Early Life and Adult Socioeconomic Influences on Mortality Risk: Preliminary Report of a ‘Pauper Rich’ Paradox in a Chilean Adult Cohort

Association of Anthropometric Indices With the Development of Diabetes Among Hypertensive Patients in China: A Cohort Study

Background

Patients with comorbidity of hypertension and diabetes are associated with higher morbidity and mortality of cardiovascular disease than those with hypertension or diabetes alone. The present study aimed to identify anthropometric risk factors for diabetes among hypertensive patients who were included in a retrospective cohort study.

Methods

Hypertensive adults without diabetes were recruited in China. Demographic, clinical, biochemical, and anthropometric indices were collected at baseline and during the follow-up. Anthropometric measures included BMI, waist circumference, waist-to-height ratio (WHtR), and waist-to-hip ratio, and several novel indices. To estimate the effect of baseline and dynamic changes of each anthropometric index on risk of new-onset diabetes (defined as self-reported physician-diagnosed diabetes and/or use of hypoglycemic medication, or new-onset FPG≥7.0 mmol/L during follow-up), Cox regression models were used.

Results

A total of 3852 hypertensive patients were studied, of whom 1167 developed diabetes during follow-up. Multivariate Cox regression analyses showed that there was a graded increased risk of incident diabetes with successively increasing anthropometric indices mentioned above (all P<0.05). Regardless of the baseline general obesity status, elevated WHtR was both related to higher risk of diabetes; the HRs (95%CI) of baseline BMI<24 kg/m2 & WHtR≥0.5 group and BMI≥24 kg/m2 & WHtR≥0.5 group were 1.34 (1.05, 1.72), 1.85 (1.48, 2.31), respectively. Moreover, the dynamic changes of WHtR could sensitively reflect diabetes risk. Diabetes risk significantly increased when patients with baseline WHtR<0.5 progressed to WHtR≥0.5 during the follow-up (HR=1.63; 95%CI, 1.11, 2.40). There was also a decreasing trend towards the risk of incident diabetes when baseline abnormal WHtR reversed to normal at follow-up (HR=1.93; 95%CI, 1.36, 2.72) compared with those whose WHtR remained abnormal at follow-up (HR=2.04; 95%CI, 1.54, 2.71).

Conclusions

Central obesity is an independent and modifiable risk factor for the development of diabetes among hypertensive patients. Measuring indices of central obesity in addition to BMI in clinics could provide incremental benefits in the discrimination of diabetes among Chinese hypertensive patients. Dynamic changes of WHtR could sensitively reflect changes in the risk of diabetes. Therefore, long-term monitoring of hypertensive patients using non-invasive anthropometric measures and timely lifestyle intervention could effectively reduce the development of diabetes.

Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda

Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.

Anthropometric Indicators of Adiposity Related to Body Weight and Body Shape as Cardiometabolic Risk Predictors in British Young Adults: Superiority of Waist-to-Height Ratio

Frequently reported poor dietary habits of young adults increase their risk of metabolic syndrome (MetS). Excess adiposity is the most established predictor of MetS, and numerous anthropometric measures have been proposed as proxy indicators of adiposity. We aimed to assess prevalence of MetS in young adult population and to make comparison between weight- and shape-oriented measures of adiposity to identify the best index in association with measured body fat and as a risk predictor for MetS. Healthy males and females aged 18-25 years from the Northwest of England were recruited using convenience sampling (n=550). As part of the assessment of the overall health of young adults, the biochemical variables and adiposity measures BMI, waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), new BMI, Body Adiposity Index (BAI), Clinica Universidad de Navarra-Body Adiposity Estimator (CUN-BAE), and A Body Shape Index (ABSI) were assessed. Linear regression analysis was used to investigate the association between the proxy indices of adiposity and measured percentage body fat. The odds ratio with 95% confidence interval was used to investigate the relationship between cardiometabolic (CM) risk factors and proxy measures of adiposity. The discriminatory power of these measures for diagnosis of MetS was investigated using area under the receiver operating characteristic curve. Body weight-related indicators of adiposity, particularly CUN-BAE, had stronger association with measured body fat compared with body shape-related indices. In relation with MetS, body shape-related indices, particularly elevated WC and WHtR, had stronger associations with CM risk compared with body weight-related measures. Amongst all indices, the best predictor for CM risk was WHtR, while ABSI had the weakest correlation with body fat, MetS, and CM risk. Indices directly associated with WC and specifically WHtR had greater diagnostic power in detection of CM risk in young adults.

