Concordance of weight status between mothers and children: a secondary analysis of the Pakistan Demographic and health survey VII.

BACKGROUND: Familial concordance of weight status is an emerging field of study that may guide the development of interventions that operate beyond the individual and within the family context. There is a dearth of published data for concordance of weight status within Pakistani households. METHODS: We assessed the associations between weight status of mothers and their children in a nationally representative sample of households in Pakistan using Demographic and Health Survey data from 2017-18. Our analysis included 3465 mother-child dyads, restricting to children under-five years of age with body mass index (BMI) information on their mothers. We used linear regression models to assess the associations between maternal BMI category (underweight, normal weight, overweight, obese) and child's weight-for-height z-score (WHZ), accounting for socio-demographic characteristics of mothers and children. We assessed these relationships in all children under-five and also stratified by age of children (younger than 2 years and 2 to 5 years). RESULTS: In all children under-five and in children 2 to 5 years, maternal BMI was positively associated with child's WHZ. For all children under-five, children of normal weight, overweight, and obese women had WHZ scores that were 0.21 [95% CI (confidence interval): 0.04, 0.37], 0.43 [95% CI: 0.25, 0.62], and 0.51 [95% CI: 0.30, 0.71] units higher than children of underweight women, respectively. For children ages 2 to 5, children of normal weight, overweight, and obese women had WHZ scores that were 0.26 [95% CI: 0.08, 0.44), 0.50 [95% CI: 0.30, 0.71), and 0.61 [95% CI: 0.37, 0.84] units higher than children of underweight women, respectively. There was no association between maternal BMI and child WHZ for children under-two. CONCLUSIONS: The findings indicate that the weight status of mother's is positively associated with that of their children, particularly after age 2. These associations further strengthen the call for research regarding interventions and policies aimed at healthy weight promotion among mothers and their children collectively, rather than focusing on individuals in isolation.

Activity limitations, use of assistive devices, and mortality and clinical events in 25 high-income, middle-income, and low-income countries: an analysis of the PURE study.

BACKGROUND: The focus of most epidemiological studies has been mortality or clinical events, with less information on activity limitations related to basic daily functions and their consequences. Standardised data from multiple countries at different economic levels in different regions of the world on activity limitations and their associations with clinical outcomes are sparse. We aimed to quantify the prevalence of activity limitations and use of assistive devices and the association of limitations with adverse outcomes in 25 countries grouped by different economic levels. METHODS: In this analysis, we obtained data from individuals in 25 high-income, middle-income, and low-income countries from the Prospective Urban Rural Epidemiological (PURE) study (175 660 participants). In the PURE study, individuals aged 35-70 years who intended to continue living in their current home for a further 4 years were invited to complete a questionnaire on activity limitations. Participant follow-up was planned once every 3 years either by telephone or in person. The activity limitation screen consisted of questions on self-reported difficulty with walking, grasping, bending, seeing close, seeing far, speaking, hearing, and use of assistive devices (gait, vision, and hearing aids). We estimated crude prevalence of self-reported activity limitations and use of assistive devices, and prevalence standardised by age and sex. We used logistic regression to additionally adjust prevalence for education and socioeconomic factors and to estimate the probability of activity limitations and assistive devices by age, sex, and country income. We used Cox frailty models to evaluate the association between each activity limitation with mortality and clinical events (cardiovascular disease, heart failure, pneumonia, falls, and cancer). The PURE study is registered with ClinicalTrials.gov, NCT03225586. FINDINGS: Between Jan 12, 2001, and May 6, 2019, 175 584 individuals completed at least one question on the activity limitation questionnaire (mean age 50·6 years [SD 9·8]; 103 625 [59%] women). Of the individuals who completed all questions, mean follow-up was 10·7 years (SD 4·4). The most common self-reported activity limitations were difficulty with bending (23 921 [13·6%] of 175 515 participants), seeing close (22 532 [13·4%] of 167 801 participants), and walking (22 805 [13·0%] of 175 554 participants); prevalence of limitations was higher with older age and among women. The prevalence of all limitations standardised by age and sex, with the exception of hearing, was highest in low-income countries and middle-income countries, and this remained consistent after adjustment for socioeconomic factors. The use of gait, visual, and hearing aids was lowest in low-income countries and middle-income countries, particularly among women. The prevalence of seeing close limitation was four times higher (6257 [16·5%] of 37 926 participants vs 717 [4·0%] of 18 039 participants) and the prevalence of seeing far limitation was five times higher (4003 [10·6%] of 37 923 participants vs 391 [2·2%] of 18 038 participants) in low-income countries than in high-income countries, but the prevalence of glasses use in low-income countries was half that in high-income countries. Walking limitation was most strongly associated with mortality (adjusted hazard ratio 1·32 [95% CI 1·25-1·39]) and most consistently associated with other clinical events, with other notable associations observed between seeing far limitation and mortality, grasping limitation and cardiovascular disease, bending limitation and falls, and between speaking limitation and stroke. INTERPRETATION: The global prevalence of activity limitations is substantially higher in women than men and in low-income countries and middle-income countries compared with high-income countries, coupled with a much lower use of gait, visual, and hearing aids. Strategies are needed to prevent and mitigate activity limitations globally, with particular emphasis on low-income countries and women. FUNDING: Funding sources are listed at the end of the Article.

