Adolescent blood pressure classification curves and cardiometabolic risk factors: a comparison of the Brazilian and American references.

BACKGROUND: The American Academy of Pediatrics (AAP) adolescent blood pressure (BP) percentiles were updated in 2017, and have been used as reference in Brazil since then. However, specific BP percentiles for Brazilian adolescents were recently proposed based on data from the Study of Cardiovascular Risk in Adolescents (ERICA). OBJECTIVES: To compare the prevalence of arterial hypertension according to each reference, as well as to assess the cardiometabolic risk associated with the reclassification by Brazilian BP percentiles. METHODS: Data from 73 399 adolescents aged 12-17 years who participated in the ERICA study were analyzed. To assess cardiometabolic risk, 6185 adolescents who were reclassified upwards by the Brazilian reference were 1 : 1 matched with adolescents that were normotensive by both references and were of the same age, sex and height percentile. The parameters evaluated were: overweight/obesity, waist circumference, total cholesterol, triglycerides, LDL-c, HDL-c, fasting glucose, HbA1c and HOMA-ir. RESULTS: The classification according to Brazilian BP percentiles resulted in a higher prevalence of arterial hypertension (14%, 95% CI 13.2-14.8), when compared with the AAP percentiles (10.6%, 95% CI 10.0-11.2). The use of the Brazilian reference also resulted in higher prevalence of arterial hypertension in girls, teenagers ranging from 12 to 14 years, and those classified with adequate weight, overweight or obesity. In the case-control analysis, cardiometabolic risk factors were present more often in adolescents reclassified with arterial hypertension by the ERICA reference. DISCUSSION: The use of the BP percentiles proposed by ERICA is a sensitive method for tracking Brazilian adolescents with hypertension and higher cardiometabolic risk.

Inspiratory Muscle Training in COPD.

BACKGROUND: The benefits of inspiratory muscle training (IMT) for patients with COPD are documented in the literature, but its isolated effect or association with other interventions, the best training methods, and what type of patient benefits the most are not clear. We sought to assess the effects of IMT on respiratory muscle strength, pulmonary function, dyspnea, functional capacity, and quality of life for subjects with COPD, considering IMT isolated or association with other interventions, presence of inspiratory muscle weakness, training load, and intervention time. METHODS: We searched the MEDLINE, EMBASE, PEDro, Cochrane CENTRAL, and LILACS databases in June 2018. We also performed a manual search of references in the studies found in the database search and included in this analysis. We included randomized controlled trials that investigated the above-mentioned outcomes and assessed IMT, either isolated or associated with other interventions, in comparison with a control group, placebo, or other interventions, in subjects with COPD. We used the GRADE approach to evaluate the quality of the evidence. RESULTS: Of 1,230 search results, 48 were included (N = 1,996 subjects). Isolated IMT increased PImax (10.64 cm H2O, 95% CI 7.61-13.66), distance walked in 6-min-walk test (34.28 m; 95% CI 29.43-39.14), and FEV1 (0.08, 95% CI 0.02-0.13). However, there was no improvement in dyspnea and quality of life. The presence of inspiratory muscle weakness did not change the results; higher loads (60-80% of PImax) promoted a greater improvement in these outcomes, and a shorter intervention time (4 weeks) improved PImax, but longer intervention times (6-8 weeks) are required to improve functional capacity. IMT associated with other interventions only showed an increase in PImax (8.44 cm H2O; 95% CI 4.98-11.91), and the presence of inspiratory muscle weakness did not change this result. CONCLUSIONS: Isolated IMT improved inspiratory muscle strength, functional capacity, and pulmonary function, without changing dyspnea and quality of life. Associated IMT only increased inspiratory muscle strength. These results indicate that isolated IMT can be considered as an adjuvant intervention in patients with COPD.

Prevalence and characteristics of polycystic ovary syndrome in Brazilian women: protocol for a nation-wide case-control study.

