Resilient clean cooking: Maintaining household clean cooking in Ecuador during the COVID-19 pandemic.

Decades of government subsidies for LPG and electricity have facilitated near-universal clean cooking access and use in Ecuador, placing the nation ahead of most other peer low- and middle-income countries. The widespread socio-economic impacts of the COVID-19 pandemic has threatened the resilience of clean cooking systems globally, including by altering households' ability to purchase clean fuels and policymakers' considerations about continuing subsidy programs. As such, assessing the resilience of clean cooking in Ecuador during the pandemic can offer important lessons for the international community, especially other countries looking to ensure resilient transitions to clean cooking. We study household energy use patterns using interviews, newspaper reports, government data on household electricity and LPG consumption, and household surveys [N = 200 across two rounds]. The LPG and electricity distribution systems experienced occasional disruptions to cylinder refill delivery and meter reading processes, respectively, which were associated with pandemic-related mobility restrictions. However, for the most part, supply and distribution activities by private and public companies continued without fundamental change. Survey participants reported increases in unemployment and reductions in household income as well as increased use of polluting biomass as a secondary fuel. Ecuador's LPG and electricity distribution systems were resilient throughout the pandemic, with only minimal interruption of the widespread provision of low-cost clean cooking fuels. Our findings inform the global audience concerned about the resilience of clean household energy use on the potential for clean fuel subsidies to facilitate continued clean cooking even during the COVID-19 pandemic.

"Compassionate City" in Patients with Advanced Illnesses and at the End of Life: A Pilot Study.

OBJECTIVES: To evaluate, in a Compassionate City pilot experience (Sevilla), the impact results on health in a population of people with advanced illness and at the end of life. METHODS: The project was undertaken in Sevilla, Spain, between January 2019 and June 2020. A longitudinal, descriptive study was conducted using a longitudinal cohort design with two cross-sectional measurements, pre and post intervention. All patients who entered the program on the start date were included. The networks of care around people with advanced illness and at the end of life, palliative care needs, quality of life, loneliness, anxiety, depression, caregivers' burden and family satisfaction were evaluated. The interventions were conducted by community promoters assigned to the "Sevilla Contigo, Compassionate City" program. RESULTS: A total of 83 people were included in the program. The average number of people involved in care at the beginning of the evaluations was 3.6, increasing to 6.1 at the end of the interventions. The average number of needs detected at the beginning was 15.58, and at the end of interventions, it was 16.56 out of 25. The unmet needs were those related to last wishes (40.7%), emotional relief (18.5%), entertainment (16%), help to walk up and down stairs (8.6%) and help to walk (6.2%). A total of 54.2% showed improved loneliness in the final evaluation. Out of 26 people evaluated for pre and post quality of life, 7 (26.9%) improved their quality of life in the general evaluation and 5 (19.2%) displayed improved anxiety/depression. A total of 6 people (28.6%) improved their quality-of-life thermometer scores. A total of 57.7% of caregivers improved their burden with a mean score of 17.8.

Equivalent Formulations of Optimal Control Problems with Maximum Cost and Applications.

We revisit the optimal control problem with maximum cost with the objective to provide different equivalent reformulations suitable to numerical methods. We propose two reformulations in terms of extended Mayer problems with state constraints, and another one in terms of a differential inclusion with upper-semi-continuous right member without state constraint. For the latter we also propose a scheme that approximates from below the optimal value. These approaches are illustrated and discussed in several examples.

The advantages of physical exercise as a preventive strategy against NAFLD in postmenopausal women.

