Educational level, relative body weight, and changes in their association over 10 years: an international perspective from the WHO MONICA Project

OBJECTIVES: This study assessed the consistency and magnitude of the association between educational level and relative body weight in populations with widely different prevalences of over-weight and investigated possible changes in the association over 10 years. METHODS: Differences in age-adjusted mean body mass index (BMI) between the highest and the lowest tertiles of years of schooling were calculated for 26 populations in the initial and final surveys of the World Health Organization (WHO) MONICA (Monitoring Trends and Determinants in Cardiovascular Disease) Project. The data are derived from random population samples, including more than 42,000 men and women aged 35 to 64 years in the initial survey (1979-1989) and almost 35,000 in the final survey (1989-1996). RESULTS: For women, almost all populations showed a statistically significant inverse association between educational level and BMI; the difference between the highest and the lowest educational tertiles ranged from -3.3 to 0.4 kg/m2. For men, the difference ranged from -1.5 to 2.2 kg/m2. In about two thirds of the populations, the differences in BMI between the educational levels increased over the 10-year period. CONCLUSION: Lower education was associated with higher BMI in about half of the male and in almost all of the female populations, and the differences in relative body weight between educational levels increased over the study period. Thus, socioeconomic inequality in health consequences of obesity may increase in many countries.     

The Worldwide WHO MONICA Project: results and perspectives

After World War II coronary heart disease (CHD) assumed epidemic proportions in western countries. In many countries the peak of the epidemic occurred in 1968. In 1978 the National Heart, Lung and Blood Institute of the NIH organized the Bethesda conference on the decline in CHD mortality. The aim of the conference was to find out whether measures of prevention or improvements in acute coronary care were responsible for the decline in age-specific CHD mortality rates. Because of lack of appropriate data in 1978 these questions remained unanswered. To answer these questions the WHO MONICA (Monitoring trends and determinants in cardiovascular disease) project was organized as a monitoring system to assess trends and determinants of cardiovascular mortality, incidence and case fatality from the mid 1980 s to the mid 1990 s in 38 populations in 21 countries worldwide. Altogether some 13 million people were monitored over a 10 year period. 166,000 myocardial infarction patients were registered and more than 300,000 men and women were sampled and examined for their cardiovascular risk factors and many other health data. In Western countries, where the CHD mortality decline was on average 2-3 % annually, two thirds of this decline could be explained by a decline in CHD incidence and one third by a decline in CHD case fatality. When relating risk factor changes to changes in CHD event rates in men over a time period of 10 years in all MONICA populations it turned out that the greatest contribution to the CHD decline came from a decrease in smoking. On a worldwide scale the Seven Countries Study, the Framingham Heart Study and the WHO MONICA Project have contributed most to the development of epidemiology and prevention of cardiovascular diseases.     

Prevalence, awareness and treatment of hypercholesterolaemia in 32 populations: results from the WHO MONICA Project

BACKGROUND: Several studies have been conducted to estimate the population prevalence of hypertension, or its diagnosis and treatment. There is no multinationally comparable information on the prevalence of hypercholesterolaemia, or its diagnosis and treatment, since individual studies are often not directly comparable. METHODS: Data from the WHO MONICA Project's final risk factor surveys were used. Data were collected using standardized methods between 1989 and 1997 for the 35-64 year age range in 32 populations, in 19 countries on 3 continents. RESULTS: The prevalence of hypercholesterolaemia (total cholesterol > or = 6.5 mmol/l or taking lipid-lowering drugs) varied across populations from 3% to 53% in men, and from 4% to 40% in women. Awareness of hypercholesterolaemia varied from 1% to 33% in men, and from 0% to 31% in women. In most populations, over 50% of men and women on lipid-lowering drugs had a cholesterol level < 6.5 mmol/l. CONCLUSIONS: There is wide variation in the prevalence, awareness, and treatment of hypercholesterolaemia between populations. For the planning and implementation of primary prevention programmes and for the development of health care systems, monitoring of changes, both within and between populations, is essential. To obtain reliable information on these changes, well-standardized methods must be applied.     