Engagement of private healthcare sector in addressing noncommunicable diseases at primary care level in the Eastern Mediterranean Region.

Background: The private healthcare sector is a critical stakeholder in the provision of health care services, including noncommunicable diseases (NCDs), and engagement with the sector is increasingly being advocated in efforts to achieve Universal Health Coverage. Aim: This study was conducted to explore the role of the private health sector in delivering NCD-related primary care services in selected countries of the WHO Eastern Mediterranean Region (EMR): Jordan, Oman, Pakistan, Sudan, and the Syrian Arab Republic. Methods: We adapted the analytical framework for this study from the "Framework for action to implement the United Nations political declaration on noncommunicable diseases". We conducted a desk review to gather evidence, identify gaps and provide direction for the subsequent stakeholder interviews. Key informant interview respondents were selected using the snowball sampling method. Data from the interviews were analysed using MAXQDA, version 2020. Results: We reviewed 26 documents and interviewed 19 stakeholders in Jordan, Oman, Pakistan, Sudan and the Syrian Arab Republic. Our results indicated increasing advocacy at the regional and national levels to align the private and public health sectors, just as there were efforts to reduce the risk factors for NCDs by implementing tobacco laws, introducing food labelling guidelines, increasing taxes on soft drinks, and promoting the healthy cities approach. NCDs health information systems varied widely among the countries, from being organized and developed to having poor recordkeeping. The private health sector is the predominant provider of care at primary level in most of the EMR countries. Conclusion: Increased collaboration between the public and private sectors is essential for better management of NCDs in the EMR. Governments need to strengthen regulation and defragment the private health sector and harness the sector's strengths as part of efforts to achieve national health targets, NCD goals and Universal Health Coverage.

Obesity and risk of hypertension in preadolescent urban school children: insights from Pakistan.

BACKGROUND: Childhood obesity and hypertension are growing concerns globally, especially in developing countries. This study investigated the association between overall and central obesity at baseline, and prehypertension or hypertension at follow-up among preadolescent school children in urban Karachi, Pakistan. METHODS: This is a sub study with cohort design embedded within a feasibility trial on School Health Education Program in Pakistan (SHEPP) in preadolescents aged 6-11 years, attending two private schools conducted from 2017 to 2019. Hypertension or prehypertension at follow-up were the outcomes and obesity or central obesity at baseline were the exposure variables. Hypertension was defined as systolic blood pressure and/or diastolic blood pressure ≥ 95th percentile for age, sex, and height. Obesity was defined as body mass index for-age and sex ≥ 95th percentile, whereas central obesity was determined by waist circumference measurements ≥ 85th percentile of age, sex, and height specific cut-offs. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to identify risk factors for hypertension and prehypertension. RESULTS: Analysis was conducted for 908 participants, evenly distributed with 454 boys and 454 girls. Hypertension was observed in 19.8% of the preadolescents, with rates of 18.5% in boys and 21.0% in girls. Prehypertension was found in 16.8% of preadolescents, with 18% among boys and 16% among girls. Additionally, 12.8% of preadolescents were classified as obese and 29.8% had central obesity. Obesity at baseline was associated with hypertension at followup (OR 8.7, 95% CI 3.5, 20.4) in the final model after adjusting for age, gender, physical activity, sedentary behavior, fruits, vegetable intake and hypertension at baseline. Central obesity at baseline also yielded high odds, with prehypertension (OR 1.9, 95% CI 1.4, 2.8) and hypertension (OR 2.7, 95% CI 1.9, 3.9) at follow up in the final model. CONCLUSION: This study highlights a concerning prevalence of hypertension and prehypertension among preadolescent school-going children. Obesity and central obesity at baseline emerged as significant predictive factors for hypertension or prehypertension at followup within this cohort. The findings emphasize the urgency of implementing comprehensive school health education programs aimed at early detection and effective management of hypertension during childhood and adolescence in school settings.

Comparison of Physical Activity Measured by Self-Reported Physical Activity and Wearable Device Xiaomi MI2 Band in Preadolescent School Children - A Pilot Cross-Sectional Study.

