Gender differences in the accuracy of dietary assessment methods to measure energy intake in adults: protocol for a systematic review and meta-analysis

INTRODUCTION

Diet is an important modifiable risk factor for many chronic diseases. Measurement of dietary intake usually relies on self-report, subject to multiple biases. There is a need to understand gender differences in the self-report of dietary intake and the implications of any differences in targeting nutrition interventions. Literature in this area is limited and it is currently unknown whether self-report dietary assessment methods are equally accurate for women and men. The aim of this systematic review is to determine whether there are differences by gender in reporting energy intake compared with a reference measure of total energy expenditure.

METHODS AND ANALYSIS

A comprehensive search of published original research studies will be performed in MEDLINE, Scopus, Web of Science, EMBASE, CINAHL and Cochrane library. Original research studies will be included if they were conducted in free-living/unhospitalised adults and included a measure for both women and men of (a) self-reported energy intake and (b) total energy expenditure by doubly labelled water. One author will conduct the electronic database searches, two authors will independently screen studies, conduct a quality appraisal of the included studies using standardised tools and extract data. If further information is needed, then study authors will be contacted. If appropriate, a random-effects meta-analysis will be conducted, with inverse probability weighting, to quantify differences in the mean difference in agreement between reported energy intake and measured energy expenditure between women and men, by self-report assessment method. Subgroup analyses will be conducted by participant factors, geographical factors and study quality.

ETHICS AND DISSEMINATION

All data used will be from published primary research studies or deidentified results provided at the discretion of any study authors that we contact. We will submit our findings to a peer-reviewed scientific journal and will disseminate results through presentations at international scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42019131715.

Leveraging Existing Cohorts to Study Health Effects of Air Pollution on Cardiometabolic Disorders: India Global Environmental and Occupational Health Hub

Air pollution is a growing public health concern in developing countries and poses a huge epidemiological burden. Despite the growing awareness of ill effects of air pollution, the evidence linking air pollution and health effects is sparse. This requires environmental exposure scientist and public health researchers to work more cohesively to generate evidence on health impacts of air pollution in developing countries for policy advocacy. In the Global Environmental and Occupational Health (GEOHealth) Program, we aim to build exposure assessment model to estimate ambient air pollution exposure at a very fine resolution which can be linked with health outcomes leveraging well-phenotyped cohorts which have information on geolocation of households of study participants. We aim to address how air pollution interacts with meteorological and weather parameters and other aspects of the urban environment, occupational classification, and socioeconomic status, to affect cardiometabolic risk factors and disease outcomes. This will help us generate evidence for cardiovascular health impacts of ambient air pollution in India needed for necessary policy advocacy. The other exploratory aims are to explore mediatory role of the epigenetic mechanisms (DNA methylation) and vitamin D exposure in determining the association between air pollution exposure and cardiovascular health outcomes. Other components of the GEOHealth program include building capacity and strengthening the skills of public health researchers in India through variety of training programs and international collaborations. This will help generate research capacity to address environmental and occupational health research questions in India. The expertise that we bring together in GEOHealth hub are public health, clinical epidemiology, environmental exposure science, statistical modeling, and policy advocacy.

Design and Rationale of the Biomarker Center of the Household Air Pollution Intervention Network (HAPIN) Trial

BACKGROUND

Biomarkers of exposure, susceptibility, and effect are fundamental for understanding environmental exposures, mechanistic pathways of effect, and monitoring early adverse outcomes. To date, no study has comprehensively evaluated a large suite and variety of biomarkers in household air pollution (HAP) studies in concert with exposure and outcome data. The Household Air Pollution Intervention Network (HAPIN) trial is a liquified petroleum gas (LPG) fuel/stove randomized intervention trial enrolling 800 pregnant women in each of four countries (i.e., Peru, Guatemala, Rwanda, and India). Their offspring will be followed from birth through 12 months of age to evaluate the role of pre- and postnatal exposure to HAP from biomass burning cookstoves in the control arm and LPG stoves in the intervention arm on growth and respiratory outcomes. In addition, up to 200 older adult women per site are being recruited in the same households to evaluate indicators of cardiopulmonary, metabolic, and cancer outcomes.

