Determinants for scalable adoption of autonomous AI in the detection of diabetic eye disease in diverse practice types: key best practices learned through collection of real-world data.

Autonomous Artificial Intelligence (AI) has the potential to reduce disparities, improve quality of care, and reduce cost by improving access to specialty diagnoses at the point-of-care. Diabetes and related complications represent a significant source of health disparities. Vision loss is a complication of diabetes, and there is extensive evidence supporting annual eye exams for prevention. Prior to the use of autonomous AI, store-and-forward imaging approaches using remote reading centers (asynchronous telemedicine) attempted to increase diabetes related eye exams with limited success. In 2018, after rigorous clinical validation, the first fully autonomous AI system [LumineticsCore™ (formerly IDx-DR), Digital Diagnostics Inc., Coralville, IA, United States] received U.S. Food and Drug Administration (FDA) De Novo authorization. The system diagnoses diabetic retinopathy (including macular edema) without specialist physician overread at the point-of-care. In addition to regulatory clearance, reimbursement, and quality measure updates, successful adoption requires local optimization of the clinical workflow. The general challenges of frontline care clinical workflow have been well documented in the literature. Because healthcare AI is so new, there remains a gap in the literature about challenges and opportunities to embed diagnostic AI into the clinical workflow. The goal of this review is to identify common workflow themes leading to successful adoption, measured as attainment number of exams per month using the autonomous AI system against targets set for each health center. We characterized the workflow in four different US health centers over a 12-month period. Health centers were geographically dispersed across the Midwest, Southwest, Northeast, and West Coast and varied distinctly in terms of size, staffing, resources, financing and demographics of patient populations. After 1 year, the aggregated number of diabetes-related exams per month increased from 89 after the first month of initial deployment to 174 across all sites. Across the diverse practice types, three primary determinants underscored sustainable adoption: (1) Inclusion of Executive and Clinical Champions; (2) Underlining Health Center Resources; and (3) Clinical workflows that contemplate patient identification (pre-visit), LumineticsCore Exam Capture and Provider Consult (patient visit), and Timely Referral Triage (post-visit). In addition to regulatory clearance, reimbursement and quality measures, our review shows that addressing the core determinants for workflow optimization is an essential part of large-scale adoption of innovation. These best practices can be generalizable to other autonomous AI systems in front-line care settings, thereby increasing patient access, improving quality of care, and addressing health disparities.

Genomic characterization of a novel pegivirus species from free-ranging bottlenose dolphins (Tursiops truncatus) in the Indian River Lagoon, Florida.

We report the discovery of the first cetacean pegivirus (family Flaviviridae) using a next-generation sequencing approach. One of two infected bottlenose dolphins had elevated activities of liver enzymes, which may suggest hepatocellular injury. Further research is needed to determine the epidemiology and pathogenicity of dolphin pegivirus.

Genomic sequencing of a virus representing a novel type within the species Dyopipapillomavirus 1 in an Indian River Lagoon bottlenose dolphin.

Fecal samples collected from free-ranging Atlantic bottlenose dolphins (BDs) in the Indian River Lagoon of Florida were processed for viral discovery using a next-generation sequencing (NGS) approach. A 693-bp contig identified in the NGS data was nearly identical to the partial L1 gene sequence of a papillomavirus (PV) previously found in a penile papilloma in a killer whale (Orcinus orca). Based on this partial bottlenose dolphin papillomavirus (BDPV) sequence, a nested inverse PCR and primer-walking strategy was employed to generate the complete genome sequence. The full BDPV genome consisted of 7299 bp and displayed a typical PV genome organization. The BDPV E6 protein contained a PDZ-binding motif, which has been shown to be involved in carcinogenic transformation involving high-risk genital human PVs. Screening of 12 individual fecal samples using a specific endpoint PCR assay revealed that the feces from a single female BD displaying a genital papilloma was positive for the BDPV. Genetic analysis indicated that this BDPV (Tursiops truncatus papillomavirus 8; TtPV8) is a new type of Dyopipapillomavirus 1, previously sequenced from an isolate obtained from a penile papilloma in a harbor porpoise (Phocoena phocoena). Although only a partial L1 sequence has been determined for a PV detected in a killer whale genital papilloma, our finding of a nearly identical sequence in an Atlantic BD may indicate that members of this viral species are capable of host jumping. Future work is needed to determine if this virus is a high-risk PV that is capable of inducing carcinogenic transformation and whether it poses a significant health risk to wild delphinid populations.