BACKGROUND: The prevalence and severity of nonalcoholic fatty liver disease (NAFLD) increase in women after menopause. This narrative review discusses the causes and consequences of NAFLD in postmenopausal women and describes how physical activity can contribute to its prevention. METHODS: The authors followed the narrative review method to perform a critical and objective analysis of the current knowledge on the topic. The Medical Subject Heading keywords 'physical exercise', 'menopause', 'hormone replacement therapy', 'estradiol' and 'NAFLD' were used to establish a conceptual framework. The databases used to collect relevant references included Medline and specialized high-impact journals. RESULTS: Higher visceral adiposity, higher rate of lipolysis in adipose tissue after oestrogen drop and changes in the expression of housekeeping proteins involved in hepatic lipid management are observed in women after menopause, contributing to NAFLD. Excessive liver steatosis leads to hepatic insulin resistance, oxidative stress and inflammation, accelerating NAFLD progression. Physical activity brings beneficial effects against several postmenopausal-associated complications, including NAFLD progression. Aerobic and resistance exercises partially counteract alterations induced by metabolic syndrome in sedentary postmenopausal women, impacting NAFLD progression and severity. CONCLUSIONS: With the increased global obesity epidemic in developing countries, NAFLD is becoming a severe problem with increased prevalence in women after menopause. Evidence shows that physical activity may delay NAFLD development and severity in postmenopausal women, although the prescription of age-appropriate physical activity programmes is advisable to assure the health benefits.

Towards a Characterization of Background Music Audibility in Broadcasted TV.

In audiovisual contexts, different conventions determine the level at which background music is mixed into the final program, and sometimes, the mix renders the music to be practically or totally inaudible. From a perceptual point of view, the audibility of music is subject to auditory masking by other aural stimuli such as voice or additional sounds (e.g., applause, laughter, horns), and is also influenced by the visual content that accompanies the soundtrack, and by attentional and motivational factors. This situation is relevant to the music industry because, according to some copyright regulations, the non-audible background music must not generate any distribution rights, and the marginally audible background music must generate half of the standard value of audible music. In this study, we conduct two psychoacoustic experiments to identify several factors that influence background music perception, and their contribution to its variable audibility. Our experiments are based on auditory detection and chronometric tasks involving keyboard interactions with original TV content. From the collected data, we estimated a sound-to-music ratio range to define the audibility threshold limits of the barely audible class. In addition, results show that perception is affected by loudness level, listening condition, music sensitivity, and type of television content.

Exploring Liver Mitochondrial Function by 13C-Stable Isotope Breath Tests: Implications in Clinical Biochemistry.

The liver is at the crossroad of key metabolic processes, which include detoxification, glycolipidic storage and export, and protein synthesis. The gut-liver axis, moreover, provides hepatocytes with a series of bacterial products and metabolites, which contribute to maintain liver function in health and disease. Breath tests (BTs) are developed as diagnostic tools for indirect, rapid, noninvasive assessment of several metabolic processes in the liver. BTs monitor the appearance of CO2 in breath as a marker of a specific substrate metabolized in the liver, typically within microsomes, cytosol, or mitochondria. The noninvasiveness of BTs originates from the use of the, nonradioactive, naturally occurring stable isotope 13C marking a specific substrate which is metabolized in the liver, leading to the appearance of 13CO2 in expired air. Some substrates (ketoisocaproic acid, methionine, and octanoic acid) provide information about dynamic liver mitochondrial function in health and disease. In humans, the application of 13C-breath tests ranges from nonalcoholic and alcoholic liver diseases to liver cirrhosis, hepatocarcinoma, preoperative and postoperative assessment of liver function, and drug-induced liver damage. 13C-BTs are an indirect, cost-effective, and easy method to evaluate dynamic liver function and gastric kinetics in health and disease, with ongoing studies focusing on further applications in clinical medicine.

Protocols for Mitochondria as the Target of Pharmacological Therapy in the Context of Nonalcoholic Fatty Liver Disease (NAFLD).

Nonalcoholic fatty liver disease (NAFLD) is one of the most frequent metabolic chronic liver diseases in developed countries and puts the populations at risk of progression to liver necro-inflammation, fibrosis, cirrhosis, and hepatocellular carcinoma. Mitochondrial dysfunction is involved in the onset of NAFLD and contributes to the progression from NAFLD to nonalcoholic steatohepatitis (NASH). Thus, liver mitochondria could become the target for treatments for improving liver function in NAFLD patients. This chapter describes the most important steps used for potential therapeutic interventions in NAFLD patients, discusses current options gathered from both experimental and clinical evidence, and presents some novel options for potentially improving mitochondrial function in NAFLD.

Multiplying effects of COVID-19 lockdown on metabolic risk and fatty liver.

