BACKGROUND:Nutrition is a critical determinant of tuberculosis (TB), providing a protective effect at high body mass index (BMI) and incurring an increased risk of TB disease at low BMI. Global nutritional transition and interventions to end hunger could directly affect the TB epidemic in high TB burden countries. METHODS:We constructed dynamic TB transmission models for 12 high TB burden countries with low HIV prevalence. We explicitly accounted for the effects of BMI on TB disease progression and treatment outcomes using a meta-analysis of longitudinal cohort studies, incorporating the effect of BMI mediated through diabetes. The models were calibrated to historical trends in TB epidemiology and mean BMI. We estimated potential changes in TB incidence and mortality between 2015 and 2030 under different scenarios of population nutrition. FINDINGS:Compared with a scenario where mean BMI remained at 2015 levels, if past trends in mean BMI continued then by 2030 TB incidence and mortality would decline by a cumulative 14.7% (95% credible interval: 12.7%-16.7%) and 15.6% (12.5%-19.2%), respectively. In comparison, achieving zero hunger by 2030 would reduce incidence and mortality by 32.0% (20.0%-43.8%) and 37.3% (26.1%-49.6%), respectively. If past trends continued and zero hunger was also achieved, incidence and mortality would be reduced by 38.2% (27.0%-49.1%) and 42.4% (32.1%-53.5%), respectively, equivalent to preventing 20.6 million people developing TB disease and averting 5.4 million TB deaths over 15 years in the 12 high-burden countries. CONCLUSIONS:Nutrition transitions and interventions to end hunger could have a major impact on the future epidemiology of TB in high-burden countries. Investment is urgently required to implement and scale up nutritional interventions.

INTRODUCTION:While trends in breast cancer incidence in Iran are generally monitored at the national level, little is known about subnational variations in these trends. This study aimed to assess the levels and trends (2000-2021) of the relative risk (RR) of breast cancer incidence at the district level in Iran and its relation to key socioeconomic dimensions to understand the full extent of geographical and social inequalities in the country associated with breast cancer morbidity. METHODS:District-level incidence data by age and sex from the National Cancer Registry System of the Iranian Ministry of Health were used. Related covariates were extracted from the Census and Household Expenditure and Income Survey (HEIS) datasets. The RR of breast cancer incidence was estimated in women above the age of 30 for all 316 districts in Iran from 2000 to 2010 using a Bayesian spatiotemporal model. Finally, predictions were estimated for the period 2011-2021. RESULTS:The national RR of breast cancer incidence in Iran increased from 0.21 (95% credible interval (CrI): 0.19, 0.22) in 2000 to 0.66 (0.63, 0.68) in 2010 and 1.23 (1.18, 1.28) in 2021. The RR of breast cancer incidence was highest in Yazd (1.96 [1.63, 2.33]), Shiraz (1.90 [1.72, 2.09]) and Shemiranat (1.90 [1.12, 2.91]) in 2010 and in Tehran (3.99 [3.86, 4.33]), Bushehr (3.89 [3.07, 4.77]) and Abadan (3.67 [2.99, 4.39]) in 2021. In contrast, Savojbolagh, Saravan and Nikshahr had the lowest RRs in both 2010 (0.11 [0.05, 0.20], 0.17 [0.08, 0.30] and 0.20 [0.09, 0.36], respectively) and 2021 (0.19 [0.10, 0.33], 0.34 [0.18, 0.54] and 0.35 [0.17, 0.62], respectively). The RR of breast cancer incidence was 60% greater across districts in the highest YOS quintile (average years of schooling: 3.9) than in those in the lowest YOS quintile (average years of schooling: 2.2; relative index of inequality: 1.6). CONCLUSIONS:The results show that the RR of breast cancer incidence has increased over time (2000-2021) at the national and subnational levels in Iran. Breast cancer is one of the few diseases with a positive education gradient, with a greater RR of breast cancer incidence among higher-educated women than among lower-educated women. However, this is likely due to better awareness of diagnostic approaches and access to those approaches rather than reflecting patterns in the true incidence of breast cancer. While social inequalities are a major barrier to reducing the prevalence and incidence of breast cancer, it is important to track the progress made at the district level based on the characteristics of specific policies aimed at reducing health inequalities. A scaling-up in the quality of healthcare services, national and subnational policies addressing prevention and treatment, and more specialised training programmes for women's health are needed.

