Health and Economic Burden of Obesity in Brazil

Introduction

Higher and lower-middle income countries are increasingly affected by obesity. Obesity-related diseases are placing a substantial health and economic burden on Brazil. Our aim is to measure the future consequences of these trends on the associated disease burden and health care costs.

Method

A previously developed micro-simulation model is used to project the extent of obesity, obesity-related diseases and associated healthcare costs to 2050. In total, thirteen diseases were considered: coronary heart disease, stroke, hypertension, diabetes, osteoarthritis, and eight cancers. We simulated three hypothetical intervention scenarios: no intervention, 1% and 5% reduction in body mass index (BMI).

Results

In 2010, nearly 57% of the Brazilian male population was overweight or obese (BMI ≥25 kg/m²), but the model projects rates as high as 95% by 2050. A slightly less pessimistic picture is predicted for females, increasing from 43% in 2010 to 52% in 2050. Coronary heart disease, stroke, hypertension, cancers, osteoarthritis and diabetes prevalence cases are projected to at least double by 2050, reaching nearly 34,000 cases of hypertension by 2050 (per 100,000). 1% and 5% reduction in mean BMI will save over 800 prevalence cases and nearly 3,000 cases of hypertension by 2050 respectively (per 100,000). The health care costs will double from 2010 ($5.8 billion) in 2050 alone ($10.1 billion). Over 40 years costs will reach $330 billion. However, with effective interventions the costs can be reduced to $302 billion by 1% and to $273 billion by 5% reduction in mean BMI across the population.

Conclusion

Obesity rates are rapidly increasing creating a high burden of disease and associated costs. However, an effective intervention to decrease obesity by just 1% will substantially reduce obesity burden and will have a significant effect on health care expenditure.     

特定人群超重及肥胖与相关疾病患病分析

目的：分析特定人群超重患病率,以及超重与高血压、糖尿病、血脂异常、脂肪肝等相关疾病的关系,为及早预防慢性非传染性疾病奠定基础。方法：对平房地区采取长效避孕措施的603名户籍农村已婚育龄妇女进行健康体检,按体重指数（BMI）分为正常组、超重组和肥胖组,比较各组间高血压、高血糖、高血脂、脂肪肝等相关疾病检出率的差异。结果：特定人群超重发病率及超重相关疾病检出率的差异均具有统计学意义（P〈0．01）。结论：平房地区特定人群超重及肥胖发病率未明显高于国内平均水平及全市水平。但超重及肥胖与高血压、糖尿病、血脂异常、脂肪肝等疾病存在较大相关关系,为了进一步降低心脑血管高危因素和死亡率。需采取早期、有效的措施控制超重和肥胖倾向。     

Ethnic Differences in Correlates of Obesity between Latin‐American and Black Women

Objective: To date, no studies have examined dietary intake, physical activity, and body image in a large sample of Latin‐American and black women recruited using the same methodology. The aim of this study was to examine three potential correlates of obesity (dietary intake, body image, and physical activity) in a large sample of Latin‐American and black women across the weight spectrum. Research Methods and Procedures: Participants were black (n = 271) and Latin‐American (n = 234) adult women who completed a 24‐hour dietary recall and physical activity and body image questionnaires. Results: After controlling for BMI, education, marital status, and number of children, black women consumed more kilocalories, dietary fat (grams), and percent calories from fat than Latin‐American women, who consumed more carbohydrates (grams) and dietary fiber (total and soluble). Black women engaged in more sedentary behavior than Latin‐American women. Although Latin‐American women weighed less than black women, they perceived their current body image as heavier and reported greater body image dissatisfaction than black women. Black women also reported a higher ideal body image than Latin‐American women. Discussion: The combined effect of a diet higher in calories and fat, increased sedentary behavior, and more accepting body image could account for higher rates of obesity among black women. Future studies should further explore cultural attitudes and beliefs related to weight that could provide information for the development of culturally competent obesity interventions.     

Premature Mortality from Cardiovascular Disease in the Americas – Will the Goal of a Decline of “25% by 2025” be Met?

