Burden of cardiovascular diseases in the Eastern Mediterranean Region, 1990-2015: findings from the Global Burden of Disease 2015 study

Trends of cause-specific cardiovascular disease mortality in China, 2009-2019: a nationwide longitudinal study

BACKGROUND

Cardiovascular disease (CVD) is the top cause of death in China. We aimed to identify trends in cause-specific CVD mortality in a rapidly developing country, thereby providing evidence for CVD prophylaxis.

MATERIALS AND METHODS

Using raw data from the Chinese National Mortality Surveillance (CNMS) system, we assessed the mortalities of all CVD and cause-specific CVD during 2009-2019. Temporal trends of crude mortality rates (CMRs) and age-standardized mortality (ASMRs) of CVD were evaluated using joinpoint regression models. Age-sex-specific CVD mortality rates were predicted by using age-period-cohort Poisson regression model.

RESULTS

A total of 10,608,402 CVD death occurred during 2009-2019, accounting for 49.8% of all-cause of death in China. The three major CVD types [cerebrovascular disease, ischemic heart disease (IHD) and hypertensive disease (HD)] accounted for 94.6% of total CVD deaths. The CMR of all CVD increased [the annual average percentage change (AAPC) = 3.4%, 95% confidence interval (CI) 2.6% to 4.1%] while the ASMR decreased (AAPC = -2.0%, 95% CI -3.5% to -0.6%). Cerebrovascular disease is predicted to be the leading cause of CVD death in men and IHD will be the top cause of CVD death in women over the period 2025-2029.

CONCLUSIONS

Although the ASMR of total CVD decreased, CVD remained the leading cause of death in China. Cerebrovascular disease, IHD and HD were the major three leading causes of CVD-related death. Inflammatory heart disease-associated death increased in the young population. Attention should be paid to premature deaths associated with cerebrovascular disease and rheumatic heart disease among rural residents.

Evaluation of the hypercholesterolemia care cascade and compliance with NCEP-ATP III guidelines in Iran based on the WHO STEPS survey

INTRODUCTION

Noncommunicable diseases (NCDs), particularly cardiovascular disease (CVD), are the leading cause of death worldwide, with hypercholesterolemia being a major risk factor for CVD. This study evaluated the hypercholesterolemia care cascade in Iran-including prevalence, diagnosis, treatment coverage, and effectiveness-using the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III) guidelines.

METHODS

This cross-sectional study drew on data from the 2021 Iran STEPS survey, which employed a systematic cluster sampling of adults aged ≥ 18 years across all provinces in Iran. Hypercholesterolemia was defined per NCEP-ATP III thresholds (LDL ≥ 160 mg/dL, total cholesterol ≥ 240 mg/dL, HDL ≤ 40 mg/dL, or ongoing lipid-lowering therapy). Weighted descriptive statistics were calculated, and Poisson regression with robust variance estimated crude and adjusted prevalence ratios for optimal lipid control among those treated. The 10-year CVD risk was determined using the Framingham Risk Score, stratifying participants into low (< 10%), intermediate (10-20%), and high (> 20%) risk categories.

RESULTS

Out of 18,074 participants, 10,582 (55.32%, 95% CI: 54.29-56.35) met NCEP-ATP III criteria for hypercholesterolemia. Among these, only 20.61% (19.55-21.72) were receiving pharmacological treatment. Treatment coverage was notably lower in males (13.15%, 11.98-14.40) than females (29.12%, 27.35-30.96). Statins were the most commonly used medication (11.43% of males, 25.87% of females). Of those receiving treatment, 52.85% (females) and 53.93% (males) achieved optimal LDL, while 76.98% (females) and 81.06% (males) attained total cholesterol < 200 mg/dL. However, only 19.89% (females) and 3.97% (males) met the HDL > 60 mg/dL goal. The 10-year CVD risk was < 10% in 57.79% of participants, 10-20% in 33.27%, and > 20% in 8.94%.

CONCLUSION

Despite a high prevalence of hypercholesterolemia in Iran, treatment coverage remains suboptimal, particularly among males and working-age adults. Although most treated individuals achieve favorable LDL and total cholesterol levels, gaps persist in achieving optimal HDL targets. These findings underscore the need for strengthened screening, treatment, and adherence strategies-alongside broader preventive measures-to reduce the burden of hypercholesterolemia and CVD in Iran.

Evaluation of the effectiveness of the Iran-package of essential non-communicable disease (IraPEN) program in reducing cardiovascular disease risk in pilot areas

BACKGROUND

To assess the effectiveness of the IraPEN program in decreasing the risk of cardiovascular disease (CVD) and associated risk factors in selected areas of Iran.

METHODS

A secondary data analysis of longitudinal data collected between 2016 and 2017 from health centers in four pilot areas. The target population consisted of people aged 40 years and above, as well as individuals aged 30-40 years who had at least one CVD risk factor. We compared mean CVD risk and risk factor levels before and one year after the intervention and utilized Generalized Estimating Equations to analyze the trends during subsequent visits.

RESULTS

A total of 160,223 eligible individuals (93,081 female) were screened at baseline, of which 25,764 individuals (17,386 female) were followed up for at least one year. The proportion of men with a CVD risk score above 10%, according to the WHO/ISH risk charts, decreased from 7.5 to 5.3%, while the proportion of women decreased from 6.1 to 4.7%. Based on the revised WHO risk score, the mean CVD risk for those with a risk score above 10% at baseline and one year later was 0.198 and 0.177 in men and 0.119 and 0.109 in women, respectively. There was a significant decrease in all risk factors, except for waist circumference in both sexes and BMI in women. The trend analysis of risk factors over time confirmed these findings.

CONCLUSION

The program was modestly effective in reducing CVD risk in the pilot areas. However, further modifications may be needed to enhance its effectiveness.

A Global Perspective on Socioeconomic Determinants of Cardiovascular Health

Cardiovascular disease (CVD) is the leading cause of mortality in the world. From 2005 to 2008, the World Health Organization (WHO) planned an initiative to reduce the mortality rate of CVD by 2030 by addressing health, finance, transport, education, and agriculture in these communities. Plans were underway by many countries to meet the goals of the WHO initiative. However, in 2020, the COVID-19 pandemic derailed these goals, and many health systems suffered as the world battled the viral pandemic. The pandemic made health inequities even more prominent and necessitated a different approach to understanding and improving the socioeconomic determinants of health (SDOH). WHO initiated a special initiative to improve SDOH globally. This paper is an update on what other regions across the globe are doing to decrease, more specifically, the impact of socioeconomic determinants of cardiovascular health. Our review highlights how countries and regions such as Canada, the United States, India, Southeast Asia, the Middle East, and Africa are uniquely affected by various socioeconomic factors and how these countries are attempting to counter these obstacles by creating policies and protocols to facilitate an infrastructure that promotes screening and treatment of CVD. Ultimately, interventions directed toward populations that have been economically and socially marginalized may aid in reducing the disease and financial burden associated with CVD.

Forecasting the Worldwide Impact of Stroke for Individuals Aged 45 and Above

BACKGROUND

We aimed to assess the global impact of stroke in people aged 45 years and older between 1990 and 2030, focusing on morbidity, mortality, and disability-adjusted life years (DALYs).

METHODS

Generalized additive models were used to project disease burden from 2020 to 2030. Additionally, the association between sociodemographic index (SDI) and stroke burden was investigated, and regional differences were assessed by Mann-Whitney U test.

RESULTS

The overall age-standardized stroke incidence rate (ASIR) among adults aged 45 years and older is projected to increase from 2020 to 2030, with an estimated annual percentage change (EAPC) of 1.29. Conversely, the age-standardized death rate (ASDR) in EAPC is expected to decrease by -1.48, and the age-standardized DALY in EAPC is expected to decrease by -1.66. By 2030, men are expected to have higher ASIR (181.81) and ASDR (87.31) than women (ASIR: 151.85, ASDR: 65.20). Regional differences are large. East Asia is expected to have the highest ASIR in 2030 (265.55). Age estimates show that older age groups, particularly those aged 75-79, are at higher risk of stroke. In addition, there is a significant inverse relationship between SDI and stroke severity, with areas with higher SDI tending to have lower morbidity, mortality, and DALYs.

CONCLUSION

From 1990 to 2030, ASIR is expected to upgrade, especially in East Asia and regions with lower SDI. Men will bear a greater burden than women.

Projections of mortality attributable to hot ambient temperatures in Cyprus under moderate and extreme climate change scenarios

BACKGROUND

Heat-related mortality has become a growing public health concern in light of climate change. However, few studies have quantified the climate-attributable health burden in Cyprus, a recognized climate change hotspot. This study aims to estimate the heat-related mortality in Cyprus for all future decades in the 21st century under moderate (SSP2-4.5) and extreme (SSP5-8.5) climate scenarios.

METHODS

We applied distributed lag non-linear models to estimate the baseline associations between temperature and mortality from 2004 to 2019 (data obtained from Department of Meteorology of the Ministry of Agriculture, Rural Development and Environment and the Health Monitoring Unit of the Cyprus Ministry of Health). The relationships were then extrapolated to future daily mean temperatures derived from downscaled global climate projections from General Circulation Models. Attributable number of deaths were calculated to determine the excess heat-related health burden compared to the baseline decade of 2000-2009 in the additive scale. The analysis process was repeated for all-cause, cardiovascular, and respiratory mortality and mortality among males, females, and adults younger or older than 65. We assumed a static population and demographic structure, no adaptation to hot temperatures over time, and did not evaluate potential interaction between temperature and humidity.

RESULTS

Compared to 2000-2009, heat-related total mortality is projected to increase by 2.7% (95% empirical confidence interval: 0.6, 4.0) and 4.75% (2.2, 7.1) by the end of the century in the moderate and extreme climate scenarios, respectively. Cardiovascular disease is expected to be an important cause of heat-related death with projected increases of 3.4% (0.7, 5.1) and 6% (2.6, 9.0) by the end of the century. Reducing carbon emission to the moderate scenario can help avoid 75% of the predicted increase in all-cause heat-related mortality by the end of the century relative to the extreme scenario.

CONCLUSIONS

Our findings suggest that climate change mitigation and sustainable adaptation strategies are crucial to reduce the anticipated heat-attributable health burden, particularly in Cyprus, where adaptation strategies such as air conditioning is nearing capacity.

