ABSTRACT Introduction: Excessive accumulations of adipose tissue are a threat to cardiometabolic health; their assessment in women would better inform about their metabolic state. Objective: To identify associations between cardiometabolic vulnerability states and atherogenic indices in the short-term postpartum period. Method: A descriptive observational study was conducted from January 2017 to August 2018 on 119 women in short-term postpartum. The study population consisted of 773 pregnant women with adequate weight and apparently healthy at the time of recruitment, who were classified based on their cardiometabolic vulnerability due to body adiposity at the Policlínico Chiqui Gómez Lubián, between January 2012 and December 2016. The association of cardiometabolic vulnerability with the atherogenic indices was studied: Castelli, Kannel and the TG/HDLc ratio. The Kruskal-Wallis test was applied to compare independent samples. Results: The Castelli (3.37), Kannel (2.02) and TG/HDL (0.71) indices showed lower mean values in women without vulnerability. The Castelli (4.20) and Kannel (2.69) indices showed higher values in women with extreme global vulnerability due to high overall adiposity and high central adiposity. The TG/HDLc index (1.18) reached the highest values in women with global vulnerability due to intermediate and high central overall adiposity. Conclusions: The values of the atherogenic indices studied in the short-term postpartum period were associated with cardiometabolic vulnerability, with higher figures in women with intermediate and high general adiposity, and high central adiposity. Cardiometabolic vulnerability due to body adiposity in the short-term postpartum period may alert about atherogenic metabolic disorders, such as cardiovascular risk.

RESUMEN Introducción: Acumulaciones excesivas de tejido adiposo constituyen una amenaza para la salud cardiometabólica, el estudio en la mujer orientaría mejor sobre su estado metabólico. Objetivo: Identificar asociaciones entre estados de vulnerabilidad cardiometabólica e índices aterogénicos en el posparto a corto plazo. Método: Se realizó un estudio observacional descriptivo, entre enero 2017 y agosto 2018, en 119 mujeres en el posparto a corto plazo, a partir de una población de 773 gestantes de peso adecuado y aparentemente sanas al momento de la captación, clasificadas por su vulnerabilidad cardiometabólica por adiposidad corporal en el Policlínico Chiqui Gómez Lubián, entre enero 2012 y diciembre 2016. Se estudió la asociación de la vulnerabilidad cardiometabólica con los índices aterogénicos: Castelli, Kannel y la relación TG/HDLc. Se aplicó la prueba de Kruskal-Wallis para la comparación de muestras independientes. Resultados: Los índices Castelli (3,37), Kannel (2,02) y TG/HDLc (0,71) tuvieron valores medios más bajos en las mujeres sin vulnerabilidad. Los índices Castelli (4,20) y Kannel (2,69) mostraron valores más elevados en mujeres con vulnerabilidad global extrema por adiposidad general alta y central alta. El índice TG/HDLc (1,18) tuvo los valores más elevados en mujeres con vulnerabilidad global por adiposidad general intermedia y central alta. Conclusiones: Los valores de los índices aterogénicos estudiados en el posparto a corto plazo estuvieron asociados con la vulnerabilidad cardiometabólica, con cifras más elevadas en mujeres con adiposidad general intermedia y alta, y adiposidad central alta. La vulnerabilidad cardiometabólica por adiposidad corporal en el posparto a corto plazo, puede alertar sobre alteraciones metabólicas aterogénicas, como riesgo cardiovascular.

ABSTRACT Introduction: Cardiometabolic vulnerability due to body fat can be a useful indicator during pregnancy and after delivery, in the prevention of cardiovascular events. Objective: To describe possible associations of cardiometabolic vulnerability due to body adiposity with changes in blood pressure in the short-term postpartum. Methods: A cross-sectional descriptive observational study was carried out from January 2017 to August 2018, in 119 women at Chiqui Gómez Lubián community clinic. The sustained weight test was applied, the mean and standard deviation of the calculated systolic, diastolic and mean arterial pressure were determined at rest and two minutes after the first reading. The quantitative changes in blood pressure at rest and with subsequent physical stimulation were analyzed, according to cardiometabolic vulnerability due to body fat, 18 months after delivery. These women were classified into three groups according to their vascular response to physical stimulation, evaluated by changes in blood pressure: normoreactive, hyperreactive and with a hypertensive response. The Kruskal-Wallis test was applied for the comparison of independent samples. Results: Increase in mean blood pressure values in women with VGlobal Extrema AGA / CA (DBP, PAS_2min, DBP_2min and MAP-2min) and with VAGI (TAS and TAM). 36.4% of the women with a hyperreactive response, had VAGI and 45.5% had VAGA. The only case with a hypertensive response had VGlobal Extrema AGA / CA. Conclusions: The early characterization of cardiometabolic vulnerability due to body adiposity can alert about changes in vascular reactivity which leads to later cardiovascular events.

