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1. Prevalence of Post-COVID conditions among Mexican COVID-19 survivors: a nationwide cross-sectional study

Author

Yenisei Ramírez-Toscano, Leticia Torres-Ibarra, Martha Carnalla, Ana Basto-Abreu, Dèsirée Vidaña-Perez, M. Arantxa Colchero, Sergio Bautista-Arredondo, Sharon Saydah, and Tonatiuh Barrientos-Gutiérrez

Subjects
COVID-19, Post-COVID condition, Long COVID, Epidemiology, Population-based study, Mexico, Public aspects of medicine, RA1-1270
Abstract

Abstract Background There are limited population-representative data that describe the potential burden of Post-COVID conditions (PCC) in Mexico. We estimated the prevalence of PCC overall and by sociodemographic characteristics among a representative sample of adults previously diagnosed with COVID-19 in Mexico. We additionally, characterized the PCC symptoms, and estimated the association between diagnosed type-2 diabetes and hypertension with PCC. Methods We used data from the 2021 National Health and Nutrition Survey in Mexico, a nationally and regionally representative survey, from August 1st to October 31st, 2021. Using the WHO definition, we estimated the prevalence of PCC by sociodemographics and prevalence of PCC symptoms. We fit multivariable log-binomial regression models to estimate the associations. Results The prevalence of PCC was 37.0%. The most common persistent symptoms were fatigue (56.8%), myalgia or arthralgia (47.5%), respiratory distress and dyspnea (42.7%), headache (34.0%), and cough (25.7%). The prevalence was higher in older people, women, and individuals with low socioeconomic status. There was no significant association between hypertension and PCC or diabetes and PCC prevalence. Conclusions About one-third of the adult Mexican population who had COVID-19 in 2021 had Post-COVID conditions. Our population-based estimates can help assess potential priorities for PCC-related health services, which is critical in light of our weak health system and limited funding.

Published
2024
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3. Predicted impact of banning nonessential, energy-dense food and beverages in schools in Mexico: A microsimulation study.

Author

Ana Basto-Abreu, Martha Carnalla, Francisco Reyes-Sánchez, Alan Reyes-García, Michelle M Haby, Isabel Junquera-Badilla, Lianca Sartoris-Ayala, Juan A Rivera, Barry M Popkin, and Tonatiuh Barrientos-Gutiérrez

Subjects
Medicine
Abstract

BackgroundChildhood obesity is a growing concern worldwide. School-based interventions have been proposed as effective means to improve nutritional knowledge and prevent obesity. In 2023, Mexico approved a reform to the General Education Law to strengthen the ban of sales and advertising of nonessential energy-dense food and beverages (NEDFBs) in schools and surroundings. We aimed to predict the expected one-year change in total caloric intake and obesity prevalence by introducing the ban of NEDFBs sales in schools, among school-aged children and adolescents (6 to 17 years old) in Mexico.Methods and findingsWe used age-specific equations to predict baseline fat-free mass (FFM) and fat mass (FM) and then estimated total energy intake (TEI) per day. The TEI after the intervention was estimated under 4 scenarios: (1) using national data to inform the intervention effect; (2) varying law compliance; (3) using meta-analytic data to inform the intervention effect size on calories; and (4) using national data to inform the intervention effect by sex and socioeconomic status (SES). We used Hall's microsimulation model to estimate the potential impact on body weight and obesity prevalence of children and adolescents 1 year after implementing the intervention in Mexican schools. We found that children could reduce their daily energy intake by 33 kcal/day/person (uncertainty interval, UI, [25, 42] kcal/day/person), reducing on average 0.8 kg/person (UI [0.6, 1.0] kg/person) and 1.5 percentage points (pp) in obesity (UI [1.1, 1.9] pp) 1 year after implementing the law. We showed that compliance will be key to the success of this intervention: considering a 50% compliance the intervention effect could reduce 0.4 kg/person (UI [0.3, 0.5] kg/person). Our sensitivity analysis showed that the ban could reduce body weight by 1.3 kg/person (UI [0.8, 1.8] kg/person) and up to 5.4 kg/person (UI [3.4, 7.5] kg/person) in the best-case scenario. Study limitations include assuming that obesity and the contribution of NEDFBs consumed at school remain constant over time, assuming full compliance, and not considering the potential effect of banning NEDFBs in stores near schools.ConclusionsEven in the most conservative scenario, banning sales of NEDFBs in schools is expected to significantly reduce obesity, but achieving high compliance will be key to its success.Why was this study done?- School-based interventions have been recognized as effective means to improve nutritional knowledge and prevent obesity-related diseases.- In December 2023, the Chamber of Representatives of Mexico approved an amendment that strengthens and updates the General Education Law (Article 75) and nutritional guidelines to ban the sales and advertising of nonessential energy-dense food and beverages (NEDFBs) in schools.What did the researchers do and find?- We used age-specific equations to predict baseline fat-free mass (FFM) and fat mass (FM) and total energy intake (TEI) per day.- We used microsimulation modeling to predict body weight and obesity prevalence of children and adolescents 1 year after implementing the intervention in Mexican schools.- Our modeling study suggests that an important impact on obesity prevalence can be expected if the law is implemented and enforced as intended.What do these findings mean?- If successful, this law could serve as an example beyond Mexico on how to achieve changes in body weight through school food regulation.- An important limitation of our main scenario is that we assumed full compliance of schools with the law, yet lower compliance will reduce its impact. We also did not consider historical trends on obesity or NEDFBs consumed in schools during our 1 year simulation, and we considered only the ban impact inside schools, excluding effects near and outside schools.

Published
2024
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4. Promoting healthy populations as a pandemic preparedness strategy: a simulation study from MexicoResearch in context

Author

Rob Johnson, Martha Carnalla, Ana Basto-Abreu, David Haw, Christian Morgenstern, Patrick Doohan, Giovanni Forchini, Katharina D. Hauck, and Tonatiuh Barrientos-Gutiérrez

Subjects
Pandemic preparedness, Epidemic response plan, BMI, Obesity, COVID-19, Population health, Public aspects of medicine, RA1-1270
Abstract

Summary: Background: The underlying health status of populations was a major determinant of the impact of the COVID-19 pandemic, particularly obesity prevalence. Mexico was one of the most severely affected countries during the COVID-19 pandemic and its obesity prevalence is among the highest in the world. It is unknown by how much the COVID-19 burden could have been reduced if systemic actions had been implemented to reduce excess weight in Mexico before the onset of the pandemic. Methods: Using a dynamic epidemic model based on nationwide data, we compare actual deaths with those under hypothetical scenarios assuming a lower body mass index in the Mexican population, as observed historically. We also model the number of deaths that would have been averted due to earlier implementation of front-of-pack warning labels or due to increases in taxes on sugar-sweetened beverages and non-essential high-energy foods in Mexico. Findings: We estimate that 52.5% (95% prediction interval (PI) 43.2, 61.6%) of COVID-19 deaths were attributable to obesity for adults aged 20–64 and 23.8% (95% PI 18.7, 29.1%) for those aged 65 and over. Had the population BMI distribution remained as it was in 2000, 2006, or 2012, COVID-19 deaths would have been reduced by an expected 20.6% (95% PI 16.9, 24.6%), 9.9% (95% PI 7.3, 12.9%), or 6.9% (95% PI 4.5, 9.5%), respectively. If the food-labelling intervention introduced in 2020 had been introduced in 2018, an expected 6.2% (95% PI 5.2, 7.3%) of COVID-19 deaths would have been averted. If taxes on sugar-sweetened beverages and high-energy foods had been doubled, trebled, or quadrupled in 2018, COVID-19 deaths would have been reduced by an expected 4.1% (95% PI 2.5, 5.7%), 7.9% (95% PI 4.9, 11.0%), or 11.6% (95% PI 7.3, 15.8%), respectively. Interpretation: Public health interventions targeting underlying population health, including non-communicable chronic diseases, is a promising line of action for pandemic preparedness that should be included in all pandemic plans. Funding: This study received funding from Bloomberg Philanthropies, awarded to Juan A. Rivera from the National Institute of Public Health; Community Jameel, the UK Medical Research Council (MRC), Kenneth C Griffin, and the World Health Organization.

Published
2024
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6. Nationally representative SARS-CoV-2 antibody prevalence estimates after the first epidemic wave in Mexico

Author

Ana Basto-Abreu, Martha Carnalla, Leticia Torres-Ibarra, Martín Romero-Martínez, Jesús Martínez-Barnetche, Irma López-Martínez, Rodrigo Aparicio-Antonio, Teresa Shamah-Levy, Celia Alpuche-Aranda, Juan A. Rivera, Tonatiuh Barrientos-Gutierrez, and ENSANUT-COVID collaborators

Subjects
Science
Abstract

SARS-CoV-2 seroprevalence surveys provide estimates of the extent of prior infection in a population. In this nationally representative survey from Mexico, the authors estimate seroprevalence after the first epidemic wave at ~25%, with variation by region, age, socioeconomic status, and education level.

Published
2022
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7. Multimorbidity matters in low and middle-income countries

Author

Ana Basto-Abreu, Tonatiuh Barrientos-Gutierrez, Alisha N Wade, Daniela Oliveira de Melo, Ana S Semeão de Souza, Bruno P Nunes, Arokiasamy Perianayagam, Maoyi Tian, Lijing L Yan, Arpita Ghosh, and J Jaime Miranda

Subjects
Medicine
Abstract

Multimorbidity is a complex challenge affecting individuals, families, caregivers, and health systems worldwide. The burden of multimorbidity is remarkable in low- and middle-income countries (LMICs) given the many existing challenges in these settings. Investigating multimorbidity in LMICs poses many challenges including the different conditions studied, and the restriction of data sources to relatively few countries, limiting comparability and representativeness. This has led to a paucity of evidence on multimorbidity prevalence and trends, disease clusters, and health outcomes, particularly longitudinal outcomes. In this paper, based on our experience of investigating multimorbidity in LMICs contexts, we discuss how the structure of the health system does not favor addressing multimorbidity, and how this is amplified by social and economic disparities and, more recently, by the COVID-19 pandemic. We argue that generating epidemiologic data around multimorbidity with similar methods and definition is essential to improve comparability, guide clinical decision-making and inform policies, research priorities, and local responses. We call for action on policy to refinance and prioritize primary care and integrated care as the center of multimorbidity.

Published
2022
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8. Factors associated with pregnancy and motherhood among Mexican women aged 15-24

Author

Celia Hubert, Aremis Villalobos, Ana Basto Abreu, Leticia Suárez-López, and Filipa de Castro

Subjects
Adolescent Pregnancy, Motherhood, Socioeconomic Factors, Medicine, Public aspects of medicine, RA1-1270
Abstract

Abstract: Adolescent pregnancy is associated with poor health and socioeconomic factors. The adolescent pregnancy rate in Mexico is the highest among the Organization for Economic Co-operation and Development (OECD) countries. We aimed to explore the factors associated with pregnancies and births in adolescent and young adult women. Using the 2015 Mexican National Survey of Boys, Girls, and Women (ENIM), we examined two dichotomous outcomes: “ever pregnant” and “being a mother” in women from 15 to 19 years and from 20 to 24 years without pregnancies during adolescence. We conducted bivariate analysis for each age group and used general linear models (GLM) to assess the association between the outcome variables and selected socioeconomic variables. Among adolescents, school attendance and tertiary education significantly decreased the likelihood of ever having been pregnant or being mothers, while being married/cohabiting increased the likelihood. Older age at first intercourse was negatively associated with ever having been pregnant. For adult women, in addition to school attendance, tertiary education, and being married/cohabiting, the region of residence also showed a significant association with ever having been pregnant. Similar socioeconomic factors were associated with pregnancy and motherhood between adolescents and young adults. However, it was found that delaying sexual debut could reduce the adolescent pregnancy rate. Our results highlight the importance of attending school and attaining tertiary education in reducing adolescent fertility rates.

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9. Prevalence of diabetes and poor glycemic control in Mexico: results from Ensanut 2016

Author

Ana Basto-Abreu, Tonatiuh Barrientos-Gutiérrez, Rosalba Rojas-Martínez, Carlos A Aguilar-Salinas, Nancy López-Olmedo, Vanessa De la Cruz-Góngora, Juan Rivera-Dommarco, Teresa Shamah-Levy, Martín Romero-Martínez, Simón Barquera, Ruy López-Ridaura, Mauricio Hernández-Ávila, and Salvador Villalpando

Subjects
diabetes mellitus tipo 2, prevalencia, glucemia, encuestas epidemiológicas, Public aspects of medicine, RA1-1270
Abstract

Objective. To estimate the prevalence of total, diagnosed and undiagnosed diabetes, and the prevalence of poor glyce­mic control in Mexico, and its associated factors. Materials and methods. Data from 3 700 adult participants were analysed in the 2016 National Health and Nutrition Survey. Diabetes prevalences were estimated with population weights, and the factors associated with total diabetes and poor glycemic control with Poisson regression models. Results The total prevalence of diabetes was 13.7% (9.5% diagnosed, 4.1% undiagnosed); 68.2% of people with diagnosed diabetes presented poor glycemic control. Longer disease duration, living in the centre or south of the country and being treated in pharmacies were associated with poor glycemic control. Being treated in a social security system was associated with better glycemic control. Conclusion. Multisectoral efforts are needed to strengthen screening, timely diagnosis and disease control, considering differences by region and type of health service.

Published
2019
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10. Barriers, refusal and a hypothetical monetary incentive for Covid-19 vaccination in Mexican adults

Author

Martha Carnalla, Ana Basto-Abreu, Dalia Stern, M Arantxa Colchero, Teresa Shamah-Levy, Celia M Alpuche-Aranda, Sergio Bautista-Arredondo, and Tonatiuh Barrientos-Gutiérrez

Subjects
Public Health, Environmental and Occupational Health
Abstract

Objective. To estimate vaccine uptake and assess sociodemographic conditions associated with vaccination barriers and refusal and to explore the effect of a monetary incentive to overcome them. Materials and methods. We used data from adults from the 2021 National Continuous Health and Nutrition Survey conducted during August-October 2021. We evaluated if an hypothetical monetary incentive between 50-650 MXN (~2.5-31 USD) would overcome barriers or refusal. Results. 73.9% were vaccinated with at least one dose, 7.5% refused, 4.8% reported barriers and 13.8% were ineligible at the time of the survey. Refusal and barriers were more frequent in men, older age, lower education and socioeconomic status, unemployed and informal workers. In people with barriers and refusal, the hypothetical incentive increased the acceptance in 57.6% (95%CI 50.7,64.4%) and 17.4% (95%CI 13.2,21.7%) in people with barriers and refusal, respectively. Conclusion. Understanding the reasons for barriers and refusal is crucial for future Covid-19 vaccination campaigns or epidemics. A monetary incentive might increase vaccination uptake, although, cost-effectiveness analyses are needed.

Published
2023
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11. Predicting obesity reduction after implementing warning labels in Mexico: A modeling study.

Author

Ana Basto-Abreu, Rossana Torres-Alvarez, Francisco Reyes-Sánchez, Romina González-Morales, Francisco Canto-Osorio, M Arantxa Colchero, Simón Barquera, Juan A Rivera, and Tonatiuh Barrientos-Gutierrez

Subjects
Medicine
Abstract

BackgroundIn October 2019, Mexico approved a law to establish that nonalcoholic beverages and packaged foods that exceed a threshold for added calories, sugars, fats, trans fat, or sodium should have an "excess of" warning label. We aimed to estimate the expected reduction in the obesity prevalence and obesity costs in Mexico by introducing warning labels, over 5 years, among adults under 60 years of age.Methods and findingsBaseline intakes of beverages and snacks were obtained from the 2016 Mexican National Health and Nutrition Survey. The expected impact of labels on caloric intake was obtained from an experimental study, with a 10.5% caloric reduction for beverages and 3.0% caloric reduction for snacks. The caloric reduction was introduced into a dynamic model to estimate weight change. The model output was then used to estimate the expected changes in the prevalence of obesity and overweight. To predict obesity costs, we used the Health Ministry report of the impact of overweight and obesity in Mexico 1999-2023. We estimated a mean caloric reduction of 36.8 kcal/day/person (23.2 kcal/day from beverages and 13.6 kcal/day from snacks). Five years after implementation, this caloric reduction could reduce 1.68 kg and 4.98 percentage points (pp) in obesity (14.7%, with respect to baseline), which translates into a reduction of 1.3 million cases of obesity and a reduction of US$1.8 billion in direct and indirect costs. Our estimate is based on experimental evidence derived from warning labels as proposed in Canada, which include a single label and less restrictive limits to sugar, sodium, and saturated fats. Our estimates depend on various assumptions, such as the transportability of effect estimates from the experimental study to the Mexican population and that other factors that could influence weight and food and beverage consumption remain unchanged. Our results will need to be corroborated by future observational studies through the analysis of changes in sales, consumption, and body weight.ConclusionsIn this study, we estimated that warning labels may effectively reduce obesity and obesity-related costs. Mexico is following Chile, Peru, and Uruguay in implementing warning labels to processed foods, but other countries could benefit from this intervention.

Published
2020
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12. The shift of obesity burden by socioeconomic status between 1998 and 2017 in Latin America and the Caribbean: a cross-sectional series study

Author

Safia S Jiwani, MSPH, Rodrigo M Carrillo-Larco, MD, Akram Hernández-Vásquez, MD, Tonatiuh Barrientos-Gutiérrez, PhD, Ana Basto-Abreu, DrPH, Laura Gutierrez, BSc, Vilma Irazola, MD, Ramfis Nieto-Martínez, MD, Bruno P Nunes, PhD, Diana C Parra, PhD, and J Jaime Miranda, ProfPhD

Subjects
Public aspects of medicine, RA1-1270
Abstract

Summary: Background: The burden of obesity differs by socioeconomic status. We aimed to characterise the prevalence of obesity among adult men and women in Latin America and the Caribbean by socioeconomic measures and the shifting obesity burden over time. Methods: We did a cross-sectional series analysis of obesity prevalence by socioeconomic status by use of national health surveys done between 1998 and 2017 in 13 countries in Latin America and the Caribbean. We generated equiplots to display inequalities in, the primary outcome, obesity by wealth, education, and residence area. We measured obesity gaps as the difference in percentage points between the highest and lowest obesity prevalence within each socioeconomic measure, and described trends as well as changing patterns of the obesity burden over time. Findings: 479 809 adult men and women were included in the analysis. Obesity prevalence across countries has increased over time, with distinct patterns emerging by wealth and education indices. In the most recent available surveys, obesity was most prevalent among women in Mexico in 2016, and the least prevalent among women in Haiti in 2016. The largest gap between the highest and lowest obesity estimates by wealth was observed in Honduras among women (21·6 percentage point gap), and in Peru among men (22·4 percentage point gap), compared with a 3·7 percentage point gap among women in Brazil and 3·3 percentage points among men in Argentina. Urban residents consistently had a larger burden than their rural counterparts in most countries, with obesity gaps ranging from 0·1 percentage points among women in Paraguay to 15·8 percentage points among men in Peru. The trend analysis done in five countries suggests a shifting of the obesity burden across socioeconomic groups and different patterns by gender. Obesity gaps by education in Mexico have reduced over time among women, but increased among men, whereas the gap has increased among women but remains relatively constant among men in Argentina. Interpretation: The increase in obesity prevalence in the Latin American and Caribbean region has been paralleled with an unequal distribution and a shifting burden across socioeconomic groups. Anticipation of the establishment of obesity among low socioeconomic groups could provide opportunities for societal gains in primordial prevention. Funding: None.

Published
2019
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13. Plataforma CLIMSS como herramienta de alfabetización en salud durante la crisis sanitaria de Covid-19

Author

Cynthia Rosas-Magallanes, Ana Basto-Abreu, Tonatiuh Barrientos-Gutiérrez, José Luis Ramírez-Martínez, Marcela Tamayo-Ortiz, Héctor Osiris Gutiérrez-Díaz, Laura Magaña-Valladares, David Barros-Sierra Cordera, Carmen María Santamaría-Guasch, and Mauricio Hernández-Ávila

Subjects
Public Health, Environmental and Occupational Health
Abstract

Objetivo. Describir a la plataforma Cursos en Línea Masivos del IMSS (CLIMSS) como herramienta de alfabetización en salud, a través de la evaluación de la eficiencia terminal, la ganancia de competencias y satisfacción de los usuarios de cursos en línea masivos en el tema de Covid-19. Material y métodos. Se analizaron datos de 20 cursos ofertados entre marzo y octubre de 2020. Se evaluaron las calificaciones pre y pos, el número total de registros, el total de cursos terminados y la satisfacción del usuario. Resultados. Se registraron un total de 4.9 millones de usuarios y 10 millo­nes de inscripciones, en todos los estados de la República mexicana, con una eficiencia terminal de 85%, una ganancia de competencias de 30% y una satisfacción de 9.34 (10). Conclusiones. La plataforma CLIMSS ha mostrado ser una herramienta para la alfabetización en salud con un alcance de millones de mexicanos en temas relacionados con la crisis sanitaria Covid-19.