An Intrinsic Gaussian Markov Random Field (IGMRF) can be used to induce conditional dependence in Bayesian hierarchical models. IGMRFs have both a precision matrix, which defines the neighborhood structure of the model, and a precision, or scaling, parameter. Previous studies have shown the importance of selecting the prior for this scaling parameter appropriately for different types of IGMRF, as it can have a substantial impact on posterior estimates. Here, we focus on cases in one and two dimensions, where tuning of the prior is achieved by mapping it to the marginal SD of an IGMRF of corresponding dimensionality. We compare the effects of scaling various IGMRFs, including an application to real two-dimensional blood pressure data using MCMC methods.

Background:Chronic complete vascular occlusion causes significant morbidity and mortality in patients with congenital heart disease (CHD). The diversity of lesions, lack of dedicated equipment, and small number of procedures performed by individual operator continue to pose a challenge to congenital interventional cardiologists.Case summary:We report two cases of percutaneous recanalization in CHD using percutaneous coronary intervention (PCI) equipment for chronic total occlusion (CTO).Discussion:Careful pre-procedural planning, access site choice, use of catheter guiding systems for support, and selection of penetrating guidewires and techniques used in CTO-PCIs are key steps to a successful outcome.

Low fruit and vegetable consumption is a major modifiable risk factor for raised blood pressure (BP), but it is unknown how heterogeneity in national supply has contributed to BP trends. To address this, we characterised supply trends from 1975 to 2015 and whether it met WHO recommendations. We then examined associations with three metrics: systolic, diastolic and raised BP. We used ecological data on fruit and vegetable supply and on BP for 159 countries. We examined trends in fruit and vegetable supply from 1975 to 2015 by country and World Bank income region. Multivariable linear regression was used to examine cross-sectional associations with BP. Global fruit and vegetable supply increased from 1975 to 2015, but with heterogeneous national and regional trends. While WHO recommendations were met globally, this target was not met in almost half the countries, of which many were low-income countries. Significant associations between combined fruit and vegetable supply and raised BP were observed. Over the past four decades, combined fruit and vegetable supply has been consistently and strongly associated with lower prevalence of raised BP globally. However, the heterogeneous regional trends in fruit and vegetable supply underpin the need for international organisations and individual governments to introduce or strengthen policies for increased fruit and vegetable supply to reduce the burden of non-communicable diseases at national and global levels.

Background: No established risk prediction tool exists in United Kingdom and Irish Paediatric Cardiology practice for patients undergoing cardiac catheterisation. The Catheterisation RISk score for Paediatrics is used primarily in North American practice to assess risk prior to cardiac catheterisation. Validating the utility and transferability of such a tool in practice provides the opportunity to employ an already established risk assessment tool in everyday practice. Aims: To ascertain whether the Catheterisation RISk score for Paediatrics assessment tool can accurately predict complications within United Kingdom and Irish congenital catheterisation practice. Methods: Clinical and procedural data including National Institute for Cardiovascular Outcomes Research derived outcome data from 1500 patients across five large congenital cardiology centres in the United Kingdom and Ireland were retrospectively collected. Catheterisation RISk score for Paediatrics were then calculated for each case and compared with the observed procedural outcomes. Chi-square analysis was used to determine the relationship between observed and predicted events. Results: Ninety-eight (6.6%) patients in this study experienced a significant complication as qualified by National Institute for Cardiovascular Outcomes Research classification. 4% experienced a moderate complication, 2.3% experienced a major complication and 0.3% experienced a catastrophic complication resulting in death. Calculated Catheterisation RISk score for Paediatrics scores correlated well with all observed adverse events for paediatric patients across all CRISP categories. The association was also transferable to adult congenital heart disease patients in lower Catheterisation RISk score for Paediatrics categories (CRISP 1-3). Conclusion: The Catheterisation RISk score for Paediatrics score accurately predicts significant complications in congenital catheterisation practice in the United Kingdom and Ireland. Our data validated the Catheterisation RISk score for Paediatrics assessment tool in five congenital centres using National Institute for Cardiovascular Outcomes Research-derived outcome data.

