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1.  Prevalence of health promotion programs in primary health care units in Brazil 
Revista de Saúde Pública  2014;48(5):837-844.
OBJECTIVE
Assessment of prevalence of health promotion programs in primary health care units within Brazil’s health system.
METHODS
We conducted a cross-sectional descriptive study based on telephone interviews with managers of primary care units. Of a total 42,486 primary health care units listed in the Brazilian Unified Health System directory, 1,600 were randomly selected. Care units from all five Brazilian macroregions were selected proportionally to the number of units in each region. We examined whether any of the following five different types of health promotion programs was available: physical activity; smoking cessation; cessation of alcohol and illicit drug use; healthy eating; and healthy environment. Information was collected on the kinds of activities offered and the status of implementation of the Family Health Strategy at the units.
RESULTS
Most units (62.0%) reported having in place three health promotion programs or more and only 3.0% reported having none. Healthy environment (77.0%) and healthy eating (72.0%) programs were the most widely available; smoking and alcohol use cessation were reported in 54.0% and 42.0% of the units. Physical activity programs were offered in less than 40.0% of the units and their availability varied greatly nationwide, from 51.0% in the Southeast to as low as 21.0% in the North. The Family Health Strategy was implemented in most units (61.0%); however, they did not offer more health promotion programs than others did.
CONCLUSIONS
Our study showed that most primary care units have in place health promotion programs. Public policies are needed to strengthen primary care services and improve training of health providers to meet the goals of the agenda for health promotion in Brazil.
doi:10.1590/S0034-8910.2014048005249
PMCID: PMC4211580  PMID: 25372175
Health Programs and Plans; Health Centers; Health Promotion; Primary Health Care; Health Surveys
2.  Geographical Variation in Health-Related Physical Fitness and Body Composition among Chilean 8th Graders: A Nationally Representative Cross-Sectional Study 
PLoS ONE  2014;9(9):e108053.
Purpose
In addition to excess adiposity, low cardiorespiratory fitness (CRF) and low musculoskeletal fitness (MSF) are important independent risk factors for future cardio-metabolic disease in adolescents, yet global fitness surveillance in adolescents is poor. The objective of this study was to describe and investigate geographical variation in levels of health-related physical fitness, including CRF, MSF, body mass index (BMI), and waist circumference (WC) in Chilean 8th graders.
Methods
This cross-sectional study was based on a population-based, representative sample of 19,929 8th graders (median age = 14 years) in the 2011 National Physical Education Survey from Chile. CRF was assessed with the 20-meter shuttle run test, MSF with standing broad jump, and body composition with BMI and WC. Data were classified according to health-related standards. Prevalence of levels of health-related physical fitness was mapped for each of the four variables, and geographical variation was explored at the country level by region and in the Santiago Metropolitan Area by municipality.
Results
Girls had significantly higher prevalence of unhealthy CRF, MSF, and BMI than boys (p<0.05). Overall, 26% of boys and 55% of girls had unhealthy CRF, 29% of boys and 35% of girls had unhealthy MSF, 29% of boys and 44% of girls had unhealthy BMI, and 31% of adolescents had unhealthy WC. High prevalence of unhealthy fitness levels concentrates in the northern and middle regions of the country and in the North and Southwest sectors for the Santiago Metropolitan Area.
Conclusion
Prevalence of unhealthy CRF, MSF, and BMI is relatively high among Chilean 8th graders, especially in girls, when compared with global estimates. Identification of geographical regions and municipalities with high prevalence of unhealthy physical fitness presents opportunity for targeted intervention.
doi:10.1371/journal.pone.0108053
PMCID: PMC4177890  PMID: 25255442
4.  Exercise-referral scheme to promote physical activity among hypertensive patients: design of a cluster randomized trial in the Primary Health Care Units of Mexico’s Social Security System 
BMC Public Health  2014;14:706.
Background
Although the benefits of physical activity (PA) on to prevent and manage non-communicable diseases are well known, strategies to help increase the levels of PA among different populations are limited. Exercise-referral schemes have emerged as one effective approach to promote PA; however, there is uncertainty about the feasibility and effectiveness of these schemes in settings outside high-income countries. This study will examine the effectiveness of a scheme to refer hypertensive patients identified in Primary Health Care facilities (PHCU) of the Mexican social security institution to a group PA program offered in the same institution.
