Educational inequalities and premature mortality: the Cuba Prospective Study.

BACKGROUND: Although socioeconomic status is a major determinant of premature mortality in many populations, the impact of social inequalities on premature mortality in Cuba, a country with universal education and health care, remains unclear. We aimed to assess the association between educational level and premature adult mortality in Cuba. METHODS: The Cuba Prospective Study (a cohort study) enrolled 146 556 adults aged 30 years and older from the general population in five provinces from Jan 1, 1996, to Nov 24, 2002. Participants were followed up until Jan 1, 2017, for cause-specific mortality. Deaths were identified through linkage to the Cuban Public Health Ministry's national mortality records. Cox regression models yielded rate ratios (RRs) for the effect of educational level (a commonly used measure for social status) on mortality at ages 35-74 years, with assessment for the mediating effects of smoking, alcohol consumption, and BMI. FINDINGS: A total of 127 273 participants aged 35-74 years were included in the analyses. There was a strong inverse association between educational level and premature mortality. Compared with a university education, men who did not complete primary education had an approximately 60% higher risk of premature mortality (RR 1·55, 95% CI 1·40-1·72), while the risk was approximately doubled in women (1·96, 1·81-2·13). Overall, 28% of premature deaths could be attributed to lower education levels. Excess mortality in women was primarily due to vascular disease, while vascular disease and cancer were equally important in men. 31% of the association with education in men and 18% in women could be explained by common modifiable risk factors, with smoking having the largest effect. INTERPRETATION: This study highlights the value of understanding the determinants of health inequalities in different populations. Although many major determinants lie outside the health system in Cuba, this study has identified the diseases and risk factors that require targeted public health interventions, particularly smoking. FUNDING: UK Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).

La hipertensión arterial en Cuba según la Encuesta Nacional de Salud 2018-2019

Introducción: La hipertensión arterial es una condición médica grave que aumenta significativamente los riesgos de enfermedades cardiovasculares y otras. La mayoría de personas hipertensas ignoran que lo son. Es muy importante medir la presión arterial de manera periódica, es la única forma de detectar la enfermedad. Objetivo: Valorar indicadores de morbilidad por hipertensión arterial y pre hipertensión en el país, a partir de los hallazgos de la prevalencia, tratamiento y control de la enfermedad dados por Encuesta Nacional de Salud, concluida en el año 2019. Métodos: Como parte de la Encuesta Nacional de Salud, Cuba 2018-2019, se realizó un estudio transversal, con el objetivo de identificar la prevalencia de hipertensión arterial, según las variables sociodemográficas, zona geográfica de residencia, en el momento del diagnóstico; el manejo y control de los hipertensos conocidos y la clasificación de los nuevos hipertensos según las cifras sisto/diastólicas presentadas en el momento del diagnóstico. Incluyó a población de 15 años y más, residentes en zonas urbanas y rurales. Resultados: La prevalencia de hipertensión arterial en Cuba fue de 37,3 %, superior en las mujeres con 40,2 %, tanto a nivel global como en las áreas geográficas urbana y rural. Predominaron los hipertensos de ambos sexos en las áreas urbanas. Se incrementó la hipertensión en la medida que lo hizo la edad. Conclusiones: Existió un incremento en la prevalencia total de hipertensión arterial en Cuba en los últimos 24 años. Esta fue superior a la dispensarización reportada a nivel nacional en el primer nivel de atención de salud.

Introduction: High blood pressure is a serious medical condition that significantly increases the risks of cardiovascular and other diseases. Most hypertensive people are unaware that they are. It is very important to measure blood pressure periodically, it is the only way to detect the disease. Objective: To assess indicators of morbidity due to hypertension and pre-hypertension in the country, based on the findings of the prevalence, treatment and control of the disease given by the National Health Survey, concluded in 2019. Methods: As part of the National Health Survey, Cuba 2018-2019, a cross-sectional study was carried out, with the aim of identifying the prevalence of high blood pressure, according to sociodemographic variables, geographic area of ​​residence, at the time of diagnosis; the management and control of known hypertensive patients and the classification of new hypertensive patients according to the systolic/diastolic figures presented at the time of diagnosis. It included the population aged 15 and over, residing in urban and rural areas. Results: The prevalence of arterial hypertension in Cuba was 37.3 %, higher in women with 40.2 %, both globally and in urban and rural geographic areas. Hypertensive patients of both sexes predominated in urban areas. Hypertension increased as age did. Conclusions: There was an increase in the total prevalence of arterial hypertension in Cuba in the last 24 years. This was higher than the dispensarization reported at the national level in the first level of health care.

Vulnerabilidad poblacional a la COVID-19 severa desde los datos de la encuesta nacional de salud

RESUMEN Introducción: Nuevas cepas de SARS-CoV-2 detectadas recientemente provocan aumento de la morbilidad y mortalidad no solo en adultos mayores. Conocer la población vulnerable es un reto. Objetivo: Estimar la prevalencia de adultos vulnerables a la COVID-19 severa y sus factores sociodemográficos asociados. Métodos: Estudio observacional transversal analítico con datos provenientes de la encuesta nacional de salud 2018-2020, que incluye 13 684 personas de 19 y más años de edad. El cuestionario estructurado provee la información de variables sociodemográficas, antecedentes patológicos personales e historia familiar, mediciones de la presión arterial y bioquímicas, entre otras. Vulnerabilidad a COVID-19 severa se construyó según propuesta del CDC de Atlanta, EE. UU y fue la variable dependiente. Resultados: La prevalencia de adultos vulnerables a COVID-19 severa en el país fue de 68,3 %, riesgo superior en el adulto mayor (86,5 %), en los no blancos y en la percepción de condiciones de vida "malas". En adultos mayores ser hombre protege, en tanto, fue riesgo, vivir en la región oriental del país. La hipertensión arterial (39,4 %), seguida del tabaquismo (22,2 %), la obesidad (16,6 %) y las enfermedades respiratorias crónicas (10,6 %) fueron las afecciones médicas más frecuentes. Conclusiones: La vulnerabilidad a la COVID-19 severa en la población adulta cubana es elevada, consecuentemente, constituye un serio problema de salud. Factores no modificables se asocian positivamente a la vulnerabilidad: ser adulto mayor, mujer, color de piel no blanca y padecer hipertensión arterial, en tanto, las "malas" condiciones de vida es el único que puede ser modificado.

