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Ferguson BK, Wilson PB. Ordered Eating and Its Effects on Various Postprandial Health Markers: A Systematic Review. JOURNAL OF THE AMERICAN NUTRITION ASSOCIATION 2023; 42:746-757. [PMID: 36574255 DOI: 10.1080/27697061.2022.2161664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/18/2022] [Indexed: 10/25/2023]
Abstract
OBJECTIVE Aberrations in glucose, insulin, and other postprandial (PP) markers are common in obesity and cardiometabolic disorders. One potentially simple lifestyle/dietary modification to manage these issues is to change the order in which foods are consumed within meals. Carbohydrate exerts the largest effect on PP glucose, and there is some evidence that ingesting dietary fat or protein before carbohydrate delays gastric emptying of carbohydrate and reduces PP glucose. Additionally, certain dietary proteins may augment insulin release if ingested with carbohydrate, thereby improving blood glucose clearance. This review aimed to systematically evaluate evidence from acute experiments that modified the order in which foods were consumed in isocaloric meals. METHODS Outcomes of interest were PP glucose and insulin (including area under the curve for both), C-peptide, gut hormones, and perceptual responses. Three databases were searched (PubMed, Cochrane CENTRAL, Web of Science) in February 2022. Additionally, reference lists of identified reports were searched, and an author of several studies was consulted to verify that relevant literature was included. The review included acute interventions that administered isocaloric meals of the same foods but with foods eaten in different orders. Studies were not excluded based on participant characteristics. RESULTS Eleven reports were identified. All reports that assessed glucose and insulin showed a tendency toward lower levels, at least over parts of the PP period, by consuming carbohydrates last. GLP-1 tended to be higher in carbohydrate-last conditions, though this was only measured in a few studies. Perceptual responses (hunger, fullness, etc.) were not consistently different between conditions in two studies, but the certainty of evidence was very low. CONCLUSIONS Findings indicate that, at least acutely, there may be benefits to eating carbohydrate after vegetable and/or protein-rich foods. The most consistent effect (judged as moderate certainty) is that carbohydrate-last meal orders tend to lower blood glucose and insulin excursions.
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Affiliation(s)
- Brian K Ferguson
- Human Performance Laboratory, Human Movement Sciences Department, Old Dominion University, Norfolk, Virginia, USA
| | - Patrick B Wilson
- Human Performance Laboratory, Human Movement Sciences Department, Old Dominion University, Norfolk, Virginia, USA
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Morinaga A, Iwanaga K, Maki K, Ueno T, Kawano K, Funakoshi S, Yamanokuchi T, Tsuji M, Abe M, Satoh A, Kawazoe M, Maeda T, Yoshimura C, Takahashi K, Tada K, Ito K, Yasuno T, Kawanami D, Masutani K, Arima H. Association between serum ALT levels and incidence of new-onset diabetes in general population of Japanese: a longitudinal observational study (ISSA-CKD). BMJ Open 2023; 13:e074007. [PMID: 37550028 PMCID: PMC10407361 DOI: 10.1136/bmjopen-2023-074007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/24/2023] [Indexed: 08/09/2023] Open
Abstract
OBJECTIVE We aimed to clarify the relationship between serum alanine transaminase (ALT) levels and incidence of new-onset diabetes in a Japanese general population. SETTING Population-based retrospective cohort study using annual health check-up data for residents of Iki City, Nagasaki Prefecture, Japan. PARTICIPANTS A total of 5330 Japanese individuals (≥30 years old) without diabetes at baseline were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES Serum ALT levels were determined using an enzymatic method and were classified into gender-specific quartile groups as follows: group 1 (3-16 U/L in men and 3-13 U/L in women), group 2 (17-21 U/L in men and 14-16 U/L in women), group 3 (22-29 U/L in men and 17-22 U/L in women) and group 4 (30-428 U/L in men and 23-268 U/L in women). The study outcome was the incidence of diabetes (fasting glucose ≥7.0 mmol/L, non-fasting glucose ≥11.1 mmol/L, glycated haemoglobin ≥6.5% or use of glucose-lowering therapies). RESULTS After an average follow-up period of 5.0 years, 279 individuals developed diabetes. The incidence rate of diabetes increased with elevation of serum ALT levels (0.7% per 100 person-years in group 1, 0.9% in group 2, 0.9% in group 3 and 1.7% in group 4) (p<0.001 for trend). This association was significant after adjustment for other risk factors including age, sex, obesity, hypertension, dyslipidaemia, smoking, current daily alcohol intake and regular exercise (p<0.001 for trend). Comparable associations were observed between men and women (p=0.459 for interaction). CONCLUSION Serum ALT levels were associated with future development of diabetes in the general Japanese population.
