Understanding the rise of cardiometabolic diseases in low- and middle-income countries

Gender and Age Differences in Meal Structures, Food Away from Home, Chrono-Nutrition, and Nutrition Intakes among Adults and Children in Tanzania Using a Newly Developed Tablet-Based 24-Hour Recall Tool

Background

In many regions of the world, little is known about meal structures, meal patterns, and nutrient intake because the collection of quantitative dietary intake is expensive and labor-intensive.

Objectives

We describe the development and field feasibility of a tablet-based Tanzania 24-h recall tool (TZ-24hr-DR) and dietary intakes collected from adults and children in rural and urban settings.

Methods

Using the Tanzanian food-composition table, the TZ-24hr-DR tool was developed on an Android platform using the Open Data Kit. The module provides food lists, meal lists, ingredient lists, quantity and amount consumed, breastfeeding frequency, and a recipe feature. Similar to the USDA Automated Multiple Pass Method, this TZ-24hr-DR contains review features such as time in-between meals, a summary of meals, and portion sizes.

Results

Dietary intake using TZ-24hr-DR was collected among 1) 845 children 0-18 mo of age enrolled in the Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) trial (ClinicalTrials.gov identifier: NCT03759821) in Mara, Tanzania, and 2) 312 adult families from the Diet, Environment, and Choices of positive living (DECIDE) observational study in peri-urban Dar es Salaam. Interviewers were trained on paper-based methods with food models and tablet-based collection. Conversion to nutrient intake was readily linked and accessible, enabling rapid review and analysis. Overall, 2158 and 8197 dietary meal records were collected from the DECIDE study and EFFECTS trial, respectively. Among adults, 63% of men and 92% of women reported eating at home, and there were differences in protein, fat, and zinc. Food consumed outside the home typically occurs for the first 2 meals. Children's intake of nutrients increased with age; however, median micronutrient intakes for calcium, iron, zinc, and vitamin A remained below recommended nutrient intakes.

Conclusions

The TZ-24hr-DR is a field- and user-friendly tool that can collect large samples of dietary intakes. Further validation is needed. The tool is available freely for research purposes and can be further adapted to other contexts in East Africa.

Younger age of stroke in low-middle income countries is related to healthcare access and quality

Stroke is the second leading cause of mortality globally with higher burden and younger age in low‐middle income countries (LMICs) than high‐income countries (HICs). However, it is unclear to what extent differences in healthcare access and quality (HAQ) and prevalence of risk factors between LMICs and HICs contribute to younger age of stroke in LMICs. In this systematic review, we conducted meta‐analysis of 67 articles and compared the mean age of stroke between LMICs and HICs, before and after adjusting for HAQ index. We also compared the prevalence of main stroke risk factors between HICs and LMICs. The unadjusted mean age of stroke in LMICs was significantly lower than HICs (63.1 vs. 68.6), regardless of gender (63.9 vs. 66.6 among men, and 65.6 vs. 70.7 among women) and whether data were collected in population‐ (64.7 vs. 69.5) or hospital‐based (62.6 vs. 65.9) studies (all p < 0.01). However, after adjusting for HAQ index, the difference in the mean age of stroke between LMICs and HICs was not significant (p ≥ 0.10), except among women (p = 0.048). In addition, while the median prevalence of hypertension in LMICs was 23.4% higher than HICs, the prevalence of all other risk factors was lower in LMICs than HICs. Our findings suggest a much larger contribution of HAQ to the younger mean age of stroke in LMICs, as compared with other potential factors. Additional studies on stroke care quality and accessibility are needed in LMICs.

Associations of Urban Environment Features with Hypertension and Blood Pressure across 230 Latin American Cities

BACKGROUND

Features of the urban physical environment may be linked to the development of high blood pressure, a leading risk factor for global burden of disease.

OBJECTIVES

We examined associations of urban physical environment features with hypertension and blood pressure measures in adults across 230 Latin American cities.

METHODS

In this cross-sectional study we used health, social, and built environment data from the SALud URBana en América Latina (SALURBAL) project. The individual-level outcomes were hypertension and levels of systolic and diastolic blood pressure. The exposures were city and subcity built environment features, mass transit infrastructure, and green space. Odds ratios (ORs) and mean differences and 95% confidence intervals (CIs) were estimated using multilevel logistic and linear regression models, with single- and multiple-exposure models adjusted for individual-level age, sex, education, and subcity educational attainment.

RESULTS

A total of 109,176 participants from 230 cities and eight countries were included in the hypertension analyses and 50,228 participants from 194 cities and seven countries were included in the blood pressure measures analyses. Participants were 18-97 years of age. In multiple-exposure models, higher city fragmentation was associated with higher odds of having hypertension (OR per standard deviation (SD) increase=1.11; 95% CI: 1.01, 1.21); presence (vs. no presence) of mass transit in the city was associated with higher odds of having hypertension (OR=1.30; 95% CI: 1.09, 1.54); higher subcity population density was associated with lower odds of having hypertension (OR per SD increase=0.90; 95% CI: 0.85, 0.94); and higher subcity intersection density was associated with higher odds of having hypertension [OR per SD increase=1.09; 95% CI: 1.04, 1.15). The presence of mass transit was also associated with slightly higher systolic and diastolic blood pressure in multiple-exposure models adjusted for treatment. Except for the association between intersection density and hypertension, associations were attenuated after adjustment for country. An inverse association of greenness with continuous blood pressure emerged after country adjustment.

DISCUSSION

Our results suggest that urban physical environment features-such as fragmentation, mass transit, population density, and intersection density-may be related to hypertension in Latin American cities. Reducing chronic disease risks in the growing urban areas of Latin America may require attention to integrated management of urban design and transport planning. https://doi.org/10.1289/EHP7870.

Associations of Urban Environment Features with Hypertension and Blood Pressure across 230 Latin American Cities

BACKGROUND

Features of the urban physical environment may be linked to the development of high blood pressure, a leading risk factor for global burden of disease.

OBJECTIVES

We examined associations of urban physical environment features with hypertension and blood pressure measures in adults across 230 Latin American cities.

METHODS

In this cross-sectional study we used health, social, and built environment data from the SALud URBana en América Latina (SALURBAL) project. The individual-level outcomes were hypertension and levels of systolic and diastolic blood pressure. The exposures were city and subcity built environment features, mass transit infrastructure, and green space. Odds ratios (ORs) and mean differences and 95% confidence intervals (CIs) were estimated using multilevel logistic and linear regression models, with single- and multiple-exposure models adjusted for individual-level age, sex, education, and subcity educational attainment.

RESULTS

A total of 109,176 participants from 230 cities and eight countries were included in the hypertension analyses and 50,228 participants from 194 cities and seven countries were included in the blood pressure measures analyses. Participants were 18-97 years of age. In multiple-exposure models, higher city fragmentation was associated with higher odds of having hypertension (OR per standard deviation (SD) increase=1.11; 95% CI: 1.01, 1.21); presence (vs. no presence) of mass transit in the city was associated with higher odds of having hypertension (OR=1.30; 95% CI: 1.09, 1.54); higher subcity population density was associated with lower odds of having hypertension (OR per SD increase=0.90; 95% CI: 0.85, 0.94); and higher subcity intersection density was associated with higher odds of having hypertension [OR per SD increase=1.09; 95% CI: 1.04, 1.15). The presence of mass transit was also associated with slightly higher systolic and diastolic blood pressure in multiple-exposure models adjusted for treatment. Except for the association between intersection density and hypertension, associations were attenuated after adjustment for country. An inverse association of greenness with continuous blood pressure emerged after country adjustment.