Obesity involves excessive accumulation of body fat. While largely preventable, it has become increasingly common in most of the world in recent decades. Obesity can cause severe health problems, including cardiovascular diseases, musculoskeletal disorders, respiratory conditions, and type 2 diabetes mellitus. It also leads to negative psychological outcomes such as depression and low self-esteem, as well as discrimination and stigma. Recently, the long-term obesity epidemic has interacted with the sudden onset of the COVID-19 pandemic, during which patients with obesity have experienced higher rates of hospitalisation, ICU admission and death. The increases in obesity prevalence have been caused by changes in diet, with greater availability of energy-dense foods, and reductions in physical activity. These developments have been influenced by factors such as socio-economic status.In this chapter, we describe the long-term global challenge posed by obesity. We provide an overview of patterns across the world, but focus particularly on trends in nine countries. China and India are of key importance because of their large populations; they are experiencing diverging trends in obesity in children that will have major consequences over the lifecourse. Other countries have had particular experiences of obesity, including the early-onset and severe epidemics in Nauru and the USA, and the relatively benign trends in Japan. Trends in Brazil, Germany, Iran and South Africa are also described in detail, because they are large countries that are representative of their wider regions. Finally, we suggest ways in which obesity and its determinants should be monitored in coming decades, to maximise the impact of interventions for tackling this complex global challenge.

OBJECTIVES:Since percutaneous pulmonary valve implantation (PPVI) was introduced to prolong the lifetime of surgically placed right ventricular to pulmonary artery conduits, valve technology has evolved and the indications for PPVI expanded to native and larger right ventricular outflow tracts. We explore how indications, patient populations and outcomes compare to surgical pulmonary valve replacement (PVR).METHODS:This is a retrospective cohort study of PPVI and PVR procedures between 1998 and 2020 at a single UK centre. One hundred and twenty-eight patients underwent PPVI and 365 patients PVR. Primary outcome measures were survival, infective endocarditis and reintervention.RESULTS:The most common indication for PVR was replacement of the native pulmonary valve for pulmonary regurgitation whereas PPVI was more commonly used to treat pulmonary stenosis in a previously placed bioprosthetic conduit or valve. Treatment indications for PPVI expanded over the study to include the native right ventricular outflow tract. Survival was similar for PPVI and PVR (92% PPVI and 96.8% PVR at 5 years; 85.8% PPVI and 95.1% PVR at 10 years). Preprocedural New York Heart Association class 3 and 4 was the most important predictor of poor outcome. Annualized infective endocarditis rate was significantly higher for the Melody PPVI (0.024 vs 0.0024/person/year for PVR, P < 0.05). Both groups showed significant symptomatic improvement postprocedure with remodelling of ventricular volumes and improvement in cardiac output. Long-term follow-up for PVR showed half of patients will need replacement at 10-15 years post-index procedure.CONCLUSIONS:An increasing number of patients requiring PVR can now be treated percutaneously. A lifetime strategy for re-valving should be considered at the first valve implant.

