The effectiveness of interventions to reduce cardio-metabolic risk factors among regular street food consumers in Dar es Salaam, Tanzania: The pre-post findings from a cluster randomized trial (Registered by Pan African clinical trial registry with trial # PACTR202208642850935).

INTRODUCTION: The healthy plate model (HPM) is a practical guide to modulate the portion of staple food in main meals, subsequently affecting the risks associated with Non-communicable Diseases include type2 diabetes mellitus (T2DM). OBJECTIVE: This study investigated the effectiveness of health information and the healthy plate model on cardio-metabolic risk factors, knowledge and attitude towards T2DM prevention measures. METHODS: A pre-post analysis, as part of a cluster randomized trial with street food vendors and their customers, was implemented in three randomly selected districts in Dar es Salaam, Tanzania. Two vendor-customer clusters each with 15 and more vendors from each district were randomly assigned to receive either T2DM health information only (Intervention package1 [IP1]) or IP1 plus a subsidized meal with vegetables and fruits, following the principles of the HPM (Intervention package2 [IP2]). Within the clusters the participants were informed on the importance of the intervention they received. An intervention period lasted for three months from 1st April to 31st June 2019. We applied Generalized Linear Mixed Models and Bayesian Modelling (for sensitivity analysis) to assess the effectiveness of the interventions. RESULTS: Overall, 336 (IP2 = 175 and IP1 = 161) out of 560 (280/arm) previous study participants participated in evaluation. Diastolic BP was lower among IP2 participants in the evaluation than baseline AßC = -4.1mmHg (95%CI:-5.42 to -2.76). After adjusting for the interaction between IP2 and age of the consumers, the BMI was significantly lower among IP2 in the evaluation than baseline AßC = -0.7kg/m2 (95%CI: -1.17 to -0.23). With interaction between IP2 and income, BMI was higher in the IP2 in the evaluation than baseline AßC = 0.73kg/m2 (95%CI: 0.08 to 1.38). Systolic and diastolic BP were significantly lower among IP1 in the evaluation than baseline AßC = -3.5mmHg (95%CI:-5.78 to -1.24) and AßC = -5.9mmHg (95%CI:-7.34 to -4.44) respectively. Both the knowledge scores and positive attitudes towards T2DM prevention measures were higher in the evaluation than baseline in both interventions arms. CONCLUSION: The positive effects on cardio-metabolic risk factors, knowledge and attitude were observed in both intervention arms. Due to interactions between IP2, age and income; designing interventions relating to food and cardio-metabolic risk factors, should consider combining socio-economic factors.

The Association of Socioeconomic Status With Hypertension in 76 Low- and Middle-Income Countries.

BACKGROUND: Effective equity-focused health policy for hypertension in low- and middle-income countries (LMICs) requires an understanding of the condition's current socioeconomic gradients and how these are likely to change in the future as countries develop economically. OBJECTIVES: This cross-sectional study aimed to determine how hypertension prevalence in LMICs varies by individuals' education and household wealth, and how these socioeconomic gradients in hypertension prevalence are associated with a country's gross domestic product (GDP) per capita. METHODS: We pooled nationally representative household survey data from 76 LMICs. We disaggregated hypertension prevalence by education and household wealth quintile, and used regression analyses to adjust for age and sex. RESULTS: We included 1,211,386 participants in the analysis. Pooling across all countries, hypertension prevalence tended to be similar between education groups and household wealth quintiles. The only world region with a clear positive association of hypertension with education or household wealth quintile was Southeast Asia. Countries with a lower GDP per capita had, on average, a more positive association of hypertension with education and household wealth quintile than countries with a higher GDP per capita, especially in rural areas and among men. CONCLUSIONS: Differences in hypertension prevalence between socioeconomic groups were generally small, with even the least educated and least wealthy groups having a substantial hypertension prevalence. Our cross-sectional interaction analyses of GDP per capita with the socioeconomic gradients of hypertension suggest that hypertension may increasingly affect adults in the lowest socioeconomic groups as LMICs develop economically.

Patterns of tobacco use in low and middle income countries by tobacco product and sociodemographic characteristics: nationally representative survey data from 82 countries.