Published
2022
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16. Expected changes in obesity after reformulation to reduce added sugars in beverages: A modeling study.

Author

Ana Basto-Abreu, Ariela Braverman-Bronstein, Dalia Camacho-García-Formentí, Rodrigo Zepeda-Tello, Barry M Popkin, Juan Rivera-Dommarco, Mauricio Hernández-Ávila, and Tonatiuh Barrientos-Gutiérrez

Subjects
Medicine
Abstract

BACKGROUND:Several strategies have been proposed to reduce the intake of added sugars in the population. In Mexico, a 10% sugar-sweetened beverages (SSBs) tax was implemented in 2014, and the implementation of other nutritional policies, such as product reformulation to reduce added sugars, is under discussion. WHO recommends that all individuals consume less than 10% of their total energy intake (TEI) from added sugars. We propose gradually reducing added sugars in SSBs to achieve an average 10% consumption of added sugars in the Mexican population over 10 years and to estimate the expected impact of reformulation in adult body weight and obesity. METHODS AND FINDINGS:Baseline consumption for added sugars and SSBs, sex, age, socioeconomic status (SES), height, and weight for Mexican adults were obtained from the 2012 Mexico National Health and Nutrition Survey (ENSANUT). On average, 12.6% of the TEI was contributed by added sugars; we defined a 50% reduction in added sugars in SSBs over 10 years as a reformulation target. Using a dynamic weight change model, sugar reductions were translated into individual expected changes in body weight assuming a 43% caloric compensation and a 2-year lag for the full effect of reformulation to occur. Results were stratified by sex, age, and SES. Twelve years after reformulation, the TEI from added sugars is expected to decrease to 10%, assuming no compensation from added sugars; 44% of the population would still be above WHO recommendations, requiring further sugar reductions to food. Body weight could be reduced by 1.3 kg (95% CI -1.4 to -1.2) in the adult population, and obesity could decrease 3.9 percentage points (pp; -12.5% relative to baseline). Our sensitivity analyses suggest that the impact of the intervention could vary from 0.12 kg after 6 months to 1.52 kg in the long term. CONCLUSIONS:Reformulation to reduce added sugars in SSBs could produce large reductions in sugar consumption and obesity in the Mexican adult population. This study is limited by the use of a single dietary recall and by data collected in all seasons except summer; still, these limitations should lead to conservative estimates of the reformulation effect. Reformulation success could depend on government enforcement and industry and consumer response, for which further research and evidence are needed.

Published
2018
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17. SARS-CoV-2 infection fatality rate after the first epidemic wave in Mexico

Author

Leticia Torres-Ibarra, Ana Basto-Abreu, Martha Carnalla, Rossana Torres-Alvarez, Francisco Reyes-Sanchez, Juan E Hernández-Ávila, Lina S Palacio-Mejia, Celia Alpuche-Aranda, Teresa Shamah-Levy, Juan A Rivera, and Tonatiuh Barrientos-Gutierrez

Subjects
Adult, Male, SARS-CoV-2, Seroepidemiologic Studies, Epidemiology, COVID-19, Humans, Female, General Medicine, Middle Aged, Mexico, Pandemics
Abstract

Background Estimates of SARS-CoV-2 infection fatality rates (IFRs) in developing countries remain poorly characterized. Mexico has one of the highest reported COVID-19 case-fatality rates worldwide, although available estimates do not consider serologic assessment of prior exposure nor all SARS-CoV-2-related deaths. We aimed to estimate sex- and age-specific IFRs for SARS-CoV-2 in Mexico. Methods The total number of people in Mexico with evidence of prior SARS-CoV-2 infection was derived from National Survey of Health and Nutrition-COVID-19 (ENSANUT 2020 Covid-19)—a nationally representative serosurvey conducted from August to November 2020. COVID-19 mortality data matched to ENSANUT’s dates were retrieved from the death-certificate registry, which captures the majority of COVID-19 deaths in Mexico, and from the national surveillance system, which covers the subset of COVID-19 deaths that were identified by the health system and were confirmed through a positive polymerase chain reaction test. We analysed differences in IFRs by urbanization and region. Results The national SARS-CoV-2 IFR was 0.47% (95% CI 0.44, 0.50) using death certificates and 0.30% (95% CI 0.28, 0.33) using surveillance-based deaths. The IFR increased with age, being close to zero at age Conclusion After the first wave of the COVID-19 pandemic, the overall IFR in Mexico was comparable with those of European countries. The IFR in Mexico increased with age and was higher in men than in women. The variations in IFRs across regions and places of residence within the country suggest that structural factors related to population characteristics, pandemic containment and healthcare capabilities could have influenced lethality at the local level.

Published
2022
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18. Expected reduction in obesity of a 20% and 30% tax to Sugar-Sweetened-Beverages in Brazil: a modeling study

Author

Ana Basto-Abreu, Rossana Torres-Alvarez, Tonatiuh Barrientos-Gutierrez, Paula Pereda, and Ana Clara Duran

Abstract

BackgroundThe consumption of sugar-sweetened beverages (SSB) is associated with obesity, metabolic diseases, and incremental healthcare costs. Given their health consequences, the World Health Organization (WHO) recommended that countries implement taxes to SSB. Over the last 10 years, Brazil has almost doubled its obesity prevalence, yet, in 2016, the Brazilian government cut 23 percentage points to existing federal SSB taxes to their current 4%. To simulate the potential impact of updating the fiscal policy towards SSB in Brazil, we aimed to estimate the price-elasticity of SSB and model the potential impact of a new 20 or 30% excise SSB tax on consumption, obesity prevalence, and healthcare costs.Methods and FindingsUsing household purchases data from the Brazilian Household Budget Survey (POF) from 2017/2018, we estimated constant elasticity regressions using a log-log specification by income level for all beverage categories: (1) sugar-sweetened beverages, (2) alcoholic beverages, (3) other beverages, and (4) low-calorie sweetened beverages. We estimated baseline intake for each beverage group using 24h dietary recall data from POF 2017/2018. Applying the price and cross-price elasticities to the baseline intake, we obtained changes in caloric intake. The caloric reduction was introduced into an individual dynamic model to estimate changes in weight and obesity prevalence. By multiplying the reduction in obesity cases during 10 years by the obesity costs per capita, we predicted the reduction in obesity costs attributable to the sweetened beverage tax. SSB price elasticities were higher in the low (−1.24) than in the high-income tertile (−1.13); cross-price elasticities suggest SSB were weakly substituted by milk, water, and 100% fruit juices. We estimated a caloric change of -17.3 kcal/day/person under a 20% excise tax and -25.9 kcal/day/person for a 30% tax. 10 years after implementation, a 20% tax is expected to reduce obesity prevalence by 6.7% and 9.1% for a 30% tax. These reductions translate into a -2.8 million and -3.8 million obesity cases for a 20 and 30% tax, respectively, and a reduction of $US -257.4 million and $US -345.9 million obesity costs over 10 years for a 20 and 30% tax, respectively.ConclusionsAdding a 20 to 30% excise tax on top of Brazil’s current federal tax in Brazil could help reduce the consumption of ultra-processed beverages, empty calories, and body weight while avoiding large health-related costs. Given the recent cuts to SSB taxes in Brazil, a program to revise and implement excise taxes could prove beneficial for the Brazilian population.

Published
2023
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19. Seroprevalencia de SARS-CoV-2 en adultos y adultos mayores en México y su asociación con enfermedades crónicas. Ensanut 2020 Covid-19

Author

Ana Basto-Abreu, Andrés Sánchez-Pájaro, Tonatiuh Barrientos-Gutiérrez, Juan Rivera-Dommarco, Edgar Denova-Gutiérrez, Simón Barquera, and Carolina Pérez Ferrer

Subjects
National health, Gynecology, medicine.medical_specialty, Coronavirus disease 2019 (COVID-19), Normal weight, business.industry, Total cholesterol, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Public Health, Environmental and Occupational Health, Medicine, Nutrition survey, business
Abstract

espanolObjetivo. Analizar la asociacion entre seropositividad a SARS-CoV-2 y enfermedades cronicas en adultos y adultos mayores mexicanos. Material y metodos. Se utilizo la Encuesta Nacional de Salud y Nutricion 2020 sobre Covid-19 (Ensanut 2020 Covid-19) para evaluar la asociacion de sero-positividad a SARS-CoV-2 con hipertension arterial sistemica, diabetes tipo 2, indice de masa corporal, LDL-c elevado, HDL-c bajo, colesterol total elevado e hipertrigliceridemia. Resultados. Se observo una mayor seropositividad en per-sonas con mayor indice de masa corporal. La seroprevalencia fue 25% mayor entre los adultos que presentaban obesidad en comparacion con aquellos de peso normal en modelos ajustados (RP: 1.25 IC95%: 1.08,1.46). No se observo aso-ciacion entre seropositividad y otras enfermedades cronicas en adultos o adultos mayores. Conclusiones. Las personas con obesidad podrian tener una mayor susceptibilidad ala infeccion por SARS-CoV-2. Este hallazgo debe ser confirmado con estudios longitudinales. No se encontro evidencia de asociacion para otras enfermedades. EnglishObjective. To analyze the association between seropositiv-ity to SARS-CoV-2 and chronic diseases in Mexican adults and older adults. Materials and methods. We used the 2020 National Health and Nutrition Survey on Covid-19 to evaluate the association of seropositivity to SARS-CoV-2 with high blood pressure, type 2 diabetes, body mass in-dex, elevated LDL-c, low HDL-c, high total cholesterol, and hypertriglyceridemia. Results. We observeda higher seropositivity at higher body mass index levels. In adjusted models, seroprevalence was 25% higher among adults with obesity compared to those of normal weight (PR: 1.25 95%CI: 1.08,1.46). We did not observe any association between sero-positivity and other chronic diseases in adults or older adults. Conclusions. Adults with obesity could be at increased susceptibilityof SARS-CoV2 infection. This observation needs to be confirmed through longitudinal studies. We did not find evidence of an association with other chronic diseases.

Published
2021
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20. Acceptance, refusal and hesitancy of Covid-19 vaccination in Mexico: Ensanut 2020 Covid-19

Author

Sergio Bautista-Arredondo, Ana Basto-Abreu, Dalia Stern, Juan Rivera-Dommarco, Celia Alpuche-Aranda, Martha Carnalla, Teresa Shamah-Levy, and Tonatiuh Barrientos-Gutiérrez

Subjects
National health, COVID-19 Vaccines, Coronavirus disease 2019 (COVID-19), SARS-CoV-2, Vaccination, Public Health, Environmental and Occupational Health, COVID-19, Patient Acceptance of Health Care, Mexican population, Humans, Nutrition survey, Female, Psychology, Mexico, Humanities, Aged
Abstract

Objective. To estimate the willingness to vaccinate against Covid-19 (acceptance) in the Mexican population and to identify socioeconomic factors associated with vaccine hesitancy and refusal. Materials and methods. We estimated the acceptance, refusal and hesitancy proportions using data from the Covid-19 National Health and Nutrition Survey conducted from August to November 2020. Factors associated with refusal and hesitancy were explored using multinomial logistic regression. Results. Covid-19 vaccination acceptance was 62.3%, refusal 28.2% and hesitancy 9.5%. Refusal and hesitancy were associated with being female, having older age, lower educational level, lower socioeconomic status and working in the informal sector. Conclusion. National campaigns to incentivize vaccine acceptance need to consider specific subgroups were the likelihood of hesitancy and refusal is high. In Mexico, refusal and hesitancy were higher in vulnerable groups, and people at a higher risk of Covid-19 complications and death. (English) [ABSTRACT FROM AUTHOR] Objetivo. Estimar la aceptabilidad de la vacunacion contra Covid-19 en la poblacion mexicana e identificar factores socioeconomicos asociados con el rechazo o la duda. Material y metodos. Se estimo la proporcion de aceptabilidad, rechazo y duda utilizando los datos de la Encuesta Nacional de Salud y Nutricion 2020 sobre Covid-19 levantada durante agosto y noviembre de 2020. Se exploraron los factores asociados con rechazo y duda mediante un modelo de regresion multinomial. Resultados. La aceptabilidad de la vacunacion contra Covid-19 fue de 62.3%, el rechazo de 28.2% y la duda de 9.5%. El rechazo y la duda se asociaron con ser mujer, tener mayor edad, menor nivel de educacion, menor nivel socioeconomico y trabajar en el sector informal. Conclusion. Las campanas para incentivar la aceptabilidad de la vacuna necesitan considerar los subgrupos especificos con una alta proporcion de rechazo y duda. En Mexico observamos un mayor rechazo y duda en grupos con mayor riesgo de complicaciones y muerte por Covid-19. (Spanish) [ABSTRACT FROM AUTHOR] Copyright of Salud Publica de Mexico is the property of Instituto Nacional de Salud Publica and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Published
2021
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21. Comparable diagnostic accuracy of SARS-CoV-2 Spike RBD and N-specific IgG tests to determine pre-vaccination nation-wide baseline seroprevalence in Mexico

Author

Jesús Martínez-Barnetche, Martha Carnalla, Carlos Gaspar-Castillo, Ana Basto-Abreu, Ricardo Lizardi, Rodrigo Aparicio Antonio, Irma López Martinez, Anais Cortes Escamilla, Octavio T. Ramirez, Laura A. Palomares, Daniel Barreto-Cabrera, Juan Carlos Rivera-Castro, Carlos Segura-Sánchez, Mauricio Hernández Ávila, Tonatiuh Barrientos-Gutiérrez, and Celia M. Alpuche Aranda

Subjects
Multidisciplinary, SARS-CoV-2, Seroepidemiologic Studies, Immunoglobulin G, Vaccination, Humans, COVID-19, Antibodies, Viral, Mexico, Pandemics
Abstract

A major challenge for developing countries during the COVID-19 pandemic is affordable and adequate monitoring of disease progression and population exposure as the primary source relevant epidemiological indicators. Serology testing enables assessing population exposure and to guide vaccination strategies but requires rigorous accuracy validation before population-wide implementation. We adapted a two-step ELISA protocol as a single-step protocol for detection of IgG against the Receptor Binding Domain (RBD) of SARS-CoV-2 spike protein and compared its diagnostic accuracy with a commercial immunoassay anti-nucleoprotein IgG. Both methods yielded adequate and comparable diagnostic accuracy after 3 weeks post-symptom onset and were implemented in a nation-wide population based serological survey during August–November 2020. Anti-RBD National seroprevalence was 23.6%, 1.3% lower, but not significantly, than for anti-N. Double positive seroprevalence was 19.7%. Anti-N single-positive seroprevalence was 3.72% and anti-RBD single-positive seroprevalence was 1.98%. Discrepancies in the positivity to either single marker may be due to different kinetics of each antibody marker as well as the heterogeneity of the sampling time in regards to local epidemic waves. Baseline single positivity prevalence will be useful to assess the serological impact of vaccination and natural infection in further serosurveillance efforts.

Published
2022
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22. Adherence to the DASH diet by hypertension status in Mexican men and women: A cross-sectional study

Author

Alan Reyes-García, Nancy López-Olmedo, Ana Basto-Abreu, Teresa Shamah-Levy, and Tonatiuh Barrientos-Gutierrez

Subjects
Public Health, Environmental and Occupational Health, Health Informatics
Abstract

Improving dietary patterns is a cornerstone of the non-pharmacological management of hypertension. Evidence about the adherence to healthy dietary patterns at the population level is scarce. We aimed to analyze the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet among Mexican men and women by hypertension status. We used data from the 2012 Mexican National Health and Nutrition Survey (n = 2560). Using self-reported diagnosis of hypertension and blood pressure measurements, we identified participants without, with undiagnosed, and diagnosed hypertension. We calculated DASH scores (total and dietary components) based on a single 24-hour recall and analyzed differences in adherence across hypertension status using sex-specific multivariable Poisson regression models. Overall, regardless of hypertension status, adherence to the DASH score was low, with 35% of men and 38% of women with diagnosed hypertension adhering to recommended guidelines; lower adherence was observed in men (21.8%) and women (27.2%) with undiagnosed hypertension, and with no hypertension (26.8% in men, 26.3% in women). In multivariable models for men, the prevalence of adherence to the total DASH diet was 29% lower in undiagnosed adults versus adults without hypertension (RP 0.71; 95%CI 0.50,0.99). Specifically, adherence to fruits, total dairy, and animal protein was lower in undiagnosed men. Among women, the adherence to the DASH diet was similar across hypertension status in multivariable models. Mexican adults had low adherence to DASH, regardless of hypertension status. Strategies to improve adherence to DASH are needed, focusing in patients with hypertension but also as a preventive measure for the population.

Published
2021

23. The shift of obesity burden by socioeconomic status between 1998 and 2017 in Latin America and the Caribbean: a cross-sectional series study

Author

Rodrigo M. Carrillo-Larco, J. Jaime Miranda, Akram Hernández-Vásquez, Laura Gutierrez, Safia S Jiwani, Ana Basto-Abreu, Diana C. Parra, Bruno Pereira Nunes, Vilma Irazola, Tonatiuh Barrientos-Gutiérrez, Ramfis Nieto-Martínez, and Wellcome Trust

Subjects
Male, obese patient, obesity, Latin Americans, Cross-sectional study, disease burden, 0302 clinical medicine, 030212 general & internal medicine, purl.org/pe-repo/ocde/ford#3.03.01 [http], comparative study, INDEX, Public, Environmental & Occupational Health, METABOLIC SYNDROME, lcsh:Public aspects of medicine, adult, WOMEN, General Medicine, health survey, PREVALENCE, female, Geography, priority journal, risk factor, Caribbean Region, urban population, purl.org/becyt/ford/3 [https], Female, Life Sciences & Biomedicine, SOCIOECONOMIC, 0605 Microbiology, Social status, COUNTRIES, Adult, SEX-DIFFERENCES, prevalence, 030231 tropical medicine, Social class, LATIN AMERICA, Article, South and Central America, 1117 Public Health and Health Services, purl.org/becyt/ford/3.3 [https], 03 medical and health sciences, male, health education, medicine, cross-sectional study, Humans, human, Obesity, outcome assessment, Socioeconomic status, Disease burden, Caribbean, Science & Technology, OVERWEIGHT, lcsh:RA1-1270, Health Status Disparities, medicine.disease, major clinical study, Health Surveys, social status, purl.org/pe-repo/ocde/ford#3.02.00 [https], nutritional status, Cross-Sectional Studies, Latin America, Social Class, Rural area, urban area, Demography
Abstract

Background: The burden of obesity differs by socioeconomic status. We aimed to characterise the prevalence of obesity among adult men and women in Latin America and the Caribbean by socioeconomic measures and the shifting obesity burden over time. Methods: We did a cross-sectional series analysis of obesity prevalence by socioeconomic status by use of national health surveys done between 1998 and 2017 in 13 countries in Latin America and the Caribbean. We generated equiplots to display inequalities in, the primary outcome, obesity by wealth, education, and residence area. We measured obesity gaps as the difference in percentage points between the highest and lowest obesity prevalence within each socioeconomic measure, and described trends as well as changing patterns of the obesity burden over time. Findings: 479 809 adult men and women were included in the analysis. Obesity prevalence across countries has increased over time, with distinct patterns emerging by wealth and education indices. In the most recent available surveys, obesity was most prevalent among women in Mexico in 2016, and the least prevalent among women in Haiti in 2016. The largest gap between the highest and lowest obesity estimates by wealth was observed in Honduras among women (21·6 percentage point gap), and in Peru among men (22·4 percentage point gap), compared with a 3·7 percentage point gap among women in Brazil and 3·3 percentage points among men in Argentina. Urban residents consistently had a larger burden than their rural counterparts in most countries, with obesity gaps ranging from 0·1 percentage points among women in Paraguay to 15·8 percentage points among men in Peru. The trend analysis done in five countries suggests a shifting of the obesity burden across socioeconomic groups and different patterns by gender. Obesity gaps by education in Mexico have reduced over time among women, but increased among men, whereas the gap has increased among women but remains relatively constant among men in Argentina. Interpretation: The increase in obesity prevalence in the Latin American and Caribbean region has been paralleled with an unequal distribution and a shifting burden across socioeconomic groups. Anticipation of the establishment of obesity among low socioeconomic groups could provide opportunities for societal gains in primordial prevention. Funding: None. Fil: Jiwani, Safia S. Johns Hopkins Bloomberg School Of Public Health; Estados Unidos Fil: Carrillo Larco, Rodrigo M.. Imperial College London; Reino Unido Fil: Hernández Vásquez, Akram. Centro de Excelencia En Enfermedades Crónicas; Perú Fil: Barrientos Gutiérrez, Tonatiuh. Instituto Nacional de Salud Publica; México Fil: Basto Abreu, Ana. Instituto Nacional de Salud Publica; México Fil: Gutierrez, Laura. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Irazola, Vilma. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Nieto Martínez, Ramfis. No especifíca; Fil: Nunes, Bruno P.. Universidade Federal de Pelotas; Brasil Fil: Parra, Diana C.. Washington University School Of Medicine In St. Louis; Estados Unidos Fil: Miranda, J. Jaime. Universidad Peruana Cayetano Heredia; Perú

Published
2019
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24. Cost-Effectiveness Of The Sugar-Sweetened Beverage Excise Tax In Mexico

Author

Mauricio Hernández-Ávila, M. Arantxa Colchero, Mauricio Hernández-F, Ana Basto-Abreu, Dèsirée Vidaña-Pérez, Michael W. Long, Steven L. Gortmaker, Zachary J. Ward, and Tonatiuh Barrientos-Gutiérrez

Subjects
Sugar-Sweetened Beverages, medicine.medical_specialty, Cost effectiveness, Cost-Benefit Analysis, Health Policy, Public health, Taxes, medicine.disease, Obesity, Agricultural economics, Childhood obesity, Body Mass Index, Cohort Studies, medicine, Humans, Business, Excise, Sugar, Mexico, Body mass index, Health policy
Abstract

An excise tax of 1 peso per liter on sugar-sweetened beverages was implemented in Mexico in 2014. We estimated the cost-effectiveness of this tax and an alternative tax scenario of 2 pesos per liter. We developed a cohort simulation model calibrated for Mexico to project the impact of the tax over ten years. The current tax is projected to prevent 239,900 cases of obesity, 39 percent of which would be among children. It could also prevent 61,340 cases of diabetes, lead to gains of 55,300 quality-adjusted life-years, and avert 5,840 disability-adjusted life-years. The tax is estimated to save $3.98 per dollar spent on its implementation. Doubling the tax to 2 pesos per liter would nearly double the cost savings and health impact. Countries with comparable conditions could benefit from implementing a similar tax.

