A systematic review of associations between non-communicable diseases and socioeconomic status within low- and lower-middle-income countries

Prognosis and risk factor assessment of patients with advanced lung cancer with low socioeconomic status: model development and validation

BACKGROUND

Lung cancer, a major global health concern, disproportionately impacts low socioeconomic status (SES) patients, who face suboptimal care and reduced survival. This study aimed to evaluate the prognostic performance of traditional Cox proportional hazards (CoxPH) regression and machine learning models, specifically Decision Tree (DT), Random Forest (RF), Support Vector Machine (SVM), and Extreme Gradient Boosting (XGBoost), in patients with advanced lung cancer with low SES.

DESIGN

A retrospective study.

METHOD

The 949 patients with advanced lung cancer with low SES who entered the hospice ward of a tertiary hospital in Wuhan, China, from January 2012 to December 2021 were randomized into training and testing groups in a 3:1 ratio. CoxPH regression methods and four machine learning algorithms (DT, RF, SVM, and XGBoost) were used to construct prognostic risk prediction models.

RESULTS

The CoxPH regression-based nomogram demonstrated reliable predictive accuracy for survival at 60, 90, and 120 days. Among the machine learning models, XGBoost showed the best performance, whereas RF had the lowest accuracy at 60 days, DT at 90 days, and SVM at 120 days. Key predictors across all models included Karnofsky Performance Status (KPS) score, quality of life (QOL) score, and cough symptoms.

CONCLUSIONS

CoxPH, DT, RF, SVM, and XGBoost models are effective in predicting mortality risk over 60-120 days in patients with advanced lung cancer with low SES. Monitoring KPS, QOL, and cough symptoms is crucial for identifying high-risk patients who may require intensified care. Clinicians should select models tailored to individual patient needs and preferences due to varying prediction accuracies.

REPORTING METHOD

This study was reported in strict compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Bridging the Gap: Reducing Health Inequities in Access to Preventive Health Care Services in Rural Communities in the Philippines

INTRODUCTION

We used an implementation science framework to investigate perceived health inequities in preventive health care initiatives in rural communities in the Philippines. We also identified health equity-focused quality improvement strategies.

METHODS

Three health care providers and 12 barangay clinic patients were interviewed.

RESULTS

Patient interviews showed that social determinants of health, respect, and attitudes toward health care providers affected patient empowerment to engage in self-management for noncommunicable diseases (NCDs). Health care providers identified six challenges in managing NCDs: (a) inefficient work processes; (b) staffing shortages; (c) insufficient access to low-cost medications; (d) inadequate primary preventive health education from the schools; (e) health care not considered a priority; and (f) lack of local government support.

DISCUSSION

Inadequate preventive health care and education intensify health access and resource inequities in rural communities in the Philippines. A multi-sectoral plan may improve rural health infrastructure and education toward improving health care access and decreasing care disparities.

Quantitative Definition of Low-Health-Interest Populations by Using Regression Trees: A Nationwide Internet Survey in Japan

BACKGROUND

Reducing health disparities is a public health issue. Identification of low-health-interest populations is important, but a definition of people with low health interest has not yet been established. We aimed to quantitatively define low-health-interest populations.

METHODS

A nationwide cross-sectional internet survey was conducted in 2022. We compiled regression tree (RT) analyses with/without adjustment for age, sex, and socioeconomic status with the 12-item Interest in Health Scale (IHS, score range 12-48) as an explanatory variable and the 10 composite health behaviors as a dependent variable. We defined the first IHS branching condition from the root node as a lower-health-interest group and the terminal node with the lowest health behaviors as the lowest-health-interest group.

RESULTS

The mean IHS value of 22,263 analyzed participants was 32.1 ± 5.6; it was higher in females and in those who were aged over 45 years, had a high education, a high income, or a spouse. The first branching condition was IHS 31.5, and the terminal node branched at 24.5, before/after adjustment for covariates.

CONCLUSIONS

We determined the cutoff values of the IHS as <32 for a lower-health-interest group and <25 for the lowest-health-interest group. Using these cutoffs might enable us to reveal the characteristics of low-health-interest populations.

Association between socioeconomic status and risk of chronic obstructive pulmonary disease in China: a prospective cohort study

OBJECTIVE

Socioeconomic status (SES) has been proven to be associated with chronic obstructive pulmonary disease (COPD) in Western populations, but the evidence is very limited in China. This study aimed to investigate the association between SES and the risk of COPD incident.

METHODS

This study was based on the China Kadoorie Biobank (CKB) project in Wuzhong District, Suzhou. A total of 45,484 adults aged 30-79 were included in the analysis during 2004-2008. We used Cox proportional hazard models to investigate the association between SES and the risk of COPD. Household income, education, private property and consumption potential was used to measure SES. Incident COPD cases were ascertained using hospitalization records, death certificates, and active follow-up.

RESULTS

A total of 524 COPD cases were identified during a median follow-up of 11.2 years. Household income was inversely associated with the risk of COPD (Ptrend<0.005). The adjusted hazard ratios (95% confidence intervals) for incident COPD were 0.88 (0.69-1.14), 0.77 (0.60-0.99), and 0.42 (0.31-0.57) for participants with annual household income of 10,000 ~ 19,999 yuan, 20,000 ~ 34,999 yuan and ≥ 35,000 yuan respectively, in comparison to participants with an annual household income < 10,000 yuan. Furthermore, we found that education level, refrigerator use, private toilet, private phone, and motor vehicle were adversely associated with COPD risk, while ownership of newly renovated flats was positively correlated with COPD incident.

CONCLUSIONS

This prospective study suggests that SES is associated with the risk of COPD in Chinese adults. Population-based COPD prevention strategies tailored for people with different SES could help reduce the burden of COPD in Chinese.

Standardized Wound Care: Patchwork Practices?

Standardized care is crucial in health care for ensuring consistent, safe, high-quality, efficient, and evidence-based practices. Care pathways that standardize procedures promote adherence to best practices, reduce variability in treatment, and encourage collaboration among health care teams. This approach ultimately improves patient outcomes, enhances safety, and boosts the overall effectiveness of health care services. However, despite these benefits being widespread across most of the U.S. health care system, wound care stands out as an area where standards can vary significantly. The inconsistency in wound care standards in the United States can be traced to several factors. These include limited structured clinical wound care education, the discretion of health care providers in different business environments, differences in wound care settings, varying access to advanced treatments and technology, patient demographics and socioeconomic status, as well as differences in state laws and regional or institutional practices. Addressing these disparities requires a comprehensive approach that considers the complex interplay of the abovementioned factors. Active measures are needed to improve access, equity, and the quality of wound care services for all patients, regardless of where they live, their socioeconomic status, their health care coverage, or the business interests of providers and their institutions as well as of vendors marketing wound care products inconsistent with evidence-based practice. By understanding and actively addressing these factors, we can work toward achieving more standardized, evidence-based, and patient-centered practices in wound care across the nation.

Molecular Morbidity Score-Can MicroRNAs Assess the Burden of Disease?

Multimorbidity refers to the presence of two or more chronic diseases and is associated with adverse outcomes for patients. Factors such as an ageing population have contributed to a rise in prevalence of multimorbidity globally; however, multimorbidity is often neglected in clinical guidelines. This is largely because patients with multimorbidity are systematically excluded from clinical trials. Accordingly, there is an urgent need to develop novel biomarkers and methods of prognostication for this cohort of patients. The hallmarks of ageing are now thought to potentiate the pathogenesis of multimorbidity. MicroRNAs are small, regulatory, noncoding RNAs which have been implicated in the pathogenesis and prognostication of numerous chronic diseases; there is a substantial body of evidence now implicating microRNA dysregulation with the different hallmarks of ageing in the aetiology of chronic diseases. This article proposes using the hallmarks of ageing as a framework to develop a panel of microRNAs to assess the prognostic burden of multimorbidity. This putative molecular morbidity score would have many potential applications, including assessing the efficacy of clinical interventions, informing clinical decision making and facilitating wider inclusion of patients with multimorbidity in clinical trials.

Impact of population ageing on cancer-related disability-adjusted life years: A global decomposition analysis

Background

As the global population ages, the burden of cancer is increasing. We aimed to assess the impact of population ageing on cancer-related disability-adjusted life years (DALYs).

Methods

We used the decomposition method to estimate the impact of ageing, population growth, and epidemiological change on cancer-related DALYs from 1990 to 2019, stratified by 204 countries/territories and by their sociodemographic index (SDI). This approach separates the net effect of population ageing from population growth and change in age-specific DALY rates.