ABSTRACT Introduction: New SARS-CoV-2 strains recently detected cause an increase in morbidity and mortality not only in the elderly. Identifying the vulnerable population is a challenge. Objective: To estimate the prevalence of adults vulnerable to severe COVID-19 and its associated sociodemographic factors. Methods: An observational cross-sectional analytic study using data from the 2018-2020 National Health Survey. It included 13 684 individuals aged 19 years and over. The structured questionnaire included information on the sociodemographic variables, personal and family pathological antecedents, and records of blood pressure and biochemistry tests, among others. Vulnerability to severe COVID-19 was developed based on the proposal from the CDC Atlanta, USA and it was the dependable variable. Results: The prevalence of adults vulnerable to severe COVID-19 in the country was 68.3%. At higher risk are the elderly (86.5%), non-white individuals, and those who perceived themselves as having poor living conditions. For the elderly, being male was a protective factor, while living in the western region of the country was a risk factor. High blood pressure (39.4%), smoking (22.2%), obesity (16.6%) and chronic respiratory diseases (10.6%) were the most frequent health problems. Conclusions: Vulnerability to severe COVID-19 in the Cuban adult population is high; consequently, it is considered a serious health problem. Non-modifiable factors are positively associated with vulnerability: being an older adult, female, non-white skin color, and suffering from hypertension; while "poor" living conditions is the only modifiable factor.

Prevalencia y características de la enfermedad pulmonar obstructiva crónica en La Habana (2017-2018)

RESUMEN Introducción: En Cuba la enfermedad pulmonar obstructiva crónica es sexta causa de mortalidad general. Existe insuficiente conocimiento sobre su magnitud. Objetivo: Determinar la prevalencia y características de la enfermedad en La Habana (2017-2018). Métodos: Estudio multicéntrico transversal, coordinado por Iniciative Burden of Lung Disease, incluyó 349 personas no institucionalizadas de 40 años y más de cuatro consultorios médicos (selección aleatoria). Se aplicó cuestionario con variables sociodemográficas relacionadas con diagnóstico médico previo y tabaquismo. Se realizó estudio de espirometría, pre-pos aplicación de salbutamol para determinar limitación del flujo aéreo y clasificó severidad de la enfermedad en leve, moderada, severa y muy severa. Resultados: Prevalencia global 20,9 % (IC 95 %:16,6-25,2); en hombres 25,3 %, en mujeres 17,7 %. Se incrementó con la edad. Formas leves 60 %, más frecuentes en mujeres 67 % vs. severas en hombres, 22 %. Espirometría previa 15 % de encuestados. Catorce encuestados (19,1 %) tenían el diagnóstico médico previo de enfisema pulmonar, bronquitis crónica o enfermedad pulmonar obstructiva crónica. Prevalencia de tabaquismo 36,0 %, mayor porcentaje en formas severas. La tercera parte (31,7 %), expuestos al humo de tabaco ajeno, en hogar o trabajo; media de exposición diaria 5 h. Conclusiones: La alta prevalencia y subdiagnóstico de enfermedad pulmonar obstructiva crónica la convierten en un importante problema de salud en La Habana. Se pronostica incremento de la prevalencia relacionado con la dinámica poblacional en el país y el alto consumo de tabaco en la población. Se requiere un manejo más integral de esta enfermedad prevenible.

ABSTRACT Introduction: In Cuba, chronic obstructive pulmonary disease is the sixth leading cause of death. There is insufficient knowledge concerning its scope. Objective: To determine the prevalence and characteristics of the disease in Havana (2017-2018). Methods: A multicenter, cross-sectional study coordinated by Iniciative Burden of Lung Disease. It included 349 non-hospitalized people aged 40 and over from four family doctor´s offices (random selection). A questionnaire with sociodemographic variables on previous medical diagnosis and smoking was applied. A spirometric study was conducted before and after salbutamol administration to determine airflow limitations, and the disease was classified as mild, moderate, severe, and very severe. Results: Overall prevalence was 20.9% (95 % CI: 16.6-25.2); with males accounting for 25.3%; and females for 17.7%. It increased with age. Mild forms of the disease affected 60% of the population; they were more common in females (67%) than in males (severe forms, 22%). Previous spirometry was performed in 15% of respondents. Fourteen people (19.1%) had previously been diagnosed with pulmonary emphysema, chronic bronchitis, or chronic obstructive pulmonary disease. Smoking prevalence was 36%, with a higher percentage in the severe forms of the disease. One-third (31.7%) were exposed to second-hand tobacco smoke at home or at work, with a daily average exposure of 5 hours. Conclusions: Chronic obstructive pulmonary disease is a major health problem in Havana due to its high prevalence and underdiagnosis. An increase in prevalence is predicted given the demographic dynamics in the country and the high level of tobacco consumption among the population. Therefore, more comprehensive management of this preventable disease is required.

Body-mass index, blood pressure, diabetes and cardiovascular mortality in Cuba: prospective study of 146,556 participants.

