Health effects associated with chewing tobacco: a Burden of Proof study.

Chewing tobacco use poses serious health risks; yet it has not received as much attention as other tobacco-related products. This study synthesizes existing evidence regarding the health impacts of chewing tobacco while accounting for various sources of uncertainty. We conducted a systematic review and meta-analysis of chewing tobacco and seven health outcomes, drawing on 103 studies published from 1970 to 2023. We use a Burden of Proof meta-analysis to generate conservative risk estimates and find weak-to-moderate evidence that tobacco chewers have an increased risk of stroke, lip and oral cavity cancer, esophageal cancer, nasopharynx cancer, other pharynx cancer, and laryngeal cancer. We additionally find insufficient evidence of an association between chewing tobacco and ischemic heart disease. Our findings highlight a need for policy makers, researchers, and communities at risk to devote greater attention to chewing tobacco by both advancing tobacco control efforts and investing in strengthening the existing evidence base.

Health effects associated with exposure to secondhand smoke: a Burden of Proof study.

Despite a gradual decline in smoking rates over time, exposure to secondhand smoke (SHS) continues to cause harm to nonsmokers, who are disproportionately children and women living in low- and middle-income countries. We comprehensively reviewed the literature published by July 2022 concerning the adverse impacts of SHS exposure on nine health outcomes. Following, we quantified each exposure-response association accounting for various sources of uncertainty and evaluated the strength of the evidence supporting our analyses using the Burden of Proof Risk Function methodology. We found all nine health outcomes to be associated with SHS exposure. We conservatively estimated that SHS increases the risk of ischemic heart disease, stroke, type 2 diabetes and lung cancer by at least around 8%, 5%, 1% and 1%, respectively, with the evidence supporting these harmful associations rated as weak (two stars). The evidence supporting the harmful associations between SHS and otitis media, asthma, lower respiratory infections, breast cancer and chronic obstructive pulmonary disease was weaker (one star). Despite the weak underlying evidence for these associations, our results reinforce the harmful effects of SHS on health and the need to prioritize advancing efforts to reduce active and passive smoking through a combination of public health policies and education initiatives.

La carga del sobrepeso y la obesidad en México de 1990 a 2021 / Burden of overweight and obesity in Mexico from 1990 to 2021

Resumen Antecedentes: El sobrepeso y la obesidad constituyen un grave desafío en México, con efectos en la salud, sociedad y economía. Factores demográficos, epidemiológicos, nutricionales, sociales y económicos han agravado esta problemática. Objetivo: Analizar la mortalidad y los años de vida saludable perdidos en México por sobrepeso y obesidad en el período de 1990 a 2021. Material y métodos: Se utilizó el Global Burden of Disease 2021 para analizar los datos sobre índice de masa corporal elevado como factor de riesgo y su evolución en México. Resultados: En 2021 se registraron 118 mil muertes atribuibles a índice de masa corporal elevado, que representaron 10.6 % del total de muertes y más de 4.2 millones de años de vida perdidos ajustados por discapacidad. Conclusiones: El ambiente obesogénico, influido por determinantes sociales, ha tenido un impacto significativo en la mortalidad, la carga de enfermedad y los costos económicos. Abordar el sobrepeso y la obesidad requiere intervenciones multisectoriales para fortalecer el sistema de salud mexicano.

Abstract Background: Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem. Objective: To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period. Material and methods: The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico. Results: In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost. Conclusions: The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system.

Burden of overweight and obesity in Mexico from 1990 to 2021.

BACKGROUND: Overweight and obesity (OW/OB) represent a serious challenge in Mexico, with effects on health, society and economy. Demographic, epidemiological, nutritional, social and economic factors have exacerbated this problem. OBJECTIVE: To analyze mortality and years of healthy life lost in Mexico due to OW/OB in the 1990-2021 period. MATERIAL AND METHODS: The Global Burden of Disease and Risk Factors 2021 study was used to analyze data on elevated body mass index (BMI) as a risk factor and its evolution in Mexico. RESULTS: In 2021, 118 thousand deaths attributable to high BMI were recorded, which accounted for 10.6% of total deaths and more than 4.2 million disability-adjusted life years lost. CONCLUSIONS: The obesogenic environment, influenced by social determinants of health, has had a significant impact on mortality, burden of disease, and economic costs. Addressing OW/OB requires multisector interventions to strengthen the Mexican health system.

