Is phase angle associated with visceral adiposity and cardiometabolic risk in cardiology outpatients?

BACKGROUND/OBJECTIVES: Phase angle (PhA) serves as a prognostic marker in various clinical scenarios, reflecting oxidative stress and cellular damage. Despite its clinical relevance, its connection with adiposity and cardiovascular risk markers remains underexplored. Hence, our study sought to investigate the relationship between PhA and metabolic, adiposity, and cardiovascular risk parameters among outpatients with cardiology diagnosis. SUBJECTS/METHODS: Adults aged between 26 and 59 years, under the care of a cardiology unit, were included. Ultrasound imaging was used to assess visceral adipose tissue (VAT). Single-frequency bioelectrical impedance analysis (BIA) [50 kHz] was employed to calculate PhA, from BIA's resistance and reactance measurements. Muscle strength, body mass index, waist circumference, and waist-to-height ratio were also evaluated. Framingham's risk score was calculated to estimate the cardiovascular risk events. Metabolic blood samples' results were obtained from medical records. RESULTS: One hundred and five participants were included in our study. Low PhA was observed in 29.5% of our sample. Higher PhA values were independently and inversely associated with both higher VAT and cardiovascular risk (adjusted OR: 0.79 [95% CI 0.69;0.91], OR: 0.74 [95% CI 0.60;0.89], respectively). Lower PhA values (≤5.59) were goodly associated with high VAT (AUC: 0.82 p < 0.001). Lower PhA values (≤5.06) were fairly associated with higher cardiovascular risk (AUC: 0.70 p = 0.003). CONCLUSION: Our study provides evidence that PhA is independently and inversely associated with elevated VAT and cardiovascular risk. These findings underscore the potential of PhA as a valuable complementary marker in assessing cardiometabolic health.

Visceral adiposity indices and cardiometabolic risk markers in patients with hypertension.

Objective: Arterial hypertension (AH) is a risk factor for cardiovascular diseases (CVD). We sought to evaluate the association between two adiposity indices (visceral adiposity index [VAI] and lipid accumulation product [LAP]) with traditional markers of cardiometabolic risk in hypertensive patients. Materials and methods: This is a cross-sectional study with 1,273 subjects with hypertension treated as outpatients at a university hospital. The VAI and LAP were calculated using formulas stratified by sex. Cardiometabolic risk variables were considered: overweight, risk for waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHA), and altered biochemical test values. The predictive effect of independent variables on outcomes was assessed by multivariate linear regression analysis. There was statistical significance when p ≤ 0.05. Results: Higher cardiometabolic risk (according to BMI, WHR, WHA, and altered biochemical parameters) was associated with higher values of VAI and LAP with statistical significance (p ≤ 0.05). The regression models used explained 30.7% and 10.5% of the changes in LAP and VAI, respectively. Conclusion: LAP and VAI are associated with cardiometabolic risk parameters in the individuals evaluated, suggesting that these indices can be used to screen for CVD risk in individuals with AH.

Association between diet quality index, food and nutrient intake and metabolic parameters in adolescents from Recife, northeastern Brazil.

Nutritional studies shifted the focus of attention to the analysis of food quality, addressing general diet considering the foods, food groups and nutrients included. This study evaluates the association between diet quality index, food and nutrient intake and metabolic parameters of adolescents from Recife, northeastern Brazil. It is a cross-sectional study involving adolescents aged 12 to 19 years. Food intake was assessed using the FFQ to estimate the adapted Diet Quality Index for Adolescents for Brazilians (DQIA-BR-A). The analysis included metabolic parameters (glucose, lipid profile, apo A1 and B, α-1-acid glycoprotein, retinol, ß-carotene, α-tocopherol, 25-hydroxyvitamin D and parathormone). Multiple linear regression analysis between the DQIA-BR-A and daily nutrient intake showed a positive correlation (R2adjusted = 0·29) for linoleic fatty acid, Ca and folate and a negative correlation for oleic fatty acid, carbohydrates and vitamins B2 and C, in addition to a low correlation (R2adjusted < 0·07) with all metabolic parameters. However, the DQIA-BR-A correlated significantly (R2adjusted = 0·62; P < 0·001) with food intake. In this way, the DQIA-BR-A can be considered as an accurate and useful instrument for assessing the overall quality of adolescent diets. The diet of the adolescents was considered to be of moderate quality. Changes are required to ensure a balanced diet, considering the high-sugar intake and consumption of sweets as well as the low consumption of vegetables, milk and dairy products, oils, fats and seeds. Such changes should prioritise the consumption of foods rich in essential fatty acids and poor in saturated fat.

