Publications by authors named "Goodarz Danaei"

132 Publications

Aquatic foods to nourish nations.

Nature 2021 10 15;598(7880):315-320. Epub 2021 Sep 15.

WorldFish, Bayan Lepas, Malaysia.

Despite contributing to healthy diets for billions of people, aquatic foods are often undervalued as a nutritional solution because their diversity is often reduced to the protein and energy value of a single food type ('seafood' or 'fish'). Here we create a cohesive model that unites terrestrial foods with nearly 3,000 taxa of aquatic foods to understand the future impact of aquatic foods on human nutrition. We project two plausible futures to 2030: a baseline scenario with moderate growth in aquatic animal-source food (AASF) production, and a high-production scenario with a 15-million-tonne increased supply of AASFs over the business-as-usual scenario in 2030, driven largely by investment and innovation in aquaculture production. By comparing changes in AASF consumption between the scenarios, we elucidate geographic and demographic vulnerabilities and estimate health impacts from diet-related causes. Globally, we find that a high-production scenario will decrease AASF prices by 26% and increase their consumption, thereby reducing the consumption of red and processed meats that can lead to diet-related non-communicable diseases while also preventing approximately 166 million cases of inadequate micronutrient intake. This finding provides a broad evidentiary basis for policy makers and development stakeholders to capitalize on the potential of aquatic foods to reduce food and nutrition insecurity and tackle malnutrition in all its forms.
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http://dx.doi.org/10.1038/s41586-021-03917-1DOI Listing
October 2021

Social Awareness of Whole Grains and the Feasibility of Replacement with Refined Grains: A Qualitative Study.

Int J Prev Med 2021 27;12:56. Epub 2021 May 27.

Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.

Background: A correlation between type 2 diabetes and refined carbohydrates has been proven, while several studies have indicated that Iranian daily diets are poor in term of proper carbohydrates. It was thus considered absolutely critical to conduct a qualitative study in terms of people's attitudes toward whole grains, and the feasibility of their replacing existing refined carbohydrates in their diets. The aim of this study is to probe Iranian awareness of whole grains, to explore barriers to refined-grain substitution with whole grains and legumes, and to assess whole-grain sensory perceptions.

Methods: Focus group discussions (FGDs) and taste tests conducted between July 2016 and March 2017 in urban and rural areas of Kurdistan, Yazd, and Tehran provinces in Iran. A total of 96 healthy men and women (aged 40-65, BMI ≥25 kg/m) were selected through purposive sampling with maximum variation. FGDs were categorized by content analysis method. As for taste test, ANOVA analysis with Bonferroni post-hoc was used to determine significant differences ( < 0.05).

Results: Four themes and 11 sub-themes emerged. Cultural beliefs, traditional eating patterns, sensory properties, and familial acceptance were the most influential factors in choosing the type of bread and rice. Simultaneously they are the most prominent barriers to consuming whole grains and legumes. Plain cooked brown rice had the lowest mean sensory attribute score and traditional whole-wheat flatbread was the highest.

Conclusions: There was a higher acceptance tendency toward using traditional whole-wheat flatbread rather than refined grains, as it was consistent with preference and priority. However, low availability was the largest substitution problem.
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http://dx.doi.org/10.4103/ijpvm.IJPVM_401_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8356947PMC
May 2021

Household-level double burden of malnutrition in Ethiopia: a comparison of Addis Ababa and the rural district of Kersa.

Public Health Nutr 2021 Aug 27:1-15. Epub 2021 Aug 27.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building 1, 11th Floor, Boston, MA02115, USA.

Objective: To examine the prevalence of and factors associated with different forms of household-level double burden of malnutrition (DBM) in Ethiopia.

Design: We defined DBM using anthropometric measures for adult overweight (BMI ≥ 25 kg/m2), child stunting (height-for-age Z-score <-2 sd) and overweight (weight-for-height Z-score ≥2 sd). We considered sixteen biological, environmental, behavioural and socio-demographic factors. Their association with DBM forms was assessed using generalised linear models.

Setting: We used data from two cross-sectional studies in an urban (Addis Ababa, January-February 2018), and rural setting (Kersa District, June-September 2019).

Participants: Five hundred ninety-two urban and 862 rural households with an adult man, adult woman and child <5 years.

Results: In Addis Ababa, overweight adult and stunted child was the most prevalent DBM form (9 % (95 % CI 7, 12)). Duration of residence in Addis Ababa (adjusted OR (aOR) 1·03 (95 % CI 1·00, 1·06)), Orthodox Christianity (aOR 1·97 (95 % CI 1·01, 3·85)) and household size (aOR 1·24 (95 % CI 1·01, 1·54)) were associated factors. In Kersa, concurrent child overweight and stunting was the most prevalent DBM form (11 % (95 % CI 9, 14)). Housing quality (aOR 0·33 (95 % CI 0·20, 0·53)), household wealth (aOR 1·92 (95 % CI 1·18, 3·11) and sanitation (aOR 2·08 (95 % CI 1·07, 4·04)) were associated factors. After adjusting for multiple comparisons, only housing quality remained a significant factor.

Conclusions: DBM prevalence was low among urban and rural Ethiopian households. Environmental, socio-economic and demographic factors emerged as potential associated factors. However, we observed no common associated factors among urban and rural households.
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http://dx.doi.org/10.1017/S1368980021003700DOI Listing
August 2021

Birth weight and adult earnings: a systematic review and meta-analysis.

J Dev Orig Health Dis 2021 Jul 30:1-8. Epub 2021 Jul 30.

Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA.

