Insights from Chilean NCDs Hospitalization Data during COVID-19.

The COVID-19 pandemic has affected the lifestyles of people of all ages, conditions and occupations. Social distance, remote working, changes in diet and a lack of physical activity have directly and indirectly affected many aspects of mental and physical health, particularly in patients with many comorbidities and non-communicable diseases (NCDs). In our paper, we analyzed COVID-19 hospitalized and non-hospitalized cases according to comorbidities to assess the average monthly percentage change (AMPC) and monthly percentage change (MPC) using open access data from the Chilean Ministry of Science, Technology, Knowledge and Innovation. As expected, the infection mainly affected patients with comorbidities, including cardiovascular risk factors. The hospitalized cases with obesity and chronic lung disease increased throughout the period of June 2020-August 2021 (AMPC = ↑20.8 and ↑19.4%, respectively, p < 0.05), as did all the non-hospitalized cases with comorbidities throughout the period (AMPC = ↑15.6 to ↑30.3 [p < 0.05]). The increases in hospitalizations and non-hospitalizations with comorbidities may be associated with physical inactivity. A healthy lifestyle with regular physical activity may have had a protective effect on the COVID-19 severity and related events in the post-pandemic period, especially for the NCD population.

O2 Saturation Predicted the ICU Stay of COVID-19 Patients in a Hospital at Altitude: A Low-Cost Tool for Post-Pandemic.

Background and Objectives: Patients at high altitudes with COVID-19 may experience a decrease in their partial oxygen saturation (PO2S) levels. The objective was to assess the association between PO2S and intensive care unit (ICU) stay in patients at high altitudes with COVID-19. Materials and Methods: Clinical records of 69 COVID-19 patients (36% women) admitted to the ICU were analyzed. Median values were considered for intra-group categories ("≤11 days" and ">11 days" in the ICU) and for PO2S height categories ("<90%" and "≥90%"). Logistic regression and linear regression models adjusted for confounding variables were used. Results: Patients with >11 days in the ICU had 84% lower odds of having a PO2S ≥ 90% (OR: 0.16 [CI: 0.02, 0.69], p = 0.005) compared to those with ≤11 days in the ICU. An increase in PO2S by 1% reduced ICU stay by 0.22 days (ß: -0.22 [CI: -0.33, -0.11], p < 0.001), potentially leading to a reduction of up to 1.44 days. Conclusions: PO2S is a crucial factor in estimating ICU stays for COVID-19 patients at high altitudes and serves as an accessible and cost-effective measure. It should be used in infected patients to complement the prognosis of post-pandemic ICU stay.

Association between a lifestyle score and all-cause mortality: a prospective analysis of the Chilean National Health Survey 2009-2010.

OBJECTIVE: To investigate the association between a lifestyle score and all-cause mortality in the Chilean population. DESIGN: Prospective study. SETTINGS: The score was based on seven modifiable behaviours: salt intake, fruit and vegetable intake, alcohol consumption, sleep duration, smoking, physical activity and sedentary behaviours. 1-point was assigned for each healthy recommendation. Points were summed to create an unweighted score from 0 (less healthy) to 7 (healthiest). According to their score, participants were then classified into: less healthy (0-2 points), moderately healthy (3-4 points) and the healthiest (5-7 points). Associations between the categories of lifestyle score and all-cause mortality were investigated using Cox proportional hazard models adjusted for confounders. Nonlinear associations were also investigated. PARTICIPANTS: 2706 participants from the Chilean National Health Survey 2009-2010. RESULTS: After a median follow-up of 10·9 years, 286 (10·6 %) participants died. In the maximally adjusted model, and compared with the healthiest participants, those less healthy had 2·55 (95 % CI 1·75, 3·71) times higher mortality risk due to any cause. Similar trends were identified for the moderately healthy group. Moreover, there was a significant trend towards increasing the mortality risk when increasing unhealthy behaviours (hazard ratio model 3: 1·61 (95 % CI 1·34, 1·94)). There was no evidence of nonlinearity between the lifestyle score and all-cause mortality. CONCLUSION: Individuals in the less healthy lifestyle category had higher mortality risk than the healthiest group. Therefore, public health strategies should be implemented to promote adherence to a healthy lifestyle across the Chilean population.

A descriptive ranking of blood pressure and physical fitness of Latin-American ethnic schoolchildren.