DISCUSSION

Our results suggest that urban physical environment features-such as fragmentation, mass transit, population density, and intersection density-may be related to hypertension in Latin American cities. Reducing chronic disease risks in the growing urban areas of Latin America may require attention to integrated management of urban design and transport planning. https://doi.org/10.1289/EHP7870.

Changes in the Retail Food Environment in Mexican Cities and Their Association with Blood Pressure Outcomes

Shifting food environments in Latin America have potentially contributed to an increase in the consumption of ultra-processed foods and sugar-sweetened beverages, along with decreases in healthy foods, such as fruits and vegetables. Yet, little is known about the impact that such changes in the food environment have on blood pressure in low- and middle-income countries, including Mexico. We utilized individual-level systolic and diastolic blood pressure (SBP and DBP) measures from the 2016 Mexican Health and Nutrition Survey (ENSANUT, n = 2798 adults). Using an inventory of food stores based on the economic census for 2010 and 2016, we calculated the change in the density of fruit and vegetable stores, convenience stores, and supermarkets. Multilevel regression was used to estimate the association between the 2010–2016 food environment neighborhood-level changes with individual-level blood pressure measured in 2016. Declines in neighborhood-level density of fruit and vegetable stores were associated with higher individual SBP (2.67 mmHg, 95% CI: 0.1, 5.2) in unadjusted models, and marginally associated after controlling for individual-level and area-level covariates. Increases in the density of supermarkets were associated with higher blood pressure outcomes among adults with undiagnosed hypertension. Structural interventions targeting the retail food environment could potentially contribute to better nutrition-related health outcomes in Latin American cities.

Role of Ceramides in the Molecular Pathogenesis and Potential Therapeutic Strategies of Cardiometabolic Diseases: What we Know so Far

Ceramides represent a class of biologically active lipids that are involved in orchestrating vital signal transduction pathways responsible for regulating cellular differentiation and proliferation. However, accumulating clinical evidence have shown that ceramides are playing a detrimental role in the pathogenesis of several diseases including cardiovascular disease, type II diabetes and obesity, collectively referred to as cardiometabolic disease. Therefore, it has become necessary to study in depth the role of ceramides in the pathophysiology of such diseases, aiming to tailor more efficient treatment regimens. Furthermore, understanding the contribution of ceramides to the pathological molecular mechanisms of those interrelated conditions may improve not only the therapeutic but also the diagnostic and preventive approaches of the preceding hazardous events. Hence, the purpose of this article is to review currently available evidence on the role of ceramides as a common factor in the pathological mechanisms of cardiometabolic diseases as well as the mechanism of action of the latest ceramides-targeted therapies.

Impact of objectively-measured sleep duration on cardiometabolic health: A systematic review of recent evidence

Cardiometabolic disease is a spectrum of diseases including, cardiovascular diseases, and metabolic syndrome. It is the leading cause of morbidity and mortality worldwide, with premature deaths being preventable. Currently, sleep has emerged as a potential target for cardiometabolic disease prevention. Several epidemiological studies have provided ample evidence that objectively measured short sleep duration increases the risk of cardiometabolic disease. However, the findings are inconsistent, and few studies measure sleep duration on cardiometabolic profiles objectively. Therefore, in this review, we focused on the recently published literature that explored the association between objectively measured sleep duration and cardiometabolic profiles (cardiovascular diseases, type 2 diabetes mellitus, and metabolic syndrome), seeking more insights regarding the applicability and, in turn, the impact of objectively measured sleep duration on cardiometabolic health, which is relatively understudied. We retrieved the information manually from PubMed, Google Scholar, HINARI, and the Cochrane Library from 2015 to 2022 using appropriate search terms, we included 49 articles. In this review, we found a strong relationship between objectively measured sleep duration and the risk of cardiometabolic disease, indicating that objectively measured short sleep durations increase cardiometabolic risks. In general, the association between objectively measured sleep duration and increased cardiometabolic risks (CMR) has been well-documented in higher-income countries. Several studies found that longer sleep duration was associated with a more favorable cardiometabolic profile in early adolescence, independent of other risk factors. On the other hand, objectively measured short sleep duration is associated with adverse cardiometabolic health outcomes such as coronary heart disease, hypertension, type 2 diabetes mellitus, and metabolic syndrome.

Multimorbidity matters in low and middle-income countries

Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

Scaling of mortality in 742 metropolitan areas of the Americas

We explored how mortality scales with city population size using vital registration and population data from 742 cities in 10 Latin American countries and the United States. We found that more populated cities had lower mortality (sublinear scaling), driven by a sublinear pattern in U.S. cities, while Latin American cities had similar mortality across city sizes. Sexually transmitted infections and homicides showed higher rates in larger cities (superlinear scaling). Tuberculosis mortality behaved sublinearly in U.S. and Mexican cities and superlinearly in other Latin American cities. Other communicable, maternal, neonatal, and nutritional deaths, and deaths due to noncommunicable diseases were generally sublinear in the United States and linear or superlinear in Latin America. Our findings reveal distinct patterns across the Americas, suggesting no universal relation between city size and mortality, pointing to the importance of understanding the processes that explain heterogeneity in scaling behavior or mortality to further advance urban health policies.

Metabolic flexibility differs by body composition in adults

BACKGROUND & AIMS

With the rise of global cardiometabolic diseases, it is important to investigate risk factors such as obesity. Metabolic flexibility, the ability to maintain metabolic homeostasis following an acute challenge, can reflect cardiometabolic health. We investigated the association between body composition and the metabolic flexibility following meal consumption in an adult population.

METHODS

In this study of 1027 participants (mean age 44.0 y ± SD 4.2 y), we administered a mixed-macronutrient meal challenge. Fasting and 2-h postprandial plasma were assayed for lipids, glycemic, and inflammation biomarkers. We characterized metabolic flexibility through meal-induced biomarker responses (%Δ, the difference between postprandial and fasting concentrations, divided by fasting concentration). We then compared the responses by sex-specific tertiles of body mass index (BMI) and percent body fat.

RESULTS

With every unit (kg/m²) increase in BMI, %Δ (95% confidence interval) increased by 0.17% (0.09, 0.26%) for total cholesterol, 0.31% (0.07, 0.54%) for triglycerides, and 0.11% (0.01, 0.20%) for apoA-I, whereas insulin elevation was reduced (-6.30%; -8.41, -4.20%), and the reduction in leptin was attenuated (0.64%; 0.25, 1.05%). With each unit (percent) increase in body fat, we observed similar changes in the %Δ of total cholesterol and leptin but not in triglycerides, apoA-I, or insulin. Glucose response increased by 0.29% (0.06, 0.51%) as body fat increases by one unit.

CONCLUSION

Metabolic flexibility, as assessed by biomarker responses to an acute physiological meal challenge, differed by body composition. These findings may help elucidate the pathways through which obesity contributes to cardiometabolic diseases.

