Fecha de recepción: abril 22 de 2022 Fecha de aceptación: agosto 23 2022
ARTíCULO ORIGINAL https://dx.doi.org/10.14482/sun.39.02.001.416
Factors Associated with Noncommunicable Diseases in an Indigenous population of Colombia
Factores asociados a enfermedades no trasmisibles en una población indígena en Colombia
Omar Ramos-Valencia1, Sandra Jácome-Velasco2, Andrés Villaquiran-Hurtado3, Lizet Bedoya-Luligo4, Ana Omen-Tintinago5
1 MSc in Public Health- Universidad del Valle, Universidad del Cauca. Orcid: https://orcid.org/0000-0002-1500-0973, Carrera 6 N.° 13N-50 de Popayán, sector de La Estancia, Popayán, Colombia. omaramos@unicauca.edu.co
2 PhD in Education- Universidad del Cauca, Universidad del Cauca. https://orcid.org/0000-0001-6605-8377, Carrera 6 N.° 13N-50 de Popayán, La Estancia, Popayán, Colombia. sjacome@unicauca.edu.co
3 MSc in Comprehensive Sports Intervention, Universidad del Cauca. Orcid: https://orcid.org/0000-0002-6156-6425, 3246807670, Carrera 6 N.° 13N-50 de Popayán, sector de La Estancia, Popayán, Colombia. avillaquiran@unicauca.edu.co
4 Physical Therapist- Universidad del Cauca, Hospital Universitario del Valle. Orcid: https://orcid.org/0000-0002-9683-483X, 3226365263, calle 34#2n-26 barrio Bolivariano, Cali Valle del Cauca, Colombia. lizeth.bedoya@correounivalle.edu.co
5 Physical Therapist- Universidad del Cauca, AIC Salud. Orcid: https://orcid.org/0000-0001-6094-1687, 3113179848, Carrera 8E #17-46, Popayán, Cauca, Colombia. auditoria8@aicsalud.org.co
Corresponding autor: Andres Felipe Villaquiran, teacher, Universidad del Cauca, avillaquiran@unicauca.edu.co, https://orcid.org/0000-0002-6156-6425
ABSTRACT
Descriptive, cross-sectional study of 76 people belonging to the Yanaconas Indigenous Resguardos of Rioblanco - Colombia. An instrument based on the STEPS -OMS protocol was used to determine the factors associated with noncommunicable diseases in the population. The participants were between the ages of 29 to 59 (60.5%) years old; most were physically active, with the most used means of transportation being non-motorized "walking" (46.1%). The indigenous community was found to have risk factors such as low educational level and bad eating habits; exposure to wood smoke in this population was high, at 57.9%; however, tobacco use was lower, at 3.9%, with alcohol use at 34.2%.
Keywords: Risk factors, Indigenous population, Chronic diseases, public health- Colombia*
RESUMEN
Estudio descriptivo, transversal con 76 personas pertenecientes a los Resguardos Indígenas Yanaconas de Rioblanco - Colombia. Se utilizó un instrumento basado en el protocolo STEPS -OMS, para determinar los factores asociados a las enfermedades no transmisibles en la población. Los participantes tuvieron entre 29 y 59 años (60,5%); En cuanto a conductas / exposiciones a la salud, la mayoría de la población es físicamente activa ya que el medio de transporte más utilizado es el "caminar" no motorizado (46,1%). Se encontró que la comunidad indígena presenta factores de riesgo como bajo nivel educativo y malos hábitos alimenticios; la exposición al humo de leña en esta población es alta en 57,9%; sin embargo, el consumo de tabaco fue menor al 3,9% y el consumo de alcohol al 34,2%.