Results

Cancer-related DALYs among individuals aged ≥65 years increased by 95.14% between 1990 (52.25 million) and 2019 (101.96 million). Population growth was the main contributor to cancer-related DALYs (92.38 million, attributed proportion: 60.91%), followed by population ageing (41.38 million, 27.28%). Cancer-related DALYs attributed to population ageing followed a bell-shaped pattern when stratified by SDI, meaning they peaked in middle-SDI countries. Cancer-related DALYs attributed to ageing increased in 171 and decreased in 33 countries/territories. The top three cancer types with the highest increase in the absolute number of cancer-related DALYs associated with ageing were tracheal, bronchus, and lung (8.72 million); stomach (5.06 million); and colorectal (4.28 million) cancers, while the attributed proportion of DALYs was the highest in prostate (44.75%), pancreatic (40.93%), and non-melanoma skin (38.03%) cancers.

Conclusions

Population ageing contributed to global cancer-related DALYs, revealing a bell-shaped pattern when stratified by socioeconomic development, affecting middle-SDI countries the most. To respond to the growing ageing population and reduce cancer-related DALYs, it is necessary to allocate health care resources and prioritize interventions for older adults.

Determinants of mortality status and population attributable risk fractions of the North West Province, South African site of the international PURE study

BACKGROUND

Mortality data and comparative risk assessments from sub-Saharan Africa are limited. There is an urgent need for high quality population health surveys to be conducted, to improve the national health surveillance system. Our aim was to perform a comparative risk assesment and report on the mortality status and cause of death data of participants from a South African site of the international Prospective Urban Rural Epidemiology study.

METHODS

1 921 Black participants were included, with a median observational time of 13 years resulting in 21 525 person-years. We performed a comparative risk assessment considering four health status domains: locality (rural vs. urban), socio-economic status (SES) (education and employment), lifestyle factors (physical activity, smoking and alcohol consumption) and prevalent diseases (human immunodeficiency virus (HIV), type 2 diabetes mellitus and hypertension). Next, population-attributable fractions (PAFs) were calculated to determine the mortality risk attributable to modifiable determinants.

RESULTS

577 all-cause deaths occurred. Infectious diseases (28.1% of all deaths) were the most frequent cause of death, followed by cardiovascular disease (CVD) (22.4%), respiratory diseases (11.6%) and cancer (11.1%). The three main contributors to all-cause mortality were HIV infection, high SES and being underweight. HIV infection and underweight were the main contributors to infectious disease mortality and hypertension, the urban environment, and physical inactivity to CVD mortality. HIV had the highest PAF, followed by physical inactivity, alcohol and tobacco use and hypertension (for CVD mortality).

CONCLUSION

This African population suffers from a quadruple burden of disease. Urban locality, high SES, prevalent disease (HIV and hypertension) and lifestyle factors (physical inactivity, tobacco and alcohol use) all contributed in varying degrees to all-cause and cause-specific mortalities. Our data confirm the public health importance of addressing HIV and hypertension, but also highlights the importance of physical inactivity, tobacco use and alcohol consumption as focal points for public health strategies to produce the most efficient mortality reduction outcomes.

Impacts of Poverty and Lifestyles on Mortality: A Cohort Study in Predominantly Low-Income Americans

INTRODUCTION

Low socioeconomic status has been linked to increased mortality. However, the impacts of poverty, alone or combined with health behaviors, on mortality and life expectancy have not been adequately investigated.

METHODS

Data from the Southern Community Cohort Study was used, including nearly 86,000 participants recruited during 2002-2009 across 12 US southeastern states. Analysis was conducted from February 2022 to January 2023.

RESULTS

During a median follow-up of 12.1 years, 19,749 deaths were identified. A strong dose-response relationship was found between household incomes and mortality, with a 3.3-fold (95%CI=3.1-3.6) increased all-cause mortality observed for individuals in the lowest income group (<$15,000/year) compared with those in the highest group (≥$50,000/year). Within each income group, mortality monotonically increased with declining healthy lifestyle score. Risk was significantly lower among those in the lowest income but healthiest lifestyle group, compared to those with the highest income but unhealthiest lifestyle (HR=0.82, 95%CI=0.69-0.97). Poor White participants appeared to experience higher all-cause mortality than poor Black participants. Life expectancy was more than 10.0 years shorter for those in the lowest income group compared with those in the highest income group.

CONCLUSIONS

Poverty is strongly associated with increased risk of death, but the risks could be modestly abated by a healthier lifestyle. These findings call for a comprehensive strategy for enhancing a healthy lifestyle and improving income equality to reduce death risks, particularly among those experiencing health disparities due to poverty.

Effects of Garlic on Glucose Parameters and Lipid Profile: A Systematic Review and Meta-Analysis on Randomized Controlled Trials

(1) Background: The effect of garlic on glucose and lipid metabolism in humans remains controversial. The aim of this study was to investigate the effects of garlic on blood lipid levels and glucose levels in humans through a systematic review and meta-analysis. (2) Methods: We extensively searched four databases, including PubMed, Web of Science, Embase, and the Cochrane Library, up to February 2024. To assess the collective impact of garlic and its supplements on fasting blood glucose (FBG), glycosylated hemoglobin (HbA1c), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglycerides (TG), an analysis was conducted using a random effects model. Subgroup analyses were performed when I2 < 50%. (3) Result: We found that the garlic intervention was effective in controlling FBG (mean difference = -7.01; 95% CI: -8.53, -5.49, p < 0.001), HbA1c (mean deviation = -0.66; 95% CI: -0.76, -0.55, p < 0.001, I2 = 62.9%), TC (mean difference = -14.17; 95% CI: -19.31, -9.03, p < 0.001), and LDL-C (mean difference = -8.20; 95% CI: -15.58, -0.81, p = 0.03); moreover, it also increased the level of HDL-C in humans (mean difference = 2.06; 95% CI: 1.54, 2.59; p < 0.001). Nonetheless, the intervention involving garlic did not yield a substantial impact on triglyceride (TG) levels. (4) Conclusion: The intervention of garlic is beneficial to control blood glucose and blood lipids in humans.

The effect of socioeconomic status, depression, and diabetes symptoms severity on diabetes patient's life satisfaction in India

Evidence suggests that diabetes is on the rise in India, affecting many people's life satisfaction. Comprehensive estimation of life satisfaction among diabetes patients does not exist in the country. This study examined the effects of socioeconomic status, depression, and diabetes symptoms severity on the life satisfaction of diabetes patients by controlling various demographic variables. It was a cross-sectional study comprising 583 diabetes patients from Punjab, India. Patients were interviewed using a multi-stage purposeful random sampling method. Descriptive analysis and partial least squares structural equation modelling were used in the study to test the hypotheses. Results revealed that socioeconomic status, depression and diabetes symptoms severity significantly influence the life satisfaction of diabetes patients. A 1% drop in diabetes symptoms severity corresponds to a 0.849% increase in life satisfaction, whereas a 1% decrease in depression results in a 0.898% increase in life satisfaction. Patients with higher diabetes symptoms severity were coping with common mental disorders. Women reported higher diabetes symptoms severity and depression than men, resulting in lower life satisfaction. An experimental evaluation of the effects of socioeconomic status, depression and diabetes symptoms severity, and numerous demographic factors on life satisfaction was reported. The findings will help policymakers understand the problem associated with life satisfaction among diabetes patients in the country.

Multimorbid life expectancy across race, socio-economic status, and sex in South Africa

Multimorbidity is increasing globally as populations age. However, it is unclear how long individuals live with multimorbidity and how it varies by social and economic factors. We investigate this in South Africa, whose apartheid history further complicates race, socio-economic, and sex inequalities. We introduce the term 'multimorbid life expectancy' (MMLE) to describe the years lived with multimorbidity. Using data from the South African National Income Dynamics Study (2008-17) and incidence-based multistate Markov modelling, we find that females experience higher MMLE than males (17.3 vs 9.8 years), and this disparity is consistent across all race and education groups. MMLE is highest among Asian/Indian people and the post-secondary educated relative to other groups and lowest among African people. These findings suggest there are associations between structural inequalities and MMLE, highlighting the need for health-system and educational policies to be implemented in a way proportional to each group's level of need.

Investigating the role of the built environment, socio-economic status, and lifestyle factors in the prevalence of chronic diseases in Mashhad: PLS-SEM model

Background

Chronic diseases remain a significant contributor to both mortality and disability in our modern world. Physical inactivity and an unhealthy diet are recognized as significant behavioral risk factors for chronic diseases, which can be influenced by the built environment and socio-economic status (SES). This study aims to investigate the relationship between the built environment, SES, and lifestyle factors with chronic diseases.

Methods

The current study was conducted in Mashhad's Persian cohort, which included employees from Mashhad University of Medical Sciences (MUMS). In the study, 5,357 participants from the cohort were included. To assess the state of the built environment in Mashhad, a Geographic Information System (GIS) map was created for the city and participants in the Persian Mashhad study. Food intake and physical exercise were used to assess lifestyle. A food frequency questionnaire (FFQ) was used to assess food intake. To assess food intake, the diet quality index was computed. To assess the link between variables, the structural model was created in accordance with the study's objectives, and partial least square structural equation modeling (PLS-SEM) was utilized.