Complete Genome Sequencing of a Novel Type of Omikronpapillomavirus 1 in Indian River Lagoon Bottlenose Dolphins (Tursiops truncatus).

The genome sequence of a papillomavirus was determined from fecal samples collected from bottlenose dolphins in the Indian River Lagoon, FL. The genome was 7,772 bp and displayed a typical papillomavirus genome organization. Phylogenetic analysis supported the bottlenose dolphin papillomavirus as being a novel type of Omikronpapillomavirus1.

Mucocutaneous lesions in free-ranging Atlantic bottlenose dolphins Tursiops truncatus from the southeastern USA.

Mucocutaneous lesions were biopsied from free-ranging Atlantic bottlenose dolphins Tursiops truncatus inhabiting the Indian River Lagoon (IRL), Florida, and estuarine waters of Charleston (CHS), South Carolina, USA, between 2003 and 2013. A total of 78 incisional biopsies from 58 dolphins (n=43 IRL, n=15 CHS) were examined. Thirteen dolphins had 2 lesions biopsied at the same examination, and 6 dolphins were re-examined and re-biopsied at time intervals varying from 1 to 8 yr. Biopsy sites included the skin (n=47), tongue (n=2), and genital mucosa (n=29). Pathologic diagnoses were: orogenital sessile papilloma (39.7%), cutaneous lobomycosis (16.7%), tattoo skin disease (TSD; 15.4%), nonspecific chronic to chronic-active dermatitis (15.4%), and epidermal hyperplasia (12.8%). Pathologic diagnoses from dolphins with 2 lesions were predominately orogenital sessile papillomas (n=9) with nonspecific chronic to chronic-active dermatitis (n=4), TSD (n=3), lobomycosis (n=1), and epidermal hyperplasia (n=1). Persistent pathologic diagnoses from the same dolphins re-examined and re-biopsied at different times included genital sessile papillomas (n=3), lobomycosis (n=2), and nonspecific dermatitis (n=2). This is the first study documenting the various types, combined prevalence, and progression of mucocutaneous lesions in dolphins from the southeastern USA. The data support other published findings describing the health patterns in dolphins from these geographic regions. Potential health impacts related to the observed suite of lesions are important for the IRL and CHS dolphin populations, since previous studies have indicated that both populations are affected by complex infectious diseases often associated with immunologic disturbances and anthropogenic contaminants.

Clinicoimmunopathologic findings in Atlantic bottlenose dolphins Tursiops truncatus with positive Chlamydiaceae antibody titers.

Sera from free-ranging Atlantic bottlenose dolphins Tursiops truncatus inhabiting the Indian River Lagoon (IRL), Florida, and coastal waters of Charleston (CHS), South Carolina, USA, were tested for antibodies to Chlamydiaceae as part of a multidisciplinary study of individual and population health. A suite of clinicoimmunopathologic variables was evaluated in Chlamydiaceae-seropositive dolphins (n = 43) and seronegative healthy dolphins (n = 83). Fibrinogen, lactate dehydrogenase, amylase, and absolute numbers of neutrophils, lymphocytes, and basophils were significantly higher, and serum bicarbonate, total alpha globulin, and alpha-2 globulin were significantly lower in dolphins with positive Chlamydiaceae titers compared with seronegative healthy dolphins. Several differences in markers of innate and adaptive immunity were also found. Concanavalin A-induced T lymphocyte proliferation, lipopolysaccharide-induced B lymphocyte proliferation, and granulocytic phagocytosis were significantly lower, and absolute numbers of mature CD 21 B lymphocytes, natural killer cell activity and lysozyme concentration were significantly higher in dolphins with positive Chlamydiaceae antibody titers compared to seronegative healthy dolphins. Additionally, dolphins with positive Chlamydiaceae antibody titers had significant increases in ELISA antibody titers to Erysipelothrix rhusiopathiae. These data suggest that Chlamydiaceae infection may produce subclinical clinicoimmunopathologic perturbations that impact health. Any potential subclinical health impacts are important for the IRL and CHS dolphin populations, as past studies have indicated that both dolphin populations are affected by other complex infectious and neoplastic diseases, often associated with immunologic perturbations and anthropogenic contaminants.