While substantial evidence has identified low birth weight (LBW; <2500 g) as a risk factor for early life morbidity, mortality and poor childhood development, relatively little is known on the links between birth weight and economic outcomes in adulthood. The objective of this study was to systematically review the economics (EconLit) and biomedical literature (Medline) and estimate the pooled association between birth weight and adult earnings. A total of 15 studies from mostly high-income countries were included. On average, each standard deviation increase in birth weight was associated with a 2.75% increase in annual earnings [(95% CI: 1.44 to 4.07); 9 estimates]. A negative, but not statistically significant, association was found between being born LBW and earnings, compared to individuals not born LBW [mean difference: -3.41% (95% CI: -7.55 to 0.73); 7 estimates]. No studies from low-income countries were identified and all studies were observational. Overall, birth weight was consistently associated with adult earnings, and therefore, interventions that improve birth weight may provide beneficial effects on adult economic outcomes.
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http://dx.doi.org/10.1017/S2040174421000404DOI Listing
July 2021

Impact of scaling up prenatal nutrition interventions on human capital outcomes in low- and middle-income countries: a modeling analysis.

Am J Clin Nutr 2021 Jul 28. Epub 2021 Jul 28.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Background: Prenatal nutrition interventions can lead to improved birth outcomes, which in turn are associated with better education and human capital outcomes later in life.

Objective: We estimated the impact of scaling up iron-folic acid (IFA), calcium, multiple micronutrient (MMS), and balanced energy protein (BEP) supplementation for pregnant women, on human capital outcomes in low- and middle-income countries (LMIC).

Methods: We used mathematical modeling with proportional reductions in adverse birth outcomes to estimate the potential gains in school years and lifetime income due to scaling up each prenatal nutrition intervention. Estimates of intervention effects on birth outcomes were derived from meta-analyses of randomized trials. Estimates of the associations between birth outcomes and schooling and lifetime income were derived from de novo meta-analyses of observational studies.

Results: Across 132 LMIC, scaling up prenatal nutrition interventions to 90% coverage was estimated to increase school years and lifetime income per birth cohort by: 2.28 million y (95% uncertainty intervals (UI): -0.44, 6.26) and $8.26 billion (95% UI: -1.60, 22.4) for IFA; 4.08 million y (95% UI: 0.12, 9.68) and $18.9 billion (95% UI: 0.59, 44.6) for calcium; 5.02 million y (95% UI: 1.07, 11.0) and $18.1 billion (95% UI: 3.88, 39.1) for MMS; and 0.53 million y (95% UI: -0.49, 1.70) and $1.34 billion (95% UI: -1.10, 3.10 billion) for BEP supplementation. South Asia and Sub-Saharan Africa tended to have the largest estimated regional gains in school years for scaling up each intervention due to the large population size and high burden of poor birth outcomes. Absolute income benefits for each intervention were estimated to be the largest in Latin America, where returns to education and incomes are higher relative to other regions.

Conclusion: Increasing coverage of prenatal nutrition interventions in LMIC may lead to substantial gains in schooling and lifetime income. Decision makers should consider the potential long-term human capital returns of investments in maternal nutrition.
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http://dx.doi.org/10.1093/ajcn/nqab234DOI Listing
July 2021

Modelling the potential cost-effectiveness of food-based programs to reduce malnutrition.

Glob Food Sec 2021 Jun;29:100550

Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA.

Poor quality diets contribute to malnutrition globally, but evidence is weak on the cost-effectiveness of food-based interventions that shift diets. This study assessed 11 candidate interventions developed through Delphi techniques to improve diets in India, Nigeria, and Ethiopia. A Markov simulation model incorporated time, individual-level, nutrition, and policy parameters to estimate health impacts and cost-effectiveness for reducing stunting, anaemia, diarrhea, and mortality in preschool children. At an assumed 80% coverage, interventions considered would potentially save between 0·16 and 3·20 years of life per child. The average cost-effectiveness ratio ranged from US$9 to US$2000 per life year saved. This approach, linking expert knowledge, known costs, and modelling, offers potential for estimating cost-effective investments for better informed policy choice where empirical evidence is limited.
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http://dx.doi.org/10.1016/j.gfs.2021.100550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202230PMC
June 2021

An innovative approach to improve the detection and treatment of risk factors in poor urban settings: a feasibility study in Argentina.

BMC Public Health 2021 03 22;21(1):567. Epub 2021 Mar 22.

Department of Research in Chronic Diseases, Institute for Clinical Effectiveness and Health Policy (IECS), Emilio Ravignani 2024 (C1414CPV), Buenos Aires, Argentina.

Background: The effective management of cardiovascular (CVD) prevention among the population with exclusive public health coverage in Argentina is low since less than 30% of the individuals with predicted 10-year CVD risk ≥10% attend a clinical visit for CVD risk factors control in the primary care clinics (PCCs).

Methods: We conducted a non-controlled feasibility study using a mixed methods approach to evaluate acceptability, adoption and fidelity of a multi-component intervention implemented in the public healthcare system. The eligibility criteria were having exclusive public health coverage, age ≥ 40 years, residence in the PCC's catchment area and 10-year CVD risk ≥10%. The multi-component intervention addressed (1) system barriers through task shifting among the PCC's staff, protected medical appointments slots and a new CVD form and (2) Provider barriers through training for primary care physicians and CHW and individual barriers through a home-based intervention delivered by community health workers (CHWs).

Results: A total of 185 participants were included in the study. Of the total number of eligible participants, 82.2% attended at least one clinical visit for risk factor control. Physicians intensified drug treatment in 77% of participants with BP ≥140/90 mmHg and 79.5% of participants with diabetes, increased the proportion of participants treated according to GCP from 21 to 32.6% in hypertensive participants, 7.4 to 33.3% in high CVD risk and 1.4 to 8.7% in very high CVD risk groups. Mean systolic and diastolic blood pressure were lower at the end of follow up (156.9 to 145.4 mmHg and 92.9 to 88.9 mmHg, respectively) and control of hypertension (BP < 140/90 mmHg) increased from 20.3 to 35.5%.

