Worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults

BACKGROUND

Underweight and obesity are associated with adverse health outcomes throughout the life course. We estimated the individual and combined prevalence of underweight or thinness and obesity, and their changes, from 1990 to 2022 for adults and school-aged children and adolescents in 200 countries and territories.

METHODS

We used data from 3663 population-based studies with 222 million participants that measured height and weight in representative samples of the general population. We used a Bayesian hierarchical model to estimate trends in the prevalence of different BMI categories, separately for adults (age ≥20 years) and school-aged children and adolescents (age 5-19 years), from 1990 to 2022 for 200 countries and territories. For adults, we report the individual and combined prevalence of underweight (BMI <18·5 kg/m2) and obesity (BMI ≥30 kg/m2). For school-aged children and adolescents, we report thinness (BMI <2 SD below the median of the WHO growth reference) and obesity (BMI >2 SD above the median).

FINDINGS

From 1990 to 2022, the combined prevalence of underweight and obesity in adults decreased in 11 countries (6%) for women and 17 (9%) for men with a posterior probability of at least 0·80 that the observed changes were true decreases. The combined prevalence increased in 162 countries (81%) for women and 140 countries (70%) for men with a posterior probability of at least 0·80. In 2022, the combined prevalence of underweight and obesity was highest in island nations in the Caribbean and Polynesia and Micronesia, and countries in the Middle East and north Africa. Obesity prevalence was higher than underweight with posterior probability of at least 0·80 in 177 countries (89%) for women and 145 (73%) for men in 2022, whereas the converse was true in 16 countries (8%) for women, and 39 (20%) for men. From 1990 to 2022, the combined prevalence of thinness and obesity decreased among girls in five countries (3%) and among boys in 15 countries (8%) with a posterior probability of at least 0·80, and increased among girls in 140 countries (70%) and boys in 137 countries (69%) with a posterior probability of at least 0·80. The countries with highest combined prevalence of thinness and obesity in school-aged children and adolescents in 2022 were in Polynesia and Micronesia and the Caribbean for both sexes, and Chile and Qatar for boys. Combined prevalence was also high in some countries in south Asia, such as India and Pakistan, where thinness remained prevalent despite having declined. In 2022, obesity in school-aged children and adolescents was more prevalent than thinness with a posterior probability of at least 0·80 among girls in 133 countries (67%) and boys in 125 countries (63%), whereas the converse was true in 35 countries (18%) and 42 countries (21%), respectively. In almost all countries for both adults and school-aged children and adolescents, the increases in double burden were driven by increases in obesity, and decreases in double burden by declining underweight or thinness.

INTERPRETATION

The combined burden of underweight and obesity has increased in most countries, driven by an increase in obesity, while underweight and thinness remain prevalent in south Asia and parts of Africa. A healthy nutrition transition that enhances access to nutritious foods is needed to address the remaining burden of underweight while curbing and reversing the increase in obesity.

FUNDING

UK Medical Research Council, UK Research and Innovation (Research England), UK Research and Innovation (Innovate UK), and European Union.

User requirements for non-invasive and minimally invasive glucose self-monitoring devices in low-income and middle-income countries: a qualitative study in Kyrgyzstan, Mali, Peru and Tanzania

AIMS

Development of non-invasive and minimally invasive glucose monitoring devices (NI-MI-GMDs) generally takes place in high-income countries (HICs), with HIC's attributes guiding product characteristics. However, people living with diabetes (PLWD) in low-income and middle-income countries (LMICs) encounter different challenges to those in HICs. This study aimed to define requirements for NI-MI-GMDs in LMICs to inform a target product profile to guide development and selection of suitable devices.

METHODS

This was a multiple-methods, exploratory, qualitative study conducted in Kyrgyzstan, Mali, Peru and Tanzania. Interviews and group discussions/activities were conducted with healthcare workers (HCWs), adults living with type 1 (PLWD1) or type 2 diabetes (PLWD2), adolescents living with diabetes and caregivers.

RESULTS

Among 383 informants (90 HCW, 100 PLWD1, 92 PLWD2, 24 adolescents, 77 caregivers), a range of differing user requirements were reported, including preferences for area of glucose measurement, device attachment, data display, alert type and temperature sensitivity. Willingness to pay varied across countries; common requirements included ease of use, a range of guiding functions, the possibility to attach to a body part of choice and a cost lower than or equal to current glucose self-monitoring.

CONCLUSIONS

Ease-of-use and affordability were consistently prioritised, with broad functionality required for alarms, measurements and attachment possibilities. Perspectives of PLWD are crucial in developing a target product profile to inform characteristics of NI-MI-GMDs in LMICs. Stakeholders must consider these requirements to guide development and selection of NI-MI-GMDs at country level, so that devices are fit for purpose and encourage frequent glucose monitoring among PLWD in these settings.

Health equity: access to quality services and caring for underserved populations

Barriers to access to quality services and caring for underserved populations are a call to action for researchers and other key partners to achieve health equity. In order to accomplish this, several key partners play important roles. More participation of younger generations, women and people of color from different contexts should be encouraged and facilitated. This editorial serves to present this journal issue that includes the articles of young women from low- and middle-income countries. Different methodologies are used to demonstrate the problem of access to quality services and care in a comprehensive way. After understanding the public health problems using an equity lens, we need to implement evidence-based interventions to improve the health system response.

Diminishing benefits of urban living for children and adolescents' growth and development

Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1-6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5-19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was <1.1 kg m-2 in the vast majority of countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified.

Association between multimorbidity with cognitive dysfunction in a Peruvian population

BACKGROUND

Previous studies have shown that multimorbidity is a risk factor for cognitive dysfunction (CD).Type 2 diabetes mellitus (T2DM) and hypertension (HT) are very common risk factors.The association between multimorbidity due to both diseases and CD has been understudied in low and middle-income countries, in which the strength of the association might be stronger.

AIM

To evaluate the association between multimorbidity due to T2DM and HT with CD among adults ≥50 years in Tumbes.