Acute phase protein quantitation in serum samples from healthy Atlantic bottlenose dolphins (Tursiops truncatus).

Acute phase proteins (APPs) have been studied in many companion and large animals and have been reported to have a differential sensitivity to traditional markers of inflammation. Studies have been performed indicating the conservation of these proteins as well as the application and cross-reactivity of automated assays among different species, but few reports have detailed APPs in marine mammal species. In the present study, automated assays were utilized to generate reference intervals for C-reactive protein, haptoglobin, and serum amyloid A using 44 serum samples from healthy Atlantic bottlenose dolphins (Tursiops truncatus). A total of 25 samples were obtained from dolphins under human care and 19 samples were obtained from free-ranging dolphins. Mild yet statistically significant differences were observed in levels of haptoglobin and serum amyloid A between these groups. The reference intervals from the combined groups were as follows: C-reactive protein 3.1-19.7 mg/l, haptoglobin 0-0.37 mg/ml, and serum amyloid A 17.5-42.9 mg/l. These baseline data should provide an important foundation for future studies of the application of APP quantitation in monitoring the health and stressors of dolphins under human care and with live capture of free-ranging dolphins.

Clinicopathologic findings from Atlantic bottlenose dolphins (Tursiops truncatus) with cytologic evidence of gastric inflammation.

As part of the Bottlenose Dolphin Health and Risk Assessment study, blood, gastric, fecal, and blowhole samples were collected from 114 Atlantic bottlenose dolphins (Tursiops truncatus) in the Indian River Lagoon, Florida (IRL), and from 73 dolphins from the estuarine waters around Charleston, South Carolina (CHS), to assess the presence and degree of cytologic evidence of gastric inflammation from 2003 to 2007. The prevalence of moderate and severe gastric inflammation was 9.6% in the IRL and 11.0% at CHS. A case-control study of 19 dolphins with cytologic evidence of gastric inflammation and 82 with normal cytology from the combined populations was conducted. Blood parameters evaluated included hematology, serum chemistry, serum protein electrophoresis, and stress hormones. Few differences of clinical or statistical significance were found between affected and unaffected dolphins. Serum norepinephrine and cortisol were significantly higher in cases compared to the controls, and aldosterone was marginally higher (P = 0.06) based on eight cases. None of the hematologic, serum chemistry, or serum electrophoresis results were significantly different. Gastric fluid pH was not significantly different between cases and controls. There were no clinically significant aerobic-anaerobic or fungal culture results from gastric contents; bacteria cultured from both groups were considered to represent normal flora. The prevalence of inflammation did not differ by gender. Historically, cytologic evidence of gastric inflammation has constituted a marker of systemic illness in dolphins; however, there was little evidence to indicate systemic illness among affected animals. The data obtained from this study provide a basis for further investigation and evaluation of gastric cytology in wild and managed bottlenose dolphins.

Associations between mercury and hepatic, renal, endocrine, and hematological parameters in Atlantic bottlenose dolphins (Tursiops truncatus) along the eastern coast of Florida and South Carolina.

We evaluated associations between total mercury (Hg) concentrations in blood and skin and endocrine, hepatic, renal, and hematological parameters in free-ranging bottlenose dolphins (Tursiops truncatus). Dolphins in Indian River Lagoon, FL had higher concentrations of Hg in blood (0.67 µg/l wet wt) and skin (7.24 µg/g dry wt) compared with those from Charleston Harbor, SC (0.15 µg/l wet wt, 1.68 µg/g dry wt). An inverse relationship was observed between blood and skin Hg concentrations and total thyroxine, triiodothyronine, absolute numbers of lymphocytes, eosinophils, and platelets. Adrenocorticotropic hormone (ACTH), blood urea nitrogen, and gamma-glutamyl transferase increased with increasing concentrations of Hg in blood and skin; lactate dehydrogenase and neutrophils increased with concentrations in skin only. Hemoglobin and mean corpuscular hemoglobin increased with increasing concentrations of Hg in blood. Selenium was negatively associated with free T4, progesterone, and absolute numbers of monocytes, and positively correlated with absolute numbers of eosinophils and lymphocytes, and mean corpuscular volume. The results suggest the potential for a deleterious effect of Hg in highly exposed dolphins.

