National and Subnational Cardiovascular Diseases Mortality Attributable to Salt Consumption in Iran by Sex and Age From 1990 to 2016

Peer reviewedPublisher PD

Dietary quality among men and women in 187 countries in 1990 and 2010: a systematic assessment

Background Healthy dietary patterns are a global priority to reduce non-communicable diseases. Yet neither worldwide patterns of diets nor their trends with time are well established. We aimed to characterise global changes (or trends) in dietary patterns nationally and regionally and to assess heterogeneity by age, sex, national income, and type of dietary pattern. Methods In this systematic assessment, we evaluated global consumption of key dietary items (foods and nutrients) by region, nation, age, and sex in 1990 and 2010. Consumption data were evaluated from 325 surveys (71·7% nationally representative) covering 88·7% of the global adult population. Two types of dietary pattern were assessed: one refl ecting greater consumption of ten healthy dietary items and the other based on lesser consumption of seven unhealthy dietary items. The mean intakes of each dietary factor were divided into quintiles, and each quintile was assigned an ordinal score, with higher scores being equivalent to healthier diets (range 0–100). The dietary patterns were assessed by hierarchical linear regression including country, age, sex, national income, and time as exploratory variables. Findings From 1990 to 2010, diets based on healthy items improved globally (by 2·2 points, 95% uncertainty interval (UI) 0·9 to 3·5), whereas diets based on unhealthy items worsened (–2·5, –3·3 to –1·7). In 2010, the global mean scores were 44·0 (SD 10·5) for the healthy pattern and 52·1 (18·6) for the unhealthy pattern, with weak intercorrelation (r=–0·08) between countries. On average, better diets were seen in older adults compared with younger adults, and in women compared with men (p<0·0001 each). Compared with low-income nations, high-income nations had better diets based on healthy items (+2·5 points, 95% UI 0·3 to 4·1), but substantially poorer diets based on unhealthy items (–33·0, –37·8 to –28·3). Diets and their trends were very heterogeneous across the world regions. For example, both types of dietary patterns improved in high-income countries, but worsened in some low-income countries in Africa and Asia. Middle-income countries showed the largest improvement in dietary patterns based on healthy items, but the largest deterioration in dietary patterns based on unhealthy items. Interpretation Consumption of healthy items improved, while consumption of unhealthy items worsened across the world, with heterogeneity across regions and countries. These global data provide the best estimates to date of nutrition transitions across the world and inform policies and priorities for reducing the health and economic burdens of poor diet quality

Global, regional and national consumption of major food groups in 1990 and 2010 : a systematic analysis including 266 country-specific nutrition surveys worldwide

Objective: To quantify global intakes of key foods related to non-communicable diseases in adults by region (n=21), country (n=187), age and sex, in 1990 and 2010. Design: We searched and obtained individual-level intake data in 16 age/sex groups worldwide from 266 surveys across 113 countries. We combined these data with food balance sheets available in all nations and years. A hierarchical Bayesian model estimated mean food intake and associated uncertainty for each age-sex-country-year stratum, accounting for differences in intakes versus availability, survey methods and representativeness, and sampling and modelling uncertainty. Setting/population: Global adult population, by age, sex, country and time. Results: In 2010, global fruit intake was 81.3 g/day (95% uncertainty interval 78.9–83.7), with country-specific intakes ranging from 19.2–325.1 g/day; in only 2 countries (representing 0.4% of the world's population), mean intakes met recommended targets of ≥300 g/day. Country-specific vegetable intake ranged from 34.6–493.1 g/day (global mean=208.8 g/day); corresponding values for nuts/seeds were 0.2–152.7 g/day (8.9 g/day); for whole grains, 1.3–334.3 g/day (38.4 g/day); for seafood, 6.0–87.6 g/day (27.9 g/day); for red meats, 3.0–124.2 g/day (41.8 g/day); and for processed meats, 2.5–66.1 g/day (13.7 g/day). Mean national intakes met recommended targets in countries representing 0.4% of the global population for vegetables (≥400 g/day); 9.6% for nuts/seeds (≥4 (28.35 g) servings/week); 7.6% for whole grains (≥2.5 (50 g) servings/day); 4.4% for seafood (≥3.5 (100 g) servings/week); 20.3% for red meats (≤1 (100 g) serving/week); and 38.5% for processed meats (≤1 (50 g) serving/week). Intakes of healthful foods were generally higher and of less healthful foods generally lower at older ages. Intakes were generally similar by sex. Vegetable, seafood and processed meat intakes were stable over time; fruits, nuts/seeds and red meat, increased; and whole grains, decreased. Conclusions: These global dietary data by nation, age and sex identify key challenges and opportunities for optimising diets, informing policies and priorities for improving global health.peer-reviewe