Published
2019
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25. Adherence to Dietary Guidelines in Adults by Diabetes Status: Results From the 2012 Mexican National Health and Nutrition Survey

Author

Tonatiuh Barrientos-Gutiérrez, Ana Basto-Abreu, Nancy López-Olmedo, Carolyn J. Alish, Alan Reyes-García, Teresa Shamah-Levy, and Satya Jonnalagadda

Subjects
Adult, Male, dietary patterns, lcsh:TX341-641, Disease, Article, Nutrition Policy, 03 medical and health sciences, 0302 clinical medicine, Nutrient, Diabetes mellitus, Environmental health, Vegetables, medicine, Diabetes Mellitus, Nutrition survey, Humans, 030212 general & internal medicine, Micronutrients, Mexican adults, Mexico, Aged, National health, 030505 public health, Nutrition and Dietetics, diabetes, business.industry, Diabetes status, Middle Aged, medicine.disease, Micronutrient, Nutrition Surveys, Confidence interval, Cross-Sectional Studies, Multivariate Analysis, Linear Models, Patient Compliance, Female, Diet, Healthy, 0305 other medical science, business, Energy Intake, lcsh:Nutrition. Foods and food supply, Food Science
Abstract

The aims of the present study were to compare the adherence to dietary guidelines and evaluate potential differences in nutrient profiles among adults by diabetes status. We used the Mexican Alternate Healthy Eating Index (MxAHEI) to evaluate adherence to dietary guidelines. We calculated the MxAHEI scores (total and by dietary component) with scales from 0 (non-adherence) to 100 (perfect adherence) based on a food frequency questionnaire. Mean daily intakes of macronutrients and micronutrients (g, mg, mcg/1000 kcal per day) were also estimated by diabetes status. Sex-specific, multivariable linear regression models were estimated to test whether MxAHEI scores as well as nutrient intakes were different by diabetes status. Mexican adults had low adherence to the dietary guidelines irrespective of their diabetes status (score &lt, 50 points). Among men, the MxAHEI score was 2.6 points higher among those with diabetes than those without diabetes (46.9, 95% confidence intervals (CI): 44.6, 49.2 vs. 44.3, 95% CI: 44.2, 45.6, respectively). Among women, the total MxAHEI score was similar in individuals with diabetes compared to those without diabetes. Lower intakes of carbohydrates and added sugars and higher intakes of protein, calcium, and zinc were observed in individuals with diabetes. Our findings support the development of strategies focused on promoting dietary patterns that can help to prevent and control the disease.

Published
2020

26. Macronutrient and Micronutrient Intakes, and Dietary Patterns in Adults by Diabetes Status: Results from the 2012 Mexican National Health and Nutrition Survey

Author

Alan Reyes-García, Teresa Shamah-Levy, Tonatiuh Barrientos-Gutiérrez, Carolyn J. Alish, Ana Basto-Abreu, Nancy López-Olmedo, and Satya Jonnalagadda

Subjects
National health, Nutrition and Dietetics, business.industry, Dietary Patterns, Diabetes status, Medicine (miscellaneous), Secondary data, Micronutrient, medicine.disease, Nutrient, Environmental health, Diabetes mellitus, Vitamin D and neurology, Medicine, Nutrition survey, business, Food Science
Abstract

OBJECTIVES: To compare the intake of macronutrients, micronutrients, and dietary patterns between Mexican adults with and without diabetes. METHODS: Design: We calculated the mean intakes and adequacies of energy, macronutrients and micronutrients, and factor analysis was used to identify dietary patterns. We computed sex-specific, age- and energy-adjusted and fully-adjusted linear regression models to test whether nutrient intakes and dietary patterns scores were different by diabetes status. Setting: Mexico Participants: Mexican men (n 1142) and women (n 1620) participating in the Mexican National Health and Nutrition Survey 2012. RESULTS: The energy intake from carbohydrates and added sugars was lower in men and women with diabetes than in men and women without diabetes, but slightly above the recommended among adults with diabetes. Men with diabetes consumed more protein, total, monounsaturated and saturated fatty acids, vitamin D, calcium, and potassium than men without diabetes. The score for the prudent pattern and basic dietary pattern was 0.49 higher and 0.35 lower, respectively, among men with diabetes versus men without diabetes (P

Published
2020

27. Fraction of COVID-19 hospitalizations and deaths attributable to chronic diseases

Author

Juan A Rivera, Dwight Dyer, Francisco Canto-Osorio, Ruy López Ridaura, Rossana Torres-Alvarez, Ana Basto-Abreu, Romina González-Morales, Francisco Reyes-Sánchez, Tonatiuh Barrientos-Gutiérrez, and Christian Arturo Zaragoza Jiménez

Subjects
Adult, medicine.medical_specialty, Epidemiology, Population, Disease, Article, Pulmonary Disease, Chronic Obstructive, symbols.namesake, Risk Factors, Internal medicine, Diabetes mellitus, medicine, Humans, Poisson regression, education, Aged, education.field_of_study, SARS-CoV-2, business.industry, Incidence (epidemiology), Public Health, Environmental and Occupational Health, COVID-19, medicine.disease, Obesity, Hospitalization, Attributable risk, symbols, business, Kidney disease
Abstract

AimTo estimate the fraction of hospitalizations and deaths from COVID-19 attributable to chronic diseases due to poor nutrition and smoking in Mexico.MethodsWe used data from the Mexican surveillance system of COVID-19. We considered six chronic diseases (obesity, COPD, hypertension, diabetes, cardiovascular disease, and chronic kidney disease) to define a multimorbidity variable: no diseases, 1 disease, 2 diseases, or 3 or more diseases. We calibrated the database using bias quantification methods to consider the undiagnosed cases of chronic diseases. To estimate the risks of hospitalization and death due to chronic diseases, we fitted Poisson regression models with robust standard errors, adjusting for possible confounders. Using these risks, we calculated attributable fractions using the population attributable fraction (PAF).ResultsChronic diseases accounted for to 25.4% (24.8%, 26.1%), 28.3% (27.8%, 28.7%) and 15.3% (14.9%,15.7%) of the hospitalizations among adults below 40 years, 40 to 59, and 60 years and older respectively (95% CI). For COVID-19-related deaths, 50.1% (48.6%, 51.5%), 40.5% (39.7%, 41.3%), and 18.7% (18.0%, 19.5%) were attributable to chronic diseases in adults under 40 years, 40 to 59, and 60 years and older, respectively.ConclusionChronic diseases linked to malnutrition and tobacco use contributed to a higher burden of hospitalization and deaths from COVID-19 in Mexico, particularly among younger adults. Medical and structural interventions to curb chronic disease incidence and facilitate disease control are urgently needed.

Published
2022
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28. The Relationship of Socioeconomic Status with Body Mass Index Depends on the Socioeconomic Measure Used

Author

Vanessa Camacho, Ana Basto-Abreu, Rodrigo Zepeda-Tello, Tonatiuh Barrientos-Gutiérrez, David Gimeno Ruiz de Porras, and Mauricio Hernández-Ávila

Subjects
National health, Multivariate statistics, Nutrition and Dietetics, Endocrinology, Diabetes and Metabolism, Medicine (miscellaneous), 030209 endocrinology & metabolism, Social class, 03 medical and health sciences, 0302 clinical medicine, Endocrinology, Single indicator, Linear regression, 030212 general & internal medicine, Young adult, Psychology, Body mass index, Socioeconomic status, Demography
Abstract

Objective The association between socioeconomic status (SES) and body mass index (BMI) in middle-income countries is mixed. Heterogeneity in SES indicators used could explain some differences. This study aimed to identify SES indicators consistently associated with BMI in Mexican adults in 2006, 2012, and 2016. Methods Data were obtained from the Mexican National Health and Nutrition Surveys of 2006, 2012, and 2016, including adults 20 to 59 years old. Given expected differences by sex, sex-stratified linear regression models were fitted for each survey. Age-adjusted and multivariate models were fit by using seven noncollinear SES indicators. Results In age-adjusted models, most SES indicators were associated with a higher BMI in men; mixed associations were found for women. In multivariate models, living in urban areas was associated with a higher BMI for both men and women in 2006 and 2012. Across all surveys, education was associated with a lower BMI in women, while household assets were associated with a higher BMI in men. Conclusions The association between SES indicators and BMI is complex. Differences by sex need to be explicitly recognized when modeling this association. Approaches that rely on a single indicator could be confounded by other SES indicators. Adjusted models show the specific SES attributes that may influence BMI.

Published
2017
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29. Complementary feeding practices in Mexican healthy infants: How close are they to the current guidelines?

Author

Andrea Venegas-Andrade, Paola Rodriguez-Santaolaya, Ana Basto-Abreu, José Iglesias-Leboreiro, Lucía V López-Arzat, Dèsirée Vidaña-Pérez, Andrés Blanco-Montero, and Celia Monserratte Ortega-Cisneros

Subjects
Adult, Male, Health Knowledge, Attitudes, Practice, Adolescent, 030309 nutrition & dietetics, Mothers, Young Adult, 03 medical and health sciences, Vegetables, Humans, Pediatricians, Infant Nutritional Physiological Phenomena, Mexico, 0303 health sciences, 030505 public health, Philosophy, Nutritional Requirements, Infant, Middle Aged, Nutrition Surveys, Infant Formula, Breast Feeding, Cross-Sectional Studies, Pediatrics, Perinatology and Child Health, Educational Status, Female, Guideline Adherence, 0305 other medical science, Humanities
Abstract

The foundations for the growth and optimal development of every human being are laid in the first 2 years of life. Exclusive breastfeeding (EBF) up to 6 months of age and the introduction of complementary feeding (CF) from this age are considered the preventive interventions with the most significant impact on a child's life. The objective of this study was to determine if pediatricians base their recommendations by following the Guidelines for CF in Healthy Infants (GCFHI) and if mothers have any awareness and knowledge of these recommendations.Surveys based on the GCFHI were conducted in a group of mothers (n = 377) and pediatricians (n = 104) living in Mexico.Not all pediatricians recommended the EBF, and 76% recommended infant formula before 6 months of age. Regarding mothers, 76.9% practiced the EBF for the first 6 months. Vegetables were the leading starting food of CF suggested by pediatricians and mothers (87% and 91%, respectively), contrasting with food sources of iron (44%), which are the foods of choice according to the GCFHI. The practices performed by the mothers were statistically different from the recommendations of the pediatricians.The results reflect a lack of updating regarding CF. It is imperative to reinforce efforts to maintain the EBF for 6 months and to continue it together with the CF, as well as to promote the beginning of CF based on macro- and micro-nutrients.En los primeros dos años de vida se crean las bases para el crecimiento y desarrollo óptimo de todo ser humano. La lactancia materna exclusiva (LME) hasta los 6 meses de edad y la introducción de alimentación complementaria (AC) a partir de esta edad están consideradas como las intervenciones preventivas de mayor impacto en la vida de un niño. El presente trabajo evalúa en qué medida los pediatras basan sus recomendaciones en el Consenso para las prácticas de alimentación complementaria en lactantes sanos (CALCS) y si las madres están familiarizadas con estas recomendaciones.Se realizaron encuestas para madres (n = 377) y pediatras (n = 104) residentes en México basadas en el CALCS.: Se detectó que no todos los pediatras recomendaron la LME, y el 76% la complementa con sucedáneos de la leche materna antes de los 6 meses. El 76.9% de las madres practicaron la LME por 6 meses. Las verduras fueron el principal alimento de inicio de AC sugerido por pediatras y madres (87% y 91%, respectivamente), lo que contrasta con alimentos fuente de hierro (44%) que según el CALCS son los alimentos de elección. Las prácticas de las madres tuvieron diferencias significativas con las recomendaciones de los pediatras.Hay una falta de formación y actualización en esta materia. Es imperativo reforzar los esfuerzos para mantener la LME por 6 meses y continuarla junto con la AC, así como promover el inicio de la AC con base en los macro y micronutrientes.

Published
2019
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30. Dissonant health transition in the states of Mexico, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013

Author

Marta C Hijar-Medina, Mohammad H. Forouzanfar, Eduardo González-Pier, Lucía Cuevas-Nasu, Astrid Schilmann, Ana Basto-Abreu, Carlos Magis-Rodriguez, Nancy Fullman, Leticia Avila-Burgos, Grea Litai Moreno-Banda, Theo Vos, Christopher J L Murray, Tonatiuh Barrientos-Gutiérrez, Catalina Medina-Garcia, Alejandra Montoya, Vanessa De la Cruz-Góngora, José Luis Texcalac-Sangrador, Alejandra Contreras-Manzano, Nancy López-Olmedo, Julio Cesar Montañez, Simón Barquera, Armando García-Guerra, Alejandra Jáuregui, Ricardo Correa-Rotter, Luz María Sánchez-Romero, Haidong Wang, Tania G Sánchez-Pimienta, Christian Razo-García, Luz D González-Castell, Carolina Batis, María Elena Medina-Mora, Héctor Gómez-Dantés, Lucero Cahuana-Hurtado, Horacio Riojas-Rodríguez, Martha María Téllez-Rojo, Andrea Pedroza-Tobías, Ileana Heredia-Pi, Alan D. Lopez, Ismael R. Campos-Nonato, Vesta L Richardson-López-Collada, Martha Romero Mendoza, Guilherme Borges, Fabiola Mejía-Rodríguez, Pablo Montero, Rogelio Pérez-Padilla, Rafael Lozano, Alejandra de Jesús Cantoral-Preciado, Maria Jesus Rios Blancas, Tania Aburto-Soto, Juan A Rivera, Aida Jimenez-Corona, María de Lourdes García-García, Julio César Campuzano-Rincón, Teresa Shamah-Levy, Teresita González de Cossío, Amado D Quezada, Blair G. Darney, Mohsen Naghavi, Edson Serván-Mori, José Luis Díaz-Ortega, Elga Filipa Amorin de Castro, and Héctor Lamadrid-Figueroa

Subjects
Male, Gerontology, Global Health, Communicable Diseases, Global Burden of Disease, 03 medical and health sciences, Life Expectancy, 0302 clinical medicine, Health Transition, Risk Factors, Environmental health, Global health, Humans, Medicine, Disabled Persons, 030212 general & internal medicine, Mortality, Risk factor, Mexico, Disease burden, 030505 public health, business.industry, Mortality rate, General Medicine, Quality-adjusted life year, Epidemiological transition, Years of potential life lost, Socioeconomic Factors, Chronic Disease, Life expectancy, Female, Quality-Adjusted Life Years, 0305 other medical science, business
Abstract

Summary Background Child and maternal health outcomes have notably improved in Mexico since 1990, whereas rising adult mortality rates defy traditional epidemiological transition models in which decreased death rates occur across all ages. These trends suggest Mexico is experiencing a more complex, dissonant health transition than historically observed. Enduring inequalities between states further emphasise the need for more detailed health assessments over time. The Global Burden of Diseases, Injuries, and Risk Factors Study 2013 (GBD 2013) provides the comprehensive, comparable framework through which such national and subnational analyses can occur. This study offers a state-level quantification of disease burden and risk factor attribution in Mexico for the first time. Methods We extracted data from GBD 2013 to assess mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE) in Mexico and its 32 states, along with eight comparator countries in the Americas. States were grouped by Marginalisation Index scores to compare subnational burden along a socioeconomic dimension. We split extracted data by state and applied GBD methods to generate estimates of burden, and attributable burden due to behavioural, metabolic, and environmental or occupational risks. We present results for 306 causes, 2337 sequelae, and 79 risk factors. Findings From 1990 to 2013, life expectancy from birth in Mexico increased by 3·4 years (95% uncertainty interval 3·1–3·8), from 72·1 years (71·8–72·3) to 75·5 years (75·3–75·7), and these gains were more pronounced in states with high marginalisation. Nationally, age-standardised death rates fell 13·3% (11·9–14·6%) since 1990, but state-level reductions for all-cause mortality varied and gaps between life expectancy and years lived in full health, as measured by HALE, widened in several states. Progress in women's life expectancy exceeded that of men, in whom negligible improvements were observed since 2000. For many states, this trend corresponded with rising YLL rates from interpersonal violence and chronic kidney disease. Nationally, age-standardised YLL rates for diarrhoeal diseases and protein-energy malnutrition markedly decreased, ranking Mexico well above comparator countries. However, amid Mexico's progress against communicable diseases, chronic kidney disease burden rapidly climbed, with age-standardised YLL and DALY rates increasing more than 130% by 2013. For women, DALY rates from breast cancer also increased since 1990, rising 12·1% (4·6–23·1%). In 2013, the leading five causes of DALYs were diabetes, ischaemic heart disease, chronic kidney disease, low back and neck pain, and depressive disorders; the latter three were not among the leading five causes in 1990, further underscoring Mexico's rapid epidemiological transition. Leading risk factors for disease burden in 1990, such as undernutrition, were replaced by high fasting plasma glucose and high body-mass index by 2013. Attributable burden due to dietary risks also increased, accounting for more than 10% of DALYs in 2013. Interpretation Mexico achieved sizeable reductions in burden due to several causes, such as diarrhoeal diseases, and risks factors, such as undernutrition and poor sanitation, which were mainly associated with maternal and child health interventions. Yet rising adult mortality rates from chronic kidney disease, diabetes, cirrhosis, and, since 2000, interpersonal violence drove deteriorating health outcomes, particularly in men. Although state inequalities from communicable diseases narrowed over time, non-communicable diseases and injury burdens varied markedly at local levels. The dissonance with which Mexico and its 32 states are experiencing epidemiological transitions might strain health-system responsiveness and performance, which stresses the importance of timely, evidence-informed health policies and programmes linked to the health needs of each state. Funding Bill & Melinda Gates Foundation, Instituto Nacional de Salud Publica.