BACKGROUND: Cardiovascular disease accounts for about one-third of all premature deaths (ie, age < 70) in Cuba. Yet, the relevance of major risk factors, including systolic blood pressure (SBP), diabetes, and body-mass index (BMI), to cardiovascular mortality in this population remains unclear. METHODS: In 1996-2002, 146,556 adults were recruited from the general population in five areas of Cuba. Participants were interviewed, measured (height, weight and blood pressure) and followed up by electronic linkage to national death registries until Jan 1, 2017; in 2006-08, 24,345 participants were resurveyed. After excluding all with missing data, cardiovascular disease at recruitment, and those who died in the first 5 years, Cox regression (adjusted for age, sex, education, smoking, alcohol and, where appropriate, BMI) was used to relate cardiovascular mortality rate ratios (RRs) at ages 35-79 years to SBP, diabetes and BMI; RR were corrected for regression dilution to give associations with long-term average (ie, 'usual') levels of SBP and BMI. RESULTS: After exclusions, there were 125,939 participants (mean age 53 [SD12]; 55% women). Mean SBP was 124 mmHg (SD15), 5% had diabetes, and mean BMI was 24.2 kg/m2 (SD3.6); mean SBP and diabetes prevalence at recruitment were both strongly related to BMI. During follow-up, there were 4112 cardiovascular deaths (2032 ischaemic heart disease, 832 stroke, and 1248 other). Cardiovascular mortality was positively associated with SBP (>=120 mmHg), diabetes, and BMI (>=22.5 kg/m2): 20 mmHg higher usual SBP about doubled cardiovascular mortality (RR 2.02, 95%CI 1.88-2.18]), as did diabetes (2.15, 1.95-2.37), and 10 kg/m2 higher usual BMI (1.92, 1.64-2.25). RR were similar in men and in women. The association with BMI and cardiovascular mortality was almost completely attenuated following adjustment for the mediating effect of SBP. Elevated SBP (>=120 mmHg), diabetes and raised BMI (>=22.5 kg/m2) accounted for 27%, 14%, and 16% of cardiovascular deaths, respectively. CONCLUSIONS: This large prospective study provides direct evidence for the effects of these major risk factors on cardiovascular mortality in Cuba. Despite comparatively low levels of these risk factors by international standards, the strength of their association with cardiovascular death means they nevertheless exert a substantial impact on premature mortality in Cuba.

Alcohol consumption and cause-specific mortality in Cuba: prospective study of 120 623 adults.

BACKGROUND: The associations of cause-specific mortality with alcohol consumption have been studied mainly in higher-income countries. We relate alcohol consumption to mortality in Cuba. METHODS: In 1996-2002, 146 556 adults were recruited into a prospective study from the general population in five areas of Cuba. Participants were interviewed, measured and followed up by electronic linkage to national death registries until January 1, 2017. After excluding all with missing data or chronic disease at recruitment, Cox regression (adjusted for age, sex, province, education, and smoking) was used to relate mortality rate ratios (RRs) at ages 35-79 years to alcohol consumption. RRs were corrected for long-term variability in alcohol consumption using repeat measures among 20 593 participants resurveyed in 2006-08. FINDINGS: After exclusions, there were 120 623 participants aged 35-79 years (mean age 52 [SD 12]; 67 694 [56%] women). At recruitment, 22 670 (43%) men and 9490 (14%) women were current alcohol drinkers, with 15 433 (29%) men and 3054 (5%) women drinking at least weekly; most alcohol consumption was from rum. All-cause mortality was positively and continuously associated with weekly alcohol consumption: each additional 35cl bottle of rum per week (110g of pure alcohol) was associated with ∼10% higher risk of all-cause mortality (RR 1.08 [95%CI 1.05-1.11]). The major causes of excess mortality in weekly drinkers were cancer, vascular disease, and external causes. Non-drinkers had ∼10% higher risk (RR 1.11 [1.09-1.14]) of all-cause mortality than those in the lowest category of weekly alcohol consumption (<1 bottle/week), but this association was almost completely attenuated on exclusion of early follow-up. INTERPRETATION: In this large prospective study in Cuba, weekly alcohol consumption was continuously related to premature mortality. Reverse causality is likely to account for much of the apparent excess risk among non-drinkers. The findings support limits to alcohol consumption that are lower than present recommendations in Cuba. FUNDING: Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).

Association of childhood smoking and adult mortality: prospective study of 120 000 Cuban adults.

BACKGROUND: The average age at which people start smoking has been decreasing in many countries, but insufficient evidence exists on the adult hazards of having started smoking in childhood and, especially, in early childhood. We aimed to investigate the association between smoking habits (focusing on the age when smokers started) and cause-specific premature mortality in a cohort of adults in Cuba. METHODS: For this prospective study, adults were recruited from five provinces in Cuba. Participants were interviewed (data collected included socioeconomic status, medical history, alcohol consumption, and smoking habits) and had their height, weight, and blood pressure measured. Participants were followed up until Jan 1, 2017 for cause-specific mortality; a subset was resurveyed in 2006-08. We used Cox regression to calculate adjusted rate ratios (RRs) for mortality at ages 30-69 years, comparing never-smokers with current smokers by age they started smoking and number of cigarettes smoked per day and with ex-smokers by the age at which they had quit. FINDINGS: Between Jan 1, 1996, and Nov 24, 2002, 146 556 adults were recruited into the study, of whom 118 840 participants aged 30-69 years at recruitment contributed to the main analyses. 27 264 (52%) of 52 524 men and 19 313 (29%) of 66 316 women were current smokers. Most participants reported smoking cigarettes; few smoked only cigars. About a third of current cigarette smokers had started before age 15 years. Compared with never-smokers, the all-cause mortality RR was highest in participants who had started smoking at ages 5-9 years (RR 2·51, 95% CI 2·21-2·85), followed by ages 10-14 years (1·83, 1·72-1·95), 15-19 years (1·56, 1·46-1·65), and ages 20 years or older (1·50, 1·39-1·62). Smoking accounted for a quarter of all premature deaths in this population, but quitting before about age 40 years avoided almost all of the excess mortality due to smoking. INTERPRETATION: In this cohort of adults in Cuba, starting to smoke in childhood was common and quitting was not. Starting in childhood approximately doubled the rate of premature death (ie, before age 70 years). If this 2-fold mortality RR continues into old age, about half of participants who start smoking before age 15 years and do not stop will eventually die of complications from their habit. The greatest risks were found among adults who began smoking before age 10 years. FUNDING: UK Medical Research Council, Cancer Research UK, British Heart Foundation, US Centers for Disease Control and Prevention (CDC) Foundation (with support from Amgen).

Burden of hypertension and associated risks for cardiovascular mortality in Cuba: a prospective cohort study.