Microbial metabolite delta-valerobetaine is a diet-dependent obesogen

Obesity and obesity-related metabolic disorders are linked to the intestinal microbiome. However, the causality of changes in the microbiome-host interaction affecting energy metabolism remains controversial. Here, we show the microbiome-derived metabolite δ-valerobetaine (VB) is a diet-dependent obesogen that is increased with phenotypic obesity and is correlated with visceral adipose tissue mass in humans. VB is absent in germ-free mice and their mitochondria but present in ex-germ-free conventionalized mice and their mitochondria. Mechanistic studies in vivo and in vitro show VB is produced by diverse bacterial species and inhibits mitochondrial fatty acid oxidation through decreasing cellular carnitine and mitochondrial long-chain acyl-coenzyme As. VB administration to germ-free and conventional mice increases visceral fat mass and exacerbates hepatic steatosis with a western diet but not control diet. Thus, VB provides a molecular target to understand and potentially manage microbiome-host symbiosis or dysbiosis in diet-dependent obesity.

Androgen-dependent tissue factor pathway inhibitor regulating protein: a review of its peripheral actions and association with cardiometabolic diseases

The first genome-wide association study on coronary artery disease (CAD) in the Han Chinese population identified C6orf105 as a susceptibility gene. The C6orf105 gene was later found to encode for a protein that regulates tissue factor pathway inhibitor (TFPI) expression in endothelial cells in an androgen-dependent manner, and the novel protein was thus termed androgen-dependent TFPI-regulating protein (ADTRP). Since the identification of ADTRP, there have been several studies associating genetic variants on the ADTRP gene with CAD risk, as well as research providing mechanistic insights on this novel protein and its functional role. ADTRP is a membrane protein, whose expression is upregulated by androgen, GATA-binding protein 2, oxidized low-density lipoprotein, peroxisome proliferator-activated receptors, and low-density lipoprotein receptors. ADTRP regulates multiple downstream targets involved in coagulation, inflammation, endothelial function, and vascular integrity. In addition, ADTRP functions as a fatty acid esters of hydroxy fatty acid (FAHFA)-specific hydrolase that is involved in energy metabolism. Current evidence suggests that ADTRP may play a role in the pathogenesis of atherosclerosis, CAD, obesity, and metabolic disorders. This review summarizes the current literature on ADTRP, with a focus on the peripheral actions of ADTRP, including expression, genetic variations, signaling pathways, and function. The evidence linking ADTRP and cardiometabolic diseases will also be discussed.

Childhood Socioeconomic Position and Risk of Cardiovascular Disease in Adulthood: Systematic Review of Evidence From Low- and Middle-Income Countries

INTRODUCTION

Socioeconomic disadvantage in childhood is strongly associated with a higher risk of cardiovascular disease in high-income countries. However, the association in low- and middle-income countries, where childhood poverty remains prevalent, has not been reviewed.

METHODS

The authors systematically searched Embase, MEDLINE, and Global Health databases for articles on the association between childhood socioeconomic position and risk of cardiovascular disease in adulthood in low- and middle-income countries until September 2020. Outcomes included measures of cardiovascular disease, its subclinical markers (e.g., carotid intima-media thickness), and its major risk factors (e.g., hypertension, dyslipidemia, diabetes). Where available, associations were extracted before and after adjustment for socioeconomic position in adulthood. Results were synthesized qualitatively by outcome. The study protocol is registered on PROSPERO (CRD42018086984).

RESULTS

The search returned 3,568 unique abstracts, from which 29 eligible articles from 14 middle-income countries were identified, representing >150,000 participants. The most commonly reported outcomes were cardiovascular risk factors; very few studies reported prevalent measures of cardiovascular disease, and no studies reported cardiovascular disease incidence or mortality. Of the 46 reported associations between childhood socioeconomic position and risk of cardiovascular disease, 8 were inverse, 0 were positive, and 38 showed no clear evidence of association. All articles had high (16/29) or medium (13/29) risk of bias.

CONCLUSIONS

Current evidence from middle-income countries provides little support for an association between childhood socioeconomic position and risk of cardiovascular disease, and evidence from low-income countries is lacking. It would be premature to consider childhood poverty as a target for cardiovascular disease prevention in these settings.

Senescence and Type 2 Diabetic Cardiomyopathy: How Young Can You Die of Old Age?

Inflammation is well understood to be a physiological process of ageing however it also underlies many chronic diseases, including conditions without an obvious pathogenic inflammatory element. Recent findings have unequivocally identified type 2 diabetes (T2D) as a chronic inflammatory disease characterized by inflammation and immune senescence. Immunosenescence is a hallmark of the prolonged low-grade systemic inflammation, in particular associated with metabolic syndrome and can be a cause as well as a consequence of T2D. Diabetes is a risk factor for cardiovascular mortality and remodelling and with particular changes to myocardial structure, function, metabolism and energetics collectively resulting in diabetic cardiomyopathy. Both cardiomyocytes and immune cells undergo metabolic remodelling in T2D and as a result become trapped in a vicious cycle of lost metabolic flexibility, thus losing their key adaptive mechanisms to dynamic changes in O₂ and nutrient availability. Immunosenescence driven by metabolic stress may be both the cause and key contributing factor to cardiac dysfunction in diabetic cardiomyopathy by inducing metabolic perturbations that can lead to impaired energetics, a strong predictor of cardiac mortality. Here we review our current understanding of the cross-talk between inflammaging and cardiomyocytes in T2D cardiomyopathy. We discuss potential mechanisms of metabolic convergence between cell types which, we hypothesize, might tip the balance between resolution of the inflammation versus adverse cardiac metabolic remodelling in T2D cardiomyopathy. A better understanding of the multiple biological paradigms leading to T2D cardiomyopathy including the immunosenescence associated with inflammaging will provide a powerful target for successful therapeutic interventions.

Development of a target product profile for a point-of-care cardiometabolic device

Introduction

Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs).

Methods

A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate.

Results

Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access.

Conclusion

This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02298-7.

Gender discrepancy in the predictive effect of metabolic syndrome and its components on newly onset cardiovascular disease in elderly from rural China

BACKGROUND

This study aimed to estimate whether metabolic syndrome (MetS) and its components could be used to predict cardiovascular disease (CVD) in a longitudinal analysis in a rural elderly Chinese population.

METHOD

At baseline during 2012-2013, a total of 2486 elderly from rural Chinese were enrolled and were followed up during 2015-2017. Stroke and coronary heart disease (CHD) were included in CVD and were diagnosed by clinicians. The National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III), the American Heart Association/National Heart, Lung, and Blood Institute (AHA/NHLBI) and the International Diabetes Federation (IDF) criteria were used to define MetS separately.

RESULT

Hazard ratios adjusting for CHD, stroke and CVD in those with MetS using the NCEP ATP III criteria in females were 1.27 (95 % CI 0.73, 2.21), 1.54 (95 % CI 0.99, 2.40) and 1.45 (95 % CI 1.00, 2.10), respectively; 1.33 (95 % CI 0.77, 2.32), 1.44 (95 % CI 0.92, 2.25) and 1.36 (95 % CI 0.94, 1.97), respectively, with the AHA/NHLBI criteria; and 1.10 (95 % CI 0.89,1.36), 1.62 (95 % CI 1.03, 2.55) and 1.36 (95 % CI 0.93, 1.97), respectively, with the IDF criteria. Additionally, abdominal obesity using the AHA/NHLBI criteria was significantly associated with the incidence of stroke (HR: 1.60; 95 % CI 1.01, 2.52). However, among rural elderly males, neither MetS nor its components predicted new-onset CVD.

CONCLUSIONS

MetS is correlated with high incidence of CVD among rural elderly female, and only using the NCEP ATP III criteria to define MetS could make the incidence of CVD obvious difference. In order to reduce rural elderly CVD, effective measures to prevent, diagnose, and treat MetS should be enacted in a timely manner, especially among females.