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Affiliation(s)
- Akiko Morinaga
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazuyo Iwanaga
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kaori Maki
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tamami Ueno
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazumi Kawano
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Shunsuke Funakoshi
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Toshitaka Yamanokuchi
- Department of Physical Therapy, Faculty of Medical Science, Fukuoka International University of Health and Welfare, Fukuoka, Japan
| | - Masayoshi Tsuji
- Department of Lifestyle and Welfare Information, Kindai University Kyushu Junior College, Iizuka, Japan
| | - Makiko Abe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Atsushi Satoh
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Miki Kawazoe
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Toshiki Maeda
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Chikara Yoshimura
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Koji Takahashi
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kazuhiro Tada
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Kenji Ito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tetsuhiko Yasuno
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Daiji Kawanami
- Department of Endocrinology and Diabetes Mellitus, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Zhang S, Jiang H, Wang L, Jia X, Zhang J, Wang H, Zhang B, Wang Z, Ding G. Longitudinal relationship between body fat percentage and risk of type 2 diabetes in Chinese adults: Evidence from the China Health and Nutrition Survey. Front Public Health 2022; 10:1032130. [PMID: 36523583 PMCID: PMC9744757 DOI: 10.3389/fpubh.2022.1032130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/14/2022] [Indexed: 12/03/2022] Open
Abstract
Objective Body fat percentage (BF%) might be an alternative index of obesity which is the major risk factor for developing type 2 diabetes (T2D). We aim to longitudinally evaluated the relationship between BF% and risk of T2D. Methods A sample of 5,595 adults aged 18-65 who participated in two waves of China Health and Nutrition Survey (CHNS 2015 and 2018) was analyzed. Two level mixed-effects modified Poisson regression with robust estimation of variance stratified by sex was used to evaluate the risk ratios (RRs) for T2D according to quintiles of BF%, and the curves of receiver operating characteristic (ROC) were plotted to identify the optimal total and trunk BF% cut-off points for predicting an increased T2D risk. Results In males, compared with subjects in the first quintile of total BF%, those in the third (RR = 2.03, 95% CI 1.09-3.79), fourth (RR = 2.56, 95%CI 1.46-4.48), and fifth (RR = 2.16, 95%CI 1.22-3.82) quintile had higher risk of T2D after adjusting for all potential confounders (p-trend < 0.001). For females, the RR (95% CI) was 1.92 (1.14, 3.24) in the fifth quintile (p-trend = 0.014). Males and females with a trunk BF% >25.5 and 34.4% (≥ quintile 4), respectively, were at significantly increased risk of T2D (p-trend = 0.001). Besides, the optimal cut-off values of total and trunk BF% were 21.9 and 25.2% for males, and 36.7 and 30.3% for females, respectively. Conclusions The incident risk of T2D significantly increased over specific level of total and trunk BF% in both Chinese males and females, and the optimal BF% cut-off values were valuable for clinical application of BF% based on sex difference, which may be a cost-effective implementation for prevention and treatment of T2D in China.