BACKGROUND: Social containment measures imposed in Europe during the lockdown to face COVID-19 pandemic can generate long-term potential threats for metabolic health. METHODS: A cohort of 494 non-COVID-19 subjects living in 21 EU countries were interviewed by an anonymous questionnaire exploring anthropometric and lifestyle changes during 1-month lockdown. A subgroup of 41 overweight/obese Italian subjects with previously diagnosed nonalcoholic fatty liver (NAFLD) joined the study following a 12-month follow-up period promoting weight loss by healthy lifestyle. RESULTS: During the lockdown, body weight increased in 55% of subjects (average 2.4 ± 0.9 kg). Weight change increased with age, but not baseline body mass index. Subjects living in Italy had greater weight gain than those living in other European Countries. Weight gain during the lockdown was highest in subjects reporting no physical activity, and low adherence to Mediterranean diet. In the NAFLD group, weight gain occurred in 70% of cases. Subjects reporting weight loss during lockdown had decreased fatty liver score at 3 months before the lockdown, as compared with 1 year before. CONCLUSIONS: Strict measures of social containment-even short-term-pave the way to the increased risk of metabolic abnormalities in the medium-long term. In this context, adherence to Mediterranean diet and regular physical activity play a protective role both in terms of weight gain and fatty liver development/progression, with implication for primary and secondary prevention. When adopting measures imposing social containment, intensive educational campaigns must increase public awareness about beneficial effects of healthy lifestyles.

Adiponectin involved in portal flow hepatic extraction of 13C-methacetin in obesity and non-alcoholic fatty liver.

Obesity and non-alcoholic fatty liver disease (NAFLD) are high prevalence, inter-related conditions at increased risk for advanced liver diseases and related mortality. Adiponectin and leptin have divergent roles in the pathogenesis of fat accumulation and NAFLD. However, the relationships between body and liver fat accumulation, early modification of liver function and unbalanced adipokine levels are still scarcely explored. We studied by (13C)-methacetin breath test ((13C)-MBT) 67 adults stratified according to body mass index, and to presence/absence of ultrasonographic nonalcoholic fatty liver disease (uNAFLD). uNAFLD was detected in 20%, 73% and 96% of normal weight, overweight and obese subjects, respectively. The delta over baseline after 15 min (DOB15), a marker of hepatic extraction efficiency from portal blood flow, was lower in obese than in normal weight subjects, and in subjects with-, as compared to those without uNAFLD. The cumulative percent dose recovery after 30 min (cPDR30), a marker of liver microsomal function, was lower in uNAFLD patients. DOB15 was positively correlated with adiponectin levels in obese and in uNAFLD patients. uNAFLD patients also showed a positive correlation between cPDR30 values and adiponectin. Our data indicate the existence of early alterations of liver function in obese and in patients with uNAFLD. These dysfunctions are linked to altered leptin/adiponectin balance and can be identified noninvasively by (13C)-MBT.

(13C)-Methacetin breath test provides evidence of subclinical liver dysfunction linked to fat storage but not lifestyle.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) is characterised by the presence of hepatic steatosis in the absence of other causes of secondary hepatic fat accumulation, and is usually associated with visceral, metabolically active obesity. However, the subclinical effects of body and liver fat accumulation on liver function are still unclear. METHODS: We used orally administered (13C)-methacetin and breath test to quantify the efficiency of hepatic extraction from portal blood flow and liver microsomal function in 81 participants, in relation to presence/absence of ultrasonographic NAFLD, extent of body fat accumulation, insulin resistance, dietary models, and lifestyle. RESULTS: NAFLD was present in 23% of participants with normal weight, and prevalence increased with body fat and insulin resistance. Fat accumulation, NAFLD, and insulin resistance were associated with decreased hepatic extraction efficiency, and liver microsomal function was impaired in moderate-to-severe NAFLD. Caloric intake, dietary models, and lifestyles had a minor role in promoting functional changes. CONCLUSIONS: The interplay between body fat accumulation, insulin resistance, and NAFLD is linked with altered hepatic extraction efficiency from blood flow and deranged microsomal function. Non-invasive diagnosis of subclinical alterations of liver function is relevant for primary and secondary prevention measures. Furthermore, the occurrence of NAFLD in lean individuals and the evidence that caloric intake, dietary models, and lifestyle played a minor role require further studies exploring the role of environmental factors in the natural history of these diseases. LAY SUMMARY: Obesity is progressively increasing worldwide and is paralleled by fat accumulation in the liver (non-alcoholic fatty liver disease [NAFLD]), the most common chronic liver disease worldwide. NAFLD can alter liver structure and function, with a variety of consequences ranging from asymptomatic and subclinical alterations to cirrhosis and cancer. (13C)-Methacetin breath test, a non-invasive diagnostic tool, can reveal early subclinical alterations of liver dynamic function in individuals with obesity and in patients with NAFLD.