Background

Cardiovascular diseases (CVD) are the underlying cause 1.6 million deaths per year in the Americas, accounting for 30% of total mortality and 38% of by non-communicable deaths diseases (NCDs). A 25% reduction in premature mortality due four main NCDs was targeted by the 2011 High-level Meeting of the General Assembly on the Prevention and Control of NCDs. While overall CVD mortality fell in the Americas during the past decade, trends in premature CVD mortality during the same period have not been described, particularly in the countries of Latin America and the Caribbean.

Methods

This is a population-based trend-series study based on a total of 6,133,666 deaths to describe the trends and characteristics of premature mortality due to CVD and to estimates of the average annual percentage of change during the period 2000–2010 in the Americas.

Findings

Premature mortality due to CVD in the Americas fell by 21% in the period 2000–2010 with a -2.5% average annual rate of change in the last 5 year—a statistically significant reduction of mortality—. Mortality from ischemic diseases, declined by 25% - 24% among men and 26% among women. Cerebrovascular diseases declined by 27% -26% among men and 28% among women. Guyana, Trinidad and Tobago, the Dominican Republic, Bahamas, and Brazil had CVD premature mortality rates over 200 per 100,000 population, while the average for the Region was 132.7. US and Canada will meet the 25% reduction target before 2025. Mexico, Costa Rica, Venezuela, Dominican Republic, Panama, Guyana, and El Salvador did not significantly reduce premature mortality among men and Guyana, the Dominican Republic, and Panama did not achieve the required annual reduction in women.

Conclusions

Trends in premature mortality due to CVD observed in last decade in the Americas would indicate that if these trends continue, the Region as a whole and a majority of its countries will be able to reach the goal of a 25% relative reduction in premature mortality even before 2025.     

Cut‐off Point of BMI and Obesity‐Related Comorbidities and Mortality in Middle‐Aged Koreans

Objective: The need for a lower BMI to classify overweight in Asian populations has been controversial. Using both disease and mortality outcomes, we investigated whether lower BMI cut‐off points are appropriate for identifying increased health risk in Koreans. Research Methods and Procedures: We conducted a cohort study among 773, 915 men and women from 30 to 59 years old with 8‐ to 10‐year follow‐up periods. Primary outcomes were change of obesity prevalence, obesity‐related disease incidence, and all‐cause mortality. Results: Prevalence of overweight (BMI of 25.0‐29.9) has steadily increased (1.3% annually), whereas obesity (BMI ≥ 30) showed a lower prevalence and only a slight increase (0.1%‐0.2% annually). Our study revealed that dose‐response relationships exist between obesity and related disease incidences (hypertension, type 2 diabetes, and hypercholesterolemia) beginning at lower BMI levels than previously reported. Compared with those in the healthy weight range, Koreans with a BMI ≥ 25 were not at greater risk of hypertension, type 2 diabetes, or hypercholesterolemia than has been reported for whites in similar studies. Obesity‐related all‐cause mortality also did not seem so different from that of whites. Discussion: Our findings did not support the use of a lower BMI cut‐off point for defining overweight in Koreans compared with whites for the purpose of identifying different risks. However, populations with BMI ≥ 25 are rapidly increasing and have substantial risks of diseases. To preempt the rapid increases in obesity and related health problems that are occurring in Western countries, Korea should consider using a BMI of 25 as an action point for obesity prevention and control interventions.     

The Changing Body Mass–Mortality Association in the United States: Evidence of Sex-Specific Cohort Trends from Three National Health and Nutrition Examination Surveys

The association between body mass index (BMI) categories and mortality remains uncertain. Using three National Health and Nutrition Examination Surveys covering the 1971–2006 period for cohorts born between 1896 and 1968, this study estimates separately for men and women models for year-of-birth (cohort) and year-of-observation (period) trends in how age-specific mortality rates differ across BMI categories. Among women, relative to the normal weight (BMI 18.5–24.9 kg/m²), there are increasing trends in mortality rates for the overweight (BMI 25–29.9) or obese (BMI ≥ 30). Among men, mortality rates relative to the normal weight decrease for the overweight, do not change for the moderately obese (BMI 30–34.9), and increase for the severely obese (BMI ≥ 35). Period and cohort trends are similar, but the cohort trends are more consistent. In the latest cohorts, compared with the normal weight, mortality rates are 50 percent lower for overweight men, not different for moderately obese men, and 100–200 percent higher for severely obese men and for overweight or obese women. For U.S. cohorts born after the 1920s, a lower overweight than normal weight mortality is confined to men. I speculate on possible reasons why the mortality association with overweight and obesity varies by sex and cohort.     