MATERIALS AND METHODS

A secondary analysis of a population-based cross-sectional study was conducted. The exposure variable was the presence of both T2DM and HT, split into categories: without HT or T2DM, only T2DM, only HT, and with T2DM and HT; whereas CD was the outcome variable, defined as a score ≤26 in the Leganes Cognitive Test. Crude and adjusted generalized linear models were used to estimate the association of interest, and prevalence ratio (PR) and 95% confidence interval (95%CI) were reported.

RESULTS

688 participants were analyzed. The prevalence of CD was 39.1%. There was a 56.1% of participants without TDM2 nor HT, 8.3% with T2DM, 28.9% with HT and 6.7% with both diseases. A significant association was found between multimorbidity and CD (PR = 1.43, 95%CI 1.04-1.97). Multimorbidity had a statistically significant association with CD in the group of participants with ≥7 years of education (PR = 2.56,95%CI 1.55-4.21), but no in the group with <7 years.

CONCLUSIONS

There is association between the morbidity of T2DM and HT, and CD among adults ≥50 years of age in Tumbes. Education was an effect modifier of the association between HT and T2DM on the presence of CD.

Anxiety, Depression, and Post-Traumatic Stress Disorder (PTSD) Symptomatology According to Gender in Health-Care Workers during the COVID-19 Pandemic in Peru Shortened Title: "Psychological Impact of the Pandemic on Women"

OBJECTIVE

The current study will evaluate the association that the COVID-19 pandemic has had with health-care workers and identify the factors that influenced the female gender being more affected.

METHODS

This is a cross-sectional study conducted in two hospitals in Arequipa (a Peruvian city). The participants were health-care workers. We applied a questionnaire with sociodemographic information and three scales: the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, and the Primary Care Post-Traumatic Stress Disorder (PTSD) Screen for DSM-5. The main outcomes were anxiety, depression, and PTSD scores. The exposure of interest was gender. The scores of the scales were estimated by medians and percentiles 25-75 (p25-p75), and we used linear regression to estimate the crude and adjusted coefficients and their respective confidence intervals at 95% (CI 95%).

RESULTS

There were 109 participants, and 43.1% were women. The anxiety, depression, and PTSD median (p25-p75) scores in the study population were 6 (2-11), 6 (2-10), and 1 (0-3), respectively. The adjusted analysis showed that the female sex had 4.48 (CI 95% 2.95-6.00), 4.50 (CI 95% 2.39-6.62), and 1.13 (CI 95% 0.50-1.76) higher points on average for the scales of anxiety, depression, and PTSD symptoms in comparison to males, respectively.

CONCLUSIONS

Female health-care workers showed increased scores of mental health issues in comparison to male health-care workers.

Process evaluation of complex interventions in non-communicable and neglected tropical diseases in low- and middle-income countries: a scoping review

OBJECTIVES

The aim of this review is to map out the use of process evaluation (PE) in complex interventions that address non-communicable diseases (NCDs) and neglected tropical diseases (NTDs) to identify gaps in the design and conduct, as well as strengths, limitations and implications, of this type of research in low- and middle-income countries (LMICs).

DESIGN

Scoping review of PE studies of complex interventions implemented in LMICs. Six databases were searched focused on studies published since 2008.

DATA SOURCES

Embase, PubMed, EbscoHost, Web of Science (WOS), Virtual Health Library (VHL) Regional Portal and Global Index Medicus: Regional Indexes AIM (AFRO), LILACS (AMRO/PAHO), IMEMR (EMRO), IMSEAR (SEARO), WPRIM (WPRO) Global Index Regional Indexes, MEDLINE, SciELO.

ELIGIBILITY CRITERIA

Studies conducted in LMICs on PEs of randomised controlled trials (RCTs) and non-RCTs published between January 2008 and January 2020. Other criteria were studies of interventions for people at risk or having physical and mental NCDs, and/or NTDs, and/or their healthcare providers and/or others related to achieve better health for these two disease groups. Studies were excluded if they were not reported in English or Spanish or Portuguese or French, not peer-reviewed articles, not empirical research and not human research.

DATA EXTRACTION AND SYNTHESIS

Data extracted to be evaluated were: available evidence in the utilisation of PE in the areas of NCDs and NTDs, including frameworks and theories used; methods applied to conduct PEs; and in a subsample, the barriers and facilitators to implement complex interventions identified through the PE. Variables were extracted and categorised. The information was synthesised through quantitative analysis by reporting frequencies and percentages. Qualitative analysis was also performed to understand facilitators and barriers presented in these studies. The implications for PEs, and how the information from the PE was used by researchers or other stakeholders were also assessed in this approach.

RESULTS

303 studies were identified, 79% were for NCDs, 12% used the label 'PE', 27% described a theory or framework for the PE, and 42% used mixed methods to analyse their findings. Acceptability, barriers and facilitators to implement the interventions, experiences and perceptions, and feasibility were the outcomes most frequently evaluated as part of the PEs. Barriers and facilitators themes identified were contextual factors, health system factors, human resources, attitudes and policy factors.

CONCLUSIONS

PEs in NCDs and NTDs are used in LMICs with a wide variety of methods. This review identified many PEs that were not labelled by the authors as such, as well as a limited application of PE-related theories and frameworks, and heterogeneous reporting of this type of study.

Pilot Feasibility Assessment of a Tailored Physical Activity Prescription in Overweight and Obese People in a Public Hospital

We aimed to evaluate the feasibility of a tailored physical activity (PA) prescription in overweight and obese people in a tertiary hospital in Lima, Peru. A feasibility pre-post-pilot study was conducted using mixed methods. Participants received a tailored prescription scheme for PA that lasted twelve weeks. It included two prescription sessions, three follow-up phone calls, and three evaluations. Primary feasibility outcomes were recruitment, visits, and phone call adherence. Primary intervention outcomes were self-reported PA levels and the 6 min walk test. Out of 228 people invited to participate, 30 were enrolled and received the first session of prescription, 11 went to the second session, and 21 went to the final evaluation; phone call participation decreased progressively during follow-up. There were no differences in the 6th week and the 12th week compared to the baseline for all the measures, except in the 6 min walk test. The participants considered the intervention was well designed, but they suggested complementing it with dietary instructions. The prescription of PA in overweight and obese people is feasible for promoting PA, but its implementation requires refinements to anticipate possible barriers to changing behavior.