Methods and design
We will describe the methods of a cluster randomized trial study designed to evaluate the effectiveness of an exercise referral scheme to increasing physical activity in hypertensive patients compared to a non-referral scheme. Four PHCU were selected for the study; the PHCU will take part as the unit of randomization and sedentary hypertensive patients as the unit of assessment. 2 PHCU of control group (GC) will provide information to hypertensive patients about physical activity benefits and ways to increase it safely. 2 PHCU of intervention group (IG) will refer patients to sports facilities at the same institution, to follow a group-based PA program developed to increase the PA levels with a designed based on the Transtheoretical Model and Social Cognitive Theory. To evaluate the effects of the intervention as well as short-term maintenance of the intervention’s effects, PA will be assessed at baseline, at 24 and 32 weeks of follow-up.
The main outcome will be the difference before and after intervention in the percentage of participants meeting recommended levels of PA between and within intervention and control groups. PA will be measured through self-report and with objective measure by accelerometer.
Discussion
This study will allow us to evaluate a multidisciplinary effort to link the primary care and community-based areas of the same health care system. Our findings will provide important information about the feasibility and effectiveness of an exercise-referral scheme and will be useful for decision-making about the implementation of strategies for increasing PA among hypertensive and other clinical populations in Mexico and Latin America.
Trial registration
Clinicaltrials.gov Identifier: NCT01910935. Date of registration: 07/05/2013.
doi:10.1186/1471-2458-14-706
PMCID: PMC4227118  PMID: 25011612
Exercise-referral; Physical activity; Hypertension; Mexico
5.  Muscular strength and adiposity as predictors of adulthood cancer mortality in men 
BACKGROUND
We examined the associations between muscular strength, markers of overall and central adiposity and cancer mortality in men.
METHODS
Prospective cohort study including 8,677 men aged 20-82 years followed from 1980 to 2003. Participants were enrolled in The Aerobics Centre Longitudinal Study, the Cooper Clinic in Dallas, Texas, U.S. Muscular strength was quantified by combining 1-repetition maximal measures for leg and bench presses. Adiposity was assessed by body mass index (BMI), percent body fat, and waist circumference.
RESULTS
Cancer death rates per 10,000 person-years adjusted for age and examination year were: 17.5, 11.0, and 10.3 across incremental thirds of muscular strength (P=0.001); 10.9, 13.4, and 20.1 across BMI groups of 18.5-24.9, 25.0-29.9, and ≥30kg/m2, respectively (P=0.008); 11.6 and 17.5 for normal (<25%) and high percent body fat (≥25%), respectively (P=0.006); and 12.2 and 16.7 for normal (≤102 cm) and high waist circumference (>102 cm), respectively (P=0.06). After adjusting for additional potential confounders, hazard ratios (95% confidence intervals) were 1.00 (referent), 0.65 (0.47-0.90), and 0.61 (0.44-0.85) across incremental thirds of muscular strength, respectively (P=0.003 for linear trend). Further adjustment for BMI, percent body fat, waist circumference, or cardiorespiratory fitness had little effect on the association. The associations of BMI, percent body fat, or waist circumference with cancer mortality did not persist after further adjusting for muscular strength (all P≥0.1).
CONCLUSIONS
Higher levels of muscular strength are associated with lower cancer mortality risk in men, independent of clinically established measures of overall and central adiposity, and other potential confounders.
doi:10.1158/1055-9965.EPI-08-1075
PMCID: PMC3762582  PMID: 19366909
Muscular strength; obesity; cancer; cardiorespiratory fitness; resistance exercise
6.  Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors 
BMC Public Health  2013;13:794.
Background
The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil.
Methods
A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses.
Results
The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient’s physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient’s physical activity was a significant correlate among physicians whereas assessing patient’s physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses.
Conclusions
Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.
doi:10.1186/1471-2458-13-794
PMCID: PMC3844313  PMID: 24005006
Physical activity promotion; Physical activity counseling; Primary health care; Physicians; Nurses; Knowledge; Associated factors
7.  Impact of Physical Inactivity on the World’s Major Non-Communicable Diseases 
Lancet  2012;380(9838):219-229.
Summary
Background
Strong evidence shows that physical inactivity increases the risk of many adverse health conditions, including the world’s major non-communicable diseases (NCDs) of coronary heart disease (CHD), type 2 diabetes, and breast and colon cancers, and shortens life expectancy. Because much of the world’s population is inactive, this presents a major public health problem. We aimed to quantify the impact of physical inactivity on these major NCDs by estimating how much disease could be averted if those inactive were to become active and to estimate gain in life expectancy, at the population level.
Methods
Using conservative assumptions, we calculated population attributable fractions (PAF) associated with physical inactivity for each of the major NCDs, by country, to estimate how much disease could be averted if physical inactivity were eliminated, and used life table analysis to estimate gains in life expectancy of the population.
