Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

The association between body mass index and abdominal obesity with hypertension among South Asian population: findings from nationally representative surveys

OBJECTIVE

This study aimed to determine the association between body mass index (BMI) and abdominal obesity with hypertension among the South Asian adults (18-69 years).

METHODS

This study utilized the nationally representative WHO STEPwise approach to surveillance data (n = 24,413) from Afghanistan, Bangladesh, Bhutan, Nepal, and Sri Lanka. Hypertension was defined as having a systolic blood pressure of 140 mmHg or higher, a diastolic blood pressure of 90 mmHg or higher, and/or taking antihypertensive medications. A waist circumference ≥ 90 cm in men and ≥ 80 cm in women was considered as abdominal obesity. BMI was categorized according to Asia-specific cutoff and overweight was defined as BMI of 23.0-27.5 kg/m2 and obesity was defined as BMI ≥ 27.5 kg/m2. Multivariable logistic regression analyses were conducted to identify the association between BMI and abdominal obesity with hypertension. The odds ratio (OR) with a 95% confidence interval (CI) was reported.

RESULTS

Abdominal obesity increased the odds of hypertension 31%-105% compared to those who did not have abdominal obesity (OR: Afghanistan: 2.05; 95% CI: 1.27-3.31; Bangladesh: 1.55; 95% CI: 1.18-2.04; Bhutan: 1.31; 95% CI: 1.03-1.66; Nepal: 1.69; 95% CI: 1.31-2.18; Sri Lanka:1.55; 95% CI: 1.23-1.95). The odds increased among participants with both overweight/obesity and abdominal obesity. In all five countries under study, participants with both overweight and abdominal obesity (OR: Afghanistan: 2.75; 95% CI: 1.75-4.34; Bangladesh: 2.53; 95% CI: 1.90-3.37; Bhutan: 2.22; 95% CI: 1.64-3.00; Nepal: 2.08; 95% CI: 1.54-2.81; Sri Lanka: 2.29; 95% CI: 1.77-2.98), as well as those with obesity and abdominal obesity (OR: Afghanistan: 6.94; 95% CI: 4.68-10.30; Bangladesh: 2.95; 95% CI: 2.19-3.97; Bhutan: 3.02; 95% CI: 2.23-4.09; Nepal: 4.40; 95% CI: 3.05-6.34; Sri Lanka: 3.96; 95% CI: 2.94-5.32), exhibited higher odds of having hypertension as compared to participants with a normal BMI and no abdominal obesity.

CONCLUSION

Having both abdominal obesity and overweight/obesity increased the odds of hypertension among South Asian adults. Preventing overweight/obesity and abdominal obesity is necessary for preventing the burden of hypertension in South Asia.

Socio-demographic predictors of obesity among 12,975 adult ever married Egyptian women of reproductive age group: evidence from nationwide survey

AIM

We aimed to explore the predictors associated with obesity among adult ever-married Egyptian women aged 20-49 years based on the Egyptian Demographic and Health Survey (EDHS).

METHOD

We included adult ever married women from the EDHS conducted in 2014 that initially recruited 21,903 women. Univariate and multivariable analysis was conducted to identify socio-demographic predictors of women's obesity.

RESULT

We included 12,975 Egyptian women. Among them, 76% of the total respondents were obese where as 24% were with normal body mass index (BMI). In multivariable analysis, the results revealed that increasing age, higher wealth index, listening to radio at least once a week and women with primary and secondary education were at significant odds of developing obesity (p < 0.05). However, we found no association between residence of participants and the frequency of watching television upon the development of obesity (p > 0.05).

CONCLUSION

Appropriate and targeted interventions should be implemented among the Egyptian reproductive age women to reduce the obesity as well as non-communicable diseases load associated with obesity. National Health Service policy makers should take multilevel approach targeting high risk sub-groups to raise awareness and to provide prevention against obesity and the subsequent complications.

The burden of psychological distress and unhealthy dietary behaviours among 222,401 school-going adolescents from 61 countries

We aimed to calculate the sex-specific prevalence of psychological distress and unhealthy eating habits among adolescents across countries and regions, and to explore their potential associations. We used data from the Global School-Based Health Survey (GSHS) for 61 countries. Psychological distress was defined based on the existence of ≥ 2 factors from the following: loneliness, anxiety, suicide ideation, suicide planning, and suicide attempt. Four unhealthy dietary behaviours were examined: inadequate fruit intake, inadequate vegetable intake, daily consumption of soft drinks, and weekly fast-food consumption. We used random-effects meta-analysis to estimate the overall and regional pooled prevalence. Mixed-effect multilevel logistic regressions were used to estimate adjusted odds ratios (aORs) of unhealthy dietary behaviours in relation to psychological distress. Among 222,401 school-going adolescents (53.3% girls), the prevalence of psychological distress was 17.9%, with girls reporting higher than boys (20.8% vs. 14.9%). Adolescents in the African region reported the highest prevalence (22.5%), while those in the South-East Asia region reported the lowest (11.3%). The prevalence of inadequate fruit intake, inadequate vegetable intake, daily soft drink consumption, and weekly fast-food consumption was 37.0%, 28.5%, 50.0%, and 57.4% respectively. Psychological distress was associated with inadequate fruit intake (pooled aOR = 1.19, 95% CI 1.17-1.23), inadequate vegetable intake (pooled OR = 1.19, 1.16-1.22), daily consumption of soft drinks (pooled aOR = 1.14, 1.12-1.17), and weekly consumption of fast food (pooled aOR = 1.12, 1.09-1.15). Our findings indicate a substantial variance in the burden of psychological distress and unhealthy dietary behaviours across different regions. Adolescents experiencing psychological distress were more likely to have unhealthy dietary habits.

Impact of family history of cancer on colorectal cancer screening: a propensity score-matched analysis from the Health Information National Trends Survey (HINTS)

BACKGROUND

Early detection of colon cancer leads to better survival outcomes. This can be achieved through colorectal cancer (CRC) screening. People with a family history of cancer (FHC) have increased risk of developing CRC. Increasing screening in this group will reduce CRC mortality. This study evaluated CRC screening in people with FHC.

METHODS

The study used data from the Health Information National Trends Survey (HINTS) 5, cycle 3. This is an annual cross-sectional survey with a nationally representative sample of American adults. The objective was to study the association between FHC and performing CRC screening. Propensity score matching was used to create a matched population with variables that constituted beliefs in cancer from the survey. Replication procedure, which is based on repeated sampling and allows for accurate computation of standard errors, was used for calculating statistical tests. Multivariable models were fitted in the matched population to assess the association between FHC and performing CRC screening.

RESULTS

People with FHC were 14% (OR = 1.14; 95% CI: 0.81-1.60) more likely to perform CRC screening than those without FHC, even though not statistically significant. Age in years (OR = 1.14; 95% CI: 1.12-5.27) had increased likelihood of performing CRC screening, while other races such as American Indians/Alaskan Natives (except African Americans) compared to Caucasians (OR = 0.49; 95% CI: 0.29-0.84) had significantly decreased likelihood of performing CRC screening.

CONCLUSION

FHC was not significantly associated with having a colorectal cancer screening test. Public health advocacy should be directed towards increasing awareness of CRC screening among people with FHC.

The burden of diseases and risk factors in Bangladesh, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Bangladesh has made substantial progress in improving socioeconomic and health indicators over the past 50 years, but data on national disease burden are scarce. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to estimate the burden of diseases and risk factors in Bangladesh from 1990 to 2019.

METHODS

For this systematic analysis, we analysed data from vital registration systems, surveys, and censuses using multistage modelling processes to estimate life expectancy at birth, mortality rate, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs). Additionally, we compared the health status of Bangladesh with that of the other countries in the GBD south Asia region-Bhutan, India, Nepal, and Pakistan.

FINDINGS

Life expectancy at birth in Bangladesh increased from 58·2 years (95% uncertainty interval 57·1-59·2) in 1990 to 74·6 years (72·4-76·7) in 2019. Between 1990 and 2019, the age-standardised mortality rate decreased from 1509·3 (1428·6-1592·1) to 714·4 (604·9-838·2) deaths per 100 000 population. In 2019, non-communicable diseases represented 14 of the top 20 causes of death; the leading three causes were stroke, ischaemic heart disease, and chronic obstructive pulmonary disease. High blood pressure, high fasting plasma glucose, and smoking were the top three risk factors. From 1990 to 2019, the rate of all-cause DALYs decreased by 54·9% (48·8-60·4). In 2019, the leading causes of DALYs and YLLs were neonatal disorders, stroke, and ischaemic heart disease, whereas musculoskeletal disorders, depressive disorders, and low back pain were the leading causes of YLDs. Bangladesh has the lowest age-standardised rates of mortality, YLDs, and YLLs and the highest life expectancy at birth in south Asia.

