Examinando por Autor "Seron, Pamela"
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- PublicaciónAcceso abiertoAlcohol consumption and cardiovascular disease, cancer, injury, admission to hospital, and mortality : A prospective cohort study(2015-10-14) Smyth, Andrew; Teo, Koon; Rangarajan, Sumathy; O’Donnell, Martin J.; Zhang, Xiaohe; Rana, Punam; Leong, Darryl P.; Dagenais, Gilles; Seron, Pamela; Rosengren, Annika; Schutte, Aletta Elisabeth; Lopez-Jaramillo, Patricio; Oguz, Ayetkin; Chifamba, Jephat; Diaz, Rafael; Lear, Scott A.; Avezum, Alvaro; Kumar, Rajesh; Mohan, Viswanathan; Szuba, Andrzej; Wei, Li; Yang, Wang; Jian, Bo; McKee, Martin; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBackground Alcohol consumption is proposed to be the third most important modifiable risk factor for death and disability. However, alcohol consumption has been associated with both benefits and harms, and previous studies were mostly done in high-income countries. We investigated associations between alcohol consumption and outcomes in a prospective cohort of countries at different economic levels in five continents. Methods We included information from 12 countries participating in the Prospective Urban Rural Epidemiological (PURE) study, a prospective cohort study of individuals aged 35–70 years. We used Cox proportional hazards regression to study associations with mortality (n=2723), cardiovascular disease (n=2742), myocardial infarction (n=979), stroke (n=817), alcohol-related cancer (n=764), injury (n=824), admission to hospital (n=8786), and for a composite of these outcomes (n=11 963). Findings We included 114 970 adults, of whom 12 904 (11%) were from high-income countries (HICs), 24 408 (21%) were from upper-middle-income countries (UMICs), 48 845 (43%) were from lower-middle-income countries (LMICs), and 28 813 (25%) were from low-income countries (LICs). Median follow-up was 4·3 years (IQR 3·0–6·0). Current drinking was reported by 36 030 (31%) individuals, and was associated with reduced myocardial infarction (hazard ratio [HR] 0·76 [95% CI 0·63–0·93]), but increased alcohol-related cancers (HR 1·51 [1·22–1·89]) and injury (HR 1·29 [1·04–1·61]). High intake was associated with increased mortality (HR 1·31 [1·04–1·66]). Compared with never drinkers, we identified significantly reduced hazards for the composite outcome for current drinkers in HICs and UMICs (HR 0·84 [0·77–0·92]), but not in LMICs and LICs, for which we identified no reductions in this outcome (HR 1·07 [0·95–1·21]; pinteraction<0·0001). Interpretation Current alcohol consumption had differing associations by clinical outcome, and differing associations by income region. However, we identified sufficient commonalities to support global health strategies and national initiatives to reduce harmful alcohol use. Funding Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
- PublicaciónAcceso abiertoAssessing global risk factors for non-fatal injuries from road traffic accidents and falls in adults aged 35–70 years in 17 countries : A cross-sectional analysis of the prospective urban rural Epidemiological (PURE) study(2016) Raina, Parminder; Sohel, Nazmul; Oremus, Mark; Shannon, Harry; Mony, Prem; Kumar, Rajesh; Li, Wei; Wang, Yang; Wang, Xingyu; Yusoff, Khalid; Yusuf, Rita; Iqbal, Romaina; Szuba, Andrzej; Oguz, Aytekin; Rosengren, Annika; Kruger, Annamarie; Chifamba, Jephat; Mohammadifard, Noushin; Darwish, Ebtihal Ahmad; Dagenais, Gilles; Diaz, Rafael; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Seron, Pamela; Rangarajan, Sumathy; Teo, Koon; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsObjectives To assess risk factors associated with non-fatal injuries (NFIs) from road traffic accidents (RTAs) or falls. Methods Our study included 151 609 participants from the Prospective Urban Rural Epidemiological study. Participants reported whether they experienced injuries within the past 12 months that limited normal activities. Additional questions elicited data on risk factors. We employed multivariable logistic regression to analyse data. Results Overall, 5979 participants (3.9% of 151 609) reported at least one NFI. Total number of NFIs was 6300: 1428 were caused by RTAs (22.7%), 1948 by falls (30.9%) and 2924 by other causes (46.4%). Married/common law status was associated with fewer falls, but not with RTA. Age 65–70 years was associated with fewer RTAs, but more falls; age 55–64 years was associated with more falls. Male versus female was associated with more RTAs and fewer falls. In lower-middle-income countries, rural residence was associated with more RTAs and falls; in low-income countries, rural residence was associated with fewer RTAs. Previous alcohol use was associated with more RTAs and falls; current alcohol use was associated with more falls. Education was not associated with either NFI type. Conclusions This study of persons aged 35–70 years found that some risk factors for NFI differ according to whether the injury is related to RTA or falls. Policymakers may use these differences to guide the design of prevention policies for RTA-related or fall-related NFI.
- PublicaciónAcceso abiertoThe association between ownership of common household devices and obesity and diabetes in high, middle and low income countries(2014-03-04) Lear, Scott A.; Teo, Koon; Gasevic, Danijela; Zhang, Xiaohe; Poirier, Paul P.; Rangarajan, Sumathy; Seron, Pamela; Kelishadi, Roya; Mohd Tamil, Azmi; Kruger, Annamarie; Iqbal, Romaina; Swidan, Hani; Gómez Arbeláez, Diego; Yusuf, Rita; Chifamba, Jephat; Kutty, V. Raman; Karsıdag, Kubilay; Kumar, Rajesh; Li, Wei; Szuba, Andrzej; Avezum, Alvaro; Diaz, Rafael; Anand, Sonia S.; Rosengren, Annika; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBackground: Household devices (e.g., television, car, computer) are common in high income countries, and their use has been linked to obesity and type 2 diabetes mellitus. We hypothesized that device ownership is associated with obesity and diabetes and that these effects are explained through reduced physical activity, increased sitting time and increased energy intake. Methods: We performed a cross-sectional analysis using data from the Prospective Urban Rural Epidemiology study involving 153 996 adults from high, upper-middle, lower-middle and low income countries. We used multilevel regression models to account for clustering at the community and country levels. Results: Ownership of a household device increased from low to high income countries (4% to 83% for all 3 devices) and was associated with decreased physical activity and increased sitting, dietary energy intake, body mass index and waist circumference. There was an increased odds of obesity and diabetes with the ownership of any 1 household device compared to no device ownership (obesity: odds ratio [OR] 1.43, 95% confidence interval [CI] 1.32–1.55; diabetes: OR 1.38, 95% CI 1.28–1.50). Ownership of a second device increased the odds further but ownership of a third device did not. Subsequent adjustment for lifestyle factors modestly attenuated these associations. Of the 3 devices, ownership of a television had the strongest association with obesity (OR 1.39, 95% CI 1.29–1.49) and diabetes (OR 1.33, 95% CI 1.23–1.44). When stratified by country income level, the odds of obesity and diabetes when owning all 3 devices was greatest in low income countries (obesity: OR 3.15, 95% CI 2.33-4.25; diabetes: OR 1.97, 95% CI 1.53–2.53) and decreased through country income levels such that we did not detect an association in high income countries. Interpretation: The ownership of household devices increased the likelihood of obesity and diabetes, and this was mediated in part by effects on physical activity, sitting time and dietary energy intake. With increasing ownership of household devices in developing countries, societal interventions are needed to mitigate their effects on poor health.
