Showing papers by "Pan American Health Organization published in 2008"
TL;DR: The roadmap for the control and elimination of the more widespread NTDs will require an inter-sectoral approach that bridges public health, social services, and environmental interventions.
Abstract: The neglected tropical diseases (NTDs) represent some of the most common infections of the poorest people living in the Latin American and Caribbean region (LAC). Because they primarily afflict the disenfranchised poor as well as selected indigenous populations and people of African descent, the NTDs in LAC are largely forgotten diseases even though their collective disease burden may exceed better known conditions such as of HIV/AIDS, tuberculosis, or malaria. Based on their prevalence and healthy life years lost from disability, hookworm infection, other soil-transmitted helminth infections, and Chagas disease are the most important NTDs in LAC, followed by dengue, schistosomiasis, leishmaniasis, trachoma, leprosy, and lymphatic filariasis. On the other hand, for some important NTDs, such as leptospirosis and cysticercosis, complete disease burden estimates are not available. The NTDs in LAC geographically concentrate in 11 different sub-regions, each with a distinctive human and environmental ecology. In the coming years, schistosomiasis could be eliminated in the Caribbean and transmission of lymphatic filariasis and onchocerciasis could be eliminated in Latin America. However, the highest disease burden NTDs, such as Chagas disease, soil-transmitted helminth infections, and hookworm and schistosomiasis co-infections, may first require scale-up of existing resources or the development of new control tools in order to achieve control or elimination. Ultimately, the roadmap for the control and elimination of the more widespread NTDs will require an inter-sectoral approach that bridges public health, social services, and environmental interventions.
655 citations
TL;DR: This systematic review highlights the need for rigorous evaluation of promising interventions to increase physical activity in Latin America and develops evidence-based recommendations for physical activity interventions.
209 citations
TL;DR: While few changes in tobacco use among youth have been observed in the GYTS in Peru, the data in this report can be used as baseline measures for future evaluation efforts.
Abstract: In 2004, Peru ratified the Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and in 2006 passed Law 28705 for tobacco consumption and exposure reduction. The Global Youth Tobacco Survey (GYTS) provides data on youth tobacco use for development of tobacco control programs. Findings from the GYTS conducted in four main cities in Peru in 2000 and 2003 are reported in this paper and can be used to monitor provisions of the WHO FCTC. The GYTS is a school-based survey that uses a standardized methodology for sampling, questionnaire construction, field procedures, and data management. In total, 5,332 and 7,824 students aged 13 to 15 years participated in the 2000 and 2003 surveys conducted in Huancayo, Lima, Tarapoto and Trujillo. In both years, Lima had the highest lifetime (54.6% and 59.6%) and current use of tobacco (18.6% and 19.2%) of the four cities. According to gender, boys smoked more than girls and less than 20% of students initiated smoking before the age of 10. Among smokers, more than 60% bought their cigarettes in a store with no restriction for their age, and approximately 12% had ever been offered "free cigarettes". Around 90% of students were in favor of banning smoking in public places. Changes between 2000 and 2003 included an increase in the percentage of smokers who wanted to have a cigarette first thing in the morning in Tarapoto (from 0% to 1.2%) and a decrease in exposure to tobacco at home in Huancayo (from 23.7% to 17.8%) and Trujillo (from 27.8% to 19.8%) While few changes in tobacco use among youth have been observed in the GYTS in Peru, the data in this report can be used as baseline measures for future evaluation efforts. At this time, tobacco control efforts in Peru need to focus on enhancing Law 28705 to include enforcement of existing provisions and inclusion of new laws and regulations. Most of these provisions are required of all countries, such as Peru, that have ratified the WHO FCTC.
206 citations
TL;DR: Examining the existing reporting frameworks for research against information sought by users of systematic reviews of public health interventions and suggesting additional items that should be considered are suggested to improve the quality and usefulness of published evidence and increase its impact on public health program planning.
