Effects of red meat taxes and warning labels on food groups selected in a randomized controlled trial.

BACKGROUND: High consumption of red and processed meat contributes to both health and environmental harms. Warning labels and taxes for red meat reduce selection of red meat overall, but little is known about how these potential policies affect purchases of subcategories of red meat (e.g., processed versus unprocessed) or of non-red-meat foods (e.g., cheese, pulses) relevant to health and environmental outcomes. This study examined consumer responses to warning labels and taxes for red meat in a randomized controlled trial. METHODS: In October 2021, we recruited 3,518 US adults to complete a shopping task in a naturalistic online grocery store. Participants were randomly assigned to one of four arms: control (no warning labels or tax), warning labels only (health and environmental warning labels appeared next to products containing red meat), tax only (prices of products containing red meat were increased 30%) or combined warning labels + tax. Participants selected items to hypothetically purchase, which we categorized into food groups based on the presence of animal- and plant-source ingredients (e.g., beef, eggs, pulses), meat processing level (e.g., processed pork versus unprocessed pork), and meat species (e.g., beef versus pork). We assessed the effects of the warning labels and tax on selections from each food group. RESULTS: Compared to control, all three interventions led participants to select fewer items with processed meat (driven by reductions in processed pork) and (for the tax and warning labels + tax interventions only) fewer items with unprocessed meat (driven by reductions in unprocessed beef). All three interventions also led participants to select more items containing cheese, while only the combined warning labels + tax intervention led participants to select more items containing processed poultry. Except for an increase in selection of pulses in the tax arm, the interventions did not affect selections of fish or seafood (processed or unprocessed), eggs, or plant-based items (pulses, nuts & seeds, tofu, meat mimics, grains & potatoes, vegetables). CONCLUSIONS: Policies to reduce red meat consumption are also likely to affect consumption of other types of foods that are relevant to both health and environmental outcomes. TRIAL REGISTRATION: NCT04716010 on www. CLINICALTRIALS: gov .

Dietary quality and dietary greenhouse gas emissions in the USA: a comparison of the planetary health diet index, healthy eating index-2015, and dietary approaches to stop hypertension.

BACKGROUND: The Planetary Health Diet Index (PHDI) measures adherence to the dietary pattern presented by the EAT-Lancet Commission, which aligns health and sustainability targets. There is a need to understand how PHDI scores correlate with dietary greenhouse gas emissions (GHGE) and how this differs from the carbon footprints of scores on established dietary recommendations. The objectives of this study were to compare how the PHDI, Healthy Eating Index-2015 (HEI-2015) and Dietary Approaches to Stop Hypertension (DASH) relate to (a) dietary GHGE and (b) to examine the influence of PHDI food components on dietary GHGE. METHODS: We used life cycle assessment data from the Database of Food Recall Impacts on the Environment for Nutrition and Dietary Studies to calculate the mean dietary GHGE of 8,128 adult participants in the 2015-2016 and 2017-2018 cycles of the National Health and Nutrition Examination Survey (NHANES). Poisson regression was used to estimate the association of (a) quintiles of diet score and (b) standardized dietary index Z-scores with dietary GHGE for PHDI, HEI-2015, and DASH scores. In secondary analyses, we used Poisson regression to assess the influence of individual PHDI component scores on dietary GHGE. RESULTS: We found that higher dietary quality on all three indices was correlated with lower dietary GHGE. The magnitude of the dietary quality-dietary GHGE relationship was larger for PHDI [-0.4, 95% CI (-0.5, -0.3) kg CO2 equivalents per one standard deviation change] and for DASH [-0.5, (-0.4, -0.6) kg CO2-equivalents] than for HEI-2015 [-0.2, (-0.2, -0.3) kg CO2-equivalents]. When examining PHDI component scores, we found that diet-related GHGE were driven largely by red and processed meat intake. CONCLUSIONS: Improved dietary quality has the potential to lower the emissions impacts of US diets. Future efforts to promote healthy, sustainable diets could apply the recommendations of the established DASH guidelines as well as the new guidance provided by the PHDI to increase their environmental benefits.

Impact of taxes and warning labels on red meat purchases among US consumers: A randomized controlled trial.