Conclusion: The proposed CHWs-led intervention was feasible and well accepted to improve the detection and treatment of risk factors in the poor population with exclusive public health coverage and with moderate or high CVD risk at the primary care setting in Argentina. Task sharing activities with CHWs did not only stimulate teamwork among PCC staff, but it also improved quality of care. This study showed that community health workers could have a more active role in the detection and clinical management of CVD risk factors in low-income communities.
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http://dx.doi.org/10.1186/s12889-021-10569-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986565PMC
March 2021

A qualitative inquiry of access to and quality of primary healthcare in seven communities in East and West Africa (SevenCEWA): perspectives of stakeholders, healthcare providers and users.

BMC Fam Pract 2021 02 25;22(1):45. Epub 2021 Feb 25.

Lown Scholars Program, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Background: Universal health coverage is one of the Sustainable Development Goal targets known to improve population health and reduce financial burden. There is little qualitative data on access to and quality of primary healthcare in East and West Africa. The aim of this study was to describe the viewpoints of healthcare users, healthcare providers and other stakeholders on health-seeking behaviour, access to and quality of healthcare in seven communities in East and West Africa.

Methods: A qualitative study was conducted in four communities in Nigeria and one community each in Kenya, Uganda and Tanzania in 2018. Purposive sampling was used to recruit: 155 respondents (mostly healthcare users) for 24 focus group discussions, 25 healthcare users, healthcare providers and stakeholders for in-depth interviews and 11 healthcare providers and stakeholders for key informant interviews. The conceptual framework in this study combined elements of the Health Belief Model, Health Care Utilisation Model, four 'As' of access to care, and pathway model to better understand the a priori themes on access to and quality of primary healthcare as well as health-seeking behaviours of the study respondents. A content analysis of the data was done using MAXQDA 2018 qualitative software to identify these a priori themes and emerging themes.

Results: Access to primary healthcare in the seven communities was limited, especially use of health insurance. Quality of care was perceived to be unacceptable in public facilities whereas cost of care was unaffordable in private facilities. Health providers and users as well as stakeholders highlighted shortage of equipment, frequent drug stock-outs and long waiting times as major issues, but had varying opinions on satisfaction with care. Use of herbal medicines and other traditional treatments delayed or deterred seeking modern healthcare in the Nigerian sites.

Conclusions: There was a substantial gap in primary healthcare coverage and quality in the selected communities in rural and urban East and West Africa. Alternative models of healthcare delivery that address social and health inequities, through affordable health insurance, can be used to fill this gap and facilitate achieving universal health coverage.
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http://dx.doi.org/10.1186/s12875-021-01394-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7908656PMC
February 2021

Glycemic Index (GI) Values for Major Sources of Dietary Carbohydrates in Iran.

Int J Endocrinol Metab 2020 Jul 27;18(3):e99793. Epub 2020 Jun 27.

Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.

Background: The glycemic index (GI) values of staple foods are not available in a standardized method in Iran.

Objectives: The aim of this study was to measure the GI values of the major carbohydrate sources in a typical Iranian diet.

Methods: Using the international standard method, the GI values were determined for four wheat flatbreads, barley and rye bread, white and brown rice, as well as white and brown rice mixed with lentils. Twelve healthy adults were given 50 g anhydrous glucose three times (as the reference carbohydrate) and the test foods once each throughout the study. Using finger-prick blood samples, capillary blood glucose was measured using a reliable glucometer. The GI was calculated using the trapezoidal method.

Results: The GI values of the following types of bread were: Barley 66, Lavash 72, Taftoon 79, Sangak 82, rye 84, and Barbari 99. The GI values for brown and white rice were 65 and 71, respectively. The mixture of brown rice with lentils had a GI value of 55, and the mixture of white rice with lentils had a GI of 79.

Conclusions: The most common types of bread and white rice consumed in Iran have high GI values. There is potential to reduce the overall GI values in the Iranian diet by encouraging the consumption of barley bread and brown rice.
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http://dx.doi.org/10.5812/ijem.99793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7695225PMC
July 2020

Reply to: Concerns over calculating injury-related deaths associated with temperature.

Nat Med 2020 12 16;26(12):1827-1828. Epub 2020 Nov 16.

MRC Centre for Environment and Health, Imperial College London, London, UK.

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http://dx.doi.org/10.1038/s41591-020-1114-yDOI Listing
December 2020

Hypertension prevalence, awareness, treatment, and control and predicted 10-year CVD risk: a cross-sectional study of seven communities in East and West Africa (SevenCEWA).

BMC Public Health 2020 Nov 13;20(1):1706. Epub 2020 Nov 13.

Lown Scholars Program, Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Background: Few studies have characterized the epidemiology and management of hypertension across several communities with comparable methodologies in sub-Saharan Africa. We assessed prevalence, awareness, treatment, and control of hypertension and predicted 10-year cardiovascular disease risk across seven sites in East and West Africa.

Methods: Between June and August 2018, we conducted household surveys among adults aged 18 years and above in 7 communities in Kenya, Nigeria, Tanzania, and Uganda. Following a standardized protocol, we collected data on socio-demographics, health insurance, and healthcare utilization; and measured blood pressure using digital blood pressure monitors. We estimated the 10-year cardiovascular disease (CVD) risk using a country-specific risk score and fitted hierarchical models to identify determinants of hypertension prevalence, awareness, and treatment.

Results: We analyzed data of 3549 participants. The mean age was 39·7 years (SD 15·4), 60·5% of whom were women, 9·6% had ever smoked cigarettes, and 32·7% were overweight/obese. A quarter of the participants (25·4%) had hypertension, more than a half of whom (57·2%) were aware that they had diagnosed hypertension. Among those diagnosed, 50·5% were taking medication, and among those taking medication 47·3% had controlled blood pressure. After adjusting for other determinants, older age was associated with increased hypertension prevalence, awareness, and treatment whereas primary education was associated with lower hypertension prevalence. Health insurance was associated with lower hypertension prevalence and higher chances of treatment. Median predicted 10-yr CVD risk across sites was 4·9% (Interquartile range (IQR), 2·4%, 10·3%) and 13·2% had predicted 10-year CVD risk of 20% or greater while 7·1% had predicted 10-year CVD risk of > 30%.

