Establishing research impact assessment in Iran: The first report from a non-high-income country.

Background: This study presents the first report on research impact assessment (RIA) in non-high-income countries, undertaken as a pilot initiative in 2021. Within it, we aimed to explore the feasibility of employing the 'payback' model for evaluating the impact of health research and enhancing the accountability of universities. We focussed on three key impact domains: 'production of decision support documents and knowledge-based products,' 'implementation of research results,' and 'health and economic impact.' Methods: We adopted a case study approach to assess the impact of 5334 health research projects conducted by researchers from 18 universities from 2018 to 2020. Researchers were required to submit evidence related to at least one of the specified impact domains; six scientific committees verified and scored claimed impacts at the national level. Results: Only 25% of the assessed projects achieved impact in at least one domain, with the production of decision support documents and knowledge products being the most reported impact. Notably, economic impact was verified in only three projects, indicating room for improvement in this area. Technology research exhibited the highest acceptance rate of claimed impact, suggesting a positive correlation between technology-focused projects and impactful outcomes. Conclusions: This study demonstrates the feasibility of employing a case study approach and the 'payback' model to evaluate the impact of health research, even within the constraints of a moderately equipped research infrastructure. These findings underscore the potential of integrating RIA into the governance of health research in Iran and other non-high-income countries, as well as the importance of using RIA to assess the accountability of health research systems, guide the allocation of research funding, and advocate for the advancement of health research. The study sets a precedent for future assessments in similar contexts and contributes to the ongoing global dialogue on the societal impact of health research.

Health risk assessment of exposure to triclosan in pregnant women using Monte Carlo simulation techniques: based on biomonitoring data.

This study aimed to assess the triclosan (TCS) health risk in an Iranian pregnant women sample by Monte Carlo simulation (MCS). The urinary TCS of 99 women after the 28th week of pregnancy was detected by gas chromatography/mass spectrometry detector (GC/MS), and the MCS model implemented a health risk assessment. The corresponding hazard quotient (HQ) and the sensitivity analysis were calculated. TCS was measured in 100% of the urine samples with a median concentration of 2.89 µg/L. The median of HQ was obtained at 1.93 × 10-4. The TCS exposure risk in the studied population was lower than the allowable limit. A comparison between HQ values in the two weight subgroups of pregnant women showed that the risk level is almost equal, and there was minimal health risk in pregnant women from exposure to TCS.

Association of the triglyceride glucose index as a measure of insulin resistance with mortality and cardiovascular disease in populations from five continents (PURE study): a prospective cohort study.