Body Mass Index and Cardiovascular Disease Risk Factors in Seven Asian and Five Latin American Centers: Data from the International Clinical Epidemiology Network (INCLEN)

We have tested the hypothesis that the relationship between body mass index (BMI) and other cardiovascular disease (CVD) risk factors as well as socioeconomic status is different in five Latin American populations (where BMI is high) and seven Asian populations (where BMI is low). Random samples of approximately 200 males aged between 35 and 65 years were selected from 12 general or industrial populations in Latin America and Asia. Standardized measures of height, weight, blood pressure, blood cholesterol, cigarette smoking, highest level of completed education, occupation and income were made. The mean BMI (kg/m₂) was 253 (SD 3.74) in the five Latin American populations (which were all urban), 22.2 (SD 3.24) in the four Asian urban populations and 21.4 (SD 3.33) in the three Asian rural populations. Despite the differences in mean BMI levels, statistically significant positive relationships of a similar magnitude were seen between BMI and blood pressure levels in Latin America and Asia. Similarly, there was a statistically significant positive relationship found between BMI and total cholesterol in both Latin American and Asian urban samples, but of a higher magnitude in Asian rural samples. Current cigarette smokers had significantly lower BMI than ex-smokers or never smokers in Latin America and Asia. In Asia, there were statistically significant positive associations between BMI and levels of education and income as well as with occupation — these relationships were stronger for education and occupation in rural than in urban samples. There were no statistically significant associations between BMI and these measures of socioeconomic status in Latin America. The similarities of the associations between BMI and blood pressure and cholesterol levels in the two groups suggest that efforts to reduce BMI in all populations is likely to be important in reducing risk of CVD. Preventing the future rise of BMI in populations tions where BMI is still relatively low is a high priority. The difference in association between BMI and socioeconomic status in the different population groups requires study of the way sociocultural factors influence behavior that determines BMI levels.     

Reduction in morbidity and mortality from childhood diarrhoeal disease after species A rotavirus vaccine introduction in Latin America - a review

Countries in Latin America were among the first to implement routine vaccination against species A rotavirus (RVA). We evaluate data from Latin America on reductions in gastroenteritis and RVA disease burden following the introduction of RVA vaccine. Published literature was reviewed to identify case-control studies of vaccine effectiveness and population-based studies examining longitudinal trends of diarrhoeal disease reduction after RVA vaccine introduction in Latin American countries. RVA vaccine effectiveness and impact on gastroenteritis mortality and hospitalization rates and RVA hospitalization rates are described. Among middle-income Latin American countries with published data (Mexico, Brazil, El Salvador and Panama), RVA vaccine contributed to a gastroenteritis-associated mortality reduction of 22-41%, a gastroenteritis-associated hospitalization reduction of 17-51% and a RVA hospitalization reduction of 59-81% among children younger than five years of age. In Brazil and El Salvador, case-control studies demonstrated that a full RVA vaccination schedule was 76-85% effective against RVA hospitalization; a lower effectiveness of 46% was seen in Nicaragua, the only low-income country with available data. A growing body of literature offers convincing evidence of "real world" vaccine program successes in Latin American settings, which may be expanded as more countries in the region include RVA vaccine in their immunization programs.     

Smoking particles enhance endothelin A and endothelin B receptor-mediated contractions by enhancing translation in rat bronchi

Background

The prevalence of asthma and allergic diseases has increased in industrialised countries, and it is known that rates vary according whether the area is urban or rural and to socio-economic status. Surveys conducted in some urban settings in Latin America found high prevalence rates, only exceeded by the rates observed in industrialised English-speaking countries. It is likely that the marked changes in the environment, life style and living conditions in Latin America are responsible for these observations. The understanding of the epidemiological and immunological changes that underlie the increase in asthma and allergic diseases in Latin America aimed by SCAALA studies in Brazil and Ecuador will be crucial for the identification of novel preventive interventions.

