ijcs International Journal of Cardiovascular Sciences Int J Cardiovasc Sci 2359-4802 2359-5647 Sociedade Brasileira de Cardiologia rTTHmQYN3N8DfqPrXD5fSNm S2359-56472026000103801 03801 10.36660/ijcs.20250126 Letter to the Editor Comments on "Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Areas in the Backlands of Bahia – A Cross-Sectional Study" 0009-0001-9537-0025 Noor Rubah 1 0009-0004-9442-955X Kumari Ritika 1 0009-0006-1426-0075 Laveesha 1 Peoples University of Medical and Health Sciences for Women Nawabshah Pakistan Peoples University of Medical and Health Sciences for Women, Nawabshah – Pakistan Rubah Noor • Peoples University of Medical and Health Sciences for Women - Road, Nawabshah, Shaheed Benazirabad District, Sindh, Nawabshah, SINDH, 67450 - Pakistan E-mail: rubahnoor.110@gmail.com 25 05 2026 2026 39 e20250126 10 07 2025 28 07 2025 28 07 2025 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Keywords Pediatric Obesity Blood Pressure Urban Health Rural Health Brazil

Dear Editor,

I recently came across the article titled "Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Areas in the Backlands of Bahia – A Cross-Sectional Study," and I felt compelled to write in. First and foremost, I want to commend the authors for tackling a subject that's growing more urgent with each passing year. Childhood obesity and elevated blood pressure are emerging earlier and becoming more frequent across the globe, and this study makes a meaningful contribution by examining the problem in a region that's often overlooked.1

The statistic that nearly 28% of children aged five to ten were either overweight or obese—and that around 8% had elevated blood pressure—is worrying, but unfortunately, not unexpected. These numbers mirror broader global patterns, yet the study's strength lies in its comparative approach. Looking at rural and urban populations side by side highlights distinctions that can often get lost in national averages. The finding that urban children had a higher rate of abdominal obesity didn't surprise me; urban settings tend to promote sedentary behavior and greater intake of processed foods.

One thing I would've liked to see, though, is some consideration of the kids’ physical activity levels. Even rough estimates—based on parent or teacher input, for example—would have added valuable context. We know from studies in other countries, like the long-term survey work out of China, that fitness levels among young people have been falling for years, while cardiovascular risks have risen in tandem.2 It's not always about what children eat; sometimes, it's also about what they lack, such as play or move regularly.

Another point that stood out to me was how broadly the study defined its geographic focus. The phrase "backlands of Bahia" evokes a lot but does not offer enough detail. As McGee has pointed out, Bahia's interior regions can be tricky to map in terms of clear administrative or cultural boundaries.3 Without a clearer specification or even a map, it becomes harder to judge how generalizable the findings might be, or to compare them with data from similar regions.

Lastly, I hope this research leads to further studies that take a longer view. Cross-sectional designs are useful, but they do not capture how these health markers evolve over time. Following up with a cohort study or evaluating the outcomes of school-based interventions—ones that encourage more physical activity or improve diet—could offer actionable solutions for policymakers and school systems alike.

All in all, this is a thoughtful and timely paper. I appreciate the work that went into it and hope future efforts will continue building on this foundation with even more granular and longitudinal data.

References Lopes A Valois ALV Lisboa HLA Gomes AN Lago R Menezes CA Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Area in the Backlands of Bahia Int J Cardiovasc Sci 2025 38 e20240136 10.36660/ijcs.20240136 1 Lopes A, Valois ALV, Lisboa HLA, Gomes AN, Lago R, Menezes CA, et al. Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Area in the Backlands of Bahia. Int J Cardiovasc Sci. 2025;38:e20240136. doi: 10.36660/ijcs.20240136. Ferreira IBB Gomes AN Almeida IBC Fernandes MD Coutinho LF Lago R Childhood Obesity is Associated with a High Degree of Metabolic Disturbance in Children from Brazilian Semi-Arid Region Sci Rep 2024 14 1 17569 17569 10.1038/s41598-024-68661-8 2 Ferreira IBB, Gomes AN, Almeida IBC, Fernandes MD, Coutinho LF, Lago R, et al. Childhood Obesity is Associated with a High Degree of Metabolic Disturbance in Children from Brazilian Semi-Arid Region. Sci Rep. 2024;14(1):17569. doi: 10.1038/s41598-024-68661-8. Menezes CA Zanette DL Magalhães LB Lago RMRS Gomes AN Santos RA Impact of Plant-Based School Meals on Gut Bifidobacterium spp. Abundance and Health Outcomes in Schoolchildren from Bahia, Brazil Int J Mol Sci 2024 25 23 13073 13073 10.3390/ijms252313073 3 Menezes CA, Zanette DL, Magalhães LB, Lago RMRS, Gomes AN, Santos RA, et al. Impact of Plant-Based School Meals on Gut Bifidobacterium spp. Abundance and Health Outcomes in Schoolchildren from Bahia, Brazil. Int J Mol Sci. 2024;25(23):13073. doi: 10.3390/ijms252313073. Letter to the Editor Reply Valois Ana Luísa Vaz 1 Ladeia Ana Marice Teixeira 1 Escola Bahiana de Medicina e Saúde Pública Salvador BA Brazil Escola Bahiana de Medicina e Saúde Pública, Salvador, BA – Brazil