Assessing global dietary habits: a comparison of national estimates from the FAO and the Global Dietary Database.

BACKGROUND: Accurate data on dietary habits are crucial for understanding impacts on disease and informing policy priorities. Nation-specific food balance sheets from the United Nations FAO provided the only available global dietary estimates but with uncertain validity. OBJECTIVES: We investigated how FAO estimates compared with nationally representative, individual-based dietary surveys from the Global Dietary Database (GDD) and developed calibration equations to improve the validity of FAO data to estimate dietary intakes. DESIGN: FAO estimates were matched to GDD data for 113 countries across the following 9 major dietary metrics for 30 y of data (1980-2009): fruit, vegetables, beans and legumes, nuts and seeds, whole grains, red and processed meats, fish and seafood, milk, and total energy. Both absolute and percentage differences in FAO and GDD mean estimates were evaluated. Linear regression was used to evaluate whether FAO estimates predicted GDD dietary intakes and whether this prediction varied according to age, sex, region, and time. Calibration equations were developed to adjust FAO estimates to approximate national dietary surveys validated by using randomly split data sets. RESULTS: For most food groups, FAO estimates substantially overestimated individual-based dietary intakes by 74.5% (vegetables) and 270% (whole grains) while underestimating beans and legumes (-50%) and nuts and seeds (-29%) (P < 0.05 for each). In multivariate regressions, these overestimations and underestimations for each dietary factor further varied by age, sex, region, and time (P < 0.001 for each). Split-data set calibration models, which accounted for country-level covariates and other sources of heterogeneity, effectively adjusted FAO estimates to approximate estimates from national survey data (r = 0.47-0.80) with small SEs of prediction (generally 1-5 g/d). CONCLUSIONS: For all food groups and total energy, FAO estimates substantially exceeded or underestimated individual-based national surveys of individual intakes with significant variation depending on age, sex, region, and time. Calibration models effectively adjusted the comprehensive, widely accessible FAO data to facilitate a more-accurate estimation of individual-level dietary intakes nationally and by age and sex.Supported by a grant from the Bill & Melinda Gates Foundation (Global Dietary Habits among Women, Price and Income Elasticities, and Validity of Food Balance Sheets; to LCDG, SH, RM, PS and DM) and the Medical Research Council Epidemiology Unit Core Support (MC_UU_12015/5; to FI).This is the final version of the article. It first appeared from the American Society for Nutrition via http://dx.doi.org/10.3945/​ajcn.114.08740

Global sodium consumption and death from cardiovascular causes.

