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      Rethinking the “Diseases of Affluence” Paradigm: Global Patterns of Nutritional Risks in Relation to Economic Development

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          Cardiovascular diseases and their nutritional risk factors—including overweight and obesity, elevated blood pressure, and cholesterol—are among the leading causes of global mortality and morbidity, and have been predicted to rise with economic development.

          Methods and Findings

          We examined age-standardized mean population levels of body mass index (BMI), systolic blood pressure, and total cholesterol in relation to national income, food share of household expenditure, and urbanization in a cross-country analysis. Data were from a total of over 100 countries and were obtained from systematic reviews of published literature, and from national and international health agencies.

          BMI and cholesterol increased rapidly in relation to national income, then flattened, and eventually declined. BMI increased most rapidly until an income of about I$5,000 (international dollars) and peaked at about I$12,500 for females and I$17,000 for males. Cholesterol's point of inflection and peak were at higher income levels than those of BMI (about I$8,000 and I$18,000, respectively). There was an inverse relationship between BMI/cholesterol and the food share of household expenditure, and a positive relationship with proportion of population in urban areas. Mean population blood pressure was not correlated or only weakly correlated with the economic factors considered, or with cholesterol and BMI.


          When considered together with evidence on shifts in income–risk relationships within developed countries, the results indicate that cardiovascular disease risks are expected to systematically shift to low-income and middle-income countries and, together with the persistent burden of infectious diseases, further increase global health inequalities. Preventing obesity should be a priority from early stages of economic development, accompanied by population-level and personal interventions for blood pressure and cholesterol.


          Cardiovascular diseases, traditionally thought of as diseases of affluence, are likely to become a substantial public health in low-income and middle-income countries.

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          Most cited references 57

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          Global burden of cardiovascular diseases: part I: general considerations, the epidemiologic transition, risk factors, and impact of urbanization.

          This two-part article provides an overview of the global burden of atherothrombotic cardiovascular disease. Part I initially discusses the epidemiologic transition which has resulted in a decrease in deaths in childhood due to infections, with a concomitant increase in cardiovascular and other chronic diseases; and then provides estimates of the burden of cardiovascular (CV) diseases with specific focus on the developing countries. Next, we summarize key information on risk factors for cardiovascular disease (CVD) and indicate that their importance may have been underestimated. Then, we describe overarching factors influencing variations in CVD by ethnicity and region and the influence of urbanization. Part II of this article describes the burden of CV disease by specific region or ethnic group, the risk factors of importance, and possible strategies for prevention.
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            Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988-2000.

            Prior analyses of National Health and Nutrition Examination Survey (NHANES) data through 1991 have suggested that hypertension prevalence is declining, but more recent self-reported rates of hypertension suggest that the rate is increasing. To describe trends in the prevalence, awareness, treatment, and control of hypertension in the United States using NHANES data. Survey using a stratified multistage probability sample of the civilian noninstitutionalized population. The most recent NHANES survey, conducted in 1999-2000 (n = 5448), was compared with the 2 phases of NHANES III conducted in 1988-1991 (n = 9901) and 1991-1994 (n = 9717). Individuals aged 18 years or older were included in this analysis. Hypertension, defined as a measured blood pressure of 140/90 mm Hg or greater or reported use of antihypertensive medications. Hypertension awareness and treatment were assessed with standardized questions. Hypertension control was defined as treatment with antihypertensive medication and a measured blood pressure of less than 140/90 mm Hg. In 1999-2000, 28.7% of NHANES participants had hypertension, an increase of 3.7% (95% confidence interval [CI], 0%-8.3%) from 1988-1991. Hypertension prevalence was highest in non-Hispanic blacks (33.5%), increased with age (65.4% among those aged > or =60 years), and tended to be higher in women (30.1%). In a multiple regression analysis, increasing age, increasing body mass index, and non-Hispanic black race/ethnicity were independently associated with increased rates of hypertension. Overall, in 1999-2000, 68.9% were aware of their hypertension (nonsignificant decline of -0.3%; 95% CI, -4.2% to 3.6%), 58.4% were treated (increase of 6.0%; 95% CI, 1.2%-10.8%), and hypertension was controlled in 31.0% (increase of 6.4%; 95% CI, 1.6%-11.2%). Women, Mexican Americans, and those aged 60 years or older had significantly lower rates of control compared with men, younger individuals, and non-Hispanic whites. Contrary to earlier reports, hypertension prevalence is increasing in the United States. Hypertension control rates, although improving, continue to be low. Programs targeting hypertension prevention and treatment are of utmost importance.
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              Socioeconomic status and obesity in adult populations of developing countries: a review.

              A landmark review of studies published prior to 1989 on socioeconomic status (SES) and obesity supported the view that obesity in the developing world would be essentially a disease of the socioeconomic elite. The present review, on studies conducted in adult populations from developing countries, published between 1989 and 2003, shows a different scenario for the relationship between SES and obesity. Although more studies are necessary to clarify the exact nature of this relationship, particularly among men, three main conclusions emerge from the studies reviewed: 1. Obesity in the developing world can no longer be considered solely a disease of groups with higher SES. 2. The burden of obesity in each developing country tends to shift towards the groups with lower SES as the country's gross national product (GNP) increases. 3. The shift of obesity towards women with low SES apparently occurs at an earlier stage of economic development than it does for men. The crossover to higher rates of obesity among women of low SES is found at a GNP per capita of about US$ 2500, the mid-point value for lower-middle-income economies. The results of this review reinforce the urgent need to: include obesity prevention as a relevant topic on the public health agenda in developing countries; improve the access of all social classes in these countries to reliable information on the determinants and consequences of obesity; and design and implement consistent public actions on the physical, economic, and sociocultural environment that make healthier choices concerning diet and physical activity feasible for all. A significant step in this direction was taken with the approval of the Global Strategy on Diet, Physical Activity and Health by the World Health Assembly in May 2004.

                Author and article information

                Role: Academic Editor
                PLoS Med
                PLoS Medicine
                Public Library of Science (San Francisco, USA )
                May 2005
                3 May 2005
                : 2
                : 5
                1simpleHarvard School of Public Health, Boston MassachusettsUnited States of America
                2simpleClinical Trials Research Unit University of AucklandNew Zealand
                3simpleInternational Obesity Task Force LondonUnited Kingdom
                4simpleSchool of Population Health, University of Queensland BrisbaneAustralia
                simpleUniversity of California at San Francisco United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author Contributions: ME, SV, and CJLM designed the study. SV, CMML, RL, and WPTJ collected data. ME, SV, RL, and WPTJ analyzed the data. ME, SV, CMML, RL, WPTJ, ADL, AR, and CJLM contributed to writing the paper.

                *To whom correspondence should be addressed. E-mail: mezzati@
                Copyright: © 2005 Ezzati et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
                Research Article
                Cardiology/Cardiac Surgery
                Epidemiology/Public Health
                Health Policy
                Public Health
                International Health
                Cardiovascular Medicine



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