BACKGROUND: Policies to reduce red meat intake are important for mitigating climate change and improving public health. We tested the impact of taxes and warning labels on red meat purchases in the United States. The main study question was, will taxes and warning labels reduce red meat purchases? METHODS AND FINDINGS: We recruited 3,518 US adults to participate in a shopping task in a naturalistic online grocery store from October 18, 2021 to October 28, 2021. Participants were randomized to one of 4 conditions: control (no tax or warning labels, n = 887), warning labels (health and environmental warning labels appeared next to products containing red meat, n = 891), tax (products containing red meat were subject to a 30% price increase, n = 874), or combined warning labels + tax (n = 866). We used fractional probit and Poisson regression models to assess the co-primary outcomes, percent, and count of red meat purchases, and linear regression to assess the secondary outcomes of nutrients purchased. Most participants identified as women, consumed red meat 2 or more times per week, and reported doing all of their household's grocery shopping. The warning, tax, and combined conditions led to lower percent of red meat-containing items purchased, with 39% (95% confidence interval (CI) [38%, 40%]) of control participants' purchases containing red meat, compared to 36% (95% CI [35%, 37%], p = 0.001) of warning participants, 34% (95% CI [33%, 35%], p < 0.001) of tax participants, and 31% (95% CI [30%, 32%], p < 0.001) of combined participants. A similar pattern was observed for count of red meat items. Compared to the control, the combined condition reduced calories purchased (-312.0 kcals, 95% CI [-590.3 kcals, -33.6 kcals], p = 0.027), while the tax (-10.4 g, 95% CI [-18.2 g, -2.5 g], p = 0.01) and combined (-12.8 g, 95% CI [-20.7 g, -4.9 g], p = 0.001) conditions reduced saturated fat purchases; no condition affected sodium purchases. Warning labels decreased the perceived healthfulness and environmental sustainability of red meat, while taxes increased perceived cost. The main limitations were that the study differed in sociodemographic characteristics from the US population, and only about 30% to 40% of the US population shops for groceries online. CONCLUSIONS: Warning labels and taxes reduced red meat purchases in a naturalistic online grocery store. Trial Registration: http://www.clinicaltrials.gov/ NCT04716010.

Pesticide exposure and child growth in low- and middle-income countries: A systematic review.

BACKGROUND: In low- and middle-income countries (LMICs), pesticides are widely used in agricultural and residential settings. Little is known about how pesticides affect child growth. OBJECTIVES: To systematically review and synthesise the evidence on the associations between pesticide exposure and adverse birth outcomes and/or impaired postnatal growth in children up to 5 years of age in LMICs. METHODS: We searched 10 databases from inception through November 2021. We included cohort and cross-sectional studies investigating associations between self-reported or measured prenatal or postnatal pesticide exposure and child growth (postnatal child linear/ponderal growth, and/or birth outcomes). Two researchers screened studies, extracted data, and assessed certainty using GRADE. The protocol was preregistered with PROSPERO (CRD42021292919). RESULTS: Of 939 records retrieved, 31 studies met inclusion criteria (11 cohort, 20 cross-sectional). All studies assessed prenatal exposure. Twenty-four studies reported on birth weight. Four found positive associations with organochlorines (0.01-0.25 standardised mean difference (SMD)) and two found negative associations (-0.009 SMD to -55 g). Negative associations with organophosphates (-170 g, n = 1) and pyrethroids (-97 to -233 g, n = 2) were also documented. Two (out of 15) studies reporting on birth length found positive associations with organochlorines (0.21-0.25 SMD) and one found negative associations (-0.25 to -0.32 SMD). Organophosphate exposure was negatively associated with birth length (-0.37 cm, n = 1). Organophosphate exposure was also associated with higher risk/prevalence of low birth weight (2 out of nine studies) and preterm birth (2 out of six studies). Certainty of the evidence was "very low" for all outcomes. CONCLUSION: The limited literature from LMICs shows inconclusive associations between prenatal pesticide exposure, child growth, and birth outcomes. Studies with accurate quantitative data on exposure to commonly used pesticides in LMICs using consistent methodologies in comparable populations are needed to better understand how pesticides influence child growth.

How Americans eat red and processed meat: an analysis of the contribution of thirteen different food groups.