BACKGROUND: There is a general lack of information about how insufficient physical activity impacts blood pressure and physical fitness in Latin-American ethnic minorities. AIMS: To describe the interactions between insufficient physical activity, blood pressure, and physical fitness outcomes in Latin-American schoolchildren of different ethnicity. METHODS: This was a prospective, international, multi-center, and cross-sectional study of three Latin-American countries involving schoolchildren from seven ethnic groups of Colombia (Tikuna, Nasa, Embera), Brazil (African, Mulato), and Chile (Mapuche), and also European schoolchildren from Brazil and Chile. Data were categorized based on whether participants were physically active (PA) or insufficient physical activity (iPA) using the WHO physical activity recommendations. The main outcomes were systolic (SBP), diastolic (DBP), and mean arterial (MAP) blood pressure, and scores for physical and cardiorespiratory fitness (CRF, by estimated V˙O2max), handgrip muscle strength (HGS), and standing long jump (SLJ). Secondary outcomes were anthropometric measures (weight, height, body mass index [BMI], waist circumference [WC], waist-to-height ratio), and body fat percentage (BF%, limited data by country). Primary and secondary outcomes were ranked. RESULTS: For both PA and iPA categories, significant interactions between ethnic groups were found concerning SBP/DBP (F(37.7), ES 0.08; F(51.5), ES 0.08), V˙O2max (F(37.7), ES 0.08; F(51.5), ES 0.08), HGS (F(33.8), ES 0.07; F(5.03), ES 0.04), and SLJ (F(64.3), ES 0.14; F(64.3), 0.14). In the iPA category, Mapuche schoolchildren were classified 1st (119.5; 81.5) with highest SBP/DBP and highest MAP (94.6 mmHg); Embera schoolchildren were classified 1st with lowest V˙O2max (33.7 mL/kg/min); and European schoolchildren were classified 1st (19.9 kg) with lowest HGS and SLJ (121.4 m) physical fitness. CONCLUSIONS: Under conditions of insufficient physical activity conditions, Mapuche schoolchildren had the most detrimental blood pressure, whereas Embera, Tikuna, and European schoolchildren had the lowest levels of physical fitness. These results serve to highlight the need for the early and appropriate promotion of physical activity based on ethnic differences in Latin-American schools.

[Reference values and risk factors in the deterioration of the physical fitness of physically active older chilean adults]. / Valores de referencia y factores de riesgo de la condición física en personas mayores chilenas físicamente activas.

BACKGROUND: Physical fitness assessment of older adults is essential because it is a key component of functional independence and healthy aging. AIM: To establish physical fitness reference values for physically active older Chilean adults of both sexes and identify the variables associated with the deterioration of their physical condition. MATERIAL AND METHODS: Cross-sectional study that included 342 older adults aged 60 and over. Their physical fitness was assessed with the Senior Fitness Test (SFT). The timed up and go (TUG), chair stand (CS), arm curl (AC), and aerobic resistance (2 min) tests were evaluated. RESULTS: Performance in the physical fitness tests by age group decreased in all tests as older adults advanced in age. Scores for men were more evenly distributed across the different age groups. The main risk factors for the deterioration of physical fitness were age, sex, and body mass index (BMI) (p-value < 0.05). The primary risk factor for men was age and for women age and BMI. CONCLUSIONS: Performance of both men and women in the different SFT tests decreased as older adults aged. Age, sex, and BMI were the main risk factors for the deterioration of the physical fitness of physically active older adults.

[Cardiorespiratory fitness in Chilean cancer patients: A comparative Analysis]. / Asociación entre cáncer y fitness cardiorrespiratorio en población chilena: Resultados de la Encuesta Nacional de Salud 2016-2017.