Palabras clave: Factores de riesgo, Población Indígena, Enfermedades crónicas, salud pública- Colombia*
* BIREME / OPS / OMS. (2017) .Descriptores en Ciencias de la Salud: DeCS [Internet]. ed. 2017. Sao Paulo (SP). [actualizado 2017 May 18]. http://decs.bvsalud.org/E/homepagee.htm
INTRODUCTION
The World Health Organization (WHO) defines noncommunicable diseases (NCDs), also known as chronic diseases, as those with a long duration and a slow evolution1. Among them, we find cardiovascular diseases, chronic lung diseases, diabetes, and cancer2. NCDs have biological risk factors, including some modifiable ones, such as excess weight and obesity, high cholesterol levels, hyperglycemia, and high blood pressure3, in addition to behavioral risk factors such as alcohol and tobacco consumption, physical inactivity, and unhealthy diets4. Additionally, there are non-modifiable risk factors including: age, sex, genetic factors, and race5.
The majority of deaths caused by NCDs are occurring in low and middle income countries6, and a large proportion of NCD deaths occur before age 70 (i.e., during productive years)7. NCDs are the leading cause of mortality, worldwide, to the point that they claim more lives than all other causes, combined. To illustrate this, NCDs are responsible for the death of 41 million people each year, which corresponds to 71% of the total global deaths8.
In Colombia, cardiovascular diseases represent the first cause of mortality9, followed by deaths caused by other chronic diseases, such as chronic respiratory illness, diabetes mellitus, nutritional deficiencies and nutritional anemias, among others10.
It is important to note that Colombia has a rich population in terms of diversity and culture, which generates a variety of different habits and lifestyles that can lead to behavioral risk factors related to chronic diseases. One of the most noteworthy groups in Colombia is its indigenous population. According to the Colombian Institute of Rural Development- INCODER, there were 733 legally constituted indigenous Resguardos11 in 2015. According to the Colombian Ministry of Health and Protection, "in Colombia, the situation of indigenous peoples is framed in a complex and dynamic process of historical, social, economic, and environmental change, linked to the expansion and consolidation of demographic and economic groups in the different regions of the country"11.
Reports by the National Administrative Department of Statistics (DANE) mention that the Department of Cauca contains the second largest concentration of indigenous people12 in Colombia, with around 190,069 people settled in 26 of its 39 municipalities. There are 8 officially recognized ethnic groups, including the Paez community, with more than 120,000 residents; Totoro, with nearly 5,000 individuals; the Guambianos, in the Municipality of Silvia, with more than 16,000 people; the Kokonuko, in the municipality of Puracé, made up of approximately 7,000 individuals; and the indigenous Yanacona people, located in the southern area of the department, on the Colombian massif, with a population of over 25,00013.
Despite these figures, research reports on health conditions, and the identification of factors associated with NCDs for indigenous populations in Cauca, are scarce. However, the Ministry of Health and Social Protection in Colombia reported that for the 2008 to 2013 period, ischemic heart diseases, cerebrovascular diseases, chronic respiratory diseases, and hypertensive diseases were among the 10 leading causes of mortality in the indigenous population. Notably, 52.81% of the healthcare visits for indigenous patients in Colombia were related to NCDs14.
One significant contributor to inequity for this population comes from the fact that the indigenous populations largely live in rural areas. These areas can be difficult to access, making it difficult to provide timely, interdisciplinary healthcare. This barrier does not only contribute to inequities in health services, but it also increases the risk of NCDs in the indigenous population15.
This study was conducted with the Yanacona indigenous population, located in the Rioblanco Reservation, Sotara, Cauca, in the central mountain range near the Sotará volcano. Primary care for this population is available only in urban areas, which means that individuals must travel a large distance to make use of these services. Higher complexity care is even less available, as patients requiring these services must be referred to the city of Popayán. The objective of this study was to determine the factors associated with noncommunicable diseases in this population.
MATERIALS AND METHOD
This descriptive, observational, cross-sectional study was conducted with 76 people belonging to the Yanacona Indigenous Reservation of Rioblanco, located in the Sotará municipality of the department of Cauca, which has a total population of 6,159 inhabitants. The sample size was calculated with the Epidat 3.1 program, with an expected proportion of 11.9%, confidence level of 93%, and an absolute precision of 7%. Convenience sampling was done with individuals attending a health day organized by the research team to promote healthy habits and disease prevention. The program was run out of the reservation's health center. Inclusion criteria: belonging and residing in the community, being over 15 years of age, voluntarily participating in the project, and signing the informed consent format.