Published
2016
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31. Correction: Expected changes in obesity after reformulation to reduce added sugars in beverages: A modeling study

Author

Mauricio Hernandez Avila, Ana Basto-Abreu, Juan Rivera-Dommarco, Barry M. Popkin, Rodrigo Zepeda-Tello, Tonatiuh Barrientos Gutierrez, Ariela Braverman-Bronstein, and Dalia Camacho-García-Formentí

Subjects
03 medical and health sciences, 0302 clinical medicine, business.industry, Environmental health, medicine, Medicine, 030209 endocrinology & metabolism, 030212 general & internal medicine, General Medicine, medicine.disease, business, Obesity
Abstract

[This corrects the article DOI: 10.1371/journal.pmed.1002664.].

Published
2019

32. Fatores associados à gravidez e maternidade entre mulheres mexicanas com idade de 15 a 24 anos

Author

Leticia Suárez-López, Filipa de Castro, Celia Hubert, Ana Basto Abreu, and Aremis Villalobos

Subjects
Higher education, Adolescent, Sexual Behavior, lcsh:Medicine, Gravidez na Adolescência, Adolescent Pregnancy, Maternidad, Birth rate, Adult women, Young Adult, Pregnancy, Surveys and Questionnaires, medicine, Humans, Young adult, Birth Rate, Socioeconomic status, Mexico, Family Characteristics, Maternidade, business.industry, lcsh:Public aspects of medicine, Fatores Socioeconômicos, lcsh:R, Public Health, Environmental and Occupational Health, Pregnancy Outcome, Motherhood, Factores Socioeconómicos, lcsh:RA1-1270, medicine.disease, Embarazo en Adolescencia, Pregnancy rate, Socioeconomic Factors, Pregnancy in Adolescence, Residence, Female, business, Demography
Abstract

Adolescent pregnancy is associated with poor health and socioeconomic factors. The adolescent pregnancy rate in Mexico is the highest among the Organization for Economic Co-operation and Development (OECD) countries. We aimed to explore the factors associated with pregnancies and births in adolescent and young adult women. Using the 2015 Mexican National Survey of Boys, Girls, and Women (ENIM), we examined two dichotomous outcomes: “ever pregnant” and “being a mother” in women from 15 to 19 years and from 20 to 24 years without pregnancies during adolescence. We conducted bivariate analysis for each age group and used general linear models (GLM) to assess the association between the outcome variables and selected socioeconomic variables. Among adolescents, school attendance and tertiary education significantly decreased the likelihood of ever having been pregnant or being mothers, while being married/cohabiting increased the likelihood. Older age at first intercourse was negatively associated with ever having been pregnant. For adult women, in addition to school attendance, tertiary education, and being married/cohabiting, the region of residence also showed a significant association with ever having been pregnant. Similar socioeconomic factors were associated with pregnancy and motherhood between adolescents and young adults. However, it was found that delaying sexual debut could reduce the adolescent pregnancy rate. Our results highlight the importance of attending school and attaining tertiary education in reducing adolescent fertility rates. Resumen: El embarazo durante la adolescencia se asocia con una salud precaria y consecuencias socioeconómicas negativas. La tasa de embarazo adolescente en México es la más alta entre los países de la Organización para la Cooperación y el Desarrollo Económicos (OCDE). Nuestro objetivo fue explorar factores asociados a embarazos y nacimientos en mujeres adolescentes y adultas jóvenes. Utilizando la Encuesta Nacional de Niños, Niñas y Mujeres (ENIM), 2015, examinamos dos resultados dicotómicos: “embarazadas alguna vez” y “ser madre” en mujeres de 15 a 19 años y de 20 a 24 sin embarazos durante la adolescencia. Realizamos un análisis bivariado por grupo de edad y usamos modelos lineales generales (MLG) para evaluar la asociación entre el resultado de las variables y las variables socioeconómicas seleccionadas. Entre adolescentes, la asistencia escolar y contar con educación terciaria disminuía significativamente la posibilidad de haber estado embarazada o ser madres, mientras que estar casada/unida con alguien incrementó la posibilidad. Una edad más avanzada durante las relaciones sexuales estuvo negativamente asociada con haber estado alguna vez embarazada. Para las mujeres adultas, además de la asistencia escolar, educación terciaria, y estar casada/unida con alguien, la región de residencia también mostró una asociación significativa con haber estado alguna vez embarazada. Factores socioeconómicos similares estuvieron asociados con el embarazo y la maternidad entre adolescentes y adultos jóvenes. No obstante, se descubrió que retrasar el inicio de las relaciones sexuales podría reducir la tasa de embarazos adolescentes. Nuestros resultados subrayan la importancia de ir a la escuela y realizar estudios de nivel superior para reducir las tasas de fertilidad adolescentes. Resumo: A gravidez na adolescência está associada a desfechos socioeconômicos e de saúde ruins. A taxa de gravidez na adolescência do México é a mais alta entre os países da Organização para a Cooperação e Desenvolvimento Econômico (OCDE). Nosso objetivo foi explorar os fatores associados a gravidezes e partos em adolescentes e mulheres jovens. Usando o Inquérito Nacional de Meninos, Meninas e Mulheres (ENIM) de 2015, examinamos dois desfechos dicotômicos: “ter engravidado” e “ser mãe” em mulheres de 15 a 19 anos e de 20 a 24 anos sem gravidezes durante a adolescência. Realizamos uma análise bivariada para cada faixa etária e usamos modelos lineares generalizados (GLM) para avaliar a associação entre as variáveis de desfecho e variáveis socioeconômicas selecionadas. Entre adolescentes, a frequência escolar e a educação superior reduziram significativamente a probabilidade de ter engravidado ou ser mãe, enquanto ser casada ou morar com o parceiro aumentou essa probabilidade. Ter a primeira relação a uma idade mais avançada associou-se a uma menor prevalência de gravidez. Para mulheres adultas, além da frequência escolar, educação superior e ser casada/morar com o parceiro, a região da residência também teve uma associação significativa com ter estado alguma vez grávida engravidado. Fatores socioeconômicos similares estiveram associados à gravidez e maternidade entre adolescentes e jovens. Contudo, observou-se que adiar a iniciação sexual poderia reduzir a taxa de gravidez na adolescência. Nossos resultados assinalam a importância da frequência escolar e da obtenção da educação superior para a redução das taxas de fecundidade em adolescentes.