Burden of non-communicable diseases in Health Council of Gulf Cooperation (GCC) countries

Objectives

This study was aimed at comparing deaths, years of potential life loss (YPLL), and economic loss due to nine non-communicable diseases (NCDs) among Health Council of Gulf Cooperation (GCC) countries.

Methods

The number of deaths and life expectancy by age and sex in each country, obtained from the 2019 World Health Organization database, were used to calculate YPLL by disease and sex. Economic loss was estimated by combining the annual income adjusted for the present value multiplied by the YPLL for each disease by sex and country.

Results

The nine NCDs were responsible for 152,854 deaths, 3 million YPLL, and 23.9 billion US$ economic loss in GCC countries. The most common cause of death was ischemic heart disease, which caused 82,232 deaths (54% of the total), 1.6 million YPLL (54% of the total), and a 12.8 billion US$ economic loss (53% of the total). The least common cause of death was lung cancer, which caused 1,960 deaths, 37,287 YPLL, and a 317.6 million US$ economic loss. KSA was the most affected country among all GCC countries in terms of deaths (68,027), YPLL (1.4 million), and economic loss (14.3 billion US$). Notably, KSA had 45%, 49%, and 60% of the entire region's deaths, YPLL, and economic loss, respectively. In contrast, Qatar was the least affected country in terms of deaths and YPLL, and Yemen was the least affected country in terms of economic loss.

Conclusion

The burden of NCDs in GCC countries in terms of deaths, YPLL, and economic loss is substantial. Policymakers should pay greater attention to detecting, preventing, and controlling these NCDs and their risk factors.

Increasing the frequency of plant-based food intake in daily diets reduces the risk of cardiovascular disease among elderly Chinese: a cohort study

Objective

There is limited research on the relationship between the frequency of plant-based food intake and the risk of cardiovascular disease (CVD) among elderly Chinese. This study aims to evaluate the association between plant-based dietary index (PDI) and CVD risks, providing evidence for elderly Chinese to reduce CVD risks by increasing the frequency of plant-based food consumption.

Methods

This study analyzed data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) 2011-2018, employing a multivariate modified Poisson regression model, trend tests, and restricted cubic spline (RCS) analysis to assess the linear and non-linear relationship between the PDI and CVD risks. Subgroup analyses and interaction tests were conducted to evaluate the robustness and population-specificity of the results.

Results

This study included a total of 1,414 elderly Chinese, and at the end of follow-up, 487 participants had developed CVD. The multivariate modified Poisson regression model revealed a negative association between PDI and CVD risks [RR = 0.983, 95%CI = (0.970, 0.997)]. Similarly, the multivariate trend test (p = 0.031) and RCS analysis (P for nonlinear = 0.600) indicated a linear relationship between PDI and CVD risks. Subgroup analyses showed that the relationship between PDI and CVD risk was not influenced by gender, BMI, smoking, alcohol use, or exercise.

Conclusion

The PDI was negatively correlated with CVD risks, indicating that increasing the frequency of plant-based food intake in the diet may reduce CVD risks among elderly Chinese.

Unveiling the molecular mechanisms: dietary phytosterols as guardians against cardiovascular diseases

Until recently, the main pharmaceuticals used to control cholesterol and prevent cardiovascular disease (CVD) were statin-related drugs, known for their historical side effects. Therefore, there is growing interest in exploring alternatives, such as nutritional and dietary components, that could play a central role in CVD prevention. This review aims to provide a comprehensive understanding of how natural phytosterols found in various diets combat CVDs. We begin with a description of the overall approach, then we explore in detail the different direct and indirect mechanisms that contribute to reducing cardiovascular incidents. Phytosterols, including stigmasterol, β-sitosterol, ergosterol, and fucosterol, emerge as promising molecules within nutritional systems for protection against CVDs due to their beneficial effects at different levels through direct or indirect cellular, subcellular, and molecular mechanisms. Specifically, the mentioned phytosterols exhibit the ability to diminish the generation of various radicals, including hydroperoxides and hydrogen peroxide. They also promote the activation of antioxidant enzymes such as superoxide dismutase, catalase, and glutathione, while inhibiting lipid peroxidation through the activation of Nrf2 and Nrf2/heme oxygenase-1 (HO-1) signaling pathways. Additionally, they demonstrate a significant inhibitory capacity in the generation of pro-inflammatory cytokines, thus playing a crucial role in regulating the inflammatory/immune response by inhibiting the expression of proteins involved in cellular signaling pathways such as JAK3/STAT3 and NF-κB. Moreover, phytosterols play a key role in reducing cholesterol absorption and improving the lipid profile. These compounds can be used as dietary supplements or included in specific diets to aid control cholesterol levels, particularly in individuals suffering from hypercholesterolemia.

The burden of Cardiovascular diseases in Jordan: a longitudinal analysis from the global burden of disease study, 1990-2019

BACKGROUND

Cardiovascular Disease (CVD) is the leading cause of mortality worldwide. While countries in the Arab world continue to lack public health data and be severely understudied in health research, previous research has shown that compared to 1990, CVDs had a higher burden of disease in the Arab World in 2010. Jordan, a middle-income Arab country, is profiled with unique attributes such as a dual-sector healthcare system, political stability, and its role as a haven for refugees and migrants. These distinctive factors emphasize Jordan's suitability as a case study. This investigation aims to quantify CVD burden in Jordan and identify risk factors, contributing to a broader understanding of health challenges in the Arab region and beyond.

METHODS

The Global Burden of Disease (GBD) dataset was used to estimate prevalence, death, and disability-adjusted life-years (DALYs) as age-standardized rates from 1990 to 2019. We calculated percentage change for nine specific CVDs and reported trends by gender and age groups. Additionally, data on twelve a priori selected behavioral, clinical, and environmental risk factors attributing to overall age-standardized CVDs DALY were reported per 100,00 population.

RESULTS

In 2019, the age-standardized CVD prevalence, death, and DALYs rates in Jordan were 7980 (95% uncertainty interval [UI] 7629, 8360), 248 (95% UI 211, 288), and 4647 (95% UI 4028, 5388), respectively. Despite an increase in the absolute number of mortality and prevalence, between 1990 and 2019, the age-standardized prevalence, death, and DALYs rates all decreased by 5.5%, 45.1%, and 46.7%, respectively. In 2019, the leading risk factors contributing to overall age-standardized CVDs DALY per 100,000 population were high systolic blood pressure, high BMI, dietary risks, and high LDL cholesterol.

CONCLUSION

Despite decreasing burden rate of CVDs in Jordan between 1990 and 2019, CVDs remain the leading cause of mortality in Jordan, with an increase in the total number of prevalence and mortality. Overall, this contributes to increased healthcare costs. Further research is required to quantify the burden of CVDs and understand it better. Intervention measures and policies tailored to specific CVDs should be designed to reduce the burden of CVDs in Jordan.

Burden of Ischemic Heart Disease and Its Attributable Risk Factors in North Africa and the Middle East, 1990 to 2019: Results From the GBD Study 2019

BACKGROUND

The North Africa and Middle East (NAME) region has one of the highest burdens of ischemic heart disease (IHD) worldwide. This study reports the contemporary epidemiology of IHD in NAME.

METHODS AND RESULTS

We estimated the incidence, prevalence, deaths, years of life lost, years lived with disability, disability-adjusted life years (DALYs), and premature mortality of IHD, and its attributable risk factors in NAME from 1990 to 2019 using the results of the GBD (Global Burden of Disease study 2019). In 2019, 0.8 million lives and 18.0 million DALYs were lost due to IHD in NAME. From 1990 to 2019, the age-standardized DALY rate of IHD significantly decreased by 33.3%, mostly due to the reduction of years of life lost rather than years lived with disability. In 2019, the proportion of premature death attributable to IHD was higher in NAME compared with global measures: 26.8% versus 16.9% for women and 18.4% versus 14.8% for men, respectively. The age-standardized DALY rate of IHD attributed to metabolic risks, behavioral risks, and environmental/occupational risks significantly decreased by 28.7%, 37.8%, and 36.4%, respectively. Dietary risk factors, high systolic blood pressure, and high low-density lipoprotein cholesterol were the top 3 risks contributing to the IHD burden in most countries of NAME in 2019.

CONCLUSIONS

In 2019, IHD was the leading cause of death and lost DALYs in NAME, where premature death due to IHD was greater than the global average. Despite the great reduction in the age-standardized DALYs of IHD in NAME from 1990 to 2019, this region still had the second-highest burden of IHD in 2019 globally.

A comprehensive analysis of cardiovascular mortality trends in Peru from 2017 to 2022: Insights from 183,386 deaths of the national death registry

Background/objectives

Cardiovascular diseases are the leading cause of global mortality. Systematic studies on cardiovascular-related mortality at national and subnational levels in Peru are lacking. We aimed to describe the trends in cardiovascular-related mortality between 2017 and 2022 in Peru at national and subnational levels and by socioeconomic indicators.

Subjects/methods

We used data from the Peruvian death registry 2017-2022. Using ICD-10 codes, mortality was categorized into: hypertensive-, coronary-, and cerebrovascular- related deaths. We estimated age-standardized cardiovascular-related mortality rates by sex at national and regional levels, and by natural regions (Coast, Highlands, Amazon). We estimated the change in mortality rates between 2017-2019 and 2020-2022 and explored factors that contributed to such a change. We explored ecological relationships between mortality rates and socioeconomic indicators.

Findings

Overall 183,386 cardiovascular-related deaths were identified. Coronary-related deaths (37.2 %) were followed by hypertensive-related (25.1 %) and cerebrovascular-related deaths (22.6 %). Peru showed a marked increasing trend in cardiovascular-related mortality in 2020-2022 (77.8 %). The increase clustered in the Coast and Highlands, with the highest change observed in Lima (132.1 %). Mortality was highest in subjects with lower education and subjects with public health insurance. Gini coefficient was associated with lower mortality rates while unemployment was associated with higher mortality rates.

Interpretation

There was a notable rise in cardiovascular-related mortality in Peru, particularly during the Covid-19 pandemic with a slight decrease in 2022. Gaining a comprehensive understanding of the factors that contribute to the increase in cardiovascular deaths in Peru will facilitate the development of precise interventions at both the national and regional levels.