ANTECEDENTES: El sobrepeso y la obesidad constituyen un grave desafío en México, con efectos en la salud, sociedad y economía. Factores demográficos, epidemiológicos, nutricionales, sociales y económicos han agravado esta problemática. OBJETIVO: Analizar la mortalidad y los años de vida saludable perdidos en México por sobrepeso y obesidad en el período de 1990 a 2021. MATERIAL Y MÉTODOS: Se utilizó el Global Burden of Disease 2021 para analizar los datos sobre índice de masa corporal elevado como factor de riesgo y su evolución en México. RESULTADOS: En 2021 se registraron 118 mil muertes atribuibles a índice de masa corporal elevado, que representaron 10.6 % del total de muertes y más de 4.2 millones de años de vida perdidos ajustados por discapacidad. CONCLUSIONES: El ambiente obesogénico, influido por determinantes sociales, ha tenido un impacto significativo en la mortalidad, la carga de enfermedad y los costos económicos. Abordar el sobrepeso y la obesidad requiere intervenciones multisectoriales para fortalecer el sistema de salud mexicano.

The Burden of Proof studies: assessing the evidence of risk.

Exposure to risks throughout life results in a wide variety of outcomes. Objectively judging the relative impact of these risks on personal and population health is fundamental to individual survival and societal prosperity. Existing mechanisms to quantify and rank the magnitude of these myriad effects and the uncertainty in their estimation are largely subjective, leaving room for interpretation that can fuel academic controversy and add to confusion when communicating risk. We present a new suite of meta-analyses-termed the Burden of Proof studies-designed specifically to help evaluate these methodological issues objectively and quantitatively. Through this data-driven approach that complements existing systems, including GRADE and Cochrane Reviews, we aim to aggregate evidence across multiple studies and enable a quantitative comparison of risk-outcome pairs. We introduce the burden of proof risk function (BPRF), which estimates the level of risk closest to the null hypothesis that is consistent with available data. Here we illustrate the BPRF methodology for the evaluation of four exemplar risk-outcome pairs: smoking and lung cancer, systolic blood pressure and ischemic heart disease, vegetable consumption and ischemic heart disease, and unprocessed red meat consumption and ischemic heart disease. The strength of evidence for each relationship is assessed by computing and summarizing the BPRF, and then translating the summary to a simple star rating. The Burden of Proof methodology provides a consistent way to understand, evaluate and summarize evidence of risk across different risk-outcome pairs, and informs risk analysis conducted as part of the Global Burden of Diseases, Injuries, and Risk Factors Study.

Health effects associated with smoking: a Burden of Proof study.

As a leading behavioral risk factor for numerous health outcomes, smoking is a major ongoing public health challenge. Although evidence on the health effects of smoking has been widely reported, few attempts have evaluated the dose-response relationship between smoking and a diverse range of health outcomes systematically and comprehensively. In the present study, we re-estimated the dose-response relationships between current smoking and 36 health outcomes by conducting systematic reviews up to 31 May 2022, employing a meta-analytic method that incorporates between-study heterogeneity into estimates of uncertainty. Among the 36 selected outcomes, 8 had strong-to-very-strong evidence of an association with smoking, 21 had weak-to-moderate evidence of association and 7 had no evidence of association. By overcoming many of the limitations of traditional meta-analyses, our approach provides comprehensive, up-to-date and easy-to-use estimates of the evidence on the health effects of smoking. These estimates provide important information for tobacco control advocates, policy makers, researchers, physicians, smokers and the public.

Association between socioeconomic status and health behaviour change before and after non-communicable disease diagnoses: a multicohort study.