OBJECTIVE: Dietary patterns characterised by high intake of red and processed meat are associated with detrimental health and environmental outcomes. To better understand how Americans consume red and processed meat, this study examined the food groups that are the greatest contributors to red and processed meat intake in US diets. DESIGN: Cross-sectional analysis of total red and processed meat, unprocessed red meat and processed meat using data from the National Health and Nutrition Examination Survey (2015-2016 and 2017-2018). Items containing red or processed meat were classified into thirteen mutually exclusive food groups. For highly consumed food groups (≥10 % of meat intake), contribution to meat intake was further assessed by source, sex, income and education. SETTING: Nationally representative sample of the US population. PARTICIPANTS: Teens (aged 12-19 years) and adults (aged ≥20 years) who reported meat consumption (n 8178). RESULTS: Meat mixed dishes (18·6 % (95 % CI 16·2, 20·9)), burgers (17·3 % (95 % CI 15·3, 19·3)) and beef excluding ground (17·0 % (95 % CI 13·8, 20·1)) were the top contributors to unprocessed red meat intake. For processed meat, four food groups made up about four-fifths of total intake: cold cuts and cured meats (37·7 % (95 % CI 34·6, 40·8)), sausages and frankfurters (20·3 % (95 % CI 18·6, 22·0)), bacon (14·0 % (95 % CI 12·3, 15·6)) and pizza (10·1 % (95 % CI 8·7, 11·5)). Fast-food restaurants were the top source for burgers and pizza, whereas stores were the top source for all other highly consumed food groups. Few differences were seen in patterns of intake by sociodemographic characteristics. CONCLUSIONS: No single food group accounts for a majority of meat intake in the USA. Many behaviour change opportunities for healthier, more sustainable substitutions exist.

Awareness of and reactions to health and environmental harms of red meat among parents in the United States.

OBJECTIVE: Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat. DESIGN: Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale. SETTING: Online survey. PARTICIPANTS: 544 US parents. RESULTS: A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60-2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05). CONCLUSIONS: Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.

Unmet need for hypercholesterolemia care in 35 low- and middle-income countries: A cross-sectional study of nationally representative surveys.

BACKGROUND: As the prevalence of hypercholesterolemia is increasing in low- and middle-income countries (LMICs), detailed evidence is urgently needed to guide the response of health systems to this epidemic. This study sought to quantify unmet need for hypercholesterolemia care among adults in 35 LMICs. METHODS AND FINDINGS: We pooled individual-level data from 129,040 respondents aged 15 years and older from 35 nationally representative surveys conducted between 2009 and 2018. Hypercholesterolemia care was quantified using cascade of care analyses in the pooled sample and by region, country income group, and country. Hypercholesterolemia was defined as (i) total cholesterol (TC) ≥240 mg/dL or self-reported lipid-lowering medication use and, alternatively, as (ii) low-density lipoprotein cholesterol (LDL-C) ≥160 mg/dL or self-reported lipid-lowering medication use. Stages of the care cascade for hypercholesterolemia were defined as follows: screened (prior to the survey), aware of diagnosis, treated (lifestyle advice and/or medication), and controlled (TC <200 mg/dL or LDL-C <130 mg/dL). We further estimated how age, sex, education, body mass index (BMI), current smoking, having diabetes, and having hypertension are associated with cascade progression using modified Poisson regression models with survey fixed effects. High TC prevalence was 7.1% (95% CI: 6.8% to 7.4%), and high LDL-C prevalence was 7.5% (95% CI: 7.1% to 7.9%). The cascade analysis showed that 43% (95% CI: 40% to 45%) of study participants with high TC and 47% (95% CI: 44% to 50%) with high LDL-C ever had their cholesterol measured prior to the survey. About 31% (95% CI: 29% to 33%) and 36% (95% CI: 33% to 38%) were aware of their diagnosis; 29% (95% CI: 28% to 31%) and 33% (95% CI: 31% to 36%) were treated; 7% (95% CI: 6% to 9%) and 19% (95% CI: 18% to 21%) were controlled. We found substantial heterogeneity in cascade performance across countries and higher performances in upper-middle-income countries and the Eastern Mediterranean, Europe, and Americas. Lipid screening was significantly associated with older age, female sex, higher education, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Awareness of diagnosis was significantly associated with older age, higher BMI, comorbid diagnosis of diabetes, and comorbid diagnosis of hypertension. Lastly, treatment of hypercholesterolemia was significantly associated with comorbid hypertension and diabetes, and control of lipid measures with comorbid diabetes. The main limitations of this study are a potential recall bias in self-reported information on received health services as well as diminished comparability due to varying survey years and varying lipid guideline application across country and clinical settings. CONCLUSIONS: Cascade performance was poor across all stages, indicating large unmet need for hypercholesterolemia care in this sample of LMICs-calling for greater policy and research attention toward this cardiovascular disease (CVD) risk factor and highlighting opportunities for improved prevention of CVD.

Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data.

BACKGROUND: Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. METHODS AND FINDINGS: We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. CONCLUSIONS: This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

Testing front-of-package warnings to discourage red meat consumption: a randomized experiment with US meat consumers.

BACKGROUND: Reducing red meat is a strategy to improve public health and mitigate climate change in the United States and other high-income countries. Policies requiring warnings on the front of red meat packages are a promising intervention to shift consumers towards healthier and more sustainable food choices. We aimed to explore participants' reactions to health and environmental warning messages about red meat. METHODS: Between June and July 2020, we recruited a national convenience sample of US red meat consumers (n = 1,235; mean age 44 years) for an online survey. Participants were randomly assigned to one of four label conditions: no-label control, health warning, environment warning, and combined health and environment warning (both warnings shown side-by-side). Participants viewed three types of burritos (red meat [steak], chicken, and vegetarian) and selected their preferred item (primary outcome), the item they perceived to be most damaging to health, and the item they perceived to be most damaging to the environment (secondary outcomes). Participants then viewed their assigned warning on a series of other red meat products (no-label control participants were randomly re-assigned to one of the warning conditions) and rated the warnings on perceived message effectiveness, believability, negative emotions, perceived risk, attention, and learning something new. Finally, participants reported their intentions to reduce red meat consumption. RESULTS: There were no significant differences in selection of the steak burrito between label conditions or in selection of the item most damaging to the environment. Those exposed to the health warning were more likely to select the steak burrito as most damaging to health compared to those exposed to other label conditions (health 73 %, combined 64 %, environment 60 %, no-label control 63 %, p < 0.05). The combined and health warnings elicited higher perceived message effectiveness ratings than the environment warning (combined mean 2.91, health 2.84, environment 2.61, p < 0.05). CONCLUSIONS: Warnings did not have a significant effect on item preference in the choice experiment. However, combined and health warnings performed better than the environment warning across a variety of warning label reaction measures. More research will be needed to understand whether warnings elicit behavioral change in real-world environments. TRIAL REGISTRATION: Analyses and hypotheses were preregistered on https://aspredicted.org/ph7mb.pdf on 23 June 2020.

Cross-country comparison of dietary patterns and overweight and obesity among adult women in urban Sub-Saharan Africa.

OBJECTIVE: To derive dietary patterns (DP) among women of reproductive age (WRA) and older women in urban Sub-Saharan Africa (SSA), and to examine their association with body mass index (BMI), overweight and obesity. DESIGN: We used principal component analysis to derive DP. Their association with BMI, overweight and obesity was assessed using linear and multinomial logistic regression models controlling for age, marital status, education and wealth. SETTING: Cross-sectional data from prospective studies in Accra, Ghana (2008-2009), Dar es Salaam, Tanzania (2014) and Lilongwe and Kasungu, Malawi (2017-2018) were used. PARTICIPANTS: We compared WRA in Ghana (18-54 years, n 1762) and Malawi (19-48 years, n 137), and older women in Ghana (≥55 years, n 514) and Tanzania (≥50 years, n 134). RESULTS: Among WRA, protein and healthy DP were identified in both Ghana and Malawi. In Ghana, the protein DP was associated with higher odds of overweight or obesity (adjusted OR 1·82, 95 % CI 1·27, 2·60 for quintile 2). Among older women, three DP were identified in Ghana (cereal, protein and healthy) and two DP in Tanzania (protein and healthy). The protein DP was associated with higher BMI in Ghana (adjusted mean difference 2·83, 95 % CI 0·95, 4·71 for quartile 3). CONCLUSIONS: Higher quintiles of the protein DP were associated with higher BMI and odds of overweight or obesity among women in urban Ghana, but not in Malawi or Tanzania. Further research is needed to understand how DP influence overweight and obesity among adult women in urban SSA.