Abstract: Evidence-based public health decision-making depends on high quality and transparent accounts of what interventions are effective, for whom, how and at what cost. Improving the quality of reporting of randomized and non-randomized study designs through the CONSORT and TREND statements has had a marked impact on the quality of study designs. However, public health users of systematic reviews have been concerned with the paucity of synthesized information on context, development and rationale, implementation processes and sustainability factors.
This paper examines the existing reporting frameworks for research against information sought by users of systematic reviews of public health interventions and suggests additional items that should be considered in future recommendations on the reporting of public health intervention. Intervention model, theoretical and ethical considerations, study design choice, integrity of intervention/process evaluation, context, differential effects and inequalities and sustainability are often overlooked in reports of public health interventions.
Population health policy makers need synthesized, detailed and high quality a priori accounts of effective interventions in order to make better progress in tackling population morbidities and inequalities. Adding simple criteria to reporting standards will significantly improve the quality and usefulness of published evidence and increase its impact on public health program planning.
171 citations
TL;DR: Neighborhood food stores have the potential to provide healthy food choices, reinforce health messages, increase the population reached by nutritional interventions, and work with local residents to facilitate healthier dietary choices.
Abstract: Obesity and other diet-related chronic disease affect low-income ethnic minority populations at high rates. Formative research was used to develop a food store–based intervention for low-income African Americans in Baltimore City. A combination of qualitative and quantitative methods were used, including in-depth interviews with food store owners (n = 19) and low-income residents (n = 17), food source assessment (n = 11 census tracts), a consumer survey (n = 50), and direct observations (n = 6). Healthy food options were poorly available in low-income census tracts, with no fresh fruits and vegetables sold in 6 census tracts. Local consumers purchase less healthy options and prepare foods in ways that add fat. Corner stores are a common food source, but store owners expressed reservations about stocking healthier food options, citing low consumer demand for healthier products. Residents were unhappy with the limited range of healthy food options available but tended to see obesity as the result o...
143 citations
TL;DR: The observed homicide variability between Latin American countries can be explained largely by differences in the countries' social contexts and political models.
Abstract: BACKGROUND: Throughout the final years of the twentieth century and into the beginning of the twenty-first, violence has been one of the main public health issues in Latin America, a region which has some of the highest mortality rates due to violence in the world. However, there seems to be an uneven geographical distribution of such instances. METHODS: We reviewed epidemiological data on violence globally and in Latin America, and here, we discuss differences between the Latin American countries in the context of a sociological framework as well as from a public health perspective. RESULTS: Our results indicate marked differences by country in terms of rates of violence. Countries such as Argentina, Chile, Costa Rica, and Uruguay, have low violence mortality rates; Peru, Nicaragua, Ecuador, Dominican Republic, Panama, and Paraguay have moderate rates, and Brazil, Mexico, Colombia, El Salvador, Honduras and Venezuela have high to extremely high mortality rates. Factors related to violence include social inequalities, lack of employment opportunities, urban segregation, a culture of masculinity, local drug markets, and the availability of firearms and widespread use of alcohol. CONCLUSION: The observed homicide variability between Latin American countries can be explained largely by differences in the countries' social contexts and political models. In those countries where homicide rates are extremely high, governments should review their current policies and take preventive actions. Fortunately increasingly nowadays there are promising advancements in that direction. Language: en
123 citations
TL;DR: Action to reduce young child ID would benefit from overarching policy and programmatic guidance that informs decision makers about what to do, when to do it, and how toDo it.
Abstract: Anemia resulting from severe iron deficiency (ID) is the most prevalent and widespread nutrition-related health problem in infants and young children in low-income countries and has proven very resistant to prevention through public health interventions. Accumulative evidence from animal and human studies suggests that such deficiencies are associated with large adverse effects on child cognitive and motor development. Therefore, effective interventions to improve iron status will have large health benefits. Action to reduce young child ID would benefit from overarching policy and programmatic guidance that informs decision makers about what to do, when to do it, and how to do it. The impetus for new approaches to prevent ID in young children reflects growing recognition of the need to intervene early and often and for better vehicles to deliver iron. Prevention of ID requires strong delivery systems that enhance consumer demand and promote compliance. When this occurs, the prevalence of anemia is greatly reduced.