Conclusion: In seven communities in east and west Africa, a quarter of participants had hypertension, about 40% were unaware, half of those aware were treated, and half of those treated had controlled blood pressure. The 10-year predicted CVD risk was low across sites. Access to health insurance is needed to improve awareness, treatment, and control of hypertension in sub-Saharan Africa.
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http://dx.doi.org/10.1186/s12889-020-09829-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7666461PMC
November 2020

Gestational weight gain in low-income and middle-income countries: a modelling analysis using nationally representative data.

BMJ Glob Health 2020 11;5(11)

Department of Global Health and Population, Department of Epidemiology, Department of Nutrition, Harvard University TH Chan School of Public Health, Boston, Massachusetts, USA

Introduction: Gestational weight gain (GWG) has important implications for maternal and child health and is an ideal modifiable factor for preconceptional and antenatal care. However, the average levels of GWG across all low-income and middle-income countries of the world have not been characterised using nationally representative data.

Methods: GWG estimates across time were computed using data from the Demographic and Health Surveys Program. A hierarchical model was developed to estimate the mean total GWG in the year 2015 for all countries to facilitate cross-country comparison. Year and country-level covariates were used as predictors, and variable selection was guided by the model fit. The final model included year (restricted cubic splines), geographical super-region (as defined by the Global Burden of Disease Study), mean adult female body mass index, gross domestic product per capita and total fertility rate. Uncertainty ranges (URs) were generated using non-parametric bootstrapping and a multiple imputation approach. Estimates were also computed for each super-region and region.

Results: Latin America and Caribbean (11.80 kg (95% UR: 6.18, 17.41)) and Central Europe, Eastern Europe and Central Asia (11.19 kg (95% UR: 6.16, 16.21)) were the super-regions with the highest GWG estimates in 2015. Sub-Saharan Africa (6.64 kg (95% UR: 3.39, 9.88)) and North Africa and Middle East (6.80 kg (95% UR: 3.17, 10.43)) were the super-regions with the lowest estimates in 2015. With the exception of Latin America and Caribbean, all super-regions were below the minimum GWG recommendation for normal-weight women, with Sub-Saharan Africa and North Africa and Middle East estimated to meet less than 60% of the minimum recommendation.

Conclusion: The levels of GWG are inadequate in most low-income and middle-income countries and regions. Longitudinal monitoring systems and population-based interventions are crucial to combat inadequate GWG in low-income and middle-income countries.
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http://dx.doi.org/10.1136/bmjgh-2020-003423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661366PMC
November 2020

Iranian general populations' and health care providers' preferences for benefits and harms of statin therapy for primary prevention of cardiovascular disease.

BMC Med Inform Decis Mak 2020 11 4;20(1):288. Epub 2020 Nov 4.

Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: The use of statins for primary prevention of cardiovascular diseases is associated with different benefit and harm outcomes. The aime of this study is how important these outcomes are for people and what people's preferences are.

Methods: We conducted a preference-eliciting survey incorporating a best-worst scaling (BWS) instrument in Iran from June to November 2019. The relative importance of 13 statins-related outcomes was assessed on a sample of 1085 participants, including 913 general population (486 women) and 172 healthcare providers from the population covered by urban and rural primary health care centers. The participants made trade-off decisions and selected the most and least worrisome outcomes concurrently from 13 choice sets; each contains four outcomes generated using the balanced incomplete block design.

Results: According to the mean (SD) BWS scores, which can be (+ 4) in maximum and (- 4) in minimum, in the general population, the most worrisome outcomes were severe stroke (3.37 (0.8)), severe myocardial infarction (2.71(0.7)), and cancer (2.69 (1.33)). While myopathy (- 3. 03 (1.03)), nausea/headache (- 2.69 (0.94)), and treatment discontinuation due to side effects (- 2.24 (1.14)) were the least worrisome outcomes. Preferences were similar between rural and urban areas and among health care providers and the general population with overlapping uncertainty intervals.

Conclusion: The rank of health outcomes may be similar in various socio-cultural contexts. The preferences for benefits and harms of statin therapy are essential to assess benefit-harm balance when recommending statins for primary prevention of cardiovascular diseases.
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http://dx.doi.org/10.1186/s12911-020-01304-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7640674PMC
November 2020

Economic valuation of setting up a social health enterprise in urban poor-resource setting in Kenya.

Soc Sci Med 2020 12 19;266:113294. Epub 2020 Aug 19.

Harvard T.H. Chan School of Public Health, United States. Electronic address:

The failure of the market and government to provide quality healthcare services have been the motivation to set up social health enterprise. However, the value for money associated with setting up a social health enterprise in sub-Sahara African countries has been relatively unexplored in the literature. The study presents the first empirical estimates of the mean willingness-to-pay (WTP) for setting up a social health enterprise that will simultaneously run a health center and provide health insurance scheme in an urban resource-poor setting and explores whether the benefits outweigh the costs. The contingent valuation method is used to estimate the mean WTP for the health insurance scheme proposed by the social health enterprise in Viwandani slum (Nairobi, Kenya). The survey was conducted between June and July 2018 on 300 households. We find that the feasibility of setting up a social health enterprise could be promising with 97 percent of respondents willing to pay about US$ 2 per person per month for a scheme that would provide quality healthcare services. More importantly, setting up the social health enterprise will yield a positive net profit, and investors could expect US$ 1.11 in benefits for each US$ 1 of costs of investment in setting up the social health enterprise. We, therefore, conclude that this health policy in this urban resource-poor setting could be a viable solution to reach the neglected urban households in the Kenyan slums.
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http://dx.doi.org/10.1016/j.socscimed.2020.113294DOI Listing
December 2020

Integrating care for non-communicable diseases into routine HIV services: key considerations for policy design in sub-Saharan Africa.