- PublicaciónAcceso abiertoAssociation of egg intake with blood lipids, cardiovascular disease, and mortality in 177,000 people in 50 countries(American Journal of Clinical Nutrition, 2020-04-01) Dehghan, Mahshid; Mente, Andrew; Rangarajan, Sumathy; Mohan, Viswanathan; Lear, Scott; Swaminathan, Sumathi; Wielgosz, Andreas; Seron, Pamela; Avezum, Alvaro; Lopez-Jaramillo, Patricio; Turbide, Ginette; Chifamba, Jephat; AlHabib, Khalid F.; Mohammadifard, Noushin; Szuba, Andrzej; Khatib, Rasha; Altuntas, Yuksel; Liu, Xiaoyun; Iqbal, Romaina; Rosengren, Annika; Yusuf, Rita; Smuts, Marius; Yusufali, AfzalHussein; Li, Ning; Diaz, Rafael; Yusoff, Khalid; Kaur, Manmeet; Soman, Biju; Ismail, Noorhassim; Gupta, Rajeev; Dans, Antonio; Sheridan, Patrick; Teo, Koon; Anand, Sonia S; Yusuf, Salim; Behalf of the PURE investigators; EverestABSTRACT Background: Eggs are a rich source of essential nutrients, but they are also a source of dietary cholesterol. Therefore, some guidelines recommend limiting egg consumption. However, there is contradictory evidence on the impact of eggs on diseases, largely based on studies conducted in high-income countries. Objectives: Our aim was to assess the association of egg consumption with blood lipids, cardiovascular disease (CVD), and mortality in large global studies involving populations from low-, middle-, and high-income countries. Methods: We studied 146,011 individuals from 21 countries in the Prospective Urban Rural Epidemiology (PURE) study. Egg consumption was recorded using country-specific validated FFQs. We also studied 31,544 patients with vascular disease in 2 multinational prospective studies: ONTARGET (Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects with Cardiovascular Disease). We calculated HRs using multivariable Cox frailty models with random intercepts to account for clustering by study center separately within each study. Results: In the PURE study, we recorded 14,700 composite events (8932 deaths and 8477 CVD events). In the PURE study, after excluding those with history of CVD, higher intake of egg (≥7 egg/wk compared with <1 egg/wk intake) was not significantly associated with blood lipids, composite outcome (HR: 0.96; 95% CI: 0.89, 1.04; P-trend = 0.74), total mortality (HR: 1.04; 95% CI: 0.94, 1.15; P-trend = 0.38), or major CVD (HR: 0.92; 95% CI: 0.83, 1.01; P-trend = 0.20). Similar results were observed in ONTARGET/TRANSCEND studies for composite outcome (HR 0.97; 95% CI: 0.76, 1.25; P-trend = 0.09), total mortality (HR: 0.88; 95% CI: 0.62, 1.24; P-trend = 0.55), and major CVD (HR: 0.97; 95% CI: 0.73, 1.29; P-trend = 0.12). Conclusions: In 3 large international prospective studies including ∼177,000 individuals, 12,701 deaths, and 13,658 CVD events from 50 countries in 6 continents, we did not find significant associations between egg intake and blood lipids, mortality, or major CVD events. The ONTARGET and TRANSCEND trials were registered at clinicaltrials.gov as NCT00153101. The PURE trial was registered at clinicaltrials.gov as NCT03225586. Am J Clin Nutr 2020;111:795–803.
- PublicaciónAcceso abiertoAssociation of estimated sleep duration and naps with mortality and cardiovascular events(European Society of Cardiology, 2019-05-21) Wang, Chuangshi; Bangdiwala, Shrikant I.; Rangarajan, Sumathy; Lear, Scott A.; AlHabib, Khalid F.; Mohan, Viswanathan; Koon, Teo; Poirier, Paul; Tse, Lap Ah; Liu, Zhiguang; Rosengren, Annika; Kumar, Rajesh; Lopez-Jaramillo, Patricio; Yusoff, Khalid; Monsef, Nahed; Krishnapillai, Vijayakumar; Ismail, Noorhassim; Seron, Pamela; Dans, Antonio; Kruger, Lanthé; Yeates, Karen; Leach, Lloyd; Yusuf, Rita; Orlandini, Andres; Wolyniec, Maria; Bahonar, Ahmad; Mohan, Indu; Khatib, Rasha; Temizhan, Ahmet; Li, Wei; Yusuf, Salim; On behalf of the Prospective Urban Rural Epidemiology (PURE) study investigators; EverestAims To investigate the association of estimated total daily sleep duration and daytime nap duration with deaths and major cardiovascular events. Methods and results We estimated the durations of total daily sleep and daytime naps based on the amount of time in bed and self-reported napping time and examined the associations between them and the composite outcome of deaths and major cardiovascular events in 116 632 participants from seven regions. After a median follow-up of 7.8 years, we recorded 4381 deaths and 4365 major cardiovascular events. It showed both shorter (≤6 h/day) and longer (>8 h/day) estimated total sleep durations were associated with an increased risk of the composite outcome when adjusted for age and sex. After adjustment for demographic characteristics, lifestyle behaviours and health status, a J-shaped association was observed. Compared with sleeping 6–8 h/day, those who slept ≤6 h/day had a non-significant trend for increased risk of the composite outcome [hazard ratio (HR), 1.09; 95% confidence interval, 0.99–1.20]. As estimated sleep duration increased, we also noticed a significant trend for a greater risk of the composite outcome [HR of 1.05 (0.99–1.12), 1.17 (1.09–1.25), and 1.41 (1.30–1.53) for 8–9 h/day, 9–10 h/day, and >10 h/day, Ptrend < 0.0001, respectively]. The results were similar for each of all-cause mortality and major cardiovascular events. Daytime nap duration was associated with an increased risk of the composite events in those with over 6 h of nocturnal sleep duration, but not in shorter nocturnal sleepers (≤6 h). Conclusion Estimated total sleep duration of 6–8 h per day is associated with the lowest risk of deaths and major cardiovascular events. Daytime napping is associated with increased risks of major cardiovascular events and deaths in those with >6 h of nighttime sleep but not in those sleeping ≤6 h/night.