Smoking cessation and body weight: evidence from the Behavioral Risk Factor Surveillance Survey

Objective

To investigate the role of smoking cessation in body weight.

Data Sources

2004–2005 and 2009–2010 Behavioral Risk Factor Surveillance Surveys (BRFSS) (N = 349,000), Centers for Disease Control and Prevention; Tax Burden on Tobacco (Orzechowski and Walker 2010).

Study Design

The Gaussian treatment effect model is estimated for three age categories by gender. Treatment effects of quitting smoking on body mass index (BMI) by quit length are calculated.

Principal Findings

Quitting is found to be endogenous. Differentiated effects of quitting smoking on BMI are found among quitters by gender, between age groups, and by length of time since quitting smoking, and positive association between smoking cessation and body weight confirmed. Declining smoking rates have only a modest effect in the overweight population. The effects of quitting on BMI are considerably lower among younger men and women.

Conclusion

The price that must be paid, in terms of weight gain, to enjoy the health benefits of smoking cessation is trivial even for the obese population.     

Methods of total cholesterol measurement in the baseline survey of the WHO MONICA Project

In the WHO MONICA Project (Monitoring of Trends and Determinants of Cardiovascular Disease) total cholesterol was measured in representative samples from 51 study populations in 26 countries. The biochemical measurements were done locally by the collaborating centres' laboratories. Differences in measurement procedures among the populations were found in the following factors: fasting status, posture of the subject, tourniquet use, use of serum or plasma, storage conditions, and the analytical method itself. This paper gives an overview of the methods used, and discusses the possible effects of the differences on the comparability of the results. The use of a posture other than that recommended and the use of EDTA (ethylene diaminetetraacetate) plasma are considered to be the most important factors, and were found in 9 out of the 51 populations.     

Effect on Trend Estimates of the Difference between Survey Respondents and Non-respondents: Results from 27 Populations in the WHO MONICA Project

Introduction: In the World Health Organization (WHO) MONICA (multinational MONItoring of trends and determinants in CArdiovascular disease) Project considerable effort was made to obtain basic data on non-respondents to community based surveys of cardiovascular risk factors. The first purpose of this paper is to examine differences in socio-economic and health profiles among respondents and non-respondents. The second purpose is to investigate the effect of non-response on estimates of trends. Methods:Socio-economic and health profile between respondents and non-respondents in the WHO MONICA Project final survey were compared. The potential effect of non-response on the trend estimates between the initial survey and final survey approximately ten years later was investigated using both MONICA data and hypothetical data. Results: In most of the populations, non-respondents were more likely to be single, less well educated, and had poorer lifestyles and health profiles than respondents. As an example of the consequences, temporal trends in prevalence of daily smokers are shown to be overestimated in most populations if they were based only on data from respondents. Conclusions: The socio-economic and health profiles of respondents and non-respondents differed fairly consistently across 27 populations. Hence, the estimators of population trends based on respondent data are likely to be biased. Declining response rates therefore pose a threat to the accuracy of estimates of risk factor trends in many countries.     

The drug lag issue: the debate seen from an international perspective.

This article reviews the literature related to the "drug lag" issue, i.e., the issue of whether important new drugs are introduced relatively late, or, in certain cases, are introduced at all, in a particular country. The literature can be divided into two main parts: studies primarily related to the delay in introduction of new drugs and studies primarily related to the number of introduced new drugs. Most studies have found the United States, Sweden, and Norway to have a long delay in the introduction of new drugs. The United Kingdom and (West) Germany in general have the shortest delay. There are also large differences in the number of introduced new drugs. In most studies, the United States and Norway have introduced far fewer new drugs than any other industrialized country. In general (West) Germany, France, the United Kingdom, and Italy have introduced the largest number of new drugs. One of the reviewed studies presented a relationship between regulatory processing time and delay in introduction. Another study found an increasing influence of regulatory stringency on the number of introduced new drugs in a country. If a country's aim is to decrease the delay in introduction and/or to increase the introduction of important new drugs, a review of the local regulatory agencies and the regulations seems worthwhile.     

