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  • Development of the set of scales to assess the job satisfaction among physicians in Peru: validity and reliability assessment

    Villarreal-Zegarra, David; Torres-Puente, Roberto; Castillo-Blanco, Ronald; Cabieses, Baltica; Bellido-Boza, Luciana; Mezones-Holguin, Edward (BioMed Central Ltd, 2021-12-01)
    Background: To assess the validity and reliability of the set of scales (general professional activity, health services management, and working conditions) on the different areas of job satisfaction in Peruvian physicians based on the data from the National Survey of Satisfaction of Users in Health (ENSUSALUD). Method: We carried out a psychometric study based on the secondary data analysis of Questionnaire 2 of ENSUSALUD-2016. Participants were selected from a two-stage stratified national probability representative sampling by political region. Validity was assessed by exploratory and confirmatory factor analyses, and measurement invariance analysis. We assessed the reliability using internal consistency coefficients (alpha and omega). The set of scales were composed of items related to three different areas of job satisfaction: 1) satisfaction with general professional activity, 2) satisfaction with the health services management, and 3) satisfaction with the working conditions of the health center. Results: We included 2137 participants in the analysis. The general professional activity scale with six items (Comparative Fit Index, CFI = 0.946; Root Mean Square Error of Approximation, RMSEA = 0.071; Standardized Root Mean Square Residual, SRMR = 0.035), the health services management scale with eight items (CFI) = 0.972; RMSEA = 0.081; SRMR = 0.028), showed good measurement properties for the one-dimensional model. The working conditions scale with eight items for individual conditions and three items for infrastructural conditions (CFI = 0.914; RMSEA = 0.080; SRMR = 0.055) presented adequate measurement properties with a two-dimensional model. The invariance analysis showed that comparisons between sex, age, civil status, medical speciality, working in other institutions, work-related illness, chronic disease, and time working in the healthcare center. All scales had adequate internal consistency (ω and α between 0.70 and 0.90). Conclusions: The set of scales has a solid factorial structure and measurement invariance, making it possible for group comparison. The study achieved stability in the scores as they showed adequate internal consistency coefficients. Based on our findings, these instruments are suitable for measuring job satisfaction among outpatient physicians throughout Peru, as our data is representative of the country level.
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  • Co‐occurrence and clustering of sedentary behaviors, diet, sugar‐sweetened beverages, and alcohol intake among adolescents and adults: The latin american nutrition and health study (elans)

    Leme, Ana Carolina B.; Ferrari, Gerson; Fisberg, Regina M.; Kovalskys, Irina; Gómez, Georgina; Cortes, Lilia Yadira; Gárcia, Martha Cecilia Yépez; Herrera‐cuenca, Marianella; Rigotti, Attilo; Liria‐domínguez, María Reyna; Fisberg, Mauro (MDPI AG, 2021-06-01)
    Poor diet, sedentary behaviors, sugar‐sweetened beverages (SSB) and alcohol intake seem to co‐exist in complex ways that are not well understood. The aim of this study was to provide an understanding of the extent to which unhealthy behaviors cluster in eight Latin America countries. A secondary aim was to identify socio‐demographic characteristics associated with these behaviors by country. Data from adolescents and adults from the “Latin American Health and Nutrition Study” was used and the prevalence of screen‐time, occupational and transportation–sedentary time, socializing with friends, poor diet, SSB and alcohol intake, alone and in combination, were identified. The eight Latin America (LA) countries added to analyses were: Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela. Logistic regression was used to estimate associations between ≥2 behaviors clustering, socio‐demographics and weight status. Among 9218 individuals, the most prevalent behaviors were transportation and occupation–sedentary time, SSB and alcohol intake. Younger, female, married/living with a partner, low and middle‐income and obese individuals had higher chances for these clustering behaviors. These results provide a multi-country level of understanding of the extent to which behaviors co‐occur in the LA population.
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  • Characterization of the gut microbiota in diabetes mellitus II patients with adequate and inadequate metabolic control