HEALTH RISK TRANSITION AND LOW MORTALITY PATTERNS AMONG A NATIONAL COHORT OF ASPIRATIONAL THAI OPEN UNIVERSITY STUDENTS

In the last 50 years Thailand has achieved advanced demographic and health transitions. Many infectious diseases are controlled and infant and maternal mortality rates are among the lowest in the region. Within such a low mortality setting, however, substantial variations in health persist, with education being a major driver. This paper assesses the ongoing mortality transition in Thailand, examining relationships between risk factors and mortality outcomes among a large nationwide cohort of distance-learning Open University students, as well as examining the differential mortality benefit enjoyed by this educated group when compared with the general Thai population. The cohort comprised 87,151 participants, who in 2005 completed a questionnaire collecting detailed information on socio-demographics, health behaviours and health outcomes. Participants were aged 15-87 at baseline and lived in all regions of the country. Cohort members' citizen identification numbers were matched with official death registration records to identify mortality among participants. A total of 1401 deaths were identified up to November 2016. Results show cohort study participants experiencing mortality at approximately one-third of the rate of the general population in the same age and sex groups. The gap between the mortality rates in the two groups widened with increased age. Differential risk factor prevalence among the two populations, particularly lower overweight and obesity prevalence and lower cigarette smoking rates in the cohort, can explain some of this variation. The largely unmeasurable effect of aspiration for life improvement through distance education while embedded in their communities is shown by this study to have a powerful effect on mortality risk. With overall education levels, including higher education, rising in Thailand this growing group of educated aspirational Thais may represent future trends in Thai mortality. Identifying the drivers and characteristics of this mortality variation can help inform policies to provide health services and to help reduce mortality in the whole population.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

OBJECTIVE

To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.

DESIGN

Population-based natural experiment.

SETTING AND DATA SOURCES

Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011.

MAIN OUTCOMES

Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).

INDEPENDENT VARIABLES

Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.

MAIN RESULTS

Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.

CONCLUSIONS

Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Abdominal and general adiposity and level of asthma control in adults with uncontrolled asthma

RATIONALE

Abdominal adiposity may be an important risk factor for uncontrolled asthma in adults, controlling for general obesity. Whether the relationship, if present, is explained by other factors (e.g., asthma onset age, sex, and/or coexisting conditions) is unclear.

OBJECTIVES

To examine whether clinically applicable anthropometric measures of abdominal adiposity--waist circumference and waist-to-height ratio (WHtR)--are related to poorer asthma control in adults with uncontrolled asthma controlling for body mass index (BMI), and whether the relationship (if present) is explained by gastroesophageal reflux disorder (GERD), sleep quality, or obstructive sleep apnea (OSA) or differs by age of asthma onset or sex.

METHODS

Patients aged 18 to 70 years with uncontrolled asthma (n = 90) participated in a 6-month randomized clinical trial.