Food purchasing decisions of Malawian mothers with young children in households experiencing the nutrition transition.

As overweight/obesity prevalence increases in sub-Saharan Africa, information is needed about factors influencing food purchases in households with overweight members. This study assessed food purchasing decisions of Malawian mothers with young children (N = 54 dry season, N = 55 rainy season) among whom the mother, child, or both were overweight. Research assistants completed structured observations of mothers shopping for food during the dry season and of the types and quantities of foods in mothers' homes during the rainy season. After each observation, research assistants conducted an in-depth interview about factors that influenced food purchases, including asking mothers to sort 12 factors into piles that always, sometimes, or never influence their food purchases. Observations showed mothers most often shopped at outdoor markets to buy foods needed to prepare relish, such as tomatoes (71%), green leafy vegetables (58%), cooking oil (58%), and fish (40%). At home, maize flour (80%) and salt (66%) were the most common foods. Pile sorts and in-depth interviews revealed cost, taste preferences, freshness, and healthiness were the strongest factors influencing food purchases. Mothers described buying a smaller quantity or making substitutions (e.g., fish instead of meat) if a food is too expensive. Many mothers reported buying foods their family likes and prioritizing children's preferences. Freshness of foods, especially fruits and vegetables, and whether foods were perceived to be healthy also influenced food purchases, but mothers' knowledge of which foods were healthy was mixed. Mothers used some of their minimal funds to buy unhealthy foods (e.g., packaged or fried snacks) for their children, despite their overall emphasis on food cost and healthiness. These findings can be used by programs to reinforce healthy and decrease unhealthy food purchases by mothers with young children in Malawi.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults.

BACKGROUND: Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage. METHODS: In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval. FINDINGS: Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade. INTERPRETATION: Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage. FUNDING: Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Improving management of type 2 diabetes, hypertension and dyslipidaemia in the Caribbean: a systematic review of intervention studies.

OBJECTIVE: To evaluate published interventions aimed at improving the management of type 2 diabetes, hypertension and dyslipidaemia in the Caribbean. METHODS: We conducted a systematic review of four databases in accordance with PRISMA guidelines. Inclusion criteria were conducted in the Caribbean among adults ≥ 18 years who had type 2 diabetes, hypertension or dyslipidaemia; controlled trials, interventions, or comparative studies with pre-post designs and reported on at least one of the clinical outcomes of interest. RESULTS: Seventeen studies met the criteria for inclusion. The majority were conducted in Cuba and Trinidad and Tobago, and 35% were conducted over 10 years ago. Samples were small and largely consisted of older adult females and patients with type 2 diabetes. Four of eight (50%) studies that reported on HbA1c, 5 of 12 (42%) that reported on blood pressure and 2 of 7 (29%) that reported on body mass index observed significant improvements. Study heterogeneity precluded our ability to conduct a meta-analysis. The overall quality of evidence based on GRADE criteria was low for all outcomes assessed. CONCLUSION: There is insufficient evidence on interventions to address type 2 diabetes, hypertension and dyslipidaemia in the Caribbean.

OBJECTIF: Evaluer les interventions publiées visant à améliorer la prise en charge du diabète de type 2, de l'hypertension et de la dyslipidémie dans les Caraïbes. MÉTHODES: Nous avons effectué une revue systématique de quatre bases de données conformément aux directives PRISMA. Les critères d'inclusion étaient: menée dans les Caraïbes auprès d'adultes de 18 ans et plus qui souffraient de diabète de type 2, d'hypertension ou de dyslipidémie; essais contrôlés, interventions ou études comparatives avec des conceptions pré/post; et rapportant au moins 1 des résultats cliniques d'intérêt. RÉSULTATS: 17 études répondaient aux critères d'inclusion. La majorité a été réalisée à Cuba et à Trinité-et-Tobago et 35% ont été réalisées il y a plus de 10 ans. Les échantillons étaient petits et portaient en grande partie sur des femmes adultes plus âgées et des patients atteints de diabète de type 2. Quatre des 8 études (50%) qui rapportaient sur l'HbA1c, 5 des 12 (42%) qui rapportaient sur la pression artérielle et 2 des 7 (29%) qui rapportaient sur l'indice de masse corporelle ont observé des améliorations significatives. L'hétérogénéité de l'étude a empêché notre capacité de mener une méta-analyse. La qualité globale des données basées sur les critères de GRADE était faible pour résultats évalués. CONCLUSION: Il n'y a pas suffisamment de données sur les interventions pour lutter contre le diabète de type 2, l'hypertension et la dyslipidémie dans les Caraïbes.