BACKGROUND: Behavioural risk factors of non-communicable diseases (NCDs) are socially patterned. However, the direction and the extent to which socioeconomic status (SES) influences behaviour changes before and after the diagnosis of NCDs is not clearly understood. We aimed to investigate the influence of SES on behaviour changes (physical inactivity and smoking) before and after the diagnosis of major NCDs. METHODS: In this multicohort study, we pooled individual-level data from six prospective cohort studies across 17 countries. We included participants who were diagnosed with either diabetes, cardiovascular disease, chronic lung disease, or cancer after recruitment. Participants were surveyed every 2 years. Education and total household wealth were used to construct SES. We measured behaviour changes as whether or not participants continued or initiated physical inactivity or smoking after NCD diagnosis. We used multivariable logistic regression models to estimate odds ratios (ORs), prevalence ratios (PRs), and 95% CIs for the associations between SES and continuation or initiation of unfavourable behaviours. FINDINGS: We included 8107 individuals recruited between March, 2002, and January, 2016. Over the 4-year period before and after NCD diagnosis, 886 (60·4%) of 1466 individuals continued physical inactivity and 1018 (68·8%) of 1480 participants continued smoking; 1047 (15·8%) of 6641 participants with physical activity before diagnosis initiated physical inactivity after diagnosis and 132 (2·0%) of 6627 non-smokers before diagnosis initiated smoking after diagnosis. Compared with participants with high SES, those with low SES were more likely to continue physical inactivity (244 [70·3%] of 347 vs 23 [50.0%] of 46; PR 1·41 [95% CI 1·05-1·99]; OR 2·28 [1·18-4·41]), continue smoking (214 [75·4%] of 284 vs 39 [60·9%] of 64; PR 1·27 [1·03-1·59]; OR 2·08 [1·14-3·80]), but also to initiate physical inactivity (188 [26·1%] of 720 vs 47 [7·4%] of 639; PR 3·59 [2·58-4·85]; OR 4·31 [3·02 - 6·14]). INTERPRETATION: Low SES was associated with continuing or initiating physical inactivity and continuing smoking after NCD diagnosis. Reducing socioeconomic inequality in health behaviour changes should be prioritised and integrated into NCD-prevention programmes. FUNDING: Zhejiang University and Fundamental Research Funds for the Central Universities.

Evolution of the global smoking epidemic over the past half century: strengthening the evidence base for policy action.

BACKGROUND: Despite compelling evidence on the health hazards of tobacco products accumulated over the past 70 years, smoking remains a leading cause of death worldwide. Policy action to control smoking requires timely, comprehensive, and comparable evidence on smoking levels within and across countries. This study provides a recent assessment of that evidence based on the methods used in the Global Burden of Disease (GBD) Study. METHODS: We estimated annual prevalence of, and mortality attributable to smoking any form of tobacco from 1970 to 2020 and 1990-2020, respectively, using the methods and data sources (including 3431 surveys and studies) from the GBD collaboration. We modelled annual prevalence of current and former smoking, distributions of cigarette-equivalents per smoker per day, pack-years for current smoking, years since cessation for former smokers and estimated population-attributable fractions due to smoking. RESULTS: Globally, adult smoking prevalence in 2020 was 32.6% (32.2% to 33.1%) and 6.5% (6.3% to 6.7%) among men and women, respectively. 1.18 (0.94 to 1.47) billion people regularly smoke tobacco, causing 7.0 (2.0 to 11.2) million deaths in 2020. Smoking prevalence has declined by 27.2% (26.0% to 28.3%) for men since 1990, and by 37.9% (35.3% to 40.1%) for women. Declines have been largest in the higher sociodemographic countries, falling by more than 40% in some high-income countries, and also in several Latin American countries, notably Brazil, where prevalence has fallen by 70% since 1990. Smoking prevalence for women has declined substantially in some countries, including Nepal, the Netherlands and Denmark, and remains low throughout Asia and Africa. Conversely, there has been little decline in smoking in most low- and middle-income countries (LMICs) with over half of all men continuing to smoke in large populations in Asia (China, Indonesia), as well as the Pacific Islands. IMPLICATIONS: While global smoking prevalence has fallen, smoking is still common and causes a significant health burden worldwide. The unequal pace of declines across the globe is shifting the epidemic progressively to LMICs. Smoking is likely to remain a leading cause of preventable death throughout this century unless smoking cessation efforts can significantly and rapidly reduce the number of smokers, particularly in Asia. FUNDING: XD and EG received funding through grant projects from Bloomberg Philanthropies (funding no. 66-9468) and the Bill & Melinda Gates Foundation (funding no. 63-3452).

Burden of Cardiovascular diseases attributable to risk factors in Brazil: data from the "Global Burden of Disease 2019" study.