MEASUREMENTS AND MAIN RESULTS

Baseline measures included sociodemographics, standardized anthropometrics, Asthma Control Test (ACT), GERD Symptom Assessment Scale, Pittsburgh Sleep Quality Index, and Berlin Questionnaire for Sleep Apnea. Participants (mean [SD] age, 52 [12] yr) were racially and ethnically diverse, 67% women, and 69% overweight or obese, and 71% reported their age of asthma onset was 12 years or older. Participants had uncontrolled asthma (mean [SD] ACT score, 14.9 [3.7]) and low GERD symptoms score (0.6 [0.4]); 67% reported poor sleep quality, and 42% had a high OSA risk. General linear regression results showed that worse ACT scores were significantly associated with every SD increase in waist circumference (β = -1.03; 95% confidence interval [CI], -1.96 to -0.16; P = 0.02) and waist-to-height ratio (β = -1.16; 95% CI, -2.00 to -0.33; P = 0.008), controlling for sociodemographics. Waist-to-height ratio remained correlated with ACT (β = -2.30; 95% CI, -4.16 to -0.45; P = 0.02) after further adjusting for BMI. The BMI-controlled relationship between WHtR and ACT did not differ by age of asthma onset or sex (P > 0.05 for interactions) and persisted after additional adjustment for GERD, sleep quality, or OSA scores. Poor sleep quality was associated with worse ACT scores (β = -0.87; 95% CI, -1.71 to -0.03; P = 0.045) controlling for waist-to-height ratio, BMI, and sociodemographics.

CONCLUSIONS

Abdominal adiposity by waist-to-height ratio and poor sleep quality correlated with poorer asthma control in adults with uncontrolled asthma, after controlling for BMI and sociodemographics. These results warrant replication in larger studies of diverse populations. Clinical trial registered with www.clinicaltrials.gov (NCT 01725945).

[Cardiovascular risk of immigrants living in Spain according to origin and years of stay]

OBJECTIVE

To assess whether there are differences in the immigrant population in terms of the years since their arrival in Spain and their geographical area of origin.

DESIGN

A cross-sectional study was conducted in three immigrant groups.

PARTICIPANTS

The groups selected were: a group of Latin American immigrants (298), a group of North African immigrants (130) and a group from Eastern Europe (114). A control group of 100 from a Spanish population of similar age and sex was also included.

METHODS

Anthropometric variables were measured, including biochemical inflammatory markers, blood pressure and cardiovascular risk estimation according to the tables of the European Societies of Hypertension and Cardiology.

RESULTS

The cardiovascular risk of the three groups of immigrants is similar between them (added cardiovascular risk high or very high at 5.5% in Latin Americans, 4.3% in North Africans, and 1.6% in immigrants from eastern countries), but significantly lower than the Spanish control group (28%). After 8 years in Spain, cardiovascular risk increases in the three groups of immigrants, with those from North Africa and eastern countries being comparable to the Spanish group (added cardiovascular risk high or very high of 18.5% in North Africans, and 20% in group from eastern countries). This cardiovascular risk was higher than the other groups, including the Spanish control group (Latin American immigrants 48.7% vs 28% in Spanish group).

CONCLUSIONS

The cardiovascular risk of immigrants increases over the years in Spain, with this increase being higher if they come from Latin America. This increase becomes clinically significant after the 8 years of stay in Spain.

Changing trends in the prevalence and disparities of obesity and other cardiovascular disease risk factors in three racial/ethnic groups of USA adults

Objectives. To examine trends in the prevalence and disparities of traditional cardiovascular disease (CVD) risk factors among the major race/ethnic groups in the USA: non-Hispanic Whites (NHWs), non-Hispanic Blacks (NHBs), and Mexican Americans (MAs). Methods. We used cross-sectional trend analysis in women and men aged 25-84 years participating in the NHANES surveys, years 1988-1994 (n = 14,341) and 1999-2004 (n = 12,360). Results. The prevalence of obesity and hypertension increased significantly in NHW and NHB, both in men and women; NHB had the highest prevalence of obesity and hypertension in each time period. Diabetes prevalence showed a nonsignificant increasing trend in all groups and was higher in MA in both periods. Smoking significantly decreased in NHW men and NHB, the latter with the largest decline although the highest prevalence in each period; no changes were noted in MA, who had the lowest prevalence in both periods. Race/ethnic CVD risk factors disparities widened for obesity and hypercholesterolemia, remained unchanged for diabetes and hypertension, and narrowed for smoking. Conclusions. The increasing prevalence of obesity and hypertension underscores the need for better preventive measures, particularly in the NHB group that exhibits the worst trends. The decline in smoking rates may offset some of these unfavorable trends.