Metabolic syndrome among children aged 6 to 11 years, Al Ain, United Arab Emirates: Role of obesity.

OBJECTIVES: To evaluate the association of metabolic syndrome with the varying degrees of obesity among children aged 6 to 11 years in Al Ain, United Arab Emirates (UAE). METHODS: As an ancillary to the primary study examining prevalence of MetS in a random sample of 1186 adolescents from 114 schools in Al Ain, parents and siblings aged 6 to 11 years were invited to participate in this study. After informed consent from parents and assent from children, trained nurses administered questionnaires to assess socio-demographic and lifestyle variables and conducted anthropometric measurements. Fasting blood samples were drawn to measure plasma lipids and glucose. We used Centers for Diseases Control and Prevention (CDC)-defined categories of body mass index (BMI = kg/m2 ) for normal weight (<85th percentile), overweight (≥85th to 94th percentile), and obese (≥95th percentiles). MetS was defined according to National Cholesterol Education Program's (NCEP)/Adult Treatment Panel III (ATP III) criteria. RESULTS: Of the total 234 siblings aged 6 to 11 years, 8.9% (95% Confidence Interval [CI]: 5.6-13.4) had MetS. The prevalence of MetS increased with the severity of obesity, 4.5% in normal, 16.7% in overweight, and 30.0% in obese subjects. The age, sex, and ethnicity adjusted odds (1.55, 95% CI: 1.23-1.96) of MetS increased significantly with per unit increase in BMI. CONCLUSIONS: The prevalence of MetS in study subjects increased with an increase in BMI. School-based interventions targeting metabolic risks in this population are urgently needed.

Longitudinal association of biomarkers of pesticide exposure with cardiovascular disease risk factors in youth with diabetes.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death among individuals with diabetes, but little is known about the role of exposures to environmental chemicals such as pesticides in the early development of CVD risk in this population. OBJECTIVES: To describe changes over time in concentrations of pesticide biomarkers among youth with diabetes in the United States and to estimate the longitudinal association between these concentrations and established risk factors for CVD. METHODS: Pesticide biomarkers were quantified in urine and serum samples from 87 youth with diabetes participating in the multi-center SEARCH cohort study. Samples were obtained around the time of diagnosis (baseline visit, between 2006 and 2010) and, on average, 5.4 years later (follow-up visit, between 2012 and 2015). We calculated geometric mean (95% CI) pesticide biomarker concentrations. Eight CVD risk factors were measured at these two time points: body mass index (BMI) z-score, HbA1c, insulin sensitivity, fasting C-peptide (FCP), LDL cholesterol, HDL cholesterol, total cholesterol, and triglycerides. Linear regression models were used to estimate the associations between each pesticide biomarker at baseline and each CVD risk factor at follow-up, adjusting for baseline health outcome, elapsed time between baseline and follow up, sex, age, race/ethnicity, and diabetes type. RESULTS: Participants were, on average, 14.2 years old at their baseline visit, and most were diagnosed with type 1 diabetes (57.5%). 4-nitrophenol, 3-phenoxybenzoic acid, 2,4-dichlorophenoxyacetic acid (2,4-D), 3,5,6-trichloro-2-pyridinol, 2,2-bis(4-chlorophenyl)-1,1-dichloroethene, and hexachlorobenzene were detected in a majority of participants at both time points. Participants in the highest quartile of 2,4-D and 4-nitrophenol at baseline had HbA1c levels at follow-up that were 1.05 percentage points (95% CI: -0.40, 2.51) and 1.27 percentage points (0.22, 2.75) higher, respectively, than participants in the lowest quartile of these pesticide biomarkers at baseline. These participants also had lower log FCP levels (indicating reduced beta-cell function) compared to participants in the lowest quartile at baseline: beta (95% CI) for log FCP of -0.64 (-1.17, -0.11) for 2,4-D and -0.39 (-0.96, 0.18) for 4-nitrophenol. In other words, participants in the highest quartile of 2,4-D had a 47.3% lower FCP level compared to participants in the lowest quartile, and those in the highest quartile of 4-nitrophenol had a 32.3% lower FCP level than those in the lowest quartile. Participants with trans-nonachlor concentrations in the highest quartile at baseline had HbA1c levels that were 1.45 percentage points (-0.11, 3.01) higher and log FCP levels that were -0.28 (-0.84, 0.28) lower than participants in the lowest quartile at baseline, that is to say, participants in the highest quartile of trans-nonachlor had a 24.4% lower FCP level than those in the lowest quartile. While not all of these results were statistically significant, potentially due to the small same size, clinically, there appears to be quantitative differences. No associations were observed between any pesticide biomarker at baseline with BMI z-score or insulin sensitivity at follow-up. CONCLUSIONS: Exposure to select pesticides may be associated with impaired beta-cell function and poorer glycemic control among youth with diabetes.