We appreciate the interest in our article, "Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Areas in the Backlands of Bahia",1 and thank the author of the letter for the thoughtful comments and for emphasizing the growing relevance of childhood obesity and elevated blood pressure worldwide. We fully agree that these conditions are becoming increasingly prevalent at younger ages and that regional data, particularly from underrepresented areas, are essential for understanding their determinants.

The observation that urban children have higher rates of abdominal obesity aligns with the global trend of lifestyle-related disparities between urban and rural settings. In this context, assessing children's physical activity levels would provide valuable insights into the magnitude of sedentary behavior in this age group. We initially attempted to collect this data using the International Physical Activity Questionnaire (IPAQ). However, significant challenges in administering the questionnaire resulted in an insufficient number of valid responses for meaningful analysis. For this reason, we chose not to include the variable in the final dataset, as doing so could have compromised the validity of our results.

Regarding the second issue raised regarding the geographic scope, as detailed in the inclusion criteria, the research was conducted in four municipalities in the backlands of Bahia: Serrinha, Biritinga, Barrocas, and Teofilândia. These municipalities share similar socioeconomic and cultural characteristics — generally below the state average — but are representative of the semi-arid region of northeastern Brazil. For context, Serrinha is the most populous municipality, with a Human Development Index (HDI) of 0.634, followed by Barrocas (0.610), Teofilândia (0.566), and Biritinga (0.538), all classified as having medium human development according to the United Nations Development Programme (UNDP).2

We also concur that longitudinal approaches are crucial for understanding how these health indicators evolve. Our cross-sectional investigation was conducted within a larger research initiative that includes a cohort component. As part of this ongoing work, a school meal intervention has been implemented and analyzed, and additional studies are underway to assess its long-term effects on children's nutritional and cardiovascular health.3 This comprehensive approach provides valuable insight into how environmental and dietary modifications within the school setting may influence the outcomes observed.

We appreciate the opportunity to discuss these points further and hope this reply helps clarify the issues raised. Constructive scientific exchanges such as this one are fundamental to refining understanding and guiding future research.

Lopes et al.

References Lopes A Valois ALV Lisboa HLA Gomes AN Lago R Menezes CA Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Area in the Backlands of Bahia Int J Cardiovasc Sci 2025 38 e20240136 10.36660/ijcs.20240136 1 Lopes A, Valois ALV, Lisboa HLA, Gomes AN, Lago R, Menezes CA, et al. Assessment of Overweight/Obesity and Elevation of Blood Pressure in Schools in Rural and Urban Area in the Backlands of Bahia. Int J Cardiovasc Sci. 2025;38:e20240136. doi:10.36660/ijcs.20240136. Cai S Zhang Y Chen Z Liu Y Dang J Li J Secular Trends in Physical Fitness and Cardiovascular Risks Among Chinese College Students: An Analysis of Five Successive National Surveys between 2000 and 2019 Lancet Reg Health West Pac 2025 58 101560 101560 10.1016/j.lanwpc.2025.101560 2 Cai S, Zhang Y, Chen Z, Liu Y, Dang J, Li J, et al. Secular Trends in Physical Fitness and Cardiovascular Risks Among Chinese College Students: An Analysis of Five Successive National Surveys between 2000 and 2019. Lancet Reg Health West Pac. 2025;58:101560. doi: 10.1016/j.lanwpc.2025.101560. McGee R Mapping Brazil's Hinterlands: Geography, Identity, and Development in Bahia Lat Am Stud Rev 2014 49 2 85 102 3 McGee R. Mapping Brazil's Hinterlands: Geography, Identity, and Development in Bahia. Lat Am Stud Rev. 2014;49(2):85-102.