Methods/Design

The Salvador-SCAALA project described here is a longitudinal study involving children aged 4–11 years living in the city of Salvador, Northeastern Brazil. Data on asthma and allergic diseases (rhinitis and eczema) and potential risk factors will be collected in successive surveys using standardised questionnaire. This will be completed with data on dust collection (to dust mite and endotoxin), skin test to most common allergens, stool examinations to helminth and parasites, blood samples (to infection, total and specific IgE, and immunological makers), formaldehyde, physical inspection to diagnoses of eczema, and anthropometric measures. Data on earlier exposures when these children were 0–3 years old are available from a different project.

Discussion

It is expected that knowledge generated may help identify public health interventions that may enable countries in LA to enjoy the benefits of a "modern" lifestyle while avoiding – or minimising – increases in morbidity caused by asthma and allergies.     

Application of the UK Foresight Obesity Model in Ireland: The Health and Economic Consequences of Projected Obesity Trends in Ireland

Background

Given the scale of the current obesity epidemic and associated health consequences there has been increasing concern about the economic burden placed on society in terms of direct healthcare costs and indirect societal costs. In the Republic of Ireland these costs were estimated at €1.13 billion for 2009. The total direct healthcare costs for six major obesity related conditions (coronary heart disease & stroke, cancer, hypertension, type 2 diabetes and knee osteoarthritis) in the same year were estimated at €2.55 billion. The aim of this research is to project disease burden and direct healthcare costs for these conditions in Ireland to 2030 using the established model developed by the Health Forum (UK) for the Foresight: Tackling Obesities project.

Methodology

Routine data sources were used to derive incidence, prevalence, mortality and survival for six conditions as inputs for the model. The model utilises a two stage modelling process to predict future BMI rates, disease prevalence and costs. Stage 1 employs a non-linear multivariate regression model to project BMI trends; stage 2 employs a microsimulation approach to produce longitudinal projections and test the impact of interventions upon future incidence of obesity-related disease.

Results

Overweight and obesity are projected to reach levels of 89% and 85% in males and females respectively by 2030. This will result in an increase in the obesity related prevalence of CHD & stroke by 97%, cancers by 61% and type 2 diabetes by 21%. The direct healthcare costs associated with these increases will amount to €5.4 billion by 2030. A 5% reduction in population BMI levels by 2030 is projected to result in €495 million less being spent in obesity-related direct healthcare costs over twenty years.

Discussion

These findings have significant implications for policy, highlighting the need for effective strategies to prevent this avoidable health and economic burden.     

Trends in Longevity in the Americas: Disparities in Life Expectancy in Women and Men, 1965-2010

Objective

We describe trends in life expectancy at birth (LE) and between-country LE disparities since 1965, in Latin America and the Caribbean.

Methods & Findings

LE trends since 1965 are described for three geographical sub-regions: the Caribbean, Central America, and South America. LE disparities are explored using a suite of absolute and relative disparity metrics, with measurement consensus providing confidence to observed differences. LE has increased throughout Latin America and the Caribbean. Compared to the Caribbean, LE has increased by an additional 6.6 years in Central America and 4.1 years in South America. Since 1965, average reductions in between-country LE disparities were 14% (absolute disparity) and 23% (relative disparity) in the Caribbean, 55% and 51% in Central America, 55% and 52% in South America.

Conclusions

LE in Latin America and the Caribbean is exceeding ‘minimum standard’ international targets, and is improving relative to the world region with the highest human longevity. The Caribbean, which had the highest LE and the lowest between-country LE disparities in Latin America and the Caribbean in 1965-70, had the lowest LE and the highest LE disparities by 2005-10. Caribbean Governments have championed a collaborative solution to the growing burden of non-communicable disease, with 15 territories signing on to the Declaration of Port of Spain, signalling regional commitment to a coordinated public-health response. The persistent LE inequity between Caribbean countries suggests that public health interventions should be tailored to individual countries to be most effective. Between- and within-country disparity monitoring for a range of health metrics should be a priority, first to guide country-level policy initiatives, then to contribute to the assessment of policy success.     

