Rural Ecuador Research Articles

Malnutrition inequalities in Ecuador: differences by wealth, education level and ethnicity.

To describe and quantify the magnitude and distribution of stunting, wasting, anaemia, overweight and obesity by wealth, level of education and ethnicity in Ecuador. We used nationally representative data from the 2012 Ecuadorian National Health and Nutrition Survey. We used the Multidimensional Poverty Index (MPI) as a proxy of wealth. The MPI identifies deprivations across three dimensions (health, education and standard of living). We defined education by years of schooling and ethnicity as a social construct, based on shared social, cultural and historical experiences, using Ecuadorian census categories. Urban and rural Ecuador, including the Amazon rainforest and the Galapagos Islands. Children aged <5 years (n8580), adolescent women aged 11-19 years (n4043) and adult women aged 20-49 years (n15203). Among children <5 years, stunting and anaemia disproportionately affected low-wealth, low-education and indigenous groups. Among adolescent and adult women, higher rates of stunting, overweight and obesity were observed in the low-education and low-wealth groups. Stunting and short stature rates were higher in indigenous women, whereas overweight and obesity rates were higher in Afro-Ecuadorian women. Malnutrition differs significantly across sociodemographic groups, disproportionately affecting those in the low wealth tertile and ethnic minorities. Rates of stunting remain high compared with other countries in the region with similar economic development. The effective implementation of double-duty actions with the potential to impact both sides of the double burden is urgently required.

Performance of black ceramic water filters and their implementation in rural Ecuador

Abstract In rural Ecuador, microbial water contamination is associated with child morbidity mainly due to gastroenteritis. Black ceramic water filters (BCWF) are a new household water treatment recently developed to improve microbial removal from the classical model implemented worldwide. This study has assessed BCWF microbial performance at laboratory level by continuous filtering of spiked water with microbial surrogates (Escherichia coli and MS2 bacteriophage) and highly contaminated surface water to evaluate physicochemical pollutants' removal. At field level, baseline studies in Nanegal and Gualea districts have been performed to evaluate water quality and hygiene practices among communities and a six-month BCWF field implementation study in the Santa Marianita community. Results revealed poor drinking water quality in communities studied. Water treatment practices at household level were reported in low percentages. Conversely, results in BCWF filter assays at laboratory level for 600 litres of usage have shown 5.36 logarithms of bacterial removal and 3.83 logarithms for viral removal and significant reductions of physicochemical pollutants considering international standards. BCWF implementation in the Santa Marianita community reveals promising results on microbial water quality in households using this new technology. However, it is important to reinforce correct BCWF maintenance for better performance at field level.

Local traditional foods contribute to diversity and species richness of rural women's diet in Ecuador.

To evaluate the dietary diversity and the nutrient contribution of traditional foods (locally cultivated and wild) by conducting a food intake study in rural Ecuador. Repeated 24 h recalls over a 14 d interval and frequency of consumption served to simulate the usual diet by the Multiple Source Method. Data on missing visits (n 11) were imputed using multivariate imputation by chained equations. The intakes of three macro- and six micronutrients were reported. Nutrient Adequacy Ratios, Mean Adequacy Ratio (MAR), Dietary Species Richness (DSR) and Minimum Dietary Diversity for Women were used as measures of dietary quality. A linear quantile mixed model was used to investigate the association between DSR, local species, MAR, age, education and occupation. Guasaganda, Cotopaxi (Ecuador). Rural, indigenous adult women, non-pregnant and not breast-feeding. The studied diet had MAR of 0·78. Consumption of traditional foods contributed 38·6 % of total energy intake. Daily requirements for protein, carbohydrates, Fe and vitamin C were reached. An extra level of consumption of local species was associated with an increase in median MAR for macronutrients of 0·033 (P < 0·001). On the other hand, an extra level of consumption of local species was associated with an increase in median MAR for micronutrients of 0·052 (P < 0·001). We found statistical evidence that traditional foods contribute to adequate intakes of macro- and micronutrients and dietary diversification in the studied population. Future public health interventions should promote the cultivation and consumption of traditional foods to increase the quality of the local diet.