INTRODUCTION: To better understand trends in the main cause of death in Brazil, we sought to analyze the burden of cardiovascular risk factors (RF) and cardiovascular diseases (CVD) attributable to specific RFs in Brazil from 1990 to 2019, using the estimates from the GBD 2019 study. METHODS: To estimate RF exposure, the Summary Exposure Value (SEV) was used, whereas for disease burden attributed to RF, mortality and disability-adjusted life-years (DALY) due to CVD were used. For comparisons over time and between states, we compared age-standardized rates. The sociodemographic index (SDI) was used as a marker of socioeconomic conditions. RESULTS: In 2019, 83% of CVD mortality in Brazil was attributable to RF. For SEV, there was a reduction in smoking and environmental RF, but an increase in metabolic RF. High systolic blood pressure and dietary risks continue to be the main RF for CVD mortality and DALY. While there was a decline in age-standardized mortality rates attributable to the evaluated RF, there was also a stability or increase in crude mortality rates, with the exception of smoking. It is important to highlight the increase in the risk of death attributable to a high body mass index. Regarding the analysis per state, SEVs and mortality attributable to RF were higher in those states with lower SDIs. CONCLUSIONS: Despite the reduction in CVD mortality and DALY rates attributable to RF, the stability or increase in crude rates attributable to metabolic RFs is worrisome, requiring investments and a renewal of health policies.

Burden of disease attributable to Risk Factors in Brazil: an analysis of national and subnational estimates from the 2019 Global Burden of Disease study.

INTRODUCTION: Monitoring trends in risk factors (RFs) and the burden of diseases attributable to exposure to RFs is an important measure to identify public health advances and current inadequate efforts. Objective: Analyze the global burden of disease attributable to exposure RFs in Brazil, and its changes from 1990 to 2019, according to the sex and age group. METHODS: This study used data from the Global Burden of Disease study. The Summary Exposure Value, which represents weighted prevalence by risk, was used to estimate exposure to RFs. The mortality and DALYs (Disability Adjusted Life Years) measurements were used to estimate the burden of diseases. For comparisons by year and between Brazilian states, age-standardized rates were used. RESULTS: Arterial hypertension was the factor responsible for most deaths in both sexes. For DALYs, the most important RF was the high body mass index (BMI) for women and alcohol consumption for men. Smoking had a substantial reduction in the attributable burden of deaths in the period. An important reduction was identified in the exposure to RFs related to socioeconomic development, such as unsafe water, lack of sanitation, and child malnutrition. Metabolic RFs, such as high BMI, hypertension, and alcohol consumption showed an increase in the attributable burden. CONCLUSIONS: Our findings point to an increase in metabolic RFs, which are the main RFs for mortality and DALYs. These results can help to consolidate and strengthen public policies that promote healthy lifestyles, thus reducing disease and death.

Burden of Cardiovascular diseases attributable to risk factors in Brazil: data from the "Global Burden of Disease 2019" study

Abstract INTRODUCTION: To better understand trends in the main cause of death in Brazil, we sought to analyze the burden of cardiovascular risk factors (RF) and cardiovascular diseases (CVD) attributable to specific RFs in Brazil from 1990 to 2019, using the estimates from the GBD 2019 study. METHODS: To estimate RF exposure, the Summary Exposure Value (SEV) was used, whereas for disease burden attributed to RF, mortality and disability-adjusted life-years (DALY) due to CVD were used. For comparisons over time and between states, we compared age-standardized rates. The sociodemographic index (SDI) was used as a marker of socioeconomic conditions. RESULTS: In 2019, 83% of CVD mortality in Brazil was attributable to RF. For SEV, there was a reduction in smoking and environmental RF, but an increase in metabolic RF. High systolic blood pressure and dietary risks continue to be the main RF for CVD mortality and DALY. While there was a decline in age-standardized mortality rates attributable to the evaluated RF, there was also a stability or increase in crude mortality rates, with the exception of smoking. It is important to highlight the increase in the risk of death attributable to a high body mass index. Regarding the analysis per state, SEVs and mortality attributable to RF were higher in those states with lower SDIs. CONCLUSIONS: Despite the reduction in CVD mortality and DALY rates attributable to RF, the stability or increase in crude rates attributable to metabolic RFs is worrisome, requiring investments and a renewal of health policies.