A survey based on the World Health Organization-WHO "STEPwise approach to chronic disease risk factor surveillance"16 was used to collect basic information, including socio-demographics and economic variables; personal and family histories; measurements of anthropometric and biomedical variables; and questions regarding eating habits, physical activity, alcohol consumption, exposure to tobacco, and preventive habits.
In regards to ethics, the project followed the international standards established in the Helsinki Declaration, as well as the national standards, stipulated by the Ministry of Health in Resolution 03480 of 1993, on Health Sciences research. Respect for the rights and privacy of the participants was followed. Informed consent was obtained after explaining the purpose, risks, and benefits of the study. In addition, the study had the support of indigenous leadership.
Variables were assessed using the statistical program R Wizard and PSPP (free software), which calculated frequencies to determine the sociodemographic, biomedical, and life-style characteristics. Using a 95% confidence interval, a maximum error of 5%, and two-tailed statistical significance set at p<0.05, the following analyses were included: Correlation analysis, Chi 2 test, OR analysis, and non-parametric tests with Mann Whitney U.
RESULTS
Information on 76 individuals who met the inclusion criteria was collected.
Regarding the sociodemographic characteristics, the most frequent age category was 27 to 59 years, at 43.4% (n = 33); 52.6% identified as female (n = 40); common-law was the most frequently reported marital status, at 38.2% (n = 29). In terms of occupation, 32.9% (n=25) characterized themselves as farmers, and 34.2% (n=26) as homemakers. 56.6 % (n=43) reported a primary level of educational attainment, and 44.7% (n=34) reported having between 1 to 3 children. Finally, 55.3% (n=42) stated that their income was below the legal minimum wage (SMVL).
Biomedical findings included a family history of cancer in 10.5% (n = 8) of respondents, lung diseases in 10.5% (n = 8), hypercholesterolemia at 10.5% (n = 8), heart disease in 13.2% (n = 10), and arterial hypertension in 18.4% (n = 14) of respondents.
Body mass index (BMI) findings showed a normal BMI in 42.1% of respondents (n = 32), while 43.4% were overweight (n = 33). 60.5% (n=46) of participants were found to have normal blood pressure, and 85.5% (n=65) were observed to have a hip waist index that corresponds to an increased risk of cardiovascular disease (Table 1).
Popayán- Cauca
In the lifestyle habits section, the study found that 98.7% (n = 75) of the population had concerns about their diet, and they frequently (every one to three days) consume fruits and vegetables 56.6% (n = 43), meat 69.7 % (n = 53), and grains 65.8% (n = 50). Starches, such as potatoes, cassava, and others are consumed daily by 76.6% (n=43) of respondents. Approximately half of respondents, 48.7% (n=37), indicated that their frequency and timing of food consumption is appropriate. Sugar rich foods are consumed frequently by 65.8% (n=50) of the population, and fried foods by 78.9% (n=60). The majority, 69.7% (n=53), consume one to three glasses of water per day.
Of the participants, 76.3% (n = 58) reported being active. 36.8% (n=28) stated that they performed physical activity two or three times a week. 23.7% of respondents indicated that they were not physically active, and 10.5% (n=8) cited lack of time as the main reason. The most common method of transportation for this population was walking, at 46.1% (n=35).