INTRODUCTION: Brazil is a large country, with a population of mixed ethnic background and broad variation in dietary and physical activity traits across its five main regions. Because data on Brazilian women with polycystic ovary syndrome (PCOS) are still scarce, a nation-wide collaborative study was designed to determine the prevalence of metabolic and reproductive abnormalities and the presence of anxiety and depression in Brazilian women with PCOS. In addition, the study aims at describing how these characteristics are distributed across PCOS phenotypes and at detecting associations with regional demographic and lifestyle aspects, genetic variants, and epigenetic markers. METHODS AND ANALYSIS: The Brazilian PCOS study is being conducted in the outpatient clinics of eight university hospitals within the public healthcare network (Unified Health System) across the country. Additional centres will be included following completion of the research ethics approval process. The sample includes women with PCOS according to Rotterdam criteria at inclusion in the study and a control group of healthy women matched by age, socioeconomic status and geographical region. Data will be collected in each centre and incorporated into a unified cloud database. Clinical, demographic, socioeconomic, psychological, metabolic, epigenetic and genotypic variables will be evaluated. The data resulting from this study will be useful to guide specific public strategies for primary and secondary prevention of metabolic and reproductive comorbidities in the PCOS population of Brazil. ETHICS AND DISSEMINATION: The study protocol was approved by each local Research Ethics Committee. Written informed consent will be obtained from each participant. During data collection, analysis and publication, care will be taken to ensure confidentiality of participant information. Study results will be published in peer-reviewed journals and disseminated at international conferences. This research protocol was registered with the Research Ethics Committee of HCPA, through Plataforma Brasil. TRIAL REGISTRATION NUMBER: CAAE 18082413.9.1001.5327.

Prevalence of excessive screen time and TV viewing among Brazilian adolescents: a systematic review and meta-analysis / Prevalência de tempo excessivo de tela e tempo de TV em adolescentes brasileiros: revisão sistemática e metanálise

Abstract Purpose: To evaluate the prevalence of excessive screen-based behaviors among Brazilian adolescents through a systematic review with meta-analysis. Data source: Systematic review and meta-analysis were recorded in the International Prospective Register of Ongoing Systematic Reviews (PROSPERO-CRD 2017 CRD42017074432). This review included observational studies (cohort or cross-sectional) that evaluated the prevalence of excessive screen time (i.e. combinations involving different screen-based behaviors) or TV viewing (≥2 h/day or >2 h/day in front of screen) through indirect or direct methods in adolescents aged between 10 and 19 years. The research strategy included the following databases: MEDLINE, LILACS, SciELO and ADOLEC. The search strategy included terms for "screen time", "Brazil", and "prevalence". Random effect models were used to estimate the prevalence of excessive screen time in different categories. Data summary: Twenty-eight out of 775 studies identified in the search met the inclusion criteria. The prevalence of excessive screen time and TV viewing was 70.9% (95% CI: 65.5-76.1) and 58.8% (95% CI: 49.4-68.0), respectively. There was no difference between sexes in both analyses. The majority of studies included showed a low risk of bias. Conclusions: The prevalence of excessive screen time and TV viewing was high among Brazilian adolescents. Intervention are needed to reduce the excessive screen time among adolescents.

