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

BACKGROUND: Many physical, psychological, and cognitive disorders are highly clustered among populations with low socioeconomic status. However, the extent to which socioeconomic status is associated with different combinations of these disorders is unclear, particularly outside high-income countries. We aimed to evaluate these associations in 33 countries including high-income countries, upper-middle-income countries, and one lower-middle-income country. METHODS: This cross-sectional multi-region study pooled individual-level data from seven studies on ageing between 2017 and 2020. Education and total household wealth were used to measure socioeconomic status. Physical disorder was defined as having one or more of the self-reported chronic conditions. Psychological and cognitive disorders were measured by study-specific instruments. The outcome included eight categories: no disorders, physical disorder, psychological disorder, cognitive disorder, and their four combinations. Multivariable-adjusted logistic regression models were used to estimate odds ratios (ORs) and 95% CIs for the associations of socioeconomic status with these outcomes separately for high-income countries, upper-middle-income countries, and the lower-middle-income country. FINDINGS: Among 167 376 individuals aged 45 years and older, the prevalence of multimorbidity was 24·5% in high-income countries, 33·9% in upper-middle-income countries, and 8·1% in the lower-middle-income country (India). Lower levels of education, household wealth, and a combined socioeconomic status score were strongly associated with physical, psychological, and cognitive multimorbidity in high-income countries and upper-middle-income countries, with ORs (low vs high socioeconomic status) for physical-psychological-cognitive multimorbidity of 12·36 (95% CI 10·29-14·85; p<0·0001) in high-income countries and of 23·84 (18·85-30·14; p<0·0001) in upper-middle-income countries. The associations in the lower-middle-income country were mixed. Participants with both a low level of education and low household wealth had the highest odds of multimorbidity (eg, OR for physical-psychological-cognitive multimorbidity 21·21 [15·95-28·19; p<0·0001] in high-income countries, 37·07 [25·66-53·56; p<0·0001] in upper-middle-income countries, and 54·96 [7·66-394·38; p<0·0001] in the lower-middle-income country). INTERPRETATION: In study populations from high-income countries, upper-middle-income countries, and the lower-middle-income country, the odds of multimorbidity, which included physical, psychological, and cognitive disorders, were more than ten times greater in individuals with low socioeconomic status. Equity-oriented policies and programmes that reduce social inequalities in multimorbidity are urgently needed to achieve Sustainable Development Goals. FUNDING: Zhejiang University, Fundamental Research Funds for the Central Universities, The Key Laboratory of Intelligent Preventive Medicine of Zhejiang Province, Wellcome Trust, Medical Research Council, National Institute on Aging, and Academy of Finland. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Predicted heart age profile across 41 countries: A cross-sectional study of nationally representative surveys in six world regions.

Background: Predicted heart age (PHA) can simplify communicating the absolute cardiovascular disease (CVD) risk. Few studies have characterized PHA across multiple populations, and none has described whether people with excess PHA are eligible for preventive treatment for CVD. Methods: Pooled analysis of 41 World Health Organization (WHO) STEPS surveys conducted in 41 countries in six world regions between 2013 and 2019. PHA was calculated as per the non-laboratory Framingham risk score in adults without history of CVD. We described the differences between chronological age and PHA, the distribution of PHA, and the proportion of people with excess PHA that were eligible for antihypertensive and lipid-lowering treatment following the WHO guidelines. Logistic regression models were fitted to assess sociodemographic and health-related variables associated with PHA excess. Findings: 94,655 individuals aged 30-74 years were included. 36% of those aged 30-34 years had a PHA of 30-34 years; 9% of those aged 60-64 years had a PHA of 60-64 years. Countries in Africa had the lowest prevalence of very high PHA (i.e., PHA exceeding chronological age in ≥5 years) and countries in Western Pacific had the highest. ≥50% of the population with PHA excess (i.e., PHA exceeding chronological age in ≥1 year) was not eligible for antihypertensive nor lipid-lowering treatment. Abdominal obesity, high total cholesterol, smoking and having diabetes were associated with higher odds of having PHA excess, whereas higher education and employment were inversely associated with excess PHA. Interpretation: PHA is generally higher than chronological age in LMICs and there are regional disparities. Most people with excess PHA would not be eligible to receive preventive medication. Funding: RMC-L is supported by a Wellcome Trust International Training Fellowship (214185/Z/18/Z).

Mortality attributable to type 2 diabetes mellitus in Latin America and the Caribbean: a comparative risk assessment analysis.