RESUMEN Introducción: La vulnerabilidad cardiometabólica por adiposidad corporal puede ser un indicador de utilidad durante el embarazo y después del parto, en la prevención de eventos cardiovasculares. Objetivo: Describir posibles asociaciones de la vulnerabilidad cardiometabólica por adiposidad corporal con cambios de la presión arterial en el posparto a corto plazo. Métodos: Se realizó un estudio observacional descriptivo transversal en el período enero 2017-agosto 2018, en 119 mujeres pertenecientes al policlínico “Chiqui Gómez Lubián”. Se aplicó la prueba de peso sostenido, se determinó la media y desviación estándar de la presión arterial sistólica, diastólica y media calculada; en reposo y dos minutos después de la primera medición. Se analizaron los cambios cuantitativos de la presión arterial en reposo y con estimulación física posterior, según vulnerabilidad cardiometabólica por adiposidad corporal, 18 meses después del parto. Se clasificaron las mujeres en tres grupos según su respuesta vascular ante la estimulación física, evaluada por los cambios de la presión arterial: normorreactivas, hiperreactivas y con respuesta hipertensiva. Se aplicó la prueba de Kruskal-Wallis para la comparación de muestras independientes. Resultados: Incremento de los valores medios de presión arterial en mujeres con VGlobal Extrema AGA/CA (PAD, PAS_2min, PAD_2min y PAM-2min) y con VAGI (TAS Y TAM). De las mujeres con respuesta hiperreactiva, 36,4 % tenía VAGI y el 45,5 % con VAGA. El único caso con respuesta hipertensiva tenía VGlobal Extrema AGA/CA. Conclusiones: La caracterización temprana de la vulnerabilidad cardiometabólica por adiposidad corporal puede alertar sobre cambios en la reactividad vascular la cual conduce a eventos cardiovasculares posteriores.

ABSTRACT Introduction: Pregnancy is a period of persistent obesity risk after delivery. Among other causes, it is secondary to the nutritional status at the beginning of pregnancy and to gaining weight above the recommended. Objective: To describe gestational weight gains by nutritional categories and their association with weight retention one year after delivery. Methods: An observational and cross-sectional study was conducted with 100 women one year after delivery and from three health areas of Santa Clara Municipality, in the period from July 2016 to July 2017. Their pregnancy identification cards were reviewed to collect their weight in kilograms at the time pregnancy was identified, nutritional evaluation based on the body mass index at the first office visit, and the weight at the end of pregnancy. They were paid home visits one year after delivery. General data were collected, foot size, body weight, and waist circumference were measured. Body mass and waist/height indexes were calculated. Results: The weight condition adequate to the time pregnancy was identified (67.08%). 82.87% of women retained weight one year after delivery, more frequently in obese (90.0%) and overweight (83.01%) women according to their nutritional status at the time pregnancy was identified. All women had waist/height index above 0.50 one year after delivery. Conclusions: Women with weight gains higher than recommended have less capacity to recover their body weight one year after delivery.

RESUMEN Introducción: El embarazo es una etapa de riesgo de obesidad persistente después del parto, entre otras causas, es secundario al estado nutricional al inicio del embarazo y a las ganancias de peso por encima de lo recomendado. Objetivo: Describir las ganancias de peso gestacionales por categorías nutricionales y su asociación con la retención de peso al año del parto. Métodos: Se realizó un estudio observacional de corte transversal en 100 mujeres al año del parto, pertenecientes a tres áreas de salud del municipio Santa Clara, en el periodo comprendido de julio 2016 a julio 2017. Se revisaron los tarjetones de las embarazadas para recoger el peso en kg a la captación, su evaluación nutricional según el índice de masa corporal en la primera consulta y el peso al final de la gestación. Las mismas fueron visitadas en su domicilio al año de paridas; se recogieron datos generales, se midió la talla de pie, el peso corporal y la circunferencia de la cintura. Se calcularon los índices de masa corporal y cintura/talla. Resultados: Predominó la condición de peso adecuado a la captación (67,08 %). El 82,87 % de las mujeres retuvo peso al año de paridas; con mayor frecuencia en las obesas (90,0 %) y sobrepeso (83,01 %) según su estado nutricional a la captación. Todas las mujeres tuvieron índice cintura/talla por encima de 0,50 al año de paridas. Conclusiones: Las mujeres con mayores ganancias por encima de lo recomendado, tienen menor capacidad de recuperación del peso corporal al año de paridas.