122 citations
TL;DR: Under conditions in which maternal iron status, birth weight, gestational age, and umbilical cord clamping time are optimal, and exclusive breast-feeding is practiced, infants should have adequate iron stores for the first 6-8 mo of life, but under suboptimal conditions, infants may not reach this goal and may need to be targeted for iron supplementation before 6 mo of age.
Abstract: Iron deficiency is estimated to be the most common nutritional deficiency worldwide and is particularly persistent among infants and children. The high prevalence of anemia in 6- to 9-mo-old children raises the concern that birth iron stores in some infants are inadequate to sustain growth and development through the first 6 mo of life, and postnatal factors are contributing to early depletion of iron stores and development of anemia. At the same time, there are concerns about negative effects of excess iron in infants. Maternal iron status, infant birth weight and gestational age, as well as the timing of umbilical cord clamping at birth all contribute to the establishment of adequate total body iron at birth. Postnatally, feeding practices and growth rate are factors that will affect how quickly birth iron is depleted during the first 6 mo of life. Under conditions in which maternal iron status, birth weight, gestational age, and umbilical cord clamping time are optimal, and exclusive breast-feeding is practiced, infants should have adequate iron stores for the first 6-8 mo of life. Under suboptimal conditions, infants may not reach this goal and may need to be targeted for iron supplementation before 6 mo of age.
112 citations
TL;DR: Assessment of the mental health system in Brazil finds that services are unequally distributed across the regions of the country, and the growth of the elderly population, combined with an existing treatment gap is increasing the burden on mental health care.
Abstract: Background
The aim of this paper is to assess the mental health system in Brazil in relation to the human resources and the services available to the population.
109 citations
TL;DR: For successful rotavirus vaccine introduction, the lessons learned re-emphasize the critical need for countries to have precise plans that will ensure technical, programmatic and financial sustainability of vaccine introduction.
Abstract: In Latin America and the Caribbean, rotavirus causes approximately 15,000 deaths, 75,000 hospitalizations, 2 million clinic visits and 10 million cases of rotavirus diarrhea annually. Two safe vaccines are available that are effective in preventing severe illness. To date, seven countries in Latin America (Brazil, Ecuador, El Salvador, Panama, Mexico, Nicaragua and Venezuela) have introduced the vaccine. For successful rotavirus vaccine introduction, the lessons learned re-emphasize the critical need for countries to have precise plans that will ensure technical, programmatic and financial sustainability of vaccine introduction. Of these lessons learned, programmatic feasibility and financial sustainability were particularly challenging for countries that were the first to introduce a rotavirus vaccine.
101 citations
TL;DR: An FCF, including ferrous sulfate, delivered through public health services, is highly effective in improving weight and hemoglobin and reducing anemia in infants and young children living in poor communities and receiving government health services.
Abstract: Linear growth retardation and anemia are the most prevalent nutritional problems in the world; effective interventions are urgently needed. We evaluated Ecuador's National Food Nutrition Program (PANN 2000) that included a micronutrient-fortified complementary food (FCF), Mi Papilla, in poor periurban and rural communities of Ecuador. The program is preventive and targeted to all infants and young children living in poor communities and receiving government health services. We compared dietary intake, micronutrient status, and growth over 11 mo in a cohort of children from the catchment areas of the PANN 2000 with same-age control children in nearby communities eligible to enter the program 1 y later. PANN 2000 children enrolled in the program when they were age 9-14 mo and were age 20-25 mo at the final survey. They consumed significantly more energy, protein, fat, iron, zinc, vitamin A, and calcium than control children because of their FCF consumption. Anemia, 76% in both groups at baseline, fell to 27% in PANN 2000 children but only to 44% in control children (P < 0.001). The odds of being anemic were 58% lower for PANN 2000 children (P = 0.003). The effects on linear growth and weight were limited to children who were older when the program began (12-14 mo) and were significant for weight (interaction with age, 0.38 kg; P = 0.029) and positive but not significant for length (0.66 cm; P = 0.08). An FCF, including ferrous sulfate, delivered through public health services, is highly effective in improving weight and hemoglobin and reducing anemia.