- PublicaciónAcceso abiertoAssociation of Symptoms of Depression with Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries(American Medical Association, 2020-06-10) Rajan, Selina; McKee, Martin; Rangarajan, Sumathy; Bangdiwala, Shrikant; Rosengren, Annika; Gupta, Rajeev; Kutty, Vellappillil Raman; Wielgosz, Andreas; Lear, Scott; AlHabib, Khalid F.; Co, Homer U.; Lopez-Jaramillo, Patricio; Avezum, Alvaro; Seron, Pamela; Oguz, Aytekin; Kruger, Iolanthé M.; Diaz, Rafael; Nafiza, Mat-Nasir; Chifamba, Jephat; Yeates, Karen; Kelishadi, Roya; Sharief, Wadeia Mohammed; Szuba, Andrzej; Khatib, Rasha; Rahman, Omar; Iqbal, Romaina; Bo, Hu; Yibing, Zhu; Wei, Li; Yusuf, Salim; The Prospective Urban Rural Epidemiology (PURE) Study Investigators; EverestIMPORTANCE Depression is associated with incidence of and premature death from cardiovascular disease (CVD) and cancer in high-income countries, but it is not known whether this is true in low- and middle-income countries and in urban areas, where most people with depression now live. OBJECTIVE To identify any associations between depressive symptoms and incident CVD and all-cause mortality in countries at different levels of economic development and in urban and rural areas. DESIGN, SETTING, AND PARTICIPANTS This multicenter, population-based cohort study was conducted between January 2005 and June 2019 (median follow-up, 9.3 years) and included 370 urban and 314 rural communities from 21 economically diverse countries on 5 continents. Eligible participants aged 35 to 70 years were enrolled. Analysis began February 2018 and ended September 2019. EXPOSURES Four or more self-reported depressive symptoms from the Short-Form Composite International Diagnostic Interview. MAIN OUTCOMES AND MEASURES Incident CVD, all-cause mortality, and a combined measure of either incident CVD or all-cause mortality. RESULTS Of 145 862 participants, 61 235 (58%) were male and the mean (SD) age was 50.05 (9.7) years. Of those, 15 983 (11%) reported 4 or more depressive symptoms at baseline. Depression was associated with incident CVD (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24), all-cause mortality (HR, 1.17; 95% CI, 1.11-1.25), the combined CVD/mortality outcome (HR, 1.18; 95% CI, 1.11-1.24), myocardial infarction (HR, 1.23; 95% CI, 1.10-1.37), and noncardiovascular death (HR, 1.21; 95% CI, 1.13-1.31) in multivariable models. The risk of the combined outcome increased progressively with number of symptoms, being highest in those with 7 symptoms (HR, 1.24; 95% CI, 1.12-1.37) and lowest with 1 symptom (HR, 1.05; 95% CI, 0.92 -1.19; P for trend < .001). The associations between having 4 or more depressive symptoms and the combined outcome were similar in 7 different geographical regions and in countries at all economic levels but were stronger in urban (HR, 1.23; 95% CI, 1.13-1.34) compared with rural (HR, 1.10; 95% CI, 1.02-1.19) communities (P for interaction = .001) and in men (HR, 1.27; 95% CI, 1.13-1.38) compared with women (HR, 1.14; 95% CI, 1.06-1.23; P for interaction < .001). CONCLUSIONS AND RELEVANCE In this large, population-based cohort study, adults with depressive symptoms were associated with having increased risk of incident CVD and mortality in economically diverse settings, especially in urban areas. Improving understanding and awareness of these physical health risks should be prioritized as part of a comprehensive strategy to reduce the burden of noncommunicable diseases worldwide.
- PublicaciónRestringidoAssociation of urinary sodium excretion with blood pressure and cardiovascular clinical events in 17,033 Latin americans(2016-07) Lamelas, Pablo M.; Mente, Andrew; Diaz, Rafael; Orlandini, Andres; Avezum, Alvaro; Oliveira, Gustavo; Lanas, Fernando; Seron, Pamela; Lopez-Jaramillo, Patricio; Camacho López, Paul Anthony; O’Donnell, Martin J.; Rangarajan, Sumathy; Teo, Koon; Yusuf, SalimBACKGROUND: Information on actual sodium intake and its relationships with blood pressure (BP) and clinical events in South America is limited. The aim of this cohort study was to assess the relationship of sodium intake with BP, cardiovascular (CV) events, and mortality in South America. METHODS: We studied 17,033 individuals, aged 35–70 years, from 4 South American countries (Argentina, Brazil, Chile, and Colombia). Measures of sodium excretion, estimated from morning fasting urine, were used as a surrogate for daily sodium intake. We measured BP and monitored the composite outcome of death and major CV events. RESULTS: Overall mean sodium excretion was 4.70±1.43g/day. A positive, nonuniform association between sodium and BP was detected, with a significant steeper slope for the relationship at higher sodium excretion levels ( P < 0.001 for interaction). With a median follow-up of 4.7 years, the primary composite outcome (all-cause death, myocardial infarction, stroke, or heart failure) occurred in 568 participants (3.4%). Compared with sodium excretion of 5–6g/day (reference group), participants who excreted >7g/day had increased risks of the primary outcome (odds ratio (OR) 1.73; 95% confidence interval (CI) 1.24 to 2.40; P < 0.001), as well as death from any cause (OR 1.87; 95% CI 1.23 to 2.83; P = 0.003) and major CV disease (OR 1.77; 95% CI 1.12 to 2.81; P = 0.014). Sodium excretion of <3g/day was associated with a statistically nonsignificant increased risk of the primary outcome (OR 1.20; 95% CI 0.86 to 1.65; P = 0.26) and death from any cause (OR 1.25; 95% CI 0.81 to 1.93; P = 0.29), and a significant increased risk of major CV disease (OR 1.50; 95% CI 1.01 to 2.24; P = 0.048), as compared to the reference group. CONCLUSIONS: Our results support a positive, nonuniform association between estimated urinary sodium excretion and BP, and a possible J-shaped pattern of association between sodium excretion over the entire range and clinical outcomes.