INTRODUCTION: We quantified the proportion and the absolute number of deaths attributable to type 2 diabetes mellitus (T2DM) in Latin America and the Caribbean (LAC) using an estimation approach. RESEARCH DESIGN AND METHODS: We combined T2DM prevalence estimates from the NCD Risk Factor Collaboration, relative risks between T2DM and all-cause mortality from a meta-analysis of cohorts in LAC, and death rates from the Global Burden of Disease Study 2019. We estimated population-attributable fractions (PAFs) and computed the absolute number of attributable deaths in 1990 and 2019 by multiplying the PAFs by the total deaths in each country, year, sex, and 5-year age group. RESULTS: Between 1985 and 2014 in LAC, the proportion of all-cause mortality attributable to T2DM increased from 12.2% to 16.9% in men and from 14.5% to 19.3% in women. In 2019, the absolute number of deaths attributable to T2DM was 349 787 in men and 330 414 in women. The highest death rates (deaths per 100 000 people) in 2019 were in Saint Kitts and Nevis (325 in men, 229 in women), Guyana (313 in men, 272 in women), and Haiti (269 in men, 265 in women). CONCLUSIONS: A substantial burden of all deaths is attributed to T2DM in LAC. To decrease the mortality attributable to T2DM in LAC, policies are needed to strengthen early diagnosis and management, along with the prevention of complications.

Design of financial incentive interventions to improve lifestyle behaviors and health outcomes: A systematic review.

Background: Financial incentives may improve the initiation and engagement of behaviour change that reduce the negative outcomes associated with non-communicable diseases. There is still a paucity in guidelines or recommendations that help define key aspects of incentive-oriented interventions, including the type of incentive (e.g. cash rewards, vouchers), the frequency and magnitude of the incentive, and its mode of delivery.  We aimed to systematically review the literature on financial incentives that promote healthy lifestyle behaviours or improve health profiles, and focused on the methodological approach to define the incentive intervention and its delivery. The protocol was registered at PROSPERO on 26 July 2018 ( CRD42018102556). Methods: We sought studies in which a financial incentive was delivered to improve a health-related lifestyle behaviour (e.g., physical activity) or a health profile (e.g., HbA1c in people with diabetes). The search (which took place on March 3 rd 2018) was conducted using OVID (MEDLINE and Embase), CINAHL and Scopus. Results: The search yielded 7,575 results and 37 were included for synthesis. Of the total, 83.8% (31/37) of the studies were conducted in the US, and 40.5% (15/37) were randomised controlled trials. Only one study reported the background and rationale followed to develop the incentive and conducted a focus group to understand what sort of incentives would be acceptable for their study population. There was a degree of consistency across the studies in terms of the direction, form, certainty, and recipient of the financial incentives used, but the magnitude and immediacy of the incentives were heterogeneous. Conclusions: The available literature on financial incentives to improve health-related lifestyles rarely reports on the rationale or background that defines the incentive approach, the magnitude of the incentive and other relevant details of the intervention, and the reporting of this information is essential to foster its use as potential effective interventions.

[Healthcare challenges for people with diabetes during the national state of emergency due to COVID-19 in Lima, Peru: primary healthcare recommendations]. / Los retos del cuidado de las personas con diabetes durante el estado de emergencia nacional por COVID-19 en Lima, Perú: recomendaciones para la atención primaria.

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

Las personas con diabetes mellitus tipo 2 infectadas por SARS-CoV-2 tienen mayores riesgos de desarrollar COVID-19 con complicaciones y de morir como consecuencia de ella. La diabetes es una condición crónica en la que se requiere continuidad de cuidados que implican un contacto con los establecimientos de salud, pues deben tener acceso regular a medicamentos, exámenes y citas con personal de salud. Esta continuidad de cuidados se ha visto afectada en el Perú a raíz de la declaratoria del estado de emergencia nacional, producto de la pandemia por la COVID-19 pues muchos establecimientos de salud han suspendido las consultas externas. Este artículo describe algunas estrategias que han desarrollado los diferentes proveedores de salud peruanos en el marco de la pandemia para proveer continuidad del cuidado a las personas con diabetes y finalmente brinda recomendaciones para que reciban los cuidados que necesitan a través del fortalecimiento del primer nivel de atención, como el punto de contacto más cercano con las personas con diabetes.

The contribution of specific non-communicable diseases to the achievement of the Sustainable Development Goal 3.4 in Peru.