TL;DR: Researchers should consider SEP, community norms, behavioral risk and protective factors when studying Mexican-origin groups, and it is not spending time in the U.S. that worsens health outcomes but rather changes in health promoting behaviors.
Abstract: Objectives This paper compares select health status indicators between the U.S. and Mexico, and within the Mexican-origin population using proxy measures of acculturation. Methods Statistical data were abstracted and a Medline literature review conducted of English-language epidemiologic articles on Mexican-origin groups published during 1976–2005. Results U.S.-born Mexican-Americans have higher morbidity and mortality compared to Mexico-born immigrants. Mexico has lower healthcare resources, life expectancy, and circulatory system and cancer mortality rates, but similar infant immunization rates compared to the U.S. Along the U.S.-Mexico border, the population on the U.S. side has better health status than the Mexican side. The longer in the U.S., the more likely Mexican-born immigrants engage in behaviors that are not health promoting. Conclusions Researchers should consider SEP, community norms, behavioral risk and protective factors when studying Mexican-origin groups. It is not spendingtime in the U.S. that worsens health outcomes but rather changes in health promoting behaviors.
TL;DR: In the United Kingdom of Great Britain and Northern Ireland people from the Indian subcontinent and sub-Saharan Africa living in inner cities have higher rates of TB than the general population; particularly during the first years after arriving in the country.
Abstract: Tuberculosis (TB) remains an important public health problem in industrialized countries. The majority of cases occur in minority groups particularly recently arrived immigrants from countries with high endemicity who often congregate in deprived communities within wealthy cities. In the United Kingdom of Great Britain and Northern Ireland people from the Indian subcontinent and sub-Saharan Africa living in inner cities have higher rates of TB than the general population; particularly during the first years after arriving in the country. The HIV/AIDS epidemic has had a disproportionate impact among ethnic minorities in large industrialized cities. (excerpt)
TL;DR: The recognition of the need for increased global attention towards HepA prevention is an important outcome of this meeting, and a stepwise strategy for introduction of HepA universal immunisation of children was recommended.
Abstract: Summary. For the first time a global meeting on hepatitis A virus (HAV) infection as vaccine preventable disease was organized at the end of 2007. More than 200 experts from 46 countries gathered to investigate the changing global HAV epidemiology reflecting the increasing numbers of persons at risk for severe clinical disease and mortality from HAV infection. The benefits of childhood and adult hepatitis A (HepA) vaccination strategies and the data needed by individual countries and international health organizations to assess current HepA prevention strategies were discussed. New approaches in preventing HAV infection including universal HepA vaccination were considered. This introductory paper summarizes the major findings of the meeting and describes the changing epidemiology of HAV infections and the impact of HepA vaccination strategies in various countries. Implementation of HepA vaccination strategies should take into account the level of endemicity, the level of the socio-economic development and sanitation, and the risk of outbreaks. A stepwise strategy for introduction of HepA universal immunisation of children was recommended. This strategy should be based on accurate surveillance of cases and qualitative documentation of outbreaks and their control, secure political support on the basis of high-quality results, and comprehensive cost-effectiveness studies. The recognition of the need for increased global attention towards HepA prevention is an important outcome of this meeting.