Going digital: opportunities and barriers in the use of technology for health research

Digital health refers to the use of novel information com­munication technologies in healthcare. The use of these technologies could positively impact public health and health outcomes of populations by generating timely data, and facili­tating the process of data collection, analysis, and knowledge translation. Using selected case studies, we aim to describe the opportunities and barriers in the use of technology applied to health-related research. We focus on three areas: strategies to generate new data using novel data collection methods, strategies to use and analyze existing data, and using digital health for health-related interventions. Exemplars from seven countries are provided to illustrate activity across these areas. Although the use of health-related technologies is increasing, challenges remain to support their adoption and scale-up –especially for under-served populations. Research using digital health approaches should take a user-centered design, actively working with the population of interest to maximize their uptake and effectiveness.

Applying systems thinking to identify enablers and challenges to scale-up interventions for hypertension and diabetes in low-income and middle-income countries: protocol for a longitudinal mixed-methods study

INTRODUCTION

There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions.

METHODS AND ANALYSIS

We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (TP), initiation of implementation (T0) and 1-year postinitiation (T1). We will extract project-related data from secondary documents at TP and conduct multistakeholder qualitative interviews to gather data at T0 and T1. We will undertake descriptive statistical analysis of TP data and analyse T0 and T1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks.

ETHICS AND DISSEMINATION

The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network.

Population-based stroke incidence estimates in Peru: Exploratory results from the CRONICAS cohort study

BACKGROUND

Limited information exists about the incidence of first-ever stroke at the population level, particularly in low- and middle-income countries (LMIC). Longitudinal data from the CRONICAS Cohort Study includes both altitude and urbanization and allows a detailed assessment of stroke incidence in resource constrained settings. The aim of this study was to estimate the incidence and explore risk factors of first-ever stroke at the population level in Peru.

METHODS

Stroke was defined using a standardised approach based on information from cohort participants or family members. This information was adjudicated centrally by trained physicians using common definitions. Time of follow-up was calculated as the difference between date of enrolment and the reported date of the stroke event. Unstandardised and age-standardised, first-ever stroke incidence rate and 95% confidence intervals (95% CI) were calculated. Generalized linear models, assuming Poisson distribution and link log, were utilized to determine potential factors to develop stroke.

FINDINGS

3,601 individuals were originally enrolled in the cohort and 2,471 provided data for the longitudinal analysis. The median time of follow-up was 7.0 (range: 1 - 9) years, accruing a total of 17,308 person-years. During followup, there were 25 incident cases of stroke, resulting in an age-standardised incidence of stroke of 98.8 (95% CI: 63.8 - 154.0) per 100,000 person-years. After adjustment by age and sex, stroke incidence was higher among people with hypertension (incidence risk ratio (IRR) = 5.18; 95% CI: 1.89 - 14.16), but lower among people living at high altitude (IRR = 0.09; 95% CI: 0.01 - 0.63).

INTERPRETATION

Our results indicate a high incidence of first-ever strokes in Peruvian general population. These results are consistent with the estimates found in previous LMIC reports. Our study also found a contributing role of hypertension, increasing the risk of having a first-ever stroke. This work further advances the field of stroke epidemiology by identifying high altitude as a factor related to lower incidence of stroke in a longitudinal study. However, this information needs to be considered with cautions because of the study limitations.

Screening for Parasitic Infection and Tuberculosis in Immunosuppressed and Pre-Immunosuppressed Patients: An Observational Study

Reactivation of latent tuberculosis infection (LTBI) or latent parasitic infection (LPI) during drug-induced immunosuppression can have serious consequences. The Division of tropical and humanitarian medicine of the Geneva University Hospitals runs a specific consultation for parasitic screening of immunosuppressed or pre-immunosuppressed patients. We sought to determine the seroprevalence of LTBI and LPI in such patients and explore its relationship with country of origin or previous travel in a retrospective, single-centre observational study from 2016 to 2019. Demographic data, travel history, ongoing treatments and results of the parasitological (Strongyloides stercoralis, Trypanosoma cruzi, Echinococcus multilocularis, Entamoeba histolytica and Leishmania spp.) and TB screening were collected to calculate LPI or LTBI prevalence. Risk factors for LTBI and strongyloidiasis were analysed using Poisson regression with robust variance. Among 406 eligible patients, 24/353 (6.8%) had LTBI, 8/368 (2.2%) were positive for Strongyloides stercoralis infection, 1/32 (3.1%) was positive for Entamoeba histolytica and 1/299 (0.3%) was positive for Leishmaniasis. No cases of Trypanosoma cruzi (0/274) or Echinococcus multilocularis (0/56) infection were detected. Previous travel to or originating from high-prevalence countries was a risk factor for LTBI (PR = 3.4, CI 95%: 1.4–8.2 and 4.0, CI 95%: 1.8–8.9, respectively). The prevalence of serological Strongyloidiasis in immunosuppressed patients is lower in comparison to those without immunosuppression (PR = 0.1, CI 95%: 0.01–0.8). In conclusion, screening before immunosuppression needs to be individualized, and LTBI and LPI need to be ruled out in patients who originate from or have travelled to high-prevalence countries. The sensitivity of strongyloidiasis serology is reduced following immunosuppression, so an algorithm combining different tests or presumptive treatment should be considered.

[Toxocara canis infection in children from a public school in Iquitos, Peru]

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Quality of stroke guidelines in low- and middle-income countries: a systematic review

OBJECTIVE

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.

METHODS

We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.

FINDINGS

We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.

CONCLUSION

Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.

Diabetes care quality according to facility setting: A cross-sectional analysis in six Peruvian regions

OBJECTIVE

To characterize diabetes care across healthcare facilities in six Peruvian regions.

METHODS

Cross-sectional study of patients with type 2 diabetes mellitus (T2DM), ranging from primary care facilities to hospital-based facilities, in six Peruvian regions. Data was collected by health staff trained between 2012 and 2016. We studied six diabetes care outcomes and four adequate diabetes care outcomes considering the healthcare facility as the exposure of interest. We estimated prevalence ratios (PR) and their 95% confidence intervals (95% CI) using Poisson regression with robust variance.