OBJECTIVES: To determine the prevalence and frequency of using any tobacco product and each of a detailed set of tobacco products, how tobacco use and frequency of use vary across countries, world regions, and World Bank country income groups, and the socioeconomic and demographic gradients of tobacco use and frequency of use within countries. DESIGN: Secondary analysis of nationally representative, cross-sectional, household survey data from 82 low and middle income countries collected between 1 January 2015 and 31 December 2020. SETTING: Population based survey data. PARTICIPANTS: 1 231 068 individuals aged 15 years and older. MAIN OUTCOME MEASURES: Self-reported current smoking, current daily smoking, current smokeless tobacco use, current daily smokeless tobacco use, pack years, and current use and use frequencies of each tobacco product. Products were any type of cigarette, manufactured cigarette, hand rolled cigarette, water pipe, cigar, oral snuff, nasal snuff, chewing tobacco, and betel nut (with and without tobacco). RESULTS: The smoking prevalence in the study sample was 16.5% (95% confidence interval 16.1% to 16.9%) and ranged from 1.1% (0.9% to 1.3%) in Ghana to 50.6% (45.2% to 56.1%) in Kiribati. The user prevalence of smokeless tobacco was 7.7% (7.5% to 8.0%) and prevalence was highest in Papua New Guinea (daily user prevalence of 65.4% (63.3% to 67.5%)). Although variation was wide between countries and by tobacco product, for many low and middle income countries, the highest prevalence and cigarette smoking frequency was reported in men, those with lower education, less household wealth, living in rural areas, and higher age. CONCLUSIONS: Both smoked and smokeless tobacco use and frequency of use vary widely across tobacco products in low and middle income countries. This study can inform the design and targeting of efforts to reduce tobacco use in low and middle income countries and serve as a benchmark for monitoring progress towards national and international goals.

Body-mass index and diabetes risk in 57 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 685 616 adults.

BACKGROUND: The prevalence of overweight, obesity, and diabetes is rising rapidly in low-income and middle-income countries (LMICs), but there are scant empirical data on the association between body-mass index (BMI) and diabetes in these settings. METHODS: In this cross-sectional study, we pooled individual-level data from nationally representative surveys across 57 LMICs. We identified all countries in which a WHO Stepwise Approach to Surveillance (STEPS) survey had been done during a year in which the country fell into an eligible World Bank income group category. For LMICs that did not have a STEPS survey, did not have valid contact information, or declined our request for data, we did a systematic search for survey datasets. Eligible surveys were done during or after 2008; had individual-level data; were done in a low-income, lower-middle-income, or upper-middle-income country; were nationally representative; had a response rate of 50% or higher; contained a diabetes biomarker (either a blood glucose measurement or glycated haemoglobin [HbA1c]); and contained data on height and weight. Diabetes was defined biologically as a fasting plasma glucose concentration of 7·0 mmol/L (126·0 mg/dL) or higher; a random plasma glucose concentration of 11·1 mmol/L (200·0 mg/dL) or higher; or a HbA1c of 6·5% (48·0 mmol/mol) or higher, or by self-reported use of diabetes medication. We included individuals aged 25 years or older with complete data on diabetes status, BMI (defined as normal [18·5-22·9 kg/m2], upper-normal [23·0-24·9 kg/m2], overweight [25·0-29·9 kg/m2], or obese [≥30·0 kg/m2]), sex, and age. Countries were categorised into six geographical regions: Latin America and the Caribbean, Europe and central Asia, east, south, and southeast Asia, sub-Saharan Africa, Middle East and north Africa, and Oceania. We estimated the association between BMI and diabetes risk by multivariable Poisson regression and receiver operating curve analyses, stratified by sex and geographical region. FINDINGS: Our pooled dataset from 58 nationally representative surveys in 57 LMICs included 685 616 individuals. The overall prevalence of overweight was 27·2% (95% CI 26·6-27·8), of obesity was 21·0% (19·6-22·5), and of diabetes was 9·3% (8·4-10·2). In the pooled analysis, a higher risk of diabetes was observed at a BMI of 23 kg/m2 or higher, with a 43% greater risk of diabetes for men and a 41% greater risk for women compared with a BMI of 18·5-22·9 kg/m2. Diabetes risk also increased steeply in individuals aged 35-44 years and in men aged 25-34 years in sub-Saharan Africa. In the stratified analyses, there was considerable regional variability in this association. Optimal BMI thresholds for diabetes screening ranged from 23·8 kg/m2 among men in east, south, and southeast Asia to 28·3 kg/m2 among women in the Middle East and north Africa and in Latin America and the Caribbean. INTERPRETATION: The association between BMI and diabetes risk in LMICs is subject to substantial regional variability. Diabetes risk is greater at lower BMI thresholds and at younger ages than reflected in currently used BMI cutoffs for assessing diabetes risk. These findings offer an important insight to inform context-specific diabetes screening guidelines. FUNDING: Harvard T H Chan School of Public Health McLennan Fund: Dean's Challenge Grant Program.

Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data.

BACKGROUND: Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. METHODS AND FINDINGS: We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. CONCLUSIONS: This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

The state of diabetes treatment coverage in 55 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level data in 680 102 adults.

BACKGROUND: Approximately 80% of the 463 million adults worldwide with diabetes live in low- and middle-income countries (LMICs). A major obstacle to designing evidence-based policies to improve diabetes outcomes in LMICs is the limited nationally representative data on the current patterns of treatment coverage. The objectives of this study are (1) to estimate the proportion of adults with diabetes in LMICs who receive coverage of recommended pharmacological and non-pharmacological diabetes treatment and (2) to describe country-level and individual-level characteristics that are associated with treatment. METHODS: We conducted a cross-sectional analysis of pooled, individual data from 55 nationally representative surveys in LMICs. Our primary outcome of self-reported diabetes treatment coverage was based upon population-level monitoring indicators recommended in the 2020 World Health Organization Package of Essential Noncommunicable Disease Interventions. We assessed coverage of three pharmacological and three non-pharmacological treatments among people with diabetes. At the country level, we estimated the proportion of individuals reporting coverage by per-capita gross national income and geographic region. At the individual level, we used logistic regression models to assess coverage along several key individual characteristics including sex, age, BMI, wealth quintile, and educational attainment. In the primary analysis, we scaled sample weights such that countries were weighted equally. FINDINGS: The final pooled sample from the 55 LMICs included 680,102 total individuals and 37,094 individuals with diabetes. Using equal weights for each country, diabetes prevalence was 9.0% (95% confidence interval [CI], 8.7-9.4), with 43.9% (95% CI, 41.9-45.9) reporting a prior diabetes diagnosis. Overall, 4.6% (95% CI, 3.9-5.4) of individuals with diabetes self-reported meeting need for all treatments recommended for them. Coverage of glucose-lowering medication was 50.5% (95% CI, 48.6-52.5); antihypertensive medication, 41.3% (95% CI, 39.3-43.3); cholesterol-lowering medication, 6.3% (95% CI, 5.5-7.2); diet counseling, 32.2% (95% CI, 30.7-33.7); exercise counseling, 28.2% (95% CI, 26.6-29.8); and weight-loss counseling, 31.5% (95% CI, 29.3-33.7). Countries at higher income levels tended to have greater coverage. Female sex and higher age, BMI, educational attainment, and household wealth were also associated with greater coverage. INTERPRETATION: Fewer than one in ten people with diabetes in LMICs receive coverage of guideline-based comprehensive diabetes treatment. Scaling-up the capacity of health systems to deliver treatment not only to lower glucose but also to address cardiovascular disease risk factors such as hypertension and high cholesterol are urgent global diabetes priorities.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

Sociodemographic inequities associated with participation in leisure-time physical activity in sub-Saharan Africa: an individual participant data meta-analysis.

BACKGROUND: Leisure-time physical activity (LTPA) is an important contributor to total physical activity and the focus of many interventions promoting activity in high-income populations. Little is known about LTPA in sub-Saharan Africa (SSA), and with expected declines in physical activity due to rapid urbanisation and lifestyle changes we aimed to assess the sociodemographic differences in the prevalence of LTPA in the adult populations of this region to identify potential barriers for equitable participation. METHODS: A two-step individual participant data meta-analysis was conducted using data collected in SSA through 10 population health surveys that included the Global Physical Activity Questionnaire. For each sociodemographic characteristic, the pooled adjusted prevalence and risk ratios (RRs) for participation in LTPA were calculated using the random effects method. Between-study heterogeneity was explored through meta-regression analyses and tests for interaction. RESULTS: Across the 10 populations (N = 26,022), 18.9% (95%CI: 14.3, 24.1; I2 = 99.0%) of adults (≥ 18 years) participated in LTPA. Men were more likely to participate in LTPA compared with women (RR for women: 0.43; 95%CI: 0.32, 0.60; P < 0.001; I2 = 97.5%), while age was inversely associated with participation. Higher levels of education were associated with increased LTPA participation (RR: 1.30; 95%CI: 1.09, 1.55; P = 0.004; I2 = 98.1%), with those living in rural areas or self-employed less likely to participate in LTPA. These associations remained after adjusting for time spent physically active at work or through active travel. CONCLUSIONS: In these populations, participation in LTPA was low, and strongly associated with sex, age, education, self-employment and urban residence. Identifying the potential barriers that reduce participation in these groups is necessary to enable equitable access to the health and social benefits associated with LTPA.