TL;DR: Research is evolving on mental health service utilization in developed countries, although most disasters occur in developing countries, and the model for mental healthcare delivery following a disaster that has gained acceptance is Psychological First Aid.
Abstract: PURPOSE OF REVIEW: A sizable proportion of individuals following a disaster develop mental health problems. The consequences of these disorders can be long lasting. Only recently has research focused on mental health service delivery following disasters. This review examines the rates, predictors, and barriers to mental health service utilization following a disaster. RECENT FINDINGS: Most of the data on mental health service delivery come from three sources: a fireworks disaster in The Netherlands, the September 11, 2001, attack on New York City, and hurricane Katrina. Most survivors of disasters are reluctant to utilize mental health services and face barriers to accessing care. Even among disaster victims who are severely mentally ill, only a minority receive treatment. Among those who do receive assistance, more than half drop out shortly thereafter. Mental health service utilization following a disaster is influenced by a set of predisposing characteristics, enabling resources, and perceived need. The model for mental healthcare delivery following a disaster that has gained acceptance is Psychological First Aid. SUMMARY: Research is evolving on mental health service utilization. It is limited however to developed countries, although most disasters occur in developing countries. More research is needed, particularly among populations with scarce resources. Language: en
TL;DR: In the LAC region, if effective delivery mechanisms can achieve high coverage rates in young adolescent girls, vaccination against HPV-16 and 18 will provide similar health value for resources invested as other new vaccines such as rotavirus.
TL;DR: An advanced cost-benefit analysis, using models calibrated to specific countries in the region, presents the range of options and relative costs thus providing evidence-based scientific guidance to governments and providers in the context of a significant and systematic international review effort.
TL;DR: High mean systolic and mean diastolic blood pressures were important predictors of intensification and clinical distractions and shortcomings in continuity and coordination of care are possible targets for improvement.
Abstract: Background
Although tight blood pressure control is crucial in reducing vascular complications of diabetes, primary care providers often fail to appropriately intensify antihypertensive medications.
TL;DR: This paper explores different international vaccine financing and procurement strategies used by the Pan American Health Organization, United Nation's Children's Fund, the Global Alliance for Vaccines and Immunization, the Gulf Cooperation Model, and the Advanced Market Commitments to identify lessons learned to help ensure equitable distribution of life-saving vaccines for cervical cancer prevention.
TL;DR: A reformulation of cervical cancer screening policies to be based on HPV testing using validated methods followed by cytologic triage is proposed, which would serve as the central component of a system that plays the dual role of providing screening and surveillance as integrated and complementary activities sharing centralized resources and coordination.
TL;DR: To assess the effectiveness of cryotherapy treatment delivered by general practitioners in primary care settings, as part of a screen‐and‐treat approach for cervical cancer prevention, a cryotherapy study is conducted.
TL;DR: The cause of the outbreak was DEG-contaminated cough syrup as mentioned in this paper, which led to the recall of approximately 60, 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.
Abstract: OBJECTIVE: In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak. METHODS: Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (± 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls. FINDINGS: Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup. CONCLUSION: The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.
TL;DR: Prophylactic human papillomavirus (HPV) vaccines provide promise as a key component of future cervical cancer prevention programs in the Latin America and the Caribbean region but more research is required to determine what messages and strategies will work in these communities.
TL;DR: Measles is no longer an endemic disease in the Americas and interruption of transmission has been documented in most countries and this experience demonstrates that interruption of measles transmission can be achieved and sustained over a long period of time.