Results

The chronic diseases were positively associated with male sex (p < 0.001), married (p < 0.001), and higher age (p < 0.001). The chronic diseases were negatively associated with larger family size (p < 0.05), higher SES (p < 0.001), and higher diet quality index (DQI) (p < 0.001). No significant relationship was found between chronic disease and physical activity.

Conclusion

Food intake and socioeconomic status have a direct impact on the prevalence of chronic diseases. It seems that in order to reduce the prevalence of chronic diseases, increasing economic access, reducing the class gap and increasing literacy and awareness should be emphasized, and in the next step, emphasis should be placed on the built environment.

The prevalence of cardiovascular disease risk factors among adults living in extreme poverty

Evidence on cardiovascular disease (CVD) risk factor prevalence among adults living below the World Bank's international line for extreme poverty (those with income <$1.90 per day) globally is sparse. Here we pooled individual-level data from 105 nationally representative household surveys across 78 countries, representing 85% of people living in extreme poverty globally, and sorted individuals by country-specific measures of household income or wealth to identify those in extreme poverty. CVD risk factors (hypertension, diabetes, smoking, obesity and dyslipidaemia) were present among 17.5% (95% confidence interval (CI) 16.7-18.3%), 4.0% (95% CI 3.6-4.5%), 10.6% (95% CI 9.0-12.3%), 3.1% (95% CI 2.8-3.3%) and 1.4% (95% CI 0.9-1.9%) of adults in extreme poverty, respectively. Most were not treated for CVD-related conditions (for example, among those with hypertension earning <$1.90 per day, 15.2% (95% CI 13.3-17.1%) reported taking blood pressure-lowering medication). The main limitation of the study is likely measurement error of poverty level and CVD risk factors that could have led to an overestimation of CVD risk factor prevalence among adults in extreme poverty. Nonetheless, our results could inform equity discussions for resource allocation and design of effective interventions.

Social determinants of chronic diseases reporting among slum dwellers in Egypt

The high prevalence of chronic diseases in urban slums poses increasing challenges to future social and economic development for these disadvantaged areas. Assessing the health status of slum residents offers guidance for formulating appropriate policies and interventions to improve slum residents' health outcomes. This research aimed to identify the social determinants of chronic diseases reporting among slum dwellers in Egypt. A cross-sectional survey was conducted from March to December 2021 in three slum areas in Giza governorate, Egypt, including 3,500 individuals. We constructed an asset index and a welfare index to measure the economic status and living conditions of slum residents, respectively. We used these indices, along with demographic and socio-economic factors, as independent variables in the analysis. We modeled factors associated with health status using a two-level mixed logistic model to control the effects of slum areas and the potential correlation between household members. The study contributed significantly to a better understanding of the context in which slum dwellers live and the interlinkages among poor living conditions, low economic status, and health outcomes. The results showed a high rate of self-reported chronic diseases among adults aged 18 and older, reaching more than 22%, while it did not exceed 2.0% among children in the slum areas. Therefore, measuring the determinants of chronic diseases was limited to adults. The sample size was 2530 adults after excluding 970 children. The prevalence of chronic diseases among adults ranged between 16.3% in Zenin and 22.6% in Bein El Sarayat. Our findings indicated that low socio-economic status was significantly associated with reporting chronic diseases. Future policies should be dedicated to improving living conditions and providing necessary healthcare services for these vulnerable areas.

Prevalence of Diabetes and the Relationship Between Wealth and Social Demographic Characteristics Across 6 Low-and-Middle Income Countries

Background

As the global burden of diabetes persists, research is needed to understand the role of wealth and correlates of diabetes across regions of the world. The purpose of this study is to examine the prevalence and role of wealth and diabetes across 6 low- and middle- income countries while also accounting for independent correlates of diabetes by country.

Methods

Data from the Study on Global Ageing and Adult Health (SAGE), SAGE Wave 1 was used. Self-reported diabetes status was the primary dependent variable and wealth quintile, number of dwelling characteristics and possession of a set of assets, was the independent variable. Logistic regression models examined the relationship between wealth and presence of diabetes across 6 countries with the highest wealth quintile, quintile 1, serving as the reference group.

Results

Sample size by country included Ghana N = 5573, South Africa N = 4227, Russia N = 4947, Mexico N = 5448, India N = 12198, and China N = 15050. Average age across country ranged from 49 to 63 years of age. Prevalence of diabetes across country included 3.4% and 9.2% for Ghana and South Africa, respectively. In Russia, 8.3%; Mexico, 18.1%; India, 4.9%; and China, 5.9% of the sample reported having diabetes. In the adjusted logistic model, wealth was associated with higher odds of diabetes in Ghana (OR 2.26; CI 1.28; 4.13), South Africa (OR 4.57; CI 2.25; 10.32), Mexico (OR 2.00; CI 1.14; 3.60), India (OR 2.45; CI 1.60; 3.86), and China (OR 2.16; CI 1.62, 2.93).

Conclusions

These findings add to the growing body of evidence in our understanding between wealth and diabetes. As diabetes persists as a leading cause of death globally, future work should focus on mechanisms underlying the relationship between wealth and diabetes while also developing interventions to mitigate his burgeoning disease affecting communities across low- and middle-income countries.

Factors associated with happiness among community-dwelling older adults: a systematic review

OBJECTIVES

To identify factors associated with self-reported happiness among community-dwelling older adults.

METHODS

A systematic review of the literature was conducted. Searches were conducted in the PsycInfo, Web of Science, Scopus and Pubmed databases for relevant articles published in English, Spanish or Portuguese using the following search strategy and Boolean operators: (happiness*) AND (elder* OR (old adult*)). No restriction was imposed with regards to year of publication. This review was registered in PROSPERO (CRD42018107302).

RESULTS

Forty-six articles met the eligibility criteria and were included in the review. Economic, social and health-related factors were associated with happiness among community-dwelling older adults. The sociodemographic characteristics of older adults, such as the female sex, being married, an older age, a higher level of schooling and having a religion, were also associated with happiness.

CONCLUSIONS

The articles included in the present systematic review demonstrate that social, economic and health-related aspects have an association with happiness in community-dwelling older adults.

Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases

High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.

A drink equals how many cigarettes? Equating mortality risks from alcohol and tobacco use in Canada

Objective

To quantify and communicate risk equivalencies for alcohol-and tobacco-attributable mortality by comparing per standard drinks consumed to per number of cigarettes smoked in Canada.

Methods

Alcohol-and tobacco-attributable premature deaths (≤75 years of age) and years of life lost (YLL) were estimated using a lifetime risk modeling approach. Alcohol-attributable death statistics were obtained from the 2023 Canadian Guidance on Alcohol and Health data source. Tobacco-attributable death statistics were derived from the Mortality Population Risk Tool (MPoRT) model.

Results

The risk of alcohol use on premature death and YLL increased non-linearly with the number of drinks consumed, while the risk for tobacco use on these two measures increased linearly with the number of cigarettes smoked. Males who consumed 5 drinks/day-a standard drink contains 13.45 grams of alcohol in Canada-had an equivalent risk as smoking 4.9 cigarettes/day (when modeling for premature death) and 5.1 cigarettes/day (when modeling for YLL). Females who consumed 5 drinks/day experienced an equivalent risk as smoking 4.2 cigarettes/day for premature deaths and YLL. At all levels of alcohol consumption females and males who consumed <5 drinks/day have less risks from consuming a standard drink than from smoking a cigarette. For males who consumed 5 drinks/day, the increased risks of death from per drink consumed and per cigarette smoked were equal.

Conclusion

Risk equivalencies comparing alcohol use to tobacco use could help people who drink improve their knowledge and understanding of the mortality risks associated with increased number of drinks consumed per day.

The effect of PFAS exposure on glucolipid metabolism in children and adolescents: a meta-analysis

Background

Previous studies showed that per- and polyfluoroalkyl substances (PFAS), which are widely found in the environment, can disrupt endocrine homeostasis when they enter the human body. This meta-analysis aimed to evaluate current human epidemiological evidence on the relationship between PFAS exposure and glucolipid metabolism in childhood and adolescence.

Methods

We searched PubMed, Web of Science, Embase, and Cochrane Library databases, and identified population-based epidemiological studies related to PFAS and glucolipid metabolism indexes that were published before 30 December 2022. The heterogeneity of the included literature was assessed using the I-square (I2) test and statistics Q. Random-effects and fixed-effects models were used to combine the effect size. Subgroup analysis based on age and sex of the study participants was performed. A sensitivity analysis was used to evaluate the robustness and reliability of the combined results. Egger's and Begg's tests were used to analyze publication bias.