BACKGROUND: The triglyceride glucose (TyG) index is an easily accessible surrogate marker of insulin resistance, an important pathway in the development of type 2 diabetes and cardiovascular diseases. However, the association of the TyG index with cardiovascular diseases and mortality has mainly been investigated in Asia, with few data available from other regions of the world. We assessed the association of insulin resistance (as determined by the TyG index) with mortality and cardiovascular diseases in individuals from five continents at different levels of economic development, living in urban or rural areas. We also examined whether the associations differed according to the country's economical development. METHODS: We used the TyG index as a surrogate measure for insulin resistance. Fasting triglycerides and fasting plasma glucose were measured at the baseline visit in 141 243 individuals aged 35-70 years from 22 countries in the Prospective Urban Rural Epidemiology (PURE) study. The TyG index was calculated as Ln (fasting triglycerides [mg/dL] x fasting plasma glucose [mg/dL]/2). We calculated hazard ratios (HRs) using a multivariable Cox frailty model with random effects to test the associations between the TyG index and risk of cardiovascular diseases and mortality. The primary outcome of this analysis was the composite of mortality or major cardiovascular events (defined as death from cardiovascular causes, and non-fatal myocardial infarction, or stroke). Secondary outcomes were non-cardiovascular mortality, cardiovascular mortality, all myocardial infarctions, stroke, and incident diabetes. We also did subgroup analyses to examine the magnitude of associations between insulin resistance (ie, the TyG index) and outcome events according to the income level of the countries. FINDINGS: During a median follow-up of 13·2 years (IQR 11·9-14·6), we recorded 6345 composite cardiovascular diseases events, 2030 cardiovascular deaths, 3038 cases of myocardial infarction, 3291 cases of stroke, and 5191 incident cases of type 2 diabetes. After adjusting for all other variables, the risk of developing cardiovascular diseases increased across tertiles of the baseline TyG index. Compared with the lowest tertile of the TyG index, the highest tertile (tertile 3) was associated with a greater incidence of the composite outcome (HR 1·21; 95% CI 1·13-1·30), myocardial infarction (1·24; 1·12-1·38), stroke (1·16; 1·05-1·28), and incident type 2 diabetes (1·99; 1·82-2·16). No significant association of the TyG index was seen with non-cardiovascular mortality. In low-income countries (LICs) and middle-income countries (MICs), the highest tertile of the TyG index was associated with increased hazards for the composite outcome (LICs: HR 1·31; 95% CI 1·12-1·54; MICs: 1·20; 1·11-1·31; pinteraction=0·01), cardiovascular mortality (LICs: 1·44; 1·15-1·80; pinteraction=0·01), myocardial infarction (LICs: 1·29; 1·06-1·56; MICs: 1·26; 1·10-1·45; pinteraction=0·08), stroke (LICs: 1·35; 1·02-1·78; MICs: 1·17; 1·05-1·30; pinteraction=0·19), and incident diabetes (LICs: 1·64; 1·38-1·94; MICs: 2·68; 2·40-2·99; pinteraction <0·0001). In contrast, in high-income countries, higher TyG index tertiles were only associated with an increased hazard of incident diabetes (2·95; 2·25-3·87; pinteraction <0·0001), but not of cardiovascular diseases or mortality. INTERPRETATION: The TyG index is significantly associated with future cardiovascular mortality, myocardial infarction, stroke, and type 2 diabetes, suggesting that insulin resistance plays a promoting role in the pathogenesis of cardiovascular and metabolic diseases. Potentially, the association between the TyG index and the higher risk of cardiovascular diseases and type 2 diabetes in LICs and MICs might be explained by an increased vulnerability of these populations to the presence of insulin resistance. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

The Assessment of Neonatal Anthropometric Indices Association with Umbilical Cord Blood Zinc and Magnesium Levels.

Background: The present research aims to find the association between neonatal anthropometric parameters and zinc and magnesium concentration in cord blood. Materials and Methods: The current cross-sectional report is a sub-study from the "PERSIAN Birth Cohort Study" conducted on 112 pairs of mother-neonate referring to the index hospitals for giving birth to their children during 2018-19. Umbilical cord blood was collected at delivery for the measurement of zinc and magnesium. Anthropometric indices were measured in standard protocols. Validated questionnaires were used for maternal diet in different trimesters. Dietary patterns were acquired based on exploratory factor analysis. Results: The birth weight was reversely correlated with zinc concentration (r = -0.249, P-value = 0.008); however, the other anthropometric parameters did not show any association with zinc levels (P-value > 0.05). Similar evaluations for magnesium revealed no association between any of the anthropometric indices and this micronutrient agent (P-value > 0.05). Further evaluations represented insignificant differences in both zinc (P-value = 0.51) and magnesium levels (P-value = 0.49) between those with normal versus low birth weight. There was a negative association between the Western dietary pattern in the first trimester of pregnancy and cord blood zinc concentration (ß (SE) = -0.21 (0.10); P = 0.026); while healthy and traditional dietary patterns in second and third trimesters were positively related to cord zinc concentration (all P < 0.05). Conclusion: This research did not document a positive statistical association of cord blood zinc and magnesium with birth weight. The association of maternal Western dietary patterns with lower cord blood zinc levels highlights the importance of healthy nutritional habits in pregnancy.

Socioeconomic inequality in violent behaviors, life dissatisfaction, and self-rated health in pediatric population: the CASPIAN-V study.