OBJECTIVES

Here we describe the rationale and ultimate design of a comprehensive biomarker plan to enable us to explore more fully how exposure is related to disease outcome.

METHODS

HAPIN enrollment and data collection began in May 2018 and will continue through August 2021. As a part of data collection, dried blood spot (DBS) and urine samples are being collected three times during pregnancy in pregnant women and older adult women. DBS are collected at birth for the child. DBS and urine samples are being collected from the older adult women and children three times throughout the child's first year of life. Exposure biomarkers that will be longitudinally measured in all participants include urinary hydroxy-polycyclic aromatic hydrocarbons, volatile organic chemical metabolites, metals/metalloids, levoglucosan, and cotinine. Biomarkers of effect, including inflammation, endothelial and oxidative stress biomarkers, lung cancer markers, and other clinically relevant measures will be analyzed in urine, DBS, or blood products from the older adult women. Similarly, genomic/epigenetic markers, microbiome, and metabolomics will be measured in older adult women samples.

DISCUSSION

Our study design will yield a wealth of biomarker data to evaluate, in great detail, the link between exposures and health outcomes. In addition, our design is comprehensive and innovative by including cutting-edge measures such as metabolomics and epigenetics. https://doi.org/10.1289/EHP5751.

Design and Rationale of the HAPIN Study: A Multicountry Randomized Controlled Trial to Assess the Effect of Liquefied Petroleum Gas Stove and Continuous Fuel Distribution

BACKGROUND

Globally, nearly 3 billion people rely on solid fuels for cooking and heating, the vast majority residing in low- and middle-income countries (LMICs). The resulting household air pollution (HAP) is a leading environmental risk factor, accounting for an estimated 1.6 million premature deaths annually. Previous interventions of cleaner stoves have often failed to reduce exposure to levels that produce meaningful health improvements. There have been no multicountry field trials with liquefied petroleum gas (LPG) stoves, likely the cleanest scalable intervention.

OBJECTIVE

This paper describes the design and methods of an ongoing randomized controlled trial (RCT) of LPG stove and fuel distribution in 3,200 households in 4 LMICs (India, Guatemala, Peru, and Rwanda).

METHODS

We are enrolling 800 pregnant women at each of the 4 international research centers from households using biomass fuels. We are randomly assigning households to receive LPG stoves, an 18-month supply of free LPG, and behavioral reinforcements to the control arm. The mother is being followed along with her child until the child is 1 year old. Older adult women (40 to < 80   years of age) living in the same households are also enrolled and followed during the same period. Primary health outcomes are low birth weight, severe pneumonia incidence, stunting in the child, and high blood pressure (BP) in the older adult woman. Secondary health outcomes are also being assessed. We are assessing stove and fuel use, conducting repeated personal and kitchen exposure assessments of fine particulate matter with aerodynamic diameter ≤ 2.5 μ m (PM 2.5 ), carbon monoxide (CO), and black carbon (BC), and collecting dried blood spots (DBS) and urinary samples for biomarker analysis. Enrollment and data collection began in May 2018 and will continue through August 2021. The trial is registered with ClinicalTrials.gov (NCT02944682).

CONCLUSIONS

This study will provide evidence to inform national and global policies on scaling up LPG stove use among vulnerable populations. https://doi.org/10.1289/EHP6407.

Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in 29 Low- and Middle-Income Countries

OBJECTIVE

Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk.

RESEARCH DESIGN AND METHODS

We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR).

RESULTS

Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]).

CONCLUSIONS

Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.

Synthetic Chemical Trade as a Potential Driver of Global Health Disparities and Data Gaps on Synthetic Chemicals in Vulnerable Populations

PURPOSE OF REVIEW

Most research on toxic exposures in vulnerable populations focuses on air pollution. Synthetic chemical production, however, is a multi-billion-dollar industry that lacks appropriate international regulation to protect those exposed to toxic chemicals. This paper aims to describe the country-level import and export of key groups of synthetic chemicals using data from the United Nations Comtrade Database and provide a narrative review of the evidence from January 2018 to August 2019 on exposure to, health effects of, and interventions to reduce synthetic chemicals in vulnerable populations around the world.