Results

A total of 12 studies were included in this analysis. There was a positive association between PFAS and TC (β = 1.110, 95% CI: 0.601, 1.610) and LDL (β = 1.900, 95% CI: 1.030, 2.770), and a negative association between PFAS and HOMA-IR in children and adolescents (β = -0.130, 95% CI: -0. 200, -0.059). PFOS was significant positive associated with TC (β = 8.22, 95% CI: 3.93, 12.51), LDL (β = (12.04, 95% CI: 5.08, 18.99), and HOMA-IR (β = -0.165, 95% CI: -0.292, -0.038). Subgroup analysis showed that exposure to PFAS in the adolescent group was positively associated with TC and LDL levels, and the relationship was stronger in females.

Conclusion

PFAS exposure is associated with glucolipid metabolism in children and adolescents. Among them, PFOS may play an important role. Recognition of environmental PFAS exposure is critical for stabilizing the glycolipid metabolism relationship during the growth and development of children and adolescents.

Assessing the effects of air pollution and residential greenness on frailty in older adults: a prospective cohort study from China

Many studies have established a correlation between air pollution and green space with age-related diseases, yet the relationship between air pollution, green space, and frailty among older adults is not fully understood. The primary objective of this investigation is to examine the longitudinal association among air pollution, green space, and frailty in older adults, as well as the potential interaction and mediating effect. Analyzed data were obtained from the multi-wave CLHLS investigation (2008-2018). The participants' environmental exposure was evaluated using six air pollutants (PM1, PM2.5, PM10, PM10-2.5, O3, and NO2), and normalized difference vegetation index (NDVI). Annual ambient air pollutants were estimated using satellite-based spatiotemporal models. Time-varying Cox proportional risk models were employed to investigate the longitudinal relationships between air pollutants, greenness, and the onset of frailty in the elderly population. We conducted a variety of subgroup analyses, sensitivity analyses, and assessed potential interaction and causal mediating effects. A total of 6953 eligible elderly individuals were enrolled in our study. In the fully adjusted model, per IQR uptick in levels of PM1, PM2.5, PM10, PM10-2.5, O3, and NO2 corresponded to a 17% (95% CI 1.10-1.24), 25% (95% CI 1.17-1.34), 29% (95% CI 1.20-1.39), 35% (95% CI 1.24-1.47), 12% (95% CI 1.04-1.20), and 11% (95% CI 1.05-1.18) increase in frailty risk, respectively. For NDVI, increased IQR was significantly negatively associated with the risk of frailty (aHR 0.82, 95% CI 0.77-0.87). Our results revealed a significant interaction effect among O3, NO2, and residential greenness. PM1, PM2.5, PM10, and PM10-2.5 play a mediating role in the estimated relationship between residential greenness and frailty. In summary, our study reveals that PM1, PM2.5, PM10, PM10-2.5, O3, and NO2 correspond to elevated risks of frailty in the elderly. Residential greenness is associated with a lower risk of frailty in the elderly. Residential greenness can exert a positive impact on frailty by reducing particulate matter concentrations.

Overadjustment bias in systematic reviews and meta-analyses of socio-economic inequalities in health: a meta-research scoping review

BACKGROUND

Overadjustment bias occurs when researchers adjust for an explanatory variable on the causal pathway from exposure to outcome, which leads to biased estimates of the causal effect of the exposure. This meta-research review aimed to examine how previous systematic reviews and meta-analyses of socio-economic inequalities in health have managed overadjustment bias.

METHODS

We searched Medline and Embase until 16 April 2021 for systematic reviews and meta-analyses of observational studies on associations between individual-level socio-economic position and health outcomes in any population. A set of criteria were developed to examine methodological approaches to overadjustment bias adopted by included reviews (rated Yes/No/Somewhat/Unclear).

RESULTS

Eighty-four reviews were eligible (47 systematic reviews, 37 meta-analyses). Regarding approaches to overadjustment, whereas 73% of the 84 reviews were rated as Yes for clearly defining exposures and outcomes, all other approaches were rated as Yes for <55% of reviews; for instance, 5% clearly defined confounders and mediators, 2% constructed causal diagrams and 35% reported adjusted variables for included studies. Whereas only 2% included overadjustment in risk of bias assessment, 54% included confounding. Of the 37 meta-analyses, 16% conducted sensitivity analyses related to overadjustment.

CONCLUSIONS

Our findings suggest that overadjustment bias has received insufficient consideration in systematic reviews and meta-analyses of socio-economic inequalities in health. This is a critical issue given that overadjustment bias is likely to result in biased estimates of health inequalities and accurate estimates are needed to inform public health interventions. There is a need to highlight overadjustment bias in review guidelines.

Socioeconomic status is negatively associated with immunosenescence but positively associated with inflammation among middle-aged women in Cebu, Philippines

BACKGROUND

Socioeconomic status (SES) gradients in health are well-documented, and while biological pathways are incompletely understood, chronic inflammation and accelerated immune aging (immunosenescence) among lower SES individuals have been implicated. However, previous findings have come from samples in higher income countries, and it is unclear how generalizable they are to lower- and middle-income countries (LMIC) with different infectious exposures and where adiposity-an important contributor to chronic inflammation-might show different SES patterning. To address this gap, we explored associations between SES and inflammation and immunosenescence in a sample of women in Cebu, Philippines.

METHODS

Data came from the mothers of the Cebu Longitudinal Health and Nutrition Survey birth cohort (mean age: 47.7, range: 35-69 years). SES was measured as a combination of annual household income, education level, and assets. Chronic inflammation was measured using C-reactive protein (CRP) in plasma samples from 1,834 women. Immunosenescence was measured by the abundance of exhausted CD8T (CD8 + CD28-CD45RA-) and naïve CD8T and CD4T cells, estimated from DNA methylation in whole blood in a random subsample of 1,028. Possible mediators included waist circumference and a collection of proxy measures of pathogen exposure.

RESULTS

SES was negatively associated with the measures of immunosenescence, with slight evidence for mediation by a proxy measure for pathogen exposure from the household's drinking water source. In contrast, SES was positively associated with CRP, which was explained by the positive association with waist circumference.

CONCLUSIONS

Similar to higher income populations, in Cebu there is an SES-gradient in pathogen exposures and immunosenescence. However, lifestyle changes occurring more rapidly among higher SES individuals is contributing to a positive association between SES and adiposity and inflammation. Our results suggest more studies are needed to clarify the relationship between SES and inflammation and immunosenescence across LMIC.

Lower regional urbanicity and socioeconomic status attenuate associations of green spaces with hypertension and diabetes mellitus: a national representative cross-sectional study in China

BACKGROUND

High blood pressure (HBP) and diabetes mellitus (DM) are two of the most prevalent cardiometabolic disorders globally, especially among individuals with lower socio-economic status (SES). Studies have linked residential greenness to decreased risks of HBP and DM. However, there has been limited evidence on whether SES may modify the associations of residential greenness with HBP and DM.

METHODS

Based on a national representative cross-sectional study among 44,876 adults, we generated the normalized difference vegetation index (NDVI) at 1 km spatial resolution to characterize individuals' residential greenness level. Administrative classification (urban/rural), nighttime light index (NLI), individual income, and educational levels were used to characterize regional urbanicity and individual SES levels.

RESULTS

We observed weaker inverse associations of NDVI with HBP and DM in rural regions compared to urban regions. For instance, along with per interquartile range (IQR, 0.26) increment in residential NDVI at 0∼5 year moving averages, the ORs of HBP were 1.04 (95%CI: 0.94, 1.15) in rural regions and 0.85 (95%CI: 0.79, 0.93) in urban regions (P = 0.003). Along with the decrease in NLI levels, there were continuously decreasing inverse associations of NDVI with DM prevalence (P for interaction <0.001). In addition, weaker inverse associations of residential NDVI with HBP and DM prevalence were found among individuals with lower income and lower education levels compared to their counterparts.

CONCLUSIONS

Lower regional urbanicity and individual SES could attenuate the associations of residential greenness with odds of HBP and DM prevalence.

Area-level deprivation and individual-level socioeconomic correlates of the diabetes care cascade among black south africans in uMgungundlovu, KwaZulu-Natal, South Africa

South Africa is experiencing a rapidly growing diabetes epidemic that threatens its healthcare system. Research on the determinants of diabetes in South Africa receives considerable attention due to the lifestyle changes accompanying South Africa's rapid urbanization since the fall of Apartheid. However, few studies have investigated how segments of the Black South African population, who continue to endure Apartheid's institutional discriminatory legacy, experience this transition. This paper explores the association between individual and area-level socioeconomic status and diabetes prevalence, awareness, treatment, and control within a sample of Black South Africans aged 45 years or older in three municipalities in KwaZulu-Natal. Cross-sectional data were collected on 3,685 participants from February 2017 to February 2018. Individual-level socioeconomic status was assessed with employment status and educational attainment. Area-level deprivation was measured using the most recent South African Multidimensional Poverty Index scores. Covariates included age, sex, BMI, and hypertension diagnosis. The prevalence of diabetes was 23% (n = 830). Of those, 769 were aware of their diagnosis, 629 were receiving treatment, and 404 had their diabetes controlled. Compared to those with no formal education, Black South Africans with some high school education had increased diabetes prevalence, and those who had completed high school had lower prevalence of treatment receipt. Employment status was negatively associated with diabetes prevalence. Black South Africans living in more deprived wards had lower diabetes prevalence, and those residing in wards that became more deprived from 2001 to 2011 had a higher prevalence diabetes, as well as diabetic control. Results from this study can assist policymakers and practitioners in identifying modifiable risk factors for diabetes among Black South Africans to intervene on. Potential community-based interventions include those focused on patient empowerment and linkages to care. Such interventions should act in concert with policy changes, such as expanding the existing sugar-sweetened beverage tax.