BACKGROUND: Bullying, being a victim of violent behaviors, life satisfaction (LS) and self-rated health (SRH) in children and adolescents, all have consistently been recognized as vital factors in school performance and future individual life. METHODS: This cross-sectional data secondary study was a part of the fifth Childhood and Adolescence Surveillance and Prevention of Adult Non-communicable disease (CASPIAN-V) in 2015. A total of 14,400 students 7-18 years and their parents living in 30 provinces in Iran were studied. A validated questionnaire of the World Health Organization on Global School-based Health Survey (WHO-GSHS) was used to measure the outcomes and socioeconomic variables. Family's socioeconomic status (SES) was determined using principal component analysis (PCA). The crude and adjusted odds ratios (95% confidence interval (CI)) were estimated using multiple logistic regressions for each outcome. RESULTS: A total of 14,274 students completed the study, of whom 50.6% were boys. Overall, the prevalence of bullying, being a victim, life dissatisfaction (LDS), and poor SRH among students was 35.6, 21.4, 21.1, and 19.0%, respectively. In multiple-logistic regression analysis (Adjusted OR, (95%CI), students with an illiterate father and mother (1.60, (1.25-2.04), 1.28, (1.03-1.61), unemployed father (1.58, (1.29-1.81)), and one-parent family (1.32, (1.05 - 1.64) had a higher odd of Poor-SRH. Besides, a family size larger than four members (1.14, (1.03-1.25), and low-SES (1.35, (1.15-1.56), and illiteracy of the mother (1.64, (1.30-2.08) had a direct association with LDS. Mother illiteracy also increased the odds of bullying (1.77, (1.45-2.16) and being a victim (1.58, (1.26-1.98). CONCLUSIONS: Some socioeconomic variables can be proposed as the statistically significant attribution of bullying and being a victim, LDS, and Poor-SRH in children and adolescents.

Health risk assessment of exposure to chlorpyrifos in pregnant women using deterministic and probabilistic approaches.

Since chlorpyrifos (CPF), a major organophosphorus pesticide, is widely used for agricultural and domestic purposes, thus, humans may be exposed to these toxic compounds through multiple sources. In recent years, significant concerns have been raised regarding the deleterious effects of exposure to CPF on human health, especially growing fetus. Therefore, in this study, we aimed to evaluate the health risks of exposure to CPF among pregnant women living in Isfahan province, Iran, using deterministic and probabilistic approaches. The urinary concentration of 3, 5, 6-trichloro-2-pyridinol (TCP), the most common metabolite of CPF, was measured as the biomarker of current exposure to CPF. For this purpose, spot urine samples were taken from 110 pregnant women and the urinary concentrations of TCP were quantified. The estimated daily intake and hazard quotient (HQ) for CPF exposure were measured according to the reference values set by World Health Organization (WHO) and United States Environmental Protection Agency (US EPA) for acute and chronic exposure to CPF. Based on the results, TCP was detected in more than 70% of samples (3.8 ± 2.72 µg/L). The estimated daily intake for some participants was found to be higher than the suggested reference dose by USEPA for chronic exposure to CPF. Furthermore, the HQ>1 was obtained for 20% of the study population in Monte-Carlo analysis using USEPA chronic reference dose, indicating that chronic toxic effects are expected at least for a part of the target population. Based on the findings, proper measures should be taken to reduce the exposure of Iranian pregnant women to CPF and resultant health risks.

Social inequalities in meal skipping patterns among children and adolescents: The CASPIAN-V study.

BACKGROUND & AIM: The appropriate meal consumption affects the children's and adolescents' health. Few studies have shown an association between the socioeconomic inequality and the eating behavior among children and adolescents. Therefore, the aim of this study was to assess the socioeconomic inequality in meal skipping patterns among children and adolescents. MATERIALS & METHODS: The data were accessible through the fifth round of a school-based program in Iran in 2015. In this cross-sectional nationwide study, 14,286 students aged 7-18 years were selected via the multistage cluster sampling from 30 provinces of Iran. The Global School-based Health Survey validated questionnaire was used to assess the socioeconomic variables and meal consumption patterns among children and adolescents. Socioeconomic status (SES) was computed using principle component analysis method. Multivariate logistic regression analysis was used to assess the socioeconomic inequality in meal skipping patterns. RESULTS: The frequency of breakfast, lunch, and dinner skipping were 13.8% (95% CI: 13.3-14.5), 6.8% (95% CI: 6.4-7.2), and 7.5% (95% CI: 7.1-7.9), respectively. In multivariate model, living in a two-parent family compared to living in a single-parent family decreased the odds of breakfast skipping (OR: 0.53, 95% CI: 0.42-0.67)). Low SES level was associated with higher odds of skipping breakfast (OR: 1.79, 95% CI: 1.50-2.14) and dinner (OR: 1.80, 95% CI: 1.42-2.28). Moreover, maternal illiteracy and unemployment were associated with skipping breakfast, lunch, and dinner (all p values < 0.05). CONCLUSION: Some demographic and socioeconomic characteristics, such as maternal illiteracy and unemployment, low SES level, and living in a single-parent family were suggested as the main predictors of meal skipping patterns in children and adolescents.