BACKGROUND: In Cuba, hypertension control in primary care has been prioritised as a cost-effective means of addressing premature death from cardiovascular disease. However, there is little evidence from large-scale studies on the prevalence and management of hypertension in Cuba, and no direct evidence of the expected benefit of such efforts on cardiovascular mortality. METHODS: In a prospective cohort study, adults in the general population identified via local family medical practices were interviewed between Jan 1, 1996, and Nov 24, 2002, in five areas of Cuba, and a subset of participants were resurveyed between July 14, 2006, and Oct 19, 2008, in one area. During household visits, blood pressure was measured and information obtained on diagnosis and treatment of hypertension. We calculated the prevalence of hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, or receiving treatment for hypertension) and the proportion of people with hypertension in whom it was diagnosed, treated, and controlled (systolic blood pressure <140 mm Hg, diastolic blood pressure <90 mm Hg). Deaths were identified through linkage by national identification numbers to the Cuban Public Health Ministry records, to Dec 31, 2016. We used Cox regression analysis to compare cardiovascular mortality between participants with versus without uncontrolled hypertension. Rate ratios (RRs) were used to estimate the fraction of cardiovascular deaths attributable to hypertension. FINDINGS: 146 556 participants were interviewed in the baseline survey in 1996-2002 and 24 345 were interviewed in the resurvey in 2006-08. After exclusion for incomplete data and age outside the range of interest, 136 111 respondents aged 35-79 years (mean age 54 [SD 12] years; 75 947 [56%] women, 60 164 [44%] men) were eligible for inclusion in the analyses. 34% of participants had hypertension. Among these, 67% had a diagnosis of hypertension. 76% of participants with diagnosed hypertension were receiving treatment and blood pressure was controlled in 36% of those people. During 1·7 million person-years of follow-up there were 5707 cardiovascular deaths. In the age groups 35-59, 60-69, and 70-79 years, uncontrolled hypertension at baseline was associated with RRs of 2·15 (95% CI 1·88-2·46), 1·86 (1·69-2·05), and 1·41 (1·32-1·52), respectively, and accounted for around 20% of premature cardiovascular deaths. INTERPRETATION: In this Cuban population, a third of people had hypertension. Although levels of hypertension diagnosis and treatment were commensurate with those in some high-income countries, the proportion of participants whose blood pressure was controlled was low. As well as reducing hypertension prevalence, improvement in blood pressure control among people with diagnosed hypertension is required to prevent premature cardiovascular deaths in Cuba. FUNDING: Medical Research Council, British Heart Foundation, Cancer Research UK.

Caracterización clínico-epidemiológica de parejas infértiles / Clinical-Epidemiological characterization of infertile couples

Introducción: Aproximadamente, el 15 por ciento de todos los matrimonios no tienen hijos. Según estudios realizados en Cuba, la prevalencia de infertilidad oscila entre 12 y 14 por ciento, destacándose dentro de sus causas los factores pélvicos que afectan las trompas o el endometrio con 30-50 por ciento, seguido de la disfunción ovulatoria con el 10 a 25 por ciento y solo 10 por ciento son de causa desconocida. Objetivo: Caracterizar a las parejas infértiles según variables clínico epidemiológicas seleccionadas. Métodos: Se realizó un estudio observacional, descriptivo, transversal a 224 parejas infértiles, en la provincia Santiago de Cuba. Cuba, en el periodo 2015-2016. Resultados: El 40,3 por ciento de las parejas estudiados presentaron infecciones de transmisión sexual de diferentes etiologías y el 45,6 por ciento se diagnosticaron con infertilidad secundaria. Conclusiones: La edad de la mujer por encima de los 35 años, los antecedentes patológicos personales, la ingestión de medicamentos, la presencia previa de infección de trasmisión sexual así como el antecedente de varios episodios de enfermedad pélvica inflamatoria, están relacionadas con la etiología infecciosa de la infertilidad y pudieran constituir las principales causas de este trastorno en nuestro país(AU)

Introduction: Approximately 15 percent of all marriages do not have any children. According to studies carried out in Cuba, the prevalence of infertility ranges from 12 to 14 percent, among whose highlighted causes are pelvic factors that affect the tubes or the endometrium, accounting for 30-50 percent, followed by ovulatory dysfunction, accounting for 10-25 percent, while only 10 percent are of unknown cause. Objective: To characterize infertile couples based in the selected clinical-epidemiological variables. Methods: An observational, descriptive, cross-sectional study was carried out with 224 infertile couples in Santiago de Cuba Province, Cuba, in the period from 2015 to 2016. Results: 40.3 percent of the studied couples had sexually transmitted infections of different etiologies, while 45.6 percent were diagnosed with secondary infertility. Conclusions: The age of the woman over 35 years, personal pathological antecedents, ingestion of medications, the previous presence of sexually transmitted infections, as well as the history of several episodes of pelvic inflammatory disease, are related to the infectious etiology of infertility and could be the main causes of this disorder in our country(AU)

Impacto del sobrepeso y obesidad en la mortalidad por enfermedades no trasmisibles en Cuba / Impact of overweight and obesity in mortality due to non-communicable diseases in Cuba

Introducción: La mortalidad por sobrepeso y obesidad es prevenible, ambas condiciones representan un problema de salud en Cuba. Objetivo: estimar la mortalidad atribuible al sobrepeso-obesidad en la población de 20 años o más. Métodos: estudio descriptivo que utilizó fuentes de datos secundarias para prevalencias de sobrepeso-obesidad y datos de mortalidad por enfermedades no trasmisibles seleccionadas. El impacto del exceso de peso en la mortalidad, se obtuvo calculando las fracciones atribuibles poblacionales a partir de riesgos relativos procedentes de estudios previos. Fue calculada la mortalidad atribuible por causa y sexo. Resultados: del total de muertes (30 656), por los tres grupos de causas seleccionados, 3 785 fueron atribuidas al sobrepeso y la obesidad: 12,3 por ciento. En hombres, 8,1 por ciento; en mujeres 16,8 por ciento. Respecto a las defunciones por todas las causas reportadas en el año para este grupo de edad y sexo, los porcentajes fueron 4 por ciento, 2,4 por ciento y 5,7 por ciento respectivamente. La enfermedad cardiovascular fue la causa más frecuente de mortalidad atribuible: 53 por ciento del total. La segunda causa fue diabetes mellitus tipo II: 25 por ciento y a su vez, la causa específica en la que el exceso de peso tuvo una contribución mayor: 63 por ciento. En hombres la mitad de las defunciones (49 por ciento), se atribuyó al sobrepeso- obesidad; en tanto en las mujeres, en siete de cada diez fallecidas (72 por ciento). Conclusiones: La mortalidad asociada al exceso de peso en Cuba es alta y requiere un enfoque efectivo multisectorial centrado en potenciar oportunidades para un mayor consumo de alimentos nutritivos e incremento de la actividad física(AU)