On the Association Between Sleep Quality and Arterial Stiffness: A Population Study in Community-Dwelling Older Adults Living in Rural Ecuador (The Atahualpa Project).

Evidence of an association between atherosclerosis and sleep quality is limited and has not been studied in remote rural settings, where living conditions are different than in urban centers. We aimed to assess the relationship between the aortic pulse wave velocity (PWV) and sleep quality in older adults living in rural Ecuador. Atahualpa residents aged 60 years or older identified during door-to-door surveys, who consented to participate, underwent face-to-face interviews with the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality. Aortic PWV determinations were performed for arterial stiffness estimation (as a surrogate of atherosclerosis). A total of 303 individuals were included (mean age: 70.3 ± 7.8 years; 59% women). Univariate logistic regression showed a significant association between the aortic PWV and poor sleep quality (odds ratio [OR] 1.22; 95% confidence interval [CI] 1.07-1.39; P = .003). A multivariate logistic regression model, adjusted for demographics, cardiovascular risk factors, oily fish intake and psychological distress showed a significant association between increased PWV and poor sleep quality (OR 1.59; 95% CI 1.12-2.25; P = .009). Similar significance was noted when the model was adjusted for neuroimaging signatures of cerebral small-vessel disease and stroke (OR 1.47; 95% CI 1.07-2.03; P = .019). This study shows a significant independent association between the aortic PWV and poor sleep quality in older adults living in rural Ecuador. Results provide more insights into the relevance of the impact of sleep disorders on cardiovascular diseases. The Atahualpa Project has been registered at ClinicalTrials.gov. The identifier number is NCT01627600, and the date was: 10/02/2012. Del Brutto OH, Mera RM, Peñaherrera E, Costa AF, Peñaherrera R, Castillo PR. On the association between sleep quality and arterial stiffness: a population study in community-dwelling older adults living in rural ecuador (the atahualpa project). J Clin Sleep Med. 2019;15(8):1101-1106.

Medical pluralism in maternal health-seeking behavior of rural women in Southern Ecuador

In rural Ecuador pregnant women face complex challenges navigating the terrain between traditional and biomedical maternal health care services. Semi-structured interviews were conducted in three rural communities in Southern Ecuador that have presented active Chagas disease transmission with women who were pregnant or have given birth within the last five years. This study was conducted to identify and understand the experiences of mothers in these communities and the decisions they make to maintain the wellness of themselves and their children. The researchers recorded women’s maternal health stories, analyzed their access to maternal health care, and explored factors influencing their birth location preferences and health seeking behaviors. The researchers found that women in this region are utilizing medical pluralism to sustain maternal health and the well-being of their children.

A Formative Assessment of the Vulnerability Context of Three Indigenous Communities in Rural Ecuador for Improved Intervention Design

A Formative Assessment of the Vulnerability Context of Three Indigenous Communities in Rural Ecuador for Improved Intervention Design

Double Burden of Malnutrition in Rural Ecuador: Adult Overweight and Child Stunting Co-occur at the Community but Not the Household Level (P10-075-19)

ObjectivesNorthern coastal Ecuador has seen rapid market integration since the initiation of a road system in the late 1990 s connecting the region to the Andean mountains. We previously demonstrated that, between 2003 and 2013, living in a relatively remote (less accessible) community was protective against stunting in children under five. Our objectives were to characterize trends in BMI among rural adults over the same period, and to examine the co-occurrence of adult overweight or obesity (OB/OW) and child stunting. MethodsAdult anthropometry was collected through a series of case-control studies repeated over a decade across thirty communities (N = 2053). Anthropometry was measured for all children under five in every community (N = 4170). Logistic and mixed-effect Poisson models, weighted to account for the case-control sampling design, were used to estimate the prevalence of OW/OB over time, to examine individual- and household-level risk factors associated with adult OW/OB, and to examine the co-occurrence of adult OW/OB and under-five stunting within households. ResultsAmong men, OW/OB increased over time (35.0% in 2003 to 52.9% by 2013) and was most common in the least remote versus the most remote communities (46.2% versus 26.9% across the study period). Among women, OW/OB was more prevalent (65.4%), but was not associated with community remoteness and did not increase over time. At the community level, the prevalence of under-five stunting was correlated with the prevalence of OW/OB among men (Spearman’s ρ = 0.56, P = 0.002) but not women (Spearman’s ρ = 0.16, P = 0.404). However, the presence of a stunted child under five within the household was not associated with adult OW/OB (odds ratio 0.87, P = 0.151). ConclusionsChanges in food environments and livelihoods due to the presence of roads may have driven increasing OW/OB among men over the study period. The positive association between adult male OW/OB and child stunting at the community level, but not at the household level, suggests that strategies to address the double burden of malnutrition that target the community (e.g., the food environment) are more likely to be effective than interventions targeted to households alone. Funding SourcesThis project was supported by the National Institutes of Health [R01-AI050038].