    Hamasaki-Matos, Angie Joyce; Cóndor-Marín, Katherine Marlene; Aquino-Ortega, Ronald; Carrillo-Ng, Hugo; Ugarte-Gil, Cesar; Silva-Caso, Wilmer; Aguilar-Luis, Miguel Angel; del Valle-Mendoza, Juana (BioMed Central Ltd, 2021-12-01)
    Objective: The objective of this study was to characterize the composition of the gut microbiota in type 2 Diabetes Mellitus (T2DM) patients with adequate and inadequate metabolic control, and its relationship with fiber consumption. Results: A total of 26 patients with type 2 diabetes mellitus (T2DM) were enrolled, of which 7 (26.9%) cases had adequate metabolic control (HbA1c < 7%) and 19 (73.1%) inadequate metabolic control (HbA1c ≥ 7%). It was observed that among patients with controlled T2DM, 2 (28.6%) cases presented good intake of fiber and 5 (71.4%) cases a regular intake. In contrast, in patients with uncontrolled T2DM, 13 (68.4%) patients reported a regular intake and 6 (31.6%) a poor intake. In relation to the identification of the gut microbiota, both groups presented a similar characterization. There were differences in the population of bacteria identified in both groups, however, the results were not statistically significant. The most frequently identified bacteria in controlled and uncontrolled T2DM patients were Prevotella (71.4% vs 52.6%), followed by Firmicutes (71.4% vs 42.1%), Proteobacteria (71.4% vs 36.8%) and Bacteroidetes (57.1% vs 37.8%). On the other hand, Fusobacterium, Actinobacteria were not identified in either of the two groups of study.
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  • An Evaluation of the COVID-19 Pandemic and Perceived Social Distancing Policies in Relation to Planning, Selecting, and Preparing Healthy Meals: An Observational Study in 38 Countries Worldwide

    Backer, Charlotte De; Teunissen, Lauranna; Cuykx, Isabelle; Decorte, Paulien; Pabian, Sara; Gerritsen, Sarah; Matthys, Christophe; Sabbah, Haleama Al; Royen, Kathleen Van; Bergheim, Ina; Staltner, Raphaela; Devine, Amanda; Sambell, Ros; Wallace, Ruth; Allehdan, Sabika Salem; Alalwan, Tariq Abdulkarim; Al-Mannai, Mariam Ahamad; Ismail, Leila Cheikh; Backer, Charlotte De; Ouvrein, Gaelle; Poels, Karolien; Vandebosch, Heidi; Maldoy, Katrien; Matthys, Christophe; Smits, Tim; Vrinten, Jules; Desmet, Ann; Teughels, Nelleke; Geuens, Maggie; Vermeir, Iris; Proesmans, Viktor; Hudders, Liselot; De Barcellos, Marcia Dutra; Ostermann, Cristina; Brock, Ana Luiza; Favieiro, Cynthia; Trizotto, Rafaela; Stangherlin, Isadora; Mafra, Anthonieta Looman; Varella, Marco Antonio Correa; Valentova, Jaroslava Varella; Fisher, Maryanne L.; Maceacheron, Melanie; White, Katherine; Habib, Rishad; Dobson, David S.; Schnettler, Berta; Orellana, Ligia; Miranda-Zapata, Edgardo; Chang, Angela Wen Yu; Jiao, Wen; Tingchi, Matthew; Liu; Grunert, Klaus G.; Christensen, Rikke Nyland; Reisch, Lucia; Janssen, Meike; Abril-Ulloa, Victoria; Encalada, Lorena; Kamel, Iman; Vainio, Annukka; Niva, Mari; Salmivaara, Laura; Makela, Johanna; Torkkeli, Kaisa; Mai, Robert; Kerschke-Risch, Pamela; Altsitsiadis, Efthymios; Stamos, Angelos; Antronikidis, Andreas; Tsafarakis, Stelios; Delias, Pavlos; Rasekhi, Hamid; Vafa, Mohammad Reza; Majid, Karandish; Eftekhari, Hassan; Henchion, Maeve; McCarthy, Sinead; McCarthy, Mary; Micalizzi, Alessandra; Schulz, Peter J.; Farinosi, Manuela; Komatsu, Hidenori; Tanaka, Nobuyuki; Kubota, Hiromi; Tayyem, Reema; Al-Awwad, Narmeen J.; Al-Bayyari, Nahla; Ibrahim, Mohammed O.; Hammouh, Fadwa; Dashti, Somaia; Dashti, Basma; Alkharaif, Dhuha; Alshatti, Amani; Mazedi, Maryam Al (Frontiers Media S.A., 2021-02-04)
    Objectives: To examine changes in planning, selecting, and preparing healthy foods in relation to personal factors (time, money, stress) and social distancing policies during the COVID-19 crisis. Methods: Using cross-sectional online surveys collected in 38 countries worldwide in April-June 2020 (N = 37,207, Mage 36.7 SD 14.8, 77% women), we compared changes in food literacy behaviors to changes in personal factors and social distancing policies, using hierarchical multiple regression analyses controlling for sociodemographic variables. Results: Increases in planning (4.7 SD 1.3, 4.9 SD 1.3), selecting (3.6 SD 1.7, 3.7 SD 1.7), and preparing (4.6 SD 1.2, 4.7 SD 1.3) healthy foods were found for women and men, and positively related to perceived time availability and stay-at-home policies. Psychological distress was a barrier for women, and an enabler for men. Financial stress was a barrier and enabler depending on various sociodemographic variables (all p < 0.01). Conclusion: Stay-at-home policies and feelings of having more time during COVID-19 seem to have improved food literacy. Stress and other social distancing policies relate to food literacy in more complex ways, highlighting the necessity of a health equity lens.
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  • Comment about the article: «Understanding of different front-of-package labels by the Spanish population: Results of a comparative study»