Abstract: Measles is one of the most infectious diseases. Before the introduction of the measles vaccine, nearly all children contracted measles. By the end of the 1980s, most countries of the world had incorporated the measles vaccine into their routine vaccination programs. Globally, some 345,000 deaths due to measles still occur every year. Eradication of measles would play an important role in improving child survival. The goal to eradicate measles from the Americas was set by the Pan-American Sanitary Conference in 1994. Progress to date has been remarkable. Measles is no longer an endemic disease in the Americas and interruption of transmission has been documented in most countries. As of December 2007, 5 years have elapsed since the detection of the last endemic case in Venezuela in November 2002. This experience demonstrates that interruption of measles transmission can be achieved and sustained over a long period of time. Global eradication should be feasible if the appropriate strategies are implemented. Even in a new paradigm in which eradication is not followed by the discontinuation of vaccination, eradication of measles should be a good investment to avoid expensive epidemics and save those children that would potentially die due to infection with the measles virus. It is not only a dream to think that we will see a world free of measles by the year 2015.
TL;DR: In this paper, the authors discuss implementation of five large-scale Health and Nutrition Days (HNDs) using NIDs as a platform to monitor nutritional status and estimate coverage of health and social welfare services, including conditional cash transfer benefits.
Abstract: PROBLEM: To achieve the Millennium Development Goals it is necessary to set up low-cost, real-time monitoring systems which can provide feedback to managers and policy-makers in a timely fashion. The gold-standard approach for monitoring nutritional situations is to conduct household surveys. However, they are costly, time consuming and do not furnish information about smaller disaggregated units. APPROACH: Brazil pioneered National Immunization Days (NIDs) in the 1980s, and later integrated them with vitamin A supplementation. This report discusses implementation of five large-scale Health and Nutrition Days (HNDs) using NIDs as a platform to monitor nutritional status and estimate coverage of health and social welfare services, including conditional cash transfer benefits. LOCAL SETING: Brazil is composed of 26 states, one federal district and 5564 municipalities, with around 18 million children under five years of age. It was decided that HNDs would be carried out among high-risk populations: children from the semi-arid north-eastern region; agrarian reform settlements; isolated rural black communities or quilombolas and municipalities of Amazonas state. RELEVANT CHANGES: It was possible to draw inferences for almost 3 million children from different subgroups of underprivileged populations who had never before been studied in such detail, including state-level data. LESSONS LEARNED: Implementation of large scale HNDs in conjunction with NIDs proved to be feasible in Brazil and resulted in data which are very relevant for policy-makers, obtained over a short period of time and at reasonably low cost. It is sensible to conclude that the experience reported here could be reproduced wherever NID coverage is very high.
TL;DR: The proposed strategy has the possibility of stimulating and accelerating the introduction of new screening technology and HPV vaccines into programmes throughout Latin America and the Caribbean.
TL;DR: The work of a forgotten pioneer- Fritz Jahr- who coined the term bioethics in 1927 and anticipated many of the arguments and discussions now current in biological research involving animals is drawn attention.
Abstract: Reviewing fundamental aspects of bioethics and outlining the work of the Bioethics Program of the Pan American Health Organization, this paper draws attention to the work of a forgotten pioneer- Fritz Jahr- who coined the term bioethics in 1927 and anticipated many of the arguments and discussions now current in biological research involving animals
TL;DR: The characteristics of violence-related injury (VRI) cases presenting at emergency departments (EDs) in Brazil are described to improve understanding of the scope and characteristics of VRIs in Brazil, contribute to national injury prevention efforts, and help identify areas for future research.
Abstract: OBJECTIVE: This article describes the characteristics of violence-related injury (VRI) cases presenting at emergency departments (EDs) in Brazil and compares circumstances for assault-related and self-inflicted cases. METHODS: The study is cross-sectional. The data describe cases seen in September 2006 in 62 EDs, representing all 26 states and the Federal District. A total of 4 835 case records were analyzed. Basic statistical tabulations were complemented by logistic regression analysis to assess potential associations between type of violence (assault or self-harm) and multiple factors. RESULTS: Males comprised 72.8% of cases while those aged 20 to 29 comprised 35.4%. Alcohol use was reported or suspected in 42.7% of cases, more commonly among males. Assault victims comprised 91.4% of cases versus self-inflicted injuries, which accounted for 8.6%. Three-fourths of the assault victims were male, while over half of the self-inflicted injury victims were female. The leading mechanism for assaults was physical force/blunt objects (46.2%), whereas poisoning was the predominant mechanism for self-inflicted injuries (71.4%). Younger females were significantly more likely to have been victims of self-inflicted injuries than younger males, while younger males were more likely to have been victims of assault; this finding is more pronounced in cases where alcohol use was reported. Self-inflicted injuries were significantly more likely to occur in residences, while assaults were more likely to occur away from home. CONCLUSION: These results can improve understanding of the scope and characteristics of VRIs in Brazil (and thus contribute to national injury prevention efforts), and help identify areas for future research.