COVID-19 Vaccine Boosters: The Good, the Bad, and the Ugly.

Pursuing vaccinations against COVID-19 brings hope to limit the spread of SARS-CoV-2 and remains the most rational decision under pandemic conditions. However, it does not come without challenges, including temporary shortages in vaccine doses, significant vaccine inequity, and questions regarding the durability of vaccine-induced immunity that remain unanswered. Moreover, SARS-CoV-2 has undergone evolution with the emergence of its novel variants, characterized by enhanced transmissibility and ability to at least partially evade neutralizing antibodies. At the same time, serum antibody levels start to wane within a few months after vaccination, ultimately increasing the risk of breakthrough infections. This article discusses whether the administration of booster doses of COVID-19 vaccines is urgently needed to control the pandemic. We conclude that, at present, optimizing the immunity level of wealthy populations cannot come at the expense of low-income regions that suffer from vaccine unavailability. Although the efficiency of vaccination in protecting from infection may decrease over time, current data show that efficacy against severe disease, hospitalization, and death remains at a high level. If vaccine coverage continues at extremely low levels in various regions, including African countries, SARS-CoV-2 may sooner or later evolve into variants better adapted to evade natural and vaccine-induced immunity, ultimately bringing a global threat that, of course, includes wealthy populations. We offer key recommendations to increase vaccination rates in low-income countries. The pandemic is, by definition, a major epidemiological event and requires looking beyond one's immediate self-interest; otherwise, efforts to contain it will be futile.

Scrutinize of healthy school canteen policy in Iran's primary schools: a mixed method study.

BACKGROUND: Schools provide an opportunity for developing strategies to create healthy food environments for children. The present study aimed to analyze the Healthy School Canteen (HSC) policy and identify challenges of its implementation to improve the school food environment in Iran. METHODS: This mixed method study included two qualitative and quantitative phases. In the qualitative phase, triangulation approach was applied by using semi-structured interviews with key informants, documents review and direct observation. Data content analysis was conducted through policy analysis triangle framework. In the quantitative phase, food items available in 64 canteens of primary schools of Tehran province were gathered. The food's nutrient data were evaluated using their nutrition facts label. The number and proportion of foods that met the criteria based on Iran's HSC guideline and the World Health Organization nutrient profile model for the Eastern Mediterranean Region (WHO-EMR) were determined. RESULTS: The main contextual factors that affected adoption of HSC policy included health (nutritional transition, high prevalence of non-communicable diseases and unhealthy food environment in and around the schools), political (upstream supportive policies and joint memorandums about health children between the Ministry of Health and Medical Education and Ministry of Education), structural (the lack of unified stewardship, inadequate human resource capacity, poor inter-sectional cooperation), economic (school financial problems, poor fiscal supportive of food policies), and socio-cultural (mothers working outside the home, the role of children's peer group, low nutrition knowledge of school principals) factors. Assessment of the school canteens showed that a large proportion of available foods did not comply with the national guidelines (54.7 ± 2.54%) and WHO-EMR model (85.6 ± 2.34%). The main reasons identified for incomplete implementation of the policy were inadequate physical and economic infrastructure to set up standard school canteens, lack of scientific criteria for food categorization, poor monitoring, high price of healthy foods, and conflict of interest among the actors. CONCLUSION: The majority of foods and beverages available in the school canteens did not comply with national and regional standards. Iran HSC policy needs to be improved by using an evidence-based approach and active interaction between all key actors.

Decomposition of socioeconomic inequality in growth disorders to its determinants in pediatric population: the CASPIAN IV study.