Overcoming barriers in the management of hypertension: the experience of the cardiovascular health program in chilean primary health care centers

Objective. To assess the blood pressure control and cardiovascular risk factors (CVRFs) in a population of hypertensive patients with access to care under a government-financed program, the Cardiovascular Health Program (CHP). Design. A cross-sectional and multicenter study. Setting. 52 primary care centers, metropolitan area of Santiago, Chile. Participants. 1,194 patients were selected by a systematic random sampling from a universe of 316,654 hypertensive patients. Key Measurements. Demographic information, blood pressure (BP) measurements, and CVRF were extracted from medical records of patients followed for a 12-month period. Results. 59.7% of patients reached target BP <140/90 mmHg. More women were captured in the sampling (2.1 : 1), achieving better BP control than men. Diabetic patients (26.4%) had worse BP control than nondiabetics. Antihypertensive medications were used in 91.5%, with multidrug therapy more frequent in patients with higher BP and more difficult control. Conclusions. The success in improving the BP control to values <140/90 mmHg from 45.3% to 59.7% underscores the contribution of this program in the Chilean primary care cardiovascular preventive strategies. However, fewer hypertensive men than women were captured by this program, and it is of concern the underperforming of BP control observed in diabetics.

Women's education level, maternal health facilities, abortion legislation and maternal deaths: a natural experiment in Chile from 1957 to 2007

BACKGROUND

The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).

METHODS

Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957-2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.

RESULTS

During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (-13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (-1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (-69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.

CONCLUSION

Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

Waist-to-height ratio is a better screening tool than waist circumference and BMI for adult cardiometabolic risk factors: systematic review and meta-analysis

Our aim was to differentiate the screening potential of waist-to-height ratio (WHtR) and waist circumference (WC) for adult cardiometabolic risk in people of different nationalities and to compare both with body mass index (BMI). We undertook a systematic review and meta-analysis of studies that used receiver operating characteristics (ROC) curves for assessing the discriminatory power of anthropometric indices in distinguishing adults with hypertension, type-2 diabetes, dyslipidaemia, metabolic syndrome and general cardiovascular outcomes (CVD). Thirty one papers met the inclusion criteria. Using data on all outcomes, averaged within study group, WHtR had significantly greater discriminatory power compared with BMI. Compared with BMI, WC improved discrimination of adverse outcomes by 3% (P < 0.05) and WHtR improved discrimination by 4-5% over BMI (P < 0.01). Most importantly, statistical analysis of the within-study difference in AUC showed WHtR to be significantly better than WC for diabetes, hypertension, CVD and all outcomes (P < 0.005) in men and women. For the first time, robust statistical evidence from studies involving more than 300 000 adults in several ethnic groups, shows the superiority of WHtR over WC and BMI for detecting cardiometabolic risk factors in both sexes. Waist-to-height ratio should therefore be considered as a screening tool.

Stagnant in cardiovascular prevention: alarming trends and persistent socioeconomic obstacles

Recently it has been suggested that the decline in cardiovascular mortality observed over the last 50 years may be coming to an end. This alarming trend, which has been noted mainly in younger adults from lower socioeconomic strata, may be linked to other changes, namely the increasing prevalence of modifiable risk factors, the most important of which is obesity. In contrast, our ability to predict cardiovascular risk continues to improve steadily, although it is unclear which will be its ability in designing more effective global preventive measures. Coronary heart disease appears to develop through multiple pathways, whose association with cardiovascular risk is mediated by complex processes involving numerous factors ranging from genetic predisposition to unfavorable socioeconomic circumstances. Although some attention has been paid to the latter, more effort has been put into controlling isolated risk factors. For example, numerous large studies have involved looking at the effect of single-drug therapies aimed at specific targets rather than examining more comprehensive approaches to managing multiple risk factors. In conclusion, an effective strategy for controlling modifiable risk factors in both individuals and populations must address this complex scenario and should consider significant socioeconomic factors such as education, income and the built environment. The unfavorable trend observed in cardiovascular health makes it essential that current preventive strategies are reassessed.