GeNuIne (gene-nutrient interactions) Collaboration: towards implementing multi-ethnic population-based nutrigenetic studies of vitamin B12 and D deficiencies and metabolic diseases

Gene-nutrient interactions (GeNuIne) collaboration, a large-scale collaborative project, has been initiated to investigate the impact of gene-nutrient interactions on cardiometabolic diseases using population-based studies from ethnically diverse populations. In this project, the relationship between deficiencies of vitamins B12 and D, and metabolic diseases was explored using a nutrigenetic approach. A genetic risk score (GRS) analysis was used to examine the combined effect of several genetic variations that have been shown to be associated with metabolic diseases and vitamin B12 and D deficiencies, respectively. In Sri Lankan, Indonesian and Brazilian populations, those carrying a high B12-GRS had an increased risk of metabolic diseases under the influence of dietary protein, fibre and carbohydrate intakes, respectively; however, in Asian Indians, genetically instrumented metabolic disease risk showed a significant association with low vitamin B12 status. With regards to nutrigenetic studies on vitamin D status, although high metabolic-GRS showed an interaction with dietary carbohydrate intake on vitamin D status, the study in Indonesian women demonstrated a vitamin D GRS-carbohydrate interaction on body fat percentage. In summary, these nutrigenetic studies from multiple ethnic groups have provided evidence for the influence of the dietary factors on the relationship between vitamin B12/D deficiency and metabolic outcomes. Furthermore, these studies highlight the existence of genetic heterogeneity in gene-diet interactions across ethnically diverse populations, which further implicates the significance of personalised dietary approaches for the prevention of these micronutrient deficiencies and metabolic diseases.

Dietary patterns and cardiometabolic risks in diverse less-developed ethnic minority regions: results from the China Multi-Ethnic Cohort (CMEC) Study

Background In Western developed countries, food-based dietary patterns have been associated with the risk of cardiometabolic diseases, but little is known about such associations in less developed ethnic minority regions (LEMRs), where the cardiometabolic disease burden is growing rapidly and food patterns differ substantially.

Methods Between May 2018 and September 2019, we recruited 99556 participants aged 30-79 years from the China Multi-Ethnic Cohort (CMEC) Study. We measured habitual dietary intake with validated food frequency questionnaire (FFQ) and then calculated dietary pattern scores for two of the most studied a priori dietary patterns, i.e., Dietary Approaches to Stop Hypertension (DASH) and alternative Mediterranean (aMED) style diets, and three a posteriori dietary patterns. Four cardiometabolic risks, including hypertension, diabetes, dyslipidaemia and metabolic syndrome (MetS), were newly diagnosed by medical examination and blood tests. We estimated adjusted odds ratios (OR) relating various dietary pattern scores to cardiometabolic risks using marginal structural models under the guidance of directed acyclic graphs. For the above associations, we further calculated the proportion mediated by overweight (PM) using regression-based mediation analysis for better public health implications.

Findings The final study sample consisted of 68834 participants. Among them, we newly diagnosed 12803 hypertension, 3527 diabetes, 16342 hyperlipidaemia, and 8198 MetS cases. Overall, all 5 dietary patterns showed considerable associations with risks of hypertension and MetS. Comparing the highest with the lowest quintiles, the DASH score showed the strongest inverse associations with risks of hypertension (OR=0.74, 95% CI:0.70-0.79; PM=10%) and MetS (OR=0.79, 95% CI:0.74-0.85; PM=35%); conversely, scores of the localized a posteriori Yunnan-Guizhou plateau dietary pattern in LEMRs showed the strongest positive associations with risks of hypertension (OR=1.44, 95% CI:1.35-1.52; PM=10%) and MetS (OR=1.35, 95% CI:1.26-1.46; PM=33%), with all P values for trend <0.001. These associations were consistent in various subgroups defined by sex, age, smoking and physical activity, but with magnitudes that differed substantially across different ethnic regions and urbanicity. By investigating the single-component effects of dietary patterns, the dairy intake component contributed a major proportion to the beneficial effects of DASH (41.9% for hypertension and 100.5% for MetS).

Interpretation Substantial socioeconomic status and ethnic disparities in diet quality and related cardiometabolic risks were seen in LEMRs, with hypertension being the top diet-related cardiometabolic risk. Our findings support that DASH provides superior dietary guidance compared to aMED for reducing cardiometabolic risks in LEMRs. In particular, the dairy intake encouraged by DASH may produce considerable beneficial effects.

Funding This study was funded by the National Key R&D Program of China; full funding sources listed in the acknowledgements.

Evolution of Lactase Persistence: Turbo-Charging Adaptation in Growth Under the Selective Pressure of Maternal Mortality?

The emergence of the capacity to digest milk in some populations represents a landmark in human evolution, linking genetic change with a component of niche construction, namely dairying. Alleles promoting continued activity of the enzyme lactase through the life-course (lactase persistence) evolved in several global regions within the last 7,000 years. In some European regions, these alleles underwent rapid selection and must have profoundly affected fertility or mortality. Elsewhere, alleles spread more locally. However, the functional benefits underlying the rapid spread of lactase persistence remain unclear. Here, we set out the hypothesis that lactase persistence promoted skeletal growth, thereby offering a generic rapid solution to childbirth complications arising from exposure to ecological change, or to new environments through migration. Since reduced maternal growth and greater neonatal size both increase the risk of obstructed labour, any ecological exposure impacting these traits may increase maternal mortality risk. Over many generations, maternal skeletal dimensions could adapt to new ecological conditions through genetic change. However, this adaptive strategy would fail if ecological change was rapid, including through migration into new niches. We propose that the combination of consuming milk and lactase persistence could have reduced maternal mortality by promoting growth of the pelvis after weaning, while high calcium intake would reduce risk of pelvic deformities. Our conceptual framework provides locally relevant hypotheses to explain selection for lactase persistence in different global regions. For any given diet and individual genotype, the combination of lactase persistence and milk consumption would divert more energy to skeletal growth, either increasing pelvic dimensions or buffering them from worsening ecological conditions. The emergence of lactase persistence among dairying populations could have helped early European farmers adapt rapidly to northern latitudes, East African pastoralists adapt to sudden climate shifts to drier environments, and Near Eastern populations counteract secular declines in height associated with early agriculture. In each case, we assume that lactase persistence accelerated the timescale over which maternal skeletal dimensions could change, thus promoting both maternal and offspring survival. Where lactase persistence did not emerge, birth weight was constrained at lower levels, and this contributes to contemporary variability in diabetes risk.

Educational inequalities, urbanicity and levels of non-communicable diseases risk factors: evaluating trends in Argentina (2005-2013)

BACKGROUND

We investigated a) whether urbanicity is associated with individual-level non-communicable diseases (NCD) risk factors and whether urbanicity modifies trends over time in risk factors; and (b) whether educational inequalities in NCD risk factors change over time or are modified by province urbanicity.

METHODS

We used data from three large national surveys on NCD risk factors (Encuesta Nacional de Factores de Riesgo; ENFR2005-2009-2013) conducted in urban areas of Argentina (n = 108,489). We used gender-stratified logistic random-intercept models (individuals nested within provinces) to determine adjusted associations of self-reported individual NCD risk factors (hypertension, diabetes, obesity, and current smoking) with education and urbanicity.