Introduction: Overweight and obesity mortality is preventable. Objective: to estimate the mortality attributable to overweight-obesity in the Cuban population aged 20 years or older. Method: descriptive study that used secondary data sources for prevalence of overweight and obesity and mortality data from selected non-transmissible diseases: diabetes, cancer and cardiovascular diseases. The impact of excess weight on mortality was obtained by calculating the population attributable fractions from relative risks from previous studies. The attributable mortality by cause and sex was calculated. Results: of the total number of deaths (30 656), 3 785 were attributed to overweight and obesity: 12.3 percent. In men, 8.1 percent; in women, 16.8 percent. Regarding the deaths from all causes reported in the year for this age group and sex, the percentages were 4 percent, 2.4 percent and 5.7 percent, respectively. Cardiovascular disease was the most frequent cause of attributable mortality: 53 percent of the total. The second cause was type II diabetes mellitus: 25 percent and in turn, the specific cause in which excess weight had a greater contribution: 63 percent. In men, half of the deaths (49 percent) were attributed to overweight or obesity; in women, seven out of ten deaths (72 percent). Conclusions: The mortality associated with overweight in Cuba is high and requires an effective multisectorial approach focused on enhancing opportunities for greater consumption of nutritious foods and increased physical activity(AU)

Enfermedades no transmisibles: factores de riesgo y acciones para su prevención y control en Cuba

[RESUMEN]. Las enfermedades no transmisibles (ENT) representan uno de los mayores desafíos para el desarrollo en el siglo XXI, debido al devastador impacto social, económico y de la salud pública que provocan. El propósito de este artículo es describir la evolución y los factores de riesgo de las ENT en Cuba, principalmente en el período 1990–2015, reseñar las acciones emprendidas por el Ministerio de Salud Pública y destacar los desafíos más importantes para su prevención y control. La información contenida proviene de los datos colectados y publicados por la Dirección de Registros Médicos y Estadísticas de Salud, investigaciones sobre los factores de riesgo, otros estudios fundamentados y la documentación de acciones integrales. La mortalidad en Cuba está determinada por cuatro grandes problemas de salud: enfermedades cardiovasculares, tumores malignos, enfermedades crónicas de las vías respiratorias inferiores y diabetes mellitus, que en conjunto causan el 68,0% de los fallecimientos. La tendencia del cáncer es al ascenso y la enfermedad renal crónica emerge como un grave problema de salud. Cuba cuenta con una línea de base conocida sobre los factores de riesgo, de ellos la hipertensión y el consumo de tabaco son los principales relacionados con la mortalidad por ENT. En consonancia con la importancia de estas enfermedades se aprecian hitos e intervenciones de impacto positivo, así como brechas y desafíos en el marco del Plan de Acción Mundial de la Organización Mundial de la Salud para el enfrentamiento a las ENT.

[ABSTRACT]. Non-communicable diseases (NCDs) represent one of the greatest challenges for development of the 21st century due to their devastating social, economic and public health impact. The objective of this article are to describe the evolution and risk factors for NCDs in Cuba, mainly in the period 1990–2015, to outline actions undertaken by the Ministry of Public Health of Cuba, and to highlight the most important challenges with a focus on their prevention and control. The information is based on data collected and published by the Directorate of Medical Records and Health Statistics, research on risk factors, other studies and documentation of comprehensive actions. Mortality in Cuba is determined by four major health problems: cardiovascular diseases, malignant tumors, chronic diseases of the lower respiratory tract and diabetes mellitus, which together cause 68.0% of deaths. Cancer presents a growing trend, and chronic kidney disease emerges as a serious health problem. Cuba has a known baseline on risk factors, and hypertension and tobacco consumption are the main factors related to NCDs mortality. In line with the importance of these diseases, there are milestones and interventions with a positive impact, as well as gaps and challenges within the framework of the World Health Organization’s Global Action Plan for the Prevention and Control of NCDs.

[RESUMO]. As doenças não transmissíveis (DNT) representam um dos maiores desafios do século 21 para o desenvolvimento devido ao desvastador impacto social, econômico e de saúde pública que elas causam. O objetivo deste artigo é descrever a evolução e os fatores de risco das doenças não transmissíveis em Cuba, principalmente no período de 1990–2015, para delinear as ações realizadas pelo Ministério da Saúde Pública de Cuba e destacar os desafios mais importantes para sua prevenção e controle. A informação vem dos dados coletados e publicados pela Diretoria de Registros Médicos e Estatísticas de Saúde, pesquisa sobre fatores de risco, outros estudos fundamentados e documentação de ações abrangentes. A mortalidade em Cuba é determinada por quatro principais problemas de saúde: doenças cardiovasculares, tumores malignos, doenças crônicas do trato respiratório inferior e diabetes mellitus, que em conjunto causam 68,0% das mortes. O câncer tem uma tendência crescente, e a doença renal crônica surge como um grave problema de saúde. Cuba tem uma linha de base conhecida sobre os fatores de risco, dos quais a hipertensão e o consumo de tabaco são os principais relacionados à mortalidade por DNT. Em consonância com a importância dessas doenças, há marcos e intervenções com impacto positivo, bem como lacunas e desafios no âmbito do Plano de Ação Mundial da Organização Mundial da Saúde para enfrentar as doenças não transmissíveis.

[Non-communicable diseases: risk factors and actions for their prevention and control in CubaDoenças não transmissíveis: fatores de risco e ações para sua prevenção e controle em Cuba]. / Enfermedades no transmisibles: factores de riesgo y acciones para su prevención y control en Cuba.