Clinicoimmunopathologic findings in Atlantic bottlenose dolphins Tursiops truncatus with positive cetacean morbillivirus antibody titers.

Sera from free-ranging Atlantic bottlenose dolphins Tursiops truncatus inhabiting the Indian River Lagoon (IRL), Florida were tested for antibodies to cetacean morbilliviruses from 2003 to 2007 as part of a multidisciplinary study of individual and population health. A suite of clinicoimmunopathologic variables were evaluated in morbillivirus-seropositive dolphins (n = 14) and seronegative healthy dolphins (n = 49). Several important differences were found. Serum alkaline phosphatase, creatine phosphokinase, chloride, albumin and albumin/globulin ratios were significantly lower in seropositive dolphins. Innate immunity appeared to be upregulated with significant increases in lysozyme concentration and marginally significant increases in monocytic phagocytosis. Adaptive immunity was also impacted in dolphins with positive morbillivirus antibody titers. Mitogen-induced T lymphocyte proliferation responses were significantly reduced in dolphins with positive morbillivirus antibody titers, and marginally significant decreases were found for absolute numbers of CD4+ lymphocytes. The findings suggest impairment of cell-mediated adaptive immunity, similar to the immunologic pattern reported with acute morbillivirus infection in other species. In contrast, dolphins with positive morbillivirus antibody titers appeared to have at least a partially upregulated humoral immune response with significantly higher levels of gamma globulins than healthy dolphins, which may represent an antibody response to morbillivirus infection or other pathogens. These data suggest that subclinical dolphin morbillivirus infection in IRL dolphins may produce clinicoimmunopathologic perturbations that impact overall health.

Morbillivirus infection in free-ranging Atlantic bottlenose dolphins (Tursiops truncatus) from the Southeastern United States: seroepidemiologic and pathologic evidence of subclinical infection.

From 2003 to 2007, sera (n=234) from free-ranging Atlantic bottlenose dolphins (Tursiops truncatus) inhabiting two southeast Atlantic estuarine regions, the Indian River Lagoon (IRL), FL and Charleston, SC (CHS) were tested for antibodies to cetacean morbilliviruses as part of a multidisciplinary study of individual and population health. Positive morbillivirus titers were found on initial capture in 12 of 122 (9.8%) IRL dolphins in the absence of an epizootic. All CHS dolphins were seronegative. Positive fluctuating morbillivirus titers and seroconversion were found in IRL dolphins. Seropositivity was detected in dolphins 8-13 years of age as well as in dolphins that were alive during the 1987-1988 epizootic. During the study period, pathologic and immunohistochemical findings from stranded IRL dolphins (n=14) did not demonstrate typical morbillivirus-associated lesions or the presence of morbillivirus antigen. The findings suggest that morbillivirus infections are occurring in the absence of widespread mortality in IRL dolphins.

Antibiotic-resistant organisms cultured from Atlantic bottlenose dolphins (Tursiops truncatus) inhabiting estuarine waters of Charleston, SC and Indian River Lagoon, FL.

Bottlenose dolphins (Tursiops truncatus) from estuarine waters of Indian River Lagoon, FL (IRL) and Charleston, SC (CHS) were cultured to screen for microorganism colonization and to assess antibiotic sensitivity. Swabs (n = 909) were collected from the blowhole, gastric fluid, and feces of 171 individual dolphins The most frequently cultured organisms were Plesiomonas shigelloides (n = 161), Aeromonas hydrophila (n = 144), Escherichia coli (n = 85), and Pseudomonas fluorescens (n = 82). In descending frequency, organisms demonstrated resistance to erythromycin, ampicillin, and cephalothin. Human and animal pathogens resistant to antibiotics used in human and veterinary medicine were cultured. Escherichia coli (E. coli) more often was resistant in IRL dolphins. Three cases of methicillin-resistant Staphylococcus aureus (MRSA) were found at CHS. Emergence of antibiotic resistance is not confined to humans. Bottlenose dolphins may serve as sentinels for transfer of resistance from humans and animals or indicate that antibiotics are reaching the marine environment and causing resistance to emerge through selective pressure and genetic adaptation.

Evaluation and comparison of the health status of Atlantic bottlenose dolphins from the Indian River Lagoon, Florida, and Charleston, South Carolina.