- PublicaciónAcceso abiertoThe effect of physical activity on mortality and cardiovascular disease in 130 000 people from 17 high-income, middle-income, and low-income countries: The PURE study(2017-12) Lear, Scott A.; Hu, Weihong; Rangarajan, Sumathy; Gasevic, Danijela; Leong, Darryl P.; Iqbal, Romaina; Casanova, Amparo; Swaminathan, Sumathi; Anjana, Ranjit Mohan; Kumar, Rajesh; Rosengren, Annika; Wei, Li; Yang, Wang; Chuangshi, Wang; Huaxing, Liu; Nair, Sanjeev; Diaz, Rafael; Swidon, Hany; Gupta, Rajeev; Mohammadifard, Noushin; Lopez-Jaramillo, Patricio; Oguz, Aytekin; Zatonska, Katarzyna; Seron, Pamela; Avezum, Alvaro; Poirier, Paul P.; Teo, Koon; Yusuf, SalimBackground: Physical activity has a protective effect against cardiovascular disease (CVD) in high-income countries, where physical activity is mainly recreational, but it is not known if this is also observed in lower-income countries, where physical activity is mainly non-recreational. We examined whether different amounts and types of physical activity are associated with lower mortality and CVD in countries at different economic levels. Methods: In this prospective cohort study, we recruited participants from 17 countries (Canada, Sweden, United Arab Emirates, Argentina, Brazil, Chile, Poland, Turkey, Malaysia, South Africa, China, Colombia, Iran, Bangladesh, India, Pakistan, and Zimbabwe). Within each country, urban and rural areas in and around selected cities and towns were identified to reflect the geographical diversity. Within these communities, we invited individuals aged between 35 and 70 years who intended to live at their current address for at least another 4 years. Total physical activity was assessed using the International Physical Activity Questionnaire (IPQA). Participants with pre-existing CVD were excluded from the analyses. Mortality and CVD were recorded during a mean of 6·9 years of follow-up. Primary clinical outcomes during follow-up were mortality plus major CVD (CVD mortality, incident myocardial infarction, stroke, or heart failure), either as a composite or separately. The effects of physical activity on mortality and CVD were adjusted for sociodemographic factors and other risk factors taking into account household, community, and country clustering. Findings: Between Jan 1, 2003, and Dec 31, 2010, 168 916 participants were enrolled, of whom 141 945 completed the IPAQ. Analyses were limited to the 130 843 participants without pre-existing CVD. Compared with low physical activity (<600 metabolic equivalents [MET] × minutes per week or <150 minutes per week of moderate intensity physical activity), moderate (600–3000 MET × minutes or 150–750 minutes per week) and high physical activity (>3000 MET × minutes or >750 minutes per week) were associated with graded reduction in mortality (hazard ratio 0·80, 95% CI 0·74–0·87 and 0·65, 0·60–0·71; p<0·0001 for trend), and major CVD (0·86, 0·78–0·93; p<0·001 for trend). Higher physical activity was associated with lower risk of CVD and mortality in high-income, middle-income, and low-income countries. The adjusted population attributable fraction for not meeting the physical activity guidelines was 8·0% for mortality and 4·6% for major CVD, and for not meeting high physical activity was 13·0% for mortality and 9·5% for major CVD. Both recreational and non-recreational physical activity were associated with benefits. Interpretation: Recreational and non-recreational physical activity was associated with a lower risk of mortality and CVD events in individuals from low-income, middle-income, and high-income countries. Increasing physical activity is a simple, widely applicable, low cost global strategy that could reduce deaths and CVD in middle age. Funding: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Ontario SPOR Support Unit, Ontario Ministry of Health and Long-Term Care, AstraZeneca, Sanofi-Aventis, Boehringer Ingelheim, Servier, GSK, Novartis, King Pharma, and national and local organisations in participating countries that are listed at the end of the Article.
- PublicaciónRestringidoThe environmental profile of a community’s health : A cross-sectional study on tobacco marketing in 16 countries(2015-07) Savell, Emily; Gilmore, Anna B.; Sims, Michelle; Mony, Prem; Koon, Teo; Yusoff, Khalid; Lear, Scott A.; Seron, Pamela; Ismail, Noorhassim; Tumerdem Calik, K Burcu; Rosengren, Annika; Bahonar, Ahmad; Kumar, Rajesh; Vijayakumar, Krishnapillai; Kruger, Annamarie; Swidan, Hany; Gupta, Rajeev; Igumbor, Ehimario; Afridi, Asad; Rahman, Omar; Chifamba, Jephat; Zatonska, Katarzyna; Mohan, Viswanathan; Mohan, Deepa; Lopez-Jaramillo, PatricioObjective To examine and compare tobacco marketing in 16 countries while the Framework Convention on Tobacco Control requires parties to implement a comprehensive ban on such marketing. Methods Between 2009 and 2012, a kilometre-long walk was completed by trained investigators in 462 communities across 16 countries to collect data on tobacco marketing. We interviewed community members about their exposure to traditional and non-traditional marketing in the previous six months. To examine differences in marketing between urban and rural communities and between high-, middle- and low-income countries, we used multilevel regression models controlling for potential confounders. Findings Compared with high-income countries, the number of tobacco advertisements observed was 81 times higher in low-income countries (incidence rate ratio, IRR: 80.98; 95% confidence interval, CI: 4.15–1578.42) and the number of tobacco outlets was 2.5 times higher in both low- and lower-middle-income countries (IRR: 2.58; 95% CI: 1.17–5.67 and IRR: 2.52; CI: 1.23–5.17, respectively). Of the 11842 interviewees, 1184 (10%) reported seeing at least five types of tobacco marketing. Self-reported exposure to at least one type of traditional marketing was 10 times higher in low-income countries than in high-income countries (odds ratio, OR: 9.77; 95% CI: 1.24–76.77). For almost all measures, marketing exposure was significantly lower in the rural communities than in the urban communities. Conclusion Despite global legislation to limit tobacco marketing, it appears ubiquitous. The frequency and type of tobacco marketing varies on the national level by income group and by community type, appearing to be greatest in low-income countries and urban communities.