Evaluation of sex differences in dietary behaviours and their relationship with cardiovascular risk factors: a cross-sectional study of nationally representative surveys in seven low- and middle-income countries.

BACKGROUND: Cardiovascular diseases (CVD) are the leading causes of death for men and women in low-and-middle income countries (LMIC). The nutrition transition to diets high in salt, fat and sugar and low in fruit and vegetables, in parallel with increasing prevalence of diet-related CVD risk factors in LMICs, identifies the need for urgent action to reverse this trend. To aid identification of the most effective interventions it is crucial to understand whether there are sex differences in dietary behaviours related to CVD risk. METHODS: From a dataset of 46 nationally representative surveys, we included data from seven countries that had recorded the same dietary behaviour measurements in adults; Bhutan, Eswatini, Georgia, Guyana, Kenya, Nepal and St Vincent and the Grenadines (2013-2017). Three dietary behaviours were investigated: positive salt use behaviour (SUB), meeting fruit and vegetable (F&V) recommendations and use of vegetable oil rather than animal fats in cooking. Generalized linear models were used to investigate the association between dietary behaviours and waist circumference (WC) and undiagnosed and diagnosed hypertension and diabetes. Interaction terms between sex and dietary behaviour were added to test for sex differences. RESULTS: Twenty-four thousand three hundred thirty-two participants were included. More females than males reported positive SUB (31.3 vs. 27.2% p-value < 0.001), yet less met F&V recommendations (13.2 vs. 14.8%, p-value< 0.05). The prevalence of reporting all three dietary behaviours in a positive manner was 2.7%, varying by country, but not sex. Poor SUB was associated with a higher prevalence of undiagnosed hypertension for females (13.1% vs. 9.9%, p-value = 0.04), and a higher prevalence of undiagnosed diabetes for males (2.4% vs. 1.5%, p-value = 0.02). Meeting F&V recommendations was associated with a higher prevalence of high WC (24.4% vs 22.6%, p-value = 0.01), but was not associated with undiagnosed or diagnosed hypertension or diabetes. CONCLUSION: Interventions to increase F&V intake and positive SUBs in the included countries are urgently needed. Dietary behaviours were not notably different between sexes. However, our findings were limited by the small proportion of the population reporting positive dietary behaviours, and further research is required to understand whether associations with CVD risk factors and interactions by sex would change as the prevalence of positive behaviours increases.

Factors Associated with Acute Complications among Individuals with Type 1 Diabetes in China: The 3C Study.