Spatial expansions and travelling waves of rabies in vampire bats

A major obstacle to anticipating the cross-species transmission of zoonotic diseases and developing novel strategies for their control is the scarcity of data informing how these pathogens circulate within natural reservoir populations. Vampire bats are the primary reservoir of rabies in Latin America, where the disease remains among the most important viral zoonoses affecting humans and livestock. Unpredictable spatiotemporal dynamics of rabies within bat populations have precluded anticipation of outbreaks and undermined widespread bat culling programs. By analysing 1146 vampire bat-transmitted rabies (VBR) outbreaks in livestock across 12 years in Peru, we demonstrate that viral expansions into historically uninfected zones have doubled the recent burden of VBR. Viral expansions are geographically widespread, but severely constrained by high elevation peaks in the Andes mountains. Within Andean valleys, invasions form wavefronts that are advancing towards large, unvaccinated livestock populations that are heavily bitten by bats, which together will fuel high transmission and mortality. Using spatial models, we forecast the pathways of ongoing VBR epizootics across heterogeneous landscapes. These results directly inform vaccination strategies to mitigate impending viral emergence, reveal VBR as an emerging rather than an enzootic disease and create opportunities to test novel interventions to manage viruses in bat reservoirs.     

Decomposing adult obesity trends in China (1991–2011)

Using data from the China Health and Nutrition Survey, this study analyses two decades (1991–2011) of change in adult obesity in China with a focus on whether rising obesity rates result from all population cohorts becoming more obese across time (intra-cohort change) or recent cohorts being more obese than their earlier counterparts (inter-cohort change or cohort replacement). To do so, we decompose changes in the body mass index (BMI), waist circumference (WC), general obesity and abdominal obesity of adults aged 20+ using both Firebaugh’s linear decomposition and Das Gupta’s non-linear technique. Our analysis not only reveals significant increases in both general and abdominal obesity (8.1 and 32 percentage points, respectively) in the two decades studied but shows that the rising means in all four measures are mostly attributable to intra-cohort change. In fact, contrary to findings for the U.S., inter-cohort change for the Chinese sample is actually negative, implying that cohort replacement attenuates intra-cohort change over time. Given that intra-cohort change is the central force for the increase in BMI, WC and obesity with individual increases in obesity widely distributed across all cohorts and age groups over time, policy interventions should focus more broadly on all age groups and birth cohorts.     

Cross-Sectional Association between Length of Incarceration and Selected Risk Factors for Non-Communicable Chronic Diseases in Two Male Prisons of Mexico City

Background

Mexico City prisons are characterized by overcrowded facilities and poor living conditions for housed prisoners. Chronic disease profile is characterized by low prevalence of self reported hypertension (2.5%) and diabetes (1.8%) compared to general population; 9.5% of male inmates were obese. There is limited evidence regarding on the exposure to prison environment over prisoner’s health status; particularly, on cardiovascular disease risk factors. The objective of this study is to assess the relationship between length of incarceration and selected risk factors for non-communicable chronic diseases (NCDs).

Methods and Findings

We performed a cross-sectional analysis using data from two large male prisons in Mexico City (n = 14,086). Using quantile regression models we assessed the relationship between length of incarceration and selected risk factors for NCDs; stratified analysis by age at admission to prison was performed. We found a significant negative trend in BMI and WC across incarceration length quintiles. BP had a significant positive trend with a percentage change increase around 5% mmHg. The greatest increase in systolic blood pressure was observed in the older age at admission group.

Conclusions

This analysis provides insight into the relationship between length of incarceration and four selected risk factors for NCDs; screening for high blood pressure should be guarantee in order to identify at risk individuals and linked to the prison’s health facility. It is important to assess prison environment features to approach potential risk for developing NCDs in this context.     