Burden of disease attributable to Risk Factors in Brazil: an analysis of national and subnational estimates from the 2019 Global Burden of Disease study

Abstract INTRODUCTION: Monitoring trends in risk factors (RFs) and the burden of diseases attributable to exposure to RFs is an important measure to identify public health advances and current inadequate efforts. Objective: Analyze the global burden of disease attributable to exposure RFs in Brazil, and its changes from 1990 to 2019, according to the sex and age group. METHODS: This study used data from the Global Burden of Disease study. The Summary Exposure Value, which represents weighted prevalence by risk, was used to estimate exposure to RFs. The mortality and DALYs (Disability Adjusted Life Years) measurements were used to estimate the burden of diseases. For comparisons by year and between Brazilian states, age-standardized rates were used. RESULTS: Arterial hypertension was the factor responsible for most deaths in both sexes. For DALYs, the most important RF was the high body mass index (BMI) for women and alcohol consumption for men. Smoking had a substantial reduction in the attributable burden of deaths in the period. An important reduction was identified in the exposure to RFs related to socioeconomic development, such as unsafe water, lack of sanitation, and child malnutrition. Metabolic RFs, such as high BMI, hypertension, and alcohol consumption showed an increase in the attributable burden. CONCLUSIONS: Our findings point to an increase in metabolic RFs, which are the main RFs for mortality and DALYs. These results can help to consolidate and strengthen public policies that promote healthy lifestyles, thus reducing disease and death.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and initiation among young people in 204 countries and territories, 1990-2019.

BACKGROUND: Universally, smoking cessation rates among established smokers are poor. Preventing young people from starting use of and becoming addicted to tobacco products remains a key strategy to end the tobacco epidemic. Previous country-specific studies have found that initiation of smoking tobacco use occurs predominantly among young people and have found mixed progress in reducing the prevalence of smoking tobacco use among young people. Current and comparable estimates for all countries are needed to inform targeted interventions and policies. METHODS: We modelled two indicators: prevalence of current smoking tobacco use among young adults aged 15-24 years, and the age at which current smokers aged 20-54 years in 2019 began smoking regularly. We synthesised data from 3625 nationally representative surveys on prevalence of smoking and 254 on age at initiation. We used spatiotemporal Gaussian process regression to produce estimates of the prevalence of smoking and age of initiation by sex, for 204 countries and territories for each year between 1990 and 2019. FINDINGS: Globally in 2019, an estimated 155 million (95% uncertainty interval 150-160) individuals aged 15-24 years were tobacco smokers, with a prevalence of 20·1% (19·4-20·8) among males and 4·95% (4·64-5·29) among females. We estimated that 82·6% (82·1-83·1) of current smokers initiated between ages 14 and 25 years, and that 18·5% (17·7-19·3) of smokers began smoking regularly by age 15 years. Although some countries have made substantial progress in reducing the prevalence of smoking tobacco use among young people, prevalence in 2019 still exceeds 20% among males aged 15-24 years in 120 countries and among females aged 15-24 years in 43 countries. INTERPRETATION: The fact that most smokers start smoking regularly before age 20 years highlights the unique window of opportunity to target prevention efforts among young people and save millions of lives and avert health-care costs in the future. Countries can substantially improve the health of their populations by implementing and enforcing evidence-based tobacco control policies that prevent the next generation from initiating smoking. FUNDING: Bloomberg Philanthropies.

The effects of tobacco control policies on global smoking prevalence.

Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development2. Here we show that comprehensive tobacco control policies-including smoking bans, health warnings, advertising bans and tobacco taxes-are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

Trends in prevalence and mortality burden attributable to smoking, Brazil and federated units, 1990 and 2017.