State of cancer care in India and opportunities for innovation

Cancer is one of the leading causes of morbidity and mortality in India. Despite recent medical and technological advances, the cancer burden in India remains high and continues to rise. Moreover, substantial regional disparities in cancer incidence and access to essential medical resources exist throughout the country. While innovative and effective cancer therapies hold promise for improving patient outcomes, several barriers hinder their development and utilization in India. Here we provide an overview of these barriers, including challenges related to patient awareness, inadequate infrastructure, scarcity of trained oncology professionals, and the high cost of cancer care. Furthermore, we discuss the limited availability of cancer clinical trials in the country, along with an examination of potential avenues to enhance cancer care in India. By confronting these hurdles head-on and implementing innovative, pragmatic solutions, we take an indispensable step toward a future where every cancer patient in the country can access quality care.

Socioeconomic inequalities in physical, psychological, and cognitive multimorbidity in middle-aged and older adults in 33 countries: a cross-sectional study

BACKGROUND

Many physical, psychological, and cognitive disorders are highly clustered among populations with low socioeconomic status. However, the extent to which socioeconomic status is associated with different combinations of these disorders is unclear, particularly outside high-income countries. We aimed to evaluate these associations in 33 countries including high-income countries, upper-middle-income countries, and one lower-middle-income country.

METHODS

This cross-sectional multi-region study pooled individual-level data from seven studies on ageing between 2017 and 2020. Education and total household wealth were used to measure socioeconomic status. Physical disorder was defined as having one or more of the self-reported chronic conditions. Psychological and cognitive disorders were measured by study-specific instruments. The outcome included eight categories: no disorders, physical disorder, psychological disorder, cognitive disorder, and their four combinations. Multivariable-adjusted logistic regression models were used to estimate odds ratios (ORs) and 95% CIs for the associations of socioeconomic status with these outcomes separately for high-income countries, upper-middle-income countries, and the lower-middle-income country.

FINDINGS

Among 167 376 individuals aged 45 years and older, the prevalence of multimorbidity was 24·5% in high-income countries, 33·9% in upper-middle-income countries, and 8·1% in the lower-middle-income country (India). Lower levels of education, household wealth, and a combined socioeconomic status score were strongly associated with physical, psychological, and cognitive multimorbidity in high-income countries and upper-middle-income countries, with ORs (low vs high socioeconomic status) for physical-psychological-cognitive multimorbidity of 12·36 (95% CI 10·29-14·85; p<0·0001) in high-income countries and of 23·84 (18·85-30·14; p<0·0001) in upper-middle-income countries. The associations in the lower-middle-income country were mixed. Participants with both a low level of education and low household wealth had the highest odds of multimorbidity (eg, OR for physical-psychological-cognitive multimorbidity 21·21 [15·95-28·19; p<0·0001] in high-income countries, 37·07 [25·66-53·56; p<0·0001] in upper-middle-income countries, and 54·96 [7·66-394·38; p<0·0001] in the lower-middle-income country).

INTERPRETATION

In study populations from high-income countries, upper-middle-income countries, and the lower-middle-income country, the odds of multimorbidity, which included physical, psychological, and cognitive disorders, were more than ten times greater in individuals with low socioeconomic status. Equity-oriented policies and programmes that reduce social inequalities in multimorbidity are urgently needed to achieve Sustainable Development Goals.

FUNDING

Zhejiang University, Fundamental Research Funds for the Central Universities, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Wellcome Trust, Medical Research Council, National Institute on Aging, and Academy of Finland.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Inequality of opportunity in outpatient expenditure among the elderly with multimorbidity: evidence from China

BACKGROUND

Inequality of opportunity (IOp) stemming from social circumstances exists in outpatient service utilization for the multimorbid elderly in China. However, little is known regarding the magnitude of the IOp and its composition. Therefore, this study aims to measure the IOp in outpatient expenditure and provide potential pathways for policy reform by assessing the contribution of each circumstance.

METHODS

This study included 3527 elderly aged ≥ 65 years with multimorbidity from the Chinese Longitudinal Healthy Longevity Study conducted in 2017-2018. An ordinary least squares regression model was used to analyze the circumstance-influencing factors of outpatient expenditure. The parametric approach was performed to quantify the IOp in outpatient expenditure and the Shapley value decomposition method was employed to determine the contribution of each circumstance. By extracting heterogeneity in the residual of the circumstance-dependent equation of outpatient expenditure across circumstance groups divided based on cluster analysis, we captured the effect of unobserved circumstances.

RESULTS

Except for pension and distance to health facilities, all the associations between circumstance and outpatient expenditure were statistically significant. The inequality caused by circumstances accounted for 25.18% of the total inequality. The decomposition results revealed that the reimbursement rate contributed 82.92% of the IOp, followed by education duration (4.55%), household registration (3.21%), household income (3.18%), pension (1.49%), medical insurance (1.26%), physical labor (0.99%), unobserved circumstances (0.86%), distance to health facilities (0.83%) and region (0.71%).

CONCLUSIONS

The priority of policy enhancement is to effectively improve the outpatient reimbursement benefit for treating chronic diseases. Additional crucial actions include enhancing the health literacy of the multimorbid elderly to promote the shift from medical needs to demands and accelerating the construction of rural capacity for providing high-quality healthcare to the elderly with multimorbidity.

The Relationship between Whole-Milk Dairy Foods and Metabolic Health Highlights an Opportunity for Dietary Fat Recommendations to Evolve with the State of the Science

The science of dietary fats has evolved, and a body of evidence indicates they are complex bioactive nutrients that have different effects on health depending on their food source, chain length, degree of saturation, and other factors that can be affected by food processing, handling, and storage. As such, it is becoming increasingly clear that the effects of foods on obesity and metabolic health cannot be predicted simply with their fat content. The aim of this opinion article is to provide a brief overview of select recent research on the effects of whole-milk dairy foods on body composition and indicators of metabolic health across the lifespan to show the gap between current knowledge and dietary guidance. As the state of the science on dietary fats and human health evolves to consider the complexity of food matrices, the total nutrient package they deliver, and the health impacts associated with dietary patterns, so too must guidelines for dietary fat.

"Academia da Saúde" program: mapping evidence from the largest health promotion community program in Brazil

The aim of this scoping review was to map the literature related to the "Academia da Saúde" Program, including the objective and rationale of the studies, activities carried out in the program's centers, as well as the actors involved in these actions. The search for evidence was conducted in the MEDLINE, LILACS, Web of Science, Scopus, COCHRANE, and SciELO databases. Additional evidence was investigated in the Catalog of Theses and Dissertations of the Coordination of Improvement of Higher Education Personnel (CAPES-Brazil) and in the Brazilian Digital Library of Theses and Dissertations, in addition to manual searches in the references of the studies/documents. Out of 642 initial records, the information synthesis was composed of 74 studies/documents (n = 54; 73.0% scientific articles, n = 48; 64.9% with cross-sectional design, n = 45; 60.8% quantitative analysis). Nutrition (n = 24; 32.2%) and evaluation of the Program (n = 27; 36.5%) were the main themes analyzed. Regarding the participant/object analyzed in each study, users (n = 39; 52.6%) were the main actors investigated. Future studies should consider investigating the effectiveness of the actions developed in the program centers, especially physical activity and healthy eating practices.

Patterns of Non-Communicable Disease, Multimorbidity, and Population Awareness in Bahir Dar, Northwest Ethiopia: A Cross-Sectional Study

Objective

Ethiopia, like other developing countries, is going through an epidemiological transition, and high rates of non-communicable diseases (NCDs) are having a significant impact on the health system; however, there is limited evidence about community level NCD prevalence, multimorbidity, and population awareness that could inform targeted interventions and policy responses. This study aimed to identify factors associated with NCD prevalence, multimorbidity, and population awareness of NCDs in Bahir Dar, Northwest Ethiopia.

Methods

A community-based cross-sectional survey was conducted with 417 randomly sampled adults. We performed descriptive and logistic regression analyses to evaluate associations between NCD prevalence (cardiovascular diseases, diabetes, cancer, chronic respiratory diseases, chronic kidney disease, and hypertension) multimorbidity (2 or more NCDs) and demographic, socioeconomic, individual risk factors, anthropometrics, knowledge, and attitude.