Published
2018

33. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013

Author

Yong Zhao, Hadi Danawi, Bach Xuan Tran, Gene Bukhman, Vasiliki Stathopoulou, Taavi Tillmann, Nelson Alvis-Guzman, Yongmei Li, Jerry Puthenpurakal Abraham, Sudan Prasad Neupane, Jack Caravanos, Ben Schöttker, Rafael Lozano, Damian G Hoy, Yoshihiro Kokubo, Nicholas J K Breitborde, Sergey Soshnikov, Yukito Shinohara, Randall V. Martin, Michael Brainin, Fernando Perez-Ruiz, Yingfeng Zheng, Santosh Mishra, Julio Cesar Montañez Hernandez, Michael Phillips, Belinda J. Gabbe, Hebe N. Gouda, Ziad A. Memish, Rupert R A Bourne, Guoqing Hu, Emmanuel A. Ameh, Abigail McLain, Michelle L. Bell, Christopher Margono, Marissa Iannarone, Wilkister N. Moturi, Donald H. Silberberg, Carl Abelardo T. Antonio, Nataliya Foigt, Anand Dayama, Yanping Wang, Amanda J. Mason-Jones, Bolajoko O. Olusanya, Monica S. Vavilala, Katherine B Gibney, David Tanne, Sidibe S Kany Roseline, Marcella Montico, Abhishek Singh, Sarah Derrett, Alireza Esteghamati, Seok Jun Yoon, Corine Karema, Rakhi Dandona, David M. Pereira, Kazem Rahimi, Gitanjali M. Singh, Vivekanand Jha, John Hornberger, Anne M. Riederer, Kathryn H. Jacobsen, Andrea Pedroza, Lily Alexander, Fiona M. Blyth, Tommi Vasankari, Kyle J Foreman, Rana J. Asghar, Tilahun Nigatu Haregu, Yousef Khader, Rafael Alfonso-Cristancho, Suzanne Barker-Collo, Lydia S. Atkins, Simerjot K. Jassal, Mohammad Ali Sahraian, Peter Scarborough, Hans W. Hoek, E. Ray Dorsey, Muluken Dessalegn, David C. Schwebel, Gavin Shaddick, Thomas D. Fleming, Mohammad Tavakkoli, Dorairaj Prabhakaran, Mohammad H. Forouzanfar, Christopher C. Mapoma, Jost B. Jonas, Erin C Mullany, Gene F. Kwan, Johanna M. Geleijnse, Antonio Luiz Pinho Ribeiro, Roberto Tchio Talongwa, Tolesa Bekele, Jed D. Blore, Gunn Marit Aasvang, Philimon Gona, Miguel Angel Alegretti, Babak Eshrati, Mitsuru Mukaigawara, Richard F. Gillum, Odgerel Chimed-Ochir, Ubai Alsharif, Richard C. Franklin, Felix Masiye, Richard T. Burnett, Sanjay Krishnaswami, Martin McKee, John J Huang, Lucía Cuevas-Nasu, Wagner Marcenes, Walid Ammar, Knud Juel, Joseph R. Zunt, Martha M Téllez Rojo, Mamta Swaroop, Noela M Prasad, Azmeraw T. Amare, Tim Driscoll, Michael Kravchenko, Heresh Amini, Amir Sapkota, Theo Vos, Charlotte Watts, Dennis Odai Laryea, D. Alex Quistberg, Justin Beardsley, Cheng Huang, Adnan M. Durrani, Sarah V Thackway, Rita Van Dingenen, Manami Inoue, Martha Híjar, Honglei Chen, Amany H. Refaat, Yichong Li, Vineet K. Chadha, Wenzhi Wang, Louisa Degenhardt, Kingsley N. Ukwaja, Nayu Ikeda, James D. Wilkinson, Linh N Bui, Maria Hagströmer, Gonghuan Yang, Ann Kristin Knudsen, David J. Margolis, Soewarta Kosen, Hans Kromhout, Atsushi Goto, Man Mohan Mehndiratta, Thomas N. Williams, Michael Soljak, Yun Jin Kim, Hideaki Toyoshima, Jeyaraj D Pandian, Borja del Pozo-Cruz, Soufiane Boufous, Ivy Shiue, Anders Larsson, Guilherme V. Polanczyk, John Powles, Yara A. 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Chugh, Johan Ärnlöv, Ivo Rakovac, Maurice Giroud, Haidong Kan, Ibrahim Abdelmageem Mohamed Ginawi, José Luis Texcalac-Sangrador, Luigi Naldi, Erica Leigh Slepak, Deena Alasfoor, James E. Saunders, Richard Matzopoulos, Talal Bakfalouni, Stein Emil Vollset, Andrea Werdecker, Lennert J. Veerman, Lorenzo Monasta, Henrica A. F. M. Jansen, Reyna A Gutiérrez, Brittany Wurtz, Luz Maria Sanchez, Lijing L. Yan, M. Patrice Lindsay, Michele Meltzer, Sanjay Basu, Steven van de Vijver, Alaa Badawi, Thomas Claßen, Young-Ho Khang, Brett M. Kissela, Jun Zhu, In-Hwan Oh, Fiona J Charlson, Maria Cecilia Bahit, Dinorah González-Castell, Rosario Cárdenas, Dan Poenaru, Sayed Saidul Alam, Mitchell T. Wallin, Harish Chander Gugnani, James Leigh, Ferrán Catalá-López, Lidia Morawska, Jim van Os, Stephanie J. London, Kaire Innos, Isabelle Romieu, Fiorella Cavalleri, Adrian Davis, Hwee Pin Phua, Chakib Nejjari, Héctor Gómez Dantés, Boris I. Pavlin, Karen Sliwa, Lynne Gaffikin, Constance D. Pond, Michael F. 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Thorne-Lyman, Denis Nash, Marape Marape, Rajiv Chowdhury, Dima M. Qato, Luca Ronfani, Nobhojit Roy, Daniel Kim, Yuichiro Yano, Luke D. Knibbs, Margaret Robinson, Hilda L Harb, Rogelio Pérez-Padilla, Janet L Leasher, Jonathan L. Wright, Peter Brooks, Cristiana Abbafati, Belinda K Lloyd, Victor Aboyans, Nikhil Tandon, Charles R. Newton, Simón Barquera, Ted R. Miller, Kinnari S. Murthy, Habib Benzian, Glen Mola, Paulo A. Lotufo, Burcu Kucuk Bicer, Peggy Pei-Chia Chiang, Alexander Kraemer, Solomon Meseret Woldeyohannes, Saman Fahimi, Lesley Rushton, Kim Moesgaard Iburg, Vafa Rahimi-Movaghar, Logan Sandar, Bruce Neal, Teresa Shamah Levy, Karen M. Tabb, Jeffrey A. Towbin, Christopher J L Murray, Ramesh Sahathevan, Aaron Cohen, Chanda Kulkarni, Van C. Lansingh, François Alla, Tasara T. Mazorodze, Murugesan Raju, Saeid Shahraz, Uchechukwu K.A. Sampson, Rajeev Gupta, Neil Pearce, Mustafa Z. Younis, Veena S. Kulkarni, Francisco A García-Guerra, Amanda G. Thrift, Stefan Ma, Samaya Ismayilova, Evariste Gasana, Amitava Banerjee, Aslam Pervaiz, Emilie Agardh, Abraham D. Flaxman, Farshad Farzadfar, Peter W. Gething, Ileana Heredia-Pi, Boris Bikbov, Wanqing Chen, Saad B. Omer, Ruben Castro, Neeraj Bhala, Sara Sheikhbahaei, Hilton Lam, Urbano Fra Paleo, Lidia Sanchez-Riera, Alicia Elena Beatriz Lawrynowicz, Kristen Delwiche, Richard G. Ellenbogen, Max Petzold, Yuri Y Varakin, Guilherme Borges, Guohong Jiang, Francis Guillemin, Kyle R. Heuton, Yohannes Kinfu, Victoria F Bachman, Joseph A Wagner, Carlos A Castañeda-Orjuela, Leonardo Trasande, Abbas Ali Mahdi, Josef Coresh, Chuanhua Yu, Kenji Shibuya, Berrin Serdar, Laetitia Huiart, Xiaofeng Liang, Jean de Dieu Ngirabega, Takayoshi Ohkubo, Natalie Stephens, Francis Apolinary Mhimbira, Jefferson Traebert, Amiran Gamkrelidze, Kjetil Søreide, Samath D Dharmaratne, Robert P. 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Stapelberg, Edson Serván-Mori, Anil Kaul, Foad Abd-Allah, Marek Majdan, Rahul Gupta, Giancarlo Logroscino, Kardiyoloji, Peterson, Carrie B., Laboratoire de Physique des Solides (LPS), Université Paris-Sud - Paris 11 (UP11)-Centre National de la Recherche Scientifique (CNRS), Wisconsin Division of Public Health, Laboratoire de psychologie sociale et de psychologie cognitive (LAPSCO), Centre National de la Recherche Scientifique (CNRS)-Université Blaise Pascal - Clermont-Ferrand 2 (UBP), Erosion torrentielle neige et avalanches (UR ETGR (ETNA)), Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA), London South Bank University, Metropolitan Police Service, Hong Kong Baptist University (HKBU), Institut für Informatik [München/Munich] (LMU), Ludwig-Maximilians-Universität München (LMU), Neuroépidémiologie Tropicale (NET), Institut Génomique, Environnement, Immunité, Santé, Thérapeutique (GEIST), Université de Limoges (UNILIM)-Université de Limoges (UNILIM)-CHU Limoges-Institut d'Epidémiologie Neurologique et de Neurologie Tropicale-Institut National de la Santé et de la Recherche Médicale (INSERM), Service de Chirurgie Thoracique et Vasculaire - Médecine vasculaire [CHU Limoges], CHU Limoges, Insight Centre for Data Analytics [Galway] (INSIGHT), National University of Ireland [Galway] (NUI Galway), Maladies chroniques, santé perçue, et processus d'adaptation (APEMAC), Université Paris Descartes - Paris 5 (UPD5)-Université de Lorraine (UL), Centre d'Investigation Clinique - Epidemiologie Clinique/essais Cliniques Nancy, Cancéropôle du Grand Est-Institut National de la Santé et de la Recherche Médicale (INSERM), Karolinska Institute, karolinska institute, Department of Molecular Biosciences, Department of Molecular Biosciences [Oslo], Faculty of Mathematics and Natural Sciences [Oslo], University of Oslo (UiO)-University of Oslo (UiO)-Faculty of Mathematics and Natural Sciences [Oslo], University of Oslo (UiO)-University of Oslo (UiO), Centro de Estudios Avanzados en Zonas Aridas (CEAZA), Ecole Polytechnique Fédérale de Lausanne (EPFL), Regional Genetic Service, St Mary's Hospital, Manchester, Laboratoire d'Ingénierie des Matériaux (LIM), Centre National de la Recherche Scientifique (CNRS), Computer Science Department [Bristol], University of Bristol [Bristol], Universität Mannheim [Mannheim], Lawrence Berkeley National Laboratory [Berkeley] (LBNL), Samsung Research &Development Institute India - Bangalore (Groupe Samsung) (SRI-B), Computational Science and Engineering Department [Daresbury] (STFC), Science & Technologie Facilities Council, Multimedia Research Center (MRC), University of Alberta, Division of Biostatistics (Biostat - MINNEAPOLIS), University of Minnesota [Twin Cities], University of Minnesota System-University of Minnesota System, University of Southampton, Imperial College London, Neurology Department, Ichilov Medical Center, Interactions, transferts, ruptures artistiques et culturels - EA 6301 (InTRu), Université de Tours, Institut Jacques Monod (IJM (UMR_7592)), Université Paris Diderot - Paris 7 (UPD7)-Centre National de la Recherche Scientifique (CNRS), Julius Center for Health Sciences and Primary Care, University Medical Center [Utrecht], Risk Assessment Sciences Institute, Utrecht University [Utrecht], Unité de Biologie Fonctionnelle et Adaptative (BFA (UMR_8251 / U1133)), Université Paris Diderot - Paris 7 (UPD7)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Respiratory Epidemiology and Public Health, Imperial College London-Royal Brompton Hospital-National Heart and Lung Institute [UK], CIBER de Epidemiología y Salud Pública (CIBERESP), STAR laboratory, Stanford University [Stanford], Unité de recherche Virologie et Immunologie Moléculaires (VIM), Institut National de la Recherche Agronomique (INRA), Tennent Institute of Ophthalmology, National University of Singapore (NUS), Centre de Robotique (CAOR), MINES ParisTech - École nationale supérieure des mines de Paris, Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL), Multidisciplinary Nanotechnology Centre, Swansea University, Cyprus International Institute for the Environment and Public Health, Harvard School of Public Health, Genomics Research Center, Academia Sinica, Neuro Rehab Services LLP [New Delhi], Department of Signal Theory and Communications (TSC), Univ. Politec. de Catalunya, King‘s College London, Dept. Mat. Engn. De Ma, Sao Carlos, Fed. Univ. Sao Carlos UFSCar, RESPEC (RESPEC), RESPEC, Advanced Laboratories on Embedded Systems [Roma] (ALES), Department of Biology [Miami], University of Miami [Coral Gables], Health Care, Minister Of Labour-Ministry of Labor, Health and Social Affairs, Department of Nephrology, University Medical Center, University of Groningen, Division of Human Nutrition, Wageningen University and Research Centre [Wageningen] (WUR), Spatial Ecology and Epidemiology Group, University of Oxford [Oxford], College of Medicine, University of Hail, Saudi Arabia, Laboratory of Neurologic Diseases, Mario Negri Institute, Milan, Department of Civil Engineering [Hamirpur], National Institute of Technology [Hamirpur], GEMMA — Environmental Engineering and Microbiology Research Group, Department of Hydraulic, Maritime and Environmental Engineering, Universitat Politècnica de Catalunya [Barcelona] (UPC), Department of Biosciences and Nutrition, Karolinska Institutet [Stockholm], Institut National de Recherche et d'Analyse Physico-Chimique (INRAP), Institut National de Recherche et d'Analyse Physico-chimique (Ariana, Tunisie) (INRAP), Franche-Comté Électronique Mécanique, Thermique et Optique - Sciences et Technologies (UMR 6174) (FEMTO-ST), Université de Franche-Comté (UFC), Université Bourgogne Franche-Comté [COMUE] (UBFC)-Université Bourgogne Franche-Comté [COMUE] (UBFC)-Centre National de la Recherche Scientifique (CNRS)-Ecole Nationale Supérieure de Mécanique et des Microtechniques (ENSMM)-Université de Technologie de Belfort-Montbeliard (UTBM), Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences [Tehran] (SBUMS), Shahid Beheshti University-Shahid Beheshti University, Center for Applied Medical Research (CIMA), University of Tehran, Secretariat of the Pacific Community, Public Health Division, Sociétés, Acteurs, Gouvernement en Europe (SAGE), Université de Strasbourg (UNISTRA)-Centre National de la Recherche Scientifique (CNRS), College of Precision Instrument and Optoelectronics Engineering, Tianjin University, George Washington University (GW), Sciences Economiques et Sociales de la Santé & Traitement de l'Information Médicale (SESSTIM - U912 INSERM - Aix Marseille Univ - IRD), Institut de Recherche pour le Développement (IRD)-Aix Marseille Université (AMU)-Institut National de la Santé et de la Recherche Médicale (INSERM), Universiteit Gent [Ghent], Washington State University (WSU), Laboratoire de Physique de l'ENS Lyon (Phys-ENS), École normale supérieure - Lyon (ENS Lyon)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon, Institut de recherche en informatique de Toulouse (IRIT), Université Toulouse 1 Capitole (UT1)-Université Toulouse - Jean Jaurès (UT2J)-Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-Centre National de la Recherche Scientifique (CNRS)-Institut National Polytechnique (Toulouse) (Toulouse INP), Université Fédérale Toulouse Midi-Pyrénées, School of Computer Science - China University of Geosciences (China University of Geosciences (East Area)), Centre de Recherche en Automatique de Nancy (CRAN), Université de Lorraine (UL)-Centre National de la Recherche Scientifique (CNRS), Université Catholique de Louvain (UCL), Fachbereich Physik [Berlin], Freie Universität Berlin, Div Cyclotron & Radiopharmaceut Sci (DRDO, INMAS), Univ New Delhi, School of Physics and Astronomy, University of St Andrews [Scotland], University of Cape Town, Department of Neuroscience, Department of Computer Science and Engineering [Daejeon] (Chungnam National University), Lawrence University, Gastroenterology & Hepatology, Tata Research Development and Design Center (TRDDC), TCS Innovation Labs, University of Helsinki, Google Inc [Mountain View], Research at Google, Swedish Defense Research Agency (FOI), Servicio de Neurologia (SANTIAGO - Neurologie), Universidad del Desarrollo, Novartis Pharmaceutical Corporation, Laboratoire de glaciologie et géophysique de l'environnement (LGGE), Observatoire des Sciences de l'Univers de Grenoble [1985-2015] (OSUG [1985-2015]), Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology [2007-2019] (Grenoble INP [2007-2019])-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Institut national des sciences de l'Univers (INSU - CNRS)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology [2007-2019] (Grenoble INP [2007-2019])-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Institut national des sciences de l'Univers (INSU - CNRS)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS), Department of Mechanical and Automation Engineering (CAD Laboratory), The Chinese University of Hong Kong [Hong Kong], Università degli studi di Bari, Department of Health and Human Services, National Institutes of Health [Bethesda] (NIH), Centre d'études et de recherche en informatique et communications (CEDRIC), Ecole Nationale Supérieure d'Informatique pour l'Industrie et l'Entreprise (ENSIIE)-Conservatoire National des Arts et Métiers [CNAM] (CNAM), Heuristique et Diagnostic des Systèmes Complexes [Compiègne] (Heudiasyc), Université de Technologie de Compiègne (UTC)-Centre National de la Recherche Scientifique (CNRS), College of Information and Electrical Engineering [Beijing] (CIEE), China Agricultural University (CAU), Thales Research and Technology [Palaiseau], THALES, Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Barts and The London School of Medicine and Dentistry, Queen Mary University of London (QMUL), Centre d'économie de la Sorbonne (CES), Université Panthéon-Sorbonne (UP1)-Centre National de la Recherche Scientifique (CNRS), Paris School of Economics (PSE), École supérieure du professorat et de l'éducation - Académie de Grenoble [2013-2019] (ESPE Grenoble [2013-2019]), Université Grenoble Alpes [2016-2019] (UGA [2016-2019]), Department of Mathematics, University of Iowa [Iowa City], College of Medicine, Alfaisal University, Saudi Ministry of Health, Institut national des recherches agricoles du Bénin, Centre de Recherches agricoles du Sud, Departments of Epidemiology and Nutrition, Unit of Human Nutrition, Agricultural University of Athens, Department of Animal Science, Pennsylvania State University (Penn State), Penn State System-Penn State System, University of Virginia, University of Virginia [Charlottesville], Epidemiology and Biostatistics Unit, Institute for Maternal and Child Health - IRCCS ‘‘Burlo Garofolo', Jet Propulsion Laboratory (JPL), NASA-California Institute of Technology (CALTECH), Division of Cardiovascular Medicine and Channing Division of Network Medicine, Brigham and Women's Hospital [Boston], American University of Beirut [Beyrouth] (AUB), Department of Chemistry, Scientific Computing Research Unit, Department of dermatology, Milano University-Azienda Ospedaleria Ospedali Riuniti di Bergamo, Mailman School of Public Health, Columbia University [New York], The Georges Institute for International Health, The University of Sydney, Department of epidemiology and Public Health, Faculty of Medicine, Département Optique (OPT), Université européenne de Bretagne - European University of Brittany (UEB)-Télécom Bretagne-Institut Mines-Télécom [Paris] (IMT), Laboratoire des signaux et systèmes (L2S), Université Paris-Sud - Paris 11 (UP11)-CentraleSupélec-Centre National de la Recherche Scientifique (CNRS), Universitat Pompeu Fabra [Barcelona], Center for Research in Environmental Epidemiology (CREAL), Universitat Pompeu Fabra [Barcelona]-Catalunya ministerio de salud, Nutriments Lipidiques et Prévention des Maladies Métaboliques, Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut National de la Recherche Agronomique (INRA)-Université de la Méditerranée - Aix-Marseille 2, Department of Neurology Lunds University Hospital Lund, Unit of Functional Bionanomaterials, School of Biosciences, University of Birmingham [Birmingham], Electrical Engineering and Computer Science Department - Case Western Reserve University, Case Western Reserve University [Cleveland], World Health Organization, Organisation Mondiale de la Santé / World Health Organization Office (OMS / WHO), Nordic School of Public Health, The James Hutton Institute, Horia Hulubei National Institute for Physics and Nuclear Engineering, Department of Pediatrics, University of Washington [Seattle], Institute of Public Health, Department of Physics, Clarendon Laboratory, Center for TeleInFrastruktur (CTIF), Aalborg University [Denmark] (AAU), Physikalisches Institut [Freiburg], Albert-Ludwigs-Universität Freiburg, Savoirs, Textes, Langage (STL) - UMR 8163 (STL), Centre National de la Recherche Scientifique (CNRS)-Université de Lille, Dept.of Computer Science, Indian Institute of Technology Madras (IIT Madras), Istituto Mario Negri Bergamo, Centro Ricerche e Trapianti Villa Camozzi, Universidade Estadual Paulista Júlio de Mesquita Filho [São José do Rio Preto] (UNESP), Laboratoire de Génie Informatique et Ingénierie de Production (LGI2P), IMT - MINES ALES (IMT - MINES ALES), Institut Mines-Télécom [Paris] (IMT)-Institut Mines-Télécom [Paris] (IMT), Institut geològic de Catalunya (IGC), Institut Geològic de Catalunya-IGC, Institut Cochin (IC UM3 (UMR 8104 / U1016)), Université Paris Descartes - Paris 5 (UPD5)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Laboratoire de Physiologie et Génomique des Poissons (LPGP), Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique )-Institut National de la Recherche Agronomique (INRA), Politecnico di Milano [Milan] (POLIMI), Symantec, University of Oviedo, European Microsoft Innovation Center (EMIC), Microsoft Corporation [Redmond, Wash.], Technion - Israel Institute of Technology [Haifa], Laboratoire de Mécanique, Physique et Géosciences (LMPG), Université Le Havre Normandie (ULH), Normandie Université (NU)-Normandie Université (NU), Department of Physics, Cavendish Laboratory, University of Cambridge [UK] (CAM), Laboratoire de Probabilités et Modèles Aléatoires (LPMA), Centre National de la Recherche Scientifique (CNRS)-Université Paris Diderot - Paris 7 (UPD7)-Université Pierre et Marie Curie - Paris 6 (UPMC), Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université de Strasbourg (UNISTRA), Departments of Applied Physics [New Haven], Yale University [New Haven], Center for Mathematical Modeling (CMM), Department of Global Health and Development, London School of Hygiene and Tropical Medicine (LSHTM), University of Occupational and Environmental Health [Kitakyushu] (UEOH), Department of Computer Science and Engineering [New Delhi], Indian Institute of Technology Delhi (IIT Delhi), Institut de Recherche sur les Phénomènes Hors Equilibre (IRPHE), Aix Marseille Université (AMU)-École Centrale de Marseille (ECM)-Centre National de la Recherche Scientifique (CNRS), GlaxoSmithKline, Imperial College London-Clinical Imaging Center, Universidade Federal de Pernambuco [Recife] (UFPE), Maclean Building, Benson Lane, Crowmarsh Gifford, Centre for Ecology and Hydrology, Nanoscience Institute (NEST), Dipartimento di Fisica, Università di Pisa, Aristotle University of Thessaloniki, Laboratory Of Immune Cell Biology (LICB), JRC Institute for Environment and Sustainability (IES), European Commission - Joint Research Centre [Ispra] (JRC), Institute of Human Genetics, Rheinische Friedrich-Wilhelms-Universität Bonn, Laboratorio Nacional de Computação Cientifica [Rio de Janeiro] (LNCC / MCT), Occupational Health Unit, Bologna University Hospital-Sant'Orsola-Malpighi Polyclinic, Royal Institute of Technology [Stockholm] (KTH ), NICTA [Eveleigh], National ICT Australia [Sydney] (NICTA), Division of Solid Mechanics, Lund University [Lund], University of Calgary, BioWare Corp, Manchester Academic Health Sciences Centre, Institut d'Histoire et de Philosophie des Sciences et des Techniques (IHPST), Université Panthéon-Sorbonne (UP1)-Centre National de la Recherche Scientifique (CNRS)-Département d'Etudes Cognitives - ENS Paris (DEC), École normale supérieure - Paris (ENS Paris), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-École normale supérieure - Paris (ENS Paris), Ghent University [Belgium] (UGENT), Imaging Sciences and Biomedical Engineering Division [London], Guy's and St Thomas' Hospital [London]-King‘s College London, Children’s Hospital of Philadelphia (CHOP ), Perelman School of Medicine, University of Pennsylvania [Philadelphia], Laboratoire de recherche en Hydrodynamique, Énergétique et Environnement Atmosphérique (LHEEA), École Centrale de Nantes (ECN)-Centre National de la Recherche Scientifique (CNRS), Institut de Recherche en Génie Civil et Mécanique (GeM), Université de Nantes - Faculté des Sciences et des Techniques, Université de Nantes (UN)-Université de Nantes (UN)-École Centrale de Nantes (ECN)-Centre National de la Recherche Scientifique (CNRS), Department of Physiology, Augusta University - Medical College of Georgia, University System of Georgia (USG)-University System of Georgia (USG), Neurorestoration Group, Wolfson Centre for Age-related Diseases-King‘s College London, Electronic Navigation Research Institute (ENRI), Ministry of Land, Infrastructure, Transport and Tourism, Department of Computer Science [KAIST] (CS), Korea Advanced Institute of Science and Technology (KAIST), Centre for Undergraduate Studies, University of the Punjab, Siemens Corporate Research, Siemens AG [Munich], University of Massachusetts [Boston] (UMass Boston), University of Massachusetts System (UMASS), Department of Materials Science, Sichuan University [Chengdu] (SCU), Natl Engn Res Ctr Vegetables, Key Lab Biol & Genet Improvement Hort Crops N Chi, Beijing Acad Agr & Forestry Sci, University Hospital Puerta de Hierro, Madrid, Université Blaise Pascal - Clermont-Ferrand 2 (UBP)-Centre National de la Recherche Scientifique (CNRS), Centre National de la Recherche Scientifique (CNRS)-Université Paris Diderot - Paris 7 (UPD7), Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université Paris Diderot - Paris 7 (UPD7), MINES ParisTech - École nationale supérieure des mines de Paris-PSL Research University (PSL), Université de Franche-Comté (UFC)-Centre National de la Recherche Scientifique (CNRS)-Ecole Nationale Supérieure de Mécanique et des Microtechniques (ENSMM)-Université de Technologie de Belfort-Montbeliard (UTBM), Shahid Beheshti University of Medical Sciences, École normale supérieure - Lyon (ENS Lyon)-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Centre National de la Recherche Scientifique (CNRS), MOLTECH-ANJOU (MOLTECH-ANJOU), Université d'Angers (UA)-Centre National de la Recherche Scientifique (CNRS), Universidad de Santiago de Chile [Santiago] (USACH)-Universidad del Desarrollo, Observatoire des Sciences de l'Univers de Grenoble (OSUG), Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut national des sciences de l'Univers (INSU - CNRS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut national des sciences de l'Univers (INSU - CNRS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Centre National de la Recherche Scientifique (CNRS), École supérieure du professorat et de l'éducation - Académie de Grenoble (ESPE Grenoble), Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Université Grenoble Alpes (UGA), California Institute of Technology (CALTECH)-NASA, Centre National de la Recherche Scientifique (CNRS)-CentraleSupélec-Université Paris-Sud - Paris 11 (UP11), Université de la Méditerranée - Aix-Marseille 2-Institut National de la Recherche Agronomique (INRA)-Institut National de la Santé et de la Recherche Médicale (INSERM), Université de Lille-Centre National de la Recherche Scientifique (CNRS), Institut National de la Recherche Agronomique (INRA)-Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Université Pierre et Marie Curie - Paris 6 (UPMC)-Université Paris Diderot - Paris 7 (UPD7)-Centre National de la Recherche Scientifique (CNRS), Université de Strasbourg (UNISTRA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Universidad de Santiago de Chile [Santiago] (USACH), École normale supérieure - Paris (ENS Paris)-École normale supérieure - Paris (ENS Paris), King‘s College London-Wolfson Centre for Age-related Diseases, Sichuan University, Universitat de Barcelona, Interne Geneeskunde, Medische Sociologie, MUMC+: MA Psychiatrie (3), MUMC+: Hersen en Zenuw Centrum (3), Psychiatrie & Neuropsychologie, CHU Limoges-Institut d'Epidémiologie Neurologique et de Neurologie Tropicale-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut Génomique, Environnement, Immunité, Santé, Thérapeutique (GEIST), Université de Limoges (UNILIM)-Université de Limoges (UNILIM), Centre National de la Recherche Scientifique (CNRS)-Université de Strasbourg (UNISTRA), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology [2007-2019] (Grenoble INP [2007-2019])-Institut national des sciences de l'Univers (INSU - CNRS)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology [2007-2019] (Grenoble INP [2007-2019])-Institut national des sciences de l'Univers (INSU - CNRS)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Centre National de la Recherche Scientifique (CNRS), Institut Mines-Télécom [Paris] (IMT)-Télécom Bretagne-Université européenne de Bretagne - European University of Brittany (UEB), Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Descartes - Paris 5 (UPD5)-Centre National de la Recherche Scientifique (CNRS), Cardiovascular Centre (CVC), Groningen Kidney Center (GKC), RS: MHeNs - R2 - Mental Health, Laboratoire de Physique des Solides ( LPS ), Université Paris-Sud - Paris 11 ( UP11 ) -Centre National de la Recherche Scientifique ( CNRS ), Laboratoire de psychologie sociale et de psychologie cognitive ( LAPSCO ), Université Blaise Pascal - Clermont-Ferrand 2 ( UBP ) -Centre National de la Recherche Scientifique ( CNRS ), Erosion torrentielle neige et avalanches ( UR ETGR ), Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture ( IRSTEA ), Hong Kong Baptist University ( HKBU ), Institut für Informatik [München/Munich] ( LMU ), Ludwig-Maximilians-Universität München, Neuroépidémiologie Tropicale ( NET ), CHU Limoges-Institut d'Epidémiologie Neurologique et de Neurologie Tropicale-Institut National de la Santé et de la Recherche Médicale ( INSERM ) -Institut Génomique, Environnement, Immunité, Santé, Thérapeutique ( GEIST ), Université de Limoges ( UNILIM ) -Université de Limoges ( UNILIM ), Insight Centre for Data Analytics (National University of Ireland Galway (NUIG)) ( INSIGHT ), Maladies chroniques, santé perçue, et processus d'adaptation ( APEMAC ), Université Paris Descartes - Paris 5 ( UPD5 ) -Université de Lorraine ( UL ), Cancéropôle du Grand Est-Institut National de la Santé et de la Recherche Médicale ( INSERM ), University of Oslo ( UiO ) -University of Oslo ( UiO ), Centro de Estudios Avanzados en Zonas Aridas ( CEAZA ), Ecole Polytechnique Fédérale de Lausanne ( EPFL ), Laboratoire d'Ingénierie des Matériaux ( LIM ), Centre National de la Recherche Scientifique ( CNRS ), Lawrence Berkeley National Laboratory [Berkeley] ( LBNL ), Samsung Research &Development Institute India - Bangalore (Groupe Samsung) ( SRI-B ), Computational Science and Engineering Department [Daresbury] ( STFC ), Multimedia Research Center ( MRC ), University of Alberta [Edmonton], Division of Biostatistics ( Biostat - MINNEAPOLIS ), University of Minnesota [Minneapolis], University of Southampton [Southampton], Interactions, transferts, ruptures artistiques et culturels - EA 6301 ( InTRu ), Institut Jacques Monod ( IJM ), Université Paris Diderot - Paris 7 ( UPD7 ) -Centre National de la Recherche Scientifique ( CNRS ), University Medical Center Utrecht, Biologie Fonctionnelle et