BACKGROUND: Non-communicable diseases (NCDs) have received political attention and commitment, yet surveillance is needed to measure progress and set priorities. Building on global estimates suggesting that Peru is not on target to meet the Sustainable Development Goal 3.4, we estimated the contribution of various NCDs to the change in unconditional probability of dying from NCDs in 25 regions in Peru. METHODS: Using national death registries and census data, we estimated the unconditional probability of dying between ages 30 and 69 from any and from each of the following NCDs: cardiovascular, cancer, diabetes, chronic respiratory diseases and chronic kidney disease. We estimated the contribution of each NCD to the change in the unconditional probability of dying from any of these NCDs between 2006 and 2016. RESULTS: The overall unconditional probability of dying improved for men (21.4%) and women (23.3%). Cancer accounted for 10.9% in men and 13.7% in women of the overall reduction; cardiovascular diseases also contributed substantially: 11.3% in men) and 9.8% in women. Consistently in men and women and across regions, diabetes moved in the opposite direction of the overall reduction in the unconditional probability of dying from any selected NCD. Diabetes contributed a rise in the unconditional probability of 3.6% in men and 2.1% in women. CONCLUSIONS: Although the unconditional probability of dying from any selected NCD has decreased, diabetes would prevent Peru from meeting international targets. Policies are needed to prevent diabetes and to strengthen healthcare to avoid diabetes-related complications and delay mortality.

The Andean Latin-American burden of diabetes attributable to high body mass index: A comparative risk assessment.

BACKGROUND: Body mass index (BMI) has increased in Latin-America, but the implications for the diabetes burden have not been quantified. We estimated the proportion and absolute number of diabetes cases attributable to high BMI in Bolivia, Ecuador and Peru (Andean Latin-America), with estimation of region-level indicators in Peru. METHODS: We estimated the population attributable fraction (PAF) of BMI on diabetes (regardless of type 1 or 2) from 1980 to 2014, including the number of cases attributable to overweight (BMI 25-<30), class I (30-<35), class II (BMI 35-<40) and class III (BMI ≥ 40) obesity. We used age- and sex-specific prevalence estimates of diabetes and BMI categories (NCD-RisC and Peru's DHS survey) combined with relative risks from population-based cohorts in Peru. FINDINGS: Across Andean Latin-America in 2014, there were 1,258,313 diabetes cases attributable to high BMI: 209,855 in Bolivia, 367,440 in Ecuador and 681,018 in Peru. Between 1980 and 2010, the absolute proportion of diabetes cases attributable to class I obesity increased the most (from 12.9% to 27.2%) across the region. The second greatest increase was for class II obesity (from 3.6% to 16.5%). There was heterogeneity in the fraction of diabetes cases attributable to high BMI by region in Peru, as coastal regions had the largest fractions, and so did high-income regions. INTERPRETATION: Over one million diabetes cases are attributable to high BMI in Andean Latin-America. Public health efforts should focus on implementing population-based interventions to reduce high BMI and to develop focused interventions targeted at those at highest risk of diabetes.

The shift of obesity burden by socioeconomic status between 1998 and 2017 in Latin America and the Caribbean: a cross-sectional series study.

BACKGROUND: The burden of obesity differs by socioeconomic status. We aimed to characterise the prevalence of obesity among adult men and women in Latin America and the Caribbean by socioeconomic measures and the shifting obesity burden over time. METHODS: We did a cross-sectional series analysis of obesity prevalence by socioeconomic status by use of national health surveys done between 1998 and 2017 in 13 countries in Latin America and the Caribbean. We generated equiplots to display inequalities in, the primary outcome, obesity by wealth, education, and residence area. We measured obesity gaps as the difference in percentage points between the highest and lowest obesity prevalence within each socioeconomic measure, and described trends as well as changing patterns of the obesity burden over time. FINDINGS: 479 809 adult men and women were included in the analysis. Obesity prevalence across countries has increased over time, with distinct patterns emerging by wealth and education indices. In the most recent available surveys, obesity was most prevalent among women in Mexico in 2016, and the least prevalent among women in Haiti in 2016. The largest gap between the highest and lowest obesity estimates by wealth was observed in Honduras among women (21·6 percentage point gap), and in Peru among men (22·4 percentage point gap), compared with a 3·7 percentage point gap among women in Brazil and 3·3 percentage points among men in Argentina. Urban residents consistently had a larger burden than their rural counterparts in most countries, with obesity gaps ranging from 0·1 percentage points among women in Paraguay to 15·8 percentage points among men in Peru. The trend analysis done in five countries suggests a shifting of the obesity burden across socioeconomic groups and different patterns by gender. Obesity gaps by education in Mexico have reduced over time among women, but increased among men, whereas the gap has increased among women but remains relatively constant among men in Argentina. INTERPRETATION: The increase in obesity prevalence in the Latin American and Caribbean region has been paralleled with an unequal distribution and a shifting burden across socioeconomic groups. Anticipation of the establishment of obesity among low socioeconomic groups could provide opportunities for societal gains in primordial prevention. FUNDING: None.