BACKGROUND: The present study sought to analyze smoking prevalence and smoking-attributable mortality estimates produced by the 2017 Global Burden of Disease Study for Brazil, 26 states, and the Federal District. METHODS: Prevalence of current smokers from 1990 to 2017 by sex and age was estimated using spatiotemporal Gaussian process regression. Population-attributable fractions were calculated for different risk-outcome pairs to generate estimates of smoking-attributable mortality. A cohort analysis of smoking prevalence by birth-year cohort was performed to better understand temporal age patterns in smoking. Smoking-attributable mortality rates were described and analyzed by development at state levels, using the Socio-Demographic Index (SDI). Finally, a decomposition analysis was conducted to evaluate the contribution of different factors to the changes in the number of deaths attributable to smoking between 1990 and 2017. RESULTS: Between 1990 and 2017, prevalence of smoking in the population (≥ 20 years old) decreased from 35.3 to 11.3% in Brazil. This downward trend was seen for both sexes and in all states, with a marked reduction in exposure to this risk factor in younger cohorts. Smoking-attributable mortality rates decreased by 57.8% (95% UI - 61.2, - 54.1) between 1990 and 2017. Overall, larger reductions were observed in states with higher SDI (Pearson correlation 0.637; p < 0.01). In Brazil, smoking remains responsible for a considerable amount of deaths, especially due to cardiovascular diseases and neoplasms. CONCLUSIONS: Brazil has adopted a set of regulatory measures and implemented anti-tobacco policies that, along with improvements in socioeconomic conditions, have contributed to the results presented in the present study. Other regulatory measures need to be implemented to boost a reduction in smoking in order to reach the goals established in the scope of the 2030 United Nations Agenda for Sustainable Development.

Reexamining Rates of Decline in Lung Cancer Risk after Smoking Cessation. A Meta-analysis.

Rationale: Prior studies have questioned whether prevailing eligibility criteria for lung cancer screening are sufficiently inclusive of former smokers who remain at elevated risk of disease outside current screening windows.Objectives: To characterize the percentage of the reducible relative risk (RR) remaining for lung cancer as a function of years since quitting (YSQ).Methods: MEDLINE and PubMed were searched from January 2011 to May 2018; key search terms included "smoking" and "cancer." Current smoker RRs were extracted to represent former smokers at 0 YSQ; data were transformed assuming a lognormal distribution.Results: The main review included 49 prospective cohorts across 18 studies comprising a total of 139 RRs from 20 countries and territories. At 1 year since quitting, the percentage of reducible RR remaining for lung cancer was 81.4% (64.1-98.2%). At 5 YSQ, the percentage of reducible RR remaining was 57.2% (45.7-67.3%); at 10 years, it was 36.9% (28.3-47.9%); at 15 years, it was 26.7% (20.2-34.3%); and at 20 years, it was 19.7% (13.3-26.4%). If eligibility criteria in the United States were broadened to screen former smokers at up to 20 YSQ, we estimate an additional 4.2 (3.9-4.5) million former smokers between 55 and 80 years of age would be eligible for lung cancer screening.Conclusions: At the critical screening threshold of 15 YSQ, the percentage of excess risk for lung cancer remains high and only marginally declines at time points afterward, excluding millions of former smokers who remain at elevated risk of malignancy. A risk-based algorithm for lung cancer screening that deemphasizes time after cessation as a key screening determinant would more likely capture these former smokers who remain at elevated risk of malignancy.

Mortality, morbidity, and risk factors in China and its provinces, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017.

BACKGROUND: Public health is a priority for the Chinese Government. Evidence-based decision making for health at the province level in China, which is home to a fifth of the global population, is of paramount importance. This analysis uses data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 to help inform decision making and monitor progress on health at the province level. METHODS: We used the methods in GBD 2017 to analyse health patterns in the 34 province-level administrative units in China from 1990 to 2017. We estimated all-cause and cause-specific mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), summary exposure values (SEVs), and attributable risk. We compared the observed results with expected values estimated based on the Socio-demographic Index (SDI). FINDINGS: Stroke and ischaemic heart disease were the leading causes of death and DALYs at the national level in China in 2017. Age-standardised DALYs per 100 000 population decreased by 33·1% (95% uncertainty interval [UI] 29·8 to 37·4) for stroke and increased by 4·6% (-3·3 to 10·7) for ischaemic heart disease from 1990 to 2017. Age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs in 2017. Musculoskeletal disorders, mental health disorders, and sense organ diseases were the three leading causes of YLDs in 2017, and high systolic blood pressure, smoking, high-sodium diet, and ambient particulate matter pollution were among the leading four risk factors contributing to deaths and DALYs. All provinces had higher than expected DALYs per 100 000 population for liver cancer, with the observed to expected ratio ranging from 2·04 to 6·88. The all-cause age-standardised DALYs per 100 000 population were lower than expected in all provinces in 2017, and among the top 20 level 3 causes were lower than expected for ischaemic heart disease, Alzheimer's disease, headache disorder, and low back pain. The largest percentage change at the national level in age-standardised SEVs among the top ten leading risk factors was in high body-mass index (185%, 95% UI 113·1 to 247·7]), followed by ambient particulate matter pollution (88·5%, 66·4 to 116·4). INTERPRETATION: China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. FUNDING: China National Key Research and Development Program and Bill & Melinda Gates Foundation.

Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project.

BACKGROUND: The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs). METHODS: This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach. RESULTS: 46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs. CONCLUSION: In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Identifying High-Risk Neighborhoods Using Electronic Medical Records: A Population-Based Approach for Targeting Diabetes Prevention and Treatment Interventions.

BACKGROUND: Increasing attention is being paid to the marked disparities in diabetes prevalence and health outcomes in the United States. There is a need to identify the small-area geographic variation in diabetes risk and related outcomes, a task that current health surveillance methods, which often rely on a self-reported diagnosis of diabetes, are not detailed enough to achieve. Broad adoption of electronic health records (EHR) and routine centralized reporting of patient-level data offers a new way to examine diabetes risk and highlight hotspots for intervention. METHODS AND FINDINGS: We examined small-area geographic variation in hemoglobin A1c (HgbA1C) levels in three counties though a retrospective observational analysis of the complete population of diabetic patients receiving at least two ambulatory care visits for diabetes in three counties (two urban, one rural) in Minnesota in 2013, with clinical performance measures re-aggregated to patient home zip code area. Patient level performance measures included HgbA1c, blood pressure, low-density lipoprotein cholesterol and smoking. Diabetes care was provided to 63,053 patients out of a total population of 1.48 million people aged 18-74. Within each zip code area, on average 4.1% of the population received care for diabetes. There was significant and largely consistent geographic variation in the proportion of patients within their zip code area of residence attaining HgbA1C <8.0%, ranging from 59-90% of patients within each zip code area (interquartile range (IQR) 72.0%-78.1%). Attainment of performance measures for a zip code area were correlated with household income, educational attainment and insurance coverage for the same zip code area (all p < .001). CONCLUSIONS: We identified small geographic areas with the least effective control of diabetes. Centrally-aggregated EHR provides a new means of identifying and targeting at-risk neighborhoods for community-based interventions.

Benchmarking health system performance across districts in Zambia: a systematic analysis of levels and trends in key maternal and child health interventions from 1990 to 2010.

BACKGROUND: Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide. Timely and accurate measurements of levels and trends in key health indicators at local levels are crucial to assess progress and identify drivers of success and areas that may be lagging behind. METHODS: We generated estimates of 17 key maternal and child health indicators for Zambia's 72 districts from 1990 to 2010 using surveys, censuses, and administrative data. We used a three-step statistical model involving spatial-temporal smoothing and Gaussian process regression. We generated estimates at the national level for each indicator by calculating the population-weighted mean of the district values and calculated composite coverage as the average of 10 priority interventions. RESULTS: National estimates masked substantial variation across districts in the levels and trends of all indicators. Overall, composite coverage increased from 46% in 1990 to 73% in 2010, and most of this gain was attributable to the scale-up of malaria control interventions, pentavalent immunization, and exclusive breastfeeding. The scale-up of these interventions was relatively equitable across districts. In contrast, progress in routine services, including polio immunization, antenatal care, and skilled birth attendance, stagnated or declined and exhibited large disparities across districts. The absolute difference in composite coverage between the highest-performing and lowest-performing districts declined from 37 to 26 percentage points between 1990 and 2010, although considerable variation in composite coverage across districts persisted. CONCLUSIONS: Zambia has made marked progress in delivering maternal and child health interventions between 1990 and 2010; nevertheless, substantial variations across districts and interventions remained. Subnational benchmarking is important to identify these disparities, allowing policymakers to prioritize areas of greatest need. Analyses such as this one should be conducted regularly and feed directly into policy decisions in order to increase accountability at the local, regional, and national levels.