RESULTS

In both men and women, the prevalence of obesity and diabetes increased over time but smoking decreased. Hypertension prevalence increased over time in men. Higher urbanicity was associated with higher odds of smoking and lower odds of hypertension in women but was not associated with NCD risk factors in men. Obesity increased more over time in more compared to less urbanized provinces (in men) while smoking decreased more over time in less urbanized provinces. All risk factors had a higher prevalence in persons with lower education (stronger in women than in men), except for diabetes in men and smoking in women. Educational inequalities in obesity (in men) and hypertension (in men and women) became stronger over time, while an initial inverse social gradient in smoking for women reverted and became similar to other risk factors over time. In general, the inverse associations of education with the risk factors became stronger with increasing levels of province urbanicity.

CONCLUSION

Increasing prevalence of diabetes and obesity over time and growing inequities by education highlight the need for policies aimed at reducing NCD risk factors among lower socioeconomic populations in urban environments in Argentina.

Identifying non-traditional electronic datasets for population-level surveillance and prevention of cardiometabolic diseases: a scoping review protocol

INTRODUCTION

Cardiometabolic diseases, including cardiovascular disease, obesity and diabetes, are leading causes of death and disability worldwide. Modern advances in population-level disease surveillance are necessary and may inform novel opportunities for precision public health approaches to disease prevention. Electronic data sources, such as social media and consumer rewards points systems, have expanded dramatically in recent decades. These non-traditional datasets may enhance traditional clinical and public health datasets and inform cardiometabolic disease surveillance and population health interventions. However, the scope of non-traditional electronic datasets and their use for cardiometabolic disease surveillance and population health interventions has not been previously reviewed. The primary objective of this review is to describe the scope of non-traditional electronic datasets, and how they are being used for cardiometabolic disease surveillance and to inform interventions. The secondary objective is to describe the methods, such as machine learning and natural language processing, that have been applied to leverage these datasets.

METHODS AND ANALYSIS

We will conduct a scoping review following recommended methodology. Search terms will be based on the three central concepts of non-traditional electronic datasets, cardiometabolic diseases and population health. We will search EMBASE, MEDLINE, CINAHL, Scopus, Web of Science and Cochrane Library peer-reviewed databases and will also conduct a grey literature search. Articles published from 2000 to present will be independently screened by two reviewers for inclusion at abstract and full-text stages, and conflicts will be resolved by a separate reviewer. We will report this data as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

ETHICS AND DISSEMINATION

No ethics approval is required for this protocol and scoping review, as data will be used only from published studies with appropriate ethics approval. Results will be disseminated in a peer-reviewed publication.

Time spent outdoors and risk of myocardial infarction and stroke in middle and old aged adults: Results from the UK Biobank prospective cohort

BACKGROUND

Time spent outdoors has been previously related to several cardiovascular risk factors, implying that it may confer either beneficial or harmful effects on cardiovascular health. However, no large population-based studies have examined the relation between time spent outdoors and myocardial infarction and stroke.

OBJECTIVES

We aimed to investigate the longitudinal relation between time spent outdoors and myocardial infarction and stroke in large UK population-based cohort.

METHODS

A total of 446,648 participants from UK Biobank were included in the study of which 431,146 participants (56% females and 44% males with a mean age of 56.4 ± 8.1 years) were followed for a median time of 7 years. Time spent outdoors was self-reported and participants were stratified into quantiles (less than 1.5 [reference group]; 1.5 to 2.4; 2.5 to 3.5 and more than 3.5 h per day outdoors). Myocardial infarction and stroke events were either collected from hospital records and death registries or were self-reported by the participants. Cox proportional hazard regression was used for the analysis. In addition to age and sex, analyses were adjusted for potential demographic (TDI, ethnic background, current employment status), lifestyle (alcohol intake frequency, current tobacco use, sedentary time and moderate-to-vigorous physical activity), health related factors (BMI, systolic and diastolic blood pressure) and environmental indicators (NO₂, NO_x, PM₁₀, PM_2.5-10, PM_2,5, noise pollution, % greenspace, % natural environment and % water).

RESULTS

A 20% increased risk for myocardial infarction incidence was observed among participants who reported spending more than 3.5 h/day outdoors (HR: 1.20, 95% CI: 1.06-1.36) compared to the reference group. A trend was also observed for stroke (HR: 1.14, 95% CI: 0.97-1.34).

CONCLUSION

Findings from the present study indicate that spending more than 3.5 h/day outdoors is a risk factor for myocardial infarction and stroke. Future research is needed to further understand the relation between time spent outdoors and cardiovascular disease.

Urbanization in Peru is inversely associated with double burden of malnutrition: Pooled analysis of 92,841 mother-child pairs

OBJECTIVE

This study assessed the relationship between urbanization and the double burden of malnutrition (DBM) in Peru.

METHODS

A cross-sectional analysis of the Demographic and Health Survey (2009 to 2016) was conducted. A DBM "case" comprised a child with undernutrition and a mother with overweight/obesity. For urbanization, three indicators were used: an eight-category variable based on district-level population density (inhabitants/km² ), a dichotomous urban/rural variable, and place of residence (countryside, towns, small cities, or capital/large cities).

RESULTS

The prevalence of DBM was lower in urban than in rural areas (prevalence ratio [PR] 0.70; 95% CI: 0.65-0.75), and compared with the countryside, DBM was less prevalent in towns (PR 0.75; 95% CI: 0.69-0.82), small cities (PR 0.73; 95% CI: 0.67-0.79), and capital/large cities (PR 0.53; 95% CI: 0.46-0.61). Using population density, the adjusted prevalence of DBM was 9.7% (95% CI: 9.4%-10.1%) in low-density settings (1 to 500 inhabitants/km² ), 5.9% (95% CI: 4.9%-6.8%) in mid-urbanized settings (1,001 to 2,500 inhabitants/km² ), 5.8% (95% CI: 4.5%-7.1%) in more densely populated settings (7,501 to 10,000 inhabitants/km² ), and 5.5% (95% CI: 4.1%-7.0%) in high-density settings (>15,000 inhabitants/km² ).

CONCLUSIONS

The prevalence of DBM is higher in the least-urbanized settings such as rural and peri-urban areas, particularly those under 2,500 inhabitants/km² .

Conceptualizing the commercial determinants of dietary behaviors associated with obesity: A systematic review using principles from critical interpretative synthesis

INTRODUCTION

Unhealthy diet is an important preventable risk factor for overweight and obesity. Identifying the key drivers of an unhealthy diet is an important public health aim. "Big Food" has been identified as an influential factor shaping dietary behavior and obesity, and their practices have broadly been labeled as the "commercial determinants of obesity," but there is a lack of definitions and conceptualizations for these terms. This review aimed to synthesize literature on the commercial determinants of dietary behavior associated with obesity. It presents the development of an integrative definition and a conceptual framework involving potential influences on dietary behavior, and it examines the prevalence of certain narratives within papers that focus on children and adolescents.

METHODS

Four electronic databases (Ovid MEDLINE, PubMed, Web of Science, and Scopus) were searched up to December 2020. Eighty-one articles met the inclusion criteria: they were published in a peer-reviewed academic journal, described a practice from the food/beverage industry in relation to dietary behavior or obesity. Data were integrated using critical interpretative synthesis.

RESULTS

The commercial determinants of dietary behavior are conceptualized in terms of three corporate spheres of action-political and legal; production, processing and design; and marketing and preference shaping-which enable powerful food industry to successfully pursue their business, market, and political objectives. The most frequently reported sphere of action targeting children and adolescents was marketing and preference shaping.