INTERPRETATION

Over the past 30 years, mortality rates have reduced by more than half in Bangladesh. Bangladesh must now address the double burden of communicable and non-communicable diseases. Cost-effective, multisectoral efforts are needed to prevent and control non-communicable diseases, promote healthy lifestyles, and prevent premature mortality and disabilities.

FUNDING

Bill & Melinda Gates Foundation.

TRANSLATION

For the Bangla translation of the abstract see Supplementary Materials section.

Rural-Urban Differences in Prevalence and Associated Factors of Underweight and Overweight/Obesity among Bangladeshi Adults: Evidence from Bangladesh Demographic and Health Survey 2017-2018

The aim of this study was to identify the differences in prevalence and associated factors of underweight and overweight/obesity among Bangladeshi adults (≥18 years) by analyzing the cross-sectional Bangladesh Demographic and Health Survey 2017-2018 data. Multilevel multivariable logistic regression was applied to identify the factors associated with underweight and overweight/obesity in urban and rural areas. The prevalence of underweight was 12.24% and 19.34% in urban and rural areas, respectively. The prevalence of overweight/obesity was 50.23% and 35.96%, respectively, in urban and rural areas. In the final multivariable analysis in both urban and rural areas, 30-49 years of age, female sex, being educated up to college or higher level, living in the wealthiest household, and being currently married or being separated/divorced/widowed had higher odds of being overweight/obese compared to other categories. Residence in the Mymensingh and Sylhet region was associated with decreased odds of overweight/obesity in urban and rural areas. On the other hand, being educated up to college or higher level, living in the wealthiest household, and being married were associated with reduced odds of being underweight in both areas. These high-risk groups should be brought under targeted health promotion programs to curb malnutrition.

Prevalence, pattern, and correlates of dyslipidemia in Bangladeshi individuals

BACKGROUND

The burden of dyslipidemia in Bangladesh remains inadequately characterized.

OBJECTIVES

To determine and describe the prevalence and pattern of dyslipidemia and its associated risk factors among an adult Bangladeshi population.

DESIGN

Population-based, cross-sectional study. Participants were adults living in all eight administrative divisions of Bangladesh. The total sample size was 7084 (53.1 % women, 46.9% urban residents). Primary outcome measures were triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and the use of lipid lowering medication. In addition, control of LDL-C and control of non high-density lipoprotein cholesterol (non-HDL-C) were investigated.

RESULTS

The overall dyslipidemia prevalence was 76.7%, with 35.7% showing a high TG level, 18.5% showing a high LDL-C level, 63.8% showing a low HDL-C level, and 7.2% of the participants showing all three lipid abnormalities. Sylhet division had the highest prevalence (83.8%) of overall dyslipidemia, while Rangpur had the lowest prevalence (69.3%). The control of LDL-C (<50 mg/dL) and non-HDL-C (<80 mg/dL) among adults with a previous history of atherosclerotic cardiovascular diseases (ASCVD) were 5.1% and 6.9% respectively. The regression models showed that male sex and age 45-59 years were significant predictors of overall dyslipidemia. Both smokers and smokeless tobacco users were significant factors for overall dyslipidemia and high TG. A high waist-hip ratio was associated with overall dyslipidemia and all other subtypes of dyslipidemia.

CONCLUSION

The high prevalence of dyslipidemia in Bangladesh necessitates lifestyle interventions to prevent and control this cardiovascular risk factor.

Depression and health-related quality of life of patients with type 2 diabetes attending tertiary level hospitals in Dhaka, Bangladesh

INTRODUCTION

Type 2 diabetes mellitus (T2DM) and depression are closely linked. People with T2DM are at increased risk of developing depression and vice versa. T2DM and depression comorbid conditions adversely affect Health-Related Quality of Life (HRQOL) and management of T2DM. In this study, we assessed depression and HRQOL among patients with T2DM in Dhaka, Bangladesh.

METHODS

A cross-sectional study was conducted in two tertiary-level hospitals in Dhaka, Bangladesh. Data were collected from 318 patients with T2DM. A set of standard tools, PHQ-9 (for assessing depression) and EuroQol-5D-5L (for assessing the HRQOL), were used. Statistical analyses, including Chi-square and Fisher's exact tests, Wilcoxon (Mann-Whitney), and Spearman's correlation coefficient tests, were performed using SPSS (v.20).

RESULTS

The majority of the patients (58%) were females, with a mean age (standard deviation) of 52 ± 10 years, and 74% of patients lived in urban areas. The prevalence of depression was 62% (PHQ-9 score ≥ 5). Over three-quarters (76%) reported problems in the anxiety/ depression dimension of EQ-5D, followed by pain/discomfort (74%), mobility (40%), self-care (36%), and usual activities (33%). The depression and T2DM comorbid condition were associated with all the five dimensions of EQ-5D (χ2 statistics with df = 1 was 52.33, 51.13, 52.67, 21.61, 7.92 for mobility, self-care, usual activities, pain/discomfort, and anxiety/ depression dimensions respectively, p- < 0.01). The mean EQ-5D index (0.53 vs. 0.75) and the mean EQ-5D VAS (65 vs. 76) both showed lower values in T2DM patients with depression compared to T2DM patients without depression (Wilcoxon test, p- < 0.001).

CONCLUSIONS

We conclude that the majority of the patients with T2DM had comorbid conditions, and the HRQOL was negatively affected by comorbid depression in T2DM patients. This suggests the importance of timely screening, diagnosis, treatment, and follow-up of comorbid depression in T2DM patients to improve overall health and QOL.

Obesity and Abdominal Obesity in Indian Population: Findings from a Nationally Representative Study of 698,286 Participants

This study aims to determine and compare the prevalence and correlates of obesity and abdominal obesity in India among participants aged 18-54 years. Data were acquired from the nationally representative National Family Health Survey 2019-21. Age and sex standardized descriptive analyses were conducted to determine the prevalence of obesity and abdominal obesity, and multivariable multilevel logistic regression was performed to identify the factors associated with these conditions. Gender-specific analyses were also conducted. The sample weight was adjusted throughout. The final sample size for this study was 698,286. The prevalence of obesity and abdominal obesity was 13.85% and 57.71%, respectively. Older age, being female, increased educational status and increased wealth index, being married at any point, and residing in an urban area all increased the odds of both obesity and abdominal obesity. Being a resident of the North zone and having a current alcohol intake increased the odds of abdominal obesity. On the other hand, being a resident of the South zone of India increased the odds of obesity. Targeting these high-risk groups can be a strategy for public health promotion programs.

Clustering of metabolic and behavioural risk factors for cardiovascular diseases among the adult population in South and Southeast Asia: findings from WHO STEPS data

Background

The aim of this study is to assess the current status of metabolic and behavioural risk factors for cardiovascular diseases among the adult population in South and Southeast Asia using World Health Organization (WHO) STEPS data.

Methods

We used WHO STEPS surveys data in ten South and Southeast Asian countries. Weighted mean estimates of prevalence of five metabolic risk factors and four behavioural risk factors were calculated by country and overall region. We used random-effects meta-analysis to generate country and regional pooled estimates of metabolic and behavioural risk factors, using the DerSimonian and Laird inverse-variance method.

Finding

Around 48,434 participants aged 18-69 years were included in this study. Overall 32.00% (95% CI: 31.15-32.36) of individuals in the pooled sample had one metabolic risk factor, 22.10% (95% CI: 21.73-22.47) had two, and 12.38% had three or more (95% CI: 9.09-14.00). Twenty-four percent (95% CI: 20.00-29.00) of individuals in the pooled sample had only one behavioural risk factor, 49.00% (95% CI: 42.00-56.00) had two, and 22.00% had three or more (95% CI: 16.00-29.00). Risk of high three or more metabolic risk factors was higher among women, those of older age, and those with a higher education.