Neuroimaging signatures of cerebral small vessel disease and risk of falls in stroke-free older adults living in rural Ecuador. The Atahualpa Project

PurposeThis study aimed to assess the association between neuroimaging signatures of cerebral small vessel disease (cSVD) and the risk of falls in stroke-free older adults living in rural Ecuador. MethodsRisk of falls was evaluated by the Downton Fall Risk Index (DFRI). MRI readings focused on white matter hyperintensities (WMH) of presumed vascular origin, deep cerebral microbleeds (CMB), silent lacunar infarcts (LI), and > 10 enlarged basal ganglia-perivascular spaces (BG-PVS). Logistic regression models were fitted to evaluate whether these neuroimaging signatures were associated with the DFRI, after adjusting for relevant confounders. ResultsWe included 288 participants. The DFRI was positive in 69 (24%). Moderate-to-severe WMH were noticed in 55 individuals (19%), deep CMB in 18 (6%), LI in 23 (8%), and > 10 BG-PVS in 65 (23%). Multivariate models showed a significant association between moderate-to-severe WMH and the DFRI (p = .016). There were no associations between other neuroimaging signatures of cSVD and the DFRI. Age was the single covariable remaining significant in all models. ConclusionsWMH is associated with the DFRI in stroke-free older adults living in a remote rural setting. A target for fall prevention should include the control of factors favoring the development of diffuse subcortical damage of vascular origin.

Seasonal patterns of dengue fever in rural Ecuador: 2009-2016.

Season is a major determinant of infectious disease rates, including arboviruses spread by mosquitoes, such as dengue, chikungunya, and Zika. Seasonal patterns of disease are driven by a combination of climatic or environmental factors, such as temperature or rainfall, and human behavioral time trends, such as school year schedules, holidays, and weekday-weekend patterns. These factors affect both disease rates and healthcare-seeking behavior. Seasonality of dengue fever has been studied in the context of climatic factors, but short- and long-term time trends are less well-understood. With 2009–2016 medical record data from patients diagnosed with dengue fever at two hospitals in rural Ecuador, we used Poisson generalized linear modeling to determine short- and long-term seasonal patterns of dengue fever, as well as the effect of day of the week and public holidays. In a subset analysis, we determined the impact of school schedules on school-aged children. With a separate model, we examined the effect of climate on diagnosis patterns. In the first model, the most important predictors of dengue fever were annual sinusoidal fluctuations in disease, long-term trends (as represented by a spline for the full study duration), day of the week, and hospital. Seasonal trends showed single peaks in case diagnoses, during mid-March. Compared to the average of all days, cases were more likely to be diagnosed on Tuesdays (risk ratio (RR): 1.26, 95% confidence interval (CI) 1.05–1.51) and Thursdays (RR: 1.25, 95% CI 1.02–1.53), and less likely to be diagnosed on Saturdays (RR: 0.81, 95% CI 0.65–1.01) and Sundays (RR: 0.74, 95% CI 0.58–0.95). Public holidays were not significant predictors of dengue fever diagnoses, except for an increase in diagnoses on the day after Christmas (RR: 2.77, 95% CI 1.46–5.24). School schedules did not impact dengue diagnoses in school-aged children. In the climate model, important climate variables included the monthly total precipitation, an interaction between total precipitation and monthly absolute minimum temperature, an interaction between total precipitation and monthly precipitation days, and a three-way interaction between minimum temperature, total precipitation, and precipitation days. This is the first report of long-term dengue fever seasonality in Ecuador, one of few reports from rural patients, and one of very few studies utilizing daily disease reports. These results can inform local disease prevention efforts, public health planning, as well as global and regional models of dengue fever trends.