Association between latent profile of dietary intake and cardiovascular diseases (CVDs): Results from Fasa Adults Cohort Study (FACS)

Cardiovascular diseases (CVDs) have been among the most significant non-communicable diseases. Dietary risks account for the most cause of CVDs mortalities. Evaluating overall dietary patterns (through the Latent profile of dietary intake) can provide a more accurate prediction regarding the prevalence of CVDs. The present cross-sectional study aimed to investigate the relationship between the latent profile of dietary intake and CVDs prevalence. The population of the Fasa Adults Cohort Study was employed to gather the data (n = 8319). A modified FFQ was employed to assess eating behaviors. Minerals, as well as the energy intake and total fiber, were measured using Nutritionist IV software (version 7.0). To estimate the prevalence of CVDs, accurate records of patients' histories were made. Individuals were clustered according to their dietary intake using latent profile analysis. The mean age was 48.75 ± 9.59 years, and 53.28% (4430) were women. 63.9% of participants with low Socioeconomic Status (SES) were in the low-intake profile (P < 0.001), and high SES increases the odds of being in the high-intake profile (ORhigh/low = 2.87, 95% CI 2.55-3.24). The low-intake group had the lowest amount of physical activity (Met) (P < 0.001). The result of multivariate logistic regression revealed that categorized in the low-intake group significantly increased the development of CVDs (OR = 1.32, 95% CI 1.07-1.63, P = 0.010). The mean micronutrients and total fiber, in individuals with a low intake profile, were significantly lower than other groups (P < 0.001). Overall, we estimated that a low intake of all food groups increases the odds of developing CVDs significantly.

Assessing body mass index stages, individual diabetes and hypertension history effects on the risk of developing hypertension among Ghanaians: A cross-sectional study

Background and Aims

This study aimed to understand the relationship between body mass index (BMI), diabetes and hypertension history, and other risk of hypertension among Ghanaians.

Methods

The BMI data are categorized according to the World Health Organization (WHO) definition. The data were obtained from the WHO Study on global AGEing and adult health (WHO SAGE) Ghana Wave 2. Descriptive statistics were used to summarize the variables, and the association between these variables and hypertension was assessed using the χ². Multivariable logistic regression was used to examine the relationship between hypertension and different BMI levels and other variables.

Results

Obesity class II individuals have about a 4-fold higher risk of developing hypertension compared to underweight individuals. Obesity class III, class I, and preobesity individuals have approximately a 3-fold higher risk. Normal weight is associated with increased hypertension risk. Both males and females show a significant increase in hypertension risk across all BMI categories. History of hypertension is linked to a 2.2-fold increased risk. Diabetes history is associated with hypertension when considering other factors. Elevated hypertension risk is observed among married, divorced, and widowed males then never married males. Only widowed females showed an increased risk. Older age significantly increases hypertension risk, particularly in females. Vegetable servings reduce hypertension risk, while fruit servings are associated with an increased risk. Vigorous exercise increases hypertension risk, particularly in females.

Conclusion

Regular check-ups are recommended for married, divorced, and widowed males, focusing on blood pressure (BP) levels. Regular exercise from young age helps lower BP in later years. Individuals with a history of hypertension should follow BP control measures. Encouraging the consumption of the right combination of vegetables and fruits can help lower BP. Female tobacco smoking should be strongly discouraged due to a 54% increased risk of developing hypertension.

The burden of ischemic heart disease and the epidemiologic transition in the Eastern Mediterranean Region: 1990-2019

It has been estimated that in the next decade, IHD prevalence, DALYs and deaths will increase more significantly in EMR than in any other region of the world. This study aims to provide a comprehensive description of the trends in the burden of ischemic heart disease (IHD) across the countries of the Eastern Mediterranean Region (EMR) from 1990 to 2019. Data on IHD prevalence, disability-adjusted life years (DALYs), mortality, DALYs attributable to risk factors, healthcare access and quality index (HAQ), and universal health coverage (UHC) were extracted from the Global Burden of Disease (GBD) database for EMR countries. The data were stratified based on the social demographic index (SDI). Information on cardiac rehabilitation was obtained from publications by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR), and additional country-specific data were obtained through advanced search methods. Age standardization was performed using the direct method, applying the estimated age structure of the global population from 2019. Uncertainty intervals were calculated through 1000 iterations, and the 2.5th and 97.5th percentiles were derived from these calculations. The age-standardized prevalence of IHD in the EMR increased from 5.0% to 5.5% between 1990 and 2019, while it decreased at the global level. In the EMR, the age-standardized rates of IHD mortality and DALYs decreased by 11.4% and 15.4%, respectively, during the study period, although both rates remained higher than the global rates. The burden of IHD was found to be higher in males compared to females. Bahrain exhibited the highest decrease in age-standardized prevalence (-3.7%), mortality (-65.0%), and DALYs (-69.1%) rates among the EMR countries. Conversely, Oman experienced the highest increase in prevalence (14.5%), while Pakistan had the greatest increase in mortality (30.0%) and DALYs (32.0%) rates. The top three risk factors contributing to IHD DALYs in the EMR in 2019 were high systolic blood pressure, high low-density lipoprotein cholesterol, and particulate matter pollution. The trend analysis over the 29-year period (1990-2019) revealed that high fasting plasma glucose (64.0%) and high body mass index (23.4%) exhibited increasing trends as attributed risk factors for IHD DALYs in the EMR. Our findings indicate an increasing trend in the prevalence of IHD and a decrease in mortality and DALYs in the EMR. These results emphasize the need for well-planned prevention and treatment strategies to address the risk factors associated with IHD. It is crucial for the countries in this region to prioritize the development and implementation of programs focused on health promotion, education, prevention, and medical care.

Temporal trends in inequalities of the burden of cardiovascular disease across 186 countries and territories

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality globally. The extent to which CVD affects the population's health varies across countries. Moreover, quantitative estimates of the trend of inequalities in CVD burden remain unclear. The objective of our study was to assess the socioeconomic inequalities and temporal trends of CVD burden across 186 countries and territories from 2000 to 2019.

METHODS

We extracted data from the Global Burden of Disease, Injuries, and Risk Factors Study (GBD) 2019, and conducted a cross-national time-series analysis. Age-standardized disability-adjusted life-year (DALY) rates were used to measure the burden of CVDs, and gross national income (GNI) per capita was used to approximate the socioeconomic development. Concentration curves and concentration indexes (CIs) were generated to evaluate the cross-national socioeconomic inequality of CVD burden. A joinpoint regression analysis was used to quantify the changes in trends in socioeconomic inequality of CVD burden from 2000 to 2019.

RESULTS

The age-standardized DALY rates of CVDs decreased in 170 (91%) of 186 countries from 2000 to 2019. The concentration curves of the age-standardized DALY rates of CVDs were above the equality line from 2000 to 2019, indicating a disproportional distribution of CVD burden in low-income countries. The CIs declined from - 0.091 (95% CI: -0.128 to - 0.054) in 2000 to - 0.151 (95% CI: -0.190 to - 0.112) in 2019, indicating worsened pro-poor inequality distributions of CVD burden worldwide. A four-phase trend of changes in the CIs of age-standardized DALY rates for CVD was observed from 2000 to 2019, with an average annual percentage change (AAPC) of - 2.7% (95% CI: -3.0 to - 2.4). Decreasing trends in CIs were observed in all CVD subcategories but endocarditis, with AAPC ranging from - 6.6% (95% CI: -7.3 to - 5.9) for ischemic heart disease to - 0.2% (95% CI: -0.4 to - 0.1) for hypertensive heart disease.

CONCLUSIONS

Globally, the burden of CVD has decreased in more than 90% of countries over the past two decades, accompanied by an increasing trend of cross-country inequalities. Moreover, the overall burden of CVD continues to fall primarily on low-income countries.

Novel deep learning method for coronary artery tortuosity detection through coronary angiography

Coronary artery tortuosity is usually an undetected condition in patients undergoing coronary angiography. This condition requires a longer examination by the specialist to be detected. Yet, detailed knowledge of the morphology of coronary arteries is essential for planning any interventional treatment, such as stenting. We aimed to analyze coronary artery tortuosity in coronary angiography with artificial intelligence techniques to develop an algorithm capable of automatically detecting this condition in patients. This work uses deep learning techniques, in particular, convolutional neural networks, to classify patients into tortuous or non-tortuous based on their coronary angiography. The developed model was trained both on left (Spider) and right (45°/0°) coronary angiographies following a fivefold cross-validation procedure. A total of 658 coronary angiographies were included. Experimental results demonstrated satisfactory performance of our image-based tortuosity detection system, with a test accuracy of (87 ± 6)%. The deep learning model had a mean area under the curve of 0.96 ± 0.03 over the test sets. The sensitivity, specificity, positive predictive values, and negative predictive values of the model for detecting coronary artery tortuosity were (87 ± 10)%, (88 ± 10)%, (89 ± 8)%, and (88 ± 9)%, respectively. Deep learning convolutional neural networks were found to have comparable sensitivity and specificity with independent experts' radiological visual examination for detecting coronary artery tortuosity for a conservative threshold of 0.5. These findings have promising applications in the field of cardiology and medical imaging.

Translation, Cross-Cultural Adaptation and Psychometric Validation of the Arabic Version of the Cardiac Rehabilitation Barriers Scale (CRBS-A) with Strategies to Mitigate Barriers

Cardiac rehabilitation (CR) utilization is low, particularly in Arabic-speaking countries. This study aimed to translate and psychometrically validate the CR Barriers Scale in Arabic (CRBS-A), as well as strategies to mitigate them. The CRBS was translated by two bilingual health professionals independently, followed by back-translation. Next, 19 healthcare providers, followed by 19 patients rated the face and content validity (CV) of the pre-final versions, providing input to improve cross-cultural applicability. Then, 207 patients from Saudi Arabia and Jordan completed the CRBS-A, and factor structure, internal consistency, construct, and criterion validity were assessed. Helpfulness of mitigation strategies was also assessed. For experts, item and scale CV indices were 0.8-1.0 and 0.9, respectively. For patients, item clarity and mitigation helpfulness scores were 4.5 ± 0.1 and 4.3 ± 0.1/5, respectively. Minor edits were made. For the test of structural validity, four factors were extracted: time conflicts/lack of perceived need and excuses; preference to self-manage; logistical problems; and health system issues and comorbidities. Total CRBS-A α was 0.90. Construct validity was supported by a trend for an association of total CRBS with financial insecurity regarding healthcare. Total CRBS-A scores were significantly lower in patients who were referred to CR (2.8 ± 0.6) vs. those who were not (3.6 ± 0.8), confirming criterion validity (p = 0.04). Mitigation strategies were considered very helpful (mean = 4.2 ± 0.8/5). The CRBS-A is reliable and valid. It can support identification of top barriers to CR participation at multiple levels, and then strategies for mitigating them can be implemented.