RESULTS

Data from 8879 patients with T2DM, mean age 59.1 years (SD ± 12.2), 53.6% males, was analyzed. Of these, 8096 (91.2%) were treated at primary care facilities. The proportions of patients who had HbA1c, LDL-c, and creatinine/microalbumin test performed increased with the setting of the healthcare facility. Overall, 39%-56% of patients had an adequate HbA1c control, being higher in hospital-based facilities with specialists in comparison to primary care facilities.

CONCLUSIONS

We observed that the higher the setting of the facility, the higher the rate of the assessed diabetes care outcomes and adequate diabetes care for four of the six targets (fasting glucose, HbA1c, LDL-c and creatinine or microalbumin) and for three of the four targets (glucose≤130 mg/dL, HbA1c ≤7%(53 mmol/mol) and LDL-c <100 mg/dL), respectively. Substantial gaps were observed at the primary care facilities, calling for the strengthening of diabetes care.

A global perspective on the issue of access to insulin

The discovery of insulin in 1921 changed the prognosis for people with type 1 diabetes. A century later, availability and affordability of insulin remain a challenge in many parts of the globe. Using the WHO's framework on understanding the life cycle of medicines, this review details the global and national challenges that affect patients' abilities to access and afford insulin. Current research and development in diabetes has seen some innovations, but none of these have truly been game-changing. Currently, three multinational companies control over 95% of global insulin supply. The inclusion of insulin on the WHO's Prequalification Programme is an opportunity to facilitate entry of new companies into the market. Many governments lack policies on the selection, procurement, supply, pricing and reimbursement of insulin. Moreover, mark-ups in the supply chain also affect the final price to the consumer. Whilst expenses related to diabetes are mostly covered by insurance in high-income countries, many patients from low- and middle-income countries have to pay out of their own pockets. The organisation of diabetes management within the healthcare system also affects patient access to insulin. The challenges affecting access to insulin are complex and require a wide range of solutions. Given that 2021 marks the centenary of the discovery of insulin, there is need for global advocacy to ensure that the benefits of insulin and innovations in diabetes care reach all individuals living with diabetes.

A mHealth intervention to promote hand-washing and cell phone cleaning in medical residents of a public hospital in Peru

INTRODUCTION

We explore the limitations to adherence of hand-washing and evaluate the impact of a mHealth intervention for hand hygiene in residents.

METHODOLOGY

We explore resident's perspectives about Hospital-acquired infections (HAI) and hand washing. In baseline, participants completed socio-demographic characteristics and hand-washing habits survey. The intervention consisted of sending SMS three times a week for two months about hand hygiene and "five moments" for hand washing. The cultures of hands and cell phones were analyzed at baseline, 2 months and 4 months. We used chi-square and adjusted Generalized Estimating Equations.

RESULTS

Five physicians were interviewed and 33 participants were included for quantitative analysis. Critical barriers that hinder hand washing were identified. The proportion of Staphylococcus aureus in hands was 54.5% at baseline and was significantly reduced at 2 months follow-up (p = 0.009), but, benefit was lost when the intervention was discontinued; Escherichia coli and Klebsiella sp. were observed in 22.2% of hands, no changes were noted with intervention. In cell phones, there was a tendency to lower values of bacterial colonization after intervention for Staphylococcus aureus growth.

CONCLUSIONS

High prevalence of contamination in hands and phones in medical residents were found. Serious barriers to compliance with hand washing must be overcome. It is possible that prolonged or continuous interventions could be necessary to optimize hand washing and reduce hand and cell phones contamination.

Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight

From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions.

Lessons learned about co-creation: developing a complex intervention in rural Peru

Background: Co-creation is the process of involving stakeholders in the development of interventions. Although co-creation is becoming more widespread, reports of the process and lessons learned are scarce.

Objective: To describe the process and lessons learned from using the COHESION manual, a co-creation methodology to develop interventions aimed at the improvement of diagnosis and/or management of chronic diseases at the primary healthcare level in a low-resource setting in Peru.

Methods: Observational study to describe the use of the COHESION manual ‘Moving from Research to Interventions: The COHESION Model’ developed for a multi-country project in low- and middle-income countries for co-creation and the adaptations needed to customize it to the local context of rural communities in northern Peru.

Results: The actual process of co-creation in Peru included co-creation-related questions in the formative research; an initial consultation with stakeholders at the micro, meso, and macro levels (e.g. community members, health workers, and policy-makers); the analysis of the collected data; a second consultation with each stakeholder group; the prioritization of intervention options; and finally the design of a theory of change for all activities included in the complex intervention. The complex intervention included: 1) offer training in specific diseases and soft skills to health workers, 2) create radio programs that promote chronic disease prevention and management plus empower patients to ask questions during their visits to primary health care (PHC) facilities, and 3) provide a small grant to the PHC for infrastructure improvement. Small adaptations to the COHESION manual were necessary for this co-creation process.

Conclusion: This study provides a practical example of the process of co-creating complex interventions to increase access and quality of health care in a low-resource setting. The process, components, challenges and opportunities identified could be useful for other researchers who want to co-create interventions with beneficiaries in similar settings.

[Healthcare challenges for people with diabetes during the national state of emergency due to COVID-19 in Lima, Peru: primary healthcare recommendations]

Patients diagnosed with type 2 diabetes mellitus, who then become infected with SARS-CoV-2, are at greater risk of developing complications from COVID-19, which may even lead to death. Diabetes is a chronic condition that requires continuous contact with healthcare facilities; therefore, this type of patients should have regular access to medicines, tests and appointments with healthcare personnel. In Peru, care and treatment continuity have been affected since the national state of emergency due to COVID-19 began; because many healthcare facilities suspended outpatient consultations. The strategies presented in this study were developed by different Peruvian health providers in the pandemic context to ensure care continuity for people with diabetes. This article provides recommendations to strengthen primary healthcare, because it is the first level of healthcare contact for patients with diabetes.

Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

BACKGROUND

Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents.

METHODS

For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5-19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence.

FINDINGS

We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9-10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes-gaining too little height, too much weight for their height compared with children in other countries, or both-occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls.

INTERPRETATION

The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks.

FUNDING

Wellcome Trust, AstraZeneca Young Health Programme, EU.