RECENT FINDINGS

Generally, a small number of high-income countries export the majority of synthetic chemicals, while most low-income countries import more chemicals than they export, which may contribute to higher levels of synthetic chemicals in those settings. However, few studies have quantified exposures to synthetic chemicals in low- and middle-income countries, the health effects of such exposures, or interventions to mitigate exposures. Synthetic chemicals continue to enter markets despite our limited knowledge of their effects on human health, particularly in the most vulnerable populations. We need more research to understand the health impacts of these pervasive exposures.

Factors Associated with Acute Complications among Individuals with Type 1 Diabetes in China: The 3C Study

Background: To identify the sociodemographic and clinical characteristics related to the occurrence of diabetic ketoacidosis (DKA) and frequent hypoglycemia in children, adolescents and adults with type 1 diabetes in China.Methods: The 3C Study was an epidemiological study that recruited 849 type 1 diabetes patients aged 0-78 years in Beijing and Shantou, China. Separate logistic regression models were used to evaluate the association of sociodemographic and clinical factors with the occurrence of DKA in the past 12 months or frequent hypoglycemia (≥5 episodes) in the past 7 days.Results: Children and adolescents were significantly more likely to have DKA in the past 12 months compared to adults: odds ratio (OR) and (95% confidence interval [CI]), 4.67 (1.90, 11.52) for <13 years and 4.00 (1.59, 10.10) for 13 to <19 years. Underweight participants were also more likely to have DKA relative to normal weight participants: OR (95% CI), 6.87 (2.64, 17.87). Children and participants who did not receive diabetes education in the past 12 months were more likely to have frequent hypoglycemia: OR (95% CI), 2.95 (1.23, 7.06) and 7.67 (1.77, 13.2), respectively. Participants who reported self-monitoring of blood glucose ≤2 times/week (ref: 7 times/week) and participants who had higher HbA1c levels were less likely to have frequent hypoglycemia: OR (95% CI), 0.14 (0.03, 0.64) and 0.78 (0.63, 0.96), respectively. Gender, family income, parent education, health insurance coverage, diabetes duration, and insulin administration method were not significantly associated with DKA or frequent hypoglycemia in this sample.Conclusions: Children, adolescents and underweight individuals with type 1 diabetes in China were more likely to report DKA, and children, individuals without adequate diabetes education, and those with lower HbA1c levels were more likely to have frequent hypoglycemia. These patients should be targeted for preventive interventions.

Longitudinal association of biomarkers of pesticide exposure with cardiovascular disease risk factors in youth with diabetes

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death among individuals with diabetes, but little is known about the role of exposures to environmental chemicals such as pesticides in the early development of CVD risk in this population.

OBJECTIVES

To describe changes over time in concentrations of pesticide biomarkers among youth with diabetes in the United States and to estimate the longitudinal association between these concentrations and established risk factors for CVD.

METHODS

Pesticide biomarkers were quantified in urine and serum samples from 87 youth with diabetes participating in the multi-center SEARCH cohort study. Samples were obtained around the time of diagnosis (baseline visit, between 2006 and 2010) and, on average, 5.4 years later (follow-up visit, between 2012 and 2015). We calculated geometric mean (95% CI) pesticide biomarker concentrations. Eight CVD risk factors were measured at these two time points: body mass index (BMI) z-score, HbA1c, insulin sensitivity, fasting C-peptide (FCP), LDL cholesterol, HDL cholesterol, total cholesterol, and triglycerides. Linear regression models were used to estimate the associations between each pesticide biomarker at baseline and each CVD risk factor at follow-up, adjusting for baseline health outcome, elapsed time between baseline and follow up, sex, age, race/ethnicity, and diabetes type.