PURPOSE: The current study aims to evaluate socioeconomic inequality in growth disorders and its determinants in Iranian children and adolescents. METHODS: In this nationwide cross-sectional survey, 14,880 students aged 6-18 years were selected through multistage cluster sampling method from urban and rural areas of 30 provinces of Iran in 2011. Socioeconomic status (SES) was calculated using principle component analysis. Socioeconomic inequality in growth disorders (including; underweight, excess weight, overweight, general obesity, abdominal obesity, and short stature) was assessed using concentration index (C) and slope index of inequality (SII). The Oaxaca Blinder decomposition method was used to determine determinants of this inequality. RESULTS: Totally, 13,486 students participated in this study (participation rate: 90.6%), comprising 50.8% boys and 75.6% urban inhabitants. Their mean age was 12.47 ± 3.36 years with no significant gender difference. The prevalence of excess weight, overweight, and general and abdominal obesity increased linearly as SES increased, and the prevalence of underweight and short stature decreased linearly as SES increased. The C index for underweight and short stature was negative, which suggests that inequality was in favor of high SES groups, and regarding overweight, excess weight, general and abdominal obesity, the index was positive, indicating that inequality was in favor of in low SES groups. CONCLUSION: Our findings show a considerable inequality in prevalence of growth disorders in Iranian children and adolescents. These findings provide practical information for health policies and programs.

Economic inequality in prevalence of underweight and short stature in children and adolescents: the weight disorders survey of the CASPIAN-IV study.

OBJECTIVE: The aim of this study was to determine the determinants of socio-economic inequality in the prevalence of short stature and underweight in Iranian children and adolescents. METHODS: This cross-sectional nationwide study was conducted on 36,486 participants, aged 6-18 years. This school-based surveillance (CASPIAN- IV) program and its complementary part on weight disorders evaluation was conducted in urban and rural areas of 30 provinces in Iran. In addition to physical examination, a validated questionnaire was completed from students and their parents. Socio-economic status (SES) was determined using principal component analysis, and was classified in quintile scale. Inequality in the prevalence of underweight and short stature was assessed using concentration (C) index and slop index of inequality (SII) by the Oaxaca-Blinder decomposition method. RESULTS: The prevalence (95% CI) of underweight and short stature at national level was 10.89 (10.55, 11.23) and 4.15 (3.94, 4.38), respectively; it had a downtrend from the lowest to highest SES quintile. Furthermore, the value of C for underweight and short stature was negative, i.e. inequality was in favor of high SES groups. Moreover, the prevalence gap of underweight and short stature in the first and fifth quintiles of SES was 6.58% and 5.80%, respectively. The highest proportion of this gap was explained by living area. In the multiple logistic model, odds of underweight and short stature were significantly lower in individuals with higher SES. Compared to boys, odds of underweight were decreased in girls, whereas odds of short stature were increased in them. Odds of underweight and short stature were increased in participants from rural areas than in urban areas. With increasing age, the odds of underweight and short stature decreased significantly. CONCLUSION: The results of this study showed that inequality in the prevalence of short stature and underweight was in favor of high SES groups. Moreover, living area was one of the most important determinants that explained this inequality. Therefore, this issue needs to be considered in health promotion policies.

Sociocultural factors contributing to waterpipe tobacco smoking among adolescents and young adult women: a qualitative study in Iran.

Purpose: Waterpipe tobacco smoking (WTS) is currently a serious and growing public health threat in the world, especially in adolescents and young women. The aim of the study was to explore sociocultural factors contributing to WTS among adolescents and young adult women in Iran. Methods: This qualitative study was conducted from August 2017 to January 2019 in Isfahan and Hamadan cities, Iran; it included 13-30-year-old females with experience of WTS. For data collection, in-depth semi-structured personal interviews were conducted at participants' preferred time and place. Concurrent with data collection, data were analysed through conventional content analysis. Results: The study participants described the various sociocultural factors contributing to WTS. These factors were categorized into four following main categories: waterpipe glamorization by its producers and sellers, media advertisement or silence, common sociocultural traditions, and governmental policies and regulations. Conclusion: A wide range of sociocultural factors affects WTS among Iranian adolescents and young adult women. Therefore, interdisciplinary multidimensional strategies are needed for WTS management and prevention among these at-risk groups. Public education, strict supervision of tobacco import, export, and selling, ample employment opportunities for young people and effective leisure time management are essential to reduce WTS.Abbreviation WTS: Waterpipe Tobacco Smoking; MPOWER: Monitor tobacco use and prevention policies, Protect people from tobacco smoke, Offer help to quit tobacco use, Warn about the dangers of tobacco, Enforce bans on tobacco advertising, promotion and sponsorship, Raise taxes on tobacco.

Healthy eating index in a nationally representative sample of children and adolescents by socio-demographic characteristics: the Weight disorders survey of the CASPIAN-IV Study.