The purpose of this study is to compare physical activity measured by the wearable device Xiaomi Mi2 Band and self-reported physical activity by YPAQ in preadolescent school children. A pilot cross-sectional study was performed on a subsample (5%=n=60) of preadolescent children within a parallel-group feasibility intervention trial (n=1000). All children aged 9-11 years enrolled in the schools were included in the study and children with any physical disability were excluded. Self-reported physical activity was recorded through the modified version of the Youth Physical Activity Questionnaire (YPAQ) and automatic physical activity was measured by the Xiaomi Mi2 band over 7 days. Data from the Xiaomi Mi2 band was synchronized with its mobile application from where data was transferred to an excel sheet. Data on 7-day total physical activity in minutes and 7-day total step count were recorded by the Xiaomi Mi2 band. Student's t-tests were used to determine whether significant differences were present between self-reported physical activity and by Xiaomi Mi2 band. A Bland-Altman method was also used to assess the degree of agreement between the two methods of measuring physical activity. Mean ± SD age of the children was 9.6 (± 1.0) years and 31 (51.7 %) were boys. The mean ± SD time spent in physical activity reported by YPAQ was 457.5 (± 136) minutes and by the Xiaomi Mi2 band was 594.7 (± 183) minutes. The Bland-Altman plot identified a mean bias between the methods (YPAQ and Xiaomi Mi2 band) of -157.6 (95% CI: 296.3, -611.0) minutes of 7-day physical activity. Physical activity measured by a wearable device, the Xiaomi Mi2 band can give overestimated values of physical activity compared to self-reported physical activity in preadolescent school children. However, when PA is measured through step counts by the Xiaomi Mi2 band converted to minutes, it is comparable to PA measured by YPAQ.

Sex-Specific Association of Ambient Temperature With Urine Biomarkers in Southwest Coastal Bangladesh.

Introduction: Men are vulnerable to ambient heat-related kidney disease burden; however, limited evidence exists on how vulnerable women are when exposed to high ambient heat. We evaluated the sex-specific association between ambient temperature and urine electrolytes, and 24-hour urine total protein, and volume. Methods: We pooled a longitudinal 5624 person-visits data of 1175 participants' concentration and 24-hour excretion of urine electrolytes and other biomarkers (24-hour urine total protein and volume) from southwest coastal Bangladesh (Khulna, Satkhira, and Mongla districts) during November 2016 to April 2017. We then spatiotemporally linked ambient temperature data from local weather stations to participants' health outcomes. For evaluating the relationships between average ambient temperature and urine electrolytes and other biomarkers, we plotted confounder-adjusted restricted cubic spline (RCS) plots using participant-level, household-level, and community-level random intercepts. We then used piece-wise linear mixed-effects models for different ambient temperature segments determined by inflection points in RCS plots and reported the maximum likelihood estimates and cluster robust standard errors. By applying interaction terms for sex and ambient temperature, we determined the overall significance using the Wald test. Bonferroni correction was used for multiple comparisons. Results: The RCS plots demonstrated nonlinear associations between ambient heat and urine biomarkers for males and females. Piecewise linear mixed-effects models suggested that sex did not modify the relationship of ambient temperature with any of the urine parameters after Bonferroni correction (P < 0.004). Conclusion: Our findings suggest that women are as susceptible to the effects of high ambient temperature exposure as men.

Conducting a diabetes mellitus prevention trial in women with GDM in Pakistan: a feasibility study.

BACKGROUND: Women with gestational diabetes mellitus (GDM) are at a greater risk of developing type 2 diabetes mellitus (T2DM) than women without GDM. Despite this elevated risk, few trials on the prevention of T2DM among South Asian women with GDM have been reported. Therefore, this study aimed to assess the feasibility of conducting a diabetes prevention program on women with a history of GDM to inform the development of a contextually relevant definitive trial. METHODS: Using a randomized controlled trial, women with GDM (n = 180) who delivered at the study hospitals (one public and one private teaching hospital, Karachi) with fasting blood glucose levels < 120 mg/dl at 6 weeks postpartum were randomized to the intervention (n = 88) or control arms (n = 92). Women in the intervention group received individualized home-based educational sessions from trained community health workers at 0, 1, 3, 6, and 9 months. In addition, they received short text messages, prerecorded messages, and printed educational material (calendars and pamphlets) for reinforcement. The intervention was centered on equipping women with knowledge, skills, and confidence to eat a healthy diet rich in fruits, vegetables, and low-fat dairy products and perform regular physical activity based on walking and household chores to reduce weight (up to 5% of their initial body weight). Women in the control arm received standard care. The feasibility outcomes of the study included screening, recruitment, and retention rates and in-depth interviews at 6 months post-intervention to explore women's experiences with the intervention. Descriptive analysis and thematic analysis were performed. RESULTS: Of the 324 women screened during the antenatal care visits and after delivery, 255 (78.7%) were contactable 6 weeks postpartum, and 180 (70.6%) were eligible and randomized to intervention (n = 88) and control (n = 92) groups. Loss to follow-up in the intervention and control arms was 22.7% (n = 20/88) and 18.5% (n = 17/92), respectively. Women expressed satisfaction with home-based counseling and follow-up visits, text message reminders, and printed material in the form of a calendar through our qualitative interviews. CONCLUSIONS: Home-based lifestyle modification intervention augmented with text messages and printed material is feasible. However, to evaluate the intervention's effectiveness, a larger trial is warranted to assess its long-term impact on diabetes prevention. TRIAL REGISTRATION: ISRCTN, ISRCTN11387113 . Registered 5 December 2017-retrospectively registered.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation in Bangladesh, India and Pakistan: A pilot randomized controlled trial.