ABSTRACT Obesity in pregnant women is a complex disease that can lead to further metabolic disorders; however increased adipose tissue can also occur in pregnant women of normal body weight. The objective of this communication was to reflect on the dangers of the obesity trinomial epidemic, insulin resistance and type 2 diabetes, for new generations and public health in general. The effects of excess adiposity in pregnant women were analyzed, through the changes in placental transport in the "reprogramming" of cellular energy metabolism, and its incidence on different tissues, which can cause insulin resistance and type 2 diabetes. We concluded that the awareness of the danger posed by obesity, even when it is overlapping, demands the stratification of its risk based on adiposity rather than body weight of patients.

RESUMEN La obesidad en las gestantes es una enfermedad compleja que puede condicionar trastornos metabólicos posteriores; sin embargo, la elevación del contenido adiposo en el organismo también puede ocurrir en gestantes de peso corporal normal. El objetivo de esta comunicación fue reflexionar sobre los peligros de la epidemia del trinomio obesidad, resistencia a la insulina y diabetes tipo 2, para las nuevas generaciones y la salud pública en general. Se analizaron los efectos del exceso de adiposidad de las gestantes, por intermedio de los cambios en el transporte de la placenta en la «reprogramación» del metabolismo energético celular, y su incidencia sobre diferentes tejidos, que pueden provocar insulinorresistencia y diabetes tipo 2. Se concluyó que la toma de conciencia del peligro que representa la obesidad, aun cuando esta sea solapada, demanda la estratificación de su riesgo basado en la adiposidad más que en el peso corporal de las pacientes.

Abstract Introduction: Different locations of adipose tissue determine risks for the cardiovascular and metabolic health, without having enough knowledge on how this problem manifests in healthy pregnant at the start of pregnancy. Objectives: To identify possible groups of healthy pregnant women with body adiposity and to evaluate the diagnostic capability of the indicators used. Method: Cross-sectional observational study in 1305 pregnant women in a health area of Santa Clara, from 2012 to 2016. Frequency distributions and central tendency and dispersion measures were developed, as well as clustering techniques and ROC curves (Receiver Operating Characteristic). The general and central adiposity, and the components of corporal and abdominal adiposity were studied. Results: Three clusters of general adiposity and two of central adiposity were identified. The highest average values of body mass index and body fat percentage were in the high cluster of general adiposity (33.5 kg/m2 y 41.6%), whereas for the central adiposity indicators, these values manifested in the group of high central adiposity. The sum of the tricipital and subscapular skinfolds had the largest area under the curve, both for general (0.752) and central body adiposity (0.934); while for the abdominal adiposity corresponded to visceral (0.697) and preperitoneal (0.822) fat. Conclusions: The indicators used identified groups of pregnant women with different levels of general and central adiposity, with more diagnostic capability for the sum of subscapular and tricipital skinfolds.

RESUMEN Introducción: Localizaciones distintas de tejido adiposo determinan riesgos para la salud cardiovascular y metabólica, sin que se conozca lo suficiente cómo se manifiesta esta problemática en gestantes sanas al inicio de la gestación. Objetivos: Identificar posibles agrupaciones de gestantes sanas con adiposidad corporal y evaluar la capacidad diagnóstica de los indicadores utilizados. Método: Estudio observacional transversal en 1305 gestantes de un área de salud de Santa Clara, desde 2012 al 2016. Se realizaron distribuciones de frecuencias y medidas de tendencia central y de dispersión, se aplicaron técnicas de conglomerados y curvas ROC (receiver operating characteristic). Se estudió la adiposidad general, central, y los componentes de adiposidad corporal y abdominal. Resultados: Se identificaron tres conglomerados de adiposidad general y dos de la central. Los valores medios más elevados del índice de masa corporal y el porcentaje de grasa corporal estuvieron en el conglomerado de adiposidad general alto (33,5 kg/m2 y 41,6%) y en el de adiposidad central alta. La suma de los pliegues cutáneos tricipital y subescapular tuvo la mayor área bajo la curva, tanto para la adiposidad corporal general (0,752) como central (0,934); mientras que para la adiposidad abdominal correspondió a la grasa visceral (0,697) y la preperitoneal (0,822). Conclusiones: Los indicadores utilizados identificaron agrupaciones de gestantes con diferentes niveles de adiposidad general y central, con mayor capacidad diagnóstica para la suma de los pliegues cutáneos subescapular y tricipital.