BACKGROUND: To date, the diet quality of Iranian students in relation to socio-demographic characteristics was not studied. The present study aimed to explore the association between the healthy eating index and sociodemographic characteristics among a nationally representative sample of Iranian children and adolescents. METHODS: This nationwide study was conducted in 5187 children and adolescents, aged 6-18 years. Data regarding socio-demographic variables, lifestyle factors, family and student dietary habits, and quality of life were gathered via validated questionnaires. The Alternate Healthy Eating Index-2010 (AHEI-2010) was used to calculate diet quality scores. RESULTS: The odds of high diet quality was 24% lower in adolescents (13-18years) compared to children aged 6-12 years (OR 0.76, CI 0.64-0.89, p= 0.001). Students in families with moderate (OR 1.30, CI 1.13-1.49, p < 0.001) and high socioeconomic status (OR 1.36, CI 1.18-1.57, p < 0.001) were 30% and 36% more likely to have a higher diet quality score, respectively. Lower mean AHEI-2010 scores (CI) were found for low socio-economic status (46.18-47.10), adolescents 47.40 (46.94-47.82), boys 47.51 (47.14-47.88) and South-East area 47.19 (46.54-49.15) (p < 0.05) due to lower intake of fruits and vegetables and high intake of sodium and sugar-sweetened beverages. CONCLUSIONS: The overall diet quality of Iranian children and adolescents was low with disparities across sociodemographic variables notably age and familial socio-economic status.

Economic inequality in prevalence of underweight and short stature in children and adolescents: the weight disorders survey of the CASPIAN-IV study

ABSTRACT Objective: The aim of this study was to determine the determinants of socio-economic inequality in the prevalence of short stature and underweight in Iranian children and adolescents. Subjects and methods: This cross-sectional nationwide study was conducted on 36,486 participants, aged 6-18 years. This school-based surveillance (CASPIAN- IV) program and its complementary part on weight disorders evaluation was conducted in urban and rural areas of 30 provinces in Iran. In addition to physical examination, a validated questionnaire was completed from students and their parents. Socio-economic status (SES) was determined using principal component analysis, and was classified in quintile scale. Inequality in the prevalence of underweight and short stature was assessed using concentration (C) index and slop index of inequality (SII) by the Oaxaca-Blinder decomposition method. Results: The prevalence (95% CI) of underweight and short stature at national level was 10.89 (10.55, 11.23) and 4.15 (3.94, 4.38), respectively; it had a downtrend from the lowest to highest SES quintile. Furthermore, the value of C for underweight and short stature was negative, i.e. inequality was in favor of high SES groups. Moreover, the prevalence gap of underweight and short stature in the first and fifth quintiles of SES was 6.58% and 5.80%, respectively. The highest proportion of this gap was explained by living area. In the multiple logistic model, odds of underweight and short stature were significantly lower in individuals with higher SES. Compared to boys, odds of underweight were decreased in girls, whereas odds of short stature were increased in them. Odds of underweight and short stature were increased in participants from rural areas than in urban areas. With increasing age, the odds of underweight and short stature decreased significantly. Conclusions: The results of this study showed that inequality in the prevalence of short stature and underweight was in favor of high SES groups. Moreover, living area was one of the most important determinants that explained this inequality. Therefore, this issue needs to be considered in health promotion policies.

Assessment of Lifestyle and Eating Habits among a Nationally Representative Sample of Iranian Adolescent Girls: the CASPIAN-V Study.

BACKGROUND: The present study assess lifestyle and eating habits of Iranian adolescent girls. METHODS: This cross-sectional study was conducted on 3207 adolescent girls, aged 12-18 years. Lifestyle and eating habits of adolescents were assessed. RESULTS: The prevalence of overweight was 11.3% and that of obesity was 10.2%. The frequencies of daily intake of fruits, dairy products and vegetables were 60.9%, 45.6 % and 33.5%, respectively. Skipping breakfast (15.8%) was more frequent than skipping dinner or lunch. Moreover, 10.6% of subjects had fast food daily and 16.2% had fast food weekly. Overall, 55.2% of participants watched television for at least 2 hours a day; and 27.1% reported to have a sleeping time of less than 8 hours a day. Low physical activity, i.e. less than 30 minutes per day, was less frequent among participants with high socio-economic status (SES) compared to those with medium or low SES (57.6% vs. 61.3% and 64.1%, respectively, P value = 0.010). CONCLUSION: Improvement of lifestyle habits should be considered in public health plans for health promotion of adolescent girls and the next generation. Primordial prevention of chronic diseases by improving healthy lifestyle of adolescent girls should be a national public health priority.