INTRODUCTION: Physical activity and cardiorespiratory fitness (CRF) are protective factors in cancer development. However, the CRF in the Chilean population diagnosed with cancer is unknown. This study aimed to evaluate the association that the CRF had between people with and without a cancer diagnosis and, secondarily, to compare the trend of the CRF according to years of cancer diagnosis in the Chilean population. METHODS: Data from 5,483 people from the 2016-2017 National Health Survey between 15 and 98 years old were analyzed. Cancer diagnosis (all available) was determined with standardized questions, and CRF was calculated with an abbreviated method (demographics, anthropometry, lifestyles). Linear regression analysis adjusted for confounding variables was performed with the complex sample analysis module of the STATA v.16 program (95% CI, p < 0.05). RESULTS: People with some cancer diagnosis versus those without cancer had a lower FCR level (ft: -1.23 [95% CI: -1.52; -0.94]). When comparing CRF levels according to cancer type, similar results were observed for colorectal, breast, and uterine cancer (p < 0.001) but not for thyroid cancer (p = 0.253). There was lower CRF from the first year of diagnosis of all types of cancer to over ten years, although not significant (p = 0.109). CONCLUSIONS: Those diagnosed with cancer presented lower CRF compared to those not diagnosed. In addition, in people with cancer, the CRF decreased with increasing years since the first diagnosis. It would be essential to evaluate and increase CRF in cancer patients.

[Association between Walking Pace and obesity in Chilean Population: Findings from the Chilean National Health Survey 2016-2017]. / Asociación entre la velocidad de marcha y obesidad en población chilena: Resultados de la Encuesta Nacional de Salud 2016-2017.

BACKGROUND: Walking Pace is a functional marker, used as a predictor of chronic diseases. However, there is a lack of evidence on the association between walking pace and obesity. AIM: To investigate the association between-self-reported walking pace with obesity in the Chilean adult population. METHODS: 6,183 Chilean participants (aged 15 to 98 years) from the Chilean National Health Survey 2016-2017 were included in this cross-sectional study. Weight, height, waist circumference (WC), body mass index (BMI) and waist to height ratio (WHtR) were the outcomes of interest. Self-reported walking pace (slow, average and brisk) was the exposure. The association between walking pace and obesity was determined by linear regression and Poisson regression and all analyses were adjusted in models according to sociodemographic and lifestyle factors. RESULTS: In the most adjusted model, those who reported an average and brisk walking pace had a lower BMI (¡3: -1.03, p = 0.017 and-1.56 p = 0.001), lower WC (3: -2.98, p = 0.004 and -3.64, p = 0.001) and waist to height ratio (3: -0.19, p = 0.004 and -0.26 p < 0.0001) compared to people who reported a slow walking pace. A brisk walkingpace was associated with a lower probability of obesity and central obesity. CONCLUSION: the average and brisk walkingpace was associated with lower body weight, BMI, waist circumference and waist to height ratio and a brisk walking pace was associated with a lower probability of obesity and central obesity, independently of sociodemographic and lifestyle factors.

[Effect of Sedentary behaviors on the Interaction Between the FTO Gene and Adiposity Levels in Chilean Adults - Results from the GENADIO Study]. / Efecto del sedentarismo sobre la interacción entre el gen FTO y niveles de adiposidad en adultos chilenos - Resultados del Estudio GENADIO.

BACKGROUND: The Fat-mass and obesity-associated-gene (FTO gene) and sedentary behavior time are associated with obesity. However, whether sedentary behavior time can modify the genetic predisposition to obesity in the Chilean population is unknown. Therefore, this study investigated the association between sedentary behavior, adiposity markers, and the FTO gene. METHODS: This cross-sectional study included 409 participants from the Genes, Environment, Diabetes, and Obesity (GENADIO) study. Adiposity markers studied included body weight, body mass index (BMI), waist circumference (WC), and fat mass. Sedentary behaviors were measured using accelerometers. Using multiple regression, we evaluated the interaction between sedentary behaviors and the FTO gene (rs9939609) on adiposity markers. RESULTS: Sedentary behaviors and the FTO genotype were positively associated with higher body weight, BMI, WC, and fat mass. However, the association between time of sedentary behavior and adiposity markers was higher in carriers of the risk variant for the FTO gene. For each hour of increment in sedentary behaviors, body weight increases by 1.36 kg ([95% CI: 0.27; 2.46], p = 0.015) and 2.95 kg ([95%CI: 1.24; 4.65], p = 0.001) in non-risk carriers (TT) versus risk carriers (AA), respectively. We observed similar results for WC, BMI, and body fat, but the interaction was significant only for WC. CONCLUSION: The association between sedentary behaviors and adiposity markers, especially body weight and WC, is higher in individuals who carry the risk variant of the FTO gene.

[Trend in Physical Activity Counseling and Cardiometabolic Diseases in Maule, Chile: COVID-19 Pre-Pandemic Study between 2012 and 2019]. / Tendencia de consejerías en actividad física y enfermedades cardiometabólicas en el Maule, Chile: estudio previo a pandemia por COVID-19 entre 2012 y 2019.