J Int AIDS Soc 2020 06;23 Suppl 1:e25508

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Introduction: There is great interest for integrating care for non-communicable diseases (NCDs) into routine HIV services in sub-Saharan Africa (SSA) due to the steady rise of the number of people who are ageing with HIV. Suggested health system approaches for intervening on these comorbidities have mostly been normative, with little actionable guidance on implementation, and on the practical, economic and ethical considerations of favouring people living with HIV (PLHIV) versus targeting the general population. We summarize opportunities and challenges related to leveraging HIV treatment platforms to address NCDs among PLHIV. We emphasize key considerations that can guide integrated care in SSA and point to possible interventions for implementation.

Discussion: Integrating care offers an opportunity for effective delivery of NCD services to PLHIV, but may be viewed to unfairly ignore the larger number of NCD cases in the general population. Integration can also help maintain the substantial health and economic benefits that have been achieved by the global HIV/AIDS response. Implementing interventions for integrated care will require assessing the prevalence of common NCDs among PLHIV, which can be achieved via increased screening during routine HIV care. Successful integration will also necessitate earmarking funds for NCD interventions in national budgets.

Conclusions: An expanded agenda for addressing HIV-NCD comorbidities in SSA may require adding selected NCDs to conditions that are routinely monitored in PLHIV. Attention should be given to mitigating potential tradeoffs in the quality of HIV services that may result from the extra responsibilities borne by HIV health workers. Integrated care will more likely be effective in the context of concurrent health system reforms that address NCDs in the general population, and with synergies with other HIV investments that have been used to strengthen health systems.
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http://dx.doi.org/10.1002/jia2.25508DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305410PMC
June 2020

Cost-effectiveness analysis of integrating screening and treatment of selected non-communicable diseases into HIV/AIDS treatment in Uganda.

J Int AIDS Soc 2020 06;23 Suppl 1:e25507

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Introduction: Despite growing enthusiasm for integrating treatment of non-communicable diseases (NCDs) into human immunodeficiency virus (HIV) care and treatment services in sub-Saharan Africa, there is little evidence on the potential health and financial consequences of such integration. We aim to study the cost-effectiveness of basic NCD-HIV integration in a Ugandan setting.

Methods: We developed an epidemiologic-cost model to analyze, from the provider perspective, the cost-effectiveness of integrating hypertension, diabetes mellitus (DM) and high cholesterol screening and treatment for people living with HIV (PLWH) receiving antiretroviral therapy (ART) in Uganda. We utilized cardiovascular disease (CVD) risk estimations drawing from the previously established Globorisk model and systematic reviews; HIV and NCD risk factor prevalence from the World Health Organization's STEPwise approach to Surveillance survey and global databases; and cost data from national drug price lists, expert consultation and the literature. Averted CVD cases and corresponding disability-adjusted life years were estimated over 10 subsequent years along with incremental cost-effectiveness of the integration.

Results: Integrating services for hypertension, DM, and high cholesterol among ART patients in Uganda was associated with a mean decrease of the 10-year risk of a CVD event: from 8.2 to 6.6% in older PLWH women (absolute risk reduction of 1.6%), and from 10.7 to 9.5% in older PLWH men (absolute risk reduction of 1.2%), respectively. Integration would yield estimated net costs between $1,400 and $3,250 per disability-adjusted life year averted among older ART patients.

Conclusions: Providing services for hypertension, DM and high cholesterol for Ugandan ART patients would reduce the overall CVD risk among these patients; it would amount to about 2.4% of national HIV/AIDS expenditure, and would present a cost-effectiveness comparable to other standalone interventions to address NCDs in low- and middle-income country settings.
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http://dx.doi.org/10.1002/jia2.25507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305460PMC
June 2020

Hypothetical interventions and risk of myocardial infarction in a general population: application of the parametric g-formula in a longitudinal cohort study-the Tromsø Study.

BMJ Open 2020 05 24;10(5):e035584. Epub 2020 May 24.

Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA.

Objectives: The aim of this study was to use the parametric g-formula to estimate the 19-year risk of myocardial infarction (MI) under hypothetical interventions on six cardiovascular risk factors.

Design And Setting: A populations-based cohort study with repeated measurements, the Tromsø Study.

Primary Outcome Measure: Myocardial infarction.

Participants: We estimated the relative and absolute risk reduction under feasible and intensive risk reduction strategies for smoking, physical activity, alcohol drinking, body mass index, total serum cholesterol and systolic blood pressure in 14 965 men and women with 19 years of follow-up (1994-2013).

Results: The estimated 19-year risk of MI under no intervention was 7.5% in individuals with baseline mean age 49.3 years (range 25-69). This risk was reduced by 30% (95% CI 19% to 39%) under joint feasible interventions on all risk factors, and 70% (60%, 78%) under a set of more intensive interventions. The most effective interventions were lowering of total cholesterol to 5.18 mmol/L and lowering of systolic blood pressure to 120 mm Hg (33% and 37% lower MI risk, respectively). The absolute risk reductions were significantly larger in men, in older participants, in smokers and in those with low education.

Conclusion: Modification of population levels of cardiovascular risk factors could have prevented close to one-third of the cases of MI in the municipality of Tromsø during 19 years of follow-up.
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http://dx.doi.org/10.1136/bmjopen-2019-035584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7252981PMC
May 2020

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

Public Health Nutr 2021 04 11;24(6):1393-1403. Epub 2020 May 11.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.

Objective: To derive dietary patterns (DP) among women of reproductive age (WRA) and older women in urban Sub-Saharan Africa (SSA), and to examine their association with body mass index (BMI), overweight and obesity.

Design: We used principal component analysis to derive DP. Their association with BMI, overweight and obesity was assessed using linear and multinomial logistic regression models controlling for age, marital status, education and wealth.

Setting: Cross-sectional data from prospective studies in Accra, Ghana (2008-2009), Dar es Salaam, Tanzania (2014) and Lilongwe and Kasungu, Malawi (2017-2018) were used.

Participants: We compared WRA in Ghana (18-54 years, n 1762) and Malawi (19-48 years, n 137), and older women in Ghana (≥55 years, n 514) and Tanzania (≥50 years, n 134).