Changes in the burden and underlying causes of heart failure in the Eastern Mediterranean Region, 1990-2019: An analysis of the Global Burden of Disease Study 2019

Background

The burden of heart failure (HF) is high globally, but information on its burden in the Eastern Mediterranean Region (EMR) is limited. This study provides a systematic analysis of the burden and underlying causes of HF in the EMR, including at the country level, between 1990 and 2019.

Methods

We used the 2019 Global Burden of Disease (GBD) data for estimates of prevalence, years lived with disability (YLDs), and underlying causes of HF in the EMR. Age-standardised prevalence, YLDs, and underlying causes of HF were compared by 5-year age groups (considering 15 years old and more), sex (male and female), and countries.

Findings

In contrast with the decreasing trend of HF burden globally, EMR showed an increasing trend. Globally, the HF age-standardised prevalence and YLDs decreased by 7.06% (95% UI: -7.22%, -6.9%) and 6.82% (95% UI: -6.98%, -6.66%) respectively, from 1990 to 2019. The HF age-standardised prevalence and YLDs in the EMR in 2019 were 706.43 (95% UI: 558.22-887.87) and 63.46 (95% UI: 39.82-92.59) per 100,000 persons, representing an increase of 8.07% (95% UI: 7.9%, 8.24%) and 8.79% (95% UI: 8.61%, 8.97%) from 1990, respectively. Amongst EMR countries, the age-standardised prevalence and YLDs were highest in Kuwait, while Pakistan consistently had the lowest HF burden. The dramatic increase of the age-standardised prevalence and YLDs were seen in Oman (28.79%; 95% UI: 28.51%, 29.07% and 29.56%; 95% UI: 29.28%, 29.84%), while Bahrain witnessed a reduction over the period shown (-9.66%; 95% UI: -9.84%, -9.48% and-9.14%; 95% UI: -9.32%, -8.96%). There were significant country-specific differences in trends of HF burden from 1990 to 2019. Males had relatively higher rates than females in all age groups. Among all causes of HF in 2019, ischemic heart disease accounted for the highest age-standardised prevalence and YLDs, followed by hypertensive heart disease.

Interpretation

The burden of HF in the EMR was higher than the global, with increasing age-standardised prevalence and YLDs in countries of the region. A more comprehensive approach is needed to prevent underlying causes and improve medical care to control the burden of HF in the region.

Funding

None.

Effects of sulfur dioxide and particulate matter pollution on hospital admissions for hypertensive cardiovascular disease: A time series analysis

Background and aims: Air pollution is a major environmental risk factor and the leading cause of disease burden with detrimental effects on cardiovascular systems. Cardiovascular diseases are predisposed by various risk factors, including hypertension, as the most important modifiable risk factor. However, there is a lack of sufficient data concerning the impact of air pollution on hypertension. We sought to study the associations of short-term exposure to Sulfur dioxide (SO₂) and particulate matter (PM₁₀) with the number of daily hospital admissions of hypertensive cardiovascular diseases (HCD). Methods: All hospitalized patients between March 2010 to March 2012 were recruited with the final diagnosis of HCD based on the International Classification of Diseases 10 (codes: I10-I15) from 15 hospitals in Isfahan, one of the most polluted cities in Iran. The 24-hour average concentrations of pollutants were obtained from 4 monitoring stations. In addition to single- and two-pollutant models, we used Negative Binomial and Poisson models with covariates of holidays, dew point, temperature, wind speed, and extracted latent factors of other pollutants controlling for multi-collinearity to examine the risk for hospital admissions for HCD affected by SO₂ and PM₁₀ exposures in the multi-pollutant model. Results: A total of 3132 hospitalized patients (63% female) with a mean (standard deviation) age of 64.96 (13.81) were incorporated in the study. The mean concentrations of SO2 and PM10 were 37.64 μg/m3 and 139.08 μg/m3, respectively. Our findings showed that a significantly increased risk of HCD-induced hospital admission was detected for a 10 μg/m3 increase in the 6-day and 3-day moving average of SO2 and PM₁₀ concentrations in the multi-pollutant model with a percent change of 2.11% (95% confidence interval: 0.61 to 3.63%) and 1.19% (0.33 to 2.05%), respectively. This finding was robust in all models and did not vary by gender (for SO₂ and PM₁₀) and season (for SO₂). However, people aged 35-64 and 18-34 years were vulnerable to SO2 and PM10 exposure-triggered HCD risk, respectively. Conclusions: This study supports the hypothesis of the association between short-term exposure to ambient SO₂ and PM₁₀ and the number of hospital admissions due to HCD.

Prevalence of Undiagnosed Hypertension and Its Predictors in Jordan: A Cross-Sectional Study

Introduction

Hypertension is an important cause of morbidity and mortality worldwide. Undiagnosed hypertension is a serious issue that leads to increased morbidity and mortality. In this study, we aim to identify the prevalence of undiagnosed hypertension in the healthy Jordanian population, as well as identify predictors of high blood pressure readings in presumably healthy Jordanians.

Materials and Methods

We recruited healthy visitors accompanying patients at our Jordan University Hospital Clinics ranging from 18 to 80 years of age. We measured each participant's systolic and diastolic blood pressure at our outpatient clinics on two different days, one week apart. We also obtained demographic data, weight, height, smoking status, and family history of hypertension and cardiovascular diseases.

Results

A total of 896 participants were included in this study with a mean age of 48 years. The median of systolic blood pressure readings was 125 mmHg, and the median of diastolic blood pressure readings was 83 mmHg. 38.5% had undiagnosed stage 1 hypertension and 30.5% had undiagnosed stage 2 hypertension according to the American College of Cardiology/American Heart Association guidelines. On the other hand, 25.4% had undiagnosed grade 1 hypertension and 5.1% had undiagnosed grade 2 hypertension according to the European Society of Hypertension guidelines.

Conclusion

According to the ACC/AHA guidelines, 68.5% of previously healthy Jordanians met the criteria to be diagnosed with hypertension. Predictors of high systolic blood pressure were age, BMI and family history of CAD, while female gender is associated with a lower systolic blood pressure. For diastolic blood pressure, only BMI and family history of CAD were associated with significantly higher diastolic blood pressure, while female gender and exercise were significantly associated with lower diastolic blood pressure.

Marketing of Food and Beverages to Children in the Eastern Mediterranean Region: A Situational Analysis of the Regulatory Framework

Marketing of food items high in added saturated and/or trans-fat, sugar, or sodium (HFSS) negatively affect consumption patterns of young children. The World Health Organization (WHO) advised countries to regulate the marketing of foods and non-alcoholic beverages to young populations. The aim of this manuscript is to provide a situational analysis of the regulatory framework of food marketing policies targeting children in the Eastern Mediterranean Region (EMR). A semi structured questionnaire was shared with the focal points of EMR member states inquiring about the reforms and monitoring initiatives in place. Electronic databases were searched for relevant publications between 2005 and 2021. Results revealed that even though 68% of countries discussed the recommendations, progress toward the WHO set goals has been slow with only 14% of countries implementing any kind of restrictions and none executing a comprehensive approach. Reforms have focused on local television and radio marketing and left out several loopholes related to marketing on the internet, mobile applications, and cross border marketing. Recent monitoring initiatives revealed a slight improvement in the content of advertised material. Yet, unhealthy products are the most promoted in the region. This review identified the need to intensify the efforts to legislate comprehensive food marketing policies within and across EMR countries.

A Systematic Review of Trans Fat Reduction Initiatives in the Eastern Mediterranean Region

High intakes of trans fatty acids (TFA), particularly industrially-produced TFA, are implicated in the etiology of cardiovascular diseases, which represent the leading cause of mortality in the Eastern Mediterranean Region (EMR). This systematic review aims to document existing national TFA reduction strategies in the EMR, providing an overview of initiatives that are implemented by countries of the region, and tracking progress toward the elimination of industrially-produced TFA. A systematic review of published and gray literature was conducted using a predefined search strategy. A total of 136 peer-reviewed articles, gray literature documents, websites and references from country contacts were obtained, up until 2 August 2021. Randomized-control trials, case-control studies, and studies targeting unhealthy population groups were excluded. Only articles published after 1995, in English, Arabic or French, were included. Key characteristics of strategies were extracted and classified according to a pre-developed framework, which includes TFA intake assessment; determination of TFA levels in foods; strategic approach; implementation strategies (TFA bans/limits; consumer education, labeling, interventions in public institution settings, taxation), as well as monitoring and evaluation of program impact. Thirteen out of the 22 countries of the EMR (59%) have estimated TFA intake levels, 9 have determined TFA levels in foods (41%), and 14 (63.6%) have national TFA reduction initiatives. These initiatives were mainly led by governments, or by national multi-sectoral committees. The most common TFA reduction initiatives were based on TFA limits or bans (14/14 countries), with a mandatory approach being adopted by 8 countries (Bahrain, Iran, Jordan, KSA, Kuwait, Morocco, Oman and Palestine). Complementary approaches were implemented in several countries, including consumer education (10/14), food labeling (9/14) and interventions in specific settings (7/14). Monitoring activities were conducted by few countries (5/14), and impact evaluations were identified in only Iran and the UAE. The robustness of the studies, in terms of methodology and quality of assessment, as well as the lack of sufficient data in the EMR, remain a limitation that needs to be highlighted. Further action is needed to initiate TFA reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluation of ongoing programs.

Public Health Surveillance Systems in the Eastern Mediterranean Region: Bibliometric Analysis of Scientific Literature

BACKGROUND

The Eastern Mediterranean Region (EMR) hosts some of the world's worst humanitarian and health crises. The implementation of health surveillance in this region has faced multiple constraints. New and novel approaches in surveillance are in a constant state of high and immediate demand. Identifying the existing literature on surveillance helps foster an understanding of scientific development and thus potentially supports future development directions.

OBJECTIVE

This study aims to illustrate the scientific production, quantify the scholarly impact, and highlight the characteristics of publications on public health surveillance in the EMR over the past decade.

METHODS

We performed a Scopus search using keywords related to public health surveillance or its disciplines, cross-referenced with EMR countries, from 2011 to July 2021. Data were exported and analyzed using Microsoft Excel and Visualization of Similarities Viewer. Quality of journals was determined using SCImago Journal Rank and CiteScore.