BACKGROUND: Physical activity (PA) practice reduces the adverse effects of COVID-19. PA counseling promotes healthy lifestyles and prevents cardiometabolic diseases. AIM: To assess the trend in cases of PA counseling and the cardiometabolic disease between 2012 and 2019 (before COVID-19) in a southern Chilean region. MATERIAL AND METHODS: Records of Maule Region Health Service for 731.163 men, and 829.097 women aged < 10 to ≥ 65 years were analyzed. The average annual percentage change (AAPC) during the study period and the annual percentage change (APC) during intermediate periods, were calculated. RESULTS: There was a significant decrease in PA counseling in women in the study period (AAPC: -13.6%). In the 2012-2017 period a significant decrease in counseling for total, men and women were observed (APC: -18.1, -16.5 and -19.1%, respectively). Obesity increased significantly in total, men and women in the 2012-2019 period (AAPC: 10.1, 8.5 and 10.7%, respectively). The same trend was observed for hypertension (AAPC: 8.1, 8.5 and 7.6% respectively) and elevated blood glucose (AAPC: 10, 11.5 and 9.6%, respectively). CONCLUSIONS: In the study period PA counseling decreased along with an increase in obesity, hypertension and high blood glucose. Increasing PA counseling is a mainstay in the prevention of cardiometabolic diseases and probably to prevent contagion and complement the treatment of COVID-19.

[Association of cardiorespiratory fitness with adiposity markers]. / Asociación del fitness cardiorrespiratorio con marcadores de adiposidad corporal: estudio de corte transversal de la Encuesta Nacional de Salud Chile 2016-2017.

BACKGROUND: Cardiorespiratory fitness (CRF) is inversely associated with metabolic diseases and adiposity markers. AIM: To assess the association of CRF with body mass index (BMI), waist circumference (WC) and obesity in a representative sample of the Chilean population. MATERIAL AND METHODS: Data from 5,958 participants in the Chilean National Health Survey 2016-1027 aged 15 years or above were analyzed. CRF was estimated by an equation that included sociodemographic, anthropometric and health-related data and expressed in metabolic equivalent units (METs). The association between CRF and adiposity was assessed using linear and Poisson regression models and the results were presented as Prevalence Ratio (PR). RESULTS: One MET increment in CRF was associated with a 3.27 kg/m2 (95% confidence intervals (CI): -3.35; -3.2) and 4.56 kg/m2 (95% CI: -4.67; -4.46) lower BMI in men and women, respectively. Waist circumference was 6.7 cm [95% CI: -6.98; -6.42] and 9 cm [95% CI: -9.33; -8.67] lower per 1-MET increment in CRF. With one MET increment, the probability of being obese was 34% (PR = 0.66 [95%CI: 0.63; 0.69]) and 36% (PR = 0.64 [95%CI: 0.61; 0.67]) lower in men and women, respectively. The probability of having a central obesity was 26% (PR = 0.74 [95%CI: 0.71; 0.77]) and 30% (PR = 0.70 [95%CI: 0.68; 0.73]) lower in men and women, respectively. CONCLUSIONS: A higher estimated CRF was associated with lower adiposity levels and a lower risk of being obese in both men and women. Public health policies aiming to increase physical activity are needed to increase the CRF of the Chilean population.

[Association between physical activity and income levels in chilean adults]. / Niveles de actividad física y tiempo sedente según ingreso económico en Chile: resultados de la Encuesta Nacional de Salud 2016-2017.

BACKGROUND: The Chilean population reports high levels of physical inactivity. The relationship between income level, physical activity (PA) and sedentary behaviors is not well known. AIM: To describe the levels of PA and sedentary time, according to income levels in the Chilean population. MATERIAL AND METHODS: Analysis of data from the Chilean National Health Survey 2016-2017, which included 5,130 participants (52.9% women). The levels of PA and sedentary time were measured by the Global Physical Activity Questionnaire. Income levels were established according to the self-reported income per capita of the households and presented as quintiles. PA levels according to income levels were estimated by linear regression analyses. RESULTS: Transport-related PA was higher in the lowest income quintiles (p = 0.039). There were no trends for income levels and PA domains including moderate, vigorous, total, occupational and leisure PA. The prevalence of leisure and occupational physical inactivities were higher in the lowest quintiles of income. Sitting time was higher in the higher income levels (p < 0.01). CONCLUSIONS: People in the lowest quintile for income spent more time in transport-related PA and less time sitting. However, physical inactivity prevalence during leisure and work time were higher in people with lower income.