Nicotine effects on body weight: a regulatory perspective.

Rats infused with nicotine were initially hypophagic and lost weight. Although food intake recovered, body weight remained 8-12% below normal. Elevating (or reducing) body weight before treatment prolonged (or shortened) initial hypophagia; weight reliably stabilized at the reduced level. At this reduced weight, the treated rats' daily resting energy expenditure was comparable with that of normal-weight controls (262.3 vs 261.9 kJ.d-1.kg body wt-0.75). Reducing the weight of controls to that of treated rats caused their expenditure to drop to 250.6 kJ.d-1.kg body wt-0.75, an energy-conserving adjustment that treated rats also displayed when their weight was lowered from its already-reduced level. Terminating nicotine treatment led initially to hyperphagia, which abated upon body weight being restored to normal. Normal daily energy expenditures at reduced weights suggest that nicotine lowers regulated body energy. Acute intake adjustments associated with initiation (or cessation) of nicotine treatment can be viewed as responses appropriate to bringing body energy into balance with the altered regulation level.     

Trends in cigarette smoking in 36 populations from the early 1980s to the mid-1990s: findings from the WHO MONICA Project

OBJECTIVES: This report analyzes cigarette smoking over 10 years in populations in the World Health Organization (WHO) MONICA Project (to monitor trends and determinants of cardiovascular disease). METHODS: Over 300,000 randomly selected subjects aged 25 to 64 years participated in surveys conducted in geographically defined populations. RESULTS: For men, smoking prevalence decreased by more than 5% in 16 of the 36 study populations, remained static in most others, but increased in Beijing. Where prevalence decreased, this was largely due to higher proportions of never smokers in the younger age groups rather than to smokers quitting. Among women, smoking prevalence increased by more than 5% in 6 populations and decreased by more than 5% in 9 populations. For women, smoking tended to increase in populations with low prevalence and decrease in populations with higher prevalence; for men, the reverse pattern was observed. CONCLUSIONS: These data illustrate the evolution of the smoking epidemic in populations and provide the basis for targeted public health interventions to support the WHO priority for tobacco control.     

Contraception: an international perspective

Although it is estimated that the population growth rate will decline to a replacement level by 2050, it is also now predicted that the total world population will reach 8.9 billion in that year -- far higher than the 2004 estimate of 6.4 billion. More than 26 billion new couples will need contraceptives in the next half century. Although a steady increase in contraceptive use has been observed in both developed and developing countries, the contraceptive needs of a high percentage of couples have not yet been met and the number of unplanned pregnancies continues to increase. The actual use of contraception differs from region to region. Although no new method has been registered for many years, several new products have been marketed during the last 5. Among these are new implants, medicated intrauterine systems, contraceptive vaginal rings, transdermal patches and several new combined oral contraceptive formulations. New contraceptive methods have been developed to meet the objectives of expanding contraceptive choices for both women and men and answering an unmet need for contraceptives with a long-term action that meet the expectations of consumers. Simplicity, reversibility and effectiveness are the desired features of a male contraceptive, but no new male contraceptive method is yet available. New areas of basic research include studies on genes, proteins and enzymes involved in the reproductive system. The new methods will be targeted to specific interactions within the reproductive system at the level of ovaries and testes, as well as between spermatozoa and ova. This futuristic approach still keeps in mind the need for better access to existing contraceptive methods, as well as the discovery of new contraceptives that are simple to use, safe, reversible and inexpensive. In the future, contraceptives may be combined with other medicinal agents to provide dual protection against both pregnancy and other preventable conditions, such as sexually transmitted infections.