Prevalence, Severity, and Risk of Future Falls in Community-Dwelling Older Adults Living in a Rural Community: The Atahualpa Project.

Accidental falls are a leading cause of disability and death in older adults living in urban centers. However, little is known about the consequences of falls in rural communities. We aimed to assess characteristics and risk of falls in community-dwellers aged ≥ 60years living in rural Ecuador. Of 463 older adults enrolled in the Atahualpa Project, 327 (71%) were included. Multivariate logistic regression models were fitted to assess factors associated with history of falls and risk of future falls. Sensitivity analysis was conducted to determine which component of the Downton fall risk index (DFRI) better predicts risk of future falls. A history of falls was reported by 173 (53%) individuals. Most were related to stumbling due to uneven (non-paved) streets. Only three individuals had bone fractures after the fall. Previous falls were not associated with any of the investigated covariables. The DFRI was positive in 87 (27%) participants, and was associated with age (p < 0.001) and history of stroke (p < 0.001). None of the subjects were taking tranquilizers/sedatives. The most reliable component of the DFRI was the presence of sensory/motor deficits. History of falls in our population is similar to that reported elsewhere. However, the risk of future falls is lower. Such discrepancies are probably because the DFRI does not take into account environmental factors resulting in falls. There were almost no severe complications from falls, which could be partly related to the lack of use of tranquilizers/sedatives.

Determinants of Latrine Use Behavior: The Psychosocial Proxies of Individual-Level Defecation Practices in Rural Coastal Ecuador.

There is increasing appreciation that latrine access does not imply use-many individuals who own latrines do not consistently use them. Little is known, however, about the determinants of latrine use, particularly among those with variable defecation behaviors. Using the integrated behavior model of water, sanitation, and hygiene framework, we sought to characterize determinants of latrine use in rural Ecuador. We interviewed 197 adults living in three communities with a survey consisting of 70 psychosocial defecation-related questions. Questions were excluded from analysis if responses lacked variability or at least 10% of respondents did not provide a definitive answer. All interviewed individuals had access to a privately owned or shared latrine. We then applied adaptive elastic nets (ENET) and supervised principal component analysis (SPCA) to a reduced dataset of 45 questions among 154 individuals with complete data to select determinants that predict self-reported latrine use. Latrine use was common, but not universal, in the sample (76%). The SPCA model identified six determinants and adaptive ENET selected five determinants. Three indicators were represented in both models-latrine users were more likely to report that their latrine is clean enough to use and also more likely to report daily latrine use; while those reporting that elderly men were not latrine users were less likely to use latrines themselves. Our findings suggest that social norms are important predictors of latrine use, whereas knowledge of the health benefits of sanitation may not be as important. These determinants are informative for promotion of latrine adoption.

Latent variable modeling to develop a robust proxy for sensitive behaviors: application to latrine use behavior and its association with sanitation access in a middle-income country

BackgroundGlobally, diarrhea is a leading cause of child morbidity and mortality. Although latrines are integral for reducing enteric pathogen transmission, several studies have shown no evidence that latrine ownership improved child health. There are a number of explanations for these results. One explanation is that latrine access does not equate to latrine use. Latrine use, however, is difficult to accurately ascertain, as defecation behavior is often stigmatized. To address this measurement issue, we measure latrine use as a latent variable, indicated by a suite of psychosocial variables.MethodsWe administered a survey of 16 defecation-related psychosocial questions to 251 individuals living in rural Ecuador. We applied latent class analysis (LCA) to these data to model the probability of latrine use as a latent variable. To account for uncertainty in predicted latent class membership, we used a pseudo-class approach to impute five different probabilities of latrine use for each respondent. Via regression modeling, we tested the association between household sanitation and each imputed latrine use variable.ResultsThe optimal model presented strong evidence of two latent classes (entropy = 0.86): consistent users (78%) and inconsistent users (22%), predicted by 5 of our 16 psychosocial variables. There was no evidence of an association between the probability of latrine use, predicted from the LCA, and household access to basic sanitation (OR = 1.1, 95% CI = 0.6–2.1). This suggests that home access to a sanitation facility may not ensure the use of the facility for every family member at all times.ConclusionEffective implementation and evaluation of sanitation programs requires accurate measurement of latrine use. Psychosocial variables, such as norms, perceptions, and attitudes may provide robust proxy-measures. Future longitudinal studies will help to strengthen the use of these surrogate measures, as many of these factors may be subject to secular trends. Additionally, subgroup analyses will elucidate how our proxy indicators of latrine defecation vary by individual-level characteristics.