- PublicaciónAcceso abiertoHousehold and personal air pollution exposure measurements from 120 communities in eight countries(The Lancet Planetary Health, 2020-10-01) Shupler, Matthew; Hystad, Perry; Birch, Aaron; Miller-Lionberg, Daniel; Jeronimo, Matthew; Arku, Raphael E.; Chu, Yen Li; Mushtaha, Maha; Heenan, Laura; Rangarajan, Sumathy; Seron, Pamela; Lanas, Fernando; Cazor, Fairuz; Lopez-Jaramillo, Patricio; Camacho López, Paul Anthony; Perez, Maritza; Yeates, Karen; West, Nicola; Ncube, Tatenda; Ncube, Brian; Chifamba, Jephat; Yusuf, Rita; Khan, Afreen; Hu, Bo; Liu, Xiaoyun; Wei, Li; Tse, Lap Ah; Mohan, Deepa; Kumar, Parthiban; Gupta, Rajeev; Mohan, Indu; Jayachitra, K. G.; Mony, Prem K.; Rammohan, Kamala; Nair, Sanjeev; Lakshmi, P. V. M.; Sagar, Vivek; Khawaja, Rehman; Iqbal, Romaina; Kazmi, Khawar; Yusuf, Salim; Brauer, Michael; thePURE-AIR study; EverestBackground Approximately 2·8 billion people are exposed to household air pollution from cooking with polluting fuels. Few monitoring studies have systematically measured health-damaging air pollutant (ie, fine particulate matter [PM2·5] and black carbon) concentrations from a wide range of cooking fuels across diverse populations. This multinational study aimed to assess the magnitude of kitchen concentrations and personal exposures to PM2·5 and black carbon in rural communities with a wide range of cooking environments. Methods As part of the Prospective Urban and Rural Epidemiological (PURE) cohort, the PURE-AIR study was done in 120 rural communities in eight countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Data were collected from 2541 households and from 998 individuals (442 men and 556 women). Gravimetric (or filter-based) 48 h kitchen and personal PM2·5 measurements were collected. Light absorbance (10− ⁵m− ¹) of the PM2·5 filters, a proxy for black carbon concentrations, was calculated via an image-based reflectance method. Surveys of household characteristics and cooking patterns were collected before and after the 48 h monitoring period. Findings Monitoring of household air pollution for the PURE-AIR study was done from June, 2017, to September, 2019. A mean PM2·5 kitchen concentration gradient emerged across primary cooking fuels: gas (45 μg/m³ [95% CI 43–48]), electricity (53 μg/m³ [47–60]), coal (68 μg/m³ [61–77]), charcoal (92 μg/m³ [58–146]), agricultural or crop waste (106 μg/m³ [91–125]), wood (109 μg/m³ [102–118]), animal dung (224 μg/m³ [197–254]), and shrubs or grass (276 μg/m³ [223–342]). Among households cooking primarily with wood, average PM2·5 concentrations varied ten-fold (range: 40–380 μg/m³). Fuel stacking was prevalent (981 [39%] of 2541 households); using wood as a primary cooking fuel with clean secondary cooking fuels (eg, gas) was associated with 50% lower PM2·5 and black carbon concentrations than using only wood as a primary cooking fuel. Similar average PM2·5 personal exposures between women (67 μg/m³ [95% CI 62–72]) and men (62 [58–67]) were observed. Nearly equivalent average personal exposure to kitchen exposure ratios were observed for PM2·5 (0·79 [95% 0·71–0·88] for men and 0·82 [0·74–0·91] for women) and black carbon (0·64 [0·45–0·92] for men and 0·68 [0·46–1·02] for women). Interpretation Using clean primary fuels substantially lowers kitchen PM2·5 concentrations. Importantly, average kitchen and personal PM2·5 measurements for all primary fuel types exceeded WHO’s Interim Target-1 (35 μg/m³ annual average), highlighting the need for comprehensive pollution mitigation strategies.
- PublicaciónAcceso abiertoHousehold, community, sub-national and country-level predictors of primary cooking fuel switching in nine countries from the PURE study(IOP Publishing Ltd, 2019-07-29) Shupler, Matthew; Hystad, Perry; Gustafson, Paul; Rangarajan, Sumathy; Mushtaha, Maha; Jayachtria, K.G.; Mony, Prem K.; Mohan, Deepa; Kumar, Parthiban; Lakshmi, P.V.M.; Sagar, Vivek; Gupta, Rajeev; Mohan, Indu; Nair, Sanjeev; Prasad Varma, Ravi; Li, Wei; Hu, Bo; You, Kai; Ncube, Tatenda; Ncube, Brian; Chifamba, Jephat; West, Nicola; Yeates, Karen; Iqbal, Romaina; Khawaja, Rehman; Yusuf, Rita; Khan, Afreen; Seron, Pamela; Lanas, Fernando; Lopez-Jaramillo, Patricio; Camacho López, Paul Anthony; Puoane, Thandi; Yusuf, Salim; Brauer, Michael; The Prospective Urban Rural Epidemiology (PURE) study; EverestIntroduction. Switching from polluting (e.g. wood, crop waste, coal) to clean (e.g. gas, electricity) cooking fuels can reduce household air pollution exposures and climate-forcing emissions. While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood. Methods. We examined longitudinal survey data from 24 172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology study. We assessed household-level primary cooking fuel switching during a median of 10 years of follow up (∼2005–2015). We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching. Results. One-half of study households (12 369) reported changing their primary cooking fuels between baseline and follow up surveys. Of these, 61% (7582) switched from polluting (wood, dung, agricultural waste, charcoal, coal, kerosene) to clean (gas, electricity) fuels, 26% (3109) switched between different polluting fuels, 10% (1164) switched from clean to polluting fuels and 3% (522) switched between different clean fuels. Among the 17 830 households using polluting cooking fuels at baseline, household-level factors (e.g. larger household size, higher wealth, higher education level) were most strongly associated with switching from polluting to clean fuels in India; in all other countries, community-level factors (e.g. larger population density in 2010, larger increase in population density between 2005 and 2015) were the strongest predictors of polluting-to-clean fuel switching. Conclusions. The importance of community and sub-national factors relative to household characteristics in determining polluting-to-clean fuel switching varied dramatically across the nine countries examined. This highlights the potential importance of national and other contextual factors in shaping large-scale clean cooking transitions among rural communities in low- and middle-income countries.
- PublicaciónAcceso abiertoImpact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents(BMJ Journals, 2021-03-22) Naito, Ryo; Leong, Darryl P.; Bangdiwala, Shrikant Ishver; McKee, Martin; Subramanian, S. V.; Rangarajan, Sumathy; Islam, Shofiqul; Avezum, Alvaro; Yeates, Karen; Lear, Scott A.; Gupta, Rajeev; Yusufali, Afzalhussein; Dans, Antonio L.; Szuba, Andrzej; Alhabib, Khalid F.; Kaur, Manmeet; Rahman, Omar; Seron, Pamela; Diaz, Rafael; Puoane, Thandi; Liu, Weida; Zhu, Yibing; Sheng, Yundong; Lopez-Jaramillo, Patricio; Chifamba, Jephat; Rosnah, Ismail; Karsidag, Kubilay; Kelishadi, Roya; Rosengren, Annika; Khatib, Rasha; K. R., Leela Itty Amma; Iqbal Azam, Syed; Teo, Koon; Yusuf, Salim; MasiraObjective To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries. Design Population-based prospective observational study. Setting Urban and rural communities in 20 high income, middle income and low income. Participants 119894 community-dwelling middle-aged adults. Main outcome measures Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases. Results Social isolation was more common in middleincome and high-income countries