Household fuel mixes in peri-urban and rural Ecuador: Explaining the context of LPG, patterns of continued firewood use, and the challenges of induction cooking.

Nationwide transitions from cooking with solid fuels to clean fuels promise substantial health, climate, and environmental benefits. For decades, Ecuador has invested heavily in consumption subsidies for liquified petroleum gas (LPG), a leading clean fuel. With the goal of understanding household energy use in a context where LPG is ubiquitous and cheap, we administered 808 household surveys in peri-urban and rural communities in Coastal and Andean Ecuadorian provinces. We assess cooking fuel patterns after long-term LPG access and the reach of induction stoves promoted through a recent government program. Nearly all participants reported using LPG for more than a decade and frequent, convenient access to highly subsidized LPG. Nonetheless, half of rural households and 20% of peri-urban households rely on firewood to meet specific household energy needs, like space heating or heating water for bathing. Induction was rare and many induction owners reported zero use because the required equipment had never been installed by electricity companies, their stove had broken, or due to fears of high electricity costs. Our discussion is instructive for other countries because of Ecuador's long-standing clean fuel policies, robust LPG market and standardized cylinder recirculation model, and promotion of induction stoves.

Long-standing LPG subsidies, cooking fuel stacking, and personal exposure to air pollution in rural and peri-urban Ecuador.

Ecuador presents a unique case study for evaluating personal air pollution exposure in a middle-income country where a clean cooking fuel has been available at low cost for several decades. We measured personal PM2.5 exposure, stove use, and participant location during a 48-h monitoring period for 157 rural and peri-urban households in coastal and Andean Ecuador. While nearly all households owned a liquefied petroleum gas (LPG) stove and used it as their primary cooking fuel, one-quarter of households utilized firewood as a secondary fuel and 10% used induction stoves secondary to LPG. Stove use monitoring demonstrated clear within- and across-meal fuel stacking patterns. Firewood-owning participants had higher distributions of 48-h and 10-min PM2.5 exposure as compared with primary LPG and induction stove users, and this effect became more pronounced with firewood use during monitoring.Accounting for within-subject clustering, contemporaneous firewood stove use was associated with 101 µg/m3 higher 10-min PM2.5 exposure (95% CI: 94-108 µg/m3). LPG and induction cooking events were largely not associated with contemporaneous PM2.5 exposure. Our results suggest that firewood use is associated with average and short-term personal air pollution exposure above the WHO interim-I guideline, even when LPG is the primary cooking fuel.

Aging and nutrition. Paving the way to better health.

Sufficient caloric intake is important to maintain the balanced health status, especially during the period of aging, as aging and sickness share paths. Maintaining adequate nutritional balance is the best preventive measure to counteract the risk of malnutrition. There are several causes for malnutrition in elderly people, and some techniques such as anthropometric measurements, laboratory and clinical parameters could help to diagnose malnutrition in these patients. The use of a simple validated questionnaire called the 'Mini Nutritional Assessment' measures the nutritional status of elderly patients. In this review, we discuss about the malnutrition in elderly people with and without a known cause and we present some of nutritional intervention. There are promising strategies that help overcoming malnutrition.

Physical Activity Modulating Lipid Metabolism in Gallbladder Diseases.

Physical activity encompasses a series of overall benefits on cardiovascular health and metabolic disorders. Research has recently focused on the hepatobiliary tract, as an additional target of the health-related outcomes of different types of physical exercise. Here, we focus on the global features of physical activity with respect to exercise modality and intensity, and on studies linking physical activity to lipid metabolism, gallbladder diseases (gallstones, symptoms, complications and health-related quality of life), gallbladder motor-function, enterohepatic circulation of bile acids, and systemic metabolic inflammation. Additional studies need to unravel the pathophysiological mechanisms involved in both beneficial and harmful effects of physical activity in populations with different metabolic conditions.