Finally, 65.8% (n = 50) of the population does not consume alcohol, and 96.1% (n = 73) does not use tobacco. However, 57.9% (n=44) report cooking with firewood. 87% of participants attend medical check-ups with a frequency of three times a year for 55.3% (n = 42). Breast or testicle self-examinations are not performed by 87% (n = 67), and only 40.8% (n=31) of women received cervical cytology in the last year. When asked if they have received training and health care education, 69.7% (n=53) answered yes. (Table 2)
When analyzing the bivariate correlations, a significant relationship was found between age and the following variables: participation in physical activity (p = 0.032), alcohol consumption (p = 0.033), and attendance at health talks and training sessions (p = 0.001). Education level showed a significant relationship with attendance at medical check-ups (p = 0.037) and with alcohol consumption (p = 0.006). Gender was found to have a significant relationship with the frequency of alcohol consumption (p = 0.007), and number of children demonstrated a significant linear relationship with physical activity (p = 0.006), alcohol consumption (p = 0.001), and receiving cervical cytology (p = 0.000). (Table 3)
The study also found that income had a significant linear relationship with the use of firewood for cooking (p = 0.005), with completing self-examinations (p = 0.025), with alcohol consumption (p = 0.046), and with physical activity (p = 0.036). Consumption of fruits and vegetables was significantly related to having a history of hypercholesterolemia (p = 0.020), as well as waist-hip ratio (p = 0.003). Having a history of hypertension (HTN) correlated to meat consumption (p = 0.036), and BMI demonstrated a relationship with method of transportation (p = 0.033). (Table 3)
Unrelated to gender, the study found a relationship between the use of firewood for cooking and a history of arterial hypertension (p = 0.043 OR 3.11, CI 0.097-0.996), where the use of firewood increased the odds of arterial hypertension 3.11 times (Table 4.)
When performing the correlation analysis, an inversely proportional relationship between age and alcohol consumption was found (p = 0.001, r = -0.345); as well as an inverse relationship between age and frequency of eating foods rich in sugar (p = 0.000, r = -0.409). There is a directly proportional relationship between education level and alcohol consumption (p = 0.003, r = 0.340); as well as the number of children and alcohol consumption (p = 0.000, r = 0.411).
The study found a significant relationship between gender and physical inactivity (p = 0.014; OR 4.30, CI 1.26 to 14.6), whereas women were shown to be at greater risk factor for being sedentary compared to men. However, in both alcohol consumption (p = 0.006; OR 0.25, CI 0.0091 to 0.689) and non-attendance at medical appointments (p = 0.27 OR 1.84, CI 0.36-0.93), female gender was found to be a protective factor.
Regarding non-attendance for cervical cytology, a relationship was found with marital status (p = 0.012 OR 3.58, CI 1.28-9.98), whereas married women were less likely to receive cytology on an annual basis (n = 23). Likewise, a relationship was found between lack of cytology and a history of cancer (p = 0.007 OR 7.46, CI 1.36-38.1), meaning that women who do not undergo cytology were found to have 7.46 times increased odds of presenting with a history of cancer.
DISCUSSION
Non-modifiable risk factors were found in this study to be more prevalent in middle aged (27-59) and older (over 60) populations, with children and youth making up much smaller proportions of those at risk for NCDs. According to WHO, 41 million deaths are attributed to NCDs each year8.
At the health day where the survey took place, the majority of participants were women; however, the "Professionalism and Commitment for Sotará" development plan have discovered that the majority of the overall population is actually male17. This may be an example of the trend found by the Pan American Health Organization (PAHO): women have a greater involvement and participation in health services than men18.
Low levels of education act as a risk factor in this community. Osorio comments that a high level of schooling amplifies the cognitive aspects of health and disease, protecting the subject from specific risks to their health, while supporting health promotion and disease prevention activities.19.
The average income for the study population was found to be low. Rodriguez has stated that low income is a risk factor for developing NCD because it affects lifestyle, how families organize their lives, aging of the population, social relationships, and day-to-day behavior. Likewise, low income is related to educational attainment, because it is the gateway to employment opportunities that define an individual's economic conditions, including access to food, education, and housing20.
The typical diet of this indigenous population is rich in carbohydrates, due to the large production and commercialization of potatoes and cassava. Carbohydrates, therefore, make up a large proportion of their daily food consumption, while the consumption of proteins is low. A study by Gomez shows that high carbohydrate consumption leads to increased triglycerides, visceral fat, blood pressure, and decreased HDL cholesterol. Both, individually and together, these changes increase the risk of cardiovascular disease20. Vallejo, in 2016, showed that nutritional status is dependent on the interaction between diet and the physical, social, cultural, and economic environment22.
Regarding protein consumption, it is evident that consumption of red meats, poultry, and other proteins occurs only sporadically. This low-protein diet, according to studies, may lead to multiple clinical syndromes, such as poor growth, cardiovascular dysfunction, and high risk of infectious diseases, in addition to exacerbating the deficiency of other nutrients and a worsening metabolic profile23.