CONCLUSIONS

In the included literature, the commercial determinants of dietary behavior associated with obesity have been conceptualized as being part of a complex system where corporate practices are enabled by power structures. The proposed framework can facilitate a structured identification and systematic study of the impact of specific aspects of food industry's strategies and increase opportunities for primary prevention by anticipating industry responses and by discouraging corporate practices that harm health.

Dietary Inflammatory Index and Cardiometabolic Risk in Ecuadorian Women

Low-grade systemic inflammation is implicated in metabolic syndrome (MetS) and cardiometabolic diseases. Diet is hypothesized to be an important low-grade inflammation modifier. However, few studies have examined the association of dietary inflammation with MetS and cardiometabolic risk in Latin American populations and their findings are inconsistent. Our cross-sectional study examined the association of dietary inflammatory potential with MetS and cardiometabolic risk components in 276 urban Ecuadorian women. Dietary inflammation was evaluated using an energy-adjusted Dietary Inflammatory Index (E-DII), divided into quartiles (Q). E-DII scores ranged from −4.89 (most anti-inflammatory) to 4.45 (most pro-inflammatory). Participants in the most pro-inflammatory (Q4) compared to the least inflammatory E-DII quartile (Q1) had a 4.4 increased adjusted odds for MetS (95% C.I. = 2.0, 9.63; p < 0.001). Every one-unit increase in E-DII was associated with a 1.4 increase in MetS (95% CI = 1.22, 1.52; p < 0.001). In other adjusted models, the most pro-inflammatory E-DII quartile (Q4) was positively associated with total blood cholesterol and triglycerides (p < 0.001), LDL-c (p = 0.007), diastolic blood pressure (p< 0.002), mean arterial pressure (p < 0.006), waist circumference (p < 0.008), and Framingham risk score (p < 0.001). However, the previously identified associations with pulse wave velocity and BMI were no longer evident in the models. These findings suggest that more pro-inflammatory diets may contribute to poorer cardiometabolic health. Promoting healthier diets with a lower inflammatory potential may help to prevent or slow development of cardiometabolic disorders.

Platform for Healthcare Promotion and Cardiovascular Disease Prevention

This article presents the hardware-software design and implementation of an open, integrated, and scalable healthcare platform oriented to multiple point-care scenarios for healthcare promotion and cardiovascular disease prevention. The platform has the capability to provide continuous monitoring, extended device integration, strategies based on artificial intelligence for the information analysis and cybersecurity support, delivering a secure end-to-end hardware-software solution. This platform is used to perform the remote patient health monitoring and supervision by doctors, triage procedures in hospitals, or self-care monitoring using personal devices such as tablets and cellphones. The proposed hardware architecture facilitates the integration of biomedical data acquired from different health-point cares, collecting relevant information for the detection of cardiovascular risk through deep-learning algorithms. All these characteristics make our development a strong tool to perform epidemiological profiling and future implementation of strategies for comprehensive cardiovascular risk intervention. The components of the platform are described, and their main functionalities are highlighted.

Telemedicine interventions for hypertension management in low- and middle-income countries: A scoping review

Hypertension remains the leading cause of cardiovascular disease worldwide and disproportionately impacts patients living in low- and middle-income countries (LMICs). Telemedicine offers a potential solution for improving access to health care for vulnerable patients in LMICs.

Regional and state-level patterns of type 2 diabetes prevalence in Mexico over the last three decades

AIMS

We aimed to characterize and illustrate the regional and state-level change in type 2 diabetes (T2D) prevalence in Mexico between 1990 and 2017.

METHODS

We conducted an ecological and secondary analysis using data from the Global Burden of Disease study on T2D prevalence of the adult Mexican population. We estimated the absolute increase and annual growth rate of T2D prevalence between 1990 and 2017, stratified by age group and region.

RESULTS

Nationally, between 1990 and 2017, the prevalence of T2D in Mexico increased from 9.5% to 14.3%. The highest increase in T2D prevalence was observed in the East and Southcentral regions, with the lowest absolute change in T2D prevalence observed in Northern states. The highest average annual growth rate in T2D prevalence was observed in Southern Mexico, in the three Southern states with the lowest human development index, and among individuals ages 15-49 years across all regions, compared to those 50 years and older.

CONCLUSIONS

The prevalence of T2D in Mexico has increased substantially over the past three decades, with a clear shift in T2D prevalence from Northern to Southern states and a faster increase occurring in Southern Mexico among younger adults and in areas with lower economic resources.

Urban social determinants of non-communicable diseases risk factors in Argentina

We examined associations of individual-, neighborhood- and city-level education -as proxies of SES at different levels-, with diabetes, hypertension, obesity, smoking and binge drinking (non-communicable disease risk factors -NCD/RF) among Argentinian adults. We estimated mixed models based on 21,415 individuals from the 2013 National Survey of Risk Factors, living in 2,698 neighborhoods and 33 cities. Gradients by individual-level education differed by gender and NCD/RF, and some were modified by city education. In addition, we identified contextual effects of neighborhood and city education on some NCD/RF. Urban efforts to tackle NCD/RF in Argentina should be context- and gender-sensitive, and mainly focused on socially disadvantaged groups.

Educational inequalities in obesity: a multilevel analysis of survey data from cities in Latin America

OBJECTIVE

Using newly harmonised individual-level data on health and socio-economic environments in Latin American cities (from the Salud Urbana en América Latina (SALURBAL) study), we assessed the association between obesity and education levels and explored potential effect modification of this association by city-level socio-economic development.

DESIGN

This cross-sectional study used survey data collected between 2002 and 2017. Absolute and relative educational inequalities in obesity (BMI ≥ 30 kg/m2, derived from measured weight and height) were calculated first. Then, a two-level mixed-effects logistic regression was run to test for effect modification of the education-obesity association by city-level socio-economic development. All analyses were stratified by sex.

SETTING

One hundred seventy-six Latin American cities within eight countries (Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico and Peru).

PARTICIPANTS

53 186 adults aged >18 years old.

RESULTS

Among women, 25 % were living with obesity and obesity was negatively associated with educational level (higher education-lower obesity) and this pattern was consistent across city-level socio-economic development. Among men, 18 % were living with obesity and there was a positive association between education and obesity (higher education-higher obesity) for men living in cities with lower levels of development, whereas for those living in cities with higher levels of development, the pattern was inverted and university education was protective of obesity.

CONCLUSIONS

Among women, education was protective of obesity regardless, whereas among men, it was only protective in cities with higher levels of development. These divergent results suggest the need for sex- and city-specific interventions to reduce obesity prevalence and inequalities.

Fighting non-communicable diseases in East Africa: assessing progress and identifying the next steps

Sub-Saharan Africa has seen a rapid increase in non-communicable disease (NCD) burden over the last decades. The East African Community (EAC) comprises Burundi, Rwanda, Kenya, Tanzania, South Sudan and Uganda, with a population of 177 million. In those countries, 40% of deaths in 2015 were attributable to NCDs. We review the status of the NCD response in the countries of the EAC based on the available monitoring tools, the WHO NCD progress monitors in 2017 and 2020 and the East African NCD Alliance benchmark survey in 2017. In the EAC, modest progress in governance, prevention of risk factors, monitoring, surveillance and evaluation of health systems can be observed. Many policies exist on paper, implementation and healthcare are weak and there are large regional and subnational differences. Enhanced efforts by regional and national policy-makers, non-governmental organisations and other stakeholders are needed to ensure future NCD policies and implementation improvements.