To access publisher's full text version of this article click on the hyperlink at the bottom of the pageHigh sodium intake increases blood pressure, a risk factor for cardiovascular disease, but the effects of sodium intake on global cardiovascular mortality are uncertain.We collected data from surveys on sodium intake as determined by urinary excretion and diet in persons from 66 countries (accounting for 74.1% of adults throughout the world), and we used these data to quantify the global consumption of sodium according to age, sex, and country. The effects of sodium on blood pressure, according to age, race, and the presence or absence of hypertension, were calculated from data in a new meta-analysis of 107 randomized interventions, and the effects of blood pressure on cardiovascular mortality, according to age, were calculated from a meta-analysis of cohorts. Cause-specific mortality was derived from the Global Burden of Disease Study 2010. Using comparative risk assessment, we estimated the cardiovascular effects of current sodium intake, as compared with a reference intake of 2.0 g of sodium per day, according to age, sex, and country.In 2010, the estimated mean level of global sodium consumption was 3.95 g per day, and regional mean levels ranged from 2.18 to 5.51 g per day. Globally, 1.65 million annual deaths from cardiovascular causes (95% uncertainty interval [confidence interval], 1.10 million to 2.22 million) were attributed to sodium intake above the reference level; 61.9% of these deaths occurred in men and 38.1% occurred in women. These deaths accounted for nearly 1 of every 10 deaths from cardiovascular causes (9.5%). Four of every 5 deaths (84.3%) occurred in low- and middle-income countries, and 2 of every 5 deaths (40.4%) were premature (before 70 years of age). The rate of death from cardiovascular causes associated with sodium intake above the reference level was highest in the country of Georgia and lowest in Kenya.In this modeling study, 1.65 million deaths from cardiovascular causes that occurred in 2010 were attributed to sodium consumption above a reference level of 2.0 g per day. (Funded by the Bill and Melinda Gates Foundation.).Bill and Melinda Gates Foundatio

Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk : a systematic assessment of beverage intake in 187 countries

Background: Sugar-sweetened beverages (SSBs), fruit juice, and milk are components of diet of major public health interest. To-date, assessment of their global distributions and health impacts has been limited by insufficient comparable and reliable data by country, age, and sex. Objective: To quantify global, regional, and national levels of SSB, fruit juice, and milk intake by age and sex in adults over age 20 in 2010. Methods: We identified, obtained, and assessed data on intakes of these beverages in adults, by age and sex, from 193 nationally- or subnationally-representative diet surveys worldwide, representing over half the world’s population. We also extracted data relevant to milk, fruit juice, and SSB availability for 187 countries from annual food balance information collected by the United Nations Food and Agriculture Organization. We developed a hierarchical Bayesian model to account for measurement incomparability, study representativeness, and sampling and modeling uncertainty, and to combine and harmonize nationally representative dietary survey data and food availability data. Results: In 2010, global average intakes were 0.58 (95%UI: 0.37, 0.89) 8 oz servings/day for SSBs, 0.16 (0.10, 0.26) for fruit juice, and 0.57 (0.39, 0.83) for milk. There was significant heterogeneity in consumption of each beverage by region and age. Intakes of SSB were highest in the Caribbean (1.9 servings/day; 1.2, 3.0); fruit juice consumption was highest in Australia and New Zealand (0.66; 0.35, 1.13); and milk intake was highest in Central Latin America and parts of Europe (1.06; 0.68, 1.59). Intakes of all three beverages were lowest in East Asia and Oceania. Globally and within regions, SSB consumption was highest in younger adults; fruit juice consumption showed little relation with age; and milk intakes were highest in older adults. Conclusions: Our analysis highlights the enormous spectrum of beverage intakes worldwide, by country, age, and sex. These data are valuable for highlighting gaps in dietary surveillance, determining the impacts of these beverages on global health, and targeting dietary policy.peer-reviewe

Global, regional, and national consumption levels of dietary fats and oils in 1990 and 2010: a systematic analysis including 266 country-specific nutrition surveys