While tobacco consumption is an uncommon risk factor for NCD in this population, it is important to mention that more than half of respondents reported exposure to wood smoke. Mainly women, because they use it to prepare meals. In a study by Guzman on indigenous women of the community of Pijiguay in the municipality of Tuchin Córdoba, Colombia, it was established that 100% of the surveyed population used firewood as the only heat source implement for cooking food. Generally, women from rural areas or from indigenous communities are exposed to wood smoke from the womb and throughout their lives, constituting a risk factor as important as tobacco smoke itself. Close to 9,000 women die each year from chronic obstructive pulmonary disease.24.
Most of the population participates in physical activity and, correspondingly, walking is the most common means of transportation. Similar results have been found in other studies, such as in the one carried out by Reyes, where an indigenous population in Honduras indicated that they complete their physical activity by walking from home to work and back25. This is also supported by data from the National Administrative Department of Statistics of Colombia (DANE) showing that indigenous peoples are more likely to live in rural areas, particularly rural areas that are difficult to access with less developed transportation options. For this reason, these populations cannot rely on bus or taxi services, and only a small proportion have access to motorcycles12.
It can also be highlighted that according to the aforementioned socioeconomic study, physical activity in the reservation is mainly practiced by youth, as over the course of the year there is promotion and organization of sports for young people. This corresponds with what was found in the present study, which states that there is a relationship between age and physical activity and frequency of physical activity, as well as with gender, where men perform more physical activity than women. This also coincides with the Situation Analysis in Health in Colombia 2016 (ASIS), which states that the prevalence of physical activity in men is 37% higher than in women; and men meet the physical activity recommendations 17.4% more frequently than women10.
Half of the study population does not regularly consume alcohol. In fact, the population asserts that their alcohol consumption is limited only to significant dates of community celebration, which are once or twice a year. Apart from December and January, when the community celebrates the festivities of the patron saints, there is a prohibition against the consumption of any type of alcoholic beverage; a culture maintained by reservation authorities and enforced by the indigenous guard26. The results of this study showed frequency of alcohol consumption decreased with age, which is presumed to be related to the fact that youth are the most likely to participate in this behavior. This finding coincides with a study conducted in 13 to 18 years old adolescents from Valladolid, Spain, where the average age for first experience with alcohol consumption was between 13 and 14 years27. Consistent with studies with university students regarding physical activity, tobacco use, and alcohol consumption, this study found a significant relationship between alcohol consumption and gender, whereas men consumed more alcohol (62%) than women (57%)28. Alcohol consumption in the present study correlated to income level, where, as was found in the national strategy of comprehensive response to alcohol consumption in Colombia, people in the lower income levels (strata 1 and 2) were found to have a greater alcohol consumption11. In this study, the reservation is considered to be strata 1, as it is a rural area and, therefore, the economic income of its population is low.
Another risk factor for NCD was demonstrated in the relationship between the practice of cervical cytology and cancer history, in which 2 people who had a family history of cervical cancer had never undergone cytology. A similar result was also found in a 2009 Colombian study on the effectiveness of cervical cytology for the early detection of cervical cancer. In that study, they concluded that cytology is still effective in the setting of the Colombian healthcare system, but it also highlighted that said effectiveness may be mediated by factors beyond population coverage rates and inherent qualities of the test itself29.
On the other hand, in terms of attending medical health checks, this study highlighted that women are more likely to attend for healthcare than men, in agreement with a study by Agudelo that linked gender equality and health services. Agudelo found differences between men and women who visited the healthcare system, where 81% of women had attended a healthcare visit that year. In that study, women felt they had more time available for health care and healthcare visits were shown to be a protective factor against NCDs30.
Our study showed a relationship between low fruit/vegetable consumption and baseline cholesterol levels present in the population. Andreu emphasizes that consuming fruits and vegetables would probably lower cholesterol levels, since the absorption and blood concentration of cholesterol is reduced31.
