Daniel J. Corsi

Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study

BACKGROUNDnSeveral international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability.nnnMETHODSnWe assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost.nnnFINDINGSnOf 143u2008305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130u2008402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040).nnnINTERPRETATIONnThe consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.nnnFUNDINGnPopulation Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Risk factors predictive of occult cancer detection in patients with unprovoked venous thromboembolism

Risk factors predictive of occult cancer detection in patients with a first unprovoked symptomatic venous thromboembolism (VTE) are unknown. Cox proportional hazard models and multivariate analyses were performed to assess the effect of specific risk factors on occult cancer detection within 1 year of a diagnosis of unprovoked VTE in patients randomized in the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial. A total of 33 (3.9%; 95% CI, 2.8%-5.4%) out of the 854 included patients received a new diagnosis of cancer at 1-year follow-up. Age ≥ 60 years (hazard ratio [HR], 3.11; 95% CI, 1.41-6.89; ITALIC! P= .005), previous provoked VTE (HR, 3.20; 95% CI, 1.19-8.62; ITALIC! P= .022), and current smoker status (HR, 2.80; 95% CI, 1.24-6.33; ITALIC! P= .014) were associated with occult cancer detection. Age, prior provoked VTE, and smoking status may be important predictors of occult cancer detection in patients with first unprovoked VTE. This trial was registered atwww.clinicaltrials.govas #NCT00773448.

Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries

Objectives This study examines in a cross-sectional study ‘the tobacco control environment’ including tobacco policy implementation and its association with quit ratio. Setting 545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Communitys Health (EPOCH) study from 2009 to 2014. Participants Community audits and surveys of adults (35–70u2005years, n=12u2005953). Primary and secondary outcome measures Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models. Results Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1). Conclusions This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.

An examination of the shift in school-level clustering of US adolescent electronic cigarette use and its multilevel correlates, 2011-2013.

The percent of US high school students reporting use of electronic cigarettes (i.e., e-cigarettes) tripled in recent years. Little is known about the temporal shifts in school-level e-cigarette prevalence or the multilevel correlates of teen e-cigarette use. Using multilevel regression techniques and data from the 2011 and 2013 US National Youth Tobacco Surveys, we investigate how the school-level clustering of e-cigarette use has shifted between 2011 and 2013, whether school-level e-cigarette use is associated with individual-level use, and whether this association is explained by perceptions of harm attributed to e-cigarettes. Results indicate that school-level clustering of pastmonth e-cigarette use increased between 2011 and 2013. Multilevel models show that school-level e-cigarette use is positively associated with individual use, with a small proportion of this relationship explained by perceived harm of e-cigarettes. Our findings suggest that schools could have become more differentiated from each other based on their prevalence of e-cigarette use, and that certain types of school environments facilitate e-cigarette use more efficiently than others.

Wealth and cardiovascular health: a cross-sectional study of wealth-related inequalities in the awareness, treatment and control of hypertension in high-, middle- and low-income countries

BackgroundEffective policies to control hypertension require an understanding of its distribution in the population and the barriers people face along the pathway from detection through to treatment and control. One key factor is household wealth, which may enable or limit a household’s ability to access health care services and adequately control such a chronic condition. This study aims to describe the scale and patterns of wealth-related inequalities in the awareness, treatment and control of hypertension in 21 countries using baseline data from the Prospective Urban and Rural Epidemiology study.MethodsA cross-section of 163,397 adults aged 35 to 70xa0years were recruited from 661 urban and rural communities in selected low-, middle- and high-income countries (complete data for this analysis from 151,619 participants). Using blood pressure measurements, self-reported health and household data, concentration indices adjusted for age, sex and urban-rural location, we estimate the magnitude of wealth-related inequalities in the levels of hypertension awareness, treatment, and control in each of the 21 country samples.ResultsOverall, the magnitude of wealth-related inequalities in hypertension awareness, treatment, and control was observed to be higher in poorer than in richer countries. In poorer countries, levels of hypertension awareness and treatment tended to be higher among wealthier households; while a similar pro-rich distribution was observed for hypertension control in countries at all levels of economic development. In some countries, hypertension awareness was greater among the poor (Sweden, Argentina, Poland), as was treatment (Sweden, Poland) and control (Sweden).ConclusionInequality in hypertension management outcomes decreased as countries became richer, but the considerable variation in patterns of wealth-related inequality - even among countries at similar levels of economic development - underscores the importance of health systems in improving hypertension management for all. These findings show that some, but not all, countries, including those with limited resources, have been able to achieve more equitable management of hypertension; and strategies must be tailored to national contexts to achieve optimal impact at population level.