Visceral adiposity indicators and cardiovascular risk in hemodialytic patients.

OBJECTIVE: Cardiovascular diseases represent the main cause of death in chronic kidney disease (CKD). We aimed to evaluate the prevalence and association of the hypertriglyceridemia-waist phenotype (HWP) and visceral adiposity index (VAI) with cardiometabolic risk factors (CR) in patients with CKD on hemodialysis (HD). METHODS: The study is based on a cross-sectional design with 265 HD patients in two cities in northeastern Brazil. The VAI was calculated considering the variables body mass index (BMI), waist circumference (WC), triglycerides (TG) and high density lipoprotein cholesterol (HDL-c). HWP was defined as the concomitant elevation of WC and TG. The Poisson Regression Model with robust variance estimation was adjusted considering a hierarchical approach for explanatory variables. Prevalence ratios (PR) were also estimated. The level of significance adopted was 5%. RESULTS: In our study HWP and VAI prevalence's were 29.82% and 58.49%, respectively. In the final model, there was an association between VAI and female gender (PR = 1.46; p < 0.0001) and high body fat (% BF) (PR = 1.33; p < 0.0019). HWP was associated with females (PR = 1.80; p = 0.002), alcohol consumption (PR = 1.58; p = 0.033), obesity (PR = 1.89; p = 0.0001), high %BF (PR = 1.76; p = 0.012) and reduced HDL-c (PR = 1.48; p = 0.035). CONCLUSION: The HWP stood out as the association with more CR factors, representing a promising method for tracking cardiometabolic risk in HD patients, mainly female.

Consumption of ultraprocessed foods, nutritional status, and dyslipidemia in schoolchildren: a cohort study.

This study evaluates the relation between consumption of ultraprocessed foods, nutritional status, and dyslipidemia in schoolchildren from Recife/PE, Brazil. This is a cohort study conducted in 2008-2009 and 2012-2013, with 238 students recruited from the public school system of the city of Recife, Northeast Brazil. Demographic data, stage of sexual maturation, socioeconomic, lifestyle, anthropometric, and lipid profiles were collected. There was a high prevalence of overweight, abdominal obesity, and dyslipidemia in both the time periods. The number of teenagers sufficiently active was higher in 2012-2013. There was a positive correlation between the consumption of ultraprocessed foods and age in 2008-2009. In 2008-2009, high consumption of ultraprocessed foods occurred in the majority of adolescents with normal total serum cholesterol values. In 2012-2013, low maternal schooling proved to be an important factor for a lower consumption of ultraprocessed foods. The consumption of ultraprocessed foods showed no direct relationship with overweight, abdominal obesity, and dyslipidemia in adolescents.

Prevalence and factors associated with fat-soluble vitamin deficiency in adolescents / Prevalencia y factores asociados a la deficiencia de vitaminas liposolubles en adolescentes

Background: fat-soluble vitamin deficiency may be a health problem not recognized in children and adolescents. Objective: to estimate the prevalence and factors associated with the deficiency of vitamins A, D and E among adolescent students from Northeastern Brazil. Methods: transversal study with adolescents aged 12 to 19 of both genders. A questionnaire to collect socioeconomic and lifestyle data and food intake was applied to adolescents. Then, an anthropometric evaluation and a blood sampling were performed to analyze serum concentrations of retinol, beta-carotene, alfa-tocopherol and 25-hydroxy vitamin D (25[OH]D).Results: the intake of vitamins A (50.3%), E (94.0%) and D (99.8%), as well as alfa-tocopherol (88.1%), beta-carotene (74.1%), 25(OH)D (50.9%) and retinol (46.6%) serum levels were mostly deficient/insufficient. An increased risk of α-tocopherol deficiency was observed in girls (PR = 1.11) and an increased risk of 25(OH)D deficiency was observed in boys (PR = 1.41). An increased likelihood of β-carotene (PR = 1.14) and 25(OH) D (PR = 1.38) insufficiency was observed in overweight individuals. Conclusions: the adolescents had a deficit in the intake and in serum levels of fat-soluble vitamins. The greatest risk of inadequacy was associated with gender and weight excess. However, the behavior of fat-soluble vitamins in adolescents needs further research