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Affiliation(s)
- Siting Zhang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hongru Jiang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China
| | - Liusen Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China
| | - Xiaofang Jia
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China
| | - Jiguo Zhang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China
| | - Huijun Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China
| | - Bing Zhang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China
| | - Zhihong Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China,*Correspondence: Zhihong Wang
| | - Gangqiang Ding
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, China,Key Laboratory of Trace Elements and Nutrition, National Health Commission, Beijing, China,Gangqiang Ding
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Zhang S, Li W, Jia X, Zhang J, Jiang H, Wang L, Wang H, Zhang B, Wang Z, Ding G. Association of obesity profiles with type 2 diabetes in Chinese adults: Findings from the China health and nutrition survey. Front Nutr 2022; 9:922824. [PMID: 36176634 PMCID: PMC9513418 DOI: 10.3389/fnut.2022.922824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
AimsTo examine longitudinal associations of obesity profiles, continuous BMI, and waist circumference (WC) with the risk of type 2 diabetes in Chinese adults.MethodsData were derived from three waves (2009, 2015, and 2018) of the China Health and Nutrition Survey, and 3,595 adults aged 18–65 years who participated in at least two waves of the survey and had completed data were analyzed. Obesity profiles included BMI- or WC-related single obesity and combined obesity. Combined obesity was categorized into six groups including Group 1 with normal BMI and WC, Group 2 with normal BMI but pre-abdominal obesity, Group 3 with normal BMI but abdominal obesity, Group 4 with abnormal BMI (overweight and general obesity) and normal WC, Group 5 with abnormal BMI and pre-abdominal obesity, and Group 6 with abnormal BMI and abdominal obesity. Three-level mixed-effects logistic regressions with random intercept stratified by gender and restricted cubic splines were performed to examine ORs and 95%CIs for the risk of type 2 diabetes.ResultsIn men, compared with subjects of Group 1, those in Group 3 had higher risk, with an OR of 4.83 (95% CI: 1.99–11.74), followed by those in Group 6 (OR = 4.05, 95%CI: 2.32–7.08) and Group 5 (OR = 2.98, 95%CI: 1.51–5.87) after adjusting for all potential confounders. For women, the subject of Group 6 had highest risk (OR = 8.79, 95%CI: 4.04–19.12), followed by Group 3 (OR = 3.30, 95%CI: 1.23–8.86) and Group 5 (OR = 3.16, 95%CI: 1.21–8.26). No significant association between abnormal BMI and normal WC (Group 4) was observed in both genders. Type 2 diabetes risk increased steeply at BMI of 23.5 kg/m2 and 22.5 kg/m2 or higher, and WC of 82.0 cm and 83.0 cm or higher in Chinese adult men and women, respectively (p for overall <0.001).ConclusionChinese adults with pre-abdominal or abdominal obesity had a relative high risk of type 2 diabetes independent of BMI levels. Lower BMI (≤23.5 kg/m2 for men and ≤22.5 kg/m2 for women) and lower WC (82.0 cm for men and ≤83.0 cm for women) values than the current Chinese obesity cut-offs were found to predict the risk of type 2 diabetes. These findings urge to inform WC modification and optimization of early screening guidelines.
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Gui SY, Wu KJ, Sun Y, Chen YN, Liang HR, Liu W, Lu Y, Hu CY. Traffic noise and adiposity: a systematic review and meta-analysis of epidemiological studies. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:55707-55727. [PMID: 35320480 DOI: 10.1007/s11356-022-19056-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Abstract
Traffic noise has attracted much attention as a significant and intractable public health threat. This study was designed as a systematical review to explore the association of traffic noise with different indicators of obesity, thus providing updated quantitative estimates for the pooled effect estimates of the existing literature. We conducted an extensive search for epidemiological studies that investigated the association of traffic noise with obesity in three electronic databases till February 23, 2021. We used random-effects meta-analysis to calculate the summary effect estimates for each 10-dB(A) increase in noise and compared the highest with the lowest category of noise in relation to seven obesity indicators. Meanwhile, we assessed the risk of bias and the overall quality of the evidence of each study as well as the level of evidence for each exposure-outcome pair. The initial search identified 30 studies, 13 of which were ultimately included. The meta-analysis for the highest versus the lowest category of noise exposure was generally associated with higher waist circumfluence (WC) ranging from 0.326 cm (95% confidence interval (CI) = 0.078, 0.574) to 0.705 cm (95% CI = 0.071, 1.340) and higher odds of central obesity ranging from 1.055 (95% CI = 1.000, 1.109) to 1.167 (95% CI = 1.037, 1.298). When the continuous exposure (each 10 dB(A) increase in noise) was introduced, similar results were found. This study indicated positive associations of traffic noise with WC and central obesity. However, in consideration of some limitations, there is an urgent need for future studies to increase the sample size, discriminate the etiological differences in different noise and obesity indicators, and thoroughly consider socioeconomic status.