Prevalence of cataract and barriers to cataract-related care in rural Ecuador

Introduction: Cataracts remain the leading cause of blindness worldwide. Despite this, there is a lack of information surrounding cataracts in Ecuador. We sought to assess the rate and barriers to cataract-related care in two Ecuadorian communities to identify points of intervention for local and international organizations.Methods: This was a cross-sectional assessment using a convenience sample of patients seen in clinics run by Fundacion Internacional Buen Samaritano Paul Martel, a local nonprofit providing affordable eye care in Ecuador. Two populations were assessed. Week 1 patients were from the Andean region of Chimborazo (W1) and week 2 patients from Santa Cruz Island, Galapagos (W2). All patients seen were assessed for cataracts. Patients identified as having cataracts completed a six-question survey related to barriers to care. The primary outcomes were the rate of cataracts and the leading barriers to care.Results: Forty-four total patients during W1 and 1,002 during W2 were seen and screened for cataracts. Mean age (years) was W1 – 44 years and W2 – 42 years. The overall rate of cataracts was 4 (9%) in W1 and 50 (5%) in W2. When stratified by age, the rate of cataracts in individuals aged 50 and over was 21% (W1) and 6% (W2). Forty-six participants with cataracts completed the survey. The major barriers to cataract-related care were cost (n = 26), followed by access (n = 7), and fear of surgery (n = 4).Conclusions: Our results confirm the high overall rate of cataracts in patients presenting to eye clinics in two distinct communities. We found that cost and access are the main barriers to care. These communities would benefit greatly from care delivery models that bring services close to where individuals live, through partnerships between local and global organizations.

Universal Health Coverage in Marginalized Populations: A Qualitative Evaluation of a Health Reform Implementation in Rural Ecuador.

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further.

Frailty and Risk of Falls in Community-Dwelling Older Adults Living in a Rural Setting. The Atahualpa Project.

Data supporting a link between frailty and risk of falls is mostly confined to individuals living in urban centers, where risk factors and lifestyles are different from that of rural settings. To assess the association between frailty and risk of falls in older adults living in rural Ecuador. Population-based cross-sectional study. Community-dwellers aged ≥60 years living in a rural Ecuadorian village, in whom frail status and risk of falls were assessed. Frailty was evaluated by the Edmonton Frailty Scale (EFS) and risk of falls by the Downton Fall Risk Index (DFRI). Multivariate models were fitted to evaluate whether frailty was associated with risk of falls (dependent variable), after adjusting for demographics, alcohol intake, cardiovascular risk factors, sleep quality, symptoms of depression, and history of an overt stroke. Correlation coefficients were constructed to assess confounders modifying this association. A total of 324 participants (mean age: 70.5±8 years) were included. The mean EFS score was 4.4±2.5 points, with 180 (56%) participants classified as robust, 76 (23%) as pre-frail and 68 (21%) as frail. The DFRI was positive in 87 (27%) participants. In univariate analysis, the EFS score was higher among participants with a positive DFRI (p<0.001). The number of frail individuals was higher (p<0.001), while that of robust individuals was lower (p<0.001) among those with a positive DFRI. Adjusted logistic regression models showed no association between frailty and the DFRI. Correlation coefficients showed that age, high glucose levels, and history of an overt stroke tempered the association between frailty and the risk of falls found in univariate analyses. Frailty is not independently associated with risk of falls in older adults living in a remote rural setting. Further studies are needed to assess the impact of frailty on the risk of falls in these populations.

Clinical and neuroimaging risk factors for cognitive decline in community-dwelling older adults living in rural Ecuador. A population-based prospective cohort study.