compared with lowincome countries, in urban areas than rural areas, in older individuals and among women, those with less education and the unemployed. It was more frequent among smokers and those with a poorer diet. Social isolation was associated with greater risk of mortality (HR of 1.26, 95% CI: 1.17 to 1.36), incident stroke (HR: 1.23, 95%CI: 1.07 to 1.40), cardiovascular disease (HR: 1.15, 95%CI: 1.05 to 1.25) and pneumonia (HR:1.22, 95%CI: 1.09 to 1.37), but not cancer. The associations between social isolation and mortality were observed in populations in high-income, middle-income and low-income countries (HR (95%CI): 1.69 (1.32 to 2.17), 1.27 (1.15 to 1.40) and 1.47 (1.25 to 1.73), respectively, interaction p=0.02). The HR associated with social isolation was greater in men than women and in younger than older individuals. Mediation analyses for the association between social isolation and mortality showed that unhealthy behaviours and comorbidities may account for about one-fifth of the association. Conclusion Social isolation is associated with increased risk of mortality in countries at different economic levels. The increasing share of older people in populations in many countries argues for targeted strategies to mitigate its adverse effects
- PublicaciónAcceso abiertoMultinational prediction of household and personal exposure to fine particulate matter (PM2.5) in the PURE cohort study(Elsevier, 2022-01-15) Shupler, Matthew; Hystad, Perry; Birch, Aaron; Li Chu, Yen; Jeronimo, Matthew; Miller-Lionberg, Daniel; Gustafson, Paul; Rangarajan, Sumathy; Mustaha, Maha; Heenan, Laura; Seron, Pamela; Lanas, Fernando; Cazor, Fairuz; Oliveros, Maria Jose; Lopez-Jaramillo, Patricio; Camacho López, Paul Anthony; Otero, Johanna; Perez, Maritza; Yeates, Karen; West, Nicola; Ncube, Tatenda; Ncube, Brian; Chifamba, Jephat; Yusuf, Rita; Khan, Afreen; Liu, Zhiguang; Wu, Shutong; Wei, Li; Tse, Lap Ah; Mohan, Deepa; Kuma, Parthiban; Gupta, Rajeev; Mohan, Indu; Jayachitra, K.G.; Mony, Prem; Rammohan, Kamala; Nair, Sanjeev; Lakshmi, P.V.M.; Sagar, Vivek; Khawaja, Rehman; Iqbal, Romaina; Kazmi, Khawar; Yusuf, Salim; Brauer, Michael; PURE-AIR study investigators; MasiraAbstract Introduction Use of polluting cooking fuels generates household air pollution (HAP) containing health-damaging levels of fine particulate matter (PM2.5). Many global epidemiological studies rely on categorical HAP exposure indicators, which are poor surrogates of measured PM2.5 levels. To quantitatively characterize HAP levels on a large scale, a multinational measurement campaign was leveraged to develop household and personal PM2.5 exposure models. Methods The Prospective Urban and Rural Epidemiology (PURE)-AIR study included 48-hour monitoring of PM2.5 kitchen concentrations (n = 2,365) and male and/or female PM2.5 exposure monitoring (n = 910) in a subset of households in Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania and Zimbabwe. PURE-AIR measurements were combined with survey data on cooking environment characteristics in hierarchical Bayesian log-linear regression models. Model performance was evaluated using leave-one-out cross validation. Predictive models were applied to survey data from the larger PURE cohort (22,480 households; 33,554 individuals) to quantitatively estimate PM2.5 exposures. Results The final models explained half (R2 = 54%) of the variation in kitchen PM2.5 measurements (root mean square error (RMSE) (log scale):2.22) and personal measurements (R2 = 48%; RMSE (log scale):2.08). Primary cooking fuel type, heating fuel type, country and season were highly predictive of PM2.5 kitchen concentrations. Average national PM2.5 kitchen concentrations varied nearly 3-fold among households primarily cooking with gas (20 μg/m3 (Chile); 55 μg/m3 (China)) and 12-fold among households primarily cooking with wood (36 μg/m3 (Chile)); 427 μg/m3 (Pakistan)). Average PM2.5 kitchen concentration, heating fuel type, season and secondhand smoke exposure were significant predictors of personal exposures. Modeled average PM2.5 female exposures were lower than male exposures in upper-middle/high-income countries (India, China, Colombia, Chile). Conclusion Using survey data to estimate PM2.5 exposures on a multinational scale can cost-effectively scale up quantitative HAP measurements for disease burden assessments. The modeled PM2.5 exposures can be used in future epidemiological studies and inform policies targeting HAP reduction.
- PublicaciónAcceso abiertoPersonal and household PM2.5 and black carbon exposure measures and respiratory symptoms in 8 low- and middle-income countries(2022-09-01) Wang, Ying; Shupler, Matthew; Birch, Aaron; Li-Chu, Yen; Jeronimo, Matthew; Rangarajan, Sumathy; Mustaha, Maha; Heenan, Laura; Seron, Pamela; Saavedra, Nicolas; Oliveros, Maria Jose; Lopez-Jaramillo, Patricio; Camacho-Lopez, Paul Antony; Otero, Johnna; Perez-Mayorga, Maritza; Yeates, Karen; West, Nicola; Ncube, Tatenda; Ncube, Brian; Chifamba, Jephat; Yusuf, Rita; Khan, Afreen; Liu, Zhiguang; Cheng, Xiaoru; Wei, Li; Tse, L.A.; Mohan, Deepa; Kumar, Parthiban; Gupta, Rajeev; Mohan, Indu; Jayachitra, K.G.; Mony, Prem K.; Rammohan, Kamala; Nair, Sanjeev; Lakshmi, P.V.M.; Sagar, Vivek; Khawaja, Rehman; Iqbal, Romaina; Kazmi, Khawar; Yusuf, Salim; Brauer, Michael; Hystad, Perry; PURE-AIR study investigators; MasiraBackground Household air pollution (HAP) from cooking with solid fuels has been associated with adverse respiratory effects, but most studies use surveys of fuel use to define HAP exposure, rather than on actual air pollution exposure measurements. Objective To examine associations between household and personal fine particulate matter (PM2.5) and black carbon (BC) measures and respiratory symptoms. Methods As part of the Prospective Urban and Rural Epidemiology Air Pollution study, we analyzed 48-h household and personal PM2.5 and BC measurements for 870 individuals using different cooking fuels from 62 communities in 8 countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Self-reported respiratory symptoms were collected after monitoring. Associations between PM2.5 and BC exposures and respiratory symptoms were examined using logistic regression models, controlling for individual, household, and community covariates. Results The median (interquartile range) of household and personal PM2.5 was 73.5 (119.1) and 65.3 (91.5) μg/m3, and for household and personal BC was 3.4 (8.3) and 2.5 (4.9) x10−5 m−1, respectively. We observed associations between household PM2.5 and wheeze (OR: 1.25; 95%CI: 1.07, 1.46), cough (OR: 1.22; 95%CI: 1.06, 1.39), and sputum (OR: 1.26; 95%CI: 1.10, 1.44), as well as exposure to household BC and wheeze (OR: 1.20; 95%CI: 1.03, 1.39) and sputum (OR: 1.20; 95%CI: 1.05, 1.36), per IQR increase. We observed associations between personal PM2.5 and wheeze (OR: 1.23; 95%CI: 1.00, 1.50) and sputum (OR: 1.19; 95%CI: 1.00, 1.41). For household PM2.5 and BC, associations were generally stronger for females compared to males. Models using an indicator variable of solid versus clean fuels resulted in larger OR estimates with less precision. Conclusions We used measurements of household and personal air pollution for individuals using different cooking fuels and documented strong associations with respiratory symptoms.