RESULTS

We retrieved 1987 documents, of which 1927 (96.98%) were articles or reviews. There has been an incremental increase in the number of publications (exponential growth, R2=0.80) over the past decade. Publications were mostly affiliated with Iran (501/1987, 25.21%), the United States (468/1987, 23.55%), Pakistan (243/1987, 12.23%), Egypt (224/1987, 11.27%), and Saudi Arabia (209/1987, 10.52%). However, Iran only had links with 40 other countries (total link strength 164), and the biggest collaborator from the EMR was Egypt, with 67 links (total link strength 402). Within the other EMR countries, only Morocco, Lebanon, and Jordan produced ≥79 publications in the 10-year period. Most publications (1551/1987, 78.06%) were affiliated with EMR universities. Most journals were categorized as medical journals, and the highest number of articles were published in the Eastern Mediterranean Health Journal (SCImago Journal Rank 0.442; CiteScore 1.5). Retrieved documents had an average of 18.4 (SD 125.5) citations per document and an h-index of 66. The top-3 most cited documents were from the Global Burden of Diseases study. We found 70 high-frequency terms, occurring ≥10 times in author keywords, connected in 3 clusters. COVID-19, SARS-CoV-2, and pandemic represented the most recent 2020 cluster.

CONCLUSIONS

This is the first research study to quantify the published literature on public health surveillance and its disciplines in the EMR. Research productivity has steadily increased over the past decade, and Iran has been the leading country publishing relevant research. Recurrent recent surveillance themes included COVID-19 and SARS-CoV-2. This study also sheds light on the gaps in surveillance research in the EMR, including inadequate publications on noncommunicable diseases and injury-related surveillance.

Application of Ultrasound Virtual Reality in the Diagnosis and Treatment of Cardiovascular Diseases

Cardiovascular disease is a common chronic disease in the medical field, which has a great impact on the health of Chinese residents (especially the elderly). At present, the effectiveness of the prevention and treatment of cardiovascular diseases in my country is not optimistic. Overall, the prevalence and mortality of CVD are still on the rise. The timely and effective detection and treatment of cardiovascular and cerebrovascular diseases are of great practical significance to improve the health of residents and to carry out prevention and treatment. This article aims to study the application of ultrasound-based virtual reality technology in the diagnosis and treatment of cardiovascular diseases to improve the efficiency and accuracy of the diagnosis of cardiovascular and cerebrovascular diseases by medical staff. The focus is on the application of feature attribute selection related algorithms and classification related algorithms in medical and health diagnosis systems, and a cardiovascular and cerebrovascular disease diagnosis system based on naive Bayes algorithm and improved genetic algorithm is designed and developed. The system builds a diagnostic model for cardiovascular and cerebrovascular diseases and diagnoses and displays the corresponding results based on the patient's examination data. This paper first puts forward the theoretical concepts of ultrasonic virtual reality technology, scientific computing visualization, genetic algorithm, naive Bayes algorithm, and surgery simulation system and describes them in detail. Then, we construct a three-dimensional ultrasonic virtual measurement system, from the collection and reconstruction of image data to the filtering and segmentation of image data, plus the application of three-dimensional visualization and virtual reality technology to construct a three-dimensional measurement system. The experimental results in this paper show that 10 isolated congenital heart disease models with atrial septal defect (ASD) established through the use of three-dimensional visualization and virtual reality technology measured the short diameter, long diameter, and area of the atrial septal defect in the left and right atria. Finally, a value of L less than 0.05 indicates that the statistics are meaningful, and a value of r generally greater than 0.9 indicates that the virtual measurement result is highly correlated with the real measurement result.

Salt Reduction Initiatives in the Eastern Mediterranean Region and Evaluation of Progress towards the 2025 Global Target: A Systematic Review

This study aims at identifying national salt reduction initiatives in countries of the Eastern Mediterranean Region and describing their progress towards the global salt reduction target. A systematic review of published and grey literature was conducted. Key characteristics of strategies were extracted and classified according to a pre-defined framework: salt intake assessments; leadership and strategic approach; implementation strategies; monitoring and evaluation of program impact. Salt intake levels were estimated in 15 out of the 22 countries (68%), while national salt reduction initiatives were identified in 13 (59%). The majority of countries were found to implement multifaceted reduction interventions, characterized by a combination of two or more implementation strategies. The least common implementation strategy was taxation, while the most common was reformulation (100%), followed by consumer education (77%), initiatives in specific settings (54%), and front of pack labelling (46%). Monitoring activities were conducted by few countries (27%), while impact evaluations were lacking. Despite the ongoing salt reduction efforts in several countries of the region, more action is needed to initiate reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluations of ongoing programs. Such efforts are vital for the achievement of the targeted 30% reduction in salt intake.

Non-communicable diseases deaths attributable to high body mass index in Chile

We estimated the proportion and number of deaths from non-communicable diseases (NCD) attributable to high body mass index (BMI) in Chile in 2018. We used data from 5927 adults from a 2016-2017 Chilean National Health Survey to describe the distribution of BMI. We obtained the number of deaths from NCD from the Ministry of Health. Relative risks (RR) and 95% confidence intervals per 5 units higher BMI for cardiovascular disease, cancer, and respiratory disease were retrieved from the Global BMI Mortality Collaboration meta-analyses. The prevalences of overweight and obesity were 38.9% and 39.1%, respectively. We estimated that reducing population-wide BMI to a theoretical minimum risk exposure level (mean BMI: 22.0 kg/m²; standard deviation: 1) could prevent approximately 21,977 deaths per year (95%CI 13,981-29,928). These deaths represented about 31.6% of major NCD deaths (20.1-43.1) and 20.4% of all deaths (12.9-27.7) that occurred in 2018. Most of these preventable deaths were from cardiovascular diseases (11,474 deaths; 95% CI 7302-15,621), followed by cancer (5597 deaths; 95% CI 3560-7622) and respiratory disease (4906 deaths; 95% CI 3119-6684). A substantial burden of NCD deaths was attributable to high BMI in Chile. Policies and population-wide interventions are needed to reduce the burden of NCD due to high BMI in Chile.

Trend analysis of disability adjusted life years due to cardiovascular diseases: results from the global burden of disease study 2019

BACKGROUND

Cardiovascular diseases (CVDs) are the number one cause of global mortality representing about one third of all deaths across the world. The objective of the present study was to model the global trend in disability-adjusted life years (DALY) and its components due to CVD over the past three decades. We also aimed to evaluate the longitudinal relationship between CVD DALY and Human Development Index (HDI) in this period of time.

METHODS

The age-standardized rates of years lost due to disability (YLD), years of life lost (YLL) and DALY were extracted for cardiovascular diseases from the Global Burden of Disease (GBD) Study 2019 in years 1990 to 2019. Additionally, the United Nations Development Programme (UNDP) database was used to retrieve HDI values for all world countries at the same period time. The trend analysis was performed using the joinpoint regression model.

RESULTS

The obtained revealed a significant downward trend for DALY and its components with the average annual percent change of - 1.0, - 0.3 and - 1.1 per 100,000 population, respectively for DALY, YLD and YLL. We also found that countries with high/very high levels of HDI have remarkably experienced steeper declining slope of trend than those in lower levels of HDI over the study period.

CONCLUSIONS

Although the observed decreasing trend of CVD burden is a hopeful message for all world countries, the considerable gap in slope of trend between richer and poorer parts of the world is a serious alarm for health policy makers. Regarding this, there is an urgent need to put more efforts on implementing preventive programs, improving the level of patients' care and providing efficient treatment, especially in regions with lower levels of HDI.

Identification of public health priorities, barriers, and solutions for Kuwait using the modified Delphi method for stakeholder consensus

The rapid modernization and economic developments in Kuwait, have been accompanied by substantial lifestyle changes such as unhealthy diet and physical inactivity. These modifiable behaviours have contributed to increased rates of non-communicable diseases including diabetes and cardiovascular diseases. Delphi Consensus Method was implemented in the current study to draw stakeholders from all sectors together to develop a consensus on the major public health priorities, barriers and solutions. The process involves administration of a series of questions to selected stakeholders through an iterative process that ends when a consensus has been reached among participants. Results of the iteration process identified obesity, diabetes, cardiovascular diseases along with lack of enforcement of laws and regulation as priority health issues. Results also identified lack of national vision for the development of a public health system, lack of multidisciplinary research investigating sources of disease and methods of prevention and improving efficiency with existing resources in implementation and efficiency as the main barriers identified were. Solutions suggested included investing in healthcare prevention, strengthening communication between all involved sectors through intersectoral collaboration, awareness at the primary healthcare setting and use of electronic health records. The results offer an important opportunity for stakeholders in Kuwait to tackle these priority health issues employing the suggested approaches and solution.

Clinical Manifestations of Ultrasonic Virtual Reality in the Diagnosis and Treatment of Cardiovascular Diseases

On a global scale, cardiovascular disease has become one of the most serious diseases that endangers human health and causes death and seriously threatens human life and health. If we can make accurate, timely, and effective judgments on cardiovascular-related parameters and take corresponding effective measures, the incidence of cardiovascular diseases can be reduced to a large extent. Based on this, this paper proposes the clinical application research of ultrasound virtual reality technology in the diagnosis and treatment of cardiovascular diseases. This article uses literature methods, experimental research methods, mathematical statistical analysis methods, and other research methods and in-depth study of virtual reality technology, cardiovascular disease, and other theoretical knowledge and briefly introduces ultrasound image denoising algorithms, such as bilateral filtering and PM model. And on this basis, it establishes clinical trials of ultrasound virtual reality technology in the diagnosis and treatment of cardiovascular diseases. This article mainly analyzes the application of virtual reality technology, technology comparison, and the experimental results carried out in this article. From the survey results, the total prevalence of hypertension was 25.1%, and the prevalence of males and females was 25.9% and 24.4%, respectively; the diagnostic accuracy rate of the experimental group reached 85.39%, while the diagnostic accuracy rate of the control group was 76.8%. It shows that the use of ultrasound virtual reality technology for disease diagnosis can effectively improve the accuracy of cardiovascular disease diagnosis and reduce the proportion of misdiagnosis and missed detection.