There is limited information on factors influencing cognitive decline in rural settings from low- and middle-income countries. Using the Atahualpa Project cohort, we aimed to assess the burden of cognitive decline in older adults living in a rural Ecuadorian village. The study included Atahualpa residents aged greater than or equal to 60years who had a follow-up Montreal Cognitive Assessment (MoCA) repeated at least 1year after baseline. MoCA decline was assessed by multivariable longitudinal linear models, adjusted for demographics, days between MoCA tests, cardiovascular risk factors, and neuroimaging signatures of structural brain damage. We included 252 individuals who contributed 923.7 person-years of follow-up (mean: 3.7±0.7years). The mean baseline MoCA was 19.5±4.5 points, and the follow-up MoCA was 18.1±4.9 points (P=0.001). Overall, 154 individuals (61%) had lower MoCA scores at follow-up. The best fitted longitudinal linear model showed a decline of follow-up MoCA from baseline (β: 0.14; 95% CI, 0.0-0.21; P<0.001). High glucose levels, global cortical atrophy, and white matter hyperintensities were independently and significantly associated with greater MoCA decline. This study provides evidence of cognitive decline in older adults living in a rural setting. Main targets for prevention should include glucose control and the control of factors that are deleterious for the development of cortical atrophy and white matter hyperintensities.

Sleep quality correlates with the carotid intima-media thickness in stroke-free community-dwelling adults living in rural Ecuador. The Atahualpa Project

Background/ObjectivesEvidence of an association between sleep disorders and extracranial atherosclerosis is limited and has not been studied in remote rural settings, where living conditions and cardiovascular risk factors are different than in urban centers. We assessed the relationship between the carotid intima-media thickness (cIMT) and sleep quality in stroke-free individuals aged ≥40 years living in rural Ecuador. MethodsApplying a population-based study design, participants underwent face-to-face interviews using the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and sonographic examinations for measurement of the carotid intima-media thickness (cIMT). The association between the cIMT and sleep quality (as the dependent variable) was assessed by means of generalized linear models, adjusted for relevant confounders. ResultsThe mean age of 561 participants was 60.4 ± 12.6 years (58% women). The mean PSQI was 4.6 ± 2.2 points. Of those, 79 (14%) individuals had an increased cIMT (>1 mm). A model adjusted for demographics showed a significant association between increased cIMT and the PSQI score (β: 0.602; 95% C.I.: 0.027–1.177; p = 0.040). This relationship was reduced when cardiovascular risk factors were added to the model (β: 0.514; 95% C.I.: −0.072 – 1.101; p = 0.086). When the model was adjusted for demographics and psychological distress, the association between increased cIMT and the PSQI score became significant (β: 0.573; 95% C.I.: 0.013–1.133; p = 0.045). In addition, both symptoms of depression (p = 0.032) and anxiety (p < 0.001) remained independently significant. ConclusionsThis study shows an association between increased cIMT and the PSQI score, which is, at least, partly mediated by manifestations of psychological distress.

Influence of Frailty on Cognitive Decline: A Population-Based Cohort Study in Rural Ecuador

ObjectiveTo assess the influence of frailty on cognitive decline. DesignPopulation-based prospective cohort study. Settings/participantsCommunity-dwelling older adults living in a rural Ecuadorian village, fulfilling the following criteria: age ≥60 years at baseline Montreal Cognitive Assessment (MoCA) and frailty assessment, a baseline brain magnetic resonance imaging, and a follow-up MoCA performed at least 12 months after the baseline. MeasuresFrailty was evaluated by the Edmonton Frailty Scale (EFS) and cognitive performance by MoCA. The relationship between baseline EFS and MoCA decline was assessed by longitudinal linear and fractional polynomial models, adjusted for relevant confounders. The score of the cognitive component of the EFS was subtracted, and an alternative fractional polynomial model was fitted to settle the impact of such cognitive question on the model. ResultsA total of 252 individuals, contributing 923.7 person-years of follow-up (mean: 3.7 ± 0.7 years) were included. The mean EFS score was 4.7 ± 2.5 points. The mean baseline MoCA score was 19.5 ± 4.5 points, and that of the follow-up MoCA was 18.1 ± 4.9 points (P = .001). Overall, 154 (61%) individuals had lower MoCA scores in the follow-up. The best fitted longitudinal linear model showed association between baseline EFS score and MoCA decline (P = .027). There was a continuous increase in MoCA decline in persons with an EFS ≥7 points (nonlinear relationship). Fractional polynomials explained the effect of the EFS on MoCA decline. For the complete EFS score, the β coefficient was 2.43 (95% confidence interval 1.22–3.63). For the effect of the EFS (without its cognitive component) on MoCA decline, the relationship was still significant (β 4.86; 95% confidence interval 2.6–7.13). Conclusions/implicationsOver a 3.7-year period, 61% of older adults living in Atahualpa experienced cognitive decline. Such decline was significantly associated with frailty status at baseline. Region-specific risk factors influencing this relationship should be further studied to reduce its burden in rural settings.