OBJECTIVE: To conduct health assessments and compare outcomes in 2 populations of Atlantic bottlenose dolphins. Design-Repeated cross-sectional study. ANIMALS: 171 Atlantic bottlenose dolphins. PROCEDURES: During June and August of 2003 through 2005, 89 dolphins from the Indian River Lagoon (IRL), Florida, and 82 dolphins from estuarine waters near Charleston, SC, were evaluated. A panel of 5 marine mammal veterinarians classified dolphins as clinically normal, possibly diseased, or definitely diseased on the basis of results of physical and ultrasonographic examinations, hematologic and serum biochemical analyses, and cytologic and microbiologic evaluations of gastric contents and swab specimens. RESULTS: Prevalence of dolphins classified as definitely diseased did not differ significantly between the IRL (32%) and Charleston (20%) sites. Proportions of dolphins classified as possibly diseased also did not differ. Lobomycosis was diagnosed in 9 dolphins from the IRL but in none of the dolphins from Charleston. Proportions of dolphins with orogenital papillomas did not differ significantly between the IRL (12%) and Charleston (7%) sites. From 2003 through 2005, the proportion classified as definitely diseased tripled among dolphins from the Charleston site but did not increase significantly among dolphins from the IRL. Dolphins from the Charleston site were more likely to have leukocytosis, lymphocytosis, and low serum concentrations of total protein and total J-globulins than were dolphins from the IRL. CONCLUSIONS AND CLINICAL RELEVANCE: High prevalences of diseased dolphins were identified at both sites; however, the host or environmental factors that contributed to the various abnormalities detected are unknown.

Evaluation of cetacean and sirenian cytologic samples.

Cytology is a fundamental part of marine mammal veterinary medicine that is involved in preventive medicine programs in captive animals and in the health assessment of wild populations. Marine mammals often exhibit few clinical signs of disease; thus, the cost-effective and widely accessible nature of cytologic sampling renders it one of the most important diagnostic procedures with these species. Many of these mammals are endangered, protected, and located in developing nations in which resources may be scarce. This article can be used as a field guide to advise a veterinarian, biologist, or technician working with cetaceans or sirenians. A simplistic cost-effective staining technique is used, which is ideal for situations in which funds, facilities, or time may be a limiting factor in clinical practice.

Hematologic, biochemical, and cytologic findings from apparently healthy atlantic bottlenose dolphins (Tursiops truncatus) inhabiting the Indian River Lagoon, Florida, USA.

The objective of this study was to establish reference baseline data for hematologic, biochemical, and cytologic findings in apparently healthy Atlantic bottlenose dolphins (Tursiops truncatus) inhabiting the Indian River Lagoon, Florida, USA. Sixty-two dolphins were captured, examined, and released during June 2003 and June 2004. Mean, standard deviation, and range were calculated for each parameter, and values for which published data were available, were close to or within the ranges previously reported for free-ranging bottlenose dolphins. No pathologic abnormalities were found in fecal and blowhole cytologic specimens. However, 24% (7/29) of the dolphins examined in 2003 had evidence of gastritis, which was graded as severe in 14% (4/29) of the cases. In 2004, only 4% (1/24) of dolphins sampled had evidence of mild or moderate gastritis; no severe inflammation was present. Dolphins with evidence of gastritis were 8 yr of age or older and predominantly male. Several statistically significant differences were found between males and females, between pregnant and nonpregnant animals, and between juveniles (<6 yr) and adults (> or =6 yr). However, the values remained within the established ranges for this species, and the differences were not likely to be of clinical significance.

Beaked whale auditory evoked potential hearing measurements.

Several mass strandings of beaked whales have recently been correlated with military exercises involving mid-frequency sonar highlighting unknowns regarding hearing sensitivity in these species. We report the hearing abilities of a stranded juvenile beaked whale (Mesoplodon europaeus) measured with auditory evoked potentials. The beaked whale's modulation rate transfer function (MRTF) measured with a 40-kHz carrier showed responses up to an 1,800 Hz amplitude modulation (AM) rate. The MRTF was strongest at the 1,000 and 1,200 Hz AM rates. The envelope following response (EFR) input-output functions were non-linear. The beaked whale was most sensitive to high frequency signals between 40 and 80 kHz, but produced smaller evoked potentials to 5 kHz, the lowest frequency tested. The beaked whale hearing range and sensitivity are similar to other odontocetes that have been measured.