Cancer risk reduction in the US Affiliated Pacific Islands: Utilizing a novel policy,systems, and environmental (PSE) approach

BackgroundThe Health Directors of the US Affiliated Pacific Islands (USAPI) declared a State of Emergency due to epidemic proportions of lifestyle diseases: cancer, obesity and other non-communicable diseases (NCDs) in 2010. This paper describes the development, implementation, and evaluation of a USAPI policy, system and environment (PSE) approach to address lifestyle behaviors associated with cancer and other NCDs.MethodsEach of USAPI jurisdictions applied the PSE approach to tobacco and nutrition interventions in a local institution, faith based, or community setting. A participatory community engagement process was utilized to: identify relevant deleterious health behaviors in the population, develop PSE interventions to modify the context in which the behavior occurs in a particular setting, implement the PSE intervention through five specified activities, and evaluate the activities and behavior change associated with the intervention.ResultsPSE interventions have been implemented in all USAPI jurisdictions. Current human and financial resources have been adequate to support the interventions. Process and behavior change evaluations have not been completed and is ongoing. Personnel turnover and maintaining the intervention strategy in response due to shifting community demands has been the biggest challenge in one site.ConclusionFrom 2014 through 2016 the PSE approach has been used to implement PSE interventions in all USAPI jurisdictions. The intervention evaluations have not been completed. The PSE intervention is novel and has the potential to be a scalable methodology to prevent cancer and modify NCD risk in the USAPI and small states.     

Relation between the global burden of disease and randomized clinical trials conducted in Latin America published in the five leading medical journals

Background

Since 1990 non communicable diseases and injuries account for the majority of death and disability-adjusted life years in Latin America. We analyzed the relationship between the global burden of disease and Randomized Clinical Trials (RCTs) conducted in Latin America that were published in the five leading medical journals.

Methodology/Principal Findings

We included all RCTs in humans, exclusively conducted in Latin American countries, and published in any of the following journals: Annals of Internal Medicine, British Medical Journal, Journal of the American Medical Association, Lancet, and New England Journal of Medicine. We described the trials and reported the number of RCTs according to the main categories of the global burden of disease. Sixty-six RCTs were identified. Communicable diseases accounted for 38 (57%) reports. Maternal, perinatal, and nutritional conditions accounted for 19 (29%) trials. Non-communicable diseases represent 48% of the global burden of disease but only 14% of reported trials. No trial addressed injuries despite its 18% contribution to the burden of disease in 2000.

Conclusions/Significance

A poor correlation between the burden of disease and RCTs publications was found. Non communicable diseases and injuries account for up to two thirds of the burden of disease in Latin America but these topics are seldom addressed in published RCTs in the selected sample of journals. Funding bodies of health research and editors should be aware of the increasing burden of non communicable diseases and injuries occurring in Latin America to ensure that this growing epidemic is not neglected in the research agenda and not affected by publication bias.     

Human Body Composition and the Epidemiology of Chronic Disease

Obesity and body fat distribution (FD) are established risk factors for chronic diseases. The body mass index (BMI) and the waist/hip circumference ratio (WHR) are used conventionally as indices of obesity and FD in epidemiological studies. Although some general limitations of these indices are recognized, others that affect their use in relative risks for disease are not well recognized. These include effects of sex, ethnicity, and especially age on the relationships between these indices and body composition, which can result in substantial misclassification of obesity and FD. There is considerable variability in body composition for any BMI, and some individuals with low BMIs have as much fat as those with high BMIs. This results in poor sensitivity for classifying levels of body fatness (e.g., too many “false negatives,” or overweight individuals classified as not overweight), and relative risks are attenuated across all categories of BMI. A more serious problem, however, is that at different ages the same levels of BMI correspond to different amounts of fat and fat-free mass. Data from the Rosetta Study and the New Mexico Aging Process Study show that older adults have, on average, more fat than younger adults at any BMI, due to the loss of muscle mass with age. As a result, the sensitivity of BMI cutpoints with respect to body fatness decreases with age, and the use of a fixed cutpoint for all ages results in “differential mis-classification bias.” Taken together, these issues sug- gest that the increases with age in the prevalences of overweight and obesity, and in the risks for chronic diseases, may be mis-estimated using BMI. Similar issues may affect the use of WHR for estimating prevalences and associated risks of FD. New field methods for estimating body composition are available that can be applied in large, epidemiologic follow-up studies of chronic diseases. These methods will allow epidemiologists to consider, for example, whether it is increased fat, or the replacement of fat-free mass with fat, with age that is associated with risk for chronic disease.     