Increased Colonic Permeability and Lifestyles as Contributing Factors to Obesity and Liver Steatosis.

Intestinal permeability (IP) is essential in maintaining gut-metabolic functions in health. An unequivocal evaluation of IP, as marker of intestinal barrier integrity, however, is missing in health and in several diseases. We aimed to assess IP in the whole gastrointestinal tract according to body mass index (BMI) and liver steatosis. In 120 patients (61F:59M; mean age 45 ± SEM 1.2 years, range: 18-75), IP was distinctively studied by urine recovery of orally administered sucrose (SO, stomach), lactulose/mannitol ratio (LA/MA, small intestine), and sucralose (SA, colon). By triple quadrupole mass-spectrometry and high-performance liquid chromatography, we measured urinary recovery of saccharide probes. Subjects were stratified according to BMI as normal weight, overweight, and obesity, and answered questionnaires regarding dietary habits and adherence to the Mediterranean Diet. Liver steatosis was assessed by ultrasonography. IP at every gastrointestinal tract was similar in both sexes and decreased with age. Stomach and small intestinal permeability did not differ according to BMI. Colonic permeability increased with BMI, waist, neck, and hip circumferences and was significantly higher in obese than in lean subjects. As determined by logistic regression, the odds ratio (OR) of BMI increment was significantly higher in subjects in the highest tertile of sucralose excretion, also after adjusting for age and consumption of junk food. The presence of liver steatosis was associated with increased colonic permeability. Patients with lower score of adherence to Mediterranean diet had a higher score of 'junk food'. Intestinal permeability tended to increase in subjects with a lower adherence to Mediterranean diet. In conclusion, colonic (but not stomach and small intestinal) permeability seems to be linked to obesity and liver steatosis independently from dietary habits, age, and physical activity. The exact role of these last factors, however, requires specific studies focusing on intestinal permeability. Results should pave the way to both primary prevention measures and new therapeutic strategies in metabolic and liver diseases.

Childhood obesity, cardiovascular and liver health: a growing epidemic with age.

BACKGROUND: The frequency of childhood obesity has increased over the last 3 decades, and the trend constitutes a worrisome epidemic worldwide. With the raising obesity risk, key aspects to consider are accurate body mass index classification, as well as metabolic and cardiovascular, and hepatic consequences. DATA SOURCES: The authors performed a systematic literature search in PubMed and EMBASE, using selected key words (obesity, childhood, cardiovascular, liver health). In particular, they focused their search on papers evaluating the impact of obesity on cardiovascular and liver health. RESULTS: We evaluated the current literature dealing with the impact of excessive body fat accumulation in childhood and across adulthood, as a predisposing factor to cardiovascular and hepatic alterations. We also evaluated the impact of physical and dietary behaviors starting from childhood on cardio-metabolic consequences. CONCLUSIONS: The epidemic of obesity and obesity-related comorbidities worldwide raises concerns about the impact of early abnormalities during childhood and adolescence. Two key abnormalities in this context include cardiovascular diseases, and nonalcoholic fatty liver disease. Appropriate metabolic screenings and associated comorbidities should start as early as possible in obese children and adolescents. Nevertheless, improving dietary intake and increasing physical activity performance are to date the best therapeutic tools in children to weaken the onset of obesity, cardiovascular diseases, and diabetes risk during adulthood.

Circulating CRP Levels Are Associated with Epicardial and Visceral Fat Depots in Women with Metabolic Syndrome Criteria.