Results

This study reveals that 24% of participating adults have an NCD, and 8% have multimorbidity. One-third (34.5%) have some NCD knowledge, and 75% consider NCDs more dangerous than communicable diseases. We find low NCD prevalence in participants: younger than 40 years of age (AOR 0.17, 95% CI 0.07 to 0.39); with normal body mass index (AOR 0.27, 0.10 to 0.77) and; with a family history of NCD (AOR 7.7, 4.2 to 14.1). Multimorbidity is lower in young adults (AOR 0.08, 0.03 to 0.26). NCD knowledge is higher in men (AOR 1.76, 1.06 to 2.93) and employed adults (AOR 2.91, 1.52 to 5.57), and NCD attitude in normal-weight adults (AOR 3.23, 1.42 to 7.39).

Conclusion

This study reveals a high prevalence of NCD and overall low NCD awareness in the population. Age above 40 years, family history of NCD, and weight in the obese category are significant predictors of NCD prevalence. These findings can help health professionals, health offices, and concerned stakeholders to plan targeted health interventions to reduce NCDs in the population.

An explanation on the process of production to the utilization of patient education media in chronic diseases in Iran: Protocol for a grounded theory study

BACKGROUND

Chronic diseases are always considered one of the most critical challenges of the health system in any country. Patient education on self-care is one of the basic strategies in controlling the disease process and minimizing complications in patients with chronic diseases. It seems that in the process of patient education, from the preparation of materials to their delivery to the final user, many problems prevent the proper and practical education. The study aims to explain the process of production to the utilization of patient education media in chronic diseases in Iran.

MATERIALS AND METHODS

This study employs a grounded theory (GT) methodology and the data will be analyzed by Strauss and Corbin method. Participants in this study include groups involved in the field of patient education, including policymakers, managers at all management levels, clinical, educational, and public health service providers (physicians, nurses, medical librarians, medical, and nursing professors, NGOs in the field of patient education, physiotherapists, nutritionists, and psychologists) as well as service receivers such as patients, their family, and caregivers whom will be all selected through theoretical as well as snowball sampling method. The interview method will be semi-structured and will not be ceased until the data is saturated.

CONCLUSIONS

It is anticipated that in this study, the pros and cons of the process of production to utilization of patient education media will be identified and appropriate solutions to improve this process will be provided.

Secular trend of non-communicable chronic disease prevalence throughout the life span who endured Chinese Great Famine (1959-1961)

BACKGROUND

Famine is a risk factor for non-communicable chronic diseases (NCDs), which account for over 80% of deaths in China. The effect of famine on the prevalence of NCDs in terms of various age groups, time periods and cohorts is currently poorly understood.

OBJECTIVE

This study aims to explore long-term trends in the impact of China's Great Famine (1959-1961) on NCDs in China.

METHODS

This study used data from the 2010-2020 China Family Panel Longitudinal Survey across 25 provinces in China. The subjects were aged 18-85 years, and the total number of subjects was 174,894. The prevalence of NCDs was derived from the China Family Panel Studies database (CFPS). An age-period-cohort (APC) model was used to estimate the age, period and cohort effects of NCDs in 2010-2020 and the effect of famine on the risk of NCDs in terms of cohort effects.

RESULTS

The prevalence of NCDs increased with age. Additionally, the prevalence did not clearly decrease over the survey period. Regarding the cohort effect, people born in the years adjacent to the famine period had a higher risk of NCDs; additionally, females, those born in rural areas, and those who lived in provinces with severe famine and post-famine had a higher likelihood of NCDs.

CONCLUSIONS

Experiencing famine at an early age or the experience of famine in a close relative's generation (births after the onset of famine) are associated with an increased risk of NCDs. Additionally, more severe famine is associated with a higher risk of NCDs.

Is teenage parenthood associated with early use of disability pension? Evidence from a longitudinal study

BACKGROUND

Over the past decades the number of young people using disability pensions (DP) has gradually increased in Europe but the reasons for this change are poorly understood. We hypothesize that teenage parenthood could be associated with an increased risk of receiving early DP. The aim of this study was to examine the association between having a first child at age 13-19 and receiving DP at age 20-42 (here called early DP).

METHODS

A longitudinal cohort study was undertaken based on national register data obtained from 410,172 individuals born in Sweden in 1968, 1969, and 1970. Teenage mothers and fathers were followed until age 42 and compared to non-teenage parent counterparts to examine their early receipt of DP. Descriptive analysis, Kaplan-Meier curves, and Cox regression analyses were performed.

RESULTS

The proportion of teenage parents was more than twice higher in the group that received early DP (16%) compared to the group that did not receive early DP (6%) during the study duration. A higher proportion of teenage mothers and fathers started to receive DP at 20-42 years old compared to non-teenage parents, and the difference between the two groups increased during the observation period. A strong association was observed between being a teenage parent and receiving early DP, significant both independently and after adjusting for the year of birth and the father's level of education. From the age of 30 to 42 years, teenage mothers used early DP more often than teenage fathers or non-teenage parents, and this difference also increased during the follow-up period.

CONCLUSION

A strong association was found between teenage parenthood and the use of DP between 20 and 42 years of age. Teenage mothers used DP more than teenage fathers and non-teenage parents.

Association between Mortality from Chronic Noncommunicable Diseases and Human Development Index in Brazil between 1980 and 2019

BACKGROUND

Chronic noncommunicable diseases (CNCDs) caused more than 734,000 deaths (55% of all deaths) in Brazil in 2019, with an important socioeconomic impact.

OBJECTIVES

To analyze the mortality rates from CNCDs in Brazil from 1980 to 2019 and their association with socioeconomic indicators.

METHOD

This was a descriptive, time-series study of deaths from CNCDs in Brazil from 1980 to 2019. Data on the annual frequencies of deaths and on population were obtained from the Department of Informatics of the Brazilian Unified Health System. Crude and standardized mortality rates per 100,000 inhabitants were estimated using the direct method (Brazilian population in 2000). The quartiles of each CNCD were calculated, where a quartile change, due to an increase in mortality rate, was represented by a chromatic gradient. The Municipal Human Development Index (MHDI) of each Brazilian federative unit was extracted from the Atlas Brasil website and correlated with the rates of CNCD mortality.

RESULTS

There was a reduction in mortality rates due to diseases of the circulatory system during the period, except in the Northeast Region. There was also an increase in mortality from neoplasia and diabetes, while the rates of chronic respiratory diseases showed little variation. There was an inverse correlation between the federative units with greater reduction in CNCD mortality rates and the MHDI.

CONCLUSIONS

The observed decrease in mortality due to diseases of the circulatory system may reflect an improvement in socioeconomic indicators in Brazil during the period. The increase in mortality rates due to neoplasms is probably related to the aging of the population. The higher mortality rates of diabetes seem to be associated with an increase in the prevalence of obesity in Brazilian women.

"She is My Work": Caregiving for Older Adults With Hypertension and Diabetes Mellitus

To explore the lived experiences of informal caregivers of older adults with hypertension and/or diabetes mellitus in Kumasi, Ghana. A qualitative research approach was used to conduct the study using informal caregivers of older adults with hypertension and/or diabetes mellitus at a teaching hospital in Ghana. In all, 20 participants were purposively sampled, interviewed, and data were analyzed using thematic analysis. Three main themes emerged: "Experience with care demands," "Coping with care demands," and "Motivation for caregiving." Older adults with hypertension and/or diabetes mellitus had needs that placed a burden on informal caregivers' work life, health, and social life. Informal caregivers of older adults with hypertension and/or diabetes mellitus are under strain. Caregiving is a difficult task, requiring a lot of time, effort, attention, and devotion. Nurses should plan the care of older adults with hypertension and/or diabetes mellitus in collaboration with their informal caregivers.

Mutual Associations of Healthy Behaviours and Socioeconomic Status with Respiratory Diseases Mortality: A Large Prospective Cohort Study

Little cohort evidence is available on the effect of healthy behaviours and socioeconomic status (SES) on respiratory disease mortality. We included 372,845 participants from a UK biobank (2006-2021). SES was derived by latent class analysis. A healthy behaviours index was constructed. Participants were categorized into nine groups on the basis of combinations of them. The Cox proportional hazards model was used. There were 1447 deaths from respiratory diseases during 12.47 median follow-up years. The hazard ratios (HRs, 95% CIs) for the low SES (vs. high SES) and the four or five healthy behaviours (vs. no or one healthy behaviour) were 4.48 (3.45, 5.82) and 0.44 (0.36, 0.55), respectively. Participants with both low SES and no or one healthy behaviour had a higher risk of respiratory disease mortality (aHR = 8.32; 95% CI: 4.23, 16.35) compared with those in both high SES and four or five healthy behaviours groups. The joint associations were stronger in men than in women, and in younger than older adults. Low SES and less healthy behaviours were both associated with an increased risk of respiratory disease mortality, which augmented when both presented together, especially for young man.