RESULTS

Participants were, on average, 14.2 years old at their baseline visit, and most were diagnosed with type 1 diabetes (57.5%). 4-nitrophenol, 3-phenoxybenzoic acid, 2,4-dichlorophenoxyacetic acid (2,4-D), 3,5,6-trichloro-2-pyridinol, 2,2-bis(4-chlorophenyl)-1,1-dichloroethene, and hexachlorobenzene were detected in a majority of participants at both time points. Participants in the highest quartile of 2,4-D and 4-nitrophenol at baseline had HbA1c levels at follow-up that were 1.05 percentage points (95% CI: -0.40, 2.51) and 1.27 percentage points (0.22, 2.75) higher, respectively, than participants in the lowest quartile of these pesticide biomarkers at baseline. These participants also had lower log FCP levels (indicating reduced beta-cell function) compared to participants in the lowest quartile at baseline: beta (95% CI) for log FCP of -0.64 (-1.17, -0.11) for 2,4-D and -0.39 (-0.96, 0.18) for 4-nitrophenol. In other words, participants in the highest quartile of 2,4-D had a 47.3% lower FCP level compared to participants in the lowest quartile, and those in the highest quartile of 4-nitrophenol had a 32.3% lower FCP level than those in the lowest quartile. Participants with trans-nonachlor concentrations in the highest quartile at baseline had HbA1c levels that were 1.45 percentage points (-0.11, 3.01) higher and log FCP levels that were -0.28 (-0.84, 0.28) lower than participants in the lowest quartile at baseline, that is to say, participants in the highest quartile of trans-nonachlor had a 24.4% lower FCP level than those in the lowest quartile. While not all of these results were statistically significant, potentially due to the small same size, clinically, there appears to be quantitative differences. No associations were observed between any pesticide biomarker at baseline with BMI z-score or insulin sensitivity at follow-up.

CONCLUSIONS

Exposure to select pesticides may be associated with impaired beta-cell function and poorer glycemic control among youth with diabetes.

Prevalence and correlates of household food insecurity in Delhi and Chennai, India

India is home to nearly 200 million undernourished people, yet little is known about the characteristics of those experiencing food insecurity, especially among urban households. The objectives of this study were: (1) to report the prevalence of food insecurity in two large, population-based representative samples in urban India, (2) to describe socio-economic correlates of food insecurity in this context, and (3) to compare the dietary intake of adults living in food insecure households to that of adults living in food secure households. Data are from 4334 households participating in an ongoing population-based cohort study of a representative sample of Delhi and Chennai, India. The most recent wave of data (2017-2018) were analysed. Food insecurity was measured using the 9-item Household Food Insecurity Access Scale (HFIAS) and dietary intake using a 33-item semi-quantitative food frequency questionnaire. The overall prevalence of food insecurity was 8.5% (95% confidence interval [CI], 6.8-10.2); 15.2% (95% CI 12.0-18.4) of the poorest households (lowest wealth index tertile) were food insecure compared to 1.7% (95% CI 1.0-2.3) of the wealthiest households (highest wealth index tertile). Participants experiencing food insecurity were significantly younger and more likely to be from Delhi compared to Chennai. After adjustment for socio-economic factors (city, age, sex, education, wealth index, fuel used for cooking, and source of drinking water), participants experiencing food insecurity had significantly higher meat, poultry, roots and tubers (potato), and sugar sweetened beverage intakes, and lower vegetables, fruit, dairy, and nut intakes. Food insecurity is highly prevalent among the poorest households in urban India and is associated with intake of a number of unhealthy dietary items.

Evaluation of sex differences in dietary behaviours and their relationship with cardiovascular risk factors: a cross-sectional study of nationally representative surveys in seven low- and middle-income countries

BACKGROUND

Cardiovascular diseases (CVD) are the leading causes of death for men and women in low-and-middle income countries (LMIC). The nutrition transition to diets high in salt, fat and sugar and low in fruit and vegetables, in parallel with increasing prevalence of diet-related CVD risk factors in LMICs, identifies the need for urgent action to reverse this trend. To aid identification of the most effective interventions it is crucial to understand whether there are sex differences in dietary behaviours related to CVD risk.

METHODS

From a dataset of 46 nationally representative surveys, we included data from seven countries that had recorded the same dietary behaviour measurements in adults; Bhutan, Eswatini, Georgia, Guyana, Kenya, Nepal and St Vincent and the Grenadines (2013-2017). Three dietary behaviours were investigated: positive salt use behaviour (SUB), meeting fruit and vegetable (F&V) recommendations and use of vegetable oil rather than animal fats in cooking. Generalized linear models were used to investigate the association between dietary behaviours and waist circumference (WC) and undiagnosed and diagnosed hypertension and diabetes. Interaction terms between sex and dietary behaviour were added to test for sex differences.