Lobomycosis in Atlantic bottlenose dolphins from the Indian River Lagoon, Florida.

OBJECTIVE: To determine the prevalence of lobomycosis, a mycotic infection of dolphins and humans caused by a yeastlike organism (Lacazia loboi), among dolphins in the Indian River Lagoon in Florida. DESIGN: Cross-sectional study. ANIMALS: 146 Atlantic bottlenose dolphins. PROCEDURE: Comprehensive health assessments of bottlenose dolphins in the Indian River Lagoon of Florida (n = 75) and in estuarine waters near Charleston, SC (71), were conducted during 2003 and 2004. Bottlenose dolphins were captured, examined, and released. Skin lesions were photographed and then biopsied. Tissue sections were stained with H&E and Gomori methenamine silver stains for identification of L. loboi. RESULTS: 9 of 30 (30%) dolphins captured in the southern portion of the Indian River Lagoon had lobomycosis, whereas none of the 45 dolphins captured in the northern portion of the lagoon or of the 71 dolphins captured near Charleston, SC, did. Affected dolphins had low serum alkaline phosphatase activities and high acute-phase protein concentrations. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that lobomycosis may be occurring in epidemic proportions among dolphins in the Indian River Lagoon. Localization of the disease to the southern portion of the lagoon, an area characterized by freshwater intrusion and lower salinity, suggests that exposure to environmental stressors may be contributing to the high prevalence of the disease, but specific factors are unknown. Because only dolphins and humans are naturally susceptible to infection, dolphins may represent a sentinel species for an emerging infectious disease.

How well do the HEDIS asthma inclusion criteria identify persistent asthma?

OBJECTIVES: (1) To determine if the Health Plan Employer Data and Information Set (HEDIS) asthma inclusion criteria consistently identify persistent asthma on a year-to-year basis and (2) to explore whether variation in the number of years of qualification is associated with medication and resource utilization outcomes. STUDY DESIGN: Retrospective observational study. METHODS: We identified 132 414 patients in a large healthcare program who were included in 1 or more HEDIS persistent asthma cohorts between 1999 and 2002 and who had continuous insurance and pharmacy benefit coverage for the entire 4-year observation period. Medication, emergency department, and hospital use in 2002 was identified using electronic claims and pharmacy information. RESULTS: Overall, 47.9% of the patients were identified as having persistent asthma in only 1 of 4 years, 40.8% had at least 2 consecutive years, and 28.2% had at least 3 consecutive years. In bivariate and multivariate analyses, more consecutive years of HEDIS persistent asthma qualification significantly increased the likelihood of frequent short-acting b-agonist use, inhaled antiinflammatory corticosteroid use, at least 1 emergency department visit, and at least 1 hospitalization. The strongest relationship was for 3 or more consecutive years of HEDIS qualification. CONCLUSIONS: A significant portion of the HEDIS persistent asthma cohort does not qualify on a year-to-year basis, suggesting that the current 1-year qualification period or the underlying administrative case definition for persistent asthma may be suboptimal. Further clinical validation studies are needed to determine the optimal criteria for a more useful HEDIS persistent asthma case definition.

Poverty is a predictor of non-communicable disease among adults in Peruvian cities.

BACKGROUND: Rapid health and nutrition transitional changes are resulting in greater prominence of non-communicable disease (NCD) in Latin America, particularly among the poor. OBJECTIVE: The study aims to examine the extent to which NCD pxfsrevails in Peru and the socioeconomic status (SES) as a risk factor. DESIGN: Between 1998 and 2000, health surveys and clinical assessments were completed on 2337 adults in six cities, 18 to 60 years of age. Stratified by social class, multi-staged random sampling was used. Anthropometric data, blood pressure and serum samples were collected. RESULTS: Adjusting for age, hypertension, low HDL cholesterol, high total cholesterol and diabetes was found in 47%, 40%, 21% and 17% of women and in 44%, 38%, 27% and 19% of men, respectively. Over one quarter of the population exhibited multiple risk factors, not including overweight and obesity. Across all study sites, lowest SES revealed highest burden of NCD and appeared as an independent risk factor for associated NCD indicators. CONCLUSION: The high prevalence of NCD in urban areas of Peru is not only associated with excess body weight, but also with poverty itself. The greater burden of NCD in the poorest areas of society requires a better understanding of causal determinants and may have implications in terms of public health policies and interventions.