Interpretation

The existence of multiple metabolic and behavioural risk factors among the South and Southeast Asian population demand appropriate prevention strategies to halt the progress of non-communicable disease burden within the region.

Funding

Not applicable.

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

METHODS

We distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

FINDINGS

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

INTERPRETATION

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

FUNDING

Bill & Melinda Gates Foundation.

Association of Chlorhexidine Use and Scaling and Root Planing With Birth Outcomes in Pregnant Individuals With Periodontitis: A Systematic Review and Meta-analysis

IMPORTANCE

Chlorhexidine mouthwash enhances treatment effects of conventional periodontal treatment, but data on chlorhexidine as a source of heterogeneity in meta-analyses assessing the treatment of maternal periodontitis in association with birth outcomes are lacking.

OBJECTIVE

To assess possible heterogeneity by chlorhexidine use in randomized clinical trials (RCTs) evaluating the effect of periodontal treatment (ie, scaling and root planing [SRP]) vs no treatment on birth outcomes.

DATA SOURCES

Cochrane Oral Health's Trials Register, Cochrane Pregnancy and Childbirth's Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database), US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov), and the WHO International Clinical Trials Registry Platform were searched through March 2022.

STUDY SELECTION

RCTs were included if they were conducted among pregnant individuals with periodontitis, used interventions consisting of SRP vs no periodontal treatment, and assessed birth outcomes.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted with consensus of 2 reviewers using Rayyan and assessed for bias with the Cochrane Risk of Bias 2 tool before random effects subgroup meta-analyses. Analyses were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were preterm birth (ie, <37 weeks' gestation) and low birth weight (ie, <2500 g).

RESULTS

There were 12 studies with a total of 5735 participants evaluating preterm birth. Control group participants did not receive any treatment or use chlorhexidine during pregnancy. All intervention group participants received SRP; in 5 of these studies (with 2570 participants), pregnant participants in the treatment group either received chlorhexidine mouthwash or advice to use it, but participants in the remaining 7 studies (with 3183 participants) did not. There were 8 studies with a total of 3510 participants evaluating low birth weight, including 3 studies with SRP plus chlorhexidine (with 594 participants) and 6 studies with SRP only (with 2916 participants). The SRP plus chlorhexidine groups had lower risk of preterm birth (relative risk [RR], 0.56; 95% CI, 0.34-0.93) and low birth weight (RR, 0.47; 95% CI, 0.32-0.68) but not the SRP-only groups (preterm birth: RR, 1.03; 95% CI, 0.82-1.29; low birth weight: RR, 0.82; 95% CI, 0.62-1.08).

CONCLUSIONS AND RELEVANCE

These findings suggest that treating maternal periodontitis with chlorhexidine mouthwash plus SRP was associated with reduced risk of preterm and low birth weight. Well-conducted RCTs are needed to test this hypothesis.

Prevalence and Associated Factors with Ideal Cardiovascular Health Metrics in Bangladesh: Analysis of the Nationally Representative STEPS 2018 Survey

This study aims to find out the prevalence of the American Heart Association's (AHA)'s cardiovascular health metrics and associated socio-demographic factors. A secondary analysis of the World Health Organization (WHO) STEPwise approach to surveillance survey 2018 (STEPS 2018) data was conducted. Ideal Cardiovascular Health (ICH) was defined as the presence of 5-7 ideal metrics as defined by the AHA. Design-adjusted multivariable logistic regression was used to determine the associated factors of ICH. In total, 5930 respondents were included in our analysis, and 43.1% of the participants had ICH. The odds of ICH decreased with age [compared to 18-29 years old individuals, 30-49 years: AOR (Adjusted Odds Ratio): 0.4; 95% Confidence Interval (CI): 0.4-0.5; 50-69 years: AOR: 0.7; 95% CI: 0.6-0.8], and higher educational attainment (compared to those who received no formal education, being educated up to primary level: AOR:0.7; 95% CI: 0.6-0.8; being educated up to secondary level: AOR: 0.4; 95% CI: 0.4-0.5; being educated up to college and higher: AOR: 0.4; 95% CI: 0.3-0.5). Compared with female and urban residents, the odds were 30% and 40% less among male and rural residents, respectively. The public health promotion programs of Bangladesh should raise awareness among high-risk groups to prevent cardiovascular diseases.

Prevalence and determinants of hypertension among urban slum dwellers in Bangladesh

Background

In low- and middle- income countries such as Bangladesh, urban slum dwellers are particualry vulnerable to hypertension due to inadequate facilities for screening and management, as well as inadequate health literacy among them. However, there is scarcity of evidence on hypertension among the urban slum dwellers in Bangladesh. The present study aimed to determine the prevalence and factors associated with hypertension among urban slum dwellers in Bangladesh.

Methods

Data were collected as part of a large-scale cross-sectional survey conducted by Building Resources Across Communities (BRAC) between October 2015 and January 2016. The present analysis was performed among 1155 urban slum dwellers aged 35 years or above. A structured questionnaire was adminstered to collect data electronically and blood pressure measurements were taken using standardised procedures. Binary logistic regression with generalized estimating equation modelling was performed to estimate the factors associated with hypertension.

Results

The prevalence of hypertension was 28.3% among urban slum dwellers aged 35 years and above. In adjusted analysis, urban slum dwellers aged 45–54 years (AOR: 1.64, 95% CI: 1.17–2.28), 55–64 years (AOR: 2.47, 95% CI: 1.73–3.53) and ≥ 65 years (AOR: 2.34, 95% CI: 1.47–3.72), from wealthier households (AOR: 1.94, 95% CI: 1.18–3.20), sleeping < 7 h per day (AOR: 1.87, 95% CI: 1.39–2.51), who were overweight (AOR: 1.53, 95% CI: 1.09–2.14) or obese (AOR: 2.34, 95% CI: 1.71–3.20), and having self-reported diabetes (AOR: 3.08, 95% CI: 1.88–5.04) had an increased risk of hypertension. Moreover, 51.0% of the participants were taking anti-hypertensive medications and 26.4% of them had their hypertension in control.

Conclusions

The findings highlight a high burden of hypertension and poor management of it among the slum dwellers in Bangladesh requiring a novel approach to improve care. It is integral to effectively implement the available national non-communicable disease (NCD) control guidelines and redesign the current urban primary health care system to have better coordination.

Prevalence of multiple non-communicable diseases risk factors among adolescents in 140 countries: A population-based study

BACKGROUND

Modifiable non-communicable disease (NCD) risk factors are becoming increasingly common among adolescents, with clustering of these risk factors in individuals of particular concern. The aim of this study was to assess global status of clustering of common modifiable NCD risk factors among adolescents.

METHODS

We used latest available data from nationally representative survey for 140 countries, namely the Global School-based Student Health Survey, the Health Behaviour in School-Aged Children and the longitudinal study of Australian Children. Weighted mean estimates of prevalence with corresponding 95% confidence intervals of nine NCD risk factors - physical inactivity, sedentary behaviour, insufficient fruits and vegetable consumption, carbonated soft drink consumption, fast food consumption, tobacco use, alcohol consumption and overweight/obesity - were calculated by country, region and sex.

FINDINGS

Over 487,565 adolescents, aged 11-17 years, were included in this study. According to trend analysis, prevalence of four or more NCD risk factors increased gradually over time. Prevalence of four or more NCD risk factors was 14.8% in 2003-2007 and increased to 44% in 2013-2017, an approximately three-fold increase (44.0%). Similar trends were also observed for three and two risk factors. Large variation between countries in the prevalence of adolescents with four or more risk factors was found in all regions. The country level range was higher in the South-East Asia Region (minimum Sri Lanka = 8%, maximum Myanmar = 84%) than Western Pacific Region (minimum China = 3%, maximum Niue = 72%), European Region (minimum Sweden = 13.9%, maximum Ireland = 66.0%), African Region (minimum Senegal = 0.8%, maximum Uganda = 82.1%) and Eastern Mediterranean Region (minimum Libya = 0.2%, maximum Lebanon = 80.2%). Insufficient vegetable consumption, insufficient fruit consumption and physically inactivity were three of the four most prevalent risk factors in all regions.

INTERPRETATION

Our results suggest a high prevalence of four or more NCD risk factors in adolescents globally, although variation was found between countries. Results from our study indicate that efforts to reduce adolescent NCD risk factors and the associated health burden need to be improved. These findings can assist policy makers to target the rollout of country- specific interventions.