Foot thermometry with mHeath-based supplementation to prevent diabetic foot ulcers: A randomized controlled trial

Background: Novel approaches to reduce diabetic foot ulcers (DFU) in low- and middle-income countries are needed. Our objective was to compare incidence of DFUs in the thermometry plus mobile health (mHealth) reminders (intervention) vs. thermometry-only (control). Methods: We conducted a randomized trial enrolling adults with type 2 diabetes mellitus at risk of foot ulcers (risk groups 2 or 3) but without foot ulcers at the time of recruitment, and allocating them to control (instruction to use a liquid crystal-based foot thermometer daily) or intervention (same instruction supplemented with text and voice messages with reminders to use the device and messages to promote foot care) groups, and followed for 18 months. The primary outcome was time to occurrence of DFU. A process evaluation was also conducted. Results: A total of 172 patients (63% women, mean age 61 years) were enrolled; 86 to each study group. More patients enrolled in the intervention arm had a history of previous DFU (66% vs. 48%). Follow-up for the primary endpoint was complete for 158 of 172 participants (92%). Adherence to ≥80% of daily temperature measurements was 87% (103 of 118) among the study participants who returned the logbook. DFU cumulative incidence was 24% (19 of 79) in the intervention arm and 11% (9 of 79) in the control arm. After adjusting for history of foot ulceration and study site, the hazard ratio (HR) for DFU was 1.44 (95% CI 0.65, 3.22). Conclusions: In our study, conducted in a low-income setting, the addition of mHealth to foot thermometry was not effective in reducing foot ulceration. Importantly, there was a higher rate of previous DFU in the intervention group, the adherence to thermometry was high, and the expected rates of DFU used in our sample size calculations were not met. Trial registration: ClinicalTrials.gov NCT02373592 (27/02/2015).

Social marketing interventions for the prevention and control of neglected tropical diseases: A systematic review

BACKGROUND

Social marketing is an approach to behavior change that contributes to disease prevention and control. This study aimed to understand how social marketing interventions have addressed neglected tropical diseases (NTDs). It examined the characteristics, breadth of coverage, and outcomes of social marketing interventions focused on the prevention and control of these diseases.

METHODOLOGY/PRINCIPAL FINDINGS

Studies published in any language between January 1971 and April 2017, targeting at least one of the 17 NTDs prioritized in the World Health Organization (WHO) NTD Roadmap were considered. Included studies had interventions that applied both, at least one core social marketing concept, "social behavioral influence", and one social marketing technique, "integrated intervention mix", described in the Hierarchical Model of Social Marketing. This review is registered with PROSPERO CRD42017063858. Twenty interventions, addressing eight NTDs, met the inclusion criteria. They focused on behaviors related to four of the five WHO public health strategies for NTDs. Most interventions incorporated the concepts "relationship building" and "public / people orientation focus", and the technique "insight-driven segmentation". All the interventions reported changing behavioral determinants such as knowledge, 19 reported behavior change, and four influenced health outcomes.

CONCLUSION/SIGNIFICANCE

Evidence from this study shows that social marketing has been successfully used to address behaviors related to most of the five public health strategic interventions for NTDs recommended by the WHO. It is suggested that social marketing interventions for the prevention and control of NTDs be grounded on an understanding of the audience and adapted to the contexts intervened. Building stakeholder relationships as early as possible, and involving the publics could help in reaching NTD outcomes. Elements of the intervention mix should be integrated and mutually supportive. Incorporating health education and capacity building, as well as being culturally appropriate, is also relevant. It is recommended that ongoing discussions to formulate the targets and milestones of the new global Roadmap for NTDs integrate social marketing as an approach to overcome these diseases.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Regression from prediabetes to normal glucose levels is more frequent than progression towards diabetes: The CRONICAS Cohort Study

AIMS

This study aimed to (1) estimate the prevalence of prediabetes according to different definitions, (2) evaluate regression to normal glucose levels and progression towards T2DM, and (3) determine factors associated with regression and progression across four diverse geographical settings in a Latin American country.

METHODS

The CRONICAS Cohort Study was conducted in four different areas in Peru. Enrollment started in September 2010 and follow-up was conducted in 2013. Prediabetes, T2DM and normal glucose levels were determined according to definitions from the World Health Organization (WHO), American Diabetes Association (ADA), and National Institute for Health and Care Excellence (NICE). The main outcomes were regression to normal glucose levels and incidence of T2DM. Prevalence estimates and 95% confidence intervals (95% CI) were calculated. Crude and adjusted models using Poisson regression were performed and relative risk ratios (RRR) and 95% CI were calculated.

RESULTS

At baseline, the prevalence of prediabetes varied markedly by definition used: 6.5%(95% CI 5.6-7.6%), 53.6% (95% CI 51.6-55.6%), and 24.6% (95% CI 22.8-26.4%) according to WHO, ADA and NICE criteria, respectively. After 2.2  years of follow-up, in those with prediabetes, the cumulative incidence of regression to euglycemia ranged between 31.4% and 68.9%, whereas the incidence of T2DM varied from 5.5% to 28.8%. Factors associated with regression to normal glucose levels and progression to diabetes were age, body mass index, and insulin resistance.

CONCLUSIONS

Regression from pre-diabetes back to euglycemia was much more common than progression to diabetes.

Global Inequality in Type 1 Diabetes: a Comparison of Switzerland and Low-and Middle-Income Countries

Globally it is estimated that over 1 million children and adolescents have Type 1 diabetes with large variations in incidence between different contexts. Health systems need to provide a variety of elements to ensure appropriate diabetes care, such as service delivery; healthcare workforce; information; medical products and technologies; financing and leadership and governance. Describing these elements between Geneva, Switzerland, a high-income country with high spending on healthcare and a large density of doctors, and low- and middle-income countries this article aims to highlight the global inequality of diabetes care. Type 1 diabetes can serve as a litmus as we move towards the centenary of the discovery of insulin and beyond as there is a need for a global movement to ensure that innovation in the management of diabetes benefits the whole diabetes community and not just a select few.