Increasing ambient temperature reduces emotional well-being

This study examines the impact of ambient temperature on emotional well-being in the U.S. population aged 18+. The U.S. is an interesting test case because of its resources, technology and variation in climate across different areas, which also allows us to examine whether adaptation to different climates could weaken or even eliminate the impact of heat on well-being. Using survey responses from 1.9 million Americans over the period from 2008 to 2013, we estimate the effect of temperature on well-being from exogenous day-to-day temperature variation within respondents area of residence and test whether this effect varies across areas with different climates. We find that increasing temperatures significantly reduce well-being. Compared to average daily temperatures in the 50-60°F (10-16°C) range, temperatures above 70°F (21°C) reduce positive emotions (e.g. joy, happiness), increase negative emotions (e.g. stress, anger), and increase fatigue (feeling tired, low energy). These effects are particularly strong among less educated and older Americans. However, there is no consistent evidence that heat effects on well-being differ across areas with mild and hot summers, suggesting limited variation in heat adaptation.

Is there a greater maternal than paternal influence on offspring adiposity in India

Previous research has provided conflicting evidence regarding fetal roots of adiposity in India. To compare the strength of association between maternal and paternal body mass indexes (BMIs) corrected for height with offspring BMI in India to examine the potential for intrauterine mechanisms to influence offspring adiposity in India, we analysed a sample of 16u2005528 mother-father-offspring trios from the 2005 to 2006 Indian National Family Health Survey. Children were aged 0–59u2005months with parents aged 15–49u2005years (mothers) and 15–54u2005years (fathers). Linear and logistic regression models, specified in multiple ways, were used to estimate associations between parental BMI* (BMI redefined by power term x (kg/mx) to be independent from height), and child BMI/top decile of child BMI. Higher values of maternal BMI and paternal BMI were associated with higher values of offspring BMI. In comparing the effects of maternal BMI and paternal BMI, however, no consistent differences were found in the strength of these parental influences on offspring BMI. In the fully adjusted linear model, the standardised coefficient was 0.131 (95% CI 0.110 to 0.154) for maternal BMI* and 0.079 (95% CI 0.056 to 0.103) for paternal BMI*; with evidence of heterogeneity between maternal-offspring and paternal-offspring associations (p=0.005). This was not robust in the unstandardised regression (β=0.056, 95% CI 0.044 to 0.067 for maternal BMI and β=0.039, 95% CI 0.025 to 0.053 for paternal BMI, p=0.093). Mixed results indicate that compared with paternal BMI, maternal BMI did not have a consistently stronger influence on offspring BMI in India.

Inequalities in the use of secondary prevention of cardiovascular disease by socioeconomic status: evidence from the PURE observational study