Global food systems are developing rapidly, and have resulted in a large burden of disease and a high proportion of environmental resource use. We combined global data sources on food supply and trade, environmental footprints, burdens of disease, and vulnerability to climate change to explore patterns from 1990 to 2017. Four distinct patterns of food supply (animal sources and sugar, vegetables and nuts, starchy roots and fruits, and seafood and oils) were matched to health and environmental risks. The animal sources and sugar pattern was found to have the greatest environmental footprint and to be associated with a greater burden of chronic disease than any other pattern, although it was also associated with lower undernutrition. This pattern is globally predominant, but has begun to decrease in higher income countries. Countries where this pattern is predominant are generally among the least susceptible to climate change, whereas more susceptible countries tend to have more sustainable patterns of food supply. More countries that are susceptible to climate change are increasingly exporting a larger proportion than before of their cereals, fruit, and vegetables globally, which will lead to increased risks in global food security. To increase resilience to future shocks, dietary change towards more sustainable patterns should accelerate in high-income countries, and the food systems of the most susceptible countries should be protected.

We present five cases of sinus-SuperFlex-DS stent stenosis during early follow up that resulted in inadequate ductal patency and required urgent re-stenting with a balloon-expandable stent. This causes concern that these stents lack sufficient radial force against ductal constriction and if used need to be kept under close scrutiny.

Intrinsic Gaussian Markov Random Fields (IGMRFs) can be used to induce conditional dependence in Bayesian hierarchical models. IGMRFs have both a precision matrix, which defines the neighbourhood structure of the model, and a precision, or scaling, parameter. Previous studies have shown the importance of selecting this scaling parameter appropriately for different types of IGMRF, as it can have a substantial impact on posterior results. Here, we focus on the two-dimensional case, where tuning of the parameter is achieved by mapping it to the marginal standard deviation of a two-dimensional IGMRF. We compare the effects of scaling various classes of IGMRF, including an application to blood pressure data using MCMC methods.

Many real-world phenomena are naturally bivariate. This includes blood pressure, which comprises systolic and diastolic levels. Here, we develop a Bayesian hierarchical model that estimates these values and their interactions simultaneously, using sparse data that vary substantially between countries and over time. A key element of the model is a two-dimensional second-order Intrinsic Gaussian Markov Random Field, which captures non-linear trends in the variables and their interactions. The model is fitted using Markov chain Monte Carlo methods, with a block Metropolis-Hastings algorithm providing efficient updates. Performance is demonstrated using simulated and real data.

Background In Iran, trends in breast cancer incidence and mortality have generally been monitored at national level. The purpose of this study is to examine province-level disparities in age-standardised breast cancer incidence versus mortality from 2000 to 2010 and their association with socioeconomic status. Methods In this study, data from Iran's national cancer and death registry systems, and covariates from census and household expenditure surveys were used. We estimated the age-standardised incidence and mortality rates in women aged more than 30 years for all 31 provinces in the consecutive time intervals 2000-2003, 2004-2007 and 2008-2010 using a Bayesian spatial model. Results Mean age-standardised breast cancer incidence across provinces increased over time from 15.0 per 100,000 people (95% credible interval 12.0,18.3) in 2000-2003 to 39.6 (34.5,45.1) in 2008-2010. The mean breast cancer mortality rate declined from 10.9 (8.3,13.8) to 9.9 (7.5,12.5) deaths per 100,000 people in the same period. When grouped by wealth index quintiles, provinces in the highest quintile had higher levels of incidence and mortality. In the wealthiest quintile, reductions in mortality over time were larger than those observed among provinces in the poorest quintile. Relative breast cancer mortality decreased by 16.7% in the highest quintile compared to 10.8% in the lowest quintile. Conclusions Breast cancer incidence has increased over time, with lower incidence in the poorest provinces likely driven by underdiagnoses or late-stage diagnosis. Although the reported mortality rate is still higher in wealthier provinces, the larger decline over time in these provinces indicates a possible future reversal, with the most deprived provinces having higher mortality rates. Ongoing analysis of incidence and mortality at sub-national level is crucial in addressing inequalities in healthcare systems and public health both in Iran and elsewhere.