BACKGROUND AND AIMS: Smokeless tobacco (ST) use in South Asia is high, yet interventions to support its cessation are lacking. We tested the feasibility of delivering interventions for ST cessation in South Asia. DESIGN: We used a 2 × 2 factorial design, pilot randomized controlled trial with a duration of 26 weeks, including baseline and follow-up (6, 12 and 26 weeks) assessments. SETTING: Two primary health-care facilities each in Dhaka (Bangladesh) and Karachi (Pakistan) and a walk-in cancer screening clinic in Noida (India) took part. PARTICIPANTS: Adult daily ST users willing to make a quit attempt within 30 days. Of 392 screened, 264 participants [mean age: 35 years, standard deviation = 12.5, 140 (53%) male] were recruited between December 2020 and December 2021; 132 from Bangladesh, 44 from India and 88 from Pakistan. INTERVENTIONS: Participants were randomized to one of three treatment options [8-week support through nicotine replacement therapy (NRT, n = 66), a behavioural intervention for smokeless tobacco cessation in adults (BISCA, n = 66) or their combination (n = 66)] or the control condition of very brief advice (VBA) to quit (n = 66). MEASUREMENTS: Recruitment and retention, data completeness and feasibility of intervention delivery were evaluated. Biochemically verified abstinence from tobacco, using salivary cotinine, was measured at 26 weeks. FINDINGS: Retention rates were 94.7% at 6 weeks, dropping to 89.4% at 26 weeks. Attendance in BISCA pre-quit (100%) and quit sessions (86.3%) was high, but lower in post-quit sessions (65.9%), with variability among countries. Adherence to NRT also varied (45.5% Bangladesh, 90% India). Data completion for key variables exceeded 93% among time-points, except at 26 weeks for questions on nicotine dependence (90%), urges (89%) and saliva samples (62.7%). Among follow-up time-points, self-reported abstinence was generally higher among participants receiving BISCA and/or NRT. At 26 weeks, biochemically verified abstinence was observed among 16 (12.1%) participants receiving BISCA and 13 (9.8%) participants receiving NRT. CONCLUSIONS: This multi-country pilot randomized controlled trial of tobacco cessation among adult smokeless tobacco users in South Asia demonstrated the ability to recruit and retain participants and report abstinence, suggesting that a future definitive smokeless tobacco cessation trial is viable.

Obesity and Risk of Hypertension in Preadolescent Urban School Children: Insights from a Developing Country.

Background: Childhood obesity and hypertension are growing concerns globally, especially in developing countries. This study investigated the association between overall and central obesity at baseline, and prehypertension or hypertension at follow-up among preadolescent school children in Karachi, Pakistan. Methods: This is a sub study with cohort design embedded within a feasibility trial on School Health Education Program in Pakistan (SHEPP) in preadolescent aged 6-11 years, attending two private schools, were enrolled from 2017 to 2019. Hypertension or prehypertension at follow-up were the outcomes and obesity or central obesity at baseline were the exposure variables. Hypertension was defined as systolic blood pressure and/or diastolic blood pressure ≥ 95th percentile for age, sex, and height. Obesity was defined as body mass index for-age and sex ≥ 95th percentile, whereas central obesity was determined by waist circumference measurements ≥ 85th percentile of age, sex, and height specific cut-offs. Logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) to identify risk factors for hypertension and prehypertension. Results: Analysis was conducted for 908 participants, evenly distributed with 454 boys and 454 girls. Hypertension was observed in 19.8% of the preadolescents, with rates of 18.5% in boys and 21.0% in girls. Prehypertension was found in 16.8% of preadolescents, with 18% among boys and 16% among girls. Additionally, 12.8% of preadolescents were classified as obese and 29.8% had central obesity. Obesity at baseline was associated with hypertension (OR 8.7, 95% CI 3.5, 20.4) in the final model after adjusting for age, gender, physical activity, sedentary behavior, fruits, vegetable intake and hypertension at baseline. Central obesity at baseline also yielded high odds, with prehypertension (OR 1.9, 95% CI 1.4, 2.8) and hypertension (OR 2.7, 95% CI 1.9, 3.9) in the final model. Conclusion: This study highlights a concerning prevalence of hypertension and prehypertension among preadolescent school-going children. Obesity and central obesity at baseline emerged as significant predictive factors for hypertension within this cohort. The findings emphasize the urgency of implementing comprehensive school health education programs aimed at early detection and effective management of hypertension during childhood and adolescence in school settings.