Resumo Objetivo: Avaliar a prevalência de tempo excessivo de tela e de TV em adolescentes brasileiros através de revisão sistemática com metanálise. Fontes de dados: A revisão sistemática e a metanálise foram registradas no Registro Prospectivo Internacional da Base de Dados de Análises Sistemáticas (Prospero-CRD 2017 CRD 42017074432). Esta análise incluiu estudos observacionais (coorte ou transversais) que avaliaram a prevalência de tempo excessivo de tela (ou seja, combinações que envolvem diferentes comportamentos baseados em tempo de tela) ou tempo em frente à TV (≥ 2 horas/dia ou > 2 horas/dia em frente à tela) por avaliação direta ou indireta em adolescentes com idades entre 10 a 19 anos. A estratégia de pesquisa incluiu as seguintes bases de dados: MEDLINE, LILACS, SciELO e ADOLEC. A estratégia de busca incluiu termos como "tempo de tela", "Brasil" e "prevalência". Os modelos de efeito aleatório foram utilizados para estimar a prevalência de tempo excessivo de tela em diferentes categorias. Resumo de dados: Dos 775 estudos identificados na busca 28 atenderam aos critérios de inclusão. A prevalência de tempo excessivo de tela e tempo de TV foi 70,9% (IC de 95%: 65,5 a 76,1) e 58,8% (IC de 95%: 49,4 a 68,0), respectivamente. Não houve diferença entre os sexos nas duas análises. A maior parte dos estudos incluídos mostrou baixo risco de viés. Conclusões: A prevalência de tempo excessivo de tela e tempo de TV foi alta entre os adolescentes brasileiros. São necessárias intervenções para reduzir o tempo excessivo de tela entre os adolescentes.

Prevalence of type 2 diabetes among adolescents in Brazil: Findings from Study of Cardiovascular Risk in Adolescents (ERICA).

BACKGROUND: Type 2 diabetes mellitus (T2DM) in adolescents represents a clinical challenge related to lifestyle and obesity; however, only a few data are available in developing countries. Therefore, our aim was to investigate the prevalence of T2DM and prediabetes among Brazilian adolescents, as well as to describe the cardio-metabolic profile according to the diagnosis. METHODS: This is a cross-sectional school-based multicenter study including youth aged 12 to 17 years from cities with more than 100 000 inhabitants in Brazil (n = 37 854 students). Fasting glucose, hemoglobin A1c (HbA1c) and other cardio-metabolic risk factors were measured. Prediabetes was defined by glucose levels 100 to 125 mg/dL or HbA1c 5.7% to 6.4%. T2DM was defined by self-report, glucose ≥126 mg/dL or HbA1c ≥ 6.5%. Multinomial logistic regression was used to estimate the odds ratio (OR) of prediabetes or T2DM according to covariates. RESULTS: Prevalences of prediabetes and T2DM were 22.0% (95% confidence interval [CI] 20.6%-23.4%) and 3.3% (95% CI 2.9%-3.7%), respectively. This estimates represented 213 830 adolescents living with T2DM and 1.46 million adolescents with prediabetes in Brazil. Prevalences of cardio-metabolic risk factors were higher in adolescents with prediabetes and T2DM. In the multinomial logistic model, obesity (OR 1.59, 95% CI 1.20-2.11), high waist circumference (OR 1.51, 95% CI 1.13-2.01), and skipping breakfast (OR 1.48, 95% CI 1.21-1.81) were associated with an increased OR for T2DM, while studying at rural area (OR 0.56, 95% CI 0.41-0.78) was associated with a decreased OR for T2DM. CONCLUSIONS: The prevalence of T2DM and prediabetes was high among Brazilian adolescents, which highlights that this disease became a public health challenge not only among adults in Brazil.

Prevalence of excessive screen time and TV viewing among Brazilian adolescents: a systematic review and meta-analysis.

PURPOSE: To evaluate the prevalence of excessive screen-based behaviors among Brazilian adolescents through a systematic review with meta-analysis. DATA SOURCE: Systematic review and meta-analysis were recorded in the International Prospective Register of Ongoing Systematic Reviews (PROSPERO-CRD 2017 CRD42017074432). This review included observational studies (cohort or cross-sectional) that evaluated the prevalence of excessive screen time (i.e. combinations involving different screen-based behaviors) or TV viewing (≥2h/day or >2h/day in front of screen) through indirect or direct methods in adolescents aged between 10 and 19 years. The research strategy included the following databases: MEDLINE, LILACS, SciELO and ADOLEC. The search strategy included terms for "screen time", "Brazil", and "prevalence". Random effect models were used to estimate the prevalence of excessive screen time in different categories. DATA SUMMARY: Twenty-eight out of 775 studies identified in the search met the inclusion criteria. The prevalence of excessive screen time and TV viewing was 70.9% (95% CI: 65.5-76.1) and 58.8% (95% CI: 49.4-68.0), respectively. There was no difference between sexes in both analyses. The majority of studies included showed a low risk of bias. CONCLUSIONS: The prevalence of excessive screen time and TV viewing was high among Brazilian adolescents. Intervention are needed to reduce the excessive screen time among adolescents.