Adaptative ( BFA ), Imperial College London-Royal Brompton Hospital-National Heart and Lung Institute, Unité de recherche Virologie et Immunologie Moléculaires ( VIM ), Institut National de la Recherche Agronomique ( INRA ), National University of Singapore ( NUS ), Centre de Robotique ( CAOR ), MINES ParisTech - École nationale supérieure des mines de Paris-PSL Research University ( PSL ), Department of Signal Theory and Communications ( TSC ), RESPEC ( RESPEC ), Advanced Laboratories on Embedded Systems [Roma] ( ALES ), Wageningen University and Research Centre [Wageningen] ( WUR ), Universitat Politècnica de Catalunya [Barcelona] ( UPC ), Institut National de Recherche et d'Analyse Physico-Chimique ( INRAP ), Institut National de Recherche et d'Analyse Physico-chimique (INRAP-Tunisie), Franche-Comté Électronique Mécanique, Thermique et Optique - Sciences et Technologies (UMR 6174) ( FEMTO-ST ), Université de Franche-Comté ( UFC ) -Centre National de la Recherche Scientifique ( CNRS ) -Ecole Nationale Supérieure de Mécanique et des Microtechniques ( ENSMM ) -Université de Technologie de Belfort-Montbeliard ( UTBM ), Tehran University, Sociétés, Acteurs, Gouvernement en Europe ( SAGE ), Université de Strasbourg ( UNISTRA ) -Centre National de la Recherche Scientifique ( CNRS ), Sciences Economiques et Sociales de la Santé & Traitement de l'Information Médicale ( SESSTIM - U912 INSERM - AMU - IRD ), Institut de Recherche pour le Développement ( IRD ) -Aix Marseille Université ( AMU ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ), Washington State University ( WSU ), Laboratoire de Physique de l'ENS Lyon ( Phys-ENS ), École normale supérieure - Lyon ( ENS Lyon ) -Université Claude Bernard Lyon 1 ( UCBL ), Université de Lyon-Université de Lyon-Centre National de la Recherche Scientifique ( CNRS ), Institut des Sciences Chimiques de Rennes ( ISCR ), Université de Rennes 1 ( UR1 ), Université de Rennes ( UNIV-RENNES ) -Université de Rennes ( UNIV-RENNES ) -Ecole Nationale Supérieure de Chimie de Rennes-Institut National des Sciences Appliquées ( INSA ) -Centre National de la Recherche Scientifique ( CNRS ), Institut de recherche en informatique de Toulouse ( IRIT ), Institut National Polytechnique [Toulouse] ( INP ) -Université Toulouse 1 Capitole ( UT1 ) -Université Toulouse - Jean Jaurès ( UT2J ) -Université Toulouse III - Paul Sabatier ( UPS ), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-Centre National de la Recherche Scientifique ( CNRS ), Centre de Recherche en Automatique de Nancy ( CRAN ), Université de Lorraine ( UL ) -Centre National de la Recherche Scientifique ( CNRS ), Université Catholique de Louvain ( UCL ), Freie Universität Berlin [Berlin], Div Cyclotron & Radiopharmaceut Sci ( DRDO, INMAS ), Institut de Physique Nucléaire d'Orsay ( IPNO ), Université Paris-Sud - Paris 11 ( UP11 ) -Institut National de Physique Nucléaire et de Physique des Particules du CNRS ( IN2P3 ) -Centre National de la Recherche Scientifique ( CNRS ), Tata Research Development and Design Center ( TRDDC ), Laboratoire MOLTECH-Anjou [Angers] ( MOLTECH ANJOU ), Université d'Angers ( UA ) -Centre National de la Recherche Scientifique ( CNRS ), University of Helsinki [Helsinki], Swedish Defense Research Agency ( FOI ), Servicio de Neurologia ( SANTIAGO - Neurologie ), Universidad de Santiago de Chile [Santiago] ( USACH ) -Universidad del Desarrollo, Novartis Pharmaceutical Corp., East Hanover NJ 07936, USA, Laboratoire de glaciologie et géophysique de l'environnement ( LGGE ), Observatoire des Sciences de l'Univers de Grenoble ( OSUG ), Université Joseph Fourier - Grenoble 1 ( UJF ) -Institut national des sciences de l'Univers ( INSU - CNRS ) -Centre National de la Recherche Scientifique ( CNRS ) -Université Grenoble Alpes ( UGA ) -Université Joseph Fourier - Grenoble 1 ( UJF ) -Institut national des sciences de l'Univers ( INSU - CNRS ) -Centre National de la Recherche Scientifique ( CNRS ) -Université Grenoble Alpes ( UGA ) -Centre National de la Recherche Scientifique ( CNRS ), Department of Mechanical and Automation Engineering ( CAD Laboratory ), National Institutes of Health ( NIH ), Centre d'étude et de recherche en informatique et communications ( CEDRIC ), Ecole Nationale Supérieure d'Informatique pour l'Industrie et l'Entreprise ( ENSIIE ) -Conservatoire National des Arts et Métiers [CNAM] ( CNAM ), Heuristique et Diagnostic des Systèmes Complexes [Compiègne] ( Heudiasyc ), Université de Technologie de Compiègne ( UTC ) -Centre National de la Recherche Scientifique ( CNRS ), College of Information and Electrical Engineering [Beijing] ( CIEE ), China Agricultural University ( CAU ), Queen Mary University of London ( QMUL ), Centre d'économie de la Sorbonne ( CES ), Université Panthéon-Sorbonne ( UP1 ) -Centre National de la Recherche Scientifique ( CNRS ), Paris School of Economics ( PSE ), École supérieure du professorat et de l'éducation - Académie de Grenoble ( ESPE Grenoble ), Université Savoie Mont Blanc ( USMB [Université de Savoie] [Université de Chambéry] ) -Université Grenoble Alpes ( UGA ), PennState University [Pennsylvania] ( PSU ), Jet Propulsion Laboratory ( JPL ), NASA-California Institute of Technology ( CALTECH ), American University of Beirut [Beyrouth], The University of Sydney [Sydney], Département Optique ( OPT ), Université européenne de Bretagne ( UEB ) -Télécom Bretagne-Institut Mines-Télécom [Paris], Laboratoire des signaux et systèmes ( L2S ), Université Paris-Sud - Paris 11 ( UP11 ) -CentraleSupélec-Centre National de la Recherche Scientifique ( CNRS ), Center for Research in Environmental Epidemiology ( CREAL ), Université de la Méditerranée - Aix-Marseille 2-Institut National de la Recherche Agronomique ( INRA ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ), Center for TeleInFrastruktur ( CTIF ), Aalborg University [Denmark] ( AAU ), Savoirs, Textes, Langage (STL) - UMR 8163 ( STL ), Université de Lille-Centre National de la Recherche Scientifique ( CNRS ), Indian Institute of Technology Madras ( IIT Madras ), Universidade Estadual Paulista Júlio de Mesquita ( UNESP ), Laboratoire de Génie Informatique et Ingénierie de Production ( LGI2P ), IMT - Mines Alès Ecole Mines - Télécom ( IMT - MINES ALES ), Institut geològic de Catalunya ( IGC ), Institut Cochin ( UM3 (UMR 8104 / U1016) ), Université Paris Descartes - Paris 5 ( UPD5 ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ) -Centre National de la Recherche Scientifique ( CNRS ), Laboratoire de Physiologie et Génomique des Poissons ( LPGP ), Institut National de la Recherche Agronomique ( INRA ) -Structure Fédérative de Recherche en Biologie et Santé de Rennes ( Biosit : Biologie - Santé - Innovation Technologique ), Politecnico di Milano [Milan], European Microsoft Innovation Center ( EMIC ), Laboratoire de Mécanique, Physique et Géosciences ( LMPG ), Université Le Havre Normandie ( ULH ), Normandie Université ( NU ) -Normandie Université ( NU ), University of Cambridge [UK] ( CAM ), Laboratoire de Probabilités et Modèles Aléatoires ( LPMA ), Université Pierre et Marie Curie - Paris 6 ( UPMC ) -Université Paris Diderot - Paris 7 ( UPD7 ) -Centre National de la Recherche Scientifique ( CNRS ), Institut de Génétique et de Biologie Moléculaire et Cellulaire ( IGBMC ), Université de Strasbourg ( UNISTRA ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ) -Centre National de la Recherche Scientifique ( CNRS ), Center for Mathematical Modeling ( CMM ), Universidad de Santiago de Chile [Santiago] ( USACH ), London School of Hygiene and Tropical Medicine ( LSHTM ), University of Occupational and Environmental Health [Kitakyushu] ( UEOH ), Indian Institute of Technology Delhi ( IIT Delhi ), Institut de Recherche sur les Phénomènes Hors Equilibre ( IRPHE ), Aix Marseille Université ( AMU ) -Ecole Centrale de Marseille ( ECM ) -Centre National de la Recherche Scientifique ( CNRS ), Universidade Federal de Pernambuco [Recife] ( UFPE ), Nanoscience Institute ( NEST ), Laboratory Of Immune Cell Biology ( LICB ), JRC Institute for Environment and Sustainability ( IES ), European Commission - Joint Research Centre [Ispra] ( JRC ), Bonn Universität [Bonn], Laboratorio Nacional de Computação Cientifica [Rio de Janeiro] ( LNCC / MCT ), Royal Institute of Technology [Stockholm] ( KTH ), National ICT Australia [Sydney] ( NICTA ), Institut d'Histoire et de Philosophie des Sciences et des Techniques ( IHPST ), Université Panthéon-Sorbonne ( UP1 ) -Département d'Etudes Cognitives - ENS Paris ( DEC ), École normale supérieure - Paris ( ENS Paris ) -École normale supérieure - Paris ( ENS Paris ) -Centre National de la Recherche Scientifique ( CNRS ), Ghent University [Belgium] ( UGENT ), Children’s Hospital of Philadelphia ( CHOP ), Univeristy of Pennsylvania Medical School, Laboratoire de recherche en Hydrodynamique, Énergétique et Environnement Atmosphérique ( LHEEA ), École Centrale de Nantes ( ECN ) -Centre National de la Recherche Scientifique ( CNRS ), Institut de Recherche en Génie Civil et Mécanique ( GeM ), Université de Nantes ( UN ) -École Centrale de Nantes ( ECN ) -Centre National de la Recherche Scientifique ( CNRS ), Medical College of Georgia, Electronic Navigation Research Institute ( ENRI ), Department of Computer Science [KAIST] ( CS ), Korea Advanced Institute of Science and Technology ( KAIST ), Laboratoire de l'Accélérateur Linéaire ( LAL ), University of Massachusetts [Boston] ( UMass Boston ), Forouzanfar, Mohammad H, Alexander, Lily, Anderson, H. Ro, Bachman, Victoria F, Biryukov, Stan, Brauer, Michael, Burnett, Richard, Casey, Daniel, Coates, Matthew M, Cohen, Aaron, Delwiche, Kristen, Estep, Kara, Frostad, Joseph J, Kc, Astha, Kyu, Hmwe H, Moradi Lakeh, Maziar, Ng, Marie, Slepak, Erica Leigh, Thomas, Bernadette A, Wagner, Joseph, Aasvang, Gunn Marit, Abbafati, Cristiana, Ozgoren, Ayse Abbasoglu, Abd Allah, Foad, Abera, Semaw F, Aboyans, Victor, Abraham, Biju, Abraham, Jerry Puthenpurakal, Abubakar, Ibrahim, Abu Rmeileh, Niveen M. E, Aburto, Tania C, Achoki, Tom, Adelekan, Ademola, Adofo, Koranteng, Adou, Arsène K, Adsuar, José C, Afshin, Ashkan, Agardh, Emilie E, Al Khabouri, Mazin J, Al Lami, Faris H, Alam, Sayed Saidul, Alasfoor, Deena, Albittar, Mohammed I, Alegretti, Miguel A, Aleman, Alicia V, Alemu, Zewdie A, Alfonso Cristancho, Rafael, Alhabib, Samia, Ali, Raghib, Ali, Mohammed K, Alla, Françoi, Allebeck, Peter, Allen, Peter J, Alsharif, Ubai, Alvarez, Elena, Alvis Guzman, Nelson, Amankwaa, Adansi A, Amare, Azmeraw T, Ameh, Emmanuel A, Ameli, Omid, Amini, Heresh, Ammar, Walid, Anderson, Benjamin O, Antonio, Carl Abelardo T, Anwari, Palwasha, Cunningham, Solveig Argeseanu, Arnlöv, Johan, Arsenijevic, Valentina S. Arsic, Artaman, Al, Asghar, Rana J, Assadi, Reza, Atkins, Lydia S, Atkinson, Charle, Avila, Marco A, Awuah, Baffour, Badawi, Alaa, Bahit, Maria C, Bakfalouni, Talal, Balakrishnan, Kalpana, Balalla, Shivanthi, Balu, Ravi Kumar, Banerjee, Amitava, Barber, Ryan M, Barker Collo, Suzanne L, Barquera, Simon, Barregard, Lar, Barrero, Lope H, Barrientos Gutierrez, Tonatiuh, Basto Abreu, Ana C, Basu, Arindam, Basu, Sanjay, Basulaiman, Mohammed O, Ruvalcaba, Carolina Bati, Beardsley, Justin, Bedi, Neeraj, Bekele, Tolesa, Bell, Michelle L, Benjet, Corina, Bennett, Derrick A, Benzian, Habib, Bernabé, Eduardo, Beyene, Tariku J, Bhala, Neeraj, Bhalla, Ashish, Bhutta, Zulfiqar A, Bikbov, Bori, Abdulhak, Aref A. Bin, Blore, Jed D, Blyth, Fiona M, Bohensky, Megan A, Başara, Berrak Bora, Borges, Guilherme, Bornstein, Natan M, Bose, Dipan, Boufous, Soufiane, Bourne, Rupert R, Brainin, Michael, Brazinova, Alexandra, Breitborde, Nicholas J, Brenner, Hermann, Briggs, Adam D. M, Broday, David M, Brooks, Peter M, Bruce, Nigel G, Brugha, Traolach S, Brunekreef, Bert, Buchbinder, Rachelle, Bui, Linh N, Bukhman, Gene, Bulloch, Andrew G, Burch, Michael, Burney, Peter G. J, Campos Nonato, Ismael R, Campuzano, Julio C, Cantoral, Alejandra J, Caravanos, Jack, Cárdenas, Rosario, Cardis, Elisabeth, Carpenter, David O, Caso, Valeria, Castañeda Orjuela, Carlos A, Castro, Ruben E, Catalá López, Ferrán, Cavalleri, Fiorella, Çavlin, Alanur, Chadha, Vineet K, Chang, Jung Chen, Charlson, Fiona J, Chen, Honglei, Chen, Wanqing, Chen, Zhengming, Chiang, Peggy P, Chimed Ochir, Odgerel, Chowdhury, Rajiv, Christophi, Costas A, Chuang, Ting Wu, Chugh, Sumeet S, Cirillo, Massimo, Claßen, Thomas Kd, Colistro, Valentina, Colomar, Mercede, Colquhoun, Samantha M, Contreras, Alejandra G, Cooper, Cyru, Cooperrider, Kimberly, Cooper, Leslie T, Coresh, Josef, Courville, Karen J, Criqui, Michael H, Cuevas Nasu, Lucia, Damsere Derry, Jame, Danawi, Hadi, Dandona, Lalit, Dandona, Rakhi, Dargan, Paul I, Davis, Adrian, Davitoiu, Dragos V, Dayama, Anand, de Castro, E. Filipa, De la Cruz Góngora, Vanessa, De Leo, Diego, de Lima, Graça, Degenhardt, Louisa, Del Pozo Cruz, Borja, Dellavalle, Robert P, Deribe, Kebede, Derrett, Sarah, Jarlais, Don C. De, Dessalegn, Muluken, Deveber, Gabrielle A, Devries, Karen M, Dharmaratne, Samath D, Dherani, Mukesh K, Dicker, Daniel, Ding, Eric L, Dokova, Klara, Dorsey, E. Ray, Driscoll, Tim R, Duan, Leilei, Durrani, Adnan M, Ebel, Beth E, Ellenbogen, Richard G, Elshrek, Yousef M, Endres, Matthia, Ermakov, Sergey P, Erskine, Holly E, Eshrati, Babak, Esteghamati, Alireza, Fahimi, Saman, Faraon, Emerito Jose A, Farzadfar, Farshad, Fay, Derek F. J, Feigin, Valery L, Feigl, Andrea B, Fereshtehnejad, Seyed Mohammad, Ferrari, Alize J, Ferri, Cleusa P, Flaxman, Abraham D, Fleming, Thomas D, Foigt, Nataliya, Foreman, Kyle J, Paleo, Urbano Fra, Franklin, Richard C, Gabbe, Belinda, Gaffikin, Lynne, Gakidou, Emmanuela, Gamkrelidze, Amiran, Gankpé, Fortuné G, Gansevoort, Ron T, García Guerra, Francisco A, Gasana, Evariste, Geleijnse, Johanna M, Gessner, Bradford D, Gething, Pete, Gibney, Katherine B, Gillum, Richard F, Ginawi, Ibrahim A. M, Giroud, Maurice, Giussani, Giorgia, Goenka, Shifalika, Goginashvili, Ketevan, Dantes, Hector Gomez, Gona, Philimon, de Cosio, Teresita Gonzalez, González Castell, Dinorah, Gotay, Carolyn C, Goto, Atsushi, Gouda, Hebe N, Guerrant, Richard L, Gugnani, Harish C, Guillemin, Franci, Gunnell, David, Gupta, Rahul, Gupta, Rajeev, Gutiérrez, Reyna A, Hafezi Nejad, Nima, Hagan, Holly, Hagstromer, Maria, Halasa, Yara A, Hamadeh, Randah R, Hammami, Mouhanad, Hankey, Graeme J, Hao, Yuantao, Harb, Hilda L, Haregu, Tilahun Nigatu, Haro, Josep Maria, Havmoeller, Rasmu, Hay, Simon I, Hedayati, Mohammad T, Heredia Pi, Ileana B, Hernandez, Lucia, Heuton, Kyle R, Heydarpour, Pouria, Hijar, Martha, Hoek, Hans W, Hoffman, Howard J, Hornberger, John C, Hosgood, H. Dean, Hoy, Damian G, Hsairi, Mohamed, Hu, Guoqing, Hu, Howard, Huang, Cheng, Huang, John J, Hubbell, Bryan J, Huiart, Laetitia, Husseini, Abdullatif, Iannarone, Marissa L, Iburg, Kim M, Idrisov, Bulat T, Ikeda, Nayu, Innos, Kaire, Inoue, Manami, Islami, Farhad, Ismayilova, Samaya, Jacobsen, Kathryn H, Jansen, Henrica A, Jarvis, Deborah L, Jassal, Simerjot K, Jauregui, Alejandra, Jayaraman, Sudha, Jeemon, Panniyammakal, Jensen, Paul N, Jha, Vivekanand, Jiang, Fan, Jiang, Guohong, Jiang, Ying, Jonas, Jost B, Juel, Knud, Kan, Haidong, Roseline, Sidibe S. Kany, Karam, Nadim E, Karch, André, Karema, Corine K, Karthikeyan, Ganesan, Kaul, Anil, Kawakami, Norito, Kazi, Dhruv S, Kemp, Andrew H, Kengne, Andre P, Keren, Andre, Khader, Yousef S, Khalifa, Shams Eldin Ali Hassan, Khan, Ejaz A, Khang, Young Ho, Khatibzadeh, Shahab, Khonelidze, Irma, Kieling, Christian, Kim, Daniel, Kim, Sungroul, Kim, Yunjin, Kimokoti, Ruth W, Kinfu, Yohanne, Kinge, Jonas M, Kissela, Brett M, Kivipelto, Miia, Knibbs, Luke D, Knudsen, Ann Kristin, Kokubo, Yoshihiro, Kose, M. Rifat, Kosen, Soewarta, Kraemer, Alexander, Kravchenko, Michael, Krishnaswami, Sanjay, Kromhout, Han, Ku, Tiffany, Defo, Barthelemy Kuate, Bicer, Burcu Kucuk, Kuipers, Ernst J, Kulkarni, Chanda, Kulkarni, Veena S, Kumar, G. Anil, Kwan, Gene F, Lai, Taavi, Balaji, Arjun Lakshmana, Lalloo, Ratilal, Lallukka, Tea, Lam, Hilton, Lan, Qing, Lansingh, Van C, Larson, Heidi J, Larsson, Ander, Laryea, Dennis O, Lavados, Pablo M, Lawrynowicz, Alicia E, Leasher, Janet L, Lee, Jong Tae, Leigh, Jame, Leung, Ricky, Levi, Miriam, Li, Yichong, Li, Yongmei, Liang, Juan, Liang, Xiaofeng, Lim, Stephen S, Lindsay, M. Patrice, Lipshultz, Steven E, Liu, Shiwei, Liu, Yang, Lloyd, Belinda K, Logroscino, Giancarlo, London, Stephanie J, Lopez, Nancy, Lortet Tieulent, Joannie, Lotufo, Paulo A, Lozano, Rafael, Lunevicius, Raimunda, Ma, Jixiang, Ma, Stefan, Machado, Vasco M. P, Macintyre, Michael F, Magis Rodriguez, Carlo, Mahdi, Abbas A, Majdan, Marek, Malekzadeh, Reza, Mangalam, Srikanth, Mapoma, Christopher C, Marape, Marape, Marcenes, Wagner, Margolis, David J, Margono, Christopher, Marks, Guy B, Martin, Randall V, Marzan, Melvin B, Mashal, Mohammad T, Masiye, Felix, Mason Jones, Amanda J, Matsushita, Kunihiro, Matzopoulos, Richard, Mayosi, Bongani M, Mazorodze, Tasara T, Mckay, Abigail C, Mckee, Martin, Mclain, Abigail, Meaney, Peter A, Medina, Catalina, Mehndiratta, Man Mohan, Mejia Rodriguez, Fabiola, Mekonnen, Wubegzier, Melaku, Yohannes A, Meltzer, Michele, Memish, Ziad A, Mendoza, Walter, Mensah, George A, Meretoja, Atte, Mhimbira, Francis Apolinary, Micha, Renata, Miller, Ted R, Mills, Edward J, Misganaw, Awoke, Mishra, Santosh, Ibrahim, Norlinah Mohamed, Mohammad, Karzan A, Mokdad, Ali H, Mola, Glen L, Monasta, Lorenzo, Hernandez, Julio C. Montañez, Montico, Marcella, Moore, Ami R, Morawska, Lidia, Mori, Rintaro, Moschandreas, Joanna, Moturi, Wilkister N, Mozaffarian, Dariush, Mueller, Ulrich O, Mukaigawara, Mitsuru, Mullany, Erin C, Murthy, Kinnari S, Naghavi, Mohsen, Nahas, Ziad, Naheed, Aliya, Naidoo, Kovin S, Naldi, Luigi, Nand, Devina, Nangia, Vinay, Narayan, Km Venkat, Nash, Deni, Neal, Bruce, Nejjari, Chakib, Neupane, Sudan P, Newton, Charles R, Ngalesoni, Frida N, de Dieu Ngirabega, Jean, Nguyen, Grant, Nguyen, Nhung T, Nieuwenhuijsen, Mark J, Nisar, Muhammad I, Nogueira, José R, Nolla, Joan M, Nolte, Sandra, Norheim, Ole F, Norman, Rosana E, Norrving, Bo, Nyakarahuka, Luke, Oh, In Hwan, Ohkubo, Takayoshi, Olusanya, Bolajoko O, Omer, Saad B, Opio, John Nelson, Orozco, Ricardo, Pagcatipunan, Rodolfo S, Pain, Amanda W, Pandian, Jeyaraj D, Panelo, Carlo Irwin A, Papachristou, Christina, Park, Eun Kee, Parry, Charles D, Caicedo, Angel J. Paternina, Patten, Scott B, Paul, Vinod K, Pavlin, Boris I, Pearce, Neil, Pedraza, Lilia S, Pedroza, Andrea, Stokic, Ljiljana Pejin, Pekericli, Ayfer, Pereira, David M, Perez Padilla, Rogelio, Perez Ruiz, Fernando, Perico, Norberto, Perry, Samuel A. L, Pervaiz, Aslam, Pesudovs, Konrad, Peterson, Carrie B, Petzold, Max, Phillips, Michael R, Phua, Hwee Pin, Plass, Dietrich, Poenaru, Dan, Polanczyk, Guilherme V, Polinder, Suzanne, Pond, Constance D, Pope, C. Arden, Pope, Daniel, Popova, Svetlana, Pourmalek, Farshad, Powles, John, Prabhakaran, Dorairaj, Prasad, Noela M, Qato, Dima M, Quezada, Amado D, Quistberg, D. Alex A, Racapé, Lionel, Rafay, Anwar, Rahimi, Kazem, Rahimi Movaghar, Vafa, Rahman, Sajjad Ur, Raju, Murugesan, Rakovac, Ivo, Rana, Saleem M, Rao, Mayuree, Razavi, Homie, Reddy, K. Srinath, Refaat, Amany H, Rehm, Jürgen, Remuzzi, Giuseppe, Ribeiro, Antonio L, Riccio, Patricia M, Richardson, Lee, Riederer, Anne, Robinson, Margaret, Roca, Anna, Rodriguez, Alina, Rojas Rueda, David, Romieu, Isabelle, Ronfani, Luca, Room, Robin, Roy, Nobhojit, Ruhago, George M, Rushton, Lesley, Sabin, Nsanzimana, Sacco, Ralph L, Saha, Sukanta, Sahathevan, Ramesh, Sahraian, Mohammad Ali, Salomon, Joshua A, Salvo, Deborah, Sampson, Uchechukwu K, Sanabria, Juan R, Sanchez, Luz Maria, Sánchez Pimienta, Tania G, Sanchez Riera, Lidia, Sandar, Logan, Santos, Itamar S, Sapkota, Amir, Satpathy, Maheswar, Saunders, James E, Sawhney, Monika, Saylan, Mete I, Scarborough, Peter, Schmidt, Jürgen C, Schneider, Ione J. C, Schöttker, Ben, Schwebel, David C, Scott, James G, Seedat, Soraya, Sepanlou, Sadaf G, Serdar, Berrin, Servan Mori, Edson E, Shaddick, Gavin, Shahraz, Saeid, Levy, Teresa Shamah, Shangguan, Siyi, She, Jun, Sheikhbahaei, Sara, Shibuya, Kenji, Shin, Hwashin H, Shinohara, Yukito, Shiri, Rahman, Shishani, Kawkab, Shiue, Ivy, Sigfusdottir, Inga D, Silberberg, Donald H, Simard, Edgar P, Sindi, Shireen, Singh, Abhishek, Singh, Gitanjali M, Singh, Jasvinder A, Skirbekk, Vegard, Sliwa, Karen, Soljak, Michael, Soneji, Samir, Søreide, Kjetil, Soshnikov, Sergey, Sposato, Luciano A, Sreeramareddy, Chandrashekhar T, Stapelberg, Nicolas J. C, Stathopoulou, Vasiliki, Steckling, Nadine, Stein, Dan J, Stein, Murray B, Stephens, Natalie, Stöckl, Heidi, Straif, Kurt, Stroumpoulis, Konstantino, Sturua, Lela, Sunguya, Bruno F, Swaminathan, Soumya, Swaroop, Mamta, Sykes, Bryan L, Tabb, Karen M, Takahashi, Ken, Talongwa, Roberto T, Tandon, Nikhil, Tanne, David, Tanner, Marcel, Tavakkoli, Mohammad, Te Ao, Braden J, Teixeira, Carolina M, Téllez Rojo, Martha M, Terkawi, Abdullah S, Texcalac Sangrador, José Lui, Thackway, Sarah V, Thomson, Blake, Thorne Lyman, Andrew L, Thrift, Amanda G, Thurston, George D, Tillmann, Taavi, Tobollik, Myriam, Tonelli, Marcello, Topouzis, Foti, Towbin, Jeffrey A, Toyoshima, Hideaki, Traebert, Jefferson, Tran, Bach X, Trasande, Leonardo, Trillini, Matia, Trujillo, Ulise, Dimbuene, Zacharie Tsala, Tsilimbaris, Miltiadi, Tuzcu, Emin Murat, Uchendu, Uche S, Ukwaja, Kingsley N, Uzun, Selen B, van de Vijver, Steven, Van Dingenen, Rita, van Gool, Coen H, van Os, Jim, Varakin, Yuri Y, Vasankari, Tommi J, Vasconcelos, Ana Maria N, Vavilala, Monica S, Veerman, Lennert J, Velasquez Melendez, Gustavo, Venketasubramanian, N, Vijayakumar, Lakshmi, Villalpando, Salvador, Violante, Francesco S, Vlassov, Vasiliy Victorovich, Vollset, Stein Emil, Wagner, Gregory R, Waller, Stephen G, Wallin, Mitchell T, Wan, Xia, Wang, Haidong, Wang, Jianli, Wang, Linhong, Wang, Wenzhi, Wang, Yanping, Warouw, Tati S, Watts, Charlotte H, Weichenthal, Scott, Weiderpass, Elisabete, Weintraub, Robert G, Werdecker, Andrea, Wessells, K. Ryan, Westerman, Ronny, Whiteford, Harvey A, Wilkinson, James D, Williams, Hywel C, Williams, Thomas N, Woldeyohannes, Solomon M, Wolfe, Charles D. A, Wong, John Q, Woolf, Anthony D, Wright, Jonathan L, Wurtz, Brittany, Xu, Gelin, Yan, Lijing L, Yang, Gonghuan, Yano, Yuichiro, Ye, Pengpeng, Yenesew, Muluken, Yentür, Gökalp K, Yip, Paul, Yonemoto, Naohiro, Yoon, Seok Jun, Younis, Mustafa Z, Younoussi, Zourkaleini, Yu, Chuanhua, Zaki, Maysaa E, Zhao, Yong, Zheng, Yingfeng, Zhou, Maigeng, Zhu, Jun, Zhu, Shankuan, Zou, Xiaonong, Zunt, Joseph R, Lopez, Alan D, Vos, Theo, Murray, Christopher J., Cell biology, Epidemiology, Neurosciences, Health Technology Assessment (HTA), Public Health, General practice, Bachman, Victoria F., Coates, Matthew M., Frostad, Joseph J., Astha, K.C., Kyu, Hmwe H., Moradi-Lakeh, Maziar, Thomas, Bernadette A., Abbasoglu Ozgoren, Ayse, Abd-Allah, Foad, Abera, Semaw F., Puthenpurakal Abraham, Jerry, Abu-Rmeileh, Niveen M.E., Aburto, Tania C., Adou, Arsène K., Adsuar, José C., Agardh, Emilie E., Al Khabouri, Mazin J., Al Lami, Faris H., Albittar, Mohammed I., Alegretti, Miguel A., Aleman, Alicia V., Alemu, Zewdie A., Alfonso-Cristancho, Rafael, Ali, Mohammed K., Allen, Peter J., Alvis-Guzman, Nelson, Amankwaa, Adansi A., Amare, Azmeraw T., Ameh, Emmanuel A., Anderson, Benjamin O., Antonio, Carl Abelardo T., Argeseanu Cunningham, Solveig, Arsic Arsenijevic, Valentina S., Asghar, Rana J., Atkins, Lydia S., Avila, Marco A., Bahit, Maria C., Barber, Ryan M., Barker-Collo, Suzanne L., Barrero, Lope H., Barrientos-Gutierrez, Tonatiuh, Basto-Abreu, Ana C., Basulaiman, Mohammed O., Batis Ruvalcaba, Carolina, Bell, Michelle L., Bennett, Derrick A., Beyene, Tariku J., Bhutta, Zulfiqar A., Bin Abdulhak, Aref A., Blore, Jed D., Blyth, Fiona M., Bohensky, Megan A., Bora Başara, Berrak, Bornstein, Natan M., Bourne, Rupert R., Breitborde, Nicholas J., Briggs, Adam D.M., Broday, David M., Brooks, Peter M., Bruce, Nigel G., Brugha, Traolach S., Bui, Linh N., Bulloch, Andrew G., Burney, Peter G.J., Campos-Nonato, Ismael R., Campuzano, Julio C., Cantoral, Alejandra J., Carpenter, David O., Castañeda-Orjuela, Carlos A., Castro, Ruben E., Catalá-López, Ferrán, Chadha, Vineet K., Chang, Jung-Chen, Charlson, Fiona J., Chiang, Peggy P., Chimed-Ochir, Odgerel, Christophi, Costas A., Chuang, Ting-Wu, Chugh, Sumeet S., Claßen, Thomas K.D., Colquhoun, Samantha M., Contreras, Alejandra G., Cooper, Leslie T., Courville, Karen J., Criqui, Michael H., Cuevas-Nasu, Lucia, Damsere-Derry, Jame, Dargan, Paul I., Davitoiu, Dragos V., De Castro, E. Filipa, De La Cruz-Góngora, Vanessa, De Lima, Graça, Del Pozo-Cruz, Borja, Dellavalle, Robert P., Des Jarlais, Don C., Deveber, Gabrielle A., Devries, Karen M., Dharmaratne, Samath D., Dherani, Mukesh K., Ding, Eric L., Driscoll, Tim R., Durrani, Adnan M., Ebel, Beth E., Ellenbogen, Richard G., Elshrek, Yousef M., Ermakov, Sergey P., Erskine, Holly E., Faraon, Emerito Jose A., Fay, Derek F.J., Feigin, Valery L., Feigl, Andrea B., Fereshtehnejad, Seyed-Mohammad, Ferrari, Alize J., Ferri, Cleusa P., Flaxman, Abraham D., Fleming, Thomas D., Foreman, Kyle J., Fra Paleo, Urbano, Franklin, Richard C., Gankpé, Fortuné G., Gansevoort, Ron T., García-Guerra, Francisco A., Geleijnse, Johanna M., Gessner, Bradford D., Gibney, Katherine B., Gillum, Richard F., Ginawi, Ibrahim A.M., Gomez Dantes, Hector, Gonzalez De Cosio, Teresita, González-Castell, Dinorah, Gotay, Carolyn C., Gouda, Hebe N., Guerrant, Richard L., Gugnani, Harish C., Gutiérrez, Reyna A., Hafezi-Nejad, Nima, Halasa, Yara A., Hamadeh, Randah R., Hankey, Graeme J., Harb, Hilda L., Hay, Simon I., Hedayati, Mohammad T., Heredia-Pi, Ileana B., Heuton, Kyle R., Hoek, Hans W., Hoffman, Howard J., Hornberger, John C., Hosgood, H., Hoy, Damian G., Huang, John J., Hubbell, Bryan J., Iannarone, Marissa L., Iburg, Kim M., Idrisov, Bulat T., Jacobsen, Kathryn H., Jansen, Henrica A., Jarvis, Deborah L., Jassal, Simerjot K., Jensen, Paul N., Jonas, Jost B., Kany Roseline, Sidibe S., Karam, Nadim E., Karema, Corine K., Kazi, Dhruv S., Kemp, Andrew H., Kengne, Andre P., Khader, Yousef S., Ali Hassan Khalifa, Shams Eldin, Khan, Ejaz A., Khang, Young-Ho, Kimokoti, Ruth W., Kinge, Jonas M., Kissela, Brett M., Knibbs, Luke D., Kuate Defo, Barthelemy, Kucuk Bicer, Burcu, Kuipers, Ernst J., Kulkarni, Veena S., Kwan, Gene F., Lakshmana Balaji, Arjun, Lansingh, Van C., Larson, Heidi J., Laryea, Dennis O., Lavados, Pablo M., Lawrynowicz, Alicia E., Leasher, Janet L., Lee, Jong-Tae, Lim, Stephen S., Lipshultz, Steven E., Lloyd, Belinda K., London, Stephanie J., Lortet-Tieulent, Joannie, Lotufo, Paulo A., Machado, Vasco M.P., Macintyre, Michael F., Magis-Rodriguez, Carlo, Mahdi, Abbas A., Mapoma, Christopher C., Margolis, David J., Marks, Guy B., Martin, Randall V., Marzan, Melvin B., Mashal, Mohammad T., Mason-Jones, Amanda J., Mayosi, Bongani M., Mazorodze, Tasara T., Mckay, Abigail C., Meaney, Peter A., Mejia-Rodriguez, Fabiola, Melaku, Yohannes A., Memish, Ziad A., Mensah, George A., Apolinary Mhimbira, Franci, Miller, Ted R., Mills, Edward J., Mohamed Ibrahim, Norlinah, Mohammad, Karzan A., Mokdad, Ali H., Mola, Glen L., Montañez Hernandez, Julio C., Moore, Ami R., Moturi, Wilkister N., Mueller, Ulrich O., Mullany, Erin C., Murthy, Kinnari S., Naidoo, Kovin S., Narayan, K.M. Venkat, Neupane, Sudan P., Newton, Charles R., Ngalesoni, Frida N., Ngirabega, Jean De Dieu, Nguyen, Nhung T., Nieuwenhuijsen, Mark J., Nisar, Muhammad I., Nogueira, José R., Nolla, Joan M., Norheim, Ole F., Norman, Rosana E., Oh, In-Hwan, Olusanya, Bolajoko O., Omer, Saad B., Pagcatipunan, Rodolfo S., Pain, Amanda W., Pandian, Jeyaraj D., Panelo, Carlo Irwin A., Park, Eun-Kee, Parry, Charles D., Paternina Caicedo, Angel J., Patten, Scott B., Paul, Vinod K., Pavlin, Boris I., Pedraza, Lilia S., Pejin Stokic, Ljiljana, Pereira, David M., Perez-Padilla, Rogelio, Perez-Ruiz, Fernando, Perry, Samuel A.L., Phillips, Michael R., Polanczyk, Guilherme V., Pond, Constance D., Prasad, Noela M., Qato, Dima M., Quezada, Amado D., Quistberg, D. Alex A., Rahimi-Movaghar, Vafa, Ur Rahman, Sajjad, Rana, Saleem M., Refaat, Amany H., Ribeiro, Antonio L., Riccio, Patricia M., Rojas-Rueda, David, Ruhago, George M., Sacco, Ralph L., Salomon, Joshua A., Sampson, Uchechukwu K., Sanabria, Juan R., Sánchez-Pimienta, Tania G., Sanchez-Riera, Lidia, Santos, Itamar S., Saunders, James E., Saylan, Mete I., Schmidt, Jürgen C., Schneider, Ione J.C., Schwebel, David C., Scott, James G., Sepanlou, Sadaf G., Servan-Mori, Edson E., Shamah Levy, Teresa, Shin, Hwashin H., Sigfusdottir, Inga D., Silberberg, Donald H., Simard, Edgar P., Singh, Gitanjali M., Singh, Jasvinder A., Sposato, Luciano A., Sreeramareddy, Chandrashekhar T., Stapelberg, Nicolas J.C., Stein, Dan J., Stein, Murray B., Sunguya, Bruno F., Sykes, Bryan L., Tabb, Karen M., Talongwa, Roberto T., Te Ao, Braden J., Teixeira, Carolina M., Téllez Rojo, Martha M., Terkawi, Abdullah S., Texcalac-Sangrador, José Lui, Thackway, Sarah V., Thorne-Lyman, Andrew L., Thrift, Amanda G., Thurston, George D., Towbin, Jeffrey A., Tran, Bach X., Tsala Dimbuene, Zacharie, Uchendu, Uche S., Ukwaja, Kingsley N., Uzun, Selen B., Van De Vijver, Steven, Van Gool, Coen H., Van Os, Jim, Varakin, Yuri Y., Vasankari, Tommi J., Vasconcelos, Ana Maria N., Vavilala, Monica S., Veerman, Lennert J., Velasquez-Melendez, Gustavo, Venketasubramanian, N., Violante, Francesco S., Victorovich Vlassov, Vasiliy, Wagner, Gregory R., Waller, Stephen G., Wallin, Mitchell T., Warouw, Tati S., Watts, Charlotte H., Weintraub, Robert G., Whiteford, Harvey A., Wilkinson, James D., Williams, Hywel C., Williams, Thomas N., Woldeyohannes, Solomon M., Wolfe, Charles D.A., Wong, John Q., Woolf, Anthony D., Wright, Jonathan L., Yan, Lijing L., Yentür, Gökalp K., Yoon, Seok-Jun, Younis, Mustafa Z., Zaki, Maysaa E., Zunt, Joseph R., Lopez, Alan D., and Temesgen, A.M.