Summary Background There is little evidence on the use of secondary prevention medicines for cardiovascular disease by socioeconomic groups in countries at different levels of economic development. Methods We assessed use of antiplatelet, cholesterol, and blood-pressure-lowering drugs in 8492 individuals with self-reported cardiovascular disease from 21 countries enrolled in the Prospective Urban Rural Epidemiology (PURE) study. Defining one or more drugs as a minimal level of secondary prevention, wealth-related inequality was measured using the Wagstaff concentration index, scaled from −1 (pro-poor) to 1 (pro-rich), standardised by age and sex. Correlations between inequalities and national health-related indicators were estimated. Findings The proportion of patients with cardiovascular disease on three medications ranged from 0% in South Africa (95% CI 0–1·7), Tanzania (0–3·6), and Zimbabwe (0–5·1), to 49·3% in Canada (44·4–54·3). Proportions receiving at least one drug varied from 2·0% (95% CI 0·5–6·9) in Tanzania to 91·4% (86·6–94·6) in Sweden. There was significant (p<0·05) pro-rich inequality in Saudi Arabia, China, Colombia, India, Pakistan, and Zimbabwe. Pro-poor distributions were observed in Sweden, Brazil, Chile, Poland, and the occupied Palestinian territory. The strongest predictors of inequality were public expenditure on health and overall use of secondary prevention medicines. Interpretation Use of medication for secondary prevention of cardiovascular disease is alarmingly low. In many countries with the lowest use, pro-rich inequality is greatest. Policies associated with an equal or pro-poor distribution include free medications and community health programmes to support adherence to medications. Funding Full funding sources listed at the end of the paper (see Acknowledgments).

Influence of female sex on hepatitis C virus infection progression and treatment outcomes.

Background The influence of sex on hepatitis C virus (HCV)-related outcomes is often neglected. The effects of sex on liver fibrosis progression and the effect of socioeconomic status on management are unclear. Patients and methods Data were evaluated from patients followed at The Ottawa Hospital and Regional Viral Hepatitis Program. Results Of 1978 chronic HCV-infected patients, 630 (32%) were women. Women had lower liver enzyme levels, HCV RNA levels, and weight compared with men. Women were more likely to be non-genotype-1 infected, Black or Asian, and immigrants from Africa and Asia (all P<0.01). Under 50 years of age, women on average had lower fibrosis scores than men. Beyond the age of 50 years, the mean fibrosis scores were similar, suggesting a ‘catch-up’ phase. Women were less likely to have initiated interferon-based HCV antiviral therapy (35.3 vs. 43.3%, P=0.01). Crude sustained virological responses were higher in women (65.3 vs. 56.3%, P=0.03), but were similar to men as determined by multivariable analysis (odds ratio: 0.92, 95% confidence interval: 0.58–1.46). Women of low socioeconomic status were more likely to be HIV coinfected and had higher rates of fibrosis progression. Women living in low-income neighborhoods were less likely to achieve sustained virological response (odds ratio: 0.50, 95% confidence interval: 0.34–0.75, P=0.01) compared with women in higher income regions. Conclusion Sex differences have been identified as a potential barrier to overcome when managing viral infections. Our analysis suggests that sex influences fibrosis progression, likelihood of initiating HCV antiviral therapy, and treatment outcomes.

NK cells lacking FcεRIγ are associated with reduced liver damage in chronic hepatitis C virus infection.

A novel subset of human natural killer (NK) cells, which displays potent and broad antiviral responsiveness in concert with virus‐specific antibodies, was recently uncovered in cytomegalovirus (CMV)+ individuals. This NK‐cell subset (g‐NK) was characterized by a deficiency in the expression of FcεRIγ adaptor protein and the long‐lasting memory‐like NK‐cell phenotype, suggesting a role in chronic infections. This study investigates whether the g‐NK‐cell subset is associated with the magnitude of liver disease during chronic hepatitis C virus (HCV) infection. Analysis of g‐NK‐cell proportions and function in the PBMCs of healthy controls and chronic HCV subjects showed that chronic HCV subjects had slightly lower proportions of the g‐NK‐cell subset having similarly enhanced antibody‐dependent cellular cytotoxicity responses compared to conventional NK cells. Notably, among CMV+ chronic HCV patients, lower levels of liver enzymes and fibrosis were found in those possessing g‐NK cells. g‐NK cells were predominant among the CD56neg NK cell population often found in chronic HCV patients, suggesting their involvement in immune response during HCV infection. For the first time, our findings indicate that the presence of the g‐NK cells in CMV+ individuals is associated with amelioration of liver disease in chronic HCV infection, suggesting the beneficial roles of g‐NK cells during a chronic infection.