Adiponectin levels in Brazilian adolescents: Distribution and associated factors in ERICA survey.

BACKGROUND: The aim of this study was to evaluate the distribution of adiponectin and associated factors with low adiponectin levels in a large sample of adolescents from different Brazilian regions. METHODS: This is a national, school-based, cross-sectional multicenter study of cardiovascular risk factors in Brazilian adolescents aged 12 to 17 years. Serum adiponectin levels (µg/ml) were measured by enzyme-linked immunosorbent assay kit. Given the lack of reference values, sex-and age-specific median was adopted as the cutoff point, with the values below the median representing a higher-risk profile. Associated factors with low levels of adiponectin were investigated using Poisson regression. RESULTS: The sample consisted of 4546 adolescents, the majority female (61.2%). The prevalence of overweight/obesity and abdominal obesity was 30% and 13.4%, respectively. The medians of adiponectin were 13.4 µg/ml (95%CI: 12.8-14.0) in males and 14.2 µg/ml (95%CI: 13.3-15.0) in females. Lower adiponectin levels were associated with both overweight (Prevalence Ratios (PR) = 1.17; 95%CI 1.01-1.36) and obesity (PR = 1.36; 95%CI 1.16-1.56) in males, while, in females, adiponectin levels were associated only with obesity (PR = 1.45; 95% CI 1.26-1.66). Increased waist circumference in both males and females was inversely associated with adiponectin level. CONCLUSIONS: Adiponectin levels were lower among adolescents with weight excess and abdominal obesity. Male adolescents who live in rural areas and study at private schools also showed lower adiponectin concentrations.

Common mental disorders in adolescents with and without type 1 diabetes: Reported occurrence from a countrywide survey.

AIMS: The aim of this study was to evaluate the frequency of common mental disorders symptoms in adolescents with type 1 diabetes in comparison to a population-based sample of adolescents in Brazil. METHODS: We compared characteristics of 116 youth with type 1 diabetes and 73,508 youth without type 1 diabetes from the same population-based sample of adolescents aged 12-17years, taken from the Brazilian Study of Cardiovascular Risk in Adolescents (ERICA). We evaluated the 12-item General Health Questionnaire (GHQ) score, which is a self-administered screening survey for detecting mental health symptoms. Scores ≥3 were used to determine common mental disorder. RESULTS: Adolescents with and without type 1 diabetes were comparable with respect to age and race/ethnicity distributions. Youth with type 1 diabetes did not report higher scores on the weighted GHQ analyses in comparison to youth without type 1 diabetes (3.16, SE 0.76 vs. 2.10, SE 0.03, respectively; P = .167). No differences were found regarding the odds of having a GHQ score ≥3 (OR 1.48, 95% CI 0.72-3.08). However, analyses of mental health symptoms separately consistently showed that youth with type 1 diabetes more frequently endorsed mental health barriers in comparison to youth without type 1 diabetes. CONCLUSIONS: Mental health symptoms seem to be more frequent than diagnosis of common mental disorders in adolescents with type 1 diabetes, which may also interfere in glycemic control. Our findings highlight the need for appropriate mental health assessment in diabetes care in order to prevent glycemic control deterioration.

Prevalence of high HbA1c levels in Brazilian adolescents: The Study of Cardiovascular Risk in Adolescents.