Does the medical insurance system play a real role in reducing catastrophic economic burden in elderly patients with cardiovascular disease in China? Implication for accurately targeting vulnerable characteristics

BACKGROUND

The vulnerability of cardiovascular disease (CVD) patients' health abilities, combined with the severity of the disease and the overlapping risk factors, leads such people to bear the economic burden of the disease due to the medical services. We estimated the economic burden of CVD and identified the weak link in the design of the medical insurance.

METHODS

Data from 5610 middle-aged and elderly with CVD were drawn from the 2015 wave of "China Health and Retirement Longitudinal Study" (CHARLS). The recommended method of the "World Health Organization" (WHO) was adopted to calculate "catastrophic health expenditure" (CHE), "impoverishment by medical expenses" (IME), and applied the treatment-effect model to analyze the determinants of CHE.

RESULTS

The incidence of CHE was 19.9% for the elderly families with CVD members, which was 3.6% higher than for uninsured families (16.3%). Families with CVD combined with > 3 other chronic diseases (38.88%) were the riskiest factor for the high CHE in the new rural cooperative medical system (NCMS). Moreover, families with members > 75 years old (33.33%), having two chronic disease (30.74%), and families having disabled members (33.33%), hospitalization members (32.41%) were identified as the high risky determinants for the high CHE in NCMS.

CONCLUSIONS

Elderly with physical vulnerabilities were more prone to CHE. The medical insurance only reduced barriers to accessing health resources for elderly with CVD; however it lacked the policy inclination for high-utilization populations, and had poorly accurate identification of the vulnerable characteristics of CVD, which in turn affects the economic protection ability of the medical insurance. The dispersion between the multiple medical security schemes leads to the existence of blind spots in the economic risk protection of individuals and families.

Reduction of mortality and predictions for acute myocardial infarction, stroke, and heart failure in Brazil until 2030

Cardiovascular diseases (CVD) are responsible for the majority of deaths in Brazil and worldwide, and constitute an important share of non-transmissible diseases. The objective of this study is to analyze the mortality trends of the three main CVD in Brazil and its geographic regions: acute myocardial infarction, stroke, and heart failure. Data predictions until 2030 were also carried out. An ecological study is presented herein, with data for the period 2001-2015. Mortality from these diseases was evaluated by annual trends, and grouped in five-year intervals for the predictions until 2030. All data are publicly available. Acute myocardial infarction was the leading isolated cause of death. Brazilian trends revealed a decrease in the three diseases, with different patterns across geographic regions. The Southeast, South, and Midwest regions presented reductions for the three diseases. The predictions indicated higher rates for men. There was also a reduction in the risk of death from these diseases for Brazil and, despite the different mortality patterns for the three diseases, the Southeast region presents, primarily, lower predicted rates than the other regions. The assessment of trends and predictions for the three main CVD in Brazil revealed general decreasing trends with differences across the geographic regions.

The burden of non-communicable diseases attributable to high BMI in Brazil, 1990-2017: findings from the Global Burden of Disease Study

BACKGROUND

The prevalence and burden of disease resulting from obesity have increased worldwide. In Brazil, more than half of the population is now overweight. However, the impact of this growing risk factor on disease burden remains inexact. Using the 2017 Global Burden of Disease (GBD) results, this study sought to estimate mortality and disability-adjusted life years (DALYs) lost to non-communicable diseases caused by high body mass index (BMI) in both sexes and across age categories. This study also aimed to describe the prevalence of overweight and obesity throughout the states of Brazil.

METHODS

Age-standardized prevalence of overweight and obesity were estimated between 1990 and 2017. A comparative risk assessment was applied to estimate DALYs and deaths for non-communicable diseases and for all causes linked to high BMI.

RESULTS

The prevalence of overweight and obesity increased during the period of analysis. Overall, age-standardized prevalence of obesity in Brazil was higher in females (29.8%) than in males (24.6%) in 2017; however, since 1990, males have presented greater rise in obesity (244.1%) than females (165.7%). Increases in prevalence burden were greatest in states from the North and Northeast regions of Brazil. Overall, burden due to high BMI also increased from 1990 to 2017. In 2017, high BMI was responsible for 12.3% (8.8-16.1%) of all deaths and 8.4% (6.3-10.7%) of total DALYs lost to non-communicable diseases, up from 7.2% (4.1-10.8%), and 4.6% (2.4-6.0%) in 1990, respectively. Change due to risk exposure is the leading contributor to the growth of BMI burden in Brazil. In 2017, high BMI was responsible for 165,954 deaths and 5,095,125 DALYs. Cardiovascular disease and diabetes have proven to be the most prevalent causes of deaths, along with DALYs caused by high BMI, regardless of sex or state.

CONCLUSIONS

This study demonstrates increasing age-standardized prevalence of obesity in all Brazilian states. High BMI plays an important role in disease burdens in terms of cardiovascular diseases, diabetes, and all causes of mortality. Assessing levels and trends in exposures to high BMI and the resulting disease burden highlights the current priority for primary prevention and public health action initiatives focused on obesity.

Experience of Basic Life Support among King Khalid University Health Profession Students, Southwestern Saudi Arabia

BACKGROUND

Satisfactory experience about basic life support (BLS) is crucial to ensure rapid and efficient delivery of essential life-saving care during emergency situations.

OBJECTIVES

To assess BLS experience among health profession students at King Khalid University (KKU), Southwestern Saudi Arabia.

METHODS

A cross-sectional study was conducted on a representative sample of male and female health profession students, during the academic year 2019-2020. A self-reported questionnaire was utilized to collect data about BLS experiences, which included receiving BLS training, reasons for not having BLS training, suggestions to improve BLS training, encountering a situation that required the use of BLS, practicing BLS when needed and reasons for not practicing BLS when needed.

RESULTS

Out of 1261 health profession students, 590 received formal BLS training with a prevalence rate of 46.8% (95% CI: 44.0-49.6), and 46.0% of them trained at the university. Important obstacles for non-attendance included busy academic schedule (54.7%) and high cost of the training course (18%). Overall, 84.1% supported integration of BLS training into their college curricula. Almost 26% encountered a situation that required BLS; however, only 32.4% responded. Through multivariate regression, the significant determinant of response was having formal BLS training (aOR = 4.24, 95% CI: 2.38-7.54). The frequent reasons for non-response were lack of adequate BLS knowledge (35.0%), nervousness (22.8%), and that the victim was of opposite sex (9.0%).

CONCLUSION

It is recommended that more emphasis should be given to BLS training among undergraduates of health profession colleges in Southwestern Saudi Arabia. It is recommended that BLS training be integrated into health profession college curricula. Including BLS training as a graduation requirement for health profession students might motivate students to attain BLS training courses.

Educational Intervention Based on the Health Belief Model to Modify Risk Factors of Cardiovascular Disease in Police Officers in Iran: A Quasi-experimental Study

Objectives:

Police officers may be at a greater risk for cardiovascular disease (CVD) than the general population due to their highstress occupation. This study evaluated how an educational program based on the health belief model (HBM) may protect police officers from developing CVD.

Methods:

In this single-group experimental study, 58 police officers in Iran participated in a 5-week intervention based on HBM principles. Outcomes included changes in scores on an HBM scale, time spent on moderate to vigorous physical activity (International Physical Activity Questionnaire), body mass index (BMI), blood lipid profile, blood glucose, and blood pressure. The intervention consisted of 5 HBM-based educational sessions. Follow-up was conducted at 3 months post-intervention. The paired t-test was used to examine differences between baseline and follow-up scores.

Results:

All aspects of the HBM scale improved between baseline and follow-up (p<0.05), except the cues to action subscale. Self-efficacy and preventive behaviors improved the most. BMI decreased from 26.7±2.9 kg/m² at baseline to 25.8±2.4 kg/m² at follow-up. All components of the lipid profile, including triglycerides, cholesterol, high-density lipoprotein, and low-density lipoprotein, showed significant improvements post-intervention. Blood glucose and blood pressure also decreased, but not significantly. Nearly 25% of participants who were not physically active at baseline increased their physical activity above or beyond the healthy threshold.

Conclusions:

A relatively brief educational intervention based on HBM principles led to a significant improvement in CVD risk factors among police officers. Further research is needed to corroborate the effectiveness of this intervention.

Age and sex affect deep learning prediction of cardiometabolic risk factors from retinal images

Deep neural networks can extract clinical information, such as diabetic retinopathy status and individual characteristics (e.g. age and sex), from retinal images. Here, we report the first study to train deep learning models with retinal images from 3,000 Qatari citizens participating in the Qatar Biobank study. We investigated whether fundus images can predict cardiometabolic risk factors, such as age, sex, blood pressure, smoking status, glycaemic status, total lipid panel, sex steroid hormones and bioimpedance measurements. Additionally, the role of age and sex as mediating factors when predicting cardiometabolic risk factors from fundus images was studied. Predictions at person-level were made by combining information of an optic disc centred and a macula centred image of both eyes with deep learning models using the MobileNet-V2 architecture. An accurate prediction was obtained for age (mean absolute error (MAE): 2.78 years) and sex (area under the curve: 0.97), while an acceptable performance was achieved for systolic blood pressure (MAE: 8.96 mmHg), diastolic blood pressure (MAE: 6.84 mmHg), Haemoglobin A1c (MAE: 0.61%), relative fat mass (MAE: 5.68 units) and testosterone (MAE: 3.76 nmol/L). We discovered that age and sex were mediating factors when predicting cardiometabolic risk factors from fundus images. We have found that deep learning models indirectly predict sex when trained for testosterone. For blood pressure, Haemoglobin A1c and relative fat mass an influence of age and sex was observed. However, achieved performance cannot be fully explained by the influence of age and sex. In conclusion we confirm that age and sex can be predicted reliably from a fundus image and that unique information is stored in the retina that relates to blood pressure, Haemoglobin A1c and relative fat mass. Future research should focus on stratification when predicting person characteristics from a fundus image.

Cardiovascular disease in Mexico 1990-2017: secondary data analysis from the global burden of disease study

OBJECTIVES

Cardiovascular diseases (CVD) are a major cause of death and a public health threat. To report the burden of CVD in Mexico at a national and subnational scale from 1990 to 2017 as well as risk factors driving these changes.

METHODS

Following the 2017 global burden of disease study, mortality, disability-adjusted life-years (DALYs), and risk factors of CVD were examined according to 10 subcategories.

RESULTS

The CVD burden of disease decreased between 1990 and 2017 in Mexico as a whole and in all states, with the higher decrease located in the north and central regions. Ischemic heart disease accounted for almost two-thirds of the total number of deaths from CVD and caused the highest DALY rate. The leading CVD risk factors were high systolic blood pressure, dietary risks, high LDL cholesterol, high BMI, and high fasting plasma glucose level.