Associations of the glycaemic index and the glycaemic load with risk of type 2 diabetes in 127 594 people from 20 countries (PURE): a prospective cohort study.

BACKGROUND: The association between the glycaemic index and the glycaemic load with type 2 diabetes incidence is controversial. We aimed to evaluate this association in an international cohort with diverse glycaemic index and glycaemic load diets. METHODS: The PURE study is a prospective cohort study of 127 594 adults aged 35-70 years from 20 high-income, middle-income, and low-income countries. Diet was assessed at baseline using country-specific validated food frequency questionnaires. The glycaemic index and the glycaemic load were estimated on the basis of the intake of seven categories of carbohydrate-containing foods. Participants were categorised into quintiles of glycaemic index and glycaemic load. The primary outcome was incident type 2 diabetes. Multivariable Cox Frailty models with random intercepts for study centre were used to calculate hazard ratios (HRs). FINDINGS: During a median follow-up of 11·8 years (IQR 9·0-13·0), 7326 (5·7%) incident cases of type 2 diabetes occurred. In multivariable adjusted analyses, a diet with a higher glycaemic index was significantly associated with a higher risk of diabetes (quintile 5 vs quintile 1; HR 1·15 [95% CI 1·03-1·29]). Participants in the highest quintile of the glycaemic load had a higher risk of incident type 2 diabetes compared with those in the lowest quintile (HR 1·21, 95% CI 1·06-1·37). The glycaemic index was more strongly associated with diabetes among individuals with a higher BMI (quintile 5 vs quintile 1; HR 1·23 [95% CI 1·08-1·41]) than those with a lower BMI (quintile 5 vs quintile 1; 1·10 [0·87-1·39]; p interaction=0·030). INTERPRETATION: Diets with a high glycaemic index and a high glycaemic load were associated with a higher risk of incident type 2 diabetes in a multinational cohort spanning five continents. Our findings suggest that consuming low glycaemic index and low glycaemic load diets might prevent the development of type 2 diabetes. FUNDING: Full funding sources are listed at the end of the Article.

Association between maternal experiences of intimate partner violence and child stunting: a secondary analysis of the Demographic Health Surveys of four South Asian countries.

OBJECTIVES: To determine the association between maternal exposure to intimate partner violence (IPV) and child stunting using the Demographic Health Survey (DHS) data comparing four South Asian countries. DESIGN: A secondary analysis. SETTING: Data from the seventh round of the DHS data of four South Asian countries; Pakistan, Nepal, India and Maldives. PARTICIPANTS: Married women of reproductive age (15-49 years) from each household were randomly selected, having at least one child less than 5 years of age for whom all anthropometric measures were available. OUTCOME MEASURE: The exposure variable was maternal IPV including, sexual violence, physical violence or both. The outcome variable was moderate or severe stunting, measured based on the height-for-age Z-score of children aged 6-59 months old . Multiple Cox proportional regression analyses were used separately on each country's data to determine the association between maternal IPV and child stunting. RESULTS: The prevalence of IPV among women ranged from 10.17% in the Maldives to 31% in India. The burden of child stunting was the lowest in the Maldives at 14.04% and the highest in Pakistan at 35.86%. The number of severely stunted children was the highest in Pakistan (16.60%), followed by India (14.79%). In India, children whose mothers were exposed to IPV showed a 7% increase in the prevalence of moderate to severe child stunting (OR 1.07; 95% CI 1.01 to 1.14). Additionally, in Nepal, severe stunting was strongly associated with the prevalence of physical IPV (OR 1.66; 95% CI 1.01 to 2.87). CONCLUSION: Our study findings suggest that maternal exposure to IPV is associated with child stunting. Further research investigating the relationship between IPV and child outcomes using improved and advanced statistical analyses can provide substantial evidence to enhance public awareness and potentially reduce the burden of child stunting in South Asian countries.

"If the food is finished after my brother eats then we (girls) sleep hungry." Food insecurity and dietary diversity among slum-dwelling adolescent girls and boys in Pakistan: A mixed methods study.

To explore gender differences in food insecurity (FI) and minimum dietary diversity (MDD) among adolescent girls and boys in a slum community in Karachi, we employed an explanatory sequential mixed methods study that included a survey of 391 girls and boys of 10-19 years of age and followed by semi-structured interviews of eight purposely selected food insecure adolescents. Survey data was analyzed by Cox proportional algorithm and adjusted prevalence ratios (APR) with 95% confidence intervals (CI) were estimated for associated factors of FI and thematic analysis was undertaken for qualitative work. Meta inferences for mixed methods study were drawn by joint display analysis of survey results juxtaposed to qualitative findings. Overall, FI among adolescents was prevalent (46.5%) which was not different between boys (52.7%) and girls (47.3%) (APR 0.8, (95% CI 0.6, 1.2); p-value-0.4). MDD (5/10 food groups consumed) was achieved by only 23.0% and it was also not different between boys (25.1%) and girls (20.9%) (p-value-0.3). The survey found no significant difference in FI and MDD between boys and girls however, qualitative findings provided insight into the cultural practices at mealtimes that prefer boys. Qualitative results contrasted the survey results and revealed the increased vulnerability of girls towards FI and low MDD compared to boys due to gender norms.