RESULTS

Twenty-four thousand three hundred thirty-two participants were included. More females than males reported positive SUB (31.3 vs. 27.2% p-value < 0.001), yet less met F&V recommendations (13.2 vs. 14.8%, p-value< 0.05). The prevalence of reporting all three dietary behaviours in a positive manner was 2.7%, varying by country, but not sex. Poor SUB was associated with a higher prevalence of undiagnosed hypertension for females (13.1% vs. 9.9%, p-value = 0.04), and a higher prevalence of undiagnosed diabetes for males (2.4% vs. 1.5%, p-value = 0.02). Meeting F&V recommendations was associated with a higher prevalence of high WC (24.4% vs 22.6%, p-value = 0.01), but was not associated with undiagnosed or diagnosed hypertension or diabetes.

CONCLUSION

Interventions to increase F&V intake and positive SUBs in the included countries are urgently needed. Dietary behaviours were not notably different between sexes. However, our findings were limited by the small proportion of the population reporting positive dietary behaviours, and further research is required to understand whether associations with CVD risk factors and interactions by sex would change as the prevalence of positive behaviours increases.

Improving management of type 2 diabetes, hypertension and dyslipidaemia in the Caribbean: a systematic review of intervention studies

OBJECTIVE

To evaluate published interventions aimed at improving the management of type 2 diabetes, hypertension and dyslipidaemia in the Caribbean.

METHODS

We conducted a systematic review of four databases in accordance with PRISMA guidelines. Inclusion criteria were conducted in the Caribbean among adults ≥ 18 years who had type 2 diabetes, hypertension or dyslipidaemia; controlled trials, interventions, or comparative studies with pre-post designs and reported on at least one of the clinical outcomes of interest.

RESULTS

Seventeen studies met the criteria for inclusion. The majority were conducted in Cuba and Trinidad and Tobago, and 35% were conducted over 10 years ago. Samples were small and largely consisted of older adult females and patients with type 2 diabetes. Four of eight (50%) studies that reported on HbA1c, 5 of 12 (42%) that reported on blood pressure and 2 of 7 (29%) that reported on body mass index observed significant improvements. Study heterogeneity precluded our ability to conduct a meta-analysis. The overall quality of evidence based on GRADE criteria was low for all outcomes assessed.

CONCLUSION

There is insufficient evidence on interventions to address type 2 diabetes, hypertension and dyslipidaemia in the Caribbean.

Metabolite of the pesticide DDT and incident type 2 diabetes in urban India

BACKGROUND

Previous epidemiological studies, largely conducted in high-income countries and cross-sectional, have suggested a relatively strong association between exposure to dichlorodiphenyldichloroethylene (DDE), a metabolite of the pesticide dichlorodiphenyltrichloroethane (DDT), and type 2 diabetes. DDT is widely used in India and the prevalence of type 2 diabetes there is increasing, but the association between these factors has not been explored to date.

OBJECTIVE

The objective was to estimate the association of the p,p' isomer of DDE with incident type 2 diabetes in India.

METHODS

A nested case-control study was conducted in a representative prospective cohort of adults from two cities in India. Participants were enrolled in 2010-11 (n = 12,271) and followed for annual assessment of chronic diseases including type 2 diabetes. Baseline plasma samples from incident cases of diabetes (n = 193) and sex-city-matched controls (n = 323) were selected for analysis of p,p-DDE. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using conditional logistic regression.

RESULTS

At baseline, cases had higher p,p-DDE concentrations: geometric mean (95% CI) 330 (273-399) ng/g lipid compared to 223 (189-262) ng/g lipid among controls. Delhi participants had higher p,p-DDE concentrations: 579 (521-643) ng/g lipid compared to 122 (102-145) ng/g lipid in Chennai. In unadjusted models, being in the highest versus lowest quartile of p,p-DDE was associated with a more than doubling of the odds of diabetes: unadjusted OR (95% CI), 2.30 (1.19, 4.43). However, this effect was no longer significant after adjustment for age: adjusted (95% CI), 0.97 (0.46, 2.06).

DISCUSSION

Results suggest that levels of p,p'-DDE in Delhi are exceptionally high, but we did not observe a significant association between p,p-DDE and incident type 2 diabetes. As this is the first study to evaluate this association in India, more studies are needed to inform our understanding of the association in this context, including potential routes of exposure.