    Grados-Jares, Manuel D.; Munoz-Denegri, Viviana M.; Medina-Pizzali, Maria L. (Elsevier Doyma, 2020-08-01)
    Carta al editor.
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  • Comments on: "Family life stories in teenage mothers: Qualitative study conducted at the Engativá ESE Hospital in Bogotá, Colombia"

    Rodríguez-Soto, Karen; Reyes-Aranibar, Sara; Uribe-Chincha, Tula; Torres-Slimming, Paola (NLM (Medline), 2020-06-01)
    Carta al editor.
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  • Association between household socioeconomic level and consumption of fast food and soft drinks: A cross-sectional assessment of the Young Lives cohort in Peru

    Najar, Carol Argelia; Vila-Quispe, Jessi Nataly; Astete-Robilliard, Laura; Bernabe-Ortiz, Antonio (Asociacion Espanola de Dietistas-Nutricionistas, 2020-01-01)
    Introduction: The consumption of fast food and soft drinks is a risk factor for developing overweight and obesity. This study aimed at assessing if there is association between household socioeconomic level and the consumption of fast food and soft drinks among children. Material and Methods: A cross-sectional assessment of the data from the third round (2009-2010) of the youngest cohort of the Young Lives study in Peru was conducted. Sampling was conducted in three stages: In the first one, the country was divided into equal geographical regions, excluding the 5% of the richest district; in the second stage, 20 sentinel sites were chosen and an area within each sentinel site was selected. Finally, in the third stage, eligible children were selected. Outcomes were the self-reported consumption of fast food and soft drinks (never, sometimes, and always), whereas the exposure was household socioeconomic status (in quintiles). Crude and adjusted models were created between variables of interest using Poisson regression models, with robust variance, to report prevalence ratios (PR) and 95% confidence intervals (95% CI). Results: Data of 1901 children, of which 942 (49.6%) were girls, with a mean age of 7.5 (SD: 0.5) was analyzed. A total of 24.1% (95%CI: 22.2%-26.1%) reported always consuming fast food, whilst this number was 22.4% (20.5%-24.3%) for soft drinks. Compared to the lowest socioeconomic quintile, those who were in higher socioeconomic status had more probability of consuming fast food and soft drinks (Chi-squared for trends <0.001). The highest socioeconomic quintile had a greater probability to always consume fast food (PR=1.42; 95%CI: 1.08-1.88) and soft drinks (PR=1.71; 95%CI: 1.24-2.37). Conclusions: This study shows that there is a significant association between the household socioeconomic level and the consumption of soft drinks and fast food.
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  • Are we adequately measuring food consumption and diet satisfaction in older adults?