Findings
Worldwide, we estimate that physical inactivity is responsible for 6% of the burden of disease from CHD (range: 3.2% in South-east Asia to 7.8% in the Eastern Mediterranean region); 7% of type 2 diabetes (3.9% to 9.6%), 10% of breast cancer (5.6% to 14.1%), and 10% of colon cancer (5.7% to 13.8%). Inactivity is responsible for 9% of premature mortality (5.1% to 12.5%), or >5.3 of the 57 million deaths that occurred worldwide in 2008. If inactivity were not eliminated, but decreased instead by 10% or 25%, >533,000 and >1.3 million deaths, respectively, may be averted each year. By eliminating physical inactivity, life expectancy of the world’s population is estimated to increase by 0.68 (0.41 to 0.95) years.
Interpretation
Physical inactivity has a major health impact on the world. Elimination of physical inactivity would remove between 6% and 10% of the major NCDs of CHD, type 2 diabetes, and breast and colon cancers, and increase life expectancy.
doi:10.1016/S0140-6736(12)61031-9
PMCID: PMC3645500  PMID: 22818936
8.  Cardiorespiratory Fitness and Proximity to Commercial Physical Activity Facilities Among 12th Grade Girls 
The Journal of Adolescent Health  2012;50(5):497-502.
Purpose
To investigate the relationship between proximity to commercial physical activity facilities and cardiorespiratory fitness of 12th grade girls.
Methods
Adolescent girls (N=786, 60% African American, mean age=17.6 ± 0.6 years) performed a submaximal fitness test (PWC170). Commercial physical activity facilities were mapped and counted within a 0.75-mile street-network buffer around girls’ homes using Geographic Information Systems (GIS). Sedentary activities and vigorous physical activity (VPA, greater or equal to 6 METs) were determined by the average number of 30-minute blocks reported per day on the 3-Day Physical Activity Recall (3DPAR). Mixed model regressions were calculated using school as a random variable.
Results
Girls had higher weight-relative PWC170 scores if there was a commercial physical activity facility (n=186, 12.4±4.2 kg·m/min/kg) within 0.75-mile street-network buffer of home as compared to girls without a nearby facility (n=600, 11.2±3.6 kg·m/min/kg). After adjusting for demographic variables, sports participation, sedentary behaviors and VPA, having one or more commercial physical activity facilities within a 0.75-mile street-network buffer of homes was significantly related to cardiorespiratory fitness.
Conclusions
Both with and without adjustment for covariates, the presence of a commercial physical activity facility within a 0.75-mile street-network buffer of a girl’s home was associated with higher cardiorespiratory fitness.
doi:10.1016/j.jadohealth.2011.09.018
PMCID: PMC3336089  PMID: 22525114
9.  The association between Colombian medical students' healthy personal habits and a positive attitude toward preventive counseling: cross-sectional analyses 
BMC Public Health  2009;9:218.
Background
Physician-delivered preventive counseling is important for the prevention and management of chronic diseases. Data from the U.S. indicates that medical students with healthy personal habits have a better attitude towards preventive counseling. However, this association and its correlates have not been addressed in rapidly urbanized settings where chronic disease prevention strategies constitute a top public health priority. This study examines the association between personal health practices and attitudes toward preventive counseling among first and fifth-year students from 8 medical schools in Bogotá, Colombia.
Methods
During 2006, a total of 661 first- and fifth-year medical students completed a culturally adapted Spanish version of the "Healthy Doctor = Healthy Patient" survey (response rate = 78%). Logistic regression analyses were used to assess the association between overall personal practices on physical activity, nutrition, weight control, smoking, alcohol use (main exposure variable) and student attitudes toward preventive counseling on these issues (main outcome variable), stratified by year of training and adjusting by gender and medical training-related factors (basic knowledge, perceived adequacy of training and perception of the school's promotion on each healthy habit).
Results
The median age and percentage of females for the first- and fifth-year students were 21 years and 59.5% and 25 years and 65%, respectively. After controlling for gender and medical training-related factors, consumption of ≥ 5 daily servings of fruits and/or vegetables, not being a smoker or binge drinker were associated with a positive attitude toward counseling on nutrition (OR = 4.71; CI = 1.6–14.1; p = 0.006 smoking (OR = 2.62; CI = 1.1–5.9; p = 0.022), and alcohol consumption (OR = 2.61; CI = 1.3–5.4; p = 0.009), respectively.