Common resilience factors among healthy individuals exposed to chronic adversity: a systematic review

OBJECTIVE

To identify common resilience factors against non-communicable diseases (dental caries, diabetes type II, obesity and cardiovascular disease) among healthy individuals exposed to chronic adversity.

MATERIALS AND METHODS

The databases MEDLINE (via PubMed), Scopus and CINAHL were searched. Observational studies in English assessing resilience factors among populations living in chronic adversity were included. Intervention studies, systematic reviews, non-original articles and qualitative studies were excluded. There were no restrictions regarding publication year or age. No meta-analysis could be done. Quality assessments were made with the Newcastle-Ottawa scale (NOS).

RESULTS

A final total of 41 studies were included in this systematic review. The investigated health resilience factors were divided into the following domains: environmental (community and family) and individual (behavioural and psychosocial). A narrative synthesis of the results was made according to the domains.

CONCLUSIONS

Individual psychosocial, family and environmental factors play a role as health resilience factors in populations living in chronic adversity. However, the inconclusive results suggest that these factors do not act in isolation but interplay in a complex manner and that their interaction may vary during the life course, in different contexts, and over time.

Seeing the forest through the trees: the importance of the food matrix in diet quality and human health

Poor nutrition is linked to morbidity and mortality globally. The nutrition transition towards diets composed of high amounts of ultra-processed foods that are more refined, calorie-dense and nutrient poor, is considered a factor in the rise of diet-related metabolic diseases in low- and middle-income countries. Historically, nutrition strategies aimed at mitigating metabolic diseases linked to sub-optimal diets have targeted isolated nutrients, like fat; however, they overlook the complexity and importance of the whole food and food matrices, which can lead to unintended consequences, such as avoidance of nutrient-dense foods. Dairy foods, such as milk, cheese and yogurt are underconsumed, nutrient-dense foods that are often fall in the cross-hairs of reductionist nutrition strategies because of their contribution of calories, saturated fat, and sodium to the diet. This article highlights dairy foods as an example for exploring the complex matrices of food, nutrients, and other bioactive components that are associated with improved nutrient status and reduced risk of metabolic diseases, while considering a holistic approach to improving diet quality and human health. Statement of Significance Historically, nutrition strategies aimed at mitigating metabolic diseases linked to sub-optimal diets have targeted isolated nutrients, like fat; however, they overlook the complexity and importance of the whole food and food matrices, and can lead to unintended consequences. This article explores the complex matrices of nutrients and other bioactive components that are associated with improved nutrient status and reduced risk of metabolic diseases, and considers a holistic approach to improving diet quality and human health.

The prevalence and determinants of non-communicable diseases among Ghanaian adults: A survey at a secondary healthcare level

The current epidemiological transition of diseases in Ghana necessitates understanding their burden and the associated context-specific risk factors to inform disease prevention strategies. To determine the prevalence and determinants of selected Non-Communicable Diseases (NCDs) among patients seeking healthcare services in a secondary health facility in Ghana. A facility-based survey was conducted among adult patients 18 years and above between May and July 2021, using a multi-stage sampling approach. Data regarding the prevalence of NCDs, participants' socio-demographics and lifestyle factors of NCDs were obtained using Modified STEPwise Approach to NCD Risk Factor Surveillance (STEPS). The Chi-square test and regression analysis were performed to identify the risk factors of NCDs at P < 0.05. The participants comprised 480 patients with a mean age of 37.7±16.5 years, and 57.7% (277/480) of them were females. The overall prevalence of the selected NCDs was 26.7% (CI = 0.23-0.31), of which hypertension (22.7%) was the most prevalent. More than half (54.2%) of the participants engaged in alcohol consumption and 54% were physically inactive. The odds of developing NCDs were higher in females (CI = 1.32-4.10, P = 0.004), older adults (CI = 4.11-20.68, P <0.001), overweight/obese adults (CI = 1.65-4.70, P < 0.001), family history (CI = 0.15-0.46, P<0.001), and alcohol consumption (CI = 0.12-0.40, P < 0.001). There was an overall high prevalence of NCDs, strongly influenced by the participants' age, sex, BMI, alcohol consumption, and family history. These determinants should be highlighted as part of the campaign for preventive action plans.

Economic barriers and gaps to reach the desirable consumption of salt, sugar, and fat in Iran: a qualitative study

BACKGROUND

Non-communicable diseases (NCDs), also known as chronic diseases, specifically cardiovascular diseases (CVD), cancers, respiratory diseases, and diabetes are the main reason for more than two-thirds of global deaths, in which the unhealthy diet is one of the primary risk factors. The golden solution to reducing obesity and CVD linked to an unhealthy diet is to reduce calories, salt, sugar, and fat intake. Besides, activities highlighting lifestyles that contain healthy diets usually focus on reducing salt, sugar, and saturated fat consumption. As a result, the researchers aimed to study the gaps and economic barriers to recommended consumption of salt, sugar, and fat in Iran, based on WHO recommendations.

METHODS

This is a qualitative study. We conducted semi-structured and in-depth interviews with 30 stakeholders, including academics, experts, and key informants in different sectors from December 2018 until August 2019 in Tehran, Iran. We used a purposeful and snowball sampling method to select participants. All interviews were transcribed verbatim and thematically analyzed using MAXQDA 11.

RESULTS

Economic problems and inflation in Iran caused people to eat more unhealthy foods, while a healthy diet consumption was reduced due to higher prices. Unfair political sanctions imposed on the country caused economic pressure and adversely affected family nutrition. Worse still, despite legal bans, advertising unhealthy foods via media, mainly to generate revenue, encouraged more consumption of unhealthy food. The lack of targeted subsidies and failure in tax legislation and implementation related to the unhealthy products deteriorated the conditions.

CONCLUSION

Some economic barriers have hampered plans to reduce salt, fat, and sugar consumption in Iran. Fundamental reforms in the tax and subsidy system are required to improve people's eating habits. In particular, citizens' income that has been continuously shrinking due to economic conditions, imposed sanctions, and the inevitably high inflation needs to be addressed urgently. Unless the government of Iran deals with the economic barriers to healthy nutrition, the pathway for implementing the national action plan for prevention and control of NCDs toward a 30% mortality reduction due to NCDs by 2030 looks unlikely to reach.

Disparities of obesity and non-communicable disease burden between the Tibetan Plateau and developed megacities in China

Background

Non-communicable diseases (NCDs) including risk factors, e.g., obesity, are the major causes of preventable deaths in China, yet NCD disparities in China remain under-studied.

Objective

This study aimed to compare the determinants and burden of NCDs within four selected provinces in mainland China: the least developed Qinghai-Tibet Plateau group (PG, Tibetan Autonomous Region [TAR] and Qinghai Province) and most developed megacity group (MCG, Shanghai, and Beijing).

Methods

Studies, reports, and other official sources with comparable data for NCD burden and related determinants for the four provinces were searched. Geographic, demographic, socioeconomic, and dietary characteristics and selected health indicators (e.g., life expectancy) were extracted from the China Statistical Yearbook and China Health Statistics Yearbook. Data on NCD burdens were extracted from the National Chronic Disease and Risk Factor Surveillance Study and other nationally representative studies.

Results

The overall NCD mortality rates and prevalence of metabolic risk factors including obesity, hypertension, and diabetes in mainland China have increased in the past 20 years, and this trend is expected to continue. The PG had the highest level of standardized mortality rates (SMRs) on NCDs (711.6-896.1/100,000, 6th/6-level); the MCG had the lowest (290.6-389.6/100,000, 1st/6-level) in mainland China. The gaps in SMRs were particularly high with regard to chronic respiratory diseases (PG 6th^/6-level, MCG 1st/6-level) and cardiovascular diseases (6th/6 and 4th/6 in TAR and Qinghai; 1st/6-level and 2nd/6-level in Shanghai and Beijing). In contrast, the prevalence rates of obesity, hypertension, and diabetes were generally higher or comparable in MCG compared to PG. Diabetes prevalence was particularly high in MCG (5th/5-level, 13.36-14.35%) and low in PG (1st/5-level, 6.20-10.39%). However, awareness, treatment, and control of hypertension were poor in PG. Additionally, PG had much lower and severely inadequate intakes of vegetables, fruits, and dairy products, with additional indicators of lower socioeconomic status (education, income, etc.,) compared with MCG.

Conclusion

Evidence showed large disparities in NCD burden in China's provinces. Socioeconomic disparity and dietary determinants are probably the reasons. Integrated policies and actions are needed.