Diabetes Prevalence and Its Relationship With Education, Wealth, and BMI in 29 Low- and Middle-Income Countries.

OBJECTIVE: Diabetes is a rapidly growing health problem in low- and middle-income countries (LMICs), but empirical data on its prevalence and relationship to socioeconomic status are scarce. We estimated diabetes prevalence and the subset with undiagnosed diabetes in 29 LMICs and evaluated the relationship of education, household wealth, and BMI with diabetes risk. RESEARCH DESIGN AND METHODS: We pooled individual-level data from 29 nationally representative surveys conducted between 2008 and 2016, totaling 588,574 participants aged ≥25 years. Diabetes prevalence and the subset with undiagnosed diabetes was calculated overall and by country, World Bank income group (WBIG), and geographic region. Multivariable Poisson regression models were used to estimate relative risk (RR). RESULTS: Overall, prevalence of diabetes in 29 LMICs was 7.5% (95% CI 7.1-8.0) and of undiagnosed diabetes 4.9% (4.6-5.3). Diabetes prevalence increased with increasing WBIG: countries with low-income economies (LICs) 6.7% (5.5-8.1), lower-middle-income economies (LMIs) 7.1% (6.6-7.6), and upper-middle-income economies (UMIs) 8.2% (7.5-9.0). Compared with no formal education, greater educational attainment was associated with an increased risk of diabetes across WBIGs, after adjusting for BMI (LICs RR 1.47 [95% CI 1.22-1.78], LMIs 1.14 [1.06-1.23], and UMIs 1.28 [1.02-1.61]). CONCLUSIONS: Among 29 LMICs, diabetes prevalence was substantial and increased with increasing WBIG. In contrast to the association seen in high-income countries, diabetes risk was highest among those with greater educational attainment, independent of BMI. LMICs included in this analysis may be at an advanced stage in the nutrition transition but with no reversal in the socioeconomic gradient of diabetes risk.

The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults.

BACKGROUND: Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage. METHODS: In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval. FINDINGS: Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade. INTERPRETATION: Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage. FUNDING: Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Consumption of Fruits and Vegetables Among Individuals 15 Years and Older in 28 Low- and Middle-Income Countries.

BACKGROUND: The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required. OBJECTIVES: The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation. METHODS: Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics. RESULTS: The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P < 0.0001) and with decreasing country FAO food price index (FPI; indicating greater stability of food prices; P < 0.0001). At the individual level, those with secondary education or greater were more likely to achieve the recommendation compared with individuals with no formal education: risk ratio (95% CI), 1.61 (1.24-2.09). CONCLUSIONS: Over 80% of individuals aged ≥15 y living in these 28 LMICs consumed lower amounts of fruits and vegetables than recommended by the WHO. Policies to promote fruit and vegetable consumption in LMICs are urgently needed to address the observed inequities in intake and prevent NCDs.

Health system performance for people with diabetes in 28 low- and middle-income countries: A cross-sectional study of nationally representative surveys.

BACKGROUND: The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. METHODS AND FINDINGS: We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ("treated"), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. CONCLUSIONS: The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.

Knowledge and perception on type2 diabetes and hypertension among HIV clients utilizing care and treatment services: a cross sectional study from Mbeya and Dar es Salaam regions in Tanzania.