Background: To identify the sociodemographic and clinical characteristics related to the occurrence of diabetic ketoacidosis (DKA) and frequent hypoglycemia in children, adolescents and adults with type 1 diabetes in China.Methods: The 3C Study was an epidemiological study that recruited 849 type 1 diabetes patients aged 0-78 years in Beijing and Shantou, China. Separate logistic regression models were used to evaluate the association of sociodemographic and clinical factors with the occurrence of DKA in the past 12 months or frequent hypoglycemia (≥5 episodes) in the past 7 days.Results: Children and adolescents were significantly more likely to have DKA in the past 12 months compared to adults: odds ratio (OR) and (95% confidence interval [CI]), 4.67 (1.90, 11.52) for <13 years and 4.00 (1.59, 10.10) for 13 to <19 years. Underweight participants were also more likely to have DKA relative to normal weight participants: OR (95% CI), 6.87 (2.64, 17.87). Children and participants who did not receive diabetes education in the past 12 months were more likely to have frequent hypoglycemia: OR (95% CI), 2.95 (1.23, 7.06) and 7.67 (1.77, 13.2), respectively. Participants who reported self-monitoring of blood glucose ≤2 times/week (ref: 7 times/week) and participants who had higher HbA1c levels were less likely to have frequent hypoglycemia: OR (95% CI), 0.14 (0.03, 0.64) and 0.78 (0.63, 0.96), respectively. Gender, family income, parent education, health insurance coverage, diabetes duration, and insulin administration method were not significantly associated with DKA or frequent hypoglycemia in this sample.Conclusions: Children, adolescents and underweight individuals with type 1 diabetes in China were more likely to report DKA, and children, individuals without adequate diabetes education, and those with lower HbA1c levels were more likely to have frequent hypoglycemia. These patients should be targeted for preventive interventions.

Body size preferences and food choice among mothers and children in Malawi.

Overweight in mothers and children in sub-Saharan Africa is rapidly increasing and may be related to body size perceptions and preferences. We enrolled 268 mother-child (6-59 months) pairs in central Malawi; 71% of mothers and 56% of children were overweight/obese, and the remainder were normal weight. Interviewers used seven body silhouette drawings and a questionnaire with open- and closed-ended questions to measure mothers' perceptions of current, preferred and healthy maternal and child body sizes and their relation to food choices. Overweight/obese and normal weight mothers' correct identification of their current weight status (72% vs. 64%), preference for overweight/obese body size (68% both) and selection of an overweight/obese silhouette as healthy (94% vs. 96%) did not differ by weight status. Fewer overweight/obese than normal weight mothers' preferred body silhouette was larger than their current silhouette (74% vs. 29%, p < .001). More mothers of overweight than normal weight children correctly identified the child's current weight status (55% vs. 42%, p < .05) and preferred an overweight/obese body size for the child (70% vs. 58%, p < .01), and both groups selected overweight/obese silhouettes as healthy for children. More than half of mothers in both groups wanted their child to be larger than the current size. Mothers said that increasing consumption of fruits, vegetables, meat, milk, grains, fizzy drinks and fatty foods could facilitate weight gain, but many cannot afford to purchase some of these foods. Their desired strategies for increasing weight indicate that body size preferences may drive food choice but could be limited by affordability.

Hypertension screening, awareness, treatment, and control in India: A nationally representative cross-sectional study among individuals aged 15 to 49 years.

BACKGROUND: Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups. METHODS AND FINDINGS: We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15-49 years in all states and union territories (hereafter "states") of the country. The stages of the care process-computed among those with hypertension at the time of the survey-were (i) having ever had one's blood pressure (BP) measured before the survey ("screened"), (ii) having been diagnosed ("aware"), (iii) currently taking BP-lowering medication ("treated"), and (iv) reporting being treated and not having a raised BP ("controlled"). We disaggregated these stages by state, rural-urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%-18.4%). Among those with hypertension, 76.1% (95% CI 75.3%-76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%-45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%-13.8%) were treated, and 7.9% (95% CI 7.6%-8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%-3.3%) in Nagaland to 21.0% (95% CI 9.8%-39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%-39.0%), 28.8% (95% CI 28.5%-29.2%), 28.4% (95% CI 27.7%-29.0%), and 28.4% (95% CI 27.8%-29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older-the population group in which hypertension is most common. CONCLUSIONS: Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states' economic development, there is large variation among states in health system performance in the management of hypertension. Improvements in access to hypertension diagnosis and treatment are especially important among men, in rural areas, and in populations with lower household wealth.