Association of prenatal pesticide exposures with adverse pregnancy outcomes and stunting in rural Bangladesh

BACKGROUND

Pesticide exposure during pregnancy is thought to adversely affect fetal growth, which in turn may impact child growth, but results have been inconsistent across studies and few have explored these effects in developing countries.

OBJECTIVES

To quantify urinary concentrations of pesticide biomarkers in early pregnancy (<16 weeks' gestation), and to estimate the association of these concentrations with preterm birth, low birth weight, small for gestational age, and stunting at ~1 and 2 years of age.

METHODS

Eight pesticide biomarkers were quantified in urine collected from 289 pregnant women (aged 18-40 years) participating in a birth cohort study in Bangladesh. Anthropometry measurements were conducted on the index child at birth and approximately 1 and 2 years of age. A directed acyclic graph was used to identify minimal sufficient adjustment sets. Log-binomial regression was used to estimate the relative risk (RR) with 95% confidence intervals (CI).

RESULTS

3,5,6-trichloro-2-pyridinol (TCPY), a metabolite of chlorpyrifos and chlorpyrifos methyl, and 4-nitrophenol, a metabolite of parathion and methyl parathion, were detected in nearly all women with geometric mean (95% CI) values of 3.17 (2.82-3.56) and 18.66 (17.03-20.46) µg/g creatinine, respectively. 3-phenoxybenzoic acid (3-PBA), a non-specific metabolite of several pyrethroids, and 2-isopropyl-4-methyl-6-hydroxypyrimidine (IMPY), a diazinon metabolite, were detected in 19.8% and 16.1% of women, respectively. The remaining four pesticide biomarkers were detected in <10% of women. Women in the highest quartile of 4-nitrophenol were more than 3 times more likely to deliver preterm than women in the lowest quartile: unadjusted RR (95% CI), 3.57 (1.65, 7.73). Women in the highest quartile of 4-nitrophenol were also at increased risk of having a child born small for gestational age: RR (95% CI) adjusted for household income, maternal education, and maternal total energy and meat intake, 3.81 (1.10, 13.21). Women with detectable concentrations of IMPY were at increased risk of having a child born with low birth weight compared to women with non-detectable concentrations: adjusted RR (95% CI), 2.13 (1.12, 4.08). We observed no association between any of the pesticide biomarkers and stunting at 1 or 2 years of age.

DISCUSSION

Exposure to the insecticides parathion and diazinon during early pregnancy may increase the risk of adverse birth outcomes.

Dimensions of national culture associated with different trajectories of male and female mean body mass index in countries over 25 years

Cultural determinants of obesity prevalence have been little studied but could explain significant variations in body mass index (BMI) trajectories among countries. This ecological study quantified longitudinal associations between six dimensions of national culture and mean population BMI over 25 years. National mean male and female BMI data 1990 to 2014 provided dependent variables. National dimensions of culture (from the Hofstede database for up to 87 countries) were independent variables: Individualism, Uncertainty avoidance, Indulgence, Long-term orientation, Power distance, and Masculinity. Analyses used mixed models for repeated measures for each dimension of national culture with male and female adult BMI trajectories, controlling for confounders. A higher mean BMI was significantly associated with higher Individualism, Uncertainty avoidance, Indulgence, and Masculine orientation and with lower Power distance (males only) and lower Long-term orientation (males only). Overall, the national cultural dimensions explained 62.4% (males) and 53.5% (females) of the variance in mean BMI among countries. National cultural characteristics, especially Individualism and Uncertainty avoidance, are strongly related to obesity prevalence, explaining over half of the variance among countries. More research and theory development is needed to understand the pathways for these associations so that cultural contexts can be better accounted for in policies, social marketing messages, and community-based actions for obesity prevention.

Global trends in ultraprocessed food and drink product sales and their association with adult body mass index trajectories

This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002-2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002-2014). Products were classified as UPFD/non-UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%-44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%-86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m² for men (P < .001) and 0.072 kg/m² for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m² for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population-level BMI trajectories.

Association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among adults in South Asia: The CARRS study

BACKGROUND AND OBJECTIVES

To investigate the association of dietary patterns and dietary diversity with cardiometabolic disease risk factors among South Asians.