Association of Symptoms of Depression With Cardiovascular Disease and Mortality in Low-, Middle-, and High-Income Countries.

Importance: Depression is associated with incidence of and premature death from cardiovascular disease (CVD) and cancer in high-income countries, but it is not known whether this is true in low- and middle-income countries and in urban areas, where most people with depression now live. Objective: To identify any associations between depressive symptoms and incident CVD and all-cause mortality in countries at different levels of economic development and in urban and rural areas. Design, Setting, and Participants: This multicenter, population-based cohort study was conducted between January 2005 and June 2019 (median follow-up, 9.3 years) and included 370 urban and 314 rural communities from 21 economically diverse countries on 5 continents. Eligible participants aged 35 to 70 years were enrolled. Analysis began February 2018 and ended September 2019. Exposures: Four or more self-reported depressive symptoms from the Short-Form Composite International Diagnostic Interview. Main Outcomes and Measures: Incident CVD, all-cause mortality, and a combined measure of either incident CVD or all-cause mortality. Results: Of 145 862 participants, 61 235 (58%) were male and the mean (SD) age was 50.05 (9.7) years. Of those, 15 983 (11%) reported 4 or more depressive symptoms at baseline. Depression was associated with incident CVD (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24), all-cause mortality (HR, 1.17; 95% CI, 1.11-1.25), the combined CVD/mortality outcome (HR, 1.18; 95% CI, 1.11-1.24), myocardial infarction (HR, 1.23; 95% CI, 1.10-1.37), and noncardiovascular death (HR, 1.21; 95% CI, 1.13-1.31) in multivariable models. The risk of the combined outcome increased progressively with number of symptoms, being highest in those with 7 symptoms (HR, 1.24; 95% CI, 1.12-1.37) and lowest with 1 symptom (HR, 1.05; 95% CI, 0.92 -1.19; P for trend < .001). The associations between having 4 or more depressive symptoms and the combined outcome were similar in 7 different geographical regions and in countries at all economic levels but were stronger in urban (HR, 1.23; 95% CI, 1.13-1.34) compared with rural (HR, 1.10; 95% CI, 1.02-1.19) communities (P for interaction = .001) and in men (HR, 1.27; 95% CI, 1.13-1.38) compared with women (HR, 1.14; 95% CI, 1.06-1.23; P for interaction < .001). Conclusions and Relevance: In this large, population-based cohort study, adults with depressive symptoms were associated with having increased risk of incident CVD and mortality in economically diverse settings, especially in urban areas. Improving understanding and awareness of these physical health risks should be prioritized as part of a comprehensive strategy to reduce the burden of noncommunicable diseases worldwide.

The urgent need for integrated science to fight COVID-19 pandemic and beyond.

The COVID-19 pandemic has become the leading societal concern. The pandemic has shown that the public health concern is not only a medical problem, but also affects society as a whole; so, it has also become the leading scientific concern. We discuss in this treatise the importance of bringing the world's scientists together to find effective solutions for controlling the pandemic. By applying novel research frameworks, interdisciplinary collaboration promises to manage the pandemic's consequences and prevent recurrences of similar pandemics.

The household economic burden of non-communicable diseases in 18 countries.