    Jara, Alessandra Carolina Arroyo; García, Valeria Melanie Heredia; Quispe, Jorge Luis Maguiña (ARAN Ediciones S.A., 2020-01-01)
    Carta al editor
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  • Comments to the article "Overweight and clinical course in children younger than two years old hospitalized for lower respiratory tract infection"

    Bejarano-Talavera, Grecia Odalis; Acosta, Carla Andrea Estrada; Quispe, Jorge Luis Maguiña; Cruz-Retamozo, Ximena (ARAN Ediciones S.A., 2020-01-01)
    Carta al editor.
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  • Association between sitting time and obesity: A population-based study in Peru

    Paz-Krumdiek, M. (Blackwell Publishing Ltd, 2020-04-01)
    Aim: To assess if there is an association between sitting time and obesity among adult Peruvian population, using three different anthropometric measurements. Methods: A secondary analysis using data from a population-based study, the National Household Survey (ENAHO, in Spanish), was conducted enrolling adults aged ≥18 years from the 25 regions of Peru using a multistage random sampling technique. The outcome of interest was obesity, determined by body mass index (BMI > 30 kg/m2), waist circumference (WC > 80 and >90 cm in women and men, respectively) and waist to height ratio (WHR > 0.5); while the exposure was sitting time, measured using the last domain of the International Physical Activity Questionnaire and then categorised in <4 hours/day, 4 to <8 hours/day and 8+ hours/day. Associations were estimated using Poisson regression models, reporting prevalence ratios (PRs) and their respective 95% CI. Results: Data from 8587 subjects were analysed; mean age was 38.4 (SD: 13.5) and 53.6% were females. The prevalence of obesity was 16.3% (95% CI: 15.2–17.5%) by BMI, 58.5% (95% CI: 56.9–60.0%) by WC, and 78.0% (95% CI: 76.5–79.3%) by WHR. In the multivariable model, subjects reporting a sitting time of 8+ hours/day were more likely to be obese than those reporting <4 hours/day according to BMI (PR: 1.38; 95% CI: 1.15–1.65), WC (PR: 1.20; 95% CI: 1.12–1.28) and WHR (PR: 1.05; 95% CI: 1.01–1.10). Conclusions: Subjects with greater sitting time were more likely to be obese, and this association was evident with three different anthropometric indicators. Findings suggest the need of generating public health actions to reduce sedentary behaviour.
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  • Relationship between stunting in children 6 to 36 months of age and maternal employment status in Peru: A sub-analysis of the Peruvian Demographic and Health Survey

    Chávez-Zárate, Airin; Maguiña, Jorge L.; Quichiz-Lara, Antoinette Danciana; Zapata-Fajardo, Patricia Edith; Mayta-Tristan, Percy; (Public Library of Science, 2019-04)
    Objectives This study aimed to determine the relationship between stunting in children 6 to 36 months old and maternal employment status in Peru. Methods A secondary data analysis was conducted using information from the Demographic and Health Survey (DHS) in Peru. We used a representative sample of 4637 mother-child binomials to determine the association between stunting in children 6 to 36 months of age and the employment status of their mothers. Results The prevalence of stunting among children was 15.9% (95% CI: 13.9–16.7). The prevalence of working mothers was 63.7%. No association was found between maternal employment status and the presence of stunting in children [prevalence ratio (PR) = 1.04; 95% confidence interval (95% CI): 0.9 to 1.2; p = 0.627). However, on multivariate analysis we found that the prevalence of stunting was significantly higher among children of mothers performing unpaid work (12.4%) (PR = 1.38; 95% CI: 1.2–1.6; p < 0.001) compared with those of paid working mothers. Conclusion No significant association was found between maternal employment status and the presence of stunting in children 6 to 36 months of age. However, children of mothers doing unpaid work are at higher risk of stunting. These findings support the implementation of educational programs and labour policies to reduce the prevalence of stunting among children. © 2019 Chávez-Zárate et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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  • Organically vs conventionally-grown dark and white chia seeds (salvia hispanica L.): Fatty acid composition, antioxidant activity and techno-functional properties