Socioeconomic Inequalities in Non-Communicable Diseases Prevalence in India: Disparities between Self-Reported Diagnoses and Standardized Measures

Background

Whether non-communicable diseases (NCDs) are diseases of poverty or affluence in low-and-middle income countries has been vigorously debated. Most analyses of NCDs have used self-reported data, which is biased by differential access to healthcare services between groups of different socioeconomic status (SES). We sought to compare self-reported diagnoses versus standardised measures of NCD prevalence across SES groups in India.

Methods

We calculated age-adjusted prevalence rates of common NCDs from the Study on Global Ageing and Adult Health, a nationally representative cross-sectional survey. We compared self-reported diagnoses to standardized measures of disease for five NCDs. We calculated wealth-related and education-related disparities in NCD prevalence by calculating concentration index (C), which ranges from −1 to +1 (concentration of disease among lower and higher SES groups, respectively).

Findings

NCD prevalence was higher (range 5.2 to 19.1%) for standardised measures than self-reported diagnoses (range 3.1 to 9.4%). Several NCDs were particularly concentrated among higher SES groups according to self-reported diagnoses (C_srd) but were concentrated either among lower SES groups or showed no strong socioeconomic gradient using standardized measures (C_sm): age-standardised wealth-related C: angina C_srd 0.02 vs. C_sm −0.17; asthma and lung diseases C_srd −0.05 vs. C_sm −0.04 (age-standardised education-related C_srd 0.04 vs. C_sm −0.05); vision problems C_srd 0.07 vs. C_sm −0.05; depression C_srd 0.07 vs. C_sm −0.13. Indicating similar trends of standardized measures detecting more cases among low SES, concentration of hypertension declined among higher SES (C_srd 0.19 vs. C_sm 0.03).

Conclusions

The socio-economic patterning of NCD prevalence differs markedly when assessed by standardized criteria versus self-reported diagnoses. NCDs in India are not necessarily diseases of affluence but also of poverty, indicating likely under-diagnosis and under-reporting of diseases among the poor. Standardized measures should be used, wherever feasible, to estimate the true prevalence of NCDs.     

Latin American healthcare systems in times of pandemic

The COVID‐ 19 pandemic is a critical test for the already overburdened and mostly underfunded public healthcare systems of Latin America. In a region that suffers from severe inequalities, public healthcare systems are the only source of medical care for a large sector of the population who work in the informal economy or are unemployed. State‐run hospitals and clinics are already overstressed by continuous demand for treatment of vector‐borne diseases and community‐acquired infections as well as high rates of non‐communicable diseases. Ideological misconceptions and denial among Latin America’s political leaders prevented timely preparations for the pandemic and added to chronic governance problems. As ethical expertise in Latin America focuses on research ethics, few hospitals in the region have functioning clinical ethics committees or clinical ethics policy, forcing healthcare personnel to make excruciating treatment decisions in an environment dominated by material scarcity and public distrust. This essay examines the emergence of COVID‐19 in Latin America and the serious challenge that it poses for Latin America's public healthcare systems.     

High Rates of Obesity and Chronic Disease Among United Methodist Clergy

We used self‐reported data from United Methodist clergy to assess the prevalence of obesity and having ever been told certain chronic disease diagnoses. Of all actively serving United Methodist clergy in North Carolina (NC) 95% (n = 1726) completed self‐report height and weight items and diagnosis questions from the Behavioral Risk Factor Surveillance Survey (BRFSS). We calculated BMI categories and diagnosis prevalence rates for the clergy and compared them to the NC population using BRFSS data. The obesity rate among clergy aged 35–64 years was 39.7%, 10.3% (95% CI = 8.5%, 12.1%) higher than their NC counterparts. Clergy also reported significantly higher rates of having ever been given diagnoses of diabetes, arthritis, high blood pressure, angina, and asthma compared to their NC peers. Health interventions that address obesity and chronic disease among clergy are urgently needed.