Background: Non-communicable diseases (NCDs) are the leading cause of death globally. In 2014, the United Nations committed to reducing premature mortality from NCDs, including by reducing the burden of healthcare costs. Since 2014, the Prospective Urban and Rural Epidemiology (PURE) Study has been collecting health expenditure data from households with NCDs in 18 countries. Methods: Using data from the PURE Study, we estimated risk of catastrophic health spending and impoverishment among households with at least one person with NCDs (cardiovascular disease, diabetes, kidney disease, cancer and respiratory diseases; n=17 435), with hypertension only (a leading risk factor for NCDs; n=11 831) or with neither (n=22 654) by country income group: high-income countries (Canada and Sweden), upper middle income countries (UMICs: Brazil, Chile, Malaysia, Poland, South Africa and Turkey), lower middle income countries (LMICs: the Philippines, Colombia, India, Iran and the Occupied Palestinian Territory) and low-income countries (LICs: Bangladesh, Pakistan, Zimbabwe and Tanzania) and China. Results: The prevalence of catastrophic spending and impoverishment is highest among households with NCDs in LMICs and China. After adjusting for covariates that might drive health expenditure, the absolute risk of catastrophic spending is higher in households with NCDs compared with no NCDs in LMICs (risk difference=1.71%; 95% CI 0.75 to 2.67), UMICs (0.82%; 95% CI 0.37 to 1.27) and China (7.52%; 95% CI 5.88 to 9.16). A similar pattern is observed in UMICs and China for impoverishment. A high proportion of those with NCDs in LICs, especially women (38.7% compared with 12.6% in men), reported not taking medication due to costs. Conclusions: Our findings show that financial protection from healthcare costs for people with NCDs is inadequate, particularly in LMICs and China. While the burden of NCD care may appear greatest in LMICs and China, the burden in LICs may be masked by care foregone due to costs. The high proportion of women reporting foregone care due to cost may in part explain gender inequality in treatment of NCDs.

Assessment of the Effect of Short-Term Combined High-Intensity Interval Training on TLR4, NF-κB and IRF3 Expression in Young Overweight and Obese Girls.

Obesity is commonly associated with immunometabolic dysfunctions. Activation of inflammatory macrophages through TLR4 (toll-like receptor 4) and the anti-inflammatory impact of exercise have been and are the new concerns among researchers. A new short-term combined high-intensity interval training was proposed in young sedentary overweight/obese females. All participants were allocated to one of two groups: the exercise group (EG) and the control group (CG), where the EG participated in a 2-week combined training and the CG continued its routine lifestyle. Gene expression levels of TLR4, NF-κB(nuclear factor κB), and IRF3 (interferon regulatory factor 3) were assessed by real-time PCR. Physiological, anthropometric, and biomedical metabolic factors were assessed. The between-group comparisons indicated a tendency to a decrease in NF-κB gene expression in the EG. The IRF3 levels were not significantly changed compared to CG and the levels before training. Fasting glucose levels and ß-cell function revealed a significant improvement in EG. These findings indicated that this protocol decreased meta-inflammation levels and improved insulin resistance independent of body composition changes. Consequently, combined training may be recommended as a therapeutic approach in metabolic diseases.

Modifiable risk factors, cardiovascular disease, and mortality in 155 722 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

BACKGROUND: Global estimates of the effect of common modifiable risk factors on cardiovascular disease and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methods to prospectively measure the effect of modifiable risk factors on cardiovascular disease and mortality across 21 countries (spanning five continents) grouped by different economic levels. METHODS: In this multinational, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and cardiovascular disease in 155 722 participants without a prior history of cardiovascular disease from 21 high-income, middle-income, or low-income countries (HICs, MICs, or LICs). The primary outcomes for this paper were composites of cardiovascular disease events (defined as cardiovascular death, myocardial infarction, stroke, and heart failure) and mortality. We describe the prevalence, hazard ratios (HRs), and population-attributable fractions (PAFs) for cardiovascular disease and mortality associated with a cluster of behavioural factors (ie, tobacco use, alcohol, diet, physical activity, and sodium intake), metabolic factors (ie, lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (ie, education, symptoms of depression), grip strength, and household and ambient pollution. Associations between risk factors and the outcomes were established using multivariable Cox frailty models and using PAFs for the entire cohort, and also by countries grouped by income level. Associations are presented as HRs and PAFs with 95% CIs. FINDINGS: Between Jan 6, 2005, and Dec 4, 2016, 155 722 participants were enrolled and followed up for measurement of risk factors. 17 249 (11·1%) participants were from HICs, 102 680 (65·9%) were from MICs, and 35 793 (23·0%) from LICs. Approximately 70% of cardiovascular disease cases and deaths in the overall study population were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for cardiovascular disease (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12·5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for cardiovascular disease, although different statistical methods were used for this analysis. In MICs and LICs, household air pollution, poor diet, low education, and low grip strength had stronger effects on cardiovascular disease or mortality than in HICs. INTERPRETATION: Most cardiovascular disease cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global effects (eg, hypertension and education), others (eg, household air pollution and poor diet) vary by a country's economic level. Health policies should focus on risk factors that have the greatest effects on averting cardiovascular disease and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).