AIM: To evaluate the prevalence of elevated glycated haemoglobin (HbA1c) levels in a population of adolescents participating in the Study of Cardiovascular Risk in Adolescents. METHODS: This is a school-based cross-sectional study based on a complex sample of adolescents 12-17years old representative at the national and macro-regional levels and for each Brazilian state capital. Blood was collected in schools and then evaluated in a single laboratory. HbA1c levels were considered elevated if ⩾5.7% (39mmol/mol) and were analyzed according to sex, age, macro-region, type of school, skin color, and nutritional status. RESULTS: Data from 37,804 adolescents were analyzed. The mean level of HbA1c was 5.4% (95%CI 5.4-5.4) (36mmol/mol [95%CI 36-36]), and 20.5% (95%CI 19.1-22.0) of adolescents presented values ⩾5.7% (⩾39mmol/mol). Among males, 23.6% (95%CI 21.8-25.6) showed elevated HbA1c levels compared to 17.5% (95%CI 15.9-19.2) observed in females. The prevalence of elevated levels of HbA1c was higher in adolescents with black skin color (27.6%; 95%CI 23.2-32.4) vs. white skin color (16.9%; 95%CI 15.4-18.5), and higher in those who studied in public schools (21.6%; 95%CI 20.0-23.4) vs. private schools (16.7%; 95%CI 14.7-19.0). Among obese adolescents, 29.7% (95%CI 25.4-34.3) had elevated levels of HbA1c, compared to 19.3% (95%CI 18.0-20.7) in normal weight students and 19.7% (95%CI 17.1-22.6) in overweight adolescents. CONCLUSIONS: Obese male adolescents of lower socioeconomic status had a higher prevalence of elevated HbA1c levels. Our findings highlight the importance of focusing on this high risk group for interventions to prevent diabetes.

Association between physical activity advice only or structured exercise training with blood pressure levels in patients with type 2 diabetes: a systematic review and meta-analysis.

BACKGROUND: Diabetes is associated with marked cardiovascular morbidity and mortality. However, the association between different types of exercise training and blood pressure (BP) changes is not fully clear in type 2 diabetes. OBJECTIVE: The aim of this systematic review and meta-analysis of randomized controlled clinical trials (RCTs) was to determine the effects of structured exercise training (aerobic [AER], resistance [RES], or combined [COMB]) and physical activity (PA) advice only on BP changes in patients with type 2 diabetes. METHODS: Searches in five electronic databases were conducted to retrieve studies published from 1980 to 2013. Eligible studies were RCTs consisting of structured exercise training or PA advice versus no intervention in patients with type 2 diabetes. We used random effect models to derive weighted mean differences (WMDs) of exercises on absolute changes in systolic BP (SBP) and diastolic BP (DBP). RESULTS: A total of 30 RCTs of structured training (2,217 patients) and 21 of PA advice (7,323 patients) were included. Data were extracted independently in duplicate. Structured exercise was associated with reductions in SBP (WMD -4.22 mmHg; 95% confidence interval [CI] -5.89 to -2.56) and DBP (WMD -2.07 mmHg; 95% CI -3.03 to -1.11) versus controls. In structured exercise interventions, AER and RES were associated with declines in BP, and COMB was not associated with BP changes. However, in sensitivity analysis, a high-intensity protocol within COMB was associated with declines in SBP (WMD -3.30 mmHg; 95% CI -4.71 to -1.89). Structured exercise longer than 150 min/week was associated with greater BP reductions. PA advice only was associated with reduction in SBP (WMD -2.97 mmHg; 95% CI -4.52 to -1.43) and DBP (WMD -1.41 mmHg; 95% CI -1.94 to -0.88) versus controls. CONCLUSIONS: AER, RES, and high-intensity combined training are associated with BP reduction in patients with type 2 diabetes, especially in exercise programs lasting more than 150 min/week. PA advice only is also associated with lower BP levels.