- PublicaciónAcceso abiertoPrognostic value of grip strength : Findings from the Prospective Urban Rural Epidemiology (PURE) study(2015-07) Leong, Darryl P.; Teo, Koon; Rangarajan, Sumathy; Lopez-Jaramillo, Patricio; Avezum, Alvaro; Orlandini, Andres; Seron, Pamela; Ahmed, Suad H.; Rosengren, Annika; Kelishadi, Roya; Rahman, Omar; Swaminathan, Sumathi; Iqbal, Romaina; Gupta, Rajeev; Lear, Scott A.; Oguz, Aytekin; Yusoff, Khalid; Zatonska, Katarzyna; Chifamba, Jephat; Igumbor, Ehimario; Mohan, Viswanathan; Anjana, Ranjit Mohan; Gu, Hongqiu; Li, Wei; Yusuf, Salim; The PURE (Prospective Urban Rural Epidemiology) Study investigatorsBackground Reduced muscular strength, as measured by grip strength, has been associated with an increased risk of all-cause and cardiovascular mortality. Grip strength is appealing as a simple, quick, and inexpensive means of stratifying an individual's risk of cardiovascular death. However, the prognostic value of grip strength with respect to the number and range of populations and confounders is unknown. The aim of this study was to assess the independent prognostic importance of grip strength measurement in socioculturally and economically diverse countries. Methods The Prospective Urban-Rural Epidemiology (PURE) study is a large, longitudinal population study done in 17 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35–70 years and if household members intended to stay at that address for another 4 years. Participants were assessed for grip strength, measured using a Jamar dynamometer. During a median follow-up of 4·0 years (IQR 2·9–5·1), we assessed all-cause mortality, cardiovascular mortality, non-cardiovascular mortality, myocardial infarction, stroke, diabetes, cancer, pneumonia, hospital admission for pneumonia or chronic obstructive pulmonary disease (COPD), hospital admission for any respiratory disease (including COPD, asthma, tuberculosis, and pneumonia), injury due to fall, and fracture. Study outcomes were adjudicated using source documents by a local investigator, and a subset were adjudicated centrally. Findings Between January, 2003, and December, 2009, a total of 142 861 participants were enrolled in the PURE study, of whom 139 691 with known vital status were included in the analysis. During a median follow-up of 4·0 years (IQR 2·9–5·1), 3379 (2%) of 139 691 participants died. After adjustment, the association between grip strength and each outcome, with the exceptions of cancer and hospital admission due to respiratory illness, was similar across country-income strata. Grip strength was inversely associated with all-cause mortality (hazard ratio per 5 kg reduction in grip strength 1·16, 95% CI 1·13–1·20; p<0·0001), cardiovascular mortality (1·17, 1·11–1·24; p<0·0001), non-cardiovascular mortality (1·17, 1·12–1·21; p<0·0001), myocardial infarction (1·07, 1·02–1·11; p=0·002), and stroke (1·09, 1·05–1·15; p<0·0001). Grip strength was a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure. We found no significant association between grip strength and incident diabetes, risk of hospital admission for pneumonia or COPD, injury from fall, or fracture. In high-income countries, the risk of cancer and grip strength were positively associated (0·916, 0·880–0·953; p<0·0001), but this association was not found in middle-income and low-income countries. Interpretation This study suggests that measurement of grip strength is a simple, inexpensive risk-stratifying method for all-cause death, cardiovascular death, and cardiovascular disease. Further research is needed to identify determinants of muscular strength and to test whether improvement in strength reduces mortality and cardiovascular disease. Funding Full funding sources listed at end of paper (see Acknowledgments).
- PublicaciónAcceso abiertoSecondary CV Prevention in South America in a Community Setting : The PURE Study(2017-12) Avezum, Alvaro; Oliveira, Gustavo; Lanas, Fernando; Lopez-Jaramillo, Patricio; Diaz, Rafael; Miranda, J. Jaime; Seron, Pamela; Camacho López, Paul Anthony; Orlandini, Andres; Ortiz, Antonio Bernabe; Mattos, Antônio Cordeiro; Islam, Shofiqul; Rangarajan, Sumathy; Teo, Koon; Yusuf, SalimBackground Despite the availability of evidence-based therapies, there is no information on the use of medications for the secondary prevention of cardiovascular disease in urban and rural community settings in South America. Objectives This study sought to assess the use, and its predictors, of effective secondary prevention therapies in individuals with a history of coronary heart disease (CHD) or stroke. Methods In the PURE (Prospective Urban Rural Epidemiological) study, we enrolled 24,713 individuals from South America ages 35 to 70 years from 97 rural and urban communities in Argentina, Brazil, Chile, and Colombia. We assessed the use of proven therapies with standardized questionnaires. We report estimates of drug use at national, community, and individual levels and the independent predictors of their utilization through a multivariable analysis model. Results Of 24,713 individuals, 910 had a self-reported CHD event (at a median of 5 years earlier) and 407 had stroke (6 years earlier). The proportions of individuals with CHD who received antiplatelet medications (30.1%), beta-blockers (34.2%), angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers (36.0%), or statins (18.0%) were low; with even lower proportions among stroke patients (antiplatelets 24.3%, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers 37.6%, statins 9.8%). A substantial proportion of patients did not receive any proven therapy (CHD 31%, stroke 54%). A minority of patients received either all 4 (4.1%) or 3 proven therapies (3.3%). Male sex, age >60 years, better education, more wealth, urban location, diabetes, and obesity were associated with higher rates of medication use. In a multivariable model, markers of wealth had the largest impact in secondary prevention. Conclusions There are large gaps in the use of proven medications for secondary prevention of cardiovascular disease in South America. Strategies to improve the sustained use of these medications will likely reduce cardiovascular disease burden substantially.
- PublicaciónAcceso abiertoThe household economic burden of non-communicable diseases in 18 countries(BMJ Global Health, 2020-02-11) Murphy, Adrianna; Palafox, Benjamin; Walli-Attaei, Marjan; Powell-Jackson, Timothy; Rangarajan, Sumathy; Alhabib, Khalid F.; Avezum, Alvaro; Tumerdem Calik, Kevser Burcu; Chifamba, Jephat; Choudhury, Tarzia; Dagenais, Gilles; Dans, Antonio; Gupta, Rajeev; Iqbal, Romaina; Kaur, Manmeet; Kelishadi, Roya; Khatib, Rasha; Kruger, Iolanthe Marike; Raman Kutty, Vellappillil; Lear, Scott A.; Li, Wei; Lopez-Jaramillo, Patricio; Mohan, Viswanathan; Mony, Prem K.; Orlandin, Andres; Rosengren, Annika; Rosnah, Ismail; Seron, Pamela; Teo, Koon; Tse, Lap Ah; Tsolekile, Lungiswa; Wang, Yang; Wielgosz, Andreas; Yan, Ruohua; Yeates, Karen; Yusoff, Khalid; Zatonska, Katarzyna; Hanson, Kara; Yusuf, Salim; McKee, Martin; EverestAbstract Background Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. Methods Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. Results The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. Conclusions Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.