CONCLUSIONS

These results allow the establishment of priorities, policy development, and implementation to decrease the CVD burden and can provide a benchmark for states to focus on key risk factors, improve the quality of health care, and reduce health care costs.

Normal coronary diameters in Turkish population

Background

This study aims to define normal coronary artery diameters of males and females in a sample of Turkish population, compared to Asian-Indian and Western Caucasian populations.

Methods

Angiographic and demographic data of a total of 324 patients (147 males, 177 females; mean age 55.3±10.1 years; range, 32 to 82 years) who underwent elective coronary angiography with angiographically normal coronary arteries between July 2017 and March 2019 were analyzed retrospectively. Proximal diameters of major epicardial coronary arteries were measured using the Axiom Artis software according to edge detection method. All the measurements were adjusted to the body surface area. Unadjusted and adjusted values were compared between genders and with the Asian-Indian and Caucasian population samples.

Results

The mean diameters of unadjusted/adjusted left main coronary artery, proximal left anterior descending artery, proximal left circumflex artery, and proximal right coronary artery were 4.5±0.6 mm/2.4±0.4 mm/m², 3.7±0.5 mm/1.9±0.3 mm/m², 3.3±0.6 mm/1.7±0.3 mm/m², and 3.4±0.6 mm/1.8±0.4 mm/m², respectively. Adjusted left main coronary artery and proximal left circumflex artery were narrower, and unadjusted proximal left anterior descending artery and unadjusted/adjusted proximal right coronary artery were larger in men, compared to women in the Turkish population. Turkish population had similar body surface area and unadjusted/adjusted coronary diameters with Caucasians, whereas adjusted proximal left anterior descending artery was larger in the Turkish population than in Asian-Indians.

Conclusion

Our study findings on the Turkish population contradict the traditional belief that women have narrower coronary arteries then men. Furthermore, the Turkish population have comparable adjusted/unadjusted coronary diameters with the Western Caucasians, but larger adjusted/unadjusted proximal left anterior descending artery, compared to Asian-Indians. We believe that our findings may contribute to the global data pool of normal coronary diameters and can be utilized in future studies as a database.

Effectiveness of polypill for primary and secondary prevention of cardiovascular diseases (PolyIran): a pragmatic, cluster-randomised trial

BACKGROUND

A fixed-dose combination therapy (polypill strategy) has been proposed as an approach to reduce the burden of cardiovascular disease, especially in low-income and middle-income countries (LMICs). The PolyIran study aimed to assess the effectiveness and safety of a four-component polypill including aspirin, atorvastatin, hydrochlorothiazide, and either enalapril or valsartan for primary and secondary prevention of cardiovascular disease.

METHODS

The PolyIran study was a two-group, pragmatic, cluster-randomised trial nested within the Golestan Cohort Study (GCS), a cohort study with 50 045 participants aged 40-75 years from the Golestan province in Iran. Clusters (villages) were randomly allocated (1:1) to either a package of non-pharmacological preventive interventions alone (minimal care group) or together with a once-daily polypill tablet (polypill group). Randomisation was stratified by three districts (Gonbad, Aq-Qala, and Kalaleh), with the village as the unit of randomisation. We used a balanced randomisation algorithm, considering block sizes of 20 and balancing for cluster size or natural log of the cluster size (depending on the skewness within strata). Randomisation was done at a fixed point in time (Jan 18, 2011) by statisticians at the University of Birmingham (Birmingham, UK), independent of the local study team. The non-pharmacological preventive interventions (including educational training about healthy lifestyle-eg, healthy diet with low salt, sugar, and fat content, exercise, weight control, and abstinence from smoking and opium) were delivered by the PolyIran field visit team at months 3 and 6, and then every 6 months thereafter. Two formulations of polypill tablet were used in this study. Participants were first prescribed polypill one (hydrochlorothiazide 12·5 mg, aspirin 81 mg, atorvastatin 20 mg, and enalapril 5 mg). Participants who developed cough during follow-up were switched by a trained study physician to polypill two, which included valsartan 40 mg instead of enalapril 5 mg. Participants were followed up for 60 months. The primary outcome-occurrence of major cardiovascular events (including hospitalisation for acute coronary syndrome, fatal myocardial infarction, sudden death, heart failure, coronary artery revascularisation procedures, and non-fatal and fatal stroke)-was centrally assessed by the GCS follow-up team, who were masked to allocation status. We did intention-to-treat analyses by including all participants who met eligibility criteria in the two study groups. The trial was registered with ClinicalTrials.gov, number NCT01271985.

FINDINGS

Between Feb 22, 2011, and April 15, 2013, we enrolled 6838 individuals into the study-3417 (in 116 clusters) in the minimal care group and 3421 (in 120 clusters) in the polypill group. 1761 (51·5%) of 3421 participants in the polypill group were women, as were 1679 (49·1%) of 3417 participants in the minimal care group. Median adherence to polypill tablets was 80·5% (IQR 48·5-92·2). During follow-up, 301 (8·8%) of 3417 participants in the minimal care group had major cardiovascular events compared with 202 (5·9%) of 3421 participants in the polypill group (adjusted hazard ratio [HR] 0·66, 95% CI 0·55-0·80). We found no statistically significant interaction with the presence (HR 0·61, 95% CI 0·49-0·75) or absence of pre-existing cardiovascular disease (0·80; 0·51-1·12; pinteraction=0·19). When restricted to participants in the polypill group with high adherence, the reduction in the risk of major cardiovascular events was even greater compared with the minimal care group (adjusted HR 0·43, 95% CI 0·33-0·55). The frequency of adverse events was similar between the two study groups. 21 intracranial haemorrhages were reported during the 5 years of follow-up-ten participants in the polypill group and 11 participants in the minimal care group. There were 13 physician-confirmed diagnoses of upper gastrointestinal bleeding in the polypill group and nine in the minimal care group.

INTERPRETATION

Use of polypill was effective in preventing major cardiovascular events. Medication adherence was high and adverse event numbers were low. The polypill strategy could be considered as an additional effective component in controlling cardiovascular diseases, especially in LMICs.

FUNDING

Tehran University of Medical Sciences, Barakat Foundation, and Alborz Darou.

Premature Myocardial Infarction in the Middle East and North Africa: Rationale for the Gulf PREVENT Study

The Middle East and North Africa (MENA) region has a high burden of morbidity and mortality due to premature (≤55 years in men; ≤65 years in women) myocardial infarction (MI) and acute coronary syndrome (ACS). Despite this, the prevalence of risk factors in patients presenting with premature MI or ACS is incompletely described. We compared lifestyle, clinical risk factors, and biomarkers associated with premature MI/ACS in the MENA region with selected non-MENA high-income countries. We identified English-language, peer-reviewed publications through PubMed (up to March 2018). We used the World Bank classification system to categorize countries. Patients with premature MI/ACS in the MENA region had a higher prevalence of smoking than older patients with MI/ACS but a lower prevalence of diabetes, hypertension, and dyslipidemia. Men with premature MI/ACS had a higher prevalence of smoking than women but a lower prevalence of diabetes and hypertension. The MENA region had sparse data on lifestyle, diet, psychological stress, and physical activity. To address these knowledge gaps, we initiated the ongoing Gulf Population Risks and Epidemiology of Vascular Events and Treatment (Gulf PREVENT) case-control study to improve primary and secondary prevention of premature MI in the United Arab Emirates, a high-income country in the MENA region.

Effect of CD14 polymorphisms on the risk of cardiovascular disease: evidence from a meta-analysis

Background

CD14 polymorphisms are associated with an increased risk of cardiovascular events. So far, many studies have been conducted, whereas the results were not always consistent.

Materials and methods

Twenty-six articles involving thirty-seven datasets were recruited to evaluate the association between rs2569190 (9413 patients and 7337 controls), C-159T (4813 patients and 2852 controls) polymorphisms and cardiovascular diseases in a meta-analysis. The random or fixed effect models were used to evaluate the pooled odds ratios (ORs) and their corresponding 95% confidence intervals.

Results

The strongest association was observed between rs2569190 and CVD in overall population (T vs. C, OR = 1.169, 95% CI: 1.087–1.257, p = 2.44 × 10^− 5). Analysis after stratification by ethnicity indicated that rs2569190 was related to CVD in East Asian population (T vs. C, OR = 1.370, 95% CI; 1.226–1.531, p = 2.86 × 10^− 8) and a potential relationship in European (T vs. C, OR = 1.100, 95% CI: 1.019–1.189, p = 0.015). In the stratification of endpoints, the associations were found in CHD subgroup (T vs. C, OR = 1.357, 95% CI: 1.157–1.592, p = 2.47 × 10^− 7) and in AMI subgroup (T vs. C, OR = 1.152, 95% CI: 1.036–1.281, p = 0.009). However, we did not find any association between C-159T polymorphism with cardiovascular disease under any model.

Conclusions

The SNP rs2569190 significantly contribute to susceptibility and development of cardiovascular disease, particularly in the East Asian population and in the subtype CHD group, in addition, a potential association was observed in the AMI group, T allele acts as a risk factor for cardiovascular disease.

Electronic supplementary material

The online version of this article (10.1186/s12944-019-1018-3) contains supplementary material, which is available to authorized users.

Effects of a New Combination of Medical Food on Endothelial Function and Lipid Profile in Dyslipidemic Subjects: A Pilot Randomized Trial

Nutritional approaches to improve dyslipidemias have been recently developed, but evidences on different medical foods are often incomplete. The main aim of our study was to evaluate the effects on endothelial function, lipid profile, and glucose metabolism of two different combinations of nutraceuticals, first one containing Bergavit (200 mg Citrus bergamia), Omega-3 (400 mg), Crominex 3+ (10 mcg trivalent chromium), and red yeast rice (100 mg; 5 mg monacolin K) and second one containing red yeast rice (200 mg; 3 mg monacolin K), Berberine (500 mg), Astaxanthin (0.5 mg), folic acid (200 mcg), Coenzyme Q10 (2 mg), and Policosanol (10 mg). Fifty subjects affected by dyslipidemia not requiring statin treatment were enrolled in this randomized, blind, controlled trial and submitted to blood sampling for lipid and glucose profiles and instrumental evaluation of endothelial function before and after 6 weeks of treatment with nutraceuticals. Both nutraceutical combinations improved the lipid profile; the nutraceutical containing 5 mg of monacolin K, 200 mg of the extract Citrus bergamia, 400 mg of Omega-3, and 10 mcg of trivalent chromium entailed a significant improvement of endothelial function with enhanced cholesterol lowering effect. In conclusion, this study confirms the positive effect of functional food on lipid profile and endothelial function in absence of major undesirable effects.