Non-communicable diseases (NCDs) represent one of the greatest challenges for development of the 21st century due to their devastating social, economic and public health impact. The objective of this article are to describe the evolution and risk factors for NCDs in Cuba, mainly in the period 1990-2015, to outline actions undertaken by the Ministry of Public Health of Cuba, and to highlight the most important challenges with a focus on their prevention and control. The information is based on data collected and published by the Directorate of Medical Records and Health Statistics, research on risk factors, other studies and documentation of comprehensive actions. Mortality in Cuba is determined by four major health problems: cardiovascular diseases, malignant tumors, chronic diseases of the lower respiratory tract and diabetes mellitus, which together cause 68.0% of deaths. Cancer presents a growing trend, and chronic kidney disease emerges as a serious health problem. Cuba has a known baseline on risk factors, and hypertension and tobacco consumption are the main factors related to NCDs mortality. In line with the importance of these diseases, there are milestones and interventions with a positive impact, as well as gaps and challenges within the framework of the World Health Organization's Global Action Plan for the Prevention and Control of NCDs.

As doenças não transmissíveis (DNT) representam um dos maiores desafios do século 21 para o desenvolvimento devido ao desvastador impacto social, econômico e de saúde pública que elas causam. O objetivo deste artigo é descrever a evolução e os fatores de risco das doenças não transmissíveis em Cuba, principalmente no período de 1990­2015, para delinear as ações realizadas pelo Ministério da Saúde Pública de Cuba e destacar os desafios mais importantes para sua prevenção e controle. A informação vem dos dados coletados e publicados pela Diretoria de Registros Médicos e Estatísticas de Saúde, pesquisa sobre fatores de risco, outros estudos fundamentados e documentação de ações abrangentes. A mortalidade em Cuba é determinada por quatro principais problemas de saúde: doenças cardiovasculares, tumores malignos, doenças crônicas do trato respiratório inferior e diabetes mellitus, que em conjunto causam 68,0% das mortes. O câncer tem uma tendência crescente, e a doença renal crônica surge como um grave problema de saúde. Cuba tem uma linha de base conhecida sobre os fatores de risco, dos quais a hipertensão e o consumo de tabaco são os principais relacionados à mortalidade por DNT. Em consonância com a importância dessas doenças, há marcos e intervenções com impacto positivo, bem como lacunas e desafios no âmbito do Plano de Ação Mundial da Organização Mundial da Saúde para enfrentar as doenças não transmissíveis.

Enfermedades no transmisibles: factores de riesgo y acciones para su prevención y control en Cuba / Non-communicable diseases: risk factors and actions for their prevention and control in Cuba / Doenças não transmissíveis: fatores de risco e ações para sua prevenção e controle em Cuba

RESUMEN Las enfermedades no transmisibles (ENT) representan uno de los mayores desafíos para el desarrollo en el siglo XXI, debido al devastador impacto social, económico y de la salud pública que provocan. El propósito de este artículo es describir la evolución y los factores de riesgo de las ENT en Cuba, principalmente en el período 1990-2015, reseñar las acciones emprendidas por el Ministerio de Salud Pública y destacar los desafíos más importantes para su prevención y control. La información contenida proviene de los datos colectados y publicados por la Dirección de Registros Médicos y Estadísticas de Salud, investigaciones sobre los factores de riesgo, otros estudios fundamentados y la documentación de acciones integrales. La mortalidad en Cuba está determinada por cuatro grandes problemas de salud: enfermedades cardiovasculares, tumores malignos, enfermedades crónicas de las vías respiratorias inferiores y diabetes mellitus, que en conjunto causan el 68,0% de los fallecimientos. La tendencia del cáncer es al ascenso y la enfermedad renal crónica emerge como un grave problema de salud. Cuba cuenta con una línea de base conocida sobre los factores de riesgo, de ellos la hipertensión y el consumo de tabaco son los principales relacionados con la mortalidad por ENT. En consonancia con la importancia de estas enfermedades se aprecian hitos e intervenciones de impacto positivo, así como brechas y desafíos en el marco del Plan de Acción Mundial de la Organización Mundial de la Salud para el enfrentamiento a las ENT.

ABSTRACT Non-communicable diseases (NCDs) represent one of the greatest challenges for development of the 21st century due to their devastating social, economic and public health impact. The objective of this article are to describe the evolution and risk factors for NCDs in Cuba, mainly in the period 1990-2015, to outline actions undertaken by the Ministry of Public Health of Cuba, and to highlight the most important challenges with a focus on their prevention and control. The information is based on data collected and published by the Directorate of Medical Records and Health Statistics, research on risk factors, other studies and documentation of comprehensive actions. Mortality in Cuba is determined by four major health problems: cardiovascular diseases, malignant tumors, chronic diseases of the lower respiratory tract and diabetes mellitus, which together cause 68.0% of deaths. Cancer presents a growing trend, and chronic kidney disease emerges as a serious health problem. Cuba has a known baseline on risk factors, and hypertension and tobacco consumption are the main factors related to NCDs mortality. In line with the importance of these diseases, there are milestones and interventions with a positive impact, as well as gaps and challenges within the framework of the World Health Organization's Global Action Plan for the Prevention and Control of NCDs.

RESUMO As doenças não transmissíveis (DNT) representam um dos maiores desafios do século 21 para o desenvolvimento devido ao desvastador impacto social, econômico e de saúde pública que elas causam. O objetivo deste artigo é descrever a evolução e os fatores de risco das doenças não transmissíveis em Cuba, principalmente no período de 1990-2015, para delinear as ações realizadas pelo Ministério da Saúde Pública de Cuba e destacar os desafios mais importantes para sua prevenção e controle. A informação vem dos dados coletados e publicados pela Diretoria de Registros Médicos e Estatísticas de Saúde, pesquisa sobre fatores de risco, outros estudos fundamentados e documentação de ações abrangentes. A mortalidade em Cuba é determinada por quatro principais problemas de saúde: doenças cardiovasculares, tumores malignos, doenças crônicas do trato respiratório inferior e diabetes mellitus, que em conjunto causam 68,0% das mortes. O câncer tem uma tendência crescente, e a doença renal crônica surge como um grave problema de saúde. Cuba tem uma linha de base conhecida sobre os fatores de risco, dos quais a hipertensão e o consumo de tabaco são os principais relacionados à mortalidade por DNT. Em consonância com a importância dessas doenças, há marcos e intervenções com impacto positivo, bem como lacunas e desafios no âmbito do Plano de Ação Mundial da Organização Mundial da Saúde para enfrentar as doenças não transmissíveis.