Feasibility of a peer-supported, WhatsApp-assisted, lifestyle modification intervention for weight reduction among adults in an urban slum of Karachi, Pakistan: a mixed-methods, single-group, pretest-post-test, quasi-experimental study.

OBJECTIVES: This pilot study assessed whether a peer-supported, WhatsApp-assisted lifestyle modification intervention for weight reduction is feasible to execute a definitive trial. DESIGN: A mixed-methods, single group, pretest and post-test, quasi-experimental study. SETTING: Azam Basti, an urban slum in Karachi, Pakistan. PARTICIPANTS: Fifty participants (males and females aged 20-60) with a body mass index of >23 kg/m2, along with their nominated peers from the same family. INTERVENTION: Using motivational interviewing techniques, a trained nutritionist delivered the lifestyle modification intervention to the participants and peers for 3 days after the baseline assessment and then once monthly for 1 year. The intervention was delivered in groups using WhatsApp voice calls. The education sessions mainly focused on dietary modifications, physical activity advice and peer-support assignments to achieve a 5% wt loss from the participant's initial body weight. OUTCOMES: The feasibility measures included screening, recruitment, retention and monthly interview response rates. At 1 year, in-depth interviews (IDIs) with participants and peers were conducted to explore the facilitators, barriers, acceptability and experiences of the intervention. Changes in weight, calorie intake/day and calorie expenditure/day were also assessed. RESULTS: The recruitment and retention rates were 32% (n=50/156) and 78% (n=39/50), respectively, while the response rate for monthly interviews ranged between 66% (n=33) and 94% (n=47). The mean weight loss at 1 year was 2.2 kg, and the reduction in mean calorie intake was 386 kcal/day. There were no changes in the mean calorie expenditure. During the IDIs, participants and peers reported intervention via WhatsApp and peer support as convenient, flexible and supportive. CONCLUSIONS: The quantitative and qualitative findings of the current pilot study support the scale-up of this work with minor modifications to the screening method as well as close monitoring and motivational interviewing to improve adherence in terms of physical activity. TRIAL REGISTRATION NUMBER: NCT05928338.

Children Learning About Secondhand Smoke (CLASS III): a protocol for a cluster randomised controlled trial of a school-based smoke-free intervention in Bangladesh and Pakistan.

INTRODUCTION: Secondhand smoke (SHS) exposure is a major cause of premature death and disease, especially among children. Children in economically developing countries are particularly affected as smoke-free laws are typically only partially implemented and private homes and cars remain a key source of SHS exposure. Currently, firm conclusions cannot be drawn from the available evidence on the effectiveness of non-legislative interventions designed to protect children from SHS exposure. Following the success of two feasibility studies and a pilot trial, we plan to evaluate a school-based approach to protect children from SHS exposure in Bangladesh and Pakistan-countries with a strong commitment to smoke-free environments but with high levels of SHS exposure in children. We will conduct a two-arm cluster randomised controlled trial in Bangladesh and Pakistan to assess the effectiveness and cost effectiveness of a school-based smoke-free intervention (SFI) in reducing children's exposure to SHS and the frequency and severity of respiratory symptoms. METHODS AND ANALYSIS: We plan to recruit 68 randomly selected schools from two cities-Dhaka in Bangladesh and Karachi in Pakistan. From each school, we will recruit approximately 40 students in a year (9-12 years old) with a total of 2720 children. Half of the schools will be randomly allocated to the intervention arm receiving SFI and the other half will receive usual education. Salivary cotinine concentration-a highly sensitive and specific biomarker of SHS exposure-is the primary outcome, which will be measured at month 3 post-randomisation. Secondary outcomes will include frequency and severity of respiratory symptoms, healthcare contacts, school absenteeism, smoking uptake and quality of life. Embedded economic and process evaluations will also be conducted. ETHICS AND DISSEMINATION: The trial has received ethics approval from the Research Governance Committee at the University of York. Approvals have also been obtained from Bangladesh Medical Research Council and Pakistan Health Research Council. If SFI is found effective, we will use a variety of channels to share our findings with both academic and non-academic audiences. We will work with the education departments in Bangladesh and Pakistan and advocate for including SFI within the curriculum. TRIAL REGISTRATION NUMBER: ISRCTN28878365.

School Health Education Program in Pakistan (SHEPP): findings from a feasibility trial in pre-adolescent school children from a lower middle-income country.