ABSTRACT Background: Regional accumulations of adipose tissue can be harmful due to the production of proinflammatory factors, which in overweight and obese patients would be easy to infer, but in normal weight patients such risks can be hidden. This evidences the need of including in the nutritional evaluation of adequate weight pregnant women the analysis of body adiposity. Objective: To argue the need of including in the nutritional evaluation of the adequate weight pregnant women the analysis of body adiposity at the time of detection, as a dimension with a high predictive value of cardiometabolic vulnerability. Development: Observational cross-sectional study in 1305 pregnant women, apparently healthy at the time of pregnancy detection, in the health area "Chiqui Gómez Lubián" in Santa Clara municipality, from 2012 to 2016. Descriptive statistics techniques and hierarchical conglomerates were used. Five conglomerates were formed according to the average values of the indicators of general adiposity (normal, intermediate and high) and central (normal and high); among them 773 were classified as adequate weight according to the body mass index, including 216 with some levels of body adiposity. Its coincidence in different categories of corporal adiposity, revealed 4 states of cardio metabolic vulnerability. Conclusions: The ranges of normality by body mass index do not reveal body adiposity, a condition of vulnerability to cardio metabolic risks in apparently healthy pregnant women at the time of pregnancy detection.

RESUMEN Fundamento: Las acumulaciones regionales de tejido adiposo pueden resultar perjudiciales por la producción de factores proinflamatorios, que en individuos sobrepesos y obesos sería fácil inferir, pero en normopesos tales riesgos pueden encubrirse. Esto evidencia la necesidad de incluir en la evaluación nutricional de las gestantes de peso adecuado el análisis de la adiposidad corporal. Objetivo: Argumentar la necesidad de incluir en la evaluación nutricional de las gestantes de peso adecuado el análisis de la adiposidad corporal desde la captación, como dimensión de alto valor predictivo de vulnerabilidad cardiometabólica. Desarrollo: Estudio observacional transversal en 1305 gestantes, aparentemente sanas a la captación, en el área de salud “Chiqui Gómez Lubián” del municipio de Santa Clara, entre los años 2012 a 2016. Se usaron técnicas de estadística descriptiva y de conglomerados jerárquicos. Se conformaron 5 conglomerados según los valores medios de los indicadores de adiposidad general (normal, intermedio y alto) y central (normal y alto); entre ellas 773 clasificaron de peso adecuado según el índice de masa corporal, incluidas 216 con algún nivel de adiposidad corporal. Su coincidencia en distintas categorías de adiposidad corporal, reveló 4 estados de vulnerabilidad cardiometabólica. Conclusiones: Los rangos de normalidad por índice de masa corporal no revelan adiposidad corporal, condicionante de vulnerabilidad a riesgos cardiometabólicos en las gestantes aparentemente sanas al momento de la captación.

INTRODUCTION: One reason given by the South African government for establishing a physician training agreement with Cuba is that the ethical, humanistic and solidarity principles promoted in Cuban medical education are difficult to acquire in other settings. However, Cuba's general medical training program does not provide all skills needed by a general practitioner in South Africa: other competencies are required, such as management of general and gynecological or obstetrical surgical emergencies, administration of anesthesia and nursing procedures. As long as the desired humanistic values were assured, South African authorities have preferred to complement these competencies. Thus, since 2003, the Medical University of Villa Clara has applied a curricular strategy of 12 complementary courses to develop the requested additional skills, but results have not met expectations. OBJECTIVE: Determine why the complementary curricular strategy has not been entirely successful and identify possible courses of action for improvement. METHODS: A document review was conducted of the curricular strategy applied and of minutes of meetings between Cuban and South African counterparts to identify correspondence between requested professional skills and actions to develop them. In addition, South African students were surveyed and Cuban professors were interviewed in depth. Senior university administrators and key informants were also interviewed. Variables assessed were course quality and satisfaction of students and professors. RESULTS: Some actions originally included in the curricular strategy were not implemented and there were structural weaknesses in complementary courses, primarily in objectives, teaching strategy and evaluation. Students reported insufficient practical activities and lack of relationship between content and the health situation in South Africa. Professors were dissatisfied with student levels of motivation and ability to manage their own learning. Other influencing factors were insufficient academic management and professors' lack of knowledge about the context where these future professionals would eventually practice. CONCLUSIONS: Curricular strategy deficiencies detected are primarily in academic management; overcoming them could facilitate action in specific directions identified to improve the requested skill levels.