METHODS AND STUDY DESIGN

In a population based study conducted in 2010-11, we recruited 16,287 adults aged >20 years residing in Delhi, Chennai, and Karachi. Diet was assessed using an interviewer-administered 26-item food frequency questionnaire. Principal component analysis identified three dietary patterns: Prudent, Indian, and Non-Vegetarian. We also computed a dietary diversity score. Multinomial and binary logistic regressions were used to calculate adjusted prevalence (95% confidence intervals) of cardio-metabolic disease risk factors across quartiles of dietary pattern and dietary diversity scores.

RESULTS

The adjusted prevalence of diagnosed diabetes was lower among participants in the highest versus lowest quartile of the Prudent Pattern (4.7% [3.8-5.6] versus 10.3% [8.5-12.0]), and the Indian Pattern (4.8% [3.7-5.9] versus 8.7% [6.7-10.6] in highest versus lowest quartile, respectively). Participants following the Indian Pattern also had lower adjusted prevalence of diagnosed hypertension (7.0% [5.4-8.5] versus 10.6% [8.6-12.5] in highest versus lowest quartile, respectively). Participants in the highest versus lowest quartile of the dietary diversity score had a lower adjusted prevalence of diagnosed diabetes (4.1% [3.0-5.2] versus 8.2% [7.1-9.3]), diagnosed hypertension (6.7% [5.3-8.1] versus 10.3% [9.1-11.5]), and undiagnosed hypertension (14.2% [12.0-16.4] versus 18.5% [16.9-20.1]).

CONCLUSIONS

High dietary diversity appears to be protective against cardio-metabolic disease risk factors in this urban cohort of South Asian adults. Further investigation to understand the underlying mechanism of this observation is warranted.

Nationally representative household survey data for studying the interaction between district-level development and individual-level socioeconomic gradients of cardiovascular disease risk factors in India

In this article, we describe the dataset used in our study entitled “The interaction between district-level development and individual-level socioeconomic gradients of cardiovascular disease risk factors in India: A cross-sectional study of 2.4 million adults”, recently published in Social Science & Medicine, and present supplementary analyses.

We used data from three different household surveys in India, which are representative at the district level. Specifically, we analyzed pooled data from the District-Level Household Survey 4 (DLHS-4) and the second update of the Annual Health Survey (AHS), and separately analyzed data from the National Family Health Survey (NFHS-4). The DLHS-4 and AHS sampled adults aged 18 years or older between 2012 and 2014, while the NFHS-4 sampled women aged 15–49 years and - in a subsample of 15% of households - men aged 15–54 years in 2015 and 2016.

The measures of individual-level socio-economic status that we used in both datasets were educational attainment and household wealth quintiles. The measures of district-level development, which we calculated from these data, were i) the percentage of participants living in an urban area, ii) female literacy rate, and iii) the district-level median of the continuous household wealth index. An additional measure of district-level development that we used was Gross Domestic Product per capita, which we obtained from the Planning Commission of the Government of India for 2004/2005.

Our outcome variables were diabetes, hypertension, obesity, and current smoking. The data were analyzed using both district-level regressions and multilevel modelling.

Variety, Price, and Consumer Desirability of Fresh Fruits and Vegetables in 7 Cities around the World

Few studies have attempted to quantify the variety, price, and consumer desirability of fruits and vegetables (F&Vs) across a diversity of cities. We implemented a market basket survey of F&Vs from December 2018 to February 2019 in middle-income neighborhoods of the following cities: Visakhapatnam, India; Kathmandu, Nepal; Addis Ababa, Ethiopia; Dar es Salaam, Tanzania; Mexico City, Mexico; Bangkok, Thailand; and Brookline, United States. The total variety of fruits ranged from 4.1 in Visakhapatnam to 17.3 in Brookline, and of vegetables from 6.1 in Dar es Salaam to 20.3 in Brookline. Of the 3 fruits for which price data were collected, apples tended to be the most expensive, and bananas the least expensive. For vegetables, capsicum tended to be the most expensive and eggplants the least expensive. Tablet-based market basket surveys are a useful tool for evaluating food environments. These pilot data provide further evidence of the homogenization of global diets.