    K., Alvites-Misajel; García-Gutiérrez, M.; Miranda-Rodríguez, C.; Ramos-Escudero, F.; (CSIC Consejo Superior de Investigaciones Cientificas, 2019-04-02)
    The effects of organic and conventional crop systems on chemical composition, antioxidant activity and functional properties were evaluated in white and dark chia (Salvia hispanica L.) seeds. The organic system reduced the total protein content, and increased the total carbohydrates but did not change polyunsaturated fatty acids, total phenolic or flavonoids. Organic white chia seeds showed the best techno-functional properties. The antioxidant capacity of chia extracts varied in relation to the chemical complexity and differential rate kinetics of different assays. Extractable total phenolic acids and antioxidant capacity were better in organic white chia seeds. In this first approach, we have demonstrated that the organic white chia seed has a better total antioxidant capacity measured by direct quencher approaches than its conventionally-grown counterpart. To summarize, we conclude that the organic white chia seed could be a dietary source of antioxidants with a potential to promote health benefits in systemic functions and/or microbiota and the use of its techno-functional properties for the food industry.
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  • Hipótesis alternativas sobre los beneficios de los fermentados sobre la microbiota intestinal

    Bernardi Espinoza, Diego; Jiménez Guerrero, Carlos Fernando; Milon, Pohl (ARAN Ediciones S.A., 2018-11)
    Cartas al editor
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  • Effect of vegetarian diets on the presentation of metabolic syndrome or its components: a systematic review and meta-analysis

    Picasso, Maria C.; Lo-Tayraco, Jessica A.; Ramos-Villanueva, Juselly M.; Pasupuleti, Vinay; Hernandez, Adrian V.;;;;; (Churchill Livingstone, 2018)
    Background & aims: Several studies have examined the effect of vegetarian diets (VD) on metabolic syndrome (MetS) or its components, but findings have been inconsistent. The aim of this study was to perform a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies to assess the association between VD and MetS or its components (systolic blood pressure [SBP], diastolic blood pressure [DBP], fasting glucose triglycerides, waist circumference [WC], HDL-cholesterol (HDL-C)) in adults. Methods: The Cochrane Library, EMBASE, PubMed, Web of Science, and Scopus were searched. RCTs, cohort studies and cross-sectional studies evaluating the effects of VD on MetS or its components in adults, with omnivore diet as control group, were included. Random effects meta-analyses stratified by study design were employed to calculate pooled estimates. Results: A total of 71 studies (n = 103 008) met the inclusion criteria (6 RCTs, 2 cohorts, 63 cross-sectional). VD were not associated with MetS in comparison to omnivorous diet (OR 0.96, 95% CI 0.50–1.85, p = 0.9) according to meta-analysis of five cross-sectional studies. Likewise, meta-analysis of RCTs and cohort studies indicated that consumption of VD were not associated with MetS components. Meta-analysis of cross-sectional studies demonstrated that VD were significantly associated with lower levels of SBP (mean difference [MD] −4.18 mmHg, 95%CI −5.57 to −2.80, p < 0.00001), DBP (MD −3.03 mmHg, 95% CI −4.93 to −1.13, p = 0.002), fasting glucose (MD −0.26 mmol/L, 95% CI −0.35to −0.17, p < 0.00001), WC (MD −1.63 cm, 95% CI −3.13 to −0.13, p = 0.03), and HDL-C (MD −0.05 mmol/L, 95% CI −0.07 to −0.03, p < 0.0001) in comparison to omnivorous diet. Heterogeneity of effects among cross-sectional studies was high. About, one-half of the included studies had high risk of bias. Conclusions: VD in comparison with omnivorous diet is not associated with a lower risk of MetS based on results of meta-analysis of cross-sectional studies. The association between VD and lower levels of SBP, DBP, HDL-C, and fasting glucose is uncertain due to high heterogeneity across the cross-sectional studies. Larger and controlled studies are needed to evaluate the association between VD and MetS and its components.
  • Comentario de Terrones Arias AE en: Incidencia del periodo vacacional de Navidad en el estado ponderal de escolares de Primaria

    Terrones Arias, Angel Eduardo; Carbajal Huamani, Oliverio (Asociacion Espanola de Dietistas-Nutricionistas, 2018-03-16)
    Carta al editor
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  • Ingesta de arsénico: el impacto en la alimentación y la salud humana