Objectives: To quantify global consumption of key dietary fats and oils by country, age, and sex in 1990 and 2010. Design: Data were identified, obtained, and assessed among adults in 16 age- and sex-specific groups from dietary surveys worldwide on saturated, omega 6, seafood omega 3, plant omega 3, and trans fats, and dietary cholesterol. We included 266 surveys in adults (83% nationally representative) comprising 1 630 069 unique individuals, representing 113 of 187 countries and 82% of the global population. A multilevel hierarchical Bayesian model accounted for differences in national and regional levels of missing data, measurement incomparability, study representativeness, and sampling and modelling uncertainty. Setting and population Global adult population, by age, sex, country, and time. Results: In 2010, global saturated fat consumption was 9.4%E (95%UI=9.2 to 9.5); country-specific intakes varied dramatically from 2.3 to 27.5%E; in 75 of 187 countries representing 61.8% of the world’s adult population, the mean intake was <10%E. Country-specific omega 6 consumption ranged from 1.2 to 12.5%E (global mean=5.9%E); corresponding range was 0.2 to 6.5%E (1.4%E) for trans fat; 97 to 440 mg/day (228 mg/day) for dietary cholesterol; 5 to 3,886 mg/day (163 mg/day) for seafood omega 3; and <100 to 5,542 mg/day (1,371 mg/day) for plant omega 3. Countries representing 52.4% of the global population had national mean intakes for omega 6 fat ≥5%E; corresponding proportions meeting optimal intakes were 0.6% for trans fat (≤0.5%E); 87.6% for dietary cholesterol (<300 mg/day); 18.9% for seafood omega 3 fat (≥250 mg/day); and 43.9% for plant omega 3 fat (≥1,100 mg/day). Trans fat intakes were generally higher at younger ages; and dietary cholesterol and seafood omega 3 fats generally higher at older ages. Intakes were similar by sex. Between 1990 and 2010, global saturated fat, dietary cholesterol, and trans fat intakes remained stable, while omega 6, seafood omega 3, and plant omega 3 fat intakes each increased. Conclusions: These novel global data on dietary fats and oils identify dramatic diversity across nations and inform policies and priorities for improving global health

Global, regional and national sodium intakes in 1990 and 2010: a systematic analysis of 24 h urinary sodium excretion and dietary surveys worldwide

Objectives: To estimate global, regional (21 regions) and national (187 countries) sodium intakes in adults in 1990 and 2010. Design: Bayesian hierarchical modelling using all identifiable primary sources. Data sources and eligibility We searched and obtained published and unpublished data from 142 surveys of 24 h urinary sodium and 103 of dietary sodium conducted between 1980 and 2010 across 66 countries. Dietary estimates were converted to urine equivalents based on 79 pairs of dual measurements. Modelling methods Bayesian hierarchical modelling used survey data and their characteristics to estimate mean sodium intake, by sex, 5 years age group and associated uncertainty for persons aged 20+ in 187 countries in 1990 and 2010. Country-level covariates were national income/person and composition of food supplies. Main outcome measures Mean sodium intake (g/day) as estimable by 24 h urine collections, without adjustment for non-urinary losses. Results: In 2010, global mean sodium intake was 3.95 g/day (95% uncertainty interval: 3.89 to 4.01). This was nearly twice the WHO recommended limit of 2 g/day and equivalent to 10.06 (9.88–10.21) g/day of salt. Intake in men was ∼10% higher than in women; differences by age were small. Intakes were highest in East Asia, Central Asia and Eastern Europe (mean >4.2 g/day) and in Central Europe and Middle East/North Africa (3.9–4.2 g/day). Regional mean intakes in North America, Western Europe and Australia/New Zealand ranged from 3.4 to 3.8 g/day. Intakes were lower (<3.3 g/day), but more uncertain, in sub-Saharan Africa and Latin America. Between 1990 and 2010, modest, but uncertain, increases in sodium intakes were identified. Conclusions: Sodium intakes exceed the recommended levels in almost all countries with small differences by age and sex. Virtually all populations would benefit from sodium reduction, supported by enhanced surveillance

National and sub-national trends of salt intake in Iranians from 2000 to 2016 : a systematic analysis

Acknowledgements The authors wish to thank all the staff at the Non-Communicable Diseases Research Center of Tehran University of Medical Sciences for their support. Funding This study was supported by Iran University of Medical Sciences (Grant Number: 9221128206).Peer reviewedPublisher PD

Contributions of mean and shape of blood pressure distribution to worldwide trends and variations in raised blood pressure: A pooled analysis of 1018 population-based measurement studies with 88.6 million participants

© The Author(s) 2018. Background: Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure (representing the combined effects of public health interventions and secular trends) and changes in its high-blood-pressure tail (representing successful clinical interventions to control blood pressure in the hypertensive population). Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure. Methods: We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20-29 years to 70-79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probittransformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure. Results: In 2005-16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the highincome Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association. Conclusions: Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups