87 research outputs found

    ATRIBUTOS QUÍMICOS E FÍSICOS DO SOLO, ESTOQUES DE CARBONO E NITROGÊNIO E FRAÇÕES HÚMICAS EM DIFERENTES FORMAÇÕES VEGETAIS

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    Cerrado biome is the second largest Brazilian biome, where different phyto-physiognomical features are observed, which may be influenced by soil factors. Thus, this study aimed to evaluate soil physical and fertility properties (particle size analysis, bulk density - BD and total pore volume - TPV), carbon and nitrogen stocks and chemical fractions of soil organic matter (SOM ) in areas of mesophytic forest, Cerrado and Cerrado sensu stricto in the ecological station of Pirapitinga, Minas Gerais state. The soil was classified as Oxisol and soil samples were collected from the layers 0-0.05, 0.5-0.1, 0.1-0.2, and 0.2-0.4 m. The experimental design was completely randomized. Areas of mesophytic forest and cerrado grow in soil with higher clay compared to the Cerrado sensu stricto, indicating that possibly more clayey soils have higher water holding capacity and nutrient supply to attend the demand more appropriately with larger vegetations. The mesophytic forest area by presenting high waste disposal of plant and be in the clayey soil is in some layers providing higher levels of soil organic C and humic substances, triggering lower values ​​of bulk density, greater total porosity and availability of P in relation to other vegetation types studied. However, the closed areas and Cerrado sensu stricto have higher amounts of Mg, K, and lower pH, H + Al and Al compared to mesophitic forest area, which may suggest that these phytophysiognomies settle preferentially in the most fertile soils of Cerrado biome. The relationship between the humic acid and fulvic acid fraction indicates that the forest vegetation Mesophytic presents for vegetation of Cerrado and Cerado sensu stricto soil organic matter of great quality, which allows the establishment of physical and chemical attributes favorable to the development of the plant. The largest stocks of carbon are verified in larger vegetation, cerrado and mesophytic forest. However, the higher grade and stock soil nitrogen occur in Cerrado sensu stricto.http://dx.doi.org/10.5902/1980509819613O Cerrado é o segundo maior bioma brasileiro, no qual são observadas diferentes feições fitofisionômicas, que podem ser influenciadas por fatores edáficos. Desta forma, este estudo objetivou avaliar a fertilidade e os atributos físicos do solo (análise granulométrica, densidade do solo - Ds e volume total de poros – VTP), os estoques de carbono e nitrogênio e as frações químicas da matéria orgânica do solo (MOS) em áreas de mata mesofítica, cerradão e cerrado sensu stricto na estação ecológica de Pirapitinga - MG. O solo das áreas de estudo foi classificado como Latossolo Vermelho. Em cada uma das áreas avaliadas foram coletadas amostras nas camadas de 0-0,05; 0,5-0,1; 0,1-0,2 e 0,2-0,4 m. O delineamento utilizado foi inteiramente casualizado. As áreas de mata mesofítica e cerradão desenvolvem-se em solo com maiores teores de argila em comparação à área de cerrado sensu stricto, indicando que possivelmente solos mais argilosos têm maior capacidade de retenção de água e fornecimento de nutrientes para atender mais adequadamente à demanda dessas vegetações com maior porte. A área de mata mesofítica por apresentar maior deposição de resíduos vegetais e estar em solo de textura argilosa está proporcionando em algumas camadas do solo maiores teores de C orgânico e substâncias húmicas, desencadeando menores valores de densidade do solo, maior volume total de poros e maior disponibilidade de P em relação às demais fitofisionomias estudadas. No entanto, as áreas de cerradão e cerrado sensu stricto apresentam maiores valores de Mg, K, pH e menores valores de H+Al e Al em comparação à área de mata mesofítica, o que pode sugerir que estas fitofisionomias se estabelecem preferencialmente nos solos mais férteis do bioma Cerrado. A relação entre a fração ácido húmico e fração ácido fúlvico indica que a vegetação de mata mesofítica apresenta em relação à vegetação de cerradão e cerrado sensu stricto matéria orgânica do solo de melhor qualidade, que permite o estabelecimento de atributos físicos e químicos favoráveis ao desenvolvimento de plantas. Os maiores estoques de carbono são verificados nas vegetações de maior porte, cerradão e mata mesofítica. Entretanto, o maior teor e estoque de nitrogênio do solo ocorrem na área de cerrado sensu stricto

    Economic burden of colorectal and breast cancers attributable to lack of physical activity in Brazil

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    Background: The increasing number of cancer patients has an escalating economic impact to public health systems (approximately, International dollars- Int60billionannuallyinBrazil).Physicalactivityiswidelyrecognizedasoneimportantmodifiableriskfactorforcancer.Herein,weestimatedtheeconomiccostsofcolonandpostmenopausalbreastcancersintheBrazilianUnifiedHealthSystem(SUS)attributabletolackofphysicalactivity.Methods:Populationattributablefractionswerecalculatedusingprevalencedatafrom57,962adultswhoansweredaphysicalactivityquestionnaireintheBrazilianNationalHealthSurvey,andrelativerisksofcolonandbreastcancerfromametaanalysis.Annualcosts(1Int 60 billion annually in Brazil). Physical activity is widely recognized as one important modifiable risk factor for cancer. Herein, we estimated the economic costs of colon and postmenopausal breast cancers in the Brazilian Unified Health System (SUS) attributable to lack of physical activity. Methods: Population attributable fractions were calculated using prevalence data from 57,962 adults who answered a physical activity questionnaire in the Brazilian National Health Survey, and relative risks of colon and breast cancer from a meta-analysis. Annual costs (1 Int = 2.1 reais) with hospitalization, chemotherapy and radiotherapy were obtained from the Hospital and Ambulatory Information Systems of the Brazilian SUS. Two counterfactual scenarios were considered: theoretical minimum risk exposure level (≥8000 MET-min/week) and physical activity guidelines (≥600 MET-min/week). Results: Annually, the Brazilian SUS expended Int4.5billionindirectcostsrelatedtocancertreatment,ofwhichInt 4.5 billion in direct costs related to cancer treatment, of which Int 553 million due to colon and breast cancers. Direct costs related to colon and breast cancers attributable to lack of physical activity were Int23.4millionandInt 23.4 million and Int 26.9 million, respectively. Achieving at least the physical activity guidelines would save Int10.3mi(colon,Int 10.3 mi (colon, Int 6.4 mi; breast, Int3.9mi).Conclusions:LackofphysicalactivityaccountsforInt 3.9 mi). Conclusions: Lack of physical activity accounts for Int 50.3 million annually in direct costs related to colon and post-menopausal breast cancers. Population-wide interventions aiming to promote physical activity are needed to reduce the economic burden of cancer in Brazil

    CHEMICAL AND PHYSICAL ATTRIBUTES OF SOIL, AND CARBON AND NITROGEN STOCK AND HUMIC FRACTIONS IN DIFFERENT PLANT FORMATIONS

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    O Cerrado \ue9 o segundo maior bioma brasileiro, no qual s\ue3o observadas diferentes fei\ue7\uf5es fitofision\uf4micas, que podem ser influenciadas por fatores ed\ue1ficos. Desta forma, este estudo objetivou avaliar a fertilidade e os atributos f\uedsicos do solo (an\ue1lise granulom\ue9trica, densidade do solo - Ds e volume total de poros \u2013 VTP), os estoques de carbono e nitrog\ueanio e as fra\ue7\uf5es qu\uedmicas da mat\ue9ria org\ue2nica do solo (MOS) em \ue1reas de mata mesof\uedtica, cerrad\ue3o e cerrado sensu stricto na esta\ue7\ue3o ecol\uf3gica de Pirapitinga - MG. O solo das \ue1reas de estudo foi classificado como Latossolo Vermelho. Em cada uma das \ue1reas avaliadas foram coletadas amostras nas camadas de 0-0,05; 0,05-0,1; 0,1-0,2 e 0,2-0,4 m. O delineamento utilizado foi inteiramente casualizado. As \ue1reas de mata mesof\uedtica e cerrad\ue3o desenvolvem-se em solo com maiores teores de argila em compara\ue7\ue3o \ue0 \ue1rea de cerrado sensu stricto, indicando que possivelmente solos mais argilosos t\ueam maior capacidade de reten\ue7\ue3o de \ue1gua e fornecimento de nutrientes para atender mais adequadamente \ue0 demanda dessas vegeta\ue7\uf5es com maior porte. A \ue1rea de mata mesof\uedtica por apresentar maior deposi\ue7\ue3o de res\uedduos vegetais e estar em solo de textura argilosa est\ue1 proporcionando em algumas camadas do solo maiores teores de C org\ue2nico e subst\ue2ncias h\ufamicas, desencadeando menores valores de densidade do solo, maior volume total de poros e maior disponibilidade de P em rela\ue7\ue3o \ue0s demais fitofisionomias estudadas. No entanto, as \ue1reas de cerrad\ue3o e cerrado sensu stricto apresentam maiores valores de Mg, K, pH e menores valores de H+Al e Al em compara\ue7\ue3o \ue0 \ue1rea de mata mesof\uedtica, o que pode sugerir que estas fitofisionomias se estabelecem preferencialmente nos solos mais f\ue9rteis do bioma Cerrado. A rela\ue7\ue3o entre a fra\ue7\ue3o \ue1cido h\ufamico e fra\ue7\ue3o \ue1cido f\ufalvico indica que a vegeta\ue7\ue3o de mata mesof\uedtica apresenta em rela\ue7\ue3o \ue0 vegeta\ue7\ue3o de cerrad\ue3o e cerrado sensu stricto mat\ue9ria org\ue2nica do solo de melhor qualidade, que permite o estabelecimento de atributos f\uedsicos e qu\uedmicos favor\ue1veis ao desenvolvimento de plantas. Os maiores estoques de carbono s\ue3o verificados nas vegeta\ue7\uf5es de maior porte, cerrad\ue3o e mata mesof\uedtica. Entretanto, o maior teor e estoque de nitrog\ueanio do solo ocorrem na \ue1rea de cerrado sensu stricto.Cerrado biome is the second largest Brazilian biome, where different phyto-physiognomical features are observed, which may be influenced by soil factors. Thus, this study aimed to evaluate soil physical and fertility properties (particle size analysis, bulk density - BD and total pore volume - TPV), carbon and nitrogen stocks and chemical fractions of soil organic matter (SOM ) in areas of mesophytic forest, Cerrado and Cerrado sensu stricto in the ecological station of Pirapitinga, Minas Gerais state. The soil was classified as Oxisol and soil samples were collected from the layers 0-0.05, 0.05-0.1, 0.1-0.2, and 0.2-0.4 m. The experimental design was completely randomized. Areas of mesophytic forest and cerrado grow in soil with higher clay compared to the Cerrado sensu stricto, indicating that possibly more clayey soils have higher water holding capacity and nutrient supply to attend the demand more appropriately with larger vegetations. The mesophytic forest area by presenting high waste disposal of plant and be in the clayey soil is in some layers providing higher levels of soil organic C and humic substances, triggering lower values of bulk density, greater total porosity and availability of P in relation to other vegetation types studied. However, the closed areas and Cerrado sensu stricto have higher amounts of Mg, K, and lower pH, H + Al and Al compared to mesophitic forest area, which may suggest that these phytophysiognomies settle preferentially in the most fertile soils of Cerrado biome. The relationship between the humic acid and fulvic acid fraction indicates that the forest vegetation Mesophytic presents for vegetation of Cerrado and Cerrado sensu stricto soil organic matter of great quality, which allows the establishment of physical and chemical attributes favorable to the development of the plant. The largest stocks of carbon are verified in larger vegetation, cerrado and mesophytic forest. However, the higher grade and stock soil nitrogen occur in Cerrado sensu stricto

    Uma quadra enquanto palimpsesto: em busca das camadas da memória arquitetônica do campus da ESDI / One block as a palimpsest: in search of the architectural memory layers of the ESDI campus

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    A Escola Superior de Desenho Industrial foi fundada em 1963 no bairro da Lapa no Rio de Janeiro iniciando o ensino superior do Design no Brasil. Os 3 terrenos que hoje compõem seu campus possuem muitas camadas históricas de ocupação, tanto anteriores a implantação das edificações atuais, quanto aos usos posteriores. O presente trabalho propõe apresentar as descobertas acerca da memória das transformações da morfologia urbana do campus em questão e do seu entorno imediato. Para tanto foram levantados os dados iconográficos existentes nos órgãos competentes da cidade do Rio de Janeiro, e analisados para compreender as transformações desde a inauguração do Passeio Público ate? os dias atuais. Foi preciso estabelecer uma base conceitual para a leitura do lugar, e, para tanto, foi adotada a metáfora do palimpsesto em busca das diferentes camadas da “escrita” arquitetônica e urbanística

    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

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    © 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

    Rising rural body-mass index is the main driver of the global obesity epidemic in adults

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    Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities(.)(1,2) This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity(3-6). Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017-and more than 80% in some low- and middle-income regions-was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing-and in some countries reversal-of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.Peer reviewe

    Height and body-mass index trajectories of school-aged children and adolescents from 1985 to 2019 in 200 countries and territories: a pooled analysis of 2181 population-based studies with 65 million participants

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    Summary Background Comparable global data on health and nutrition of school-aged children and adolescents are scarce. We aimed to estimate age trajectories and time trends in mean height and mean body-mass index (BMI), which measures weight gain beyond what is expected from height gain, for school-aged children and adolescents. Methods For this pooled analysis, we used a database of cardiometabolic risk factors collated by the Non-Communicable Disease Risk Factor Collaboration. We applied a Bayesian hierarchical model to estimate trends from 1985 to 2019 in mean height and mean BMI in 1-year age groups for ages 5–19 years. The model allowed for non-linear changes over time in mean height and mean BMI and for non-linear changes with age of children and adolescents, including periods of rapid growth during adolescence. Findings We pooled data from 2181 population-based studies, with measurements of height and weight in 65 million participants in 200 countries and territories. In 2019, we estimated a difference of 20 cm or higher in mean height of 19-year-old adolescents between countries with the tallest populations (the Netherlands, Montenegro, Estonia, and Bosnia and Herzegovina for boys; and the Netherlands, Montenegro, Denmark, and Iceland for girls) and those with the shortest populations (Timor-Leste, Laos, Solomon Islands, and Papua New Guinea for boys; and Guatemala, Bangladesh, Nepal, and Timor-Leste for girls). In the same year, the difference between the highest mean BMI (in Pacific island countries, Kuwait, Bahrain, The Bahamas, Chile, the USA, and New Zealand for both boys and girls and in South Africa for girls) and lowest mean BMI (in India, Bangladesh, Timor-Leste, Ethiopia, and Chad for boys and girls; and in Japan and Romania for girls) was approximately 9–10 kg/m2. In