Conclusion
As for U.S. physician and medical students, a positive association was found between the personal health habits of Colombian medical students and their corresponding attitudes toward preventive counseling, independent of gender and medial training-related factors. Our findings, the first relating to this association in medical students in developing regions, also suggest that within the medical school context, interventions focused on promoting healthy student lifestyles can potentially improve future physician's attitudes toward preventive counseling.
doi:10.1186/1471-2458-9-218
PMCID: PMC2721845  PMID: 19575806
10.  Uric Acid and the Development of Metabolic Syndrome in Women and Men 
Associations between serum uric acid (UA) levels and metabolic syndrome (MetS) have been reported in cross-sectional studies. Limited information, however, is available concerning the prospective association of UA and risk of developing MetS. The authors evaluated UA as a risk factor for incident MetS in a prospective study of 8,429 men and 1,260 women (ages 20–82 years) who were free of MetS and for whom measures of waist girth, resting blood pressure, fasting lipids and glucose were taken during baseline and follow-up examinations between 1977 and 2003. Hyperuricemia was defined as >7.0 mg/dL in men and >6.0 mg/dL in women. MetS was defined with NCEP ATP III criteria. The overall prevalence of hyperuricemia was 17%. During a mean follow-up of 5.7 years, 1120 men and 44 women developed MetS. Men with serum UA concentrations ≥6.5 mg/dL (upper third) had a 1.60-fold increase in risk of MetS (95% confidence interval [CI]: 1.34–1.91), as compared with those who had concentrations <5.5 mg/dL (lowest third). Among women, the risk of MetS was at least 2-fold higher for serum UA concentrations ≥4.6 mg/dL (p for trend=0.02). Higher serum UA is a strong and independent predictor of incident MetS in men and women.
doi:10.1016/j.metabol.2008.01.030
PMCID: PMC2486830  PMID: 18502269
11.  Physical Activity and Neighborhood Resources in High School Girls 
Background
Physical activity behavior is influenced by a person's physical environment, but few studies have used objective measures to study the influences of the physical environment on physical activity behavior in youth. The purpose of this study was to examine the relationship between selected neighborhood physical activity resources and physical activity levels in high school girls.
Methods
Participants were students in schools that had participated in a large physical activity intervention trial. The 3-Day Physical Activity Recall was completed by 1506 12th-grade girls. Data on physical activity facilities and resources in the participating communities were collected using a variety of methods. Physical activity resources within a 0.75-mile street-network buffer around each girl's home were counted using ArcGIS, version 9.1. Mixed-model regression models were used to determine if there was a relationship between three physical activity variables and the number of physical activity resources within the 0.75-mile buffer. Data were collected in 2002–2003 and analyzed in 2006–2007.
Results
On average, 3.5 physical activity resources (e.g., schools, parks, commercial facilities) were located within the 0.75-mile street-network buffer. Thirty-six percent of the girls had no physical activity resource within the buffer. When multiple physical activity resources were considered, the number of commercial physical activity facilities was significantly associated with reported vigorous physical activity, and the number of parks was associated with total METs in white girls.
Conclusions
Multiple physical activity resources within a 0.75-mile street-network buffer around adolescent girls' homes are associated physical activity in those girls. Several types of resources are associated with vigorous physical activity and total activity in adolescent girls. Future studies should examine the temporal and causal relationships between the physical environment, physical activity, and health outcomes related to physical activity.
doi:10.1016/j.amepre.2007.12.026
PMCID: PMC2408745  PMID: 18407008
12.  Association between muscular strength and mortality in men: prospective cohort study 
BMJ : British Medical Journal  2008;337(7661):92-95.
Objective To examine prospectively the association between muscular strength and mortality from all causes, cardiovascular disease, and cancer in men.
Design Prospective cohort study.
Setting Aerobics centre longitudinal study.
Participants 8762 men aged 20-80.
Main outcome measures All cause mortality up to 31 December 2003; muscular strength, quantified by combining one repetition maximal measures for leg and bench presses and further categorised as age specific thirds of the combined strength variable; and cardiorespiratory fitness assessed by a maximal exercise test on a treadmill.
Results During an average follow-up of 18.9 years, 503 deaths occurred (145 cardiovascular disease, 199 cancer). Age adjusted death rates per 10 000 person years across incremental thirds of muscular strength were 38.9, 25.9, and 26.6 for all causes; 12.1, 7.6, and 6.6 for cardiovascular disease; and 6.1, 4.9, and 4.2 for cancer (all P<0.01 for linear trend). After adjusting for age, physical activity, smoking, alcohol intake, body mass index, baseline medical conditions, and family history of cardiovascular disease, hazard ratios across incremental thirds of muscular strength for all cause mortality were 1.0 (referent), 0.72 (95% confidence interval 0.58 to 0.90), and 0.77 (0.62 to 0.96); for death from cardiovascular disease were 1.0 (referent), 0.74 (0.50 to 1.10), and 0.71 (0.47 to 1.07); and for death from cancer were 1.0 (referent), 0.72 (0.51 to 1.00), and 0.68 (0.48 to 0.97). The pattern of the association between muscular strength and death from all causes and cancer persisted after further adjustment for cardiorespiratory fitness; however, the association between muscular strength and death from cardiovascular disease was attenuated after further adjustment for cardiorespiratory fitness.