Results: Among WRA, protein and healthy DP were identified in both Ghana and Malawi. In Ghana, the protein DP was associated with higher odds of overweight or obesity (adjusted OR 1·82, 95 % CI 1·27, 2·60 for quintile 2). Among older women, three DP were identified in Ghana (cereal, protein and healthy) and two DP in Tanzania (protein and healthy). The protein DP was associated with higher BMI in Ghana (adjusted mean difference 2·83, 95 % CI 0·95, 4·71 for quartile 3).

Conclusions: Higher quintiles of the protein DP were associated with higher BMI and odds of overweight or obesity among women in urban Ghana, but not in Malawi or Tanzania. Further research is needed to understand how DP influence overweight and obesity among adult women in urban SSA.
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http://dx.doi.org/10.1017/S1368980019005202DOI Listing
April 2021

Hypothetical Lifestyle Strategies in Middle-Aged Women and the Long-Term Risk of Stroke.

Stroke 2020 05 9;51(5):1381-1387. Epub 2020 Apr 9.

From the Department of Epidemiology (P.J., J.E.M., J.M.R., M.A.H., G.D.), Harvard T.H. Chan School of Public Health, Boston, MA.

Background and Purpose- Long-term effect of lifestyle changes on stroke incidence has not been estimated in randomized trials. We used observational data to estimate the incidence of stroke under hypothetical lifestyle strategies in the NHS (Nurses' Health Study). Methods- We considered 3 nondietary strategies (smoking cessation, exercising ≥30 min/d, gradual body mass index reduction if overweight/obese) and several dietary strategies (eating ≥3 servings/wk of fish, ≤3 servings/wk of unprocessed red meat, no processed red meat, ≥1 servings/d of nuts, etc). We used the parametric g-formula to estimate the 26-year risk of stroke under these strategies. Results- In 59 727 women, mean age 52 years at baseline in 1986, the estimated 26-year risks under no lifestyle interventions were 4.7% for total stroke, 2.4% for ischemic stroke, and 0.7% for hemorrhagic stroke. Under the combined nondietary interventions, the estimated 26-year risk of total stroke was 3.5% (95% CI, 2.6%-4.3%) and ischemic stroke was 1.6% (95% CI, 1.1%-2.1%). Smaller reductions in total stroke risk were estimated under isolated dietary strategies of increased intake of fish and nuts and reduced intake of unprocessed red meat. Ischemic stroke risk was lower under reduced intake of unprocessed and processed red meat, and hemorrhagic stroke risk was lower under a strategy of increased fish consumption. Conclusions- In this population of middle-aged women, sustained, lifestyle modifications were estimated to reduce the 26-year risk of total stroke by 25% and ischemic stroke by 36%. Sustained dietary modifications were estimated to reduce the 26-year risk of total stroke by 23%.
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http://dx.doi.org/10.1161/STROKEAHA.119.026761DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185054PMC
May 2020

Multi-dimensional characterisation of global food supply from 1961-2013.

Nat Food 2020 Jan 13;1(1):70-75. Epub 2020 Jan 13.

School of Public Health, Imperial College London, London, UK.

Food systems are increasingly globalized and interdependent and diets around the world are changing. Characterising national food supplies and how they have changed can inform food policies that ensure national food security, support access to healthy diets and enhance environmental sustainability. Here, we analysed data for 171 countries on availability of 18 food groups from the United Nations Food and Agriculture Organization to identify and track multi-dimensional food supply patterns from 1961 to 2013. Four predominant food group combinations were identified that explained almost 90% of cross-country variance in food supply: animal source and sugar; vegetable; starchy root and fruit; and seafood and oilcrops. South Korea, China and Taiwan experienced the largest changes in food supply over the past five decades, with animal source foods and sugar, vegetables, and seafood and oilcrops all becoming more abundant components of food supply. In contrast, in many Western countries, the supply of animal source foods and sugar declined. Meanwhile, there was remarkably little change in food supply in countries in the sub-Saharan Africa region. These changes have led to a partial global convergence in national supply of animal source foods and sugar, and a divergence in vegetables, and seafood and oilcrops. Our analysis has generated a novel characterisation of food supply that highlights the interdependence of multiple food types in national food systems. A better understanding of how these patterns have evolved and will continue to change is needed to support the delivery of healthy and sustainable food system policies.
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http://dx.doi.org/10.1038/s43016-019-0012-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992427PMC
January 2020

Multi-dimensional characterisation of global food supply from 1961-2013.

Nat Food 2020 Jan 13;1(1):70-75. Epub 2020 Jan 13.

School of Public Health, Imperial College London, London, UK.

Food systems are increasingly globalized and interdependent and diets around the world are changing. Characterising national food supplies and how they have changed can inform food policies that ensure national food security, support access to healthy diets and enhance environmental sustainability. Here, we analysed data for 171 countries on availability of 18 food groups from the United Nations Food and Agriculture Organization to identify and track multi-dimensional food supply patterns from 1961 to 2013. Four predominant food group combinations were identified that explained almost 90% of cross-country variance in food supply: animal source and sugar; vegetable; starchy root and fruit; and seafood and oilcrops. South Korea, China and Taiwan experienced the largest changes in food supply over the past five decades, with animal source foods and sugar, vegetables, and seafood and oilcrops all becoming more abundant components of food supply. In contrast, in many Western countries, the supply of animal source foods and sugar declined. Meanwhile, there was remarkably little change in food supply in countries in the sub-Saharan Africa region. These changes have led to a partial global convergence in national supply of animal source foods and sugar, and a divergence in vegetables, and seafood and oilcrops. Our analysis has generated a novel characterisation of food supply that highlights the interdependence of multiple food types in national food systems. A better understanding of how these patterns have evolved and will continue to change is needed to support the delivery of healthy and sustainable food system policies.
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http://dx.doi.org/10.1038/s43016-019-0012-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992427PMC
January 2020

Response by Kontis et al to Letter Regarding Article, "Three Public Health Interventions Could Save 94 Million Lives in 25 Years: Global Impact Assessment Analysis".