Impact of Food Assistance Programs on Obesity in Mothers and Children: A Prospective Cohort Study in Peru.

OBJECTIVES: To assess obesity risk among mothers participating in Community Kitchens and children participating in Glass of Milk (Peru food assistance programs). METHODS: We analyzed prospective data from the Young Lives study. The exposure consisted in varying degrees of benefit from any of the programs (no participation in any of the programs, program participation for some months, or program participation nearly every month) at baseline (2006-2007). The outcome was overweight and obesity in mothers and children at follow-up (2009-2010). RESULTS: Prevalence of childhood overweight and obesity was 15.5% and 5.1%, respectively; the corresponding figures for mothers were 40.5% and 14.6%. Children exposed nearly every month to the Glass of Milk program had a 65% lower risk of becoming obese compared with children not participating in the program (relative risk [RR] = 0.35; 95% confidence interval [CI] = 0.18, 0.66). Mothers participating frequently in the Community Kitchens program had almost twice the risk of becoming obese compared with those who did not participate (RR = 1.93; 95% CI = 1.18, 3.15). CONCLUSIONS: Participating in food assistance programs in Peru was associated with a lower risk of obesity in children and greater risk of obesity in mothers.

Comparison of Nonblood-Based and Blood-Based Total CV Risk Scores in Global Populations.

BACKGROUND: Cost-effective primary prevention of cardiovascular disease (CVD) in low- and middle-income countries requires accurate risk assessment. Laboratory-based risk tools currently used in high-income countries are relatively expensive and impractical in many settings due to lack of facilities. OBJECTIVES: This study sought to assess the correlation between a non-laboratory-based risk tool and 4 commonly used, laboratory-based risk scores in 7 countries representing nearly one-half of the world's population. METHODS: We calculated 10-year CVD risk scores for 47,466 persons with cross-sectional data collected from 16 different cohorts in 9 countries. The performance of the non-laboratory-based risk score was compared with 4 laboratory-based risk scores: Pooled Cohort Risk Equations (ASCVD [Atherosclerotic Cardiovascular Disease]), Framingham, and SCORE (Systematic Coronary Risk Evaluation) for high- and low-risk countries. Rankings of each score were compared using Spearman rank correlations. Based on these correlations, we measured concordance between individual absolute CVD risk as measured by the Harvard NHANES (National Health and Nutrition Examination Survey) risk score, and the 4 laboratory-based risk scores, using both the conventional Framingham risk thresholds of >20% and the recent ASCVD guideline threshold of >7.5%. RESULTS: The aggregate Spearman rank correlations between the non-laboratory-based risk score and the laboratory-based scores ranged from 0.915 to 0.979 for women and from 0.923 to 0.970 for men. When applying the conventional Framingham risk threshold of >20% over 10 years, 92.7% to 96.0% of women and 88.3% to 92.8% of men were equivalently characterized as "high" or "low" risk. Applying the recent ASCVD guidelines risk threshold of >7.5% resulted in risk characterization agreement for women ranging from 88.1% to 94.4% and from 89.0% to 93.7% for men. CONCLUSIONS: The correlation between non-laboratory-based and laboratory-based risk scores is very high for both men and women. Potentially large numbers of high-risk individuals could be detected with relatively simple tools.

Building a platform for translational research in chronic noncommunicable diseases to address population health: lessons from NHLBI supported CRONICAS in Peru.

The CRONICAS Centre of Excellence in Chronic Diseases, based at Universidad Peruana Cayetano Heredia, was created in 2009 with support from the U.S. National Heart, Lung, and Blood Institute (NHLBI). The vision of CRONICAS is to build a globally recognized center of excellence conducting quality and innovative research and generating high-impact evidence for health. The center's identity is embedded in its core values: generosity, innovation, integrity, and quality. This review has been structured to describe the development of the CRONICAS Centre, with a focus on highlighting the ongoing translational research projects and capacity-building strategies. The CRONICAS Centre of Excellence is not a risk-averse organization: it benefits from past experiences, including past mistakes, and improves upon them and thus challenges traditional research approaches. This ethos and environment are key to fostering innovation in research.

Peruvians' sleep duration: analysis of a population-based survey on adolescents and adults.