Subjects
Male, Fine particulate matter, Nutrition and Disease, MESH : Sanitation, Health Behavior, Diseases, MESH: Metabolic Diseases, MESH: Global Health, 030204 cardiovascular system & hematology, MESH: Risk Assessment, Global Health, MESH : Nutritional Status, MESH: Occupational Exposure, 0302 clinical medicine, Unsafe Sex, MESH: Risk Factors, Risk Factors, Voeding en Ziekte, Medicine, Air-pollution, MESH : Female, 030212 general & internal medicine, MESH : Risk Assessment, Sanitation, Wasting, 2. Zero hunger, Factors de risc en les malalties, Medicine (all), [ SDV.SPEE ] Life Sciences [q-bio]/Santé publique et épidémiologie, Public Health, Global Health, Social Medicine and Epidemiology, General Medicine, MESH : Occupational Diseases, MESH: Nutritional Status, All-cause mortality, MESH : Risk Factors, humanities, Environmental Exposure, Female, Humans, Metabolic Diseases, Nutritional Status, Occupational Diseases, Occupational Exposure, Risk Assessment, Tobacco smoking, 3. Good health, Nutritional Statu, MESH : Occupational Exposure, MESH : Metabolic Diseases, Cohort, medicine.symptom, Risk assessment, Blood-pressure, Human, MESH: Occupational Diseases, Risk factors in diseases, Coronary-heart-disease, MESH : Male, MESH: Health Behavior, MESH: Environmental Exposure, Population health, Body-mass index, 03 medical and health sciences, Household cooking, Cardiovascular-disease, Environmental health, General & Internal Medicine, parasitic diseases, Life Science, MESH: Sanitation, Risk factor, MESH : Health Behavior, VLAG, GBD2013, MESH: Humans, business.industry, Risk Factor, Global Burden of Disease Study, 79 behavioural, environmental and occupational, and metabolic risks, Long-term exposure, MESH : Humans, CAUSE-SPECIFIC MORTALITY, MESH: Male, Metabolic Disease, Occupational Disease, Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi, MALE BRITISH DOCTORS, Years of potential life lost, Relative risk, Malalties, MESH : Global Health, OUTDOOR AIR-POLLUTION, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, business, MESH : Environmental Exposure, MESH: Female
Abstract

Summary Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation. Background The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the fi rst of a series of annual updates of the GBD. Risk factor quantifi cation, particularly of modifi able risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution. Methods Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk–outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990–2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the fi rst level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular fi ltration rate. For most risks, data for exposure were synthesised with a Bayesian metaregression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol. Findings All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8–58·5) of deaths and 41·6% (40·1–43·0) of DALYs. Risks quantified account for 87·9% (86·5−89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa. Interpretation Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks. Funding Bill & Melinda Gates Foundation.