BACKGROUND: Type2 Diabetes and Hypertension (T2DM/HTN) have become serious threats to the health and socio-economic development in the developing countries. People living with HIV (PLHIV) infection are more vulnerable of developing T2DM/HTN due to HIV infection itself and antiretroviral treatments. The situation is worse when behavioral and biological risk factors are pervasive to PLHIV. Despite this vicious circle; information on the level of knowledge and perception regarding prevention of T2DM/HTN, risks factors and associated complications among PLHIV is not well documented in Tanzania. The aim of this paper was assess the level of T2DM/HTN knowledge and perception among PLHIV and utilizing care and treatment clinic (CTC) services. METHODS: A cross-sectional study was conducted in randomly selected 12 CTCs between October 2011 and February 2012. Data on demographic characteristics, type 2 diabetes and hypertension knowledge and perception were collected from the study participants. RESULTS: Out of 754 PLHIV and receiving HIV services at the selected CTCs, 671 (89%) consented for the study. Overall 276/671(41.1%) respondents had low knowledge on type2 diabetes and hypertension risk factors and their associated complications. Locality (rural) (AOR = 2.2; 95%CI 1.4-3.4) and never/not recalling if ever measured blood glucose in life (AOR = 2.3; 95%CI 1.1-5.7) were significant determinants of low knowledge among clients on ART. Being currently not having HIV and T2DM/HTN co-morbidities (AOR = 2.2; 95%CI 1.2-4.9) was the only determinant of low knowledge among ART Naïve clients. With regard to perception, 293/671(43.7%) respondents had negative perception on diabetes and hypertension prevention. Sex (female) (AOR = 2.0, 95%CI 1.2-2.9), being aged < 40 years (AOR = 1.6; 95%CI 1.1-2.5) and education (primary/no formal education) (AOR = 4.4; 95%CI 2.0-9.8) were determinants for negative perception among clients on ART while for ART Naïve clients; HIV and T2DM/HTN co-morbidities (AOR = 2.0; 95%CI 1.2-4.6) was the main determinant for negative perception. CONCLUSION: Considerable number of respondents had low level of knowledge (41.1%) regarding T2DM/HTN specifically on the risk factors, prevention strategies and their associated complications and negative perception (43.7%) towards healthy practices for mitigating risk behaviors of the diseases. There is need for promoting awareness of T2DM/HTN risk factors and complications by considering determinants of low knowledge and negative perception among PLHIV.

Magnitude and risk factors of non-communicable diseases among people living with HIV in Tanzania: a cross sectional study from Mbeya and Dar es Salaam regions.

BACKGROUND: HIV and Non communicable diseases (NCDs) are major problem of public health importance in developing countries. This study was conducted to explore and establish information on the magnitude, distribution of NCDs risk factors among people living with HIV (PLWHIV) which is scarce in Tanzania. METHOD: A cross sectional study was conducted to PLWHIV from 12 care and treatment clinics in Dar es Salaam and Mbeya regions from October 2011 to February 2012. Data on demographic characteristics, NCD risk factors including behavioral, biochemical tests and physical measurements was collected from PLWHIV. RESULTS: Of 754 PLWHIV recruited, 671(89.0%) consented to participate in the study and 354/671(52.8%) were on antiretroviral therapy (ART). The following NCD risk factors: raised blood levels of low density lipoprotein (61.3% vs 38.7%, p < 0.001) total cholesterol (TC) (71.6% vs 28.4%, p < 0.001) and triglyceride (67.0% vs 33.0%, p = 0.001) as well as overweight/obesity (61.1% vs 38.9%, p = 0.010), abnormal waist circumference (61.7% vs 38.3%, p < 0.001) and being aged >40 years (63.3% vs 36.7%, p < 0.001) were more prevalent among PLWHIV on ART than ART naïve. The prevalence of Diabetes mellitus among PLWHIV was 4.2% and was slightly high among those ART naïve (4.7% vs 3.7%). The prevalence of hypertension was 26.2% and was high among those on ART (30.0% vs 21.9%, p = 0.010). Being aged >40 years (AOR = 2.52, 95% CI 1.37-4.63), abnormal waist circumference (AOR = 2.37 95% CI 1.13-5.00), overweight/obesity (AOR = 2.71, 95% CI 1.26-5.84) and male sex (AOR = 1.17, 1.02-4.20) were the predictors of hypertension among patients on ART while raised TC (AOR = 1.47 (1.01-2.21) and being aged >40 years (AOR = 3.42, 95% CI 2.06-5.70) were predictors for hypertension among ART naïve patients. CONCLUSION: This study has revealed that the magnitude of NCD risk factors is significantly higher among PLWHIV on ART than those not on ART. Initiating and strengthening of interventions for minimizing preventable NCD risks should be considered when initiating ART among PLWHIV. Regular monitoring of NCD risk factors is of paramount importance among ART patients.