Food systems are increasingly globalized and interdependent, and diets around the world are changing. Characterization of national food supplies and how they have changed can inform food policies that ensure national food security, support access to healthy diets and enhance environmental sustainability. Here we analysed data for 171 countries on the availability of 18 food groups from the United Nations Food and Agriculture Organization to identify and track multidimensional food supply patterns from 1961 to 2013. Four predominant food-group combinations were identified that explained almost 90% of the cross-country variance in food supply: animal source and sugar, vegetable, starchy root and fruit, and seafood and oilcrops. South Korea, China and Taiwan experienced the largest changes in food supply over the past five decades, with animal source foods and sugar, vegetables and seafood and oilcrops all becoming more abundant components of the food supply. In contrast, in many Western countries the supply of animal source foods and sugar declined. Meanwhile, there was remarkably little change in the food supply in countries in the sub-Saharan Africa region. These changes led to a partial global convergence in the national supply of animal source foods and sugar, and a divergence in those of vegetables and of seafood and oilcrops. Our analysis generated a novel characterization of food supply that highlights the interdependence of multiple food types in national food systems. A better understanding of how these patterns have evolved and will continue to change is needed to support the delivery of healthy and sustainable food system policies. Food systems are increasingly globalized and interdependent. Using food supply data from over 170 countries, Bentham et al. characterize global patterns of food supply change over five decades, highlighting the decline in the supply of animal source food and sugar in many Western countries, the increase in the supply of such foods in Asian countries and remarkably little change in food supply in the sub-Saharan Africa region.

Background Describing the prevalence and trends of cardiometabolic risk factors that are associated with noncommunicable diseases (NCDs) is crucial for monitoring progress, planning prevention, and providing evidence to support policy efforts. We aimed to analyse the transition in body-mass index (BMI), obesity, blood pressure, raised blood pressure, and diabetes in the Americas, between 1980 and 2014. Methods We did a pooled analysis of population-based studies with data on anthropometric measurements, biomarkers for diabetes, and blood pressure from adults aged 18 years or older. A Bayesian model was used to estimate trends in BMI, raised blood pressure (systolic blood pressure >= 140 mm Hg or diastolic blood pressure >= 90 mm Hg), and diabetes (fasting plasma glucose >= 7.0 mmol/L, history of diabetes, or diabetes treatment) from 1980 to 2014, in 37 countries and six subregions of the Americas. Findings 389 population-based surveys from the Americas were available. Comparing prevalence estimates from 2014 with those of 1980, in the non-English speaking Caribbean subregion, the prevalence of obesity increased from 3.9% (95% CI 2.2-6.3) in 1980, to 18.6% (14.3-23.3) in 2014, in men; and from 12.2% (8.2-17.0) in 1980, to 30.5% (25.7-35.5) in 2014, in women. The English-speaking Caribbean subregion had the largest increase in the prevalence of diabetes, from 5.2% (2.1-10.4) in men and 6.4% (2.6-10.4) in women in 1980, to 11.1% (6.4-17.3) in men and 13.6% (8.2-21-0) in women in 2014). Conversely, the prevalence of raised blood pressure has decreased in all subregions; the largest decrease was found in North America from 27.6% (22.3-33.2) in men and 19.9% (15.8-24-4) in women in 1980, to 15.5% (11.1-20.9) in men and 10.7% (7.7-14.5) in women in 2014. Interpretation Despite the generally high prevalence of cardiometabolic risk factors across the Americas, estimates also showed a high level of heterogeneity in the transition between countries. The increasing prevalence of obesity and diabetes observed over time requires appropriate measures to deal with these public health challenges. Our results support a diversification of health interventions across subregions and countries. Copyright (C) 2019 The Author(s). Published by Elsevier.