Arterial stiffness and total cerebral small vessel disease score in community-dwelling older adults: Results from the Atahualpa Project.

Information on the association between arterial stiffness and cerebral small vessel disease (cSVD) is limited and confined to white and Asian populations. More regional information is needed to confirm this association in different ethnic groups. Using the Atahualpa Project cohort, we aimed to assess whether the aortic pulse wave velocity (PWV) is associated with the total cSVD score, as well as with each of the neuroimaging signatures of cSVD, in a population of Amerindians living in rural Ecuador. Atahualpa residents aged ⩾ 60 years were offered a brain magnetic resonance imaging scan (MRI) and aortic PWV determination. An ordinal logistic regression model, adjusted for demographics and cardiovascular risk factors, was constructed to predict the total cSVD score by levels of aortic PWV. The association between the neuroimaging signatures of cSVD and the aortic PWV was assessed by adjusted logistic regression models. Of 437 candidates, 303 (69%) underwent a brain MRI and aortic PWV determinations. The total cSVD score was 0 points in 65% of individuals, 1 point in 18%, 2 points in 11%, and 3-4 points in 6%. The mean aortic PWV was 10.4 ± 1.8 m/s, which increased from 9.8 ± 1.2 to 12.3 ± 1.8 m/s in individuals with a cSVD score of 0 and 3-4, respectively ( p < 0.001). An ordinal logistic regression model showed significant association between the PWV and the cSVD score. A change of one unit of the aortic PWV increased the odds of having a higher total cSVD score by 1.73 (95% CI: 1.28-2.35; p < 0.001). In addition, individual neuroimaging signatures of cSVD, with the exception of lacunar infarcts, were associated with the aortic PWV. This study shows a significant association between the aortic PWV and total cSVD score and most of its individual components in older Amerindians.

Nonfatal Stroke and All-Cause Mortality among Community-Dwelling Older Adults Living in Rural Ecuador: A Population-Based, Prospective Study.

Background:Stroke is a leading cause of disability in developing countries. However, there are no studies assessing the impact of nonfatal strokes on mortality in rural areas of Latin America. Using a population-based, prospective cohort study, we aimed to assess the influence of nonfatal strokes on all-cause mortality in older adults living in an underserved rural setting.Methods:Deaths occurring during a 5-year period in Atahualpa residents aged ≥60 years were identified from overlapping sources. Tests for equality of survivor functions were used to estimate differences between observed and expected deaths for each covariate investigated. Cox proportional hazards models were used to estimate Kaplan–Meier survival curves of variables reaching significance in univariate analyses.Results:Of 437 individuals enrolled over 5 years, follow-up was achieved in 417 (95%), contributing 1776 years of follow-up (average 4.3 ± 1.3 years). Fifty-one deaths were detected, for an overall cumulative 5-year mortality rate of 12.2% (8.9%–15.6%). Being older than 70 years of age, having poor physical activity, edentulism, and history of a nonfatal stroke were related to mortality in univariate analyses. A fully adjusted Cox proportional hazards model showed that having history of a nonfatal stroke (P = 0.024) and being older than 70 years of age (P = 0.031) independently predicted mortality. In contrast, obesity was inversely correlated with mortality (P = 0.047).Conclusions:A nonfatal stroke and increasing age increase the risk of all-cause mortality in inhabitants of a remote rural village. The body mass index is inversely related to death (obesity paradox).