Finally, it is important to highlight that indigenous communities have legislation that allows them to make their own decisions on issues such as health and justice, among others, in order to preserve their customs and design their own programs. The present study can serve as the basis for the design of programs and projects that seek to improve lifestyle activities and preserve the healthy ancestral customs of the community. Likewise, it is important to mention that, due to the geographical location of the population and its characteristic as rural dispersion, it was difficult to obtain a more representative sample, becoming a limitation of the study.
CONCLUSION
The Yanacona Indigenous population of the Rioblanco Reservation has several factors associated with chronic noncommunicable diseases, including gender, overweight, at risk waist-to-hip ratio, personal and family history related to cardiovascular diseases, low protein intake, high intake of sugars and starches, as well as such as exposure to wood smoke and lack of self-care in terms of self-examination. These risks are related especially to this population's living and cultural conditions, which could be improved through education and, especially, through the empowerment of this community. However, other aspects, such as low-income levels, the use of chemicals (fertilizers for agricultural production), and the low level of education, will require joint work with government entities and indigenous authorities.
At the same time, the community has an important protective factor, which is physical activity. When added to the controlled alcohol consumption and the low tobacco consumption, these factors contribute to a better quality of life for the community. It is important that authorities and institutional organizations strengthen these protective determinants and avoid the deterioration of such healthy habits, while promoting healthy habits built from the indigenous community's own worldview.
Acknowledgements
This work was possible thanks to the support and cooperation of the Cauca University and the Yanaconas Indigenous Reservation of Rio Blanco - Colombia.
Funding
This work did not have external funding, the resources were donated by the researchers. There are no conflicts of interest.
REFERENCES
1. Salam R. Expanding the definition of noncommunicable disease. Journal of Social Health and Diabetes [Online]. 2016 [Accessed January 11, 2019];04(02): 067-070. Doi: 10.4103/2321-0656.187990. Available in: https://www.thieme-connect.com/products/ejournals/html/10.4103/2321-0656.187990
2. Bennett, J. E., Stevens, G. A., Mathers, C. D., Bonita, R., Rehm, J., Kruk, M. E., ... Ezzati, M. (2018). NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. The Lancet, 392(10152), 1072-1088. Doi:10.1016/s0140-6736(18)31992-5
3. Pelzom D, Isaakidis P, Oo MM, Gurung MS, Yangchen P. Alarming prevalence and clustering of modifiable noncommunicable disease risk factors among adults in Bhutan: a nationwide cross-sectional community survey. BMC Public Health [Online]. 2017 [Accessed January 11, 2019]; 17(1):975. Available in: https://doi.org/10.1186/s12889-017-4989-x
4. Aryal KK, Mehata S, Neupane S, Vaidya A, Dhimal M, Dhakal P, et al. The Burden and Determinants of Non Communicable Diseases Risk Factors in Nepal: Findings from a Nationwide STEPS Survey. PLoS ONE [Online]. 2015 [Accessed January 11, 2019]; 10(8): e0134834. Doi: https://doi.org/10.1371/journal.pone.0134834
5. Cardona Arias JA. Prevalencia de factores de riesgo cardiovascular en indígenas de Riosucio-Caldas, 2010-2011. MEDICINA U.P.B. [Internet]. 2012 [Consultado 12 ene 2019]; 31(2): 113-126. Available in: https://revistas.upb.edu.co/index.php/Medicina/article/viewFile/1759/1696