FUNDING

None.

Mapping development and health effects of cooking with solid fuels in low-income and middle-income countries, 2000-18: a geospatial modelling study

BACKGROUND

More than 3 billion people do not have access to clean energy and primarily use solid fuels to cook. Use of solid fuels generates household air pollution, which was associated with more than 2 million deaths in 2019. Although local patterns in cooking vary systematically, subnational trends in use of solid fuels have yet to be comprehensively analysed. We estimated the prevalence of solid-fuel use with high spatial resolution to explore subnational inequalities, assess local progress, and assess the effects on health in low-income and middle-income countries (LMICs) without universal access to clean fuels.

METHODS

We did a geospatial modelling study to map the prevalence of solid-fuel use for cooking at a 5 km × 5 km resolution in 98 LMICs based on 2·1 million household observations of the primary cooking fuel used from 663 population-based household surveys over the years 2000 to 2018. We use observed temporal patterns to forecast household air pollution in 2030 and to assess the probability of attaining the Sustainable Development Goal (SDG) target indicator for clean cooking. We aligned our estimates of household air pollution to geospatial estimates of ambient air pollution to establish the risk transition occurring in LMICs. Finally, we quantified the effect of residual primary solid-fuel use for cooking on child health by doing a counterfactual risk assessment to estimate the proportion of deaths from lower respiratory tract infections in children younger than 5 years that could be associated with household air pollution.

FINDINGS

Although primary reliance on solid-fuel use for cooking has declined globally, it remains widespread. 593 million people live in districts where the prevalence of solid-fuel use for cooking exceeds 95%. 66% of people in LMICs live in districts that are not on track to meet the SDG target for universal access to clean energy by 2030. Household air pollution continues to be a major contributor to particulate exposure in LMICs, and rising ambient air pollution is undermining potential gains from reductions in the prevalence of solid-fuel use for cooking in many countries. We estimated that, in 2018, 205 000 (95% uncertainty interval 147 000-257 000) children younger than 5 years died from lower respiratory tract infections that could be attributed to household air pollution.

INTERPRETATION

Efforts to accelerate the adoption of clean cooking fuels need to be substantially increased and recalibrated to account for subnational inequalities, because there are substantial opportunities to improve air quality and avert child mortality associated with household air pollution.

FUNDING

Bill & Melinda Gates Foundation.

Underweight, overweight or obesity, diabetes, and hypertension in Bangladesh, 2004 to 2018

Background and objectives

Bangladesh is experiencing a nutrition transition with an increase in the double burden of malnutrition and non-communicable diseases (NCDs). This study sought to: 1) examine trends and differences in underweight, overweight/obesity, hypertension and diabetes by gender, area of residence, and wealth in Bangladesh from 2004 to 2018, 2) assess what factors contributed to changes in these outcomes.

Methods

We used data from five rounds of the Bangladesh Demographic and Health Surveys (n = 76,758 women 15-49y and 10,900 men 18-95y in total). We calculated differences, slope index of inequality (SII) and concentration index (CIX) to examine trends over time and differences in outcomes by wealth and residence. We identified determinants and estimated drivers of changes in outcomes using regression-based decomposition.

Results

Between 2004 and 2018, underweight prevalence decreased in both women (33% to 12%) and men (26% to 18%), whereas overweight/obesity increased (17% to 49% in women and 21% to 34% in men). Hypertension also increased in both women (31% to 44%) and men (19% to 33%) while diabetes changed marginally (11% to 14%). In all years, underweight was concentrated in poorer and rural households while overweight/obesity, diabetes and hypertension were concentrated in wealthier and urban households. Wealth inequity decreased over time for underweight, changed little for overweight/obesity, and increased for hypertension and diabetes among men. Increases in wealth explained 35% to 50% of the reduction in underweight and 30% to 57% of the increase in overweight/obesity.

Conclusion

Our findings imply that double duty actions are required to sustain the decrease in undernutrition and slow the increase in overweight/obesity and NCDs across diverse socioeconomic sections of the population in Bangladesh.

A tale of osteoarthritis among older adults during the COVID-19 pandemic in Bangladesh: A repeated cross-sectional study

Background

Due to restrictions in social gatherings imposed due to the COVID-19 pandemic, physical and other daily activities were limited among the older adults. The present study aimed to estimate the change in osteoarthritis prevalence among older adults during the COVID-19 pandemic in Bangladesh.

Methods

This repeated cross-sectional study was conducted through telephone interviews among older adults aged 60 years and above on two successive occasions (October 2020 and September 2021) during the COVID-19 pandemic in Bangladesh. The prevalence of osteoarthritis was measured by asking the participants if they had osteoarthritis or joint pain problems.

Results

A total of 2077 participants (1032 in 2020-survey and 1045 in 2021-survey) participated in the study. The prevalence of self-reported joint pains or osteoarthritis significantly increased from 45.3% in 2020 to 54.7% in 2021 (P = 0.006), with an increasing odd in the adjusted analysis (aOR 1.27, 95% CI 1.04–1.54). We also found that osteoarthritis prevalence significantly increased among the participants from the Chattogram and Mymensingh divisions, aged 60–69 years, males, married, rural residents, and living with a family. A significant increase was also documented among those who received formal schooling, had a family income of 5000–10000 BDT, resided with a large family, were unemployed or retired, and lived away from a health facility.

Conclusions

Our study reported a significant increased prevalence of osteoarthritis among older adults from 2020 to 2021 during this pandemic in Bangladesh. This study highlights the need for the development and implementation of initiatives for the screening and management of osteoarthritis through a primary health care approach during any public health emergencies.

Differences in Prevalence and Associated Factors of Underweight and Overweight/Obesity among Bangladeshi Adults by Gender: Analysis of a Nationally Representative Survey

The objective of this study was to find the differences in prevalence and associated factors of underweight and overweight/obesity among Bangladeshi adults by gender, using the nationally representative Bangladesh Demographic and Health Survey 2017-2018 data. To identify the factors associated with underweight and overweight/obesity in both genders, multilevel multivariable logistic regression was conducted. The prevalence of underweight was 19.79% and 15.49% among males and females, respectively. The prevalence of overweight/obesity was 32.67% and 45.60% among males and females, respectively. Among both genders, participants with the highest likelihood of overweight/obesity were aged 30-49 years and 50-69 years, had the highest educational attainment up to primary and secondary level, resided in a household that belonged to the middle, richer, or richest wealth quintiles, and were currently married. On the other hand, among both genders, increased educational attainment and wealth index were inversely associated with being underweight. Health promotion programs in Bangladesh should focus on these high-risk groups to address the burden of underweight and overweight/obesity.

Estimates, trends, and drivers of the global burden of type 2 diabetes attributable to PM2·5 air pollution, 1990-2019: an analysis of data from the Global Burden of Disease Study 2019

BACKGROUND

Experimental and epidemiological studies indicate an association between exposure to particulate matter (PM) air pollution and increased risk of type 2 diabetes. In view of the high and increasing prevalence of diabetes, we aimed to quantify the burden of type 2 diabetes attributable to PM2·5 originating from ambient and household air pollution.

METHODS

We systematically compiled all relevant cohort and case-control studies assessing the effect of exposure to household and ambient fine particulate matter (PM2·5) air pollution on type 2 diabetes incidence and mortality. We derived an exposure-response curve from the extracted relative risk estimates using the MR-BRT (meta-regression-Bayesian, regularised, trimmed) tool. The estimated curve was linked to ambient and household PM2·5 exposures from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, and estimates of the attributable burden (population attributable fractions and rates per 100 000 population of deaths and disability-adjusted life-years) for 204 countries from 1990 to 2019 were calculated. We also assessed the role of changes in exposure, population size, age, and type 2 diabetes incidence in the observed trend in PM2·5-attributable type 2 diabetes burden. All estimates are presented with 95% uncertainty intervals.