Access to health services for chronic disease care during the COVID-19 pandemic in Ecuador: A qualitative analysis using a Social Determinants of Health approach

This qualitative study aims to explore how the COVID-19 pandemic impacted healthcare access for patients with chronic conditions in Ecuador from the patient's perspective. We interviewed 19 patients diagnosed with arterial hypertension or type 2 diabetes in rural and urban areas of Ecuador during August and September 2020. We used the Framework Method to analyse the interview transcripts with ATLAS.Ti 8.4 and organised the ideas discussed using categories from the World Health Organization Commission on the Social Determinants of Health conceptual framework. Reorganization of health services during the pandemic meant that patients with arterial hypertension or diabetes could no longer attend face-to-face appointments for disease follow-up. System failures related to medication supply led to increased out-of-pocket payments, which, together with reduced or absent earnings, and in a context with limited social protection policies, meant that patients frequently went for prolonged periods without medication. Rural health initiatives, support from family and use of traditional medicine were reported as ways to manage their chronic condition during this time. Barriers to disease management disproportionately affected individuals with low socioeconomic positions. Stock shortages, lack of protective labour policies and limited reach of anticipatory policies for health emergencies likely worsened pre-existing health inequities in Ecuador.

Estimating non-communicable disease treatment costs using probability-based cost estimation

The burden and impact of non-communicable diseases (NCDs) are well documented, accounting for 70% of premature deaths globally. In Sub-Saharan Africa, rising NCDs are estimated to account for 27% of mortality by 2020, a 4% increase from 2005. This increase will inevitably lead to a higher demand for NCD treatment services, exerting pressure on limited public financial resources. To get a sense of the resources required to treat NCDs, it is necessary to estimate the costs associated with the diagnosis, treatment and management thereof. Typically, in estimating costs for health services, countries use historical patient level data combined with demographic trend data and non-patient level data to arrive at estimated future costs. This methodology relies heavily on the availability of data from a wide variety of sources stretching beyond the health sector. Low-and-middle-income countries often lack the requisite data and are compelled to use less efficient ways to determine resource allocation. This study explores the use of probability-based cost estimation to estimate the cost of delivering NCD treatment services in South Africa, one such data-poor environment.Probability-based cost estimation, in combination with deterministic cost estimation, is used in arriving at a cost estimate for NCD treatment services at primary healthcare facility level. On its own, deterministic cost estimation can determine total costs, provided all the input variables are known. This is not always possible because of the lack of one or more input variables. In most instances, the lacking input variable is the quantities at which specific conditions will be treated. This problem is addressed by using probability-based cost estimation through which a mean cost is calculated and applied to the target population as a whole, eliminating the need for quantities per condition. Thus, this model contains both deterministic and probabilistic cost estimation elements.

Socioeconomic status and metabolic syndrome in Southwest Iran: results from Hoveyzeh Cohort Study (HCS)

BACKGROUND

Socioeconomic status (SES) strongly predicts morbidity and premature mortality, especially for non-communicable diseases (NCDs). However, the effect of these factors on Metabolic Syndrome (MetS) is not clear yet. This study was conducted to assess the relationship between socioeconomic indicators and MetS.

METHODS

In this prospective cohort study, 10,009 people aged 35-70 enrolled from May 2016 to August 2018. The MetS was defined according to The Standard National Cholesterol Education Program (NCEP)-adult treatment panel III (ATP III) or NCEP-ATP III criteria. Demographics and socioeconomic data were gathered face-to-face through trained interviews. Also, lab, anthropometrics, and blood pressure measurements were assayed for participants. Logistic regression was used to estimate the association between SES and MetS, adjusted for the potential confounding factors.

RESULTS

The overall prevalence of MetS in the participants was 39.1%. The crude odds ratios were statistically significant for all the assessed variables (p < 0.05). After adjustment for age, sex, physical activity, smoking, and alcohol use as potential confounders, the results indicated significant direct independent associations between skill level (p = 0.006) and Townsend index (p = 0.002) with MetS. In contrast, no significant associations between educational level and wealth status with MetS.

CONCLUSION

The results of our study showed that SES is related to MetS. Among the four assessed SES indicators, skilled levels and Townsend score are strongly associated with MetS. We recommend considering people's SES when interventional programs are planned and conducted on MetS in similar communities.

Insulin resistance phenotype is associated with vascular risk phenotype at the end of the second decade of life: a population-based study

We hypothesize that early events of diabetes and cardiovascular disease continuums would be ongoing and associated in adolescents. We investigated the association between the Insulin Resistance Phenotype and the Vascular Risk Phenotype at the end of the second decade of life and indirect pathways from social vulnerability, alcohol consumption, and body fat mass. It is a population-based study in the RPS cohort of 18-19 years (n = 2,515), São Luís, Brazil. The theoretical model analyzed the association between Insulin Resistance Phenotype and Vascular Risk Phenotype by sex, using structural equation modeling (SEM). The Insulin Resistance Phenotype was a latent variable deduced from the correlations of Triglyceride to HDL ratio, Triglyceride Glycemic index, and VLDL; the Vascular Risk Phenotype was deduced from Systolic Blood Pressure, Diastolic Blood Pressure, and Pulse Wave Velocity. The Insulin Resistance Phenotype was directly associated with the Vascular Risk Phenotype in males (standardized coefficient SC = 0.183; p < 0.001) and females (SC = 0.152; p < 0.001). The Insulin Resistance Phenotype was an indirect pathway in the association of alcohol consumption and higher values of fat mass index with the Vascular Risk Phenotype. VLDL presented the highest factor loading, appearing as a marker of insulin resistance linked to cardiovascular risk in young people. Lower values of socioeconomic status, harmful use of alcohol, and high body fat values were also associated with higher values of the two phenotypes. The association of the Insulin Resistance Phenotype with the Vascular Risk Phenotype suggests common pathophysiological mechanisms present in early events in the continuums of diabetes and cardiovascular disease in adolescence.

Association of household air pollution with glucose homeostasis markers in Chinese rural women: Effect modification of socioeconomic status

BACKGROUND

Socioeconomic status (SES) was a crucial influencing factor of household air pollution (HAP). However, few studies have explored the potential effect modification of SES on the associations of HAP with type 2 diabetes mellitus (T2DM) and glucose homeostasis.

METHODS

A total of 20900 participants were obtained from the Henan Rural Cohort. HAP reflected by cooking fuel type and cooking duration was assessed via questionnaire. SES was evaluated by two dimensions: educational level and average monthly income. Associations of cooking fuel type, cooking duration with T2DM and glucose homeostasis indices (insulin, fasting plasma glucose (FPG), and HOMA-β) were assessed by the generalized linear model. Analyses were also conducted in different SES groups to explore the potential effect modification.

RESULTS

Significant negative association of cooking fuel type and cooking duration with T2DM, FPG, and HOMA-β was not observed. However, cooking with solid fuel and long-duration cooking were associated with decreased insulin level in women, and the adjusted coefficients were - 0.35 (95% confidence interval (95% CI): - 0.53, - 0.17) and - 0.36 (95% CI: -0.50, -0.21), respectively. Results from stratified analyses showed that these associations were more prominent in women with low average monthly income, with corresponding coefficient of - 0.57 (95% CI: -0.77, -0.37) for cooking with solid fuel and - 0.34 (95% CI: -0.52, -0.16) for long-duration cooking. Among women with low average monthly income, the largest decreased insulin level was observed in those who cooked with solid fuel, long-duration and poor kitchen ventilation, while the negative association of cooking fuel type and cooking duration with insulin level was slightly alleviated in the good kitchen ventilation group.

CONCLUSIONS

Low average monthly income aggravated the negative association of HAP and insulin level among rural women, while improving kitchen ventilation may be a practical intervention.

TRAIL REGISTRATION

The Henan Rural Cohort Study has been registered at Chinese Clinical Trial Register (Registration number: ChiCTR-OOC-15006699). Date of registration: 06 July, 2015. http://www.chictr.org.cn/showproj.aspx?proj=11375.

Culinary Medicine Training in Core Medical School Curriculum Improved Medical Student Nutrition Knowledge and Confidence in Providing Nutrition Counseling

Background: Elective culinary medicine education has become popular to help fill important gaps in physician nutrition training. The implementation and outcomes among the inaugural cohort of medical students who received culinary medicine training as a required component of medical school curriculum at the University of Maryland School of Medicine are described. Methods: Following a series of elective pilot sessions, culinary medicine training was provided to all first-year medical students in the 2019-2020 academic year. The 3-hour training included evidence-based nutrition lecture, cooking simple recipes, and group discussion of the application to personal and patient care. Pre-/postsession questionnaires assessed nutrition knowledge, skills, and attitudes as well as nutritional counseling confidence. Paired t-tests estimated mean differences in outcomes pre- and posttraining. Qualitative data were subjected to thematic analysis. Results: Overall, 119 of 125 (95.2%) students provided pre- and posttraining outcomes data. All nutritional and patient counseling outcomes improved (P < .05). Themes of being better prepared to address healthy eating barriers in patient care and personal ability to make healthy dietary changes were noted in qualitative analysis. Conclusion: One session of culinary medicine training in core medical student curriculum was feasible and improved medical student nutrition knowledge, skills, and attitudes and confidence in patient nutrition counseling.