Foot thermometry with mHeath-based supplementation to prevent diabetic foot ulcers: A randomized controlled trial

Background: Three previous clinical trials have found that thermometry use reduced diabetic foot ulcers (DFUs) incidence four- to ten-fold among individuals with diabetes at high-risk of developing a DFU. However, these benefits depend on patient adherence to self-assessment. Therefore, novel approaches to improve self-management thermometry adherence are needed. Our objective was to compare incidence of DFUs in the thermometry plus mobile health (mHealth) reminders intervention arm vs. thermometry-only control arm. Methods: We conducted a randomized trial, enrolling adults with type 2 diabetes mellitus at risk of foot ulcers (risk groups 2 or 3) but without foot ulcers at the time of recruitment and allocating them to control (instruction to use a liquid crystal-based foot thermometer daily) or intervention (same instruction supplemented with text and voice messages with reminders to use the device and messages to promote foot care) groups and followed for 18 months. The primary outcome was time to occurrence of DFU. A process evaluation was also conducted. Results: A total of 172 patients (63% women, mean age 61 years) were enrolled; 86 to each study group. More patients enrolled in the intervention arm had a history of DFU (66% vs. 48%). Follow-up for the primary endpoint was complete for 158 of 172 participants (92%). DFU cumulative incidence was 24% (19 of 79) in the intervention arm and 11% (9 of 79) in the control arm. After adjusting for history of foot ulceration and study site, the Hazard Ratio (HR) for DFU was 1.44 (95% CI 0.65, 3.22). Adherence to ≥80% of daily temperature measurements was 87% (103 of 118) among the study participants who returned the logbook, with no difference between the intervention and control arms. Conclusions: This trial contributes to the evidence about the value of mHealth in preventing diabetes foot ulcers. Trial registration: ClinicalTrials.gov NCT02373592 (27/02/2015).

World Health Organization (WHO) antibiotic regimen against other regimens for the treatment of leprosy: a systematic review and meta-analysis

BACKGROUND

To evaluate the effectiveness and safety of the World Health Organization antibiotic regimen for the treatment of paucibacillary (PB) and multibacillary (MB) leprosy compared to other available regimens.

METHODS

We performed a search from 1982 to July 2018 without language restriction. We included randomized controlled trials, quasi-randomized trials, and comparative observational studies (cohorts and case-control studies) that enrolled patients of any age with PB or MB leprosy that were treated with any of the leprosy antibiotic regimens established by the WHO in 1982 and used any other antimicrobial regimen as a controller. Primary efficacy outcomes included: complete clinical cure, clinical improvement of the lesions, relapse rate, treatment failure. Data were pooled using a random effects model to estimate the treatment effects reported as relative risk (RR) with 95% confidence intervals (CI).

RESULTS

We found 25 eligible studies, 11 evaluated patients with paucibacillary leprosy, while 13 evaluated patients with MB leprosy and 1 evaluated patients of both groups. Diverse regimen treatments and outcomes were studied. Complete cure at 6 months of multidrug therapy (MDT) in comparison to rifampin-ofloxacin-minocycline (ROM) found RR of 1.06 (95% CI 0.88-1.27) in five studies. Whereas six studies compare the same outcome at different follow up periods between 6 months and 5 years, according to the analysis ROM was not better than MDT (RR of 1.01 (95% CI 0.78-1.31)) in PB leprosy.

CONCLUSION

Not better treatment than the implemented by the WHO was found. Diverse outcome and treatment regimens were studied, more statements to standardized the measurements of outcomes are needed.

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

Increases in the prevalence of noncommunicable diseases (NCDs), particularly cardiometabolic diseases such as cardiovascular disease, stroke and diabetes, and their major risk factors have not been uniform across settings: for example, cardiovascular disease mortality has declined over recent decades in high-income countries but increased in low- and middle-income countries (LMICs). The factors contributing to this rise are varied and are influenced by environmental, social, political and commercial determinants of health, among other factors. This Review focuses on understanding the rise of cardiometabolic diseases in LMICs, with particular emphasis on obesity and its drivers, together with broader environmental and macro determinants of health, as well as LMIC-based responses to counteract cardiometabolic diseases.

The role of context in implementation research for non-communicable diseases: Answering the 'how-to' dilemma

Introduction

Understanding context and how this can be systematically assessed and incorporated is crucial to successful implementation. We describe how context has been assessed (including exploration or evaluation) in Global Alliance for Chronic Diseases (GACD) implementation research projects focused on improving health in people with or at risk of chronic disease and how contextual lessons were incorporated into the intervention or the implementation process.

Methods

Using a web-based semi-structured questionnaire, we conducted a cross-sectional survey to collect quantitative and qualitative data across GACD projects (n = 20) focusing on hypertension, diabetes and lung diseases. The use of context-specific data from project planning to evaluation was analyzed using mixed methods and a multi-layered context framework across five levels; 1) individual and family, 2) community, 3) healthcare setting, 4) local or district level, and 5) state or national level.

Results

Project teams used both qualitative and mixed methods to assess multiple levels of context (avg. = 4). Methodological approaches to assess context were identified as formal and informal assessments, engagement of stakeholders, use of locally adapted resources and materials, and use of diverse data sources. Contextual lessons were incorporated directly into the intervention by informing or adapting the intervention, improving intervention participation or improving communication with participants/stakeholders. Provision of services, equipment or information, continuous engagement with stakeholders, feedback for personnel to address gaps, and promoting institutionalization were themes identified to describe how contextual lessons are incorporated into the implementation process.

Conclusions

Context is regarded as critical and influenced the design and implementation of the GACD funded chronic disease interventions. There are different approaches to assess and incorporate context as demonstrated by this study and further research is required to systematically evaluate contextual approaches in terms of how they contribute to effectiveness or implementation outcomes.

Moving from formative research to co-creation of interventions: insights from a community health system project in Mozambique, Nepal and Peru

Different methodological approaches for implementation research in global health focusing on how interventions are developed, implemented and evaluated are needed. In this paper, we detail the approach developed and implemented in the COmmunity HEalth System InnovatiON (COHESION) Project, a global health project aimed at strengthening health systems in Mozambique, Nepal and Peru. This project developed innovative formative research at policy, health system and community levels to gain a comprehensive understanding of the barriers, enablers, needs and lessons for the management of chronic disease using non-communicable and neglected tropical diseases as tracer conditions. After formative research, COHESION adopted a co-creation approach in the planning of interventions. The approach included two interactions with each type of stakeholder at policy, health system and community level in each country which aimed to develop interventions to improve the delivery of care of the tracer conditions. Diverse tools and methods were used in order to prioritise interventions based on support, resources and impact. Additionally, a COHESION score that assessed feasibility, sustainability and scaling up was used to select three potential interventions. Next steps for the COHESION Project are to further detail and develop the interventions propositioned through this process. Besides providing some useful tools and methods, this work also highlights the challenges and lessons learned from such an approach.