FINDINGS

In 2019, approximately a fifth of the global burden of type 2 diabetes was attributable to PM2·5 exposure, with an estimated 3·78 (95% uncertainty interval 2·68-4·83) deaths per 100 000 population and 167 (117-223) disability-adjusted life-years (DALYs) per 100 000 population. Approximately 13·4% (9·49-17·5) of deaths and 13·6% (9·73-17·9) of DALYs due to type 2 diabetes were contributed by ambient PM2·5, and 6·50% (4·22-9·53) of deaths and 5·92% (3·81-8·64) of DALYs by household air pollution. High burdens, in terms of numbers as well as rates, were estimated in Asia, sub-Saharan Africa, and South America. Since 1990, the attributable burden has increased by 50%, driven largely by population growth and ageing. Globally, the impact of reductions in household air pollution was largely offset by increased ambient PM2·5.

INTERPRETATION

Air pollution is a major risk factor for diabetes. We estimated that about a fifth of the global burden of type 2 diabetes is attributable PM2·5 pollution. Air pollution mitigation therefore might have an essential role in reducing the global disease burden resulting from type 2 diabetes.

FUNDING

Bill & Melinda Gates Foundation.

Assuring Bangladesh's future: non-communicable disease risk factors among the adolescents and the existing policy responses

BACKGROUND

The aim of this study is to assess the current status of non-communicable disease (NCD) risk factors amongst adolescents in Bangladesh. We also critically reviewed the existing policy responses to NCD risk among adolescents in Bangladesh.

METHODS

This study used a mixed method approach. To quantify the NCD risk burden, we used data from the Global School-based Student Health Survey conducted in Bangladesh. To understand policy response, we reviewed NCD-related policy documents introduced by the Government of Bangladesh between 1971 and 2018 using the WHO recommended NCD Action Plan 2013-2020as study framework. Information from the policy documents was extracted using a matrix, mapping each document against the six objectives of the WHO 2013-2020 Action Plan.

RESULTS

Almost all adolescents in Bangladesh had at least one NCD risk factor, and there was a high prevalence of concurrent multiple NCD risk factors; 14% had one NCD risk factor while 22% had two, 29% had three, 34% had four or more NCD risk factors. Out of 38 policy documents, eight (21.1%) were related to research and/or surveys, eight (21.1%) were on established policies, and eleven (29%) were on legislation acts. Three policy documents (7.9%) were related to NCD guidelines and eight (21.1%) were strategic planning which were introduced by the government and non-government agencies/institutes in Bangladesh.

CONCLUSIONS

The findings emphasize the needs for strengthening NCD risk factors surveillance and introducing appropriate intervention strategies targeted to adolescents. Despite the Government of Bangladesh introducing several NCD-related policies and programs, the government also needs more focus on clear planning, implementation and monitoring and evaluation approaches to preventing NCD risk factors among the adolescents in Bangladesh.

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

BACKGROUND

Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990-2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals.

FINDINGS

In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (-28·4 to -2·9) for all diabetes, and by 21·0% (-33·0 to -5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (-13·6% [-28·4 to 3·4]) and for type 1 diabetes (-13·6% [-29·3 to 8·9]).

INTERPRETATION

Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.

FUNDING

Bill & Melinda Gates Foundation.

Prevalence and factors associated with underweight, overweight and obesity among 15-49-year-old men and women in Timor-Leste

Background

Underweight and overweight both have a long-lasting significant effect on human health at the individual and population levels. However, in the context of Timor-Leste, a country that achieved independence around two decades ago, there is a severe scarcity of evidence regarding the underweight and obesity burden. We conducted this study to find out the prevalence of underweight, overweight and obesity and their associated factors.

Methods

This study used the nationally representative data of Timor-Leste Demographic Health Survey 2016 data. We conducted descriptive analysis followed by multivariable logistic regression analysis to find out the prevalence and investigate the associated factors. Both crude and adjusted odds ratio of covariates were reported with 95% confidence interval (CI).

Results

This study analyzed the data from a weighted sample of 16,488 Timorese aged 15–49 years. The prevalence of normal weight, underweight, and overweight or obesity were found to be 55.2% (95% CI: 54.2%-56.2%), 25.5% (95% CI: 24.4%-26.7%), and 19.3% (95% CI: 18.3%-20.3%), respectively. For underweight, age, sex, type of settlement (urban/rural), township, and wealth, marital, and educational status were found to have a statistically significant relationship (p < 0.05) with Body Mass Index(BMI). After adjustment for the covariates in the logistic regression model age, sex, township, and wealth and marital status were found to be statistically significant correlates (p < .05) of underweight. For overweight and obesity, all the background characteristics included in this study (i.e, age, sex, type of settlement, township, and wealth, marital, and educational status) were found to be statistically significant correlates, after adjustment for the covariates.

Conclusion

This study concludes that Timor-Leste has a significant underweight and overweight burden which needs to be addressed through appropriate interventions. Further studies are also warranted to delve deeper into the complex interplay of factors associated with underweight and overweight.

Household cooking fuels associated with elevated blood pressure among adult women: a national-wide assessment in Bangladesh

Household air pollution from cooking fuel may have adverse health effects, particularly among women from countries like Bangladesh, where women participate in most household cooking activities. However, little is known about how cooking fuel influences adult women's blood pressure (BP) status in Bangladesh. This study assessed the association between household cooking fuel and women's BP in Bangladesh. Data of 6543 women (aged ≥18 years) from the latest nationally representative Bangladesh Demographic and health survey 2017-18 were used in this study. This survey collected data on various variables, including women's BP and cooking fuel. Multivariable regression models were used for this evaluation. About 82.3% of women were living in households using solid cooking fuel. Women's average systolic BP (SBP) and diastolic BP (DBP) were 121.5 mmHg and 80.7 mmHg, respectively, and 25% had elevated BP. Women residing in a household using solid fuel had significantly higher SBP (β 3.76 mmHg, 95 confidence interval (CI) 2.00, 5.51) and DBP (β 1.17 mmHg, 95% CI 0.17, 2.18) relative to women from households using clean fuel. The odds of elevated BP was 58% higher (adjusted odds ratio, 1.58, 95% CI 1.19, 2.11) among women residing in households using solid fuels compared to their counterparts. Usage of solid cooking fuel was predominantly high and negatively impacted women's BP status in Bangladesh. In addition to other lifestyle change interventions, improved cooking facilities and clean cooking fuel provision and monitoring could be important initiatives to reduce the burden of elevated BP among women.

Inequalities in Undiagnosed Hypertension Among Adult Population in Bangladesh: Evidence from a Nationally Representative Survey

INTRODUCTION

Bangladesh has experienced a rising trend in hypertension in recent years and women are suffering from this non-communicable disease more than men. About one-fifth of the adult population is suffering from hypertension and almost three-fifth of them are undiagnosed.

AIM

This study aims to assess the prevalence and determinants of undiagnosed hypertension and to examine the extent of socioeconomic inequalities in undiagnosed hypertension among adult Bangladeshi population (≥ 18 years).

METHODS

This study used nationally representative Bangladesh Demographic and Health Survey 2017-18 data. Undiagnosed hypertension was defined as having systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg and was never told by the health professionals to lower/control blood pressure. Multiple logistic regression analysis was performed to assess factors associated with undiagnosed hypertension. Further, socioeconomic inequalities in the prevalence of undiagnosed hypertension were estimated using Concentration Index.

RESULTS

Out of total 3196 hypertensive adults, half (50.1%) were undiagnosed. In the adjusted model, older age, overweight/obesity, female gender, richest wealth quintiles had lower odds of being undiagnosed. Overall concentration index showed that poor patients were disproportionately affected by undiagnosed hypertension (Concentration Index: - 0.103, Standard Error (SE) of Concentration Index: 0.024; P value < 0.001). The poor(Q1)-to-rich(Q5) ratio of 1.3 also demonstrates that poorest hypertensive Bangladeshi adults have higher prevalence of undiagnosed hypertension than their richest counterparts.

CONCLUSION

Awareness building program should be targeted towards adults belong to poor wealth quintiles for checking blood pressure regularly. Hypertension should be diagnosed and treated to prevent further complications.

Comorbidity as a predictor of racial and ethnic disparities in cancer in the United States population

Aims

This study aims to examine the racial and ethnic disparity in cancer prevalence and determine if comorbidities can explain this disparity.

Study design

This was a cross-sectional study.

Methods

The study examined cancer prevalence among adults who self-identified as White, Black, and Other races in the US population according to data from the 2017 National Health Interview Survey.