6. Naseem S, Kulsoom U, Ghazanfar H, Irfan A. Prevalence of non-communicable diseases and their risk factors at a semi-urban community, Pakistan. The Pan African Medical Journal [Online]. 2016 [Accessed January 11, 2019]; 23(1):151. Available in: <http://dx.doi.org/10.11604/pamj.2016.23.151.8974>
7. Martínez Tyson D, Teran E, Uyên-Loan L, Chee V, Hernández I, Flores M, Reina Ortiz M, Izurieta R, Baldwin JA. "Cancer is in style": lifestyle change and the perceived impact of globalization on Andean indigenous communities in Ecuador. Ethnicity & Health [Online]. 2018 [Accessed January 12, 2019]]. Available in: https://doi.org/10.1080/13557858.2018.1493437
8. World Health Organization WHO. Noncommunicable disease fact sheet. [Online]. 2018 [Accessed January 11, 2019]. Available in: <https://www.who.int/en/news-room/fact-sheets/detail/noncommunicable-diseases>
9. Gutierrez R, Zuluaga N, Gallego F. Factores de riesgo cardiovascular en una población cafetera del Departamento de Caldas. Revista de Salud Pública [internet]. 2017 [Consultado 12 ene 2019]; 19(6):749-753. Available in: https://doi.org/10.15446/rsap.v19n6.63673
10. Republic of Colombia. Ministerio de Salud y Protección Social. Analisis de situación en salud, ASIS Colombia 2017. [Interntet]. [Consultado 12 ene 2019]. Available in: <https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/ED/PSP/asis-nacional-2017.pdf>
11. Republic of Colombia. Ministerio de Salud y Protección Social. Perfil de Salud de la Población Indígena, y medición de desigualdades en salud. Colombia 2016. [Internet]. [Consultado 12 ene 2019]. Available in: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/ED/PSP/Perfil-salud-pueblos-indigenas-colombia-2016.pdf
12. Republic of Colombia. Departamento Administrativo Nacional Estadístico DANE. La Visibilización estadística de los grupos étnicos colombianos 2005. [Interntet]. [Consultado13 ene 2019]. Available in: https://www.dane.gov.co/files/censo2005/etnia/sys/visibilidad_estadistica_etnicos.pdf
13. Republic of Colombia. Consejo Regional Indigena Del Cauca CRIC. [Internet]. [Consultado 12 ene 2019] Disponible en: https://www.cric-colombia.org/portal/estructura-organizativa/ubicacion-geografica/
14. Monroy JL, Vargas LM, et al. Comparación de resultados de políticas en salud de la población general, con grupos étnicos minoritarios. Rev. Méd. Risaralda [Internet]. 2017 [Consultado 12 ene 2019]; 23(1): 58-60. Available in: https://revistas.utp.edu.co/index.php/revistamedica/article/view/18401/11171
15. Panamerican Health Organization PAHO. Women and Men Face Different Chronic Disease Risks. [Online]. [Accessed January 13, 2019]. Available in: https://www.paho.org/hq/index.php?option=com_content&view=article&id=7732:2011-women-men-face-different-chronic-disease-risks&Itemid=4327&lang=en
16. World Health Organization WHO. STEPwise approach to NCD risk factor surveillance (STEPS). [Internet]. [Consultado 05 sept 2020] https://www.who.int/teams/noncommunicable-diseases/surveillace/systems-tools/steps/instrumentn
17. Republic of Colombia. Departamento del Cauca. Concejo Municipal de Sotara. Acuerdo Número 06 de 2012. Plan de Desarrollo "Profesionalismo y Compromiso por Sotara" para la vigencia 2012- 2015, del municipio de Sotará, Cauca. [Internet]. [Consultado 13 ene 2019] Available in: http://cdim.esap.edu.co/BancoMedios/Documentos%20PDF/sotara-pd-2012-2015.pdf.
18. Panamerican Health Organization. Prestación de servicios de salud en zonas con pueblos indígenas. [Internet]. 2009 [Consultado 20 febrero 2018 ]. Available in: http://www1.paho.org/hq/dmdocuments/2009/servicios%20salud%20zonas%20indigenas.pdf
19. Osorio AM, Romero GA, Bonilla H, Aguado LF. Socioeconomic context of the community and chronic child malnutrition in Colombia. Rev. Saúde Pública [Online]. 2018 [cited 2019 Jan 13]; 52: 73. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0034-89102018000100263&lng=en. Epub July 26, 2018. http://dx.doi.org/10.11606/s1518-8787.2018052000394.