Sexual dimorphism accounts for significant differences in adipose tissue mass and distribution. However, how the crosstalk between visceral and ectopic fat depots occurs and which are the determinants of ectopic fat expansion and dysfunction remains unknown. Here, we focused on the impact of gender in the crosstalk between visceral and epicardial fat depots and the role of adipocytokines and high-sensitivity C-reactive protein (hs-CRP). A total of 141 outward patients (both men and women) with one or more defining criteria for metabolic syndrome (MetS) were consecutively enrolled. For all patients, demographic and clinical data were collected and ultrasound assessment of visceral adipose tissue (VFth) and epicardial fat (EFth) thickness was performed. Hs-CRP and adipocytokine levels were assessed by enzyme-linked immunosorbent assay (ELISA). Men were characterized by increased VFth and EFth (p-value < 0.001 and 0.014, respectively), whereas women showed higher levels of adiponectin and leptin (p-value < 0.001 for both). However, only in women VFth and EFth significantly correlated between them (p = 0.013) and also with leptin (p < 0.001 for both) and hs-CRP (p = 0.005 and p = 0.028, respectively). Linear regression confirmed an independent association of both leptin and hs-CRP with VFth in women, also after adjustment for age and MetS (p = 0.012 and 0.007, respectively). In conclusion, men and women present differences in epicardial fat deposition and systemic inflammation. An intriguing association between visceral/epicardial fat depots and chronic low-grade inflammation also emerged. In women Although a further validation in larger studies is needed, these findings suggest a critical role of sex in stratification of obese/dysmetabolic patients.

Recomendaciones para el uso racional de la prueba 25-hidroxivitamina D Resumen de política

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The exponential increase in the request for laboratory tests of 25-Hydroxyvitamin D or [25 (OH) D has ignited the alarms and generated a strong call for attention, since it may reflect deficiencies in the standardization of clinical practice and in the use non-systematic scientific evidence for decision-making in real life, which allows to analyze the indications of the test, its frequency, interpretation and even to assess the impact for health systems, especially when contrasted with the minimum or almost. No effects of the strategy of screening or supplying indiscriminately to the general population, without considering a comprehensive clinical assessment of risks and needs of people. From a purely public health impact point of view, the consequence of massive and unspecified requests is affecting most of the health systems and institutions at the global level. The primary studies that determined average population intake values have been widely used in the formulation of recommendations in Clinical Practice Guidelines, but unfortunately misinterpreted as cut points to diagnose disease and allow the exaggerated prescription of nutritional substitution. The coefficient of variation in routine tests to measure blood levels of 25 (OH) D is high (28%), decreasing the overall accuracy of the test and simultaneously, increasing both the falsely high and falsely low values. The most recent scientific evidence analyzes and seriously questions the usefulness and the real effect of the massive and indiscriminate practice of prescribing vitamin D without an exhaustive risk analysis. The available evidence is insufficient to recommend a general substitution of vitamin D to prevent fractures, falls, changes in bone mineral density, incidence of cardiovascular diseases, cerebrovascular disease, neoplasms and also to modify the growth curve of mothers' children. They received vitamin D as a substitute during pregnancy. The recommendations presented in the document are based on the critical analysis of current evidence and the principles of good clinical practice and invite to consider a rational use of 25 (OH) D tests in the context of a clinical practice focused on people and a comprehensive assessment of needs and risks. The principles of good practice suggest that clinicians may be able to justify that the results of the 25 (OH) D test strongly influence and define clinical practice and modify the outcomes that interest people and impact their health and wellness. Currently there is no clarity on how to interpret the results, and the relationship between symptoms and 25 (OH) D levels, which may not be consistent with the high prevalence of vitamin D deficiency reported. For this reason, it is suggested to review the rationale of the request for tests for systematic monitoring of levels of 25 (OH) D or in all cases where substitution is performed. Consider the use of 25 (OH) D tests within the comprehensive evaluation of people with suspicion or confirmation of the following conditions: rickets, osteomalacia, osteoporosis, hyper or hypoparathyroidism, malabsorption syndromes, sarcopenia, metabolic bone disease.

Non-Alcoholic Fatty Liver Disease in Non-Obese Individuals: Prevalence, Pathogenesis and Treatment.

Non-alcoholic fatty liver disease (NAFLD) parallels comorbidities such as metabolic syndrome, dyslipidaemia or diabetes. Although NAFLD is very prevalent in overweight-obese individuals (i.e. body mass index ≥25 kg/m2), recent studies point to the presence of NAFLD in non-obese individuals, for both the Asian (<25 kg/m2) and Caucasian (<30 kg/m2) populations. This paper discusses the pathogenic pathways and current treatment options of NAFLD in non-obese populations. In this respect, non-obese subjects also need to undergo the medical screening for NAFLD. Across the scientific community, we aim to promote the advancement of knowledge in this emerging field.