BACKGROUND: The school environment plays an essential role in promoting health education and physical activity for children and adolescents. We aim to assess the feasibility of threefold health education program in children and its potential efficacy on physical activity and diet and cardiometabolic risk factors including blood pressure, body mass index (BMI), and waist circumference. METHODS: The SHEPP was a parallel group feasibility intervention trial conducted in two schools over 23 months. All children aged 9-11 years enrolled in the schools were included. The SHEPP intervention comprised of health education on healthy lifestyle and physical activity sessions for children, training of teachers, and awareness sessions for parents conducted over 10 months. One school received the intervention of SHEPP while the other school continued routine activity. The primary outcome was the feasibility of SHEPP in terms of recruitment, retention, and treatment fidelity. Secondary outcomes were physical activity levels, dietary intake (of fruits and vegetables), and cardiometabolic risk factors (blood pressure, BMI, and waist circumference (WC)). RESULTS: A total of 1280 preadolescent children were assessed for eligibility and 1191 were found eligible. The overall recruitment n (%) was 982/1191(82.5%) with 505(51.4) from SHEPP intervention school and 477(48.6) in routine activity school. The overall retention rate n (%) at 10-month follow-up was 912/982(92.8), with 465/505(92) in SHEPP intervention school and 447/477(93.7) in routine activity school. In treatment fidelity, 132/144(92) %). Physical activity sessions and all (100%) health education sessions were conducted for each of the twelve classes. Mean (SD) Seven-day Physical activity increased by 134 (196) min in the SHEPP intervention school v 29.8(177) in the routine activity school (P value < 0.001) from baseline to follow-up. Overall, there was an increase in vegetable intake (> 3 serving /day) in SHEPP intervention school of 5.5 to 21.4% from baseline to follow-up compared to 7.5 to 14.9% in routine activity school. The mean change (SD) in systolic blood pressure was 1.3(12) mmHg, 2.2(19.0) mm Hg in in diastolic blood pressure, - 0.09(5.4) kg/m2 in BMI and 6.2 cm in waist circumference in the intervention arm versus - 3.4(11.1) mm Hg in SBP, - 4.3(9.9) mm Hg in DBP, - 0.04((4.6) kg/m2 in BMI, and 3.8 cm in WC in the control arm. CONCLUSION: We found that intervention using SHEPP is feasible in schools and may help children to adopt a healthy lifestyle as they age by increasing physical activity. However, the potentially beneficial effect on diet, MI, and BP needs further exploration and a longer follow-up, more specifically at the juncture of teenage and adulthood. TRIAL REGISTRATION: NCT03303287.

Diet, cardiovascular disease, and mortality in 80 countries.

AIMS: To develop a healthy diet score that is associated with health outcomes and is globally applicable using data from the Prospective Urban Rural Epidemiology (PURE) study and replicate it in five independent studies on a total of 245 000 people from 80 countries. METHODS AND RESULTS: A healthy diet score was developed in 147 642 people from the general population, from 21 countries in the PURE study, and the consistency of the associations of the score with events was examined in five large independent studies from 70 countries. The healthy diet score was developed based on six foods each of which has been associated with a significantly lower risk of mortality [i.e. fruit, vegetables, nuts, legumes, fish, and dairy (mainly whole-fat); range of scores, 0-6]. The main outcome measures were all-cause mortality and major cardiovascular events [cardiovascular disease (CVD)]. During a median follow-up of 9.3 years in PURE, compared with a diet score of ≤1 points, a diet score of ≥5 points was associated with a lower risk of mortality [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.63-0.77)], CVD (HR 0.82; 0.75-0.91), myocardial infarction (HR 0.86; 0.75-0.99), and stroke (HR 0.81; 0.71-0.93). In three independent studies in vascular patients, similar results were found, with a higher diet score being associated with lower mortality (HR 0.73; 0.66-0.81), CVD (HR 0.79; 0.72-0.87), myocardial infarction (HR 0.85; 0.71-0.99), and a non-statistically significant lower risk of stroke (HR 0.87; 0.73-1.03). Additionally, in two case-control studies, a higher diet score was associated with lower first myocardial infarction [odds ratio (OR) 0.72; 0.65-0.80] and stroke (OR 0.57; 0.50-0.65). A higher diet score was associated with a significantly lower risk of death or CVD in regions with lower than with higher gross national incomes (P for heterogeneity <0.0001). The PURE score showed slightly stronger associations with death or CVD than several other common diet scores (P < 0.001 for each comparison). CONCLUSION: A diet comprised of higher amounts of fruit, vegetables, nuts, legumes, fish, and whole-fat dairy is associated with lower CVD and mortality in all world regions, especially in countries with lower income where consumption of these foods is low.

Household Air Pollution and Adult Lung Function Change, Respiratory Disease, and Mortality across Eleven Low- and Middle-Income Countries from the PURE Study.