This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002-2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002-2014). Products were classified as UPFD/non-UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%-44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%-86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m2 for men (P < .001) and 0.072 kg/m2 for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m2 for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population-level BMI trajectories.

Background In recent decades, the prevalence of obesity in children has increased dramatically. This worldwide epidemic has important consequences, including psychiatric, psychological and psychosocial disorders in childhood and increased risk of developing non-communicable diseases (NCDs) later in life. Treatment of obesity is difficult and children with excess weight are likely to become adults with obesity. These trends have led member states of the World Health Organization (WHO) to endorse a target of no increase in obesity in childhood by 2025. Main body Estimates of overweight in children aged under 5 years are available jointly from the United Nations Children’s Fund (UNICEF), WHO and the World Bank. The Institute for Health Metrics and Evaluation (IHME) has published country-level estimates of obesity in children aged 2–4 years. For children aged 5–19 years, obesity estimates are available from the NCD Risk Factor Collaboration. The global prevalence of overweight in children aged 5 years or under has increased modestly, but with heterogeneous trends in low and middle-income regions, while the prevalence of obesity in children aged 2–4 years has increased moderately. In 1975, obesity in children aged 5–19 years was relatively rare, but was much more common in 2016. Conclusions It is recognised that the key drivers of this epidemic form an obesogenic environment, which includes changing food systems and reduced physical activity. Although cost-effective interventions such as WHO ‘best buys’ have been identified, political will and implementation have so far been limited. There is therefore a need to implement effective programmes and policies in multiple sectors to address overnutrition, undernutrition, mobility and physical activity. To be successful, the obesity epidemic must be a political priority, with these issues addressed both locally and globally. Work by governments, civil society, private corporations and other key stakeholders must be coordinated.

OBJECTIVES:The objectives of this study were to describe the approach to stenting arterial shunts in adult congenital patients with single-ventricle physiology and to assess the medium-term clinical and haemodynamic outcomes following stent insertion.BACKGROUND:Adult patients with single-ventricle physiology and pulmonary blood flow dependent on a surgically placed arterial shunt who did not progress to venous palliation are extremely challenging to manage. Progressive cyanosis secondary to narrowing of the shunt has a marked impact on exercise tolerance and results in intolerable well-being for these patients. Stenting arterial shunts in adult patients is one method that can help improve pulmonary blood flow. There is very limited information in the literature about this patient.METHODS:This is a retrospective study for arterial shunts stenting conducted between 2008 and 2016. The peripheral oxygen saturations, the NYHA status, the haemoglobin, and the degree of atrio-ventricular valve regurgitation as assessed on transthoracic echo were compared before and 6-12 months after procedures.RESULTS:There was a short-term improvement in oxygen saturations; the pre-procedure mean was 75.8 (SD 2.55)% (range 70-85%) and post-procedure mean was 83 (SD 2.52)% (range 78-87%), with a p value of 0.04. Haemoglobin level decreased from a pre-procedure mean of 22.06-20.28 g/L 6 months post procedure (range 18.1-24.4 to 13-23.3 g/L), with a p value of 0.44. NYHA class decreased from a mean of 3.2-2.2 post procedure. Left atrial volume for four of the cases did not change (22.6-76.6 ml [mean 48.4 ml] to 29.6-72.9 ml [mean 52 ml], p value: 0.83).CONCLUSIONS:Stenting stenotic arterial shunts is a useful method to gain a medium-term improvement on the oxygen saturation and clinical symptoms, and may act as a useful intermediate step for further management plans.

The NCD Risk Factor Collaboration study (Dec 16, 2017, p 2627)1 is a landmark description of the progress of the obesity pandemic, but substantially underestimates the scale of the problem. The study1 defined obesity using body-mass index (BMI) in adults and BMI-for-age in children and adolescents. Systematic reviews2–4 of a large amount of high-quality and consistent evidence show that the use of BMI to define obesity (the degree of excess body fat) is highly specific, but has low to moderate sensitivity.