Circulation 2020 01 13;141(2):e5. Epub 2020 Jan 13.

Department of Global Health and Population, Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA (G.D.).

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http://dx.doi.org/10.1161/CIRCULATIONAHA.119.044418DOI Listing
January 2020

Prevalence and predictors of overweight and obesity in Brazilian immigrants in Massachusetts.

BMC Public Health 2020 Jan 10;20(1):42. Epub 2020 Jan 10.

Harvard T.H. Chan School of Public Health, Department of Global Health & Population, 665 Huntington Avenue, Bldg. 1, Boston, MA, 02215, USA.

Background: Overweight and obesity are important risk factors for chronic non-communicable diseases, and their prevalence is on the rise worldwide. This study seeks to describe the prevalence and predictors of overweight and obesity in Brazilian immigrants living in Massachusetts, United States of America (USA).

Methods: Modeled after a survey on behavioral risk factors for chronic disease conducted annually in Brazil (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico: Vigitel), Brazilian immigrants aged 18+ (n = 361) were surveyed between December 2013 and March 2014. Information was obtained from consenting participants regarding their demographic characteristics, physical activity, dietary and lifestyle habits, and other behavioral risk factors. Weight status was estimated from body mass index (BMI), calculated from self-reported height and weight data. Participants were categorized as overweight/obese if their BMI was ≥25; overweight and obese categories were combined to ensure appropriate sample size. Prevalence of overweight/obesity was estimated using STATA, and significant predictors were identified via multi-variable logistic regression. Odds ratio (OR), 95% confidence intervals (95% CI) and p-values were determined.

Results: The overall prevalence of overweight/obesity in the sample was 47.6%. Significant predictors of overweight and obesity were gender (men OR 2.30, 95% CI: 1.10, 3.78; women are comparison group), working in the 3 months prior to the survey (OR 2.90, 95% CI: 1.01, 8.30), and longer duration living in the USA (OR per additional year 1.06, 95% CI: 1.02, 1.11). Significant dietary predictors of overweight/obesity included 5 or more days per week of consumption of red meat (OR red meat 3.70, 95% CI: 1.47, 9.26) or of sweetened beverages, like soft drinks also known as soda (OR soda 2.40, 95% CI: 1.00, 5.78) compared with less frequent consumption of these foods.

Conclusions: This study suggests that long duration of time lived in the USA increases odds of overweight and obesity for Brazilian immigrants living in Massachusetts. Efforts to curb increases in overweight and obesity in this population should focus not only on the men and those who work but also the women. Possible intervention measures should target soda (soft drink) and red meat consumption in Brazilian immigrants.
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http://dx.doi.org/10.1186/s12889-020-8144-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6954574PMC
January 2020

Early life risk factors of motor, cognitive and language development: a pooled analysis of studies from low/middle-income countries.

BMJ Open 2019 10 3;9(10):e026449. Epub 2019 Oct 3.

Departamento de Medicina Preventiva, Faculdade de Medicina FMUSP, Universidade de São Paulo, Sao Paulo, Brasil.

Objective: To determine the magnitude of relationships of early life factors with child development in low/middle-income countries (LMICs).

Design: Meta-analyses of standardised mean differences (SMDs) estimated from published and unpublished data.

Data Sources: We searched Medline, bibliographies of key articles and reviews, and grey literature to identify studies from LMICs that collected data on early life exposures and child development. The most recent search was done on 4 November 2014. We then invited the first authors of the publications and investigators of unpublished studies to participate in the study.

Eligibility Criteria For Selecting Studies: Studies that assessed at least one domain of child development in at least 100 children under 7 years of age and collected at least one early life factor of interest were included in the study.

Analyses: Linear regression models were used to assess SMDs in child development by parental and child factors within each study. We then produced pooled estimates across studies using random effects meta-analyses.

Results: We retrieved data from 21 studies including 20 882 children across 13 LMICs, to assess the associations of exposure to 14 major risk factors with child development. Children of mothers with secondary schooling had 0.14 SD (95% CI 0.05 to 0.25) higher cognitive scores compared with children whose mothers had primary education. Preterm birth was associated with 0.14 SD (-0.24 to -0.05) and 0.23 SD (-0.42 to -0.03) reductions in cognitive and motor scores, respectively. Maternal short stature, anaemia in infancy and lack of access to clean water and sanitation had significant negative associations with cognitive and motor development with effects ranging from -0.18 to -0.10 SDs.

Conclusions: Differential parental, environmental and nutritional factors contribute to disparities in child development across LMICs. Targeting these factors from prepregnancy through childhood may improve health and development of children.
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http://dx.doi.org/10.1136/bmjopen-2018-026449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797384PMC
October 2019

Weight Gain After Smoking Cessation and Lifestyle Strategies to Reduce it.

Epidemiology 2020 01;31(1):7-14

From the Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.

Background: Weight gain following smoking cessation reduces the incentive to quit, especially among women. Exercise and diet interventions may reduce postcessation weight gain, but their long-term effect has not been estimated in randomized trials.

Methods: We estimated the long-term reduction in postcessation weight gain among women under smoking cessation alone or combined with (1) moderate-to-vigorous exercise (15, 30, 45, 60 minutes/day), and (2) exercise and diet modification (≤2 servings/week of unprocessed red meat; ≥5 servings/day of fruits and vegetables; minimal sugar-sweetened beverages, sweets and desserts, potato chips or fried potatoes, and processed red meat).

Results: Among 10,087 eligible smokers in the Nurses' Health Study and 9,271 in the Nurses' Health Study II, the estimated 10-year mean weights under smoking cessation were 75.0 (95% CI = 74.7, 75.5) kg and 79.0 (78.2, 79.6) kg, respectively. Pooling both cohorts, the estimated postcessation mean weight gain was 4.9 (7.3, 2.6) kg lower under a hypothetical strategy of exercising at least 30 minutes/day and diet modification, and 5.9 (8.0, 3.8) kg lower under exercising at least 60 minutes/day and diet modification, compared with smoking cessation without exercising.

