed by women and subjects engaged in physical activity. Women also showed high adherence to the dairy/dessert pattern.
Our study among young Brazilian adults has identified distinct dietary patterns that are clearly influenced by socio-economic and lifestyle characteristics, which have important policy implications in a country with marked social and economic inequalities.
PMCID: PMC3794423  PMID: 20576193
Food intake; Dietary patterns; Socio-economic factors; Young adults
Cadernos de saude publica  2010;26(10):1972-1979.
The aim of this study was to evaluate concurrent risk factors for high blood pressure in adolescents. This is a prospective cohort study including 4,452 adolescents born in Pelotas, Rio Grande do Sul State, Brazil, in 1993. Blood pressure was measured before and after the interview, and the mean value was used in the analyses. Mean systolic blood pressure was 101.9mmHg (SD = 12.3) and mean diastolic pressure was 63.4mmHg (SD = 9.9). Adolescents with black skin had higher blood pressure than those with white skin. Mean systolic pressure among subjects in the top quartile of body mass index (BMI) was 11.6mmHg higher than among those in the lowest quartile. Mean systolic pressure among postmenarcheal girls was 5.4mmHg higher than among premenarcheal girls. Similar trends were found for diastolic arterial pressure. Our findings suggest that blood pressure control must begin already in childhood and adolescence.
PMCID: PMC3794424  PMID: 20963295
Blood Pressure; Adolescent; Cohort Studies
Revista de saude publica  2011;45(4):635-643.
To describe the patterns of deliveries in a birth cohort and to compare vaginal and cesarean section deliveries.
All children born to mothers from the urban area of Pelotas, Brazil, in 2004, were recruited for a birth cohort study. Mothers were contacted and interviewed during their hospital stay when extensive information on the gestation, the birth and the newborn, along with maternal health history and family characteristics was collected. Maternal characteristics and childbirth care financing – either private or public healthcare (SUS) patients - were the main factors investigated along with a description of C-sections distribution according to day of the week and delivery time. Standard descriptive techniques, χ2 tests for comparing proportions and Poisson regression to explore the independent effect of C-section predictors were the methods used.
The overall C-section rate was 45%, 36% among SUS and 81% among private patients, where 35% of C-sections were reported elective. C-sections were more frequent on Tuesdays and Wednesdays, reducing by about a third on Sundays, while normal deliveries had a uniform distribution along the week. Delivery time for C-sections was markedly different among public and private patients. Maternal schooling was positively associated with C-section among SUS patients, but not among private patients.
C-sections were almost universal among the wealthier mothers, and strongly related to maternal education among SUS patients. The patterns we describe are compatible with the idea that C-sections are largely done to suit the doctor’s schedule. Drastic action is called for to change the current situation.
PMCID: PMC3794425  PMID: 21670862
Parturition; Cesarean Section, trends; Perinatal Care; Obstetrics; Socioeconomic Factors; Cohort Studies.
BMC Public Health  2013;13(Suppl 3):S3.
Short and long birth intervals have previously been linked to adverse neonatal outcomes. However, much of the existing literature uses cross-sectional studies, from which deriving causal inference is complex. We examine the association between short/long birth intervals and adverse neonatal outcomes by calculating and meta-analyzing associations using original data from cohort studies conducted in low-and middle-income countries (LMIC).
We identified five cohort studies. Adjusted odds ratios (aOR) were calculated for each study, with birth interval as the exposure and small-for-gestational-age (SGA) and/or preterm birth, and neonatal and infant mortality as outcomes. The associations were controlled for potential confounders and meta-analyzed.
Birth interval of shorter than 18 months had statistically significant increased odds of SGA (pooled aOR: 1.51, 95% CI: 1.31-1.75), preterm (pooled aOR: 1.58, 95% CI: 1.19-2.10) and infant mortality (pooled aOR: 1.83, 95% CI: 1.19-2.81) after controlling for potential confounding factors (reference 36-<60 months). It was also significantly associated with term-SGA, preterm-appropriate-for-gestational-age, and preterm-SGA. Birth interval over 60 months had increased risk of SGA (pooled aOR: 1.22, 95% CI: 1.07-1.39) and term-SGA (pooled aOR: 1.14, 95% CI: 1.03-1.27), but was not associated with other outcomes.
Birth intervals shorter than 18 months are significantly associated with SGA, preterm birth and death in the first year of life. Lack of access to family planning interventions thus contributes to the burden of adverse birth outcomes and infant mortality in LMICs. Programs and policies must assess ways to provide equitable access to reproductive health interventions to mothers before or soon after delivering a child, but also address underlying socioeconomic factors that may modify and worsen the effect of short intervals.
PMCID: PMC3847557  PMID: 24564484
BMC Public Health  2013;13(Suppl 3):S24.
Lives-saved estimates calculated by LiST include the implicit assumptions that there are no inequalities among different socioeconomic groups, and also that the likelihood of a mother or child receiving a given intervention is independent from the probability of receiving any other interventions. It is reasonable to assume that, as a consequence of these assumptions, LiST estimates may exaggerate the numbers of lives saved in a population, by ignoring the fact that coverage is likely to be lower and mortality higher among the poor than the rich, and also by failing to take into account that coverage with different interventions may be clustered at individual mothers and children – a phenomenon described as co-coverage. We used data from 127 DHS surveys to estimate how much these two assumptions may bias estimates produced by LiST, and conclude that under real-life conditions bias occurred in both directions, with LiST results either over or underestimating the more complex estimates. With few exceptions, bias tended to be small (less than 10% in either direction).
PMCID: PMC3847580  PMID: 24564259
PLoS ONE  2013;8(9):e74301.
Conflicting findings on the risk of obesity among subjects born by caesarean section have been published. Caesarean section should also increase the risk of obesity related cardiovascular risk factors if type of delivery is associated with obesity later in life. This study was aimed at assessing the effect of type of delivery on metabolic cardiovascular risk factors in early adulthood.
Methodology and Principal Findings
In 1982, maternity hospitals in Pelotas, southern Brazil, were visited and those livebirths whose family lived in the urban area of the city have been followed. In 2000, when male subjects undertook the Army entrance examination (n=2200), fat mass and fat free mass were estimated through bioimpedance. In 2004–2005, we attempted to follow the whole cohort (n=4297), and the following outcomes were studied: blood pressure; HDL cholesterol; triglycerides; random blood glucose, C-reactive protein, waist circumference and body mass index. The estimates were adjusted for the following confounders: family income at birth; maternal schooling; household assets index in childhood; maternal skin color; birth order; maternal age; maternal prepregnancy weight; maternal height; maternal smoking during pregnancy; birthweight and family income at early adulthood.
In the crude analyses, blood pressure (systolic, diastolic and mean arterial pressure) and body mass index were higher among subjects who were delivered through caesarean section. After controlling for confounders, systolic blood pressure was 1.15 mmHg (95% confidence interval: 0.05; 2.25) higher among subjects delivered by caesarean section, and BMI 0.40 kg/m2 (95% confidence interval: 0.08; 0.71). After controlling for BMI the effect on systolic blood pressure dropped to 0.60 mmHg (95% confidence interval: -0.47; 1.67). Fat mass at 18 years of age was also higher among subjects born by caesarean section.
Caesarean section was associated with a small increased in systolic blood pressure, body mass index and fat mass.
PMCID: PMC3767800  PMID: 24040224

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