Results

Cancer was 58.5% [OR = 0.415; 95% CI: 0.346–0.498] and 57.5% [OR = 0.425; 95%CI: 0.346–0.522] more likely to be found in the White compared to the Black adults and White compared to Other race adults, respectively. After adjusting for the comorbidities, the odds of cancer in White adults increased marginally compared to Black adults [OR = 0.407; 95%CI: 0.338–0.490] and decreased marginally compared to Other race adults [OR = 0.462; 95%CI: 0.374–0.569] even though the odds remained significant. Ever smoking, age of 50 years or more, Former and current alcohol consumption, overweight and obesity, being female and physical inactivity were found to be significantly associated with higher odds of cancer.

Conclusions

This study did identify a racial and ethnic disparity in cancer prevalence between White and Black adults and White and Other adult races. However, this racial and ethnic disparity could not be explained by comorbidities.

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Comorbidity in white and black disparity in a US population with cancer.

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Hypertension can predict cancer racial disparity.

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Comorbidity cancer prevalence in ethnic disparity.

Fidelity of kangaroo mother care services in the public health facilities in Bangladesh: a cross-sectional mixed-method study

Background

Kangaroo mother care (KMC) is a proven low-cost intervention to prevent neonatal mortality of pre-term and low birth weight babies and is very relevant to Bangladesh. KMC provides thermal regulation and thus directly avert neonatal mortality. KMC includes early, continuous, and prolonged skin-to-skin contact between an infant and caregiver, exclusive breastfeeding, early discharge from the hospital, and post-discharge follow-up. The purpose of this study was to investigate the fidelity of this intervention’s implementation according to national guidelines across all tiers of government (public) health facilities of Bangladesh.

Methods

We adopted a triangulation mixed-methods approach of both quantitative and qualitative components in this research to support and explain the information obtained from quantitative observation with the help of qualitative interviews on the fidelity of KMC practice. We used an observation checklist to find the fidelity of KMC practice and used semi-structured guidelines to explain and understand the moderators of fidelity through key informant interviews and in-depth interviews. We undertook eight facility visits in four districts, observed twenty-three neonates and their caregivers during KMC practice at those facilities, and conducted twenty-seven key informant interviews with facility managers, health care providers, and five in-depth interviews with caregivers. Extracted information was triangulated and arranged under the themes of the fidelity framework.

Results

Despite being a low-cost intervention, findings exhibit some adherence to the national guideline with several gaps in practice. Leadership played a critical role in ensuring the KMC practice. Specific components of KMC practice, like duration, nutrition maintenance, discharge criteria, and follow-up, were not consistent as recommended. Infrastructure, human resources, developmental partner support, and the demand-side and supply-side responsiveness played a critical role in enacting this human-centric approach’s fidelity. The observed interruption found in the implementation process posed threats to achieve the intended outcome as these caused violations of the basic principles of KMC.

Conclusions

The study findings will help find ways to effectively deliver this intervention so that fidelity of practice is maintained, enhancing KMC services’ quality and advocating towards the successful scale-up of this program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00215-9.

Gestational diabetes mellitus (GDM) and adverse pregnancy outcome in South Asia: A systematic review

INTRODUCTION

The prevalence of gestational diabetes mellitus (GDM) is increasing in developing countries including the South Asian Nations. The current study aimed to examine the association of GDM with adverse pregnancy outcomes from foetal and maternal perspectives in South Asia.

METHODS

A systematic review was conducted including primary studies published since January 2020 from South Asian countries. Following electronic databases were searched to locate the articles: MEDLINE, EMBASE and EMCARE. Data were extracted using a customized extraction tool and methodological quality of the included studies was assessed using modified Effective Public Health Practice Project (EPHPP) quality assessment tool. Narrative synthesis was performed as statistical pooling was not possible due to the heterogeneous nature of the studies.

RESULTS

Eight studies were included in the review. Overall, the review found a positive correlation between GDM and adverse foetal outcomes such as macrosomia, neonatal hyperglycaemia, intrauterine growth retardation (IUGR), stillbirths and low birthweight (LBW), but the findings were not conclusive. GDM was also positively associated with preeclampsia but the association between GDM and C-section delivery was not conclusive.

CONCLUSION

Policymakers, public health practitioners and researchers in South Asia should take in to account the link between GDM and adverse pregnancy outcomes while designing interventions to promote maternal health in South Asia. Researchers should focus on conducting longitudinal studies in future to clearly understand the epidemiology and pathobiology of this issue.

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

BACKGROUND

Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival.

METHODS

We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index.

FINDINGS

Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3-74·0) in 2000 to 37·1 (33·2-41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8-29·5) in 2000 to 17·9 (16·3-19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05-10·30) in 2000 and 5·05 million (4·27-6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53-4·02]) in 2000 to 48% (2·42 million; 2·06-2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71-0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27-1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35-2·58; 37% [95% UI 32-43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier.

INTERPRETATION

Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress.

FUNDING

Bill & Melinda Gates Foundation.

Prevalence, awareness, and control of hypertension among Bangladeshi adults: an analysis of demographic and health survey 2017-18

Background

The prevalence of hypertension is increasing in Bangladesh, however, few recent studies investigated the proportion of people and factors associated with prevalence, awareness, and control of this condition in this country. This study investigated these among Bangladeshi adults.

Methods

Using Bangladesh Demographic and Health Survey 2017–18 data, a cross-sectional study was conducted. Multilevel logistic regression analysis was employed after descriptive analysis and prevalence estimation.

Results

Among 12,926 persons (mean age: 40 years, 57% women), the prevalence of hypertension was 27.4% (n = 3551), it was 28.4 and 26.2% among females and males, respectively. Among hypertensive people, about 42.4% (n = 1508) people were aware of having it, 48.7% among females and 33.5% among males. Of the 1313 people who were taking antihypertensive medication, only 33.8% (n = 443) had controlled hypertension, 34.7 and 31.7% among females and males, respectively.

Among the studied factors associated with hypertension, people with older age, female gender, overweight/obesity, diabetes, richer wealth quintiles, and residence in some administrative divisions had higher odds of hypertension (p < 0.05). However, the odds of awareness was lower among younger people, males, and people without overweight/obesity, diabetes, or richer wealth quintiles. Odds of controlled hypertension was also lower among people with older age and higher among college-educated people.

Conclusion

This study identified several important factors associated with prevalence, awareness, and control of hypertension. It is important to address these factors with nationwide prevention and control programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40885-021-00174-2.

Association between television viewing and overweight and obesity among women of reproductive age in Timor-Leste: evidence from the demographic health survey 2016

OBJECTIVE

This study aimed to assess the possible relationship between television viewing and overweight and obesity among Timorese women of reproductive age.

METHODS

This cross-sectional study analysed the Timor-Leste Demographic and Health Survey 2016 dataset. A weighted sample of 11 398 Timorese women aged 15-49 years was chosen using a two-stage stratified random sampling technique. Asian criteria-based body mass index (BMI) cut-offs were used to define overweight (BMI 23.0 to <27.5 kg/m²) and obesity (BMI ≥27.5 kg/m²). Frequency of TV viewing was categorised into three groups: (1) not at all, (2) less than once a week and (3) at least once a week. Multilevel ordered logistic regression was performed to identify the correlates of overweight and obesity. Both crude and adjusted odds ratios (AOR) along with a 95% CI were calculated to show the strength of association.

RESULTS

Among 11 398 respondents, 19.4% were overweight or obese (overweight: 15.7% and obese: 3.8%). Although about half of the respondents reportedly did not watch TV at all, just over two-thirds watched TV at least once a week. Women who watched TV at least once a week were found to have 1.3 times the odds of being overweight or obese compared with those who never watched TV (AOR: 1.3, 95% CI: 1.1 to 1.5; p<0.001). However, when stratified by settlement type, the statistical significance stood for the rural women only (AOR: 1.5, 95% CI: 1.2 to 1.8; p<0.001), after adjusting for the covariates.

CONCLUSION

Watching TV at least once a week was found to be a significant correlate of overweight and obesity in rural Timorese women of reproductive age. Further studies need to be undertaken to assess physical activity, sedentary and dietary patterns to clarify the possible mechanism through which TV viewing may influence BMI in those groups.