[Association of physical inactivity with low levels of education]. / Nivel educativo y su asociación con niveles de actividad física en Chile.

BACKGROUND: A higher educational level is associated with healthier lifestyles. AIM: To assess the association between the level of compliance with physical activity recommendations and years of formal education in Chilean adults. MATERIAL AND METHODS: Analysis include 6,174 participants from the National Health Survey 2016-2017. Physical activity levels were assessed through the Global Physical Questionnaire (GPAQ v2). Physical inactivity was defined as < 600 MET/minute/week. RESULTS: Among subjects without education, 44% and 27% of women and men respectively, were physically inactive. Among women and men with the highest number of years of education (> 16) the figures for physical inactivity were 27% and 15% respectively. The odds for not meeting the physical activity recommendations was 2.3 [95% confidence intervals (CI): 1.57; 3.38] and 3.9 [95% CI: 2.27; 6.95] in women and men without any formal education respectively, as compared with those who reported 12 years of education. Women and men who reported a high level of education ≥ (16 years) did not show significant differences compared to the reference group. CONCLUSIONS: People with low levels of education are were likely to be physically inactive.

[Sociodemographic Patterning of Cardiorespiratory Fitness Derived by Equation in the Chilean Population: Findings from the Chilean Health Survey 2016-2017]. / Fitness cardiorrespiratorio estimado mediante ecuación y su caracterización sociodemográfica en población chilena: Resultados de la Encuesta Nacional de Salud 2016-2017.

BACKGROUND: Cardiorespiratory fitness is a strong predictor of mortality and chronic diseases. However, its estimation is costly and time consuming which may limit it broad use in population-based studies. AIM: To estimate the cardiorespiratory fitness of the Chilean population by using equations and to characterize fitness levels of the Chilean population by sociodemographic factors. MATERIAL AND METHODS: This cross-sectional study included 5,958 adults from the Chilean Health Survey conducted between 2016 and 2017. Cardiorespiratory fitness was estimated from sex-specific equations for men and women and expressed as METs (Energy Metabolic Equivalent). Fitness levels were characterized by sociodemographics factors (age, sex, education, income and area of residency). RESULTS: Fitness levels were higher in men (9.01 METs) than in women (6.76 METs) and in average decrease by 0.59 and 0.34 METs per each year increment in age for men and women, respectively. Fitness levels were 12.7 METs and 7.8 METs for 20-year-old men and women, respectively. However, fitness levels decreased to 7.8 METs and 4.3 METs in 90-year-old men and women, respectively. Fitness levels were also higher in individuals living in urban setting, those with higher education or income levels and lean individuals. CONCLUSIONS: This study reports fitness levels in a nationally representative sample of Chile. Fitness levels were higher in men than women however, its decline with age was more pronounce in men than women.

Association of leisure time and occupational physical activity with obesity and cardiovascular risk factors in Chile.

The aim of this study was to investigate the association between physical activity (PA), both occupational (OPA) and during leisure time (LTPA), with obesity and cardiovascular risk factors in Chilean adults. 5,157 participants from the Chilean National Health Survey 2009-2010 were included in this study. OPA and LTPA levels were assessed using the Global Physical Activity Questionnaire. The association between both PA with obesity and cardiovascular risk factors was determined using logistic regression. Our findings showed a significant trend between higher LTPA and lower odds for obesity (OR 0.64 [95% CI: 0.53; 0.76], central obesity 0.52 [0.44; 0.61]) and other cardiovascular risk factors including diabetes (OR: 0.72 [0.55; 0.94]), hypertension (OR: 0.59 [0.50; 0.71]) and metabolic syndrome (OR: 0.62 [0.50; 0.78]). In contrast, OPA was only associated with lower odds of diabetes (OR: 0.79 [0.65; 0.98]) and hypertension (0.85 [0.74; 0.98]). In conclusion, LTPA was associated with a lower risk of all major cardiovascular risk factors, whereas OPA was only associated with a lower risk of diabetes and hypertension.

[Lifestyles of Chilean housewives. Analysis of the 2009-2010 Chilean Health Survey]. / Caracterización de los estilos de vida en dueñas de casa chilenas. Análisis de la Encuesta Nacional de Salud 2009-2010.