BACKGROUND: Globally, household air pollution (HAP) is a major environmental hazard that affects respiratory health. However, few studies have examined associations between HAP and lung function decline and respiratory disease and mortality. METHODS: We used data from the Prospective Urban and Rural Epidemiology study and examined adults residing in 240 rural communities in 11 low- and middle-income countries where HAP from cooking with solid fuels is common. Spirometry was conducted for 28,574 individuals at baseline and 12,489 individuals during follow-up (mean of 8 y between spirometry measures). In cross-sectional analyses, we compared lung function measurements [forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio] in those who used solid fuels for cooking in comparison with clean fuels. Using repeated measurements of lung function, we examined the percent change in lung function measures per year, comparing individuals by baseline fuel type and individuals who used solid fuels at baseline but switched to clean fuels during follow-up. We also examined associations with prospective health events (any respiratory diseases, respiratory disease hospitalizations, and all-cause mortality). RESULTS: In adjusted cross-sectional models, use of solid fuel in comparison with clean fuels was associated with lower FEV1 of -17.5mL (95% CI: -32.7, -2.3) and FVC of -14.4mL (95% CI: -32.0, 3.2), but not FEV1/FVC. In longitudinal analyses, individuals who switched from solid fuels to clean cooking fuels during follow-up (n=3,901, 46% of those using solid fuel at baseline), showed no differences in the annual rate of change in FEV1 or FVC, but had small improvements in FEV1/FVC change (0.2% per year, 95% CI: 0.03, 0.3). Individuals who switched from solid to clean fuels had a decreased hazard ratio for respiratory events of 0.76 (95% CI: 0.57, 1.00) in comparison with persistent solid fuel users, which was not attenuated by lung function measures. CONCLUSION: We observed modest associations between HAP exposure and lung function, lung function change, and respiratory disease and mortality. https://doi.org/10.1289/EHP11179.

The Pandemic of Coronary Heart Disease in South Asia: What Clinicians Need to Know.

PURPOSE OF REVIEW: South Asia has around 1/6th of the current global population. Epidemiological studies suggest that South Asians living in South Asia and diaspora are at an increased risk of premature atherosclerotic cardiovascular diseases (ASCVDs). This is due to an interplay of genetic, acquired, and environmental risk factors. Due to its increasing share of the global population, clinicians need to know the reasons for this early predisposition, and strategies for early identification and mitigation. RECENT FINDINGS: South Asians have earlier onset of cardiometabolic risk factors such as insulin resistance, hypertension, and central adiposity. This increased risk is seen in both native South Asians and the diaspora. South Asians have earlier onset of ASCVD due to an earlier onset of cardiometabolic risk factors. Health promotion and early identification of these risk factors are essential to mitigate this ongoing crisis.

Risk Factors for Stroke in the Young (18-45 Years): A Case-Control Analysis of INTERSTROKE Data from 32 Countries.

BACKGROUND: It is not clear whether conventional vascular risk factors are responsible for most strokes in patients younger than 45 years of age. Our objective was to evaluate the association of common risk factors with stroke in individuals under 45 years. METHODS: INTERSTROKE was a case-control study carried out in 32 countries between 2007 and 2015. Patients presenting within 5 days of symptom onset of a first stroke were enrolled as cases. Controls were age and sex matched to cases and had no history of stroke. Cases and controls underwent similar evaluations. Odds ratios (ORs) and population attributable risks (PARs) were calculated to determine the association of various risk factors with all stroke, ischemic stroke, and intracranial hemorrhage, for patients 45 years of age or younger. FINDINGS: 1,582 case-control pairs were included in this analysis. The mean age of this cohort was 38.5 years (SD 6.32). Overall, 71% strokes were ischemic. Cardiac causes {OR: 8.42 (95% confidence interval [CI]: 3.01-23.5)}; binge drinking of alcohol (OR: 5.44 [95% CI: 1.81-16.4]); hypertension (OR: 5.41 [95% CI: 3.40-8.58]); ApoB/ApoA1 ratio (OR: 2.74 [95% CI: 1.69-4.46]); psychosocial stress (OR: 2.33 [95% CI: 1.01-5.41]); smoking (OR: 1.85 [95% CI: 1.17-2.94]); and increased waist-to-hip ratio (OR: 1.69 [95% CI: 1.04-2.75]) were the most important risk factors for ischemic stroke in these young cases. For intracerebral hemorrhage, only hypertension (OR: 9.08 [95% CI: 5.46-15.1]) and binge drinking (OR: 4.06 [95% CI: 1.27-13.0]) were significant risk factors. The strength of association and population attributable risk (PAR) for hypertension increased with age (PAR 23.3% in those <35 years of age, 50.7% in 35-45 years of age). INTERPRETATION: Conventional risk factors such as hypertension, smoking, binge drinking of alcohol, central obesity, cardiac causes, dyslipidemia, and psychosocial stress are important risk factors for stroke in those younger than 45 years of age. Hypertension is the most significant risk factor in all age groups and across all regions and both stroke subtypes. These risk factors should be identified and modified in early adulthood to prevent strokes in young individuals.