Role of hypertension in the association of overweight and obesity with diabetes among adults in Bangladesh: a population-based, cross-sectional nationally representative survey

AIMS

Overweight and obesity (OWOB) is a modifiable risk factor for both hypertension and diabetes. However, the association between OWOB and diabetes among Bangladeshi adults and how hypertension may mediate this relationship are not well explored. This study aimed to examine (1) whether OWOB is independently associated with diabetes among Bangladeshi adults, (2) whether this association is mediated by hypertension, and (3) the effect modification by wealth status and place of residence in the relationships.

RESEARCH DESIGN AND METHODS

We used data of 9305 adults aged ≥18 years from the most recent nationally representative cross-sectional study of Bangladesh Demographic and Health Survey 2017-2018. Design-based logistic regression was used to assess the association between OWOB and diabetes, and counterfactual framework-based weighting approach was used to evaluate the mediation effect of hypertension in the OWOB-diabetes relationship. We used stratified analyses for the effect modifications.

RESULTS

The prevalence of OWOB, diabetes and hypertension was 48.5%, 11.7% and 30.3%, respectively. We observed a significant association between OWOB and diabetes and a mediating role of hypertension in the OWOB-diabetes association. The odds of diabetes was 51% higher among adults with OWOB than those without OWOB (adjusted OR: 1.51, 95% CI 1.29 to 1.77). We observed that 18.64% (95% CI 9.84% to 34.07%) of the total effect of OWOB on the higher odds of diabetes was mediated through hypertension, and the mediation effect was higher among adults from non-poor households and from both rural and urban areas.

CONCLUSIONS

Adult OWOB status is independently associated with diabetes in Bangladesh, and hypertension mediates this association. Therefore, prevention policies should target adults with both OWOB and hypertension, particularly those from non-poor households and from both rural and urban areas, to reduce the growing burden of diabetes and its associated risk.

Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control.

METHODS

We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period.

FINDINGS

In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15-19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: -1·21% [-1·26 to -1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (-0·94% [-1·72 to -0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period.

INTERPRETATION

Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Ending the global tobacco epidemic is a defining challenge in global health. Timely and comprehensive estimates of the prevalence of smoking tobacco use and attributable disease burden are needed to guide tobacco control efforts nationally and globally.

METHODS

We estimated the prevalence of smoking tobacco use and attributable disease burden for 204 countries and territories, by age and sex, from 1990 to 2019 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study. We modelled multiple smoking-related indicators from 3625 nationally representative surveys. We completed systematic reviews and did Bayesian meta-regressions for 36 causally linked health outcomes to estimate non-linear dose-response risk curves for current and former smokers. We used a direct estimation approach to estimate attributable burden, providing more comprehensive estimates of the health effects of smoking than previously available.

FINDINGS

Globally in 2019, 1·14 billion (95% uncertainty interval 1·13-1·16) individuals were current smokers, who consumed 7·41 trillion (7·11-7·74) cigarette-equivalents of tobacco in 2019. Although prevalence of smoking had decreased significantly since 1990 among both males (27·5% [26·5-28·5] reduction) and females (37·7% [35·4-39·9] reduction) aged 15 years and older, population growth has led to a significant increase in the total number of smokers from 0·99 billion (0·98-1·00) in 1990. Globally in 2019, smoking tobacco use accounted for 7·69 million (7·16-8·20) deaths and 200 million (185-214) disability-adjusted life-years, and was the leading risk factor for death among males (20·2% [19·3-21·1] of male deaths). 6·68 million [86·9%] of 7·69 million deaths attributable to smoking tobacco use were among current smokers.

INTERPRETATION

In the absence of intervention, the annual toll of 7·69 million deaths and 200 million disability-adjusted life-years attributable to smoking will increase over the coming decades. Substantial progress in reducing the prevalence of smoking tobacco use has been observed in countries from all regions and at all stages of development, but a large implementation gap remains for tobacco control. Countries have a clear and urgent opportunity to pass strong, evidence-based policies to accelerate reductions in the prevalence of smoking and reap massive health benefits for their citizens.

FUNDING

Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Association of household wealth and education level with hypertension and diabetes among adults in Bangladesh: a propensity score-based analysis

OBJECTIVE

To determine the association of household wealth and education level with hypertension and diabetes in Bangladesh using propensity score (PS) analyses.

METHODS

A nationally representative sample of the Bangladesh Demographic and Health Survey 2017-18 was analysed to explore the research question. A weighted sample of 11 320 individuals was considered. Hypertension and diabetes were the outcomes of interest, and household wealth status (non-poor and poor) and education level (secondary/higher education and no secondary/higher education) were the exposure variables of interest. A person was defined as hypertensive if their average blood pressure was ≥140/90 mmHg or self-reported history of taking antihypertensive medications. Individuals were classified as diabetic if they had a Fasting Blood Glucose level of ≥7 mmol/l or reported taking prescribed medication for reducing high blood glucose or diabetes. We used the 1:1 nearest neighbour PS matching without replacement and PS weighting approaches to assess the association between the exposures and the outcome variables.

RESULTS

Wealth status was significantly associated with diabetes but not with hypertension, while education status was significantly associated with neither diabetes nor hypertension. We also observed a significant interaction effect between household wealth status and education level with diabetes. The odds of diabetes were approximately 60% higher among adults from non-poor households and those without secondary/higher education.

CONCLUSION

Diabetes prevention and control programs should focus on non-poor individuals, while hypertension prevention programs should target populations irrespective of educational attainment and wealth status.

Association of leisure-time physical activity with perceived general health status among hypertensive people: an analysis of NHANES 2015-18

Although leisure-time physical activity (LTPA) improves general health, little is known about its impacts on the health of hypertensive people within the United States. We investigated the general health of hypertensive people and the relationship between LTPA and general health within this population. This cross-sectional study analyzed National Health and Nutrition Examination Survey 2015-18 data. None, some, and high LTPA were defined as '0', '>0 but <150', and '≥150' minutes of LTPA in each week, respectively. Hypertension was defined as the systolic/diastolic blood pressure ≥130/80 mmHg or taking BP-lowering drugs. General health status was dichotomized as whether participants reported 'very good to excellent' health status or not. After descriptive analysis, logistic regression was performed. Among 8504 participants (48.6% male and mean age: 48.2 years), about 47.9%, 41.4%, and 39.5% of people had hypertension, 'very good to excellent' health, and high LTPA, respectively. The odds of 'very good to excellent' health was lower among hypertensives than those without hypertension (adjusted odds ratio [AOR]: 0.7, 95% confidence interval [CI]: 0.6-0.8, p < 0.001). Among hypertensive individuals, about one-third reported 'very good to excellent' health (33.1%) and high LTPA (32.0%). Lastly, compared to people with no LTPA, those with some (AOR: 1.5, 95% CI: 1.0-2.0, p < 0.05) and high (AOR: 2.3, 95% CI: 1.7-3.0, p < 0.001) LTPA had greater odds of 'very good to excellent' health. We found positive relationships between LTPA and 'very good to excellent' health of hypertensive people. Therefore, improving general health could be an added advantage of LTPA for hypertensive people.

Factors and Inequality of Underweight and Overweight among Women of Reproductive Age in Myanmar: Evidence from the Demographic Health Survey 2015-2016

(1) Background: This study aims to identify the factors of underweight and overweight/obesity among reproductive age (15-49 years) women in Myanmar, and assess the level of inequity in the double burden of malnutrition. (2) Methods: The study used Myanmar Demographic and Health Survey 2015-2016 data. Multinomial logistic regression models were fitted to identify the factors affecting underweight and overweight/obesity; and concentration indices (CI) were estimated to assess socioeconomic inequalities. (3) Results: A total of 12,643 reproductive age women were included in the analysis. Higher risk of underweight was found in women aged 20-29 years, aged 30-39 years, and 40-49 years compared to women aged 15-19 years; women who were unemployed or had manual occupation relative to those in non-manual employment. Women aged 40-49 years (compared to those who were 15-29 years); had primary education, and secondary education (compared to those who had no education); being married, and widowed/divorced/separated (compared to being never married); belonging to the poor quintile, middle quintile, richer, richest quintile (compared to the poorest quintile); having residence in urban areas (compared to rural areas) and in Kachin, Taninthayi, Yangon province (than those who lived in Naypytiaw province) had a higher risk of being overweight/obese. Socioeconomic inequalities were detected, with overweight/obesity strongly concentrated (CI: 0.19) amongst the higher quintiles and underweight concentrated (CI: -0.060) amongst the poorest. (4) Conclusions: Equity oriented nutrition interventions with a focus on improving the socioeconomic status of poor households may benefit undernourished women, while richer households should be focused to curb the overweight/obesity problem.

Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Rigorous analysis of levels and trends in exposure to leading risk factors and quantification of their effect on human health are important to identify where public health is making progress and in which cases current efforts are inadequate. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a standardised and comprehensive assessment of the magnitude of risk factor exposure, relative risk, and attributable burden of disease.

METHODS

GBD 2019 estimated attributable mortality, years of life lost (YLLs), years of life lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 87 risk factors and combinations of risk factors, at the global level, regionally, and for 204 countries and territories. GBD uses a hierarchical list of risk factors so that specific risk factors (eg, sodium intake), and related aggregates (eg, diet quality), are both evaluated. This method has six analytical steps. (1) We included 560 risk-outcome pairs that met criteria for convincing or probable evidence on the basis of research studies. 12 risk-outcome pairs included in GBD 2017 no longer met inclusion criteria and 47 risk-outcome pairs for risks already included in GBD 2017 were added based on new evidence. (2) Relative risks were estimated as a function of exposure based on published systematic reviews, 81 systematic reviews done for GBD 2019, and meta-regression. (3) Levels of exposure in each age-sex-location-year included in the study were estimated based on all available data sources using spatiotemporal Gaussian process regression, DisMod-MR 2.1, a Bayesian meta-regression method, or alternative methods. (4) We determined, from published trials or cohort studies, the level of exposure associated with minimum risk, called the theoretical minimum risk exposure level. (5) Attributable deaths, YLLs, YLDs, and DALYs were computed by multiplying population attributable fractions (PAFs) by the relevant outcome quantity for each age-sex-location-year. (6) PAFs and attributable burden for combinations of risk factors were estimated taking into account mediation of different risk factors through other risk factors. Across all six analytical steps, 30 652 distinct data sources were used in the analysis. Uncertainty in each step of the analysis was propagated into the final estimates of attributable burden. Exposure levels for dichotomous, polytomous, and continuous risk factors were summarised with use of the summary exposure value to facilitate comparisons over time, across location, and across risks. Because the entire time series from 1990 to 2019 has been re-estimated with use of consistent data and methods, these results supersede previously published GBD estimates of attributable burden.

FINDINGS

The largest declines in risk exposure from 2010 to 2019 were among a set of risks that are strongly linked to social and economic development, including household air pollution; unsafe water, sanitation, and handwashing; and child growth failure. Global declines also occurred for tobacco smoking and lead exposure. The largest increases in risk exposure were for ambient particulate matter pollution, drug use, high fasting plasma glucose, and high body-mass index. In 2019, the leading Level 2 risk factor globally for attributable deaths was high systolic blood pressure, which accounted for 10·8 million (95% uncertainty interval [UI] 9·51-12·1) deaths (19·2% [16·9-21·3] of all deaths in 2019), followed by tobacco (smoked, second-hand, and chewing), which accounted for 8·71 million (8·12-9·31) deaths (15·4% [14·6-16·2] of all deaths in 2019). The leading Level 2 risk factor for attributable DALYs globally in 2019 was child and maternal malnutrition, which largely affects health in the youngest age groups and accounted for 295 million (253-350) DALYs (11·6% [10·3-13·1] of all global DALYs that year). The risk factor burden varied considerably in 2019 between age groups and locations. Among children aged 0-9 years, the three leading detailed risk factors for attributable DALYs were all related to malnutrition. Iron deficiency was the leading risk factor for those aged 10-24 years, alcohol use for those aged 25-49 years, and high systolic blood pressure for those aged 50-74 years and 75 years and older.

INTERPRETATION

Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public.

FUNDING

Bill & Melinda Gates Foundation.

Mapping geographical inequalities in access to drinking water and sanitation facilities in low-income and middle-income countries, 2000-17

BACKGROUND

Universal access to safe drinking water and sanitation facilities is an essential human right, recognised in the Sustainable Development Goals as crucial for preventing disease and improving human wellbeing. Comprehensive, high-resolution estimates are important to inform progress towards achieving this goal. We aimed to produce high-resolution geospatial estimates of access to drinking water and sanitation facilities.

METHODS

We used a Bayesian geostatistical model and data from 600 sources across more than 88 low-income and middle-income countries (LMICs) to estimate access to drinking water and sanitation facilities on continuous continent-wide surfaces from 2000 to 2017, and aggregated results to policy-relevant administrative units. We estimated mutually exclusive and collectively exhaustive subcategories of facilities for drinking water (piped water on or off premises, other improved facilities, unimproved, and surface water) and sanitation facilities (septic or sewer sanitation, other improved, unimproved, and open defecation) with use of ordinal regression. We also estimated the number of diarrhoeal deaths in children younger than 5 years attributed to unsafe facilities and estimated deaths that were averted by increased access to safe facilities in 2017, and analysed geographical inequality in access within LMICs.

FINDINGS

Across LMICs, access to both piped water and improved water overall increased between 2000 and 2017, with progress varying spatially. For piped water, the safest water facility type, access increased from 40·0% (95% uncertainty interval [UI] 39·4-40·7) to 50·3% (50·0-50·5), but was lowest in sub-Saharan Africa, where access to piped water was mostly concentrated in urban centres. Access to both sewer or septic sanitation and improved sanitation overall also increased across all LMICs during the study period. For sewer or septic sanitation, access was 46·3% (95% UI 46·1-46·5) in 2017, compared with 28·7% (28·5-29·0) in 2000. Although some units improved access to the safest drinking water or sanitation facilities since 2000, a large absolute number of people continued to not have access in several units with high access to such facilities (>80%) in 2017. More than 253 000 people did not have access to sewer or septic sanitation facilities in the city of Harare, Zimbabwe, despite 88·6% (95% UI 87·2-89·7) access overall. Many units were able to transition from the least safe facilities in 2000 to safe facilities by 2017; for units in which populations primarily practised open defecation in 2000, 686 (95% UI 664-711) of the 1830 (1797-1863) units transitioned to the use of improved sanitation. Geographical disparities in access to improved water across units decreased in 76·1% (95% UI 71·6-80·7) of countries from 2000 to 2017, and in 53·9% (50·6-59·6) of countries for access to improved sanitation, but remained evident subnationally in most countries in 2017.

INTERPRETATION

Our estimates, combined with geospatial trends in diarrhoeal burden, identify where efforts to increase access to safe drinking water and sanitation facilities are most needed. By highlighting areas with successful approaches or in need of targeted interventions, our estimates can enable precision public health to effectively progress towards universal access to safe water and sanitation.

FUNDING

Bill & Melinda Gates Foundation.

Snow cover area analysis and its relation with climate variability in Chandra basin, Western Himalaya, during 2001-2017 using MODIS and ERA5 data

Glaciers and snow cover area (SCA) plays an important role in river runoff in Himalayan region. There is a need to monitor SCA on spatio-temporal basis for better and efficient utilization of water resources. Moderate Resolution Imaging Spectroradiometer (MODIS) provides less cloudy data due to high temporal resolution as compared to other optical sensors for high elevation regions, and its 8-day snow cover product is globally used for snow cover estimation. The main objective of the present paper is to estimate annual and seasonal SCA in Chandra basin, Western Himalaya, and analysis of its variation with elevation, aspect, and slope during 2001 to 2017 using MODIS Terra (MOD10A2) and Aqua (MYD10A2) snow cover product as well as to correlate the same with temperature and precipitation using fifth generation European Centre for Medium-Range Weather Forecasts (ECMWF) Atmospheric Reanalysis of the global climate (ERA5) data. The total average SCA observed is 84.94% of basin area during the study period. The maximum annual average SCA was found as 91.23% in 2009 with minimum being 76.37% in 2016. Strong correlation is observed in annual and seasonal SCA with temperature which indicate that SCA variability is highly sensitive to temperature.

Mapping geographical inequalities in childhood diarrhoeal morbidity and mortality in low-income and middle-income countries, 2000-17: analysis for the Global Burden of Disease Study 2017

BACKGROUND

Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.

METHODS

We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.

FINDINGS

The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54·0% (95% uncertainty interval [UI] 38·1-65·8), 17·4% (7·7-28·4), and 59·5% (34·2-86·9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.

INTERPRETATION

By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.

FUNDING

Bill & Melinda Gates Foundation.