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Affiliation(s)
- Si-Yu Gui
- Department of Ophthalmology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, China
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Ke-Jia Wu
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Yue Sun
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Yue-Nan Chen
- Department of Clinical Pharmacy, School of Pharmacy, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Huan-Ru Liang
- Department of Clinical Medicine, The Second School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Wen Liu
- Department of Clinical Medicine, The First School of Clinical Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China
| | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, 218 Jixi Road, Hefei, 230022, China.
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China.
| | - Cheng-Yang Hu
- Department of Humanistic Medicine, School of Humanistic Medicine, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China.
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, 81 Meishan Road, Hefei, 230032, China.
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Shen QM, Li HL, Li ZY, Jiang YF, Ji XW, Tan YT, Xiang YB. Joint impact of BMI, physical activity and diet on type 2 diabetes: Findings from two population-based cohorts in China. Diabet Med 2022; 39:e14762. [PMID: 34877688 DOI: 10.1111/dme.14762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
AIMS Limited epidemiological data on the combined impact of several lifestyle factors on type 2 diabetes (T2D) incidence was reported in Chinese population. This study aimed to examine how combinations of BMI, physical activity and diet relate to T2D incidence and estimate corresponding population attributable risk in the general population. METHODS A total of 56,691 male and 70,849 female participants aged 40-74 years old in two population-based cohorts from the Shanghai Men's and Women's Health Studies were used for analysis. The Cox regression model was used to estimate the association between lifestyle factors collected at baseline and T2D incidence. Multivariable-adjusted population attributable risks were calculated for specific combinations of lifestyle factors. RESULTS There were 3315 male and 5925 female incident T2D, with corresponding density incidence rates of 6.39 and 6.04 per 1000 person-years. If the healthiest group of healthy lifestyle index (HLI) was used as a reference, the hazard ratios (95% confidence intervals) of T2D increased monotonically in men [2.04 (1.75, 2.38); 2.94 (2.53, 3.42); 4.31 (3.66, 5.07)] and women [1.85 (1.64, 2.08); 2.79 (2.49, 3.13); 4.14 (3.66, 4.67)]. One point increase of HLI was related to 35% and 35% lower risk in men and women. About 52.7% and 58.4% cases in men and women could have been avoided if participants had been adherent to a healthy lifestyle of maintaining healthy body weight, eating a healthy diet and keeping physically active. CONCLUSIONS An increased number of healthy lifestyle factors were associated with a decreased risk of T2D in the Chinese population. Future interventions targeted at combined healthy lifestyle factors are needed to reduce the burden of T2D.
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Affiliation(s)
- Qiu-Ming Shen
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong-Lan Li
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuo-Ying Li
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Fei Jiang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Wei Ji
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Ting Tan
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong-Bing Xiang
- State Key Laboratory of Oncogene and Related Genes & Department of Epidemiology, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Gottfredson LS. The Transition to Noncommunicable Disease: How to Reduce Its Unsustainable Global Burden by Increasing Cognitive Access to Health Self-Management. J Intell 2021; 9:61. [PMID: 34940383 PMCID: PMC8705641 DOI: 10.3390/jintelligence9040061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/25/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
The global epidemic of noncommunicable diseases (NCDs), such as cardiovascular disease and diabetes, is creating unsustainable burdens on health systems worldwide. NCDs are treatable but not curable. They are less amenable to top-down prevention and control than are the infectious diseases now in retreat. NCDs are mostly preventable, but only individuals themselves have the power to prevent and manage the diseases to which the enticements of modernity and rising prosperity have made them so susceptible (e.g., tobacco, fat-salt-carbohydrate laden food products). Rates of nonadherence to healthcare regimens for controlling NCDs are high, despite the predictable long-term ravages of not self-managing an NCD effectively. I use international data on adult functional literacy to show why the cognitive demands of today's NCD self-management (NCD-SM) regimens invite nonadherence, especially among individuals of below-average or declining cognitive capacity. I then describe ways to improve the cognitive accessibility of NCD-SM regimens, where required, so that more patients are better able and motivated to self-manage and less likely to err in life-threatening ways. For the healthcare professions, I list tools they can develop and deploy to increase patients' cognitive access to NCD-SM. Epidemiologists could identify more WHO "best buy" interventions to slow or reverse the world's "slow-motion disaster" of NCDs were they to add two neglected variables when modeling the rising burdens of disease. The neglected two are both cognitive: the distribution of cognitive capacity levels of people in a population and the cognitive complexity of their health environments.
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