Patterns of Physical Activity and Associated Factors in Cubans Aged 15-69 Years.

INTRODUCTION Systematic measurement of population physical activity levels is an important component of public health surveillance. OBJECTIVES Describe patterns of physical activity in the Cuban population aged 15-69 years and identify factors associated with regular physical activity. METHODS A descriptive cross-sectional study was conducted using a complex sampling design, representative of urban and rural areas, sex and age groups, including 7915 individuals. The International Physical Activity Questionnaire (short format) was applied. The population was classified as active, irregularly active and sedentary, according to sex, age, marital status, education, skin color, employment and perception of health risk related to physical inactivity or overweight. Percentages, odds ratios (OR) and 95% confidence intervals (CI) were calculated and a multinomial regression model was fitted with active persons as the reference category. RESULTS Approximately 71% of the population self-classified as active, 23% as sedentary and 5.9% as irregularly active. Women had a higher probability of being sedentary (OR 2.51, CI 2.12-2.98) and irregularly active (OR 2.56, CI 95% 1.87-3.49). The probability of being sedentary increased with age (OR 1.19, CI 1.12-1.26), and also with the condition of being a homemaker, retired, or unemployed. Perceiving overweight as a high risk to health reduced likelihood of inactivity (OR 0.49, CI 0.29-0.83). CONCLUSIONS Some 7 of 10 Cubans are physically active. The groups with the highest probability of inactivity and irregular activity and associated factors have been identified through national application (for the first time) of the International Physical Activity Questionnaire. The results should be taken into account for implementation of specialized strategies to promote systematic physical activity. KEYWORDS Physical activity, physical exercise, sedentary lifestyle, health behavior, risk factors, chronic disease, women's health, surveillance, Cuba.

Tabaquismo y percepción del riesgo de fumar en trabajadores de la educación, 2010-2011 / Smoking and smoking risk perception in Cuban education workers, 2010-2011

Objetivos: determinar prevalencia y características del tabaquismo activo-pasivo, y describir la percepción del riesgo de exposición al humo de tabaco ajeno en el ámbito escolar. Métodos: estudio observacional transversal realizado entre 2010-2011. Se aplicó cuestionario a 1 959 trabajadores de 50 escuelas cubanas. Las preguntas se relacionaron, entre otros, con variables sociodemográficas, uso de productos del tabaco, conocimientos y actitudes hacia el tabaquismo, políticas en las instituciones escolares y acerca de la percepción del riesgo de la exposición. Se calcularon porcentajes, intervalo de confianza de 95 por ciento y se modeló la probabilidad de recomendación de abandono de fumar. Resultados: la prevalencia actual de tabaquismo fue de 33 por ciento (30,2-34,9) con 32,0 por ciento entre los profesores. El 88 por ciento declaró la existencia de regulaciones para fumar en la escuela. El 82 por ciento manifestó influencia del consumo de los profesores sobre el consumo de los estudiantes y el 60 por ciento estuvo expuestos al humo de tabaco ajeno. El 77 por ciento valoró como muy riesgosa la relación fumar-salud. No incluir el tema del tabaquismo en el programa escolar ni realizar actividades de prevención extra aula y considerar poco o nada riesgoso fumar activa-pasivamente, redujeron la probabilidad de recomendación de abandono de fumar. Conclusiones: la alta prevalencia de tabaquismo en los trabajadores, insuficiente preparación para abordar con efectividad la prevención y el control y el poco cumplimiento de las regulaciones establecidas, constituyen barreras objetivas para la toma de medidas que limiten la adicción en el ámbito escolar(AU)

Objectives: to determine the prevalence and characteristics of active/passive smoking and to describe the risk perception of exposure to second hand smoke in the school setting. Methods: observational and cross-sectional study conducted from 2010 to 2011. To this end, a questionnaire was given to 1 959 workers from 50 Cuban schools to collect their answers. The questions were related, among other issues, with socio-demographic variables, uses of cigar products, knowledge, attitudes toward smoking, policies established at the schools and perception of exposure risk. Percentages and 95 percent confidence intervals were estimated and the probabilities of advising to quit smoking were modeled. Results: the current prevalence of smoking was 33 percent (30.2-34.9); 32 percent among professors. In the sample, 88 percent stated that there were regulations on smoking at school. Eighty two percent admitted that smoking habit in professors had some influence in their students smoking whereas 60 percent were second-hand smokers. In the group, 77 percent assessed the smoking- health relationship as very risky. The non-inclusion of the topic of smoking in the curriculum, the non-existence of preventive activities outside the classroom and the evaluation of active and passive smoking as little dangerous or riskless decreased the probabilities of advising people to quit smoking. Conclusions: high prevalence of smoking in education workers, poor preparation to effectively address prevention and control of the habit and the non-compliance with set regulations are objective barriers to the decision-making on the restriction of this addiction in the school setting(AU)

Tabaquismo y percepción del riesgo de fumar en trabajadores de la educación, 2010-2011 / Smoking and smoking risk perception in Cuban education workers, 2010-2011