20. Rodríguez V, Rojo F, Fernández G, Mohamed K, Lardiés R, Prieto M, Rojo J. Recursos económicos y calidad de vida en la población mayor. Revista Internacional de Sociología [Internet]. 2011 [consultado 13 ene 2019]; 69(1): 195-227. Available in: http://dx.doi.org/10.3989/ris.2009.11.26
21. Gómez L, Beltrán LM, García J. [Sugar and cardiovascular disease]. Nutr. Hosp [Online]. 2013 [cited 2019 Jan 13]; 28( Suppl 4 ): 88-94. Doi: 10.3305/nh.2013.28.sup4.6801. Available in: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S0212-16112013001000011&lng=es
22. Vallejo Solarte M, Castro Castro L, Cerezo Corre M. Estado nutricional y determinantes sociales en niños entre 0 y 5 años de la comunidad de Yunguillo y de Red Unidos, Mocoa - Colombia. US [Internet]. 2016 [citado 13 ene.2019];18(1):113-25. Available in: https://doi.org/10.22267/rus.161801.24
23. Wu G. Dietary protein intake and human health. Food Funct [Online]. 2016 [cited 2019 Jan 13];7(3):1251-65. doi: 10.1039/c5fo01530h. Available in: https://pubs.rsc.org/en/Content/ArticleLanding/2016/FO/C5FO01530H#!divAbstract
24. Guzmán Sanches Y, Salazar I. Principales alteraciones pulmonares presentes en mujeres indígenas. CORPOSUCRE [Internet]. 2013 [consultado 12 ene 2019]; 1: 15-20. Available in: www.corposucre.edu.co/sites/default/files/investigacion/publicaciones/principales%20alteraciones%20pulmonares%20presentes%20en%20%20mujeres%20ind%c3%8dgenas%20de%20la%20comunidad%20 de%20pijiguay%20en%20tuchin%20c%c3%93rdoba.pdf
25. Reyes-García SZ, Zambrano LI, Fuentes I, Sierra M, Urquia-Osorio H. Estudio descriptivo de factores de riesgo cardiovascular a una muestra de la población de una comunidad indígena de Honduras. CI-MEL [Internet. 2011 [consultado 13 ene 2019]; 14(1): 32-37. Available in: http://www.redalyc.org/articulo.oa?id=71723602007
26. Palechor L.A, Gobernador del Resguardo Indígena Yanacona de Rioblanco, Interviewee, Aspectos generales del Resguardo. [interview]. 03 Diciembre 2016.
27. Vázquez Fernández ME, Muñoz Moreno MF, Fierro Urturi A, Alfaro González M, Rodríguez Carbajo ML, Rodríguez Molinero L. Consumo de sustancias adictivas en los adolescentes de 13 a 18 años y otras conductas de riesgo relacionadas. Rev Pediatr Aten Primaria [Internet]. 2014 [citado 2019 Ene 14] ; 16(62 ): 125-134. Available in: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1139-
28. Mantilla SC, Gómez A y Hidalgo M. Actividad física, tabaquismo y consumo de alcohol, en un grupo de estudiantes universitarios. Rev. salud pública [Internet]. 2011 [consultado 13 ene 2019]; 13 (5): 748758. Available in: https://doi.org/10.1590/S0124-00642011000500003
29. Murillo R, Cendales R, Wiesner C, Piñeros M, Tovar S, Efectividad de la citología cérvico-uterina para la detección temprana de cáncer de cuello uterino en el marco del sistema de salud de Colombia. Biomédica [Internet]. 2009. [Consultado 14 ene 2019]; 29(3): 354-361. Available in: https://www.revistabiomedica.org/index.php/biomedica/article/view/7/277
30. Agudelo C, Guarnizo Herreño C. Equidad de Género en el Acceso a los Servicios de Salud en Colombia. Rev. de Salud Pública [Internet]. 2008 [Consultado 14 ene 2019]; 10(1): 44-57. Disponible en: http://www.scielo.org.co/pdf/rsap/v10s1/v10s1a05.pdf
31. Palou A, Picó Segura C, Bonet Piña ML, Oliver Vara P, Serra Vich F, Rodríguez AM, et al. El libro blanco de los esteroles vegetales. 2a. ed. España, 2010: Unilever Foods S.A. Available in: http://www.nutricion.org/publicaciones/pdf/libro_blanco_esteroles_vegetales.pdf.