Conclusion Muscular strength is inversely and independently associated with death from all causes and cancer in men, even after adjusting for cardiorespiratory fitness and other potential confounders.
doi:10.1136/bmj.a439
PMCID: PMC2453303  PMID: 18595904
13.  Association between muscular strength and mortality in men: prospective cohort study 
Objective To examine prospectively the association between muscular strength and mortality from all causes, cardiovascular disease, and cancer in men.
Design Prospective cohort study.
Setting Aerobics centre longitudinal study.
Participants 8762 men aged 20-80.
Main outcome measures All cause mortality up to 31 December 2003; muscular strength, quantified by combining one repetition maximal measures for leg and bench presses and further categorised as age specific thirds of the combined strength variable; and cardiorespiratory fitness assessed by a maximal exercise test on a treadmill.
Results During an average follow-up of 18.9 years, 503 deaths occurred (145 cardiovascular disease, 199 cancer). Age adjusted death rates per 10 000 person years across incremental thirds of muscular strength were 38.9, 25.9, and 26.6 for all causes; 12.1, 7.6, and 6.6 for cardiovascular disease; and 6.1, 4.9, and 4.2 for cancer (all P<0.01 for linear trend). After adjusting for age, physical activity, smoking, alcohol intake, body mass index, baseline medical conditions, and family history of cardiovascular disease, hazard ratios across incremental thirds of muscular strength for all cause mortality were 1.0 (referent), 0.72 (95% confidence interval 0.58 to 0.90), and 0.77 (0.62 to 0.96); for death from cardiovascular disease were 1.0 (referent), 0.74 (0.50 to 1.10), and 0.71 (0.47 to 1.07); and for death from cancer were 1.0 (referent), 0.72 (0.51 to 1.00), and 0.68 (0.48 to 0.97). The pattern of the association between muscular strength and death from all causes and cancer persisted after further adjustment for cardiorespiratory fitness; however, the association between muscular strength and death from cardiovascular disease was attenuated after further adjustment for cardiorespiratory fitness.
Conclusion Muscular strength is inversely and independently associated with death from all causes and cancer in men, even after adjusting for cardiorespiratory fitness and other potential confounders.
doi:10.1136/bmj.a439
PMCID: PMC2453303  PMID: 18595904
14.  Television viewing and its association with overweight in Colombian children: results from the 2005 National Nutrition Survey: A cross sectional study 
Background
There has been an ongoing discussion about the relationship between time spent watching television and childhood obesity. This debate has special relevance in the Latin American region were the globalization process has increased the availability of screen-based entertainment at home. The aim of this study is to examine the association between television viewing and weight status in Colombian children.
Methods
This cross sectional investigation included children aged 5 to12 yrs from the National Nutrition Survey in Colombia (ENSIN 2005). Weight and height were measured in 11,137 children in order to calculate body mass index. Overweight was defined by international standards. Time spent viewing television was determined for these children through parental reports. Multiple logistic regression analyses were conducted for different subgroups and adjusted for potential confounders in order to study the association between television viewing and weight status in this population.
Results
Among the surveyed children, 41.5% viewed television less than two hours/day; 36.8% between two and 3.9 hours/day and 21.7% four or more hours/day. The prevalence of overweight (obesity inclusive) in this population was 11.1%. Children who were classified as excessive television viewers (between two and 3.9 hours/day or 4 or more hours/day) were more likely to be overweight (OR: 1.44 95% CI: 1.41–1.47 and OR: 1.32 95% CI: 1.30–1.34, respectively) than children who reported to watch television less than 2 hours/day. Stratified analyses by age, gender and urbanization levels showed similar results.
Conclusion
Television viewing was positively associated with the presence of overweight in Colombian children. A positive association between urbanization level and television viewing was detected. Considering that the majority of Colombian children lives in densely populated cities and appear to engage in excessive television viewing these findings are of public health relevance for the prevention of childhood obesity.
doi:10.1186/1479-5868-4-41
PMCID: PMC2048503  PMID: 17880726

Results 1-14 (14)