A descriptive study of potential participant preferences for the design of an incentivised weight loss programme for people with type 2 diabetes mellitus attending a public hospital in Lima, Peru

Background: Weight loss is important for the control of type 2 diabetes mellitus but is difficult to achieve and sustain. Programmes employing financial incentives have been successful in areas such as smoking cessation. However, the optimum design for an incentivised programme for weight loss is undetermined, and may depend on social, cultural and demographic factors. Methods: An original questionnaire was designed whose items addressed respondent personal and health characteristics, and preferences for a hypothetical incentivised weight loss programme. One hundred people with type 2 diabetes mellitus were recruited to complete the questionnaire from the endocrinology clinic of a public hospital in Lima, Peru. A descriptive analysis of responses was performed. Results: Ninety-five percent of subjects who had previously attempted to lose weight had found this either 'difficult' or 'very difficult'. Eighty-five percent of subjects would participate in an incentivised weight loss programme. Median suggested incentive for 1 kg weight loss every 2 weeks over 9 months was PEN 100 (~USD $30). Cash was preferred by 70% as payment method. Only 56% of subjects would participate in a deposit-contract scheme, and the median suggested deposit amount was PEN 20 (~USD $6). Eighty percent of subjects would share the incentive with a helper, and family members were the most common choice of helper. Conclusions: The challenge of achieving and sustaining weight loss is confirmed in this setting. Direct cash payments of PEN 100 were generally preferred, with substantial scope for involving a co-participant with whom the incentive could be shared. Employing direct financial incentives in future weight loss programmes appears to be widely acceptable among people with type 2 diabetes mellitus.

A descriptive study of potential participant preferences for the design of an incentivised weight loss programme for people with type 2 diabetes mellitus attending a public hospital in Lima, Peru

Background: Weight loss is important for the control of type 2 diabetes mellitus but is difficult to achieve and sustain. Programmes employing financial incentives have been successful in areas such as smoking cessation. However, the optimum design for an incentivised programme for weight loss is undetermined, and may depend on social, cultural and demographic factors. Methods: An original questionnaire was designed whose items addressed respondent personal and health characteristics, and preferences for a hypothetical incentivised weight loss programme. One hundred people with type 2 diabetes mellitus were recruited to complete the questionnaire from the endocrinology clinic of a public hospital in Lima, Peru. A descriptive analysis of responses was performed. Results: Ninety-five percent of subjects who had previously attempted to lose weight had found this either 'difficult' or 'very difficult'. Eighty-five percent of subjects would participate in an incentivised weight loss programme. Median suggested incentive for 1 kg weight loss every 2 weeks over 9 months was PEN 100 (~USD $30). Cash was preferred by 70% as payment method. Only 56% of subjects would participate in a deposit-contract scheme, and the median suggested deposit amount was PEN 20 (~USD $6). Eighty percent of subjects would share the incentive with a helper, and family members were the most common choice of helper. Conclusions: The challenge of achieving and sustaining weight loss is confirmed in this setting. Direct cash payments of PEN 100 were generally preferred, with substantial scope for involving a co-participant with whom the incentive could be shared. Employing direct financial incentives in future weight loss programmes appears to be widely acceptable among people with type 2 diabetes mellitus.

Gaps in Guidelines for the Management of Diabetes in Low- and Middle-Income Versus High-Income Countries-A Systematic Review

OBJECTIVE

The extent to which diabetes (DM) practice guidelines, often based on evidence from high-income countries (HIC), can be implemented to improve outcomes in low- and middle-income countries (LMIC) is a critical challenge. We carried out a systematic review to compare type 2 DM guidelines in individual LMIC versus HIC over the past decade to identify aspects that could be improved to facilitate implementation.

RESEARCH DESIGN AND METHODS

Eligible guidelines were sought from online databases and websites of diabetes associations and ministries of health. Type 2 DM guidelines published between 2006 and 2016 with accessible full publications were included. Each of the 54 eligible guidelines was assessed for compliance with the Institute of Medicine (IOM) standards, coverage of the cardiovascular quadrangle (epidemiologic surveillance, prevention, acute care, and rehabilitation), translatability, and its target audiences.

RESULTS

Most LMIC guidelines were inadequate in terms of applicability, clarity, and dissemination plan as well as socioeconomic and ethical-legal contextualization. LMIC guidelines targeted mainly health care providers, with only a few including patients (7%), payers (11%), and policy makers (18%) as their target audiences. Compared with HIC guidelines, the spectrum of DM clinical care addressed by LMIC guidelines was narrow. Most guidelines from the LMIC complied with less than half of the IOM standards, with 12% of the LMIC guidelines satisfying at least four IOM criteria as opposed to 60% of the HIC guidelines (P < 0.001).

CONCLUSIONS

A new approach to the contextualization, content development, and delivery of LMIC guidelines is needed to improve outcomes.

Cognitive impairment and hypertension in older adults living in extreme poverty: a cross-sectional study in Peru

BACKGROUND

Previous studies have shown that hypertension is a risk factor for cognitive impairment, but whether this association is also present in extremely poor populations in Low Middle Income Countries settings remains to be studied. Understanding other drivers of cognitive impairment in this unique population also merits attention.

METHODS

We performed a secondary analysis using data from the "Encuesta de Salud y Bienestar del Adulto Mayor", a regional survey conducted in an extremely poor population of people older than 65 years old from 12 Peruvian cities in 2012. The outcome variable was cognitive impairment, determined by a score of ≤7 in the modified Mini-Mental State Examination. The exposure was self-reported hypertension status. Variables such as age, gender, controlled hypertension, education level, occupation, depression and area of living (rural/urban) were included in the adjusted analysis. We used Poisson regression with robust variance to calculate prevalence ratios (PR) and 95% confidence interval (95% CI) adjusting for confounders.