BACKGROUND: Housewives represent a important proportion of the Chilean population. However, there is limited evidence about their lifestyles. AIM: To characterize lifestyles and determine the level of compliance with healthy lifestyles guidelines of housewives in Chile. MATERIAL AND METHODS: Housewives from the 2009-2010 National Health Survey were included. The variables studied included levels of physical activity (PA), sedentary behavior, diet, hours of sleep and smoking. Compliance with healthy lifestyle behaviors was evaluated through logistic regression, granting a value of 1 for compliance and 0 for non-compliance. A healthy lifestyle was defined as meeting at least four healthy behaviors. RESULTS: Housewives aged > 55 years had a higher BMI and waist circumference compared to those aged < 40 years. Housewives were also more likely to report moderate alcohol consumption and were more likely to meet a healthier lifestyle score (Odds ratio = 1.52 [95% confidence intervals: 1.09 to 2.11], p = 0.013). No significant age trends were observed for other lifestyle behaviors. CONCLUSIONS: Housewives had high levels of central obesity, excess body weight and high levels of salt intake but low alcohol intake. Their healthy lifestyles behaviors increased along with increasing age.

[An equation to predict maximum oxygen consumption from the six-minute walk test in healthy young adults]. / Ecuación para predecir el consumo máximo de oxígeno a partir de la prueba de caminata de seis minutos en jóvenes sanos.

BACKGROUND: The six-minute walk test (SMWT) is an easy-to-use test that measures walking distance. AIM: To elaborate an equation to estimate the maximum oxygen consumption (VO2 max) using the results of the SMWT. MATERIAL AND METHODS: Forty men and 40 women aged 22.5 ± 2 years, underwent a SMWT to measure the total walked distance and the recovery heart rate (RhR) Also, VO2 max was estimated from the maximal workload achieved in a cyclo-ergometer using the Storer test. A multivariate regression analysis resulted in a prediction equation that was validated with distributional assumptions of normality, independence and homoscedasticity. The limits of concordance of the predictive model were checked with the Bland-Altman diagram. RESULTS: Body mass index (BMI), sex, RhR and total walked distance explained VO2 max variance by 3.4, 73.1, 17.9 and 32.8%, respectively. The prediction equation achieved was VO2 max (ml.min-1) = -3672.585 + (966.472 × Sex [1: female, 2: male]) + (-18.492 X RhR [beats.minute-1]) + (9.191 X Distance [m]) + (87.707 × BMI). The R2 of the equation was 0.91 (p < 0.01). CONCLUSIONS: This equation predicts VO2 max in Chilean university students according to sex, BMI, cardiovascular response and performance in the SMWT.

Effects of an Educational Intervention Program on Positional Cranial Deformity in Premature Infants.

Positional cranial deformities are associated with prematurity evolving during the first 2 years of life due to the malleable characteristics of the skull, the first year being the main/primary therapeutic window for intervention. The objectives were (a) to describe health characteristics, peri- and postnatal pathologies, and positional cranial deformities in infants enrolled in an early intervention program and (b) to analyze the effects of a parent education-based intervention program on positional cranial deformity in premature infants. A quantitative, analytical, longitudinal study was conducted. It included 103 premature infants enrolled in an early intervention program (EIP) during the year 2017, all under 4 months of corrected age, to whom a parent education-based intervention program was applied. Cranial circumference, cranial width, diagonals, and anteroposterior diameter were measured, and the cranial asymmetry index (CAI) and cephalic index (CI) were calculated at baseline and during two subsequent evaluations separated by a 3-month period. The main results showed that 75.7% of the infants belonged to a very premature gestational age category, and 57.3% had an adequate weight for gestational age. The most frequent pathologies were premature jaundice, premature anemia, and hyaline membrane disease. The most frequent positional cranial deformity was plagiocephaly. The parent education-based intervention program resulted in (1) a significant decrease in the CAI and a significant increase in the IC, (2) plagiocephalies: an increase in the mild category and a decrease in the moderate + severe categories, (3) brachycephalies: a decrease in the absence category and an increase in the moderate + severe category, and (4) dolichocephalies: an increase in the absence category and a decrease in the mild category. In conclusion, the recommended first line of intervention was not enough for this population, and future studies should support the development of national clinical guidelines, where education is complemented with other therapeutic measures.