Introducción: la deficiencia de vitaminas liposolubles puede ser un problema de salud no reconocido en niños y adolescentes. Objetivo: estimar la prevalencia y los factores asociados a la deficiencia de las vitaminas A, D y E entre adolescentes escolares del nordeste de Brasil. Métodos: estudio transversal con adolescentes de 12 a 19 años de ambos sexos. Se utilizó un cuestionario para la recolección de datos socioeconómicos, de estilo de vida y de consumo alimentario de los adolescentes. A continuación, se realizó la evaluación antropométrica y la recolección de sangre para el análisis de las concentraciones séricas de retinol, beta-caroteno, alfa-tocoferol y 25-hidroxivitamina D (25[OH]D). Resultados: la ingesta de vitaminas A (50,3%), E (94,0%) y D (99,8%), así como los niveles séricos del alfa-tocoferol (88,1%), (R)-caroteno (74,1%), 25(OH)D (50,9%) y retinol (46,6%) se presentaron en su mayoría deficientes/insuficientes. Se observó un mayor riesgo de deficiencia del alfa-tocoferol en las niñas (RP = 1,11), y mayor riesgo de insuficiencia de 25(OH)D en los niños (RP = 1,41), así como mayor probabilidad de insuficiencia del (R)-caroteno (RP = 1,14) y 25(OH)D (RP = 1,38) en el exceso de peso. Conclusiones: los adolescentes presentaron déficit en el consumo y en los niveles séricos de las vitaminas liposolubles. El mayor riesgo de inadecuación estuvo asociado al sexo y el exceso de peso, sin embargo el comportamiento de las vitaminas hiposolubles en los adolescentes necesita una mayor investigación

Predictive models for estimating visceral fat: The contribution from anthropometric parameters.

BACKGROUND: Excessive adipose visceral tissue (AVT) represents an independent risk factor for cardiometabolic alterations. The search continues for a highly valid marker for estimating visceral adiposity that is a simple and low cost tool able to screen individuals who are highly at risk of being viscerally obese. The aim of this study was to develop a predictive model for estimating AVT volume using anthropometric parameters. OBJECTIVE: Excessive adipose visceral tissue (AVT) represents an independent risk factor for cardiometabolic alterations. The search continues for a highly valid marker for estimating visceral adiposity that is a simple and low cost tool able to screen individuals who are highly at risk of being viscerally obese. The aim of this study was to develop a predictive model for estimating AVT volume using anthropometric parameters. METHODS: A cross-sectional study involving overweight individuals whose AVT was evaluated (using computed tomography-CT), along with the following anthropometric parameters: body mass index (BMI), abdominal circumference (AC), waist-to-hip ratio (WHpR), waist-to-height ratio (WHtR), sagittal diameter (SD), conicity index (CI), neck circumference (NC), neck-to-thigh ratio (NTR), waist-to-thigh ratio (WTR), and body adiposity index (BAI). RESULTS: 109 individuals with an average age of 50.3±12.2 were evaluated. The predictive equation developed to estimate AVT in men was AVT = -1647.75 +2.43(AC) +594.74(WHpR) +883.40(CI) (R2 adjusted: 64.1%). For women, the model chosen was: AVT = -634.73 +1.49(Age) +8.34(SD) + 291.51(CI) + 6.92(NC) (R2 adjusted: 40.4%). The predictive ability of the equations developed in relation to AVT volume determined by CT was 66.9% and 46.2% for males and females, respectively (p<0.001). CONCLUSIONS: A quick and precise AVT estimate, especially for men, can be obtained using only AC, WHpR, and CI for men, and age, SD, CI, and NC for women. These equations can be used as a clinical and epidemiological tool for overweight individuals.

The effect of vitamin A supplementation with 400 000 IU vs 200 000 IU on retinol concentrations in the breast milk: A randomized clinical trial.