Published
2015
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34. Expected changes in obesity after reformulation to reduce added sugars in beverages: A modeling study

Author

Juan Rivera-Dommarco, Dalia Camacho-García-Formentí, Tonatiuh Barrientos-Gutiérrez, Barry M. Popkin, Mauricio Hernández-Ávila, Ana Basto-Abreu, Ariela Braverman-Bronstein, and Rodrigo Zepeda-Tello

Subjects
Male, 0301 basic medicine, Mexican People, Physiology, Dietary Sugars, lcsh:Medicine, Geographical locations, Body Mass Index, Toxicology, 0302 clinical medicine, Who recommendations, Medicine and Health Sciences, Ethnicities, Public and Occupational Health, 030212 general & internal medicine, education.field_of_study, Health Policy, General Medicine, Population groupings, Middle Aged, Nutrition Surveys, Socioeconomic Aspects of Health, Physiological Parameters, Female, Research Article, Adult, Population, Sugar consumption, Body weight, Beverages, Young Adult, 03 medical and health sciences, Weight Loss, medicine, Humans, Obesity, education, Sugar, Mexico, Nutrition, 030109 nutrition & dietetics, business.industry, lcsh:R, Body Weight, Weight change, Biology and Life Sciences, Correction, Latin American people, Models, Theoretical, medicine.disease, Diet, Health Care, Food, North America, People and places, Energy Intake, business, Body mass index
Abstract

Background Several strategies have been proposed to reduce the intake of added sugars in the population. In Mexico, a 10% sugar-sweetened beverages (SSBs) tax was implemented in 2014, and the implementation of other nutritional policies, such as product reformulation to reduce added sugars, is under discussion. WHO recommends that all individuals consume less than 10% of their total energy intake (TEI) from added sugars. We propose gradually reducing added sugars in SSBs to achieve an average 10% consumption of added sugars in the Mexican population over 10 years and to estimate the expected impact of reformulation in adult body weight and obesity. Methods and findings Baseline consumption for added sugars and SSBs, sex, age, socioeconomic status (SES), height, and weight for Mexican adults were obtained from the 2012 Mexico National Health and Nutrition Survey (ENSANUT). On average, 12.6% of the TEI was contributed by added sugars; we defined a 50% reduction in added sugars in SSBs over 10 years as a reformulation target. Using a dynamic weight change model, sugar reductions were translated into individual expected changes in body weight assuming a 43% caloric compensation and a 2-year lag for the full effect of reformulation to occur. Results were stratified by sex, age, and SES. Twelve years after reformulation, the TEI from added sugars is expected to decrease to 10%, assuming no compensation from added sugars; 44% of the population would still be above WHO recommendations, requiring further sugar reductions to food. Body weight could be reduced by 1.3 kg (95% CI −1.4 to −1.2) in the adult population, and obesity could decrease 3.9 percentage points (pp; −12.5% relative to baseline). Our sensitivity analyses suggest that the impact of the intervention could vary from 0.12 kg after 6 months to 1.52 kg in the long term. Conclusions Reformulation to reduce added sugars in SSBs could produce large reductions in sugar consumption and obesity in the Mexican adult population. This study is limited by the use of a single dietary recall and by data collected in all seasons except summer; still, these limitations should lead to conservative estimates of the reformulation effect. Reformulation success could depend on government enforcement and industry and consumer response, for which further research and evidence are needed., Tonatiuh Barrientos-Gutiérrez and colleagues use a weight reduction model to estimate individual level weight reductions 12 years after the introduction of the 2012 Mexican sugar tax., Author summary Why was this study done? High sugar intake is associated with obesity. Adults in Mexico consume 12.6% of their everyday energy intake from added sugars, exceeding WHO recommendations (

Published
2018
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35. The Relationship of Socioeconomic Status with Body Mass Index Depends on the Socioeconomic Measure Used

Author

Ana, Basto-Abreu, Tonatiuh, Barrientos-Gutiérrez, Rodrigo, Zepeda-Tello, Vanessa, Camacho, David, Gimeno Ruiz de Porras, and Mauricio, Hernández-Ávila

Subjects
Adult, Male, Young Adult, Social Class, Socioeconomic Factors, Humans, Female, Middle Aged, Body Mass Index
Abstract

The association between socioeconomic status (SES) and body mass index (BMI) in middle-income countries is mixed. Heterogeneity in SES indicators used could explain some differences. This study aimed to identify SES indicators consistently associated with BMI in Mexican adults in 2006, 2012, and 2016.Data were obtained from the Mexican National Health and Nutrition Surveys of 2006, 2012, and 2016, including adults 20 to 59 years old. Given expected differences by sex, sex-stratified linear regression models were fitted for each survey. Age-adjusted and multivariate models were fit by using seven noncollinear SES indicators.In age-adjusted models, most SES indicators were associated with a higher BMI in men; mixed associations were found for women. In multivariate models, living in urban areas was associated with a higher BMI for both men and women in 2006 and 2012. Across all surveys, education was associated with a lower BMI in women, while household assets were associated with a higher BMI in men.The association between SES indicators and BMI is complex. Differences by sex need to be explicitly recognized when modeling this association. Approaches that rely on a single indicator could be confounded by other SES indicators. Adjusted models show the specific SES attributes that may influence BMI.

Published
2017

36. [Prevalence of previously diagnosed diabetes mellitus in Mexico.]

Author

Rosalba Rojas-Martínez, Ana Basto-Abreu, Carlos A Aguilar-Salinas, Emiliano Zárate-Rojas, Salvador Villalpando, and Tonatiuh Barrientos-Gutiérrez

Subjects
Adult, Male, lcsh:Public aspects of medicine, lcsh:RA1-1270, Middle Aged, Health Surveys, Young Adult, Diabetes Mellitus, Prevalence, Humans, Female, encuestas epidemiológicas, Mexico, epidemiología
Abstract

To compare the prevalence of previously diagnosed diabetes in 2016 with previous national surveys and to describe treatment and its complications.Mexico's national surveys Ensa 2000, Ensanut 2006, 2012 and 2016 were used. For 2016, logistic regression models and measures of central tendency and dispersion were obtained.The prevalence of previously diagnosed diabetes in 2016 was 9.4%. The increase of 2.2% relative to 2012 was not significant and only observed in patients older than 60 years. While preventive measures have increased, the access to medical treatment and lifestyle has not changed. The treatment has been modified, with an increase in insulin and decrease in hypoglycaemic agents.Population aging, lack of screening actions and the increase in diabetes complications will lead to an increase on the burden of disease. Policy measures targeting primary and secondary prevention of diabetes are crucial.Comparar la prevalencia de diabetes por diagnóstico médico previo en 2016 con encuestas nacionales anteriores y describir su tratamiento y complicaciones.Se utilizaron la Encuesta Nacional de Salud 2000, las Encuestas Nacionales de Salud y Nutrición 2006 y 20012, y la Encuesta Nacional de Salud y Nutrición de Medio Camino 2016. Para 2016 se obtuvieron modelos de regresión logística, así como medidas de tendencia central y dispersión.La prevalencia de diabetes por diagnóstico médico en 2016 fue de 9.4%. El incremento de 2.2% respecto a 2012 no fue significativo y se observó únicamente en los mayores de 60 años. Aunque las acciones preventivas han aumentado, el acceso al tratamiento médico y los estilos de vida no han mejorado. Se observó un aumento en insulina y una diminución en hipoglucemiantes.El envejecimiento de la población, la insuficiencia de acciones de tamizaje y el aumento en las complicaciones de diabetes provocarán un aumento en la carga de enfermedad. Invertir en la prevención primaria y secundaria en diabetes es crucial.

Published
2017

37. Sexual content in video games: an analysis of the Entertainment Software Rating Board classification from 1994 to 2013

Author

Ana Basto-Abreu, Dèsirée Vidaña-Pérez, Rainer Hilscher, Tonatiuh Barrientos-Gutiérrez, Inti Barrientos-Gutiérrez, and Ariela Braverman-Bronstein

Subjects
Male, Joinpoint regression, Adolescent, Sexual Behavior, 050109 social psychology, Psychology, Social, Entertainment, 03 medical and health sciences, 0302 clinical medicine, 030225 pediatrics, Computer software, Medicine, Humans, 0501 psychology and cognitive sciences, Association (psychology), Content (Freudian dream analysis), business.industry, Social perception, 05 social sciences, Public Health, Environmental and Occupational Health, Infectious Diseases, Sexual behavior, Social Perception, Video Games, Adolescent Behavior, Female, business, human activities, Demography
Abstract

Background Video games are widely used by children and adolescents and have become a significant source of exposure to sexual content. Despite evidence of the important role of media in the development of sexual attitudes and behaviours, little attention has been paid to monitor sexual content in video games. Methods: Data was obtained about sexual content and rating for 23 722 video games from 1994 to 2013 from the Entertainment Software Rating Board database; release dates and information on the top 100 selling video games was also obtained. A yearly prevalence of sexual content according to rating categories was calculated. Trends and comparisons were estimated using Joinpoint regression. Results: Sexual content was present in 13% of the video games. Games rated ‘Mature’ had the highest prevalence of sexual content (34.5%) followed by ‘Teen’ (30.7%) and ‘E10+’ (21.3%). Over time, sexual content decreased in the ‘Everyone’ category, ‘E10+’ maintained a low prevalence and ‘Teen’ and ‘Mature’ showed a marked increase. Both top and non-top video games showed constant increases, with top selling video games having 10.1% more sexual content across the period of study. Conclusion: Over the last 20 years, the prevalence of sexual content has increased in video games with a ‘Teen’ or ‘Mature’ rating. Further studies are needed to quantify the potential association between sexual content in video games and sexual behaviour in children and adolescents.

Published
2017

38. Prevalencia de diabetes por diagnóstico médico previo en México

Author

Carlos A. Aguilar-Salinas, Emiliano Zárate-Rojas, Tonatiuh Barrientos-Gutiérrez, Ana Basto-Abreu, Salvador Villalpando, and Rosalba Rojas-Martínez

Subjects
03 medical and health sciences, 0302 clinical medicine, business.industry, Public Health, Environmental and Occupational Health, Medicine, 030209 endocrinology & metabolism, 030212 general & internal medicine, business, Humanities
Abstract

Resumen: Objetivo: Comparar la prevalencia de diabetes por diagnostico medico previo en 2016 con encuestas nacionales anteriores y describir su tratamiento y complicaciones. Material y metodos: Se utilizaron la Encuesta Nacional de Salud 2000, las Encuestas Nacionales de Salud y Nutricion 2006 y 20012, y la Encuesta Nacional de Salud y Nutricion de Medio Camino 2016. Para 2016 se obtuvieron modelos de regresion logistica, asi como medidas de tendencia central y dispersion. Resultados: La prevalencia de diabetes por diagnostico medico en 2016 fue de 9.4%. El incremento de 2.2% respecto a 2012 no fue significativo y se observo unicamente en los mayores de 60 anos. Aunque las acciones preventivas han aumentado, el acceso al tratamiento medico y los estilos de vida no han mejorado. Se observo un aumento en insulina y una diminucion en hipoglucemiantes. Conclusion: El envejecimiento de la poblacion, la insuficiencia de acciones de tamizaje y el aumento en las complicaciones de diabetes provocaran un aumento en la carga de enfermedad. Invertir en la prevencion primaria y secundaria en diabetes es crucial.

Published
2018
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39. Behaviours and opinions towards outdoor smoking bans and cigarette littering in Baja California, Mexico

Author

Rodrigo Zepeda-Tello, Paul J. Christine, Julian Israel Aguilar Duque, Martín Romero-Martínez, Luz Myriam Reynales-Shigematsu, Tonatiuh Barrientos-Gutiérrez, and Ana Basto-Abreu

Subjects
Public park, Population, 010501 environmental sciences, 01 natural sciences, 03 medical and health sciences, Smoke-Free Policy, symbols.namesake, 0302 clinical medicine, Environmental health, Surveys and Questionnaires, Humans, 030212 general & internal medicine, Poisson regression, Secondhand smoke, education, Mexico, 0105 earth and related environmental sciences, education.field_of_study, Behavior, Descriptive statistics, Health Policy, Smoking, Geography, Public Opinion, symbols, Smoking status, Tobacco Smoke Pollution, Smoking ban
Abstract

Objective Outdoor smoking bans have been implemented to reduce secondhand smoke exposure and cigarette littering. We aimed to explore outdoor smoking behaviours, cigarette littering, and support towards a recently enacted outdoor smoking ban in Baja California, Mexico. Methods From October 2013 to April 2014 a representative sample of 800 adults from urban areas of Baja California was surveyed to obtain information on demographics, smoking status, opinion towards outdoor smoking bans in general and in specific locations, and perceptions and habits regarding cigarette littering. Descriptive statistics and Poisson regression analyses were conducted to estimate prevalence ratios and corresponding 95% CI taking into account the complex survey design. Results Outdoor smoking was frequently observed, as 86.8% of the population reported having seen people smoking in parks and beaches and 94.4% in open venues such as concerts or stadiums. A smoking ban in all outdoor areas was supported by 71.8% of Baja California residents. Site-specific support ranged from 80% (stadiums) to 89% (public parks). Support for the ban was higher among never and ex-smokers than in current smokers. Cigarette littering was negatively perceived by 98% of the participants, yet 45% of all cigarettes smoked were thrown on the ground. Based on cigarette consumption and butt littering reported in the survey, we estimated that 27 million cigarette butts become litter every month in urban areas of Baja California. Conclusions Outdoor smoking is still frequent in outdoor areas where people gather, and an important source of littering. We found substantial public support towards the outdoor smoking ban, which should translate into easier implementation and compliance in Baja California, Mexico.

Published
2015

40. Caloric reductions needed to achieve obesity goals in Mexico for 2030 and 2040: A modeling study

Author

Francisco Reyes-Sánchez, Ana Basto-Abreu, Rossana Torres-Álvarez, Martha Carnalla-Cortés, Alan Reyes-García, Boyd Swinburn, Rafael Meza, Juan A. Rivera, Barry Popkin, and Tonatiuh Barientos-Gutiérrez

Subjects
Medicine
Abstract

Background In Mexico, obesity prevalence among adults increased from 23% in 2000 to 36% in 2018, approximately. Mexico has not defined short- or long-term obesity goals, obscuring the level of effort required to achieve a relevant impact. We aimed to explore potential obesity goals for 2030 and 2040 in Mexico and to estimate the required caloric reductions to achieve them. Methods and findings We obtained anthropometric and demographic information on the Mexican adult population (age ≥20 years) from the Health and Nutrition Surveys conducted in 2000, 2006, 2012, 2016, and 2018 (n = 137,907). Each survey wave is cross-sectional, multistage, and representative of the Mexican population at the national, regional, and urban/rural levels. Obesity prevalence was projected for 2030 and 2040 by combining population projections of energy intake by socioeconomic status (SES) with a weight-change microsimulation model taking into account individual-level information on sex, age, physical activity, and initial body weight and height. If current trends continue, Mexico’s obesity prevalence is expected to increase from 36% (95% CI 35% to 37%) in 2018 to 45% (uncertainty interval [UI] 41% to 48%) in 2030 and to 48% (UI 41% to 55%) in 2040. Based on expert opinion, we identified 3 obesity goals scenarios: (1) plausible (38% in 2030 and 36% in 2040); (2) intermediate (33% in 2030 and 29% in 2040); and (3) ideal based on the average prevalence of Organization for Economic Co-operation and Development countries (OECD; 19%). We estimated the caloric reductions needed to achieve the goal scenarios using the microsimulation model. Obesity was projected to increase more rapidly in the low SES (around 34% in 2018 to 48% (UI 41% to 55%) in 2040), than in the middle (around 38% to 52% (UI 45% to 56%)), or high SES group (around 36% to 45% (UI 36% to 54%)). Caloric reductions of 40 (UI 13 to 60), 75 (UI 49 to 95), and 190 (UI 163 to 215) kcal/person/day would be needed to reach the plausible, intermediate, and the ideal (OECD) average scenarios for 2030, respectively. To reach the 2040 goals, caloric reductions of 74 (UI 28 to 114), 124 (UI 78 to 169), and 209 (UI 163 to 254) kcal/person/day would be required, respectively. Study limitations include assuming a constant and sedentary physical activity level, not considering cohort-specific differences that could occur in the future, and assuming the same caloric trends under no intervention and the obesity goal scenarios. Conclusions To reach the 3 obesity goals in 2040, caloric reductions between 74 and 209 kcal/day/person would be needed in Mexico. A package of new and stronger interventions should be added to existing efforts such as food taxes and warning labels on non-nutritious food. Tonatiuh Barrientos-Gutiérrez and co-workers model anticipated changes in calories consumed per person needed to achieve population obesity goals in Mexico. Author summary Why was this study done? Mexico has one of the highest obesity prevalences worldwide. Efforts have been made to improve dietary habits, such as implementing taxes and warning labels on non-nutritious food and beverages. However, obesity prevalence in Mexico is still increasing. Mexico has not defined obesity goals to help track country-level advances and assess the effectiveness of public health policies. What did the researchers do and find? We projected the obesity prevalence in Mexico to 2030 and 2040. These predictions were estimated using a microsimulation model of body weight, informed by projections of energy intake by socioeconomic. We defined 3 obesity goals based on expert opinion and the average obesity prevalence from the Organization for Economic Co-operation and Development countries (OECD): plausible (38% in 2030 and 36% in 2040), intermediate (33% in 2030 and 29% in 2040), and ideal (19%). We estimated the caloric reductions needed to attain these goals. Obesity prevalence is expected to increase from 36% (95% CI 35% to 37%) in 2018 to 48% (uncertainty interval [UI] 41% to 55%) in 2040. To reach the obesity goals for 2040, caloric reductions of 74 kcal/person/day (UI 28 to 114), 124 kcal/person/day (UI 78 to 169), and 209 kcal/person/day (UI 163 to 254) would be needed for the plausible, intermediate, and ideal scenarios, respectively. These goals would require higher caloric reductions for people of low socioeconomic position than people of other socioeconomic levels. What do these findings mean? Defining obesity goals and estimating the required caloric reductions to achieve them are needed to assess the required impact of interventions and attain meaningful population health advances. The obesity challenge in Mexico is substantial and requires a comprehensive package of interventions to achieve obesity goals, addressing the mechanisms affecting poor diets and weight gain.

Published
2023

41. Adherence to the DASH diet by hypertension status in Mexican men and women: A cross-sectional study

Author

Alan Reyes-García, Nancy López-Olmedo, Ana Basto-Abreu, Teresa Shamah-Levy, and Tonatiuh Barrientos-Gutierrez

Subjects
DASH, Hypertension diagnosis, Healthy diet, Men and women, Mexico, Medicine
Abstract

Improving dietary patterns is a cornerstone of the non-pharmacological management of hypertension. Evidence about the adherence to healthy dietary patterns at the population level is scarce. We aimed to analyze the adherence to the Dietary Approaches to Stop Hypertension (DASH) diet among Mexican men and women by hypertension status. We used data from the 2012 Mexican National Health and Nutrition Survey (n = 2560). Using self-reported diagnosis of hypertension and blood pressure measurements, we identified participants without, with undiagnosed, and diagnosed hypertension. We calculated DASH scores (total and dietary components) based on a single 24-hour recall and analyzed differences in adherence across hypertension status using sex-specific multivariable Poisson regression models. Overall, regardless of hypertension status, adherence to the DASH score was low, with 35% of men and 38% of women with diagnosed hypertension adhering to recommended guidelines; lower adherence was observed in men (21.8%) and women (27.2%) with undiagnosed hypertension, and with no hypertension (26.8% in men, 26.3% in women). In multivariable models for men, the prevalence of adherence to the total DASH diet was 29% lower in undiagnosed adults versus adults without hypertension (RP 0.71; 95%CI 0.50,0.99). Specifically, adherence to fruits, total dairy, and animal protein was lower in undiagnosed men. Among women, the adherence to the DASH diet was similar across hypertension status in multivariable models. Mexican adults had low adherence to DASH, regardless of hypertension status. Strategies to improve adherence to DASH are needed, focusing in patients with hypertension but also as a preventive measure for the population.

Published
2022
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