Cardiovascular disease risk factors of adolescents in Peruvian shantytown

Cardiovascular Disease Risk Factors of Adolescents in Peruvian Shantytown

Growing up in an impoverished community is linked to significantly higher risk factors for cardiovascular disease among adolescents, according to a public health study published in May, 2017 in the Journal of Health, Population and Nutrition. The research was conducted by first author and UW School of Medicine and Public Health Class of 2017 student Elizabeth Abbs, MD, who spent a year conducting field work in the Lomas de Zapallal shantytown north of Lima, Peru. Her mentors included Joseph Zunt, MD, MPH, professor, Departments of Medicine and Epidemiology at the University of Washington and Heather Johnson, MD, MS, associate professor, Cardiovascular Medicine.

Dr. Abbs was a member of the UW Training in Urban Medicine and Public Health (TRIUMPH) program, where she worked on preventive medicine initiatives with Latino/a immigrants in Milwaukee, Wisconsin. “Because of my interest in in health disparities locally and globally, I wanted to observe how poverty and social environmental factors similarly or differently affected the health of marginalized urban populations outside of the United States,” she said.

The estimated 27,000 residents of Lomas de Zapallal live in poverty and have irregular access to potable water through a sanitation system installed in 2009. Many adults in the settlement work multiple jobs, spending an average of five hours a day commuting by public transportation. The largest public school in the area is Colegio Pitágoras 8183, which is attended by approximately 1,500 students. Researchers collected data from 275 adolescents at the school including measurements of blood pressure, fasting blood glucose, blood lipids, obesity, behavioral data on physical activity, diet, and substance abuse, and validated surveys to assess mental health and exposure to violence. The results surprised them, both with regard to prevalence of cardiovascular disease risk factors at such an early age, and differences between genders.

For teens in Lomas de Zapallal, burden of cardiovascular disease starts early
Nearly one third (27 percent) of subjects were overweight or obese. Hypertension rates were high in both genders, but significantly more common in males (37 percent) than females (20 percent).

Almost half of the students had cholesterol levels above 170 mg/dL, and a stunning 71 percent had impaired fasting blood glucose (although researchers noted that 31 percent of subjects did not fast prior to blood collection).

Ninety-five percent of females and 84 percent of males experienced inadequate levels of physical activity (defined as exercising fewer than five times per week), and six of every 10 females experienced depression. “Our present study highlights the importance of implementing risk prevention methods targeting this age group to address both physical and behavioral risk factors,” authors wrote.

Localized study with global ramifications
The study has important population health implications for areas beyond Peru—including high-poverty urban centers in Wisconsin and beyond. “There are multifactorial contributors to uncontrolled hypertension among adolescents of Lomas de Zapallal,” said Dr. Johnson. “However, studies like Elizabeth's help to tailor to the specific needs of each individual population, regardless of geographic area. Understanding how to manage uncontrolled hypertension, will also help us improve the diagnosis, treatment, and management of other cardiovascular risk factors across populations.”

Each study participant received a card with individualized information regarding laboratory abnormalities and a referral letter to the local health center. Seeing students’ responses to the personalized information was both interesting and surprising to Dr. Abbs. “Few people reacted to abnormal BMI, high blood pressure, cholesterol, or glucose values. Rather, students and families were quite reactive to diagnoses of anemia, perhaps due to the community's heightened familiarity with this disease,” she said.

“One major parallel [with inner-city Milwaukee] is the awareness that many people are not able to prioritize their health due other financial or social factors,” she said. Providing resources and information, she learned, isn’t enough to inspire behavorial changes in face of barriers such as long commutes or the need to forsake one’s own health to care for siblings.

Creating paths to improved health in low-resource communities
Dr. Abbs was struck by the strength of the community, even as the limitations of the shantytown were made plain. “The adolescents and adults are amazingly resilient despite…heavily polluted air, lack of solid waste depository, inconsistent water and electricity [compared to] Peruvians living a mere 30 to 60 minutes away in central Lima,” she said. But while adult residents took pride in home ownership of modest dwellings and the ability to live independently of landlords, adolescents frequently expressed discouragement about their limited financial and educational prospects—perhaps more keenly aware of the situation because of exposure to international social media.

Seeing these experiences firsthand deepened her awareness of the need for interventions to improve health outcomes in urban areas of concentrated poverty around the world. “Community efforts toward childhood and adolescent health are needed to tailor behavioral choices prior to the formation of unhealthy habits. This work is difficult for a multitude of reasons, however, especially in low-resource communities where other needs must be prioritized for familial survival,” she said.

TRIUMH program provides key training
Dr. Abbs credits the UW TRIUMPH program with providing experiences that prepared her for the field work in Peru. “TRIUMPH taught me the principles of public health research such as how to conduct focus groups, design qualitative data questionnaires, and create preventative health curriculum that serve the community,” she said.

“It has been a pleasure working with Elizabeth and the TRIUMPH program,” said Dr. Johnson. “The MD students are applying their clinical knowledge and are already engaged in global health initiatives that are having a significant impact on populations.”

Additional co-authors were José Viñoles, MD and Jorge O. Alarcón, MD, MPH, both of the Universidad Nacional Mayor de San Marcos in Lima, Peru and affiliated with the University of Washington.