Conclusions: In this study, substantial weight gain occurred in women after smoking cessation, but we estimate that exercise and dietary modifications could have averted most of it.
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http://dx.doi.org/10.1097/EDE.0000000000001106DOI Listing
January 2020

Guidance for a causal comparative effectiveness analysis emulating a target trial based on big real world evidence: when to start statin treatment.

J Comp Eff Res 2019 09 12;8(12):1013-1025. Epub 2019 Sep 12.

Department of Public Health, Health Services Research & Health Technology Assessment, Institute of Public Health, Medical Decision Making & Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics & Technology, Hall iT, Austria.

The aim of this project is to describe a causal (counterfactual) approach for analyzing when to start statin treatment to prevent cardiovascular disease using real-world evidence. We use directed acyclic graphs to operationalize and visualize the causal research question considering selection bias, potential time-independent and time-dependent confounding. We provide a study protocol following the 'target trial' approach and describe the data structure needed for the causal assessment. The study protocol can be applied to real-world data, in general. However, the structure and quality of the database play an essential role for the validity of the results, and database-specific potential for bias needs to be explicitly considered.
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http://dx.doi.org/10.2217/cer-2018-0103DOI Listing
September 2019

Training opportunities for noncommunicable diseases research in Latin America: A scoping review.

Rev Panam Salud Publica 2019 22;43:e68. Epub 2019 Aug 22.

CRONICAS Centre of Excellence in Chronic Diseases CRONICAS Centre of Excellence in Chronic Diseases Universidad Peruana Cayetano Heredia Lima Peru CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru.

Objective: To identify gaps in postgraduate training and options for building capacity in noncommunicable disease (NCDs) research in Latin America.

Methods: This was a scoping review of postgraduate opportunities in NCDs at top universities in Latin America and of training grants awarded by international funding bodies. Three global university rankings were considered-the QS Ranking, the Shanghai Ranking, and the Times Ranking. Latin American universities appearing in at least two of these were selected. University websites were searched for current graduate programs in biostatistics, epidemiology, global health, health economics, and public health. Information was extracted, summarized, and evaluated to identify any programs focused on NCDs. In addition, seven international funding bodies' websites were searched for training grants.

Results: In all, 33 universities offering 72 postgraduate programs met the inclusion criteria. One of these programs was exclusively devoted to NCD, and 12 offered NCDs as a dissertation research topic. Only two training grants were awarded to a Latin American institution for NCD capacity building. There are few NCD research training programs in Latin America and only one program exclusively focused on NCDs.

Conclusion: There seem to be few NCD-specific research training programs in Latin America. Leveraging existing programs and expanding those with a focus on NCDs could help enhance NCD research capacity in the region. These initiatives should be supported by international funding agencies through more funding opportunities.
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http://dx.doi.org/10.26633/RPSP.2019.68DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6705329PMC
August 2019

The harsh effects of sanctions on Iranian health.

Lancet 2019 08 8;394(10197):468-469. Epub 2019 Aug 8.

School of Public Health, Tehran University of Medical Sciences, Tehran, 14176, Iran; Knowledge Utilization Research Center, Tehran University of Medical Sciences, Tehran, 14176, Iran; Community-Based Participatory-Research Center, Tehran University of Medical Sciences, Tehran, 14176, Iran. Electronic address:

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http://dx.doi.org/10.1016/S0140-6736(19)31763-5DOI Listing
August 2019

Particulate matter air pollution and national and county life expectancy loss in the USA: A spatiotemporal analysis.

PLoS Med 2019 07 23;16(7):e1002856. Epub 2019 Jul 23.

Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom.

Background: Exposure to fine particulate matter pollution (PM2.5) is hazardous to health. Our aim was to directly estimate the health and longevity impacts of current PM2.5 concentrations and the benefits of reductions from 1999 to 2015, nationally and at county level, for the entire contemporary population of the contiguous United States.

Methods And Findings: We used vital registration and population data with information on sex, age, cause of death, and county of residence. We used four Bayesian spatiotemporal models, with different adjustments for other determinants of mortality, to directly estimate mortality and life expectancy loss due to current PM2.5 pollution and the benefits of reductions since 1999, nationally and by county. The covariates included in the adjusted models were per capita income; percentage of population whose family income is below the poverty threshold, who are of Black or African American race, who have graduated from high school, who live in urban areas, and who are unemployed; cumulative smoking; and mean temperature and relative humidity. In the main model, which adjusted for these covariates and for unobserved county characteristics through the use of county-specific random intercepts, PM2.5 pollution in excess of the lowest observed concentration (2.8 μg/m3) was responsible for an estimated 15,612 deaths (95% credible interval 13,248-17,945) in females and 14,757 deaths (12,617-16,919) in males. These deaths would lower national life expectancy by an estimated 0.15 years (0.13-0.17) for women and 0.13 years (0.11-0.15) for men. The life expectancy loss due to PM2.5 was largest around Los Angeles and in some southern states such as Arkansas, Oklahoma, and Alabama. At any PM2.5 concentration, life expectancy loss was, on average, larger in counties with lower income and higher poverty rate than in wealthier counties. Reductions in PM2.5 since 1999 have lowered mortality in all but 14 counties where PM2.5 increased slightly. The main limitation of our study, similar to other observational studies, is that it is not guaranteed for the observed associations to be causal. We did not have annual county-level data on other important determinants of mortality, such as healthcare access and quality and diet, but these factors were adjusted for with use of county-specific random intercepts.

Conclusions: According to our estimates, recent reductions in particulate matter pollution in the USA have resulted in public health benefits. Nonetheless, we estimate that current concentrations are associated with mortality impacts and loss of life expectancy, with larger impacts in counties with lower income and higher poverty rate.
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http://dx.doi.org/10.1371/journal.pmed.1002856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650052PMC
July 2019
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