Background. Sleep duration, either short or long, has been associated with diseases such as obesity, type-2 diabetes and cardiovascular diseases. Characterizing the prevalence and patterns of sleep duration at the population-level, especially in resource-constrained settings, will provide informative evidence on a potentially modifiable risk factor. The aim of this study was to explore the patterns of sleep duration in the Peruvian adult and adolescent population, together with its socio-demographic profile. Material and Methods. A total of 12,424 subjects, mean age 35.8 years (SD ±17.7), 50.6% males, were included in the analysis. This is a cross-sectional study, secondary analysis of the Use of Time National Survey conducted in 2010. We used weighted means and proportions to describe sleep duration according to socio-demographic variables (area and region; sex; age; education attainment; asset index; martial and job status). We used Poisson regressions, taking into account the multistage sampling design of the survey, to calculate crude and adjusted prevalence ratios (PR) and 95% confidence intervals (95% CI). Main outcomes were short- (<6 h) and long-sleep duration (≥ 9 h). Results. On average, Peruvians slept 7.7 h (95% CI [7.4-8.0]) on weekdays and 8.0 h (95% CI [7.8-8.1]) during weekends. The proportions of short- and long-sleep, during weekdays, were 4.3% (95% CI [2.9%-6.3%]) and 22.4% (95% CI [14.9%-32.1%]), respectively. Regarding urban and rural areas, a much higher proportion of short-sleep was observed in the former (92.0% vs. 8.0%); both for weekdays and weekends. On the multivariable analysis, compared to regular-sleepers (≥ 6 to <9 h), short-sleepers were twice more likely to be older and to have higher educational status, and 50% more likely to be currently employed. Similarly, relative to regular-sleep, long-sleepers were more likely to have a lower socioeconomic status as per educational attainment. Conclusions. In this nationally representative sample, the sociodemographic profile of short-sleep contrasts the long-sleep. These scenarios in Peru, as depicted by sleeping duration, differ from patterns reported in other high-income settings and could serve as the basis to inform and to improve sleep habits in the population. Moreover, it seems important to address the higher frequency of short-sleep duration found in urban versus rural settings.

Autoevaluación de habilidades investigativas e intención de dedicarse a la investigación en estudiantes de primer año de medicina de una universidad privada en Lima, Perú / Self-assessment of research skills and intention to pursue a career in research among, first year medical students from a private university in Lima, Peru

Objetivo: Determinar el número de habilidades auto-percibidas relacionadas a la investigación biomédica y la proporción de alumnos interesados en dedicar su carrera a la investigación, e identificar los factores asociados a este interés en estudiantes de medicina del primer año de una universidad privada de Lima, Perú. Material y métodos: Se realizó un estudio transversal analítico en estudiantes de medicina del primer año de la Universidad Peruana Cayetano Heredia, matriculados en el 2011. Se usó un cuestionario auto-aplicado, anónimo, validado por expertos y previamente probado, se preguntó sobre las habilidades para la investigación que los alumnos consideraban tener y la intención de dedicar su carrera a la investigación. Resultados: La proporción de respuesta fue del 100% (143 estudiantes). La mediana del número de habilidades auto-percibidas fue de 2,0 (de 7,0 posibles), siendo las habilidades menos frecuentes el análisis estadístico y el cálculo del tamaño de muestra. El 71,2% de los alumnos reportó tener la intención de dedicarse a la investigación como carrera. Luego de ajustar por el sexo, la edad, la modalidad de ingreso y el desarrollo de investigación escolar, las características asociadas a dicha intención fueron la edad y el planear involucrarse en investigación tardíamente en la carrera. Conclusiones: Aunque el nivel de habilidades auto-percibidas para la investigación en estudiantes de medicina del primer año es limitado; ellos poseen un interés significativo por dedicarse a la investigación, constituyendo una potencial fuente de recursos humanos.

Objective: To determine de number of self-perceived skills related to biomedical research and the proportion of students interested in devoting his career to research and identify the factors associated to such interest in first year medical students of a private university in Lima, Peru. Methods: We conducted a cross-sectional analytic study in first-year medical students of Universidad Peruana Cayetano Heredia, enrolled in 2011. We used a self applied, anonymous, questionnaire, which was previously tested and validated by experts, to assess the number of self-reported research-related skills, and the intention to pursue a research-oriented career. Results: The response proportion was 100% (143 students). The median number of self perceived skills was 2.0 (7.0 possible). Statistical analysis and sample size calculation were the less frequent skills reported. The 71.2% of students reported intending to pursue research as a career. After adjusting for gender, age, admission modality and development of research at school, student characteristics associated to such intention included a greater age and the plan to involve in research late in their career. Conclusions: Although self-perceived level of skills for research in first year medical students is limited, they have a significant interest in engaging in research, constituting a potential source of human resources.