Body Mass Index is Strongly Associated with Hypertension: Results from the Longevity Check-up 7+ Study

The present study was undertaken to provide a better insight into the relationship between different levels of body mass index (BMI) and changing risk for hypertension, using an unselected sample of participants assessed during the Longevity Check-up 7+ (Lookup7+) project. Lookup7+ is an ongoing cross-sectional survey started in June 2015 and conducted in unconventional settings (i.e., exhibitions, malls, and health promotion campaigns) across Italy. Candidate participants are eligible for enrolment if they are at least 18 years of age and provide written informed consent. Specific health metrics are assessed through a brief questionnaire and direct measurement of standing height, body weight, blood glucose, total blood cholesterol, and blood pressure. The present analyses were conducted in 7907 community-living adults. According to the BMI cutoffs recommended by the World Health Organization, overweight status was observed among 2896 (38%) participants; the obesity status was identified in 1135 participants (15%), with 893 (11.8%) participants in class I, 186 (2.5%) in class II, and 56 (0.7%) in class III. Among enrollees with a normal BMI, the prevalence of hypertension was 45% compared with 67% among overweight participants, 79% in obesity class I and II, and up to 87% among participants with obesity class III (p for trend < 0.001). After adjusting for age, significantly different distributions of systolic and diastolic blood pressure across BMI levels were consistent. Overall, the average systolic blood pressure and diastolic blood pressure increased significantly and linearly across BMI levels. In conclusion, we found a gradient of increasing blood pressure with higher levels of BMI. The fact that this gradient is present even in the fully adjusted analyses suggests that BMI may cause a direct effect on blood pressure, independent of other clinical risk factors.

Reducing chronic disease through changes in food aid: A microsimulation of nutrition and cardiometabolic disease among Palestinian refugees in the Middle East

BACKGROUND

Type 2 diabetes mellitus and cardiovascular disease and have become leading causes of morbidity and mortality among Palestinian refugees in the Middle East, many of whom live in long-term settlements and receive grain-based food aid. The objective of this study was to estimate changes in type 2 diabetes and cardiovascular disease morbidity and mortality attributable to a transition from traditional food aid to either (i) a debit card restricted to food purchases, (ii) cash, or (iii) an alternative food parcel with less grain and more fruits and vegetables, each valued at $30/person/month.

METHODS AND FINDINGS

An individual-level microsimulation was created to estimate relationships between food aid delivery method, food consumption, type 2 diabetes, and cardiovascular disease morbidity and mortality using demographic data from the United Nations (UN; 2017) on 5,340,443 registered Palestinian refugees in Syria, Jordan, Lebanon, Gaza, and the West Bank, food consumption data (2011-2017) from households receiving traditional food parcel delivery of food aid (n = 1,507 households) and electronic debit card delivery of food aid (n = 1,047 households), and health data from a random 10% sample of refugees receiving medical care through the UN (2012-2015; n = 516,386). Outcome metrics included incidence per 1,000 person-years of hypertension, type 2 diabetes, atherosclerotic cardiovascular disease events, microvascular events (end-stage renal disease, diabetic neuropathy, and proliferative diabetic retinopathy), and all-cause mortality. The model estimated changes in total calories, sodium and potassium intake, fatty acid intake, and overall dietary quality (Mediterranean Dietary Score [MDS]) as mediators to each outcome metric. We did not observe that a change from food parcel to electronic debit card delivery of food aid or to cash aid led to a meaningful change in consumption, biomarkers, or disease outcomes. By contrast, a shift to an alternative food parcel with less grain and more fruits and vegetables was estimated to produce a 0.08 per 1,000 person-years decrease in the incidence of hypertension (95% confidence interval [CI] 0.05-0.11), 0.18 per 1,000 person-years decrease in the incidence of type 2 diabetes (95% CI 0.14-0.22), 0.18 per 1,000 person-years decrease in the incidence of atherosclerotic cardiovascular disease events (95% CI 0.17-0.19), and 0.02 decrease per 1,000 person-years all-cause mortality (95% CI 0.01 decrease to 0.04 increase) among those receiving aid. The benefits of this shift, however, could be neutralized by a small (2%) increase in compensatory (out-of-pocket) increases in consumption of refined grains, fats and oils, or confectionaries. A larger alternative parcel requiring an increase in total food aid expenditure by 27% would be more likely to have a clinically meaningful improvement on type 2 diabetes and cardiovascular disease incidence.

CONCLUSIONS

Contrary to the supposition in the literature, our findings do not robustly support the theory that transitioning from traditional food aid to either debit card or cash delivery alone would necessarily reduce chronic disease outcomes. Rather, an alternative food parcel would be more effective, even after matching current budget ceilings. But compensatory increases in consumption of less healthy foods may neutralize the improvements from an alternative food parcel unless total aid funding were increased substantially. Our analysis is limited by uncertainty in estimates of modeling long-term outcomes from shorter-term trials, focusing on diabetes and cardiovascular outcomes for which validated equations are available instead of all nutrition-associated health outcomes, and using data from food frequency questionnaires in the absence of 24-hour dietary recall data.

Prevalence of dyslipidaemia and awareness of blood cholesterol levels among community-living people: results from the Longevity check-up 7+ (Lookup 7+) cross-sectional survey

OBJECTIVE

The aim of the present study was to investigate the prevalence of abnormal cholesterol levels and to explore awareness of cholesterol values in an unselected sample of community-living adults.

DESIGN

Cross-sectional survey.

SETTING

Exhibitions, malls and health promotion campaigns across Italy.

PARTICIPANTS

3535 community dwellers aged 18-98 years were enrolled between September 2016 and June 2017. Analyses were conducted in 3040 participants, after excluding 495 enrolees on cholesterol-lowering medications.

MAIN OUTCOME MEASURES

Total blood cholesterol levels and awareness of cholesterol values.

RESULTS

Abnormal blood cholesterol values were found in 1961 (64.5%) of participants with no differences between genders (p=0.06). Among those who believed they had normal cholesterol levels, only 48% had values below 200 mg/dL. More than 40% had cholesterol values between 200 and 240 mg/dL, and around 10% had values >240 mg/dL. More than one-third of participants had not measured cholesterol in the last year. Among them, only 36% had normal cholesterol levels.

CONCLUSIONS

Abnormal blood cholesterol is highly prevalent in our sample of Italian community dwellers, with less than half of participants being aware of their cholesterol levels.

Trends in Deaths from Rheumatic Heart Disease in the Eastern Mediterranean Region: Burden and Challenges

Rheumatic heart disease (RHD) is a preventable disease that is prevalent in developing regions of the world. Its eradication from most of the developed world indicates that this disease can be controlled and eliminated. Aim: To conduct an in-depth analysis of the trends and challenges of controlling RHD in the Eastern Mediterranean region (EMR). Methodology: Global data from the World Health Organization (WHO) data banks were retrieved for total deaths and age standardized death rate per 100,000 (ASDR) by age group, sex, and year (from 2000 to 2015). The data was compared with the five other WHO regions of the world. We also performed in-depth analysis by socio-economic groups in relation to other attributes in the region related to population growth, illiteracy, and nutritional status. Indicators of service delivery were correlated with ASDR from RHD. Findings: Prevalence of RHD in 2015 in the EMR region was one-third of that of the total deaths reported in the Asian and West Pacific regions. The total deaths for the region peaked twice: in early adulthood and again later in old age, and was higher in females than in males. There was a rising trend in deaths from RHD from 2000 to 2015. The highest total deaths were reported from Egypt, Pakistan, Iran, Afghanistan, and Yemen, representing 80% of the total death rates for the region (35,248). The highest ASDR was Afghanistan (27.5), followed by Yemen (18.78) and Egypt (15.59). The ASDR for RHD was highest in low income countries. It correlated highly, in all income groups, with anemia during pregnancy. Conclusions: Trends and patterns of deaths from RHD in the EMR have shifted to a later age group and are linked with poverty related to inequalities in development and service delivery for certain age groups and gender.

Adolescent health in the Eastern Mediterranean Region: findings from the global burden of disease 2015 study

OBJECTIVES

The 22 countries of the East Mediterranean Region (EMR) have large populations of adolescents aged 10-24 years. These adolescents are central to assuring the health, development, and peace of this region. We described their health needs.

METHODS

Using data from the Global Burden of Disease Study 2015 (GBD 2015), we report the leading causes of mortality and morbidity for adolescents in the EMR from 1990 to 2015. We also report the prevalence of key health risk behaviors and determinants.

RESULTS

Communicable diseases and the health consequences of natural disasters reduced substantially between 1990 and 2015. However, these gains have largely been offset by the health impacts of war and the emergence of non-communicable diseases (including mental health disorders), unintentional injury, and self-harm. Tobacco smoking and high body mass were common health risks amongst adolescents. Additionally, many EMR countries had high rates of adolescent pregnancy and unmet need for contraception.

CONCLUSIONS

Even with the return of peace and security, adolescents will have a persisting poor health profile that will pose a barrier to socioeconomic growth and development of the EMR.

Danger ahead: the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region, 1990-2015

OBJECTIVES

The Eastern Mediterranean Region faces several health challenges at a difficult time with wars, unrest, and economic change.

METHODS

We used the Global Burden of Disease 2015 study to present the burden of diseases, injuries, and risk factors in the Eastern Mediterranean Region from 1990 to 2015.

RESULTS

Ischemic heart disease was the leading cause of death in the region in 2015, followed by cerebrovascular disease. Changes in total deaths ranged from a reduction of 25% for diarrheal diseases to an increase of about 42% for diabetes and tracheal, bronchus, and lung cancer. Collective violence and legal intervention increased by 850% during the time period. Diet was the leading risk factor for disability-adjusted life years (DALYs) for men compared to maternal malnutrition for females. Childhood undernutrition was the leading risk factor for DALYs in 1990 and 2005, but the second in 2015 after high blood pressure.

CONCLUSIONS

Our study shows that the region is facing several health challenges and calls for global efforts to stabilise the region and to address the current and future burden of disease.