    Medina-Pizzali, María; Robles, Pamela; Mendoza, Mónica; Torres, Celeste (Instituto Nacional de Salud (INS), 2018-04-09)
    Arsenic is an element that is widely distributed throughout the environment. Its compounds are mainly in the state of pentavalent and trivalent oxidation; and in inorganic and organic forms. Arsenical species vary in their degree of toxicity, with inorganic compounds being more political than organic, and trivalent compounds more toxic than pentavalent compounds. There would be interconversion between the less toxic species and other more toxic species and the cooking and processing methods could affect it. Arsenic is a carcinogenic agent and causes multiple negative effects on human health in the short and long term. Non-occupational human exposure to arsenic occurs mainly through water and food. The regulation is variable for each country and is based on WHO standards, the Codex Alimentarius, and the European Union. Many studies focus on determining the total arsenic content but do not identify arsenical species in foods. Globally, fish and seafood, chicken, meat, rice, and seaweed have high levels of arsenic. In Peru, there are few studies on total arsenic content and arsenical species in food despite the fact that we have areas with high levels of environmental contamination. The objective of this review is to discuss exposure to arsenic through food and water intake, related regulations, toxicity, consequences on human health and main foods that contribute to its intake.
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  • Efecto de la anemia en el desarrollo infantil: Consecuencias a largo plazo

    Zavaleta, Nelly; Astete-Robilliard, Laura (Instituto Nacional de Salud (INS), 2017-12)
    La anemia en niños menores de tres años es un problema de salud pública en el Perú y el mundo. Se estima que la causa principal de la anemia, aunque no la única, es la deficiencia de hierro. Existen muchos estudios y revisiones sobre cómo esta carencia en los infantes impacta negativamente en el desarrollo psicomotor y, a pesar de corregirse la anemia, los niños con este antecedente presentan, a largo plazo, un menor desempeño en las áreas cognitiva, social y emocional. Estos hallazgos se describen en estudios observacionales, de seguimiento, así como en experimentales con grupo control. La anemia puede disminuir el desempeño escolar, y la productividad en la vida adulta, afectando la calidad de vida, y en general la economía de las personas afectadas. Se describen algunos posibles mecanismos de cómo la deficiencia de hierro, con o sin anemia, podría afectar el desarrollo en la infancia; por ello, causa preocupación la alta prevalencia de anemia que se observa en este grupo de edad. La prevención de la anemia en el primer año de vida debe ser la meta para evitar consecuencias en el desarrollo de la persona a largo plazo.
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  • Importancia de diferenciar puntos de corte del IMC de acuerdo a la edad

    Reyes Huarcaya, Rossy María Elena; Núñez Sánchez, Mery Cristy (Grupo Aula Medica S.A., 2017-09-14)
    El IMC es un indicador de la relación entre el peso y la talla. Se utiliza frecuentemente para identificar el estado nutricional de un individuo, el cual depende de la edad y/o sexo
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  • Discordancia lipídica y placa carotídea en pacientes obesos en prevención primaria

    Masson, Walter; Siniawski, Daniel; Lobo, Martín; Molinero, Graciela; (Elsevier España S.L., 2017-11)
    Introduction Obese patients with lipid discordance (non-HDL cholesterol levels 30mg/dL above the LDL-c value) may have a greater prevalence of carotid atherosclerotic plaque (CAP). Our study objectives were: 1) To assess the prevalence of lipid discordance in a primary prevention population of obese patients; 2) To investigate the association between lipid discordance and presence of CAP. Methods Obese subjects aged >18 years (BMI ≥30kg/m2) with no cardiovascular disease, diabetes, or lipid-lowering treatment from six cardiology centers were included. Lipid discordance was defined when, regardless of the LDL-c level, the non-HDL cholesterol value exceeded the LDL-c value by 30mg/dL. Presence of CAP was identified by ultrasonography. Univariate and multivariate analyses were performed to explore the association between lipid discordance and presence of CAP. Results The study simple consisted of 325 obese patients (57.2% men; mean age, 52.3 years). Prevalence of lipid discordance was 57.9%. CAP was found in 38.6% of patients, but the proportion was higher in subjects with lipid discordance as compared to those without this lipid pattern (44.4% vs. 30.7%, P=.01). In both the univariate (OR: 1.80; 95% CI: 1.14-2.87; P=.01) and the multivariate analysis (OR: 2.07; 95% CI: 1.22-3.54; P=.007), presence of lipid discordance was associated to an increased probability of CAP. Conclusion In these obese patients, lipid discordance was associated to greater prevalence of CAP. Evaluation of obese patients with this strategy could help identify subjects with higher residual cardiovascular risk.

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