- PublicaciónAcceso abiertoTiming and Length of Nocturnal Sleep and Daytime Napping and Associations with Obesity Types in High-, Middle-, and Low-Income Countries(JAMA, 2021-06-30) Tse, Lap Ah; Wang, Chuangshi; Rangarajan, Sumathy; Liu, Zhiguang; Teo, Koon; Yusufali, Afzalhussein; Avezum, Alvaro; Wielgosz, Andreas; Rosengren, Annika; Kruger, Iolanthé M.; Chifamba, Jephat; Tumerdem Calik, Kevser Burcu; Tumerdem Calik, Kevser Burcu; Zatońska, Katarzyna; AlHabib, Khalid F.; Yusoff, Khalid; Kaur, Manmeet; Ismail, Noorhassim; Seron, Pamela; Lopez-Jaramillo, Patricio; Poirier, Paul; Gupta, Rajeev; Khatib, Rasha; Kelishadi, Roya; Lear, Scott A.; Choudhury, Tarzia; Mohan, Viswanathan; Li, Wei; Yusuf, Salim; MasiraImportance Obesity is a growing public health threat leading to serious health consequences. Late bedtime and sleep loss are common in modern society, but their associations with specific obesity types are not well characterized. Objective To assess whether sleep timing and napping behavior are associated with increased obesity, independent of nocturnal sleep length. Design, Setting, and Participants This large, multinational, population-based cross-sectional study used data of participants from 60 study centers in 26 countries with varying income levels as part of the Prospective Urban Rural Epidemiology study. Participants were aged 35 to 70 years and were mainly recruited during 2005 and 2009. Data analysis occurred from October 2020 through March 2021. Exposures Sleep timing (ie, bedtime and wake-up time), nocturnal sleep duration, daytime napping. Main Outcomes and Measures The primary outcomes were prevalence of obesity, specified as general obesity, defined as body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or greater, and abdominal obesity, defined as waist circumference greater than 102 cm for men or greater than 88 cm for women. Multilevel logistic regression models with random effects for study centers were performed to calculate adjusted odds ratios (AORs) and 95% CIs. Results Overall, 136 652 participants (81 652 [59.8%] women; mean [SD] age, 51.0 [9.8] years) were included in analysis. A total of 27 195 participants (19.9%) had general obesity, and 37 024 participants (27.1%) had abdominal obesity. The mean (SD) nocturnal sleep duration was 7.8 (1.4) hours, and the median (interquartile range) midsleep time was 2:15 am (1:30 am-3:00 am). A total of 19 660 participants (14.4%) had late bedtime behavior (ie, midnight or later). Compared with bedtime between 8 pm and 10 pm, late bedtime was associated with general obesity (AOR, 1.20; 95% CI, 1.12-1.29) and abdominal obesity (AOR, 1.20; 95% CI, 1.12-1.28), particularly among participants who went to bed between 2 am and 6 am (general obesity: AOR, 1.35; 95% CI, 1.18-1.54; abdominal obesity: AOR, 1.38; 95% CI, 1.21-1.58). Short nocturnal sleep of less than 6 hours was associated with general obesity (eg, <5 hours: AOR, 1.27; 95% CI, 1.13-1.43), but longer napping was associated with higher abdominal obesity prevalence (eg, ≥1 hours: AOR, 1.39; 95% CI, 1.31-1.47). Neither going to bed during the day (ie, before 8pm) nor wake-up time was associated with obesity. Conclusions and Relevance This cross-sectional study found that late nocturnal bedtime and short nocturnal sleep were associated with increased risk of obesity prevalence, while longer daytime napping did not reduce the risk but was associated with higher risk of abdominal obesity. Strategic weight control programs should also encourage earlier bedtime and avoid short nocturnal sleep to mitigate obesity epidemic.
- PublicaciónAcceso abiertoVariations in the financial impact of the COVID-19 pandemic across 5 continents. A cross-sectional, individual level analysis(ScienceDirect, 2022-01-28) Khetan, Aditya K.; Yusuf, Salim; Lopez-Jaramillo, Patricio; Szuba, Andrzej; Orlandini, Andres; Mat-Nasir, Nafiza; Oguz, Aytekin; Gupta, Rajeev; Avezum, Alvaro; Rosnah, Ismail; Poirier, Paul; Teo, Koon; Wielgosz, Andreas; Lear, Scott A.; Palileo-Villanueva, Lia M.; Seron, Pamela; Chifamba, Jephat; Rangarajan, Sumathy; Mushtaha, Maha; Mohan, Deepa; Yeates, Karen; McKee, Martin; Mony, Prem; Walli-Attaei, Marjan; Khansaheb, Hamda; Rosengren, Annika; AlHabib, Khalid F.; Kruger, Iolanthe M.; Paucar, María-Jose; Mirrakhimov, Erkin; Assembekov, Batyrbek; Leong, Darryl P.; MasiraBackground COVID-19 has caused profound socio-economic changes worldwide. However, internationally comparative data regarding the financial impact on individuals is sparse. Therefore, we conducted a survey of the financial impact of the pandemic on individuals, using an international cohort that has been well-characterized prior to the pandemic. Methods Between August 2020 and September 2021, we surveyed 24,506 community-dwelling participants from the Prospective Urban-Rural Epidemiology (PURE) study across high (HIC), upper middle (UMIC)-and lower middle (LMIC)-income countries. We collected information regarding the impact of the pandemic on their self-reported personal finances and sources of income. Findings Overall, 32.4% of participants had suffered an adverse financial impact, defined as job loss, inability to meet financial obligations or essential needs, or using savings to meet financial obligations. 8.4% of participants had lost a job (temporarily or permanently); 14.6% of participants were unable to meet financial obligations or essential needs at the time of the survey and 16.3% were using their savings to meet financial obligations. Participants with a post-secondary education were least likely to be adversely impacted (19.6%), compared with 33.4% of those with secondary education and 33.5% of those with pre-secondary education. Similarly, those in the highest wealth tertile were least likely to be financially impacted (26.7%), compared with 32.5% in the middle tertile and 30.4% in the bottom tertile participants. Compared with HICs, financial impact was greater in UMIC [odds ratio of 2.09 (1.88–2.33)] and greatest in LMIC [odds ratio of 16.88 (14.69–19.39)]. HIC participants with the lowest educational attainment suffered less financial impact (15.1% of participants affected) than those with the highest education in UMIC (22.0% of participants affected). Similarly, participants with the lowest education in UMIC experienced less financial impact (28.3%) than those with the highest education in LMIC (45.9%). A similar gradient was seen across country income categories when compared by pre-pandemic wealth status. Interpretation The financial impact of the pandemic differs more between HIC, UMIC, and LMIC than between socio-economic categories within a country income level. The most disadvantaged socio-economic subgroups in HIC had a lower financial impact from the pandemic than the most advantaged subgroup in UMIC, with a similar disparity seen between UMIC and LMIC. Continued high levels of infection will exacerbate financial inequity between countries and hinder progress towards the sustainable development goals, emphasising the importance of effective measures to control COVID-19 and, especially, ensuring high vaccine coverage in all countries.