Effect of BMI on Prolonged Abstinence after Smoking Cessation Treatment: A Retrospective Cohort Study

BACKGROUND

 Despite the well-documented relationship between weight gain and poorer cessation outcomes among smokers, the role of the former (baseline) weight in smoking cessation is insufficiently investigated. We hypothesized that patients with higher baseline body mass index(BMI) have a worse prognosis in tobacco cessation.

OBJECTIVES

 This retrospective clinical cohort study aimed to investigate the role of the baseline BMI on abstinence over 12 months after participation in smoking cessation treatment conducted in a middle-income country (n = 664).

METHODS

 Data from a 6-week smoking cessation protocol performed in a Psychosocial Care Unit(CAPS) were used. The protocol included four medical consultations and six Cognitive-Behavioral Therapy(CBT) group sessions. Initially, 1,213 participants were evaluated for the study, but only the participants whose telephone contact was successful were included in the outcome analyses. The attrition rate was 45.3%. Continuous and categorical (normal, overweight, and obesity) BMI values were computed. Survival regression models were used to test the associations between BMI and the 12-month abstinence outcome. Self-report 4-week abstinence at the end of treatment was also investigated using logistic regression models.

RESULTS

 Baseline BMI had no significant effect on both short (4-week-point abstinence) and long (12-month prolonged abstinence) treatment outcomes.

CONCLUSION

 The possible influence of the baseline BMI on smoking cessation outcomes, especially considering prolonged abstinence, was not corroborated by our results. Regardless of our results, the detrimental health outcomes due to the combination of obesity/overweight and smoking justify that these subgroups of individuals be continuously targeted for adequate smoking prevention and treatment.

The effects of tocotrienols intake on obesity, blood pressure, inflammation, liver and glucose biomarkers: a meta-analysis of randomized controlled trials

The objective of this study is to accomplish a systematic review and meta-analysis of all randomized controlled trials that dissected the influence of tocotrienol supplementation on various anthropometric and cardiometabolic indices in all individuals, irrespective of health condition. This research was carried out in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines. 17 eligible articles were included in the final quantitative analysis. Current study revealed that tocotrienol consumption was not associated with CRP, WC, MDA, BMI, IL-6, HbA1C, ALT, AST, creatinine TNF-α, FPG, BW, DBP, and SBP. We did observe an overall increase in BW (SMD: 0.063 kg, 95% CI: -0.200, 0.327, p = 0.637) and DBP (SMD: 0.249 mmHg, 95% CI: 0.053, 0.446, p = 0.013). In addition, a significant reduction in SBP was observed (SMD: -0.616 mmHg, 95% CI: -1.123, -0.110, p = 0.017). In summary, our meta-analysis revealed that tocotrienol consumption was associated with increase in BW and DBP and decrease in SBP. Significant associations were not observed for other outcomes.

Prevalence and perinatal outcomes of non-communicable diseases in pregnancy in a regional hospital in Haiti: A prospective cohort study

Background

The prevalence of non-communicable diseases (NCDs) is rising in low and middle-income countries (LMIC). We aimed to report on the prevalence of NCDs in pregnancy and their associated perinatal outcomes in a regional hospital in Haiti.

Methods

We conducted the “Diabète et hYpertension Artéerielle et leurs issues MAternelles et Néonatales” (DYAMAN) prospective cohort study in a regional hospital in Haiti. Pregnant women presenting to care at 24-28 weeks were screened and treated for diabetes (DM) and hypertensive disorders of pregnancy (HDP) using setting-adapted protocols. Prevalence of NCDs and associated maternal-neonatal outcomes were described.

Results

715 women were included, of which 51 (7.1%) had DM, 90 (12.6%) had HDP, and 30 (4.2%) had both DM and HDP (DM/HDP). Of 422 (59%) women delivered in hospital, 58 (13.7%) had preeclampsia, including 5 (8.6%) with eclampsia. Preterm birth <32 weeks was more common in the HDP than the control, DM, and DM/HDP groups. More low birth weight babies (n = 20, 25.6%) were born to the HDP group than to the control (n = 20, 7.1%), DM (n = 1, 2.7%), and DM/HDP (n = 3, 12%) groups (P < 0.001). Macrosomia and hypoglycemia affected 5 (8%) neonates of women with DM. Perinatal mortality, affecting 36/1000 births, was mainly driven by maternal NCDs.

Conclusions

NCDs in pregnancy led to adverse maternal and perinatal outcomes. This study will help to prepare future refinements aimed at optimizing the management of NCDs in pregnancy in LMIC. Research is required to understand barriers to patient attendance at antenatal follow-up, treatment escalation for hyperglycemia, and in-hospital delivery.

Links Between Mortality and Socioeconomic Characteristics, Disease Burden, and Biological and Physical Functioning in the Aging Chinese Population

OBJECTIVES

Determinants of mortality may depend on the time and place where they are examined. China provides an important context in which to study the determinants of mortality at older ages because of its unique social, economic, and epidemiological circumstances. This study uses a nationally representative sample of persons in China to determine how socioeconomic characteristics, early-life conditions, biological and physical functioning, and disease burden predict 4-year mortality after age 60.

METHODS

We used data from the China Health and Retirement Longitudinal Study. We employed a series of Cox proportional hazard models based on exact survival time to predict 4-year all-cause mortality between the 2011 baseline interview and the 2015 interview.

RESULTS

We found that rural residence, poor physical functioning ability, uncontrolled hypertension, diabetes, cancer, a high level of systemic inflammation, and poor kidney functioning are strong predictors of mortality among older Chinese.

DISCUSSION

The results show that the objectively measured indicators of physical functioning and biomarkers are independent and strong predictors of mortality risk after accounting for several additional self-reported health measures, confirming the value of incorporating biological and performance measurements in population health surveys to help understand health changes and aging processes that lead to mortality. This study also highlights the importance of social and historical context in the study of old-age mortality.

Myocardin suppression increases lipid retention and atherosclerosis via downregulation of ABCA1 in vascular smooth muscle cells

Myocardin (MYOCD) plays an important role in cardiovascular disease. However, its underlying impact on atherosclerosis remains to be elucidated. ATP binding cassette transporter A1 (ABCA1), a key membrane-associated lipid transporter which maintains intracellular lipid homeostasis, has a protective function in atherosclerosis progress. The purpose of this study was to investigate whether and how the effect of MYOCD on atherosclerosis is associated with ABCA1 in vascular smooth muscle cells (VSMCs). We found both MYOCD and ABCA1 expression were dramatically decreased in atherosclerotic patient aortas compared to control. MYOCD knockdown inhibited ABCA1 expression in human aortic vascular smooth muscle cells (HAVSMCs), leading to reduced cholesterol efflux and increased intracellular cholesterol contents. MYOCD overexpression exerted the opposite effect. Mechanistically, MYOCD regulates ABCA1 expression in an SRF-dependent manner. Consistently, apolipoprotein E-deficient mice treated with MYOCD shRNA developed more plaques in the aortic sinus, which is associated with reduced ABCA1 expression, increased cholesterol retention in the aorta, and decreased high-density lipoprotein cholesterol levels in the plasma. Our data suggest that MYOCD deficiency exacerbates atherosclerosis by downregulating ABCA1 dependent cholesterol efflux from VSMCs, thereby providing a novel strategy for the therapeutic treatment of atherosclerotic cardiovascular disease.