Objetivos: determinar prevalencia y características del tabaquismo activo-pasivo, y describir la percepción del riesgo de exposición al humo de tabaco ajeno en el ámbito escolar. Métodos: estudio observacional transversal realizado entre 2010-2011. Se aplicó cuestionario a 1 959 trabajadores de 50 escuelas cubanas. Las preguntas se relacionaron, entre otros, con variables sociodemográficas, uso de productos del tabaco, conocimientos y actitudes hacia el tabaquismo, políticas en las instituciones escolares y acerca de la percepción del riesgo de la exposición. Se calcularon porcentajes, intervalo de confianza de 95 por ciento y se modeló la probabilidad de recomendación de abandono de fumar. Resultados: la prevalencia actual de tabaquismo fue de 33 por ciento (30,2-34,9) con 32,0 por ciento entre los profesores. El 88 por ciento declaró la existencia de regulaciones para fumar en la escuela. El 82 por ciento manifestó influencia del consumo de los profesores sobre el consumo de los estudiantes y el 60 por ciento estuvo expuestos al humo de tabaco ajeno. El 77 por ciento valoró como muy riesgosa la relación fumar-salud. No incluir el tema del tabaquismo en el programa escolar ni realizar actividades de prevención extra aula y considerar poco o nada riesgoso fumar activa-pasivamente, redujeron la probabilidad de recomendación de abandono de fumar. Conclusiones: la alta prevalencia de tabaquismo en los trabajadores, insuficiente preparación para abordar con efectividad la prevención y el control y el poco cumplimiento de las regulaciones establecidas, constituyen barreras objetivas para la toma de medidas que limiten la adicción en el ámbito escolar(AU)

Objectives: to determine the prevalence and characteristics of active/passive smoking and to describe the risk perception of exposure to second hand smoke in the school setting. Methods: observational and cross-sectional study conducted from 2010 to 2011. To this end, a questionnaire was given to 1 959 workers from 50 Cuban schools to collect their answers. The questions were related, among other issues, with socio-demographic variables, uses of cigar products, knowledge, attitudes toward smoking, policies established at the schools and perception of exposure risk. Percentages and 95 percent confidence intervals were estimated and the probabilities of advising to quit smoking were modeled. Results: the current prevalence of smoking was 33 percent (30.2-34.9); 32 percent among professors. In the sample, 88 percent stated that there were regulations on smoking at school. Eighty two percent admitted that smoking habit in professors had some influence in their student's smoking whereas 60 percent were second-hand smokers. In the group, 77 percent assessed the smoking- health relationship as very risky. The non-inclusion of the topic of smoking in the curriculum, the non-existence of preventive activities outside the classroom and the evaluation of active and passive smoking as little dangerous or riskless decreased the probabilities of advising people to quit smoking. Conclusions: high prevalence of smoking in education workers, poor preparation to effectively address prevention and control of the habit and the non-compliance with set regulations are objective barriers to the decision-making on the restriction of this addiction in the school setting(AU)

Rinitis alérgica, prevalencia y factores de riesgo en adolescentes cubanos / Allergic rhinitis, prevalence and risk factors among Cuban adolescents

Introducción: la rinitis alérgica es una afección común que afecta el 10 por ciento-30 por ciento de la población mundial. Se desconoce la prevalencia y los factores de riesgo a escala nacional. Objetivo: estimar la prevalencia de los factores de riesgo de rinitis alérgica en adolescentes de 13 y 14 años. Métodos: estudio descriptivo transversal. Diseño muestral complejo. Encuestados 5 799 escolares (áreas urbanas y rurales del país). Se aplicó el cuestionario Estudio Internacional de Asma y Alergias en la Infancia. Se añadieron variables para evaluar exposición a posibles factores de riesgo. Se calcularon razones de disparidad (IC 95 por ciento) y se trabajaron modelos de regresión logística. Se realizó revisión bibliográfica actualizada, periodo 2008-2013, para contrastar los datos obtenidos en la encuesta nacional con los referidos en la literatura internacional. Resultados: participación de estudiantes: 86 por ciento. Prevalencia de rinitis en los últimos 12 meses: 38 por ciento; rinoconjuntivitis, 29 por ciento. Se asoció significativamente a sexo femenino: 1,68 (1,66-1,70), historia familiar de asma-alergia: 2,02 (1,99-2,05), convivencia con fumadores: 1,09 (1,07-1,11), hacinamiento en vivienda: 1,14 (1,12-1,16), ventilación inadecuada: 1,15 (1,13-1,16), tenencia de mascotas: perro, 1,25 (1,23-1,27), ubicación de vivienda y escuela en avenidas principales: 1,27 (1,24-1,29) y 1,10 (1,08-1,12) respectivamente y solucionar problemas en el núcleo familiar peleando o conversando: 1,31 (1,28-1,33). Conclusiones: la rinitis alérgica es una condición frecuente y subdiagnosticada en los adolescentes cubanos. La mayoría de los factores de riesgo identificados son modificables. La vigencia de los hallazgos encontrados descansa en que la dinámica de las enfermedades crónicas no se observan variaciones a corto plazo. Se construyó una línea de base a escala nacional, que permitirá la evaluación de la efectividad de acciones preventivas y de control(AU)

Introduction: Allergic rhinitis is a common condition affecting 10 percent-30 percent of the world population. The prevalence and risk factors for allergic rhinitis on a national scale are not known. Objective: Estimate the prevalence and risk factors for allergic rhinitis among 13- and 14-year-old adolescents. Methods: Descriptive cross-sectional study. Complex sampling design. 5 799 school children from urban and rural areas were surveyed using the questionnaire International Study of Asthma and Allergies in Childhood. Variables were added to include exposure to potential risk factors. Odds ratios (CI 95 percent) were estimated and logistic regression models were developed. An updated bibliographic review was conducted of the 2008-2013 period to contrast the data obtained by the national survey with those in the international literature. Results: Participation of students: 86 percent. Prevalence of rhinitis in the last 12 months: 38 percent; rhinoconjunctivitis: 29 percent. The condition was significantly associated with the following variables: female sex: 1,68 (1,66-1,70); a family history of asthma-allergy: 2,02 (1,99-2,05); living with smokers: 1,09 (1,07-1,11); overcrowded household: 1,14 (1,12-1,16); inadequate ventilation: 1,15 (1,13-1,16); pet ownership: dog: 1,25 (1,23-1,27); location of the home and school on main avenues: 1,27 (1,24-1,29) and 1,10 (1,08-1,12), respectively; and dealing with family problems by talking or fighting: 1,31 (1,28-1,33). Conclusions: Allergic rhinitis is a frequent though underdiagnosed condition among Cuban adolescents. Most of the risk factors identified are modifiable. Currency of the findings rests on the fact that short-term variations are not typically found in the dynamics of chronic disease. A national baseline was developed which will permit evaluation of the effectiveness of prevention and control actions(AU)