BACKGROUND & AIMS: The vitamin A nutritional status is marginal for most of the newborns, and the prevention of that deficiency is promoted by breastfeeding. The Ministry of Health of Brazil established the National Vitamin A Supplementation Program, giving mega-doses of this nutrient to women right after delivery, in order to provide adequate vitamin A content in the breast milk and The International Vitamin A Consultative Group has supported the recommendation, to supplement with 400 000 IU of VA immediately after delivery. This study compares retinol concentrations in breast milk (colostrum, 2 and 4 months) from mothers supplemented during immediate postpartum with 400 000 IU versus 200 000 IU of vitamin A. METHODS: A randomized, controlled, triple-blind trial, conducted in two public maternities in Recife, Northeast Brazil. Two hundred and ten mothers were recruited and allocated into two treatment groups: 400 000 IU or 200 000 IU of Vitamin A and monitored for 4 months. RESULTS: There was no significant difference between retinol concentrations in breast milk between treatment groups (400 000 IU vs 200 000 IU) in the studied period: 2 months (p = 0.790) and 4 months (p = 0.279), although a progressive reduction of concentrations throughout the study was observed in both treatment groups, 400 000 IU (p < 0.0001) and 200 000 IU (p < 0.0001). CONCLUSIONS: The absence of an additional effect of a higher dosage justifies the 200 000 IU supplementation, according to the World Health Organization. Registered under ClinicalTrials.gov Identifier No. NCT00742937.

Characterization of eating behavior disorders in school-aged children and adolescents: a population-based study.

OBJECTIVE: Cross-sectional study to assess the characteristics of the risk behaviors for eating disorders (EDs) in school children between 10 and 14 years of age in the city of Recife, Pernambuco, Brazil. METHODS: 1405 school-aged children were assessed, using the Eating Behaviours and Body Image Test (EBBIT) to screen for EDs. The normality of the continuing variables was tested using the Kolmogorov-Smirnov test with Lilliefors correction. They were described as medians and interquartile intervals (25 and 75th percentiles). RESULTS: The criteria that represented a condition of anorexia and/or bulimia nervosa were considered as strong indicators of risk for EDs in school-aged children who indicated the following behaviors with scores superior to the 75th percentile on the scales: "compulsive eating" 3.0% (CI95% 2.2-4.0); "dissatisfaction with body image/restrictive eating" 1.3% (CI95% 0.8-2.0); children scoring superior to the 30th percentile, "compulsive eating" + "dissatisfaction with body image/restrictive eating", 0.6% (CI95% 0.3-1.2); and superior to the 50th percentile; "compensatory behavior for hyperphagia" 6.7% (CI95% 5.4-8.1). In addition, greater vulnerability of the female gender was perceived, as well as an increase in the preliminary risk factors of EDs, such as advanced age, dissatisfaction with the body image linked to restrictive behaviors and the compulsive establishment of an eating pattern. CONCLUSION: This study shows the dimension of the problem in this ecological context and the urgent need for intervention programs, developed among different sectors, from the perspective of the adolescents' empowerment to prevent and minimize the vulnerability factors of the eating disorders.

Serum retinol concentrations in mothers and newborns at delivery in a public maternity hospital in Recife, northeast Brazil.

Serum retinol concentrations were compared in a consecutive series of 65 mother-newborn pairs at delivery in a public maternity hospital in Recife, Brazil, from January to August 2008 and examined their association with biological, socioeconomic, environmental and obstetrical characteristics. Serum retinol concentrations of the newborns (umbilical cord) and mothers (brachial venipuncture) were analyzed by high-performance liquid chromatography. Prevalence of low (< 0.70 micromol/L) and inadequate (< 1.05 micromol/L) serum retinol concentrations were observed in 23.1% (95% CI 13.9-35.5) and 23.0% (95% CI 13.5-35.8) among newborns and mothers respectively. The serum retinol distribution was lower in male than female infants (-0.4 micromol/L, p = 0.01) and, across both sexes, concentrations in paired newborn and mother were correlated (r = 0.27, p = 0.04). Further, maternal status explains only 7% of the variance in retinol concentrations in newborn's cord plasma. Among mothers delivering in public facilities in Recife, hypovitaminosis may exist.

Prevalence of anemia in under five-year-old children in a children's hospital in Recife, Brazil.