Perspective: Understanding the Intersection of Climate/Environmental Change, Health, Agriculture, and Improved Nutrition - A Case Study: Type 2 Diabetes

Efforts to promote health through improved diet and nutrition demand an appreciation of the nutritional ecology that accounts for the intersection of agriculture, food systems, health, disease and a changing environment. The complexity and implications of this ecology is exemplified by current trends and efforts to address nutrition-related non-communicable diseases (NCDs), most prominently type 2 diabetes. The global prevalence of type 2 diabetes continues to rise unabated. Of particular concern is how to address the unhealthy dietary patterns that are contributing to this pandemic in a changing environment. A multi- disciplinary approach is required that will engage those communities that comprise the continuum of effort from research to translation and implementation of evidence-informed interventions, programs and policies. Using the prevention of type 2 diabetes by increasing fruit and vegetable consumption as an exemplar, we argue that the ability to effect positive change in this and other persistent nutrition-related problems can be achieved by moving away from siloed approaches that limit the integration of key components of the diet-health continuum. Ultimately the impact of preventing type 2 diabetes via increased fruit and vegetable consumption will depend on how the entire diet changes, not just fruits and vegetables. In addition, the rapidly changing physical environment that will confront our food production system going forward will also shape the interventions that are possible. Nonetheless, the proposed "team science" approach that accounts for all the elements of the nutrition ecology will better position us to achieve public health goals through safe and sustainable food systems.

The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults

BACKGROUND

Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage.

METHODS

In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval.

FINDINGS

Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade.

INTERPRETATION

Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage.

FUNDING

Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Association of Long-Term Exposure to Fine Particulate Matter and Cardio-Metabolic Diseases in Low- and Middle-Income Countries: A Systematic Review

: Background: Numerous epidemiological studies indicated high levels of particulate matter less than2.5 μm diameter (PM2.5) as a major cardiovascular risk factor. Most of the studies have been conducted in high-income countries (HICs), where average levels of PM2.5 are far less compared to low- and middle- income countries (LMICs), and their socio-economic profile, disease burden, and PM speciation/composition are very different. We systematically reviewed the association of long-term exposure to PM2.5 and cardio-metabolic diseases (CMDs) in LMICs.

METHODS

Multiple databases were searched for English articles with date limits until March 2018. We included studies investigating the association of long-term exposure to PM2.5 (defined as an annual average/average measure for 3 more days of PM2.5 exposure) and CMDs, such as hospital admissions, prevalence, and deaths due to CMDs, conducted in LMICs as defined by World Bank. We excluded studies which employed exposure proxy measures, studies among specific occupational groups, and specific episodes of air pollution.

RESULTS

A total of 5567 unique articles were identified, of which only 17 articles were included for final review, and these studies were from Brazil, Bulgaria, China, India, and Mexico. Outcome assessed were hypertension, type 2 diabetes mellitus and insulin resistance, and cardiovascular disease (CVD)-related emergency room visits/admissions, death, and mortality. Largely a positive association between exposure to PM2.5 and CMDs was found, and CVD mortality with effect estimates ranging from 0.24% to 6.11% increased per 10 μg/m3 in PM2.5. CVD-related hospitalizations and emergency room visits increased by 0.3% to 19.6%. Risk factors like hypertension had an odds ratio of 1.14, and type 2 diabetes mellitus had an odds ratio ranging from 1.14-1.32. Diversity of exposure assessment and health outcomes limited the ability to perform a meta-analysis.

CONCLUSION

Limited evidence on the association of long-term exposure to PM2.5 and CMDs in the LMICs context warrants cohort studies to establish the association.

Consumption of Fruits and Vegetables Among Individuals 15 Years and Older in 28 Low- and Middle-Income Countries

BACKGROUND

The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required.

OBJECTIVES

The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation.

METHODS

Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics.

RESULTS

The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P < 0.0001) and with decreasing country FAO food price index (FPI; indicating greater stability of food prices; P < 0.0001). At the individual level, those with secondary education or greater were more likely to achieve the recommendation compared with individuals with no formal education: risk ratio (95% CI), 1.61 (1.24-2.09).

CONCLUSIONS

Over 80% of individuals aged ≥15 y living in these 28 LMICs consumed lower amounts of fruits and vegetables than recommended by the WHO. Policies to promote fruit and vegetable consumption in LMICs are urgently needed to address the observed inequities in intake and prevent NCDs.