TL;DR: Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring, in diabetic adults, and interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.
Abstract: In diabetic adults, tight control of risk factors reduces complications. To determine whether failure to make visits, monitor risk factors, or intensify therapy affects control of blood pressure, glucose, and lipids. A non-concurrent, prospective study of data from electronic files and standardized abstraction of hard-copy medical records for the period 1/1/1999–12/31/2001. Three hundred eighty-three adults with diabetes managed in an academically affiliated managed care program. Main exposure variable: Intensification of therapy or failure to intensify, reckoned on a quarterly basis. Main outcome measure: Hemoglobin A1c (A1c), systolic blood pressure (SBP), and LDL-cholesterol at the end of the interval. In this visit-adherent cohort, control of glycemia and lipids showed improvement over 24 months, but many patients did not achieve targets. Only those with the worst blood pressure control (SBP ≥160 mmHg) showed any improvement over 2 years. Failure to intensify treatment in patients who kept visits was the single strongest predictor of sub-optimal control. Compared to their counterparts with no failures of intensification, patients with failures in ≥3 quarters showed markedly worse control of blood glucose (A1c 1.4% higher: 95% CI: 0.7, 2.1); hypertension (SBP 22.2 mmHg higher: 95% CI: 16.6, 27.9) and LDL cholesterol (LDL 43.7 mg/dl higher: 95% CI: 24.1, 63.3). These relationships were strong, graded, and independent of socio-demographic factors, baseline risk factor values, and co-morbidities. Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring. Interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.
TL;DR: In conclusion, weekly FA (either high or low dose) plus vitamin B-12 may be as efficacious as daily supplementation in improving serum folate and lowering Hcy concentrations in healthy reproductive-aged women.
Abstract: Daily folic acid (FA) supplementation improves folate status, lowers circulating homocysteine (Hcy) concentrations, and reduces the risk of neural tube defects. Little is known about the efficacy of weekly FA supplementation. The objective of this study was to compare the efficacy of weekly and daily FA supplementations in improving folate and vitamin B-12 status and lowering Hcy concentrations in healthy reproductive-aged women. A randomized, double-blind supplementation trial was conducted in Guatemala. A total of 459 women were assigned randomly to 4 groups to receive weekly (5000 or 2800 mg) or daily (400 or 200 mg) FA for 12 wk. Daily and weekly iron, zinc, and vitamin B-12 were also provided. We determined serum and RBC folate by microbiological assays, but the latter was available only at baseline. Serum Hcy and vitamin B-12 were also measured. We used generalized linear regression models to assess the effects of treatment on biochemical indicators. Supplementation improved folate status similarly across all 4 groups. Overall, mean serum folate concentrations increased by 15.4 nmol/L (95% CI: 13.8, 16.9) and the geometric mean serum Hcy concentration decreasedby 9.8% (95% CI: 212.3, 27.1). Daily supplementation improvedserum vitamin B-12 by 20% (95% CI: 8, 33.2), whereas weekly supplementation had no effect. In conclusion, weekly FA (either high or low dose) plus vitamin B-12 may be as efficacious as daily supplementation in improving serum folate and loweringHcy concentrations in healthy womenof reproductive age. J. Nutr. 138: 1491‐1498, 2008.