Association between dehydroepiandrosterone levels and cardiovascular risk in public sector health workers in a Peruvian region

Alterations in dehydroepiandrosterone sulfate (DHEAS) levels have been shown to affect the cardiovascular system. This study examined the associations between DHEAS levels and cardiovascular risk in workers of a public hospital in Lima, Peru. The analytical cross-sectional study was conducted at the Hospital de Huaycán, Peru. The cardiovascular risk was assessed in health workers using the Framingham score and categorized into high and low cardiovascular risk groups, and then the DHEAS levels of both groups were compared. Two hundred ninety-six health workers were studied, 67.2% showed low cardiovascular risk, 22.3% intermediate and 10.5% high. DHEAS levels were lower in the high cardiovascular risk group (2156.9 vs 2814.6 ng/mL; P < 0.05) and showed negative association (prevalence rate ratio 0.14, 95% IC 0.04-0.53; P < 0.05) in multivariable analysis (P < 0.05). DHEAS, glycosylated hemoglobin, pulse pressure and mean arterial pressure show an independent association with high cardiovascular risk in a group of health workers. Additional variables should be considered for cardiovascular risk assessment.

Deteriorated Dietary Patterns with Regards to Health and Environmental Sustainability among Hungarian Roma Are Not Differentiated from Those of the General Population

Nutritional epidemiology studies on Roma people are scarce and, to date, their nutrient-based dietary patterns with regards to both healthy and sustainable dietary considerations have never been reported. We report, for the first time, adherence to healthy and sustainable dietary patterns using scoring and regression models, based on recommendations defined by the World Health Organization, in the Dietary Approaches to Stop Hypertension (DASH) study and the EAT-Lancet report, as well as dietary quality based on Dietary Inflammatory Index (DII) among the Hungarian Roma (HR) population living in North East Hungary, with Hungarian general (HG) adults as reference. Data were obtained from a complex, comparative health survey involving dietary assessment, structured questionnaire-based interview, physical and laboratory examinations on 359 HG and 344 HR subjects in Northeast Hungary. Poisson regressions were fit to models that included DASH, EAT, DII and Healthy Diet Indicator as dependent variables to assess the influence of ethnicity on healthy and sustainable nutrient-based patterns. Adjusted models controlled for all relevant covariates using the residual method indicated poor dietary quality with regards to the selected dietary patterns. These associations were not ethnicity-sensitive, except for DII, where Roma ethnicity was linked to a decrease of DII score (β = −0.455, 95%CI: −0.720; −0.191, p < 0.05). Currently, HR dietary patterns appear to be relatively unhealthy and unsustainable, rendering them vulnerable to elevated risk of ill-health. Nevertheless, their dietary patterns did not strongly differ from HG, which may contribute to Hungarians being one of the most obese and malnourished nations in Europe. Further prospective research on the potential public and environmental health effects of these findings is warranted.

Cardiovascular Risk Factors and Social Development Index

Cardiovascular diseases (CVD) are the leading causes of morbidity and mortality worldwide. The complex etiology of CVD is known to be significantly affected by environmental and social factors. There is, however, a lag in our understanding of how population level components may be related to the onset and severity of CVD, and how some indicators of unsatisfied basic needs might be related to known risk factors. Here, we present a cross-sectional study aimed to analyze the association between cardiovascular risk factors (CVRF) and Social Development Index (SDI) in adult individuals within a metropolitan urban environment. The six components of SDI as well as socioeconomic, anthropometric, clinical, biochemical, and risk behavior parameters were explored within the study population. As a result, several CVRF (waist circumference, waist-to-height ratio, body mass index, systolic blood pressure, glucose, lower high-density lipoprotein cholesterol, triglycerides, and sodium) were found in a higher proportion in the low or very low levels of the SDI, and this pattern occurs more in women than in men. Canonical analysis indicates a correlation between other socioeconomic features and anthropometric, clinical, and biochemical factors (canonical coefficient = 0.8030). Further studies along these lines are needed to fully establish how to insert such associations into the design of health policy and interventions with a view to lessen the burden of cardiovascular diseases, particularly in metropolitan urban environments.

Association of education level with diabetes prevalence in Latin American cities and its modification by city social environment

Background

Diabetes prevalence continues to increase in urban areas of low-income and middle-income countries (LMIC). Evidence from high-income countries suggests an inverse association between educational attainment and diabetes, but research in LMIC is limited. We investigated educational differences in diabetes prevalence across 232 Latin American (LA) cities, and the extent to which these inequities vary across countries/cities and are modified by city socioeconomic factors.

Methods

Using harmonised health survey and census data for 110 498 city dwellers from eight LA countries, we estimated the association between education and diabetes. We considered effect modification by city Social Environment Index (SEI) as a proxy for city-level development using multilevel models, considering heterogeneity by sex and country.

Results

In women, there was an inverse dose–response relationship between education and diabetes (OR: 0.80 per level increase in education, 95% CI 0.75 to 0.85), consistent across countries and not modified by SEI. In men, Argentina, Brazil, Colombia, Chile and Mexico showed an inverse association (pooled OR: 0.92; 95% CI 0.86 to 0.99). Peru, Panama and El Salvador showed a positive relationship (pooled OR 1.24; 95% CI 1.04 to 1.49). For men, these associations were further modified by city-SEI: in countries with an inverse association, it became stronger as city-SEI increased. In countries where the association was positive, it became weaker as city-SEI increased.

Conclusion

Social inequities in diabetes inequalities increase as cities develop. To achieve non-communicable disease-related sustainable development goals in LMIC, there is an urgent need to develop policies aimed at reducing these educational inequities.

Life expectancy and mortality in 363 cities of Latin America

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

City-level analysis of data from the SALURBAL project shows vast heterogeneity in life expectancy across cities within the same country, in addition to substantive differences in causes of death among nine Latin American countries, revealing modifiable factors that could be leveraged by municipal-level policies aimed toward improving health in urban environments.

Socioeconomic position and cardiovascular mortality in 63 million adults from Brazil

BACKGROUND

It has been suggested that cardiovascular disease exhibits a 'social cross-over', from greater risk in higher socioeconomic groups to lower socioeconomic groups, on economic development, but robust evidence is lacking. We used standardised data to compare the social inequalities in cardiovascular mortality across states at varying levels of economic development in Brazil.

METHODS

We used national census and mortality data from 2010. We used age-adjusted multilevel Poisson regression to estimate the association between educational status and cardiovascular mortality by state-level economic development (assessed by quintiles of Human Development Index).

RESULTS

In 2010, there were 185 383 cardiovascular deaths among 62.5 million adults whose data were analysed. The age-adjusted cardiovascular mortality rate ratio for women with <8 years of education (compared with 8+ years) was 3.75 (95% CI 3.29 to 4.28) in the least developed one-fifth of states and 2.84 (95% CI 2.75 to 2.92) in the most developed one-fifth of states (p value for linear trend=0.002). Among men, corresponding rate ratios were 2.53 (95% CI 2.32 to 2.77) and 2.26 (95% CI 2.20 to 2.31), respectively (p value=0.258). Associations were similar across subtypes of cardiovascular disease (ischaemic heart disease and stroke) and robust to the size of geographical unit used for analysis.

CONCLUSIONS

Our results do not support a 'social crossover' in cardiovascular mortality on economic development. Our analyses, based on a large standardised dataset from a country that is currently experiencing economic transition, provide strong evidence that low socioeconomic groups experience the highest risk of cardiovascular disease, irrespective of the stage of national economic development.