RESULTS

Data from 3842 participants was analyzed, 51.8% were older than 70 years, and 45.6% were females. The prevalence of cognitive impairment was 1.7% (95% CI 1.3%-2.1%). There was no significant difference on the prevalence of cognitive impairment between the group of individuals with hypertension in comparison with those without hypertension (PR = 0.64, 95% CI 0.33-1.23).

CONCLUSIONS

The association described between hypertension and cognitive impairment was not found in a sample of extremely poor Peruvian older adults.

Association between chronic conditions and health-related quality of life: differences by level of urbanization in Peru

Purpose

To evaluate the role of urbanization as an effect modifier for the association between specific chronic conditions and number of conditions with health-related quality of life (QOL).

Methods

We analyzed cross-sectional data from the CRONICAS Cohort Study conducted in Lima (highly urbanized), Tumbes (semi-urban), as well as rural and urban sites in Puno. Exposures of interest were chronic bronchitis, depressive mood, hypertension, type 2 diabetes, and a composite variable aggregating the number of chronic conditions (the four exposures plus heart disease and stroke). QOL outcomes were assessed with EuroQol’s EQ-5D visual analogue scale (EQ-VAS). We fitted linear regressions with robust variance to evaluate the associations of interest. Study site was assessed as a potential effect modifier using the likelihood-ratio (LR) test.

Results

We evaluated data on 2433 subjects: 51.3% were female, mean age was 57.2 years. Study site was found to be an effect modifier only for the association between depressive mood and EQ-VAS score (LR test p < 0.001). Compared to those without depressive mood, participants with depressive mood scored −13.7 points on the EQ-VAS in Lima, −7.9 in urban Puno, −11.0 in semi-urban Tumbes, and −2.7 in rural Puno. Study site was not found to be an effect modifier for the association between the number of chronic conditions and EQ-VAS (LR test p = 0.64).

Conclusion

The impact of depressive mood on EQ-VAS was larger in urban than in rural sites, while site was not an effect modifier for the remaining associations.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-017-1649-7) contains supplementary material, which is available to authorized users.

Urbanization, mainly rurality, but not altitude is associated with dyslipidemia profiles

Background

Geographical and environmental features such as urbanization and altitude may influence individual's lipid profiles because of the diversity of human-environment interactions including lifestyles.

Objective

To characterize the association between altitude and urbanization and lipid profile among Peruvian adults aged ≥35 years.

Methods

Cross-sectional analysis of the CRONICAS Cohort Study. The outcomes of interest were 6 dyslipidemia traits: hypertriglyceridemia, high low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol (HDL-c), nonisolated low HDL-c, isolated low HDL-c, and high non-HDL-c. The exposures of interest were urbanization level (highly urban, urban, semi-urban, and rural) and altitude (high altitude vs sea level). Prevalence ratios (PRs) and 95% confidence intervals (95% CIs) were calculated using Poisson regression models with robust variance adjusting for potential confounders.

Results

Data from 3037 individuals, 48.5% males, mean age of 55.6 (standard deviation ±12.7) years, were analyzed. The most common dyslipidemia pattern was high non-HDL-c with a prevalence of 88.0% (95% CI: 84.9%–90.7%) in the rural area and 96.0% (95% CI: 94.5%–97.1%) in the semi-urban area. Relative to the highly urban area, living in rural areas was associated with a lower prevalence of hypertriglyceridemia (PR = 0.75; 95% CI: 0.56–0.99) and high non-HDL-c (PR = 0.96; 95% CI: 0.93–0.99), whereas living in semi-urban areas was associated with higher prevalence high low-density lipoprotein cholesterol (PR = 1.37; 95% CI: 1.11–1.67). Compared with sea level areas, high-altitude areas had lower prevalence of high non-HDL-c (PR = 0.97; 95% CI: 0.95–0.99).

Conclusion

Urbanization but not altitude was associated to several dyslipidemia traits, with the exception of high non-HDL-c in high altitude settings.

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Levels of urbanization but not altitude were associated with dyslipidemia traits.

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People in rural in comparison to urban areas had lower prevalence of dyslipidemia.

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Population from semi-urban areas showed high prevalence of some dyslipidemia traits.

Perspectives, Decision Making, and Final Mode of Delivery in Pregnant Women With a Previous C-Section in a General Hospital in Peru: Prospective Analysis

Objective: Explore the perspectives, decision-making process, and final mode of delivery among pregnant women with a previous C-section (Cesarean section) in a general public sector hospital in Lima, Peru. Methods: A qualitative prospective study using semistructured interviews at two time points in the outpatient obstetrics and gynecology clinic of a public sector, university-affiliated reference hospital in Lima, Peru. Seventeen adult pregnant women with a prior C-section who were deemed by their attending obstetrician to be candidates for a trial of labor were interviewed. The first interview was between 37 and 38 weeks of pregnancy, and the second interview was 24 to 48 hours after delivery.

MAIN OUTCOME MEASURES

Predelivery decision-making process and final mode of delivery. Results: Among the 17 participants, about half (9) of the participants stated that the physician explained that they had two approaches for delivery, a trial of labor after C-section (TOLAC) or elective repeated C-section (ERCD). Two women stated that their respective providers explained only one option, either an ERCD or TOLAC. However, 6 women did not receive any information from their providers about their delivery options. Of the 10 participants that decided TOLAC, 8 ended up having a C-section, and of the 7 patients that had planned an ERCD, 1 ended up having a vaginal delivery. Conclusion: Many participants affirmed that they made the decision about their approach of delivery. However, most of the participants that decided a TOLAC ended up having a C-section because of complications during the final weeks of pregnancy or during labor.

Innovative Approaches to Hypertension Control in Low- and Middle-Income Countries

Elevated blood pressure, a major risk factor for ischemic heart disease, heart failure, and stroke, is the leading global risk for mortality. Treatment and control rates are very low in low- and middle-income countries. There is an urgent need to address this problem. The Global Alliance for Chronic Diseases sponsored research projects focus on controlling hypertension, including community engagement, salt reduction, salt substitution, task redistribution, mHealth, and fixed-dose combination therapies. This paper reviews the rationale for each approach and summarizes the experience of some of the research teams. The studies demonstrate innovative and practical methods for improving hypertension control.