INTRODUCTION: Anemia is a nutritional problem of global importance. It is estimated that at least one-third of the population has been at one time anemic. OBJECTIVE: To evaluate the prevalence of anemia and associated factors in patients of a children's hospital in Recife. METHODS: A cross-sectional study was developed involving 595 male and female children aged from 6 to 59 months old, who were hospitalized in 2007. RESULTS: Children with a hemoglobin concentration less than 11 g/dL were considered anemic. The relationship between studied variables and anemia was evaluated by Poisson regression analysis. There was a 56.6% prevalence of anemia (95% CI: 46.6-54.6). Anemia was significantly correlated with low weight (Prevalence ratio - PR = 1.39; 95% CI: 1.18-1.64), young age (PR = 2.01; 95% CI: 1.57-2.56) and a diagnosis of acute lower respiratory disease (PR = 1.57; 95% CI: 1.27-1.96). CONCLUSION: The high prevalence of anemia suggests that it may contribute as a causal factor for hospitalization, especially because the period of hospitalization was short and the patient was likely to be anemic at the time of admission. This study stresses the importance of evaluating the overall nutritional status of patients, including their ingestion of microelements. This is especially important in children, because of their greater susceptibility to anemia. Measures directed at the prevention and control of anemia, including increased coverage of supplementation and fortification programs are strongly recommended.

Consumo alimentar e concentrações intra-eritrocitárias de folato em mulheres do Recife, Nordeste do Brasil / Folate food intake and red blood cell folate concentrations in women from Recife, Northeast of Brazil

Foi avaliado o consumo e concentrações intra-eritrocitárias de folato em mulheres do Recife, Nordeste, Brasil, mediante estudo de corte transversal, envolvendo 360 mulheres, de 15 a 45 anos, aleatoriamente rastreadas, por amostragem em dupla etapa, de 9 Unidades Públicas de Saúde, em 2007-2008. O consumo de folato foi avaliado pelo Questionário de Freqüência Alimentar Quantitativo e comparado com os valores da Dietary Reference Intakes-DRI’s. O status orgânico de folato foi avaliado pelas concentrações intra-eritrocitárias. A media geométrica do consumo diário de folato foi 627,1[IC95%600,4-655,0] µg/dia. A freqüência de mulheres com risco de ingestão de folato abaixo da recomendação foi 16,0% para adolescentes (<330µg/dia) e 6,3% para adultas jovens (<320µg/dia). A prevalência de mulheres cujo consumo excedeu o limite máximo tolerável de ingestão foi de 48,0% (>800µg/dia) e 13,7% (>1000µg/dia) para adolescentes e adultas, respectivamente. A média das concentrações de folato eritrocitário foi de 1797,8 ± 357,1 nmol/L. O consumo de alimentos-fonte de folato não mostrou correlação com as concentrações eritrocitárias (r= 0,058 e p= 0,274). Maiores concentrações de folato eritrocitário foram observadas em mulheres adultas jovens (p= 0,004) e entre aquelas com renda até dois salários mínimos (p= 0,042). Nas mulheres do Recife, tanto o consumo de alimentos-fonte de folato como as concentrações eritrocitárias de folato elevaram-se em patamares superiores às recomendações internacionais.

Folate food intake and red blood cell folate concentrations were assess in women from Recife, Northeast Brazil. Following a two stages sampling procedure, a cross-sectional study was carried out involving 360 women, between 15-45y, attending in nine Health Care Public Unit in 2007-2008. Folate intake was evaluated by a Quantitative Food Frequency Questionnaire, and compared with the values of the Dietary Reference Intakes- DRI’s. Folate status was evaluated by red blood cell folate concentrations. Geometric mean of folate intake was 627.1[IC95%600.4-655.0] µg/day. The frequency of women at risk for folate intake below the recommendation was 16.0% for adolescents (<330µg/ day) and 6.3% for young adult (<320µg/ day). The prevalence of women whose consumption exceeds the maximum tolerable intake was 48.0% (> 800µg/ day) and 13.7% (> 1000µg/ day) for adolescents and adults, respectively. The mean of red blood cell folate concentrations was 1797.8 ± 357.1nmol/L. Folate rich-food intake did not show any correlation with red blood cell folate concentrations (r= 0.058 and p= 0.274). Higher red blood cell folate concentrations were observed in adult young women (p=0.004) and among those with income up to two minimum wages (p=0.042). Folate rich-food intake as well as red blood cell folate concentrations among women from Recife were above the international recommendations.

Serum retinol concentrations in hospitalized severe protein-energy malnourished children.

BACKGROUND: Vitamin A deficiency (VAD) is a major nutritional problem in many developing countries. Vitamin A status has been reported to be adversely affected in protein-energy malnutrition (PEM). OBJECTIVE: To assess and compare serum retinol concentrations in hospitalized children with severe PEM and normal ones. METHODS: A prospective series of 34 malnourished and 29 normal control children, <60 months old, hospitalized at IMIP, Recife-PE were recruited for the study between August 2004 and May 2005. Serum retinol level was assayed by high performance liquid chromatography and concentrations adjusted for presence of inflammation as evidenced by levels of C-reactive protein. Blood retinol level was compared according to nutritional status (severe PEM versus normal), gender, age, maternal schooling, family income, breastfeeding practice, residence and perceived morbidity. RESULTS: The prevalence of low serum retinol (<0.70 micromol l(-1)) was 41.2% in children with severe PEM and 24.1% in normal children. Serum retinol concentrations were lower in children whose mothers had low schooling (p = 0.025) and families with low per capita income (p = 0.049), regardless of their nutritional status. Serum retinol concentrations had similar distribution between children with severe PEM and normal, when adjusted for gender (p > 0.05), age (p > 0.05), maternal schooling (p > 0.05), family income (p > 0.05), breastfeeding practice (p > 0.05) and residence (p > 0.05). However, malnourished children with diarrhoea showed lower serum retinol concentrations (p = 0.021) compared to those without diarrhoea. CONCLUSION: VAD was prevalent in hospitalized children with severe PEM and also among normal ones although in lesser magnitude. Intervention for prevention and control of deficiency of vitamin A are recommended in settings where diarrhea is endemic and there are unfavorable socio-economical conditions.

Vitamin A and zinc status in patients on maintenance haemodialysis.

BACKGROUND: The objective of this study was to assess the vitamin A and zinc serum levels in patients undergoing haemodialysis (HD) in the city of Recife, in the north-eastern region of Brazil. METHODS: The study comprised 55 patients and 28 healthy controls. The retinol and zinc serum concentrations were analysed by using high-performance liquid chromatography (HPLC) and atomic absorption spectrophotometry, respectively. RESULTS: The mean retinol serum concentration in patients (2.50 +/- 0.86 micromol/L) was significantly greater (P < 0.001) than that found in controls (1.26 +/- 0.86 micromol/L). The retinol serum levels in the patients were as follows: 47.3% of the patients had elevated levels (>/= 2.24 and < 3.50 micromol/L); 16.4% of the patients had serum levels >/= 3.50 micromol/L, which indicated hypervitaminosis; and 9.1% of the patients had serum levels below the normal range (<1.05 micromol/L), a rate that among the controls was 42.9% (P < 0.01). In regard to zinc, the serum levels found in the patients (10.59 +/- 3.12 micromol/L) were similar to those found in the controls (11.43 +/- 2.82 micromol/L) (P > 0.05). Although 49.1% of the patients and 35.7% of the controls were classified as deficient in zinc, this difference was not statistically significant (P > 0.05). RESULTS: The results identified a high prevalence of zinc deficiency in the groups studied, and point to a trend towards more elevated retinol serum levels in patients undergoing dialysis as compared with those in healthy controls.

[View of the different social agents on the social participation in the health system in northeastern Brazil. A qualitative approximation]. / Visión de los diferentes agentes sociales sobre la participación social en el sistema de salud en el nordeste de Brasil. Una aproximación cualitativa.

BACKGROUND: Social participation in the health system constitutes one of the basic principles of Brazilian health sector reform. This paper analyses the concepts held by different groups of stakeholders with respect to social participation in health and identifies their opinions on hindering and enabling factors for this participation. METHODS: A qualitative study was conducted using individual interviews (II) and focus groups (FG) with different groups of stakeholders: 135 users (II, GF), 14 community leaders (II, GF), 12 Municipal Health Council (MHC) members (II), 8 policymakers and (II) 37 health personnel (II, GF) were interviewed. A narrative content analysis of the results was conducted. Two municipalities in North-eastern Brazil, Cabo de Santo Agostinho and Camaragibe, made up the area of study. RESULTS: In all groups, a distinction between individual and group participation emerged and reached different levels of elaboration. Many informants' ideas described also their own ways of action. Individual participation concepts and the utilization of health services were predominant among users. Population and institutional factors were identified as obstacles to participation: users and community leaders referred both type of factors, while the health personnel and MHC members put more emphasis on the former. Some informants among the health personnel did not identify any barriers. Policymakers emphasised the lack of political will. The enabling factors mentioned reflected the same logic. CONCLUSIONS: Concepts and perceived hindering factors to participation which were described appear to show different ways of interaction among the diverse stakeholders and the health services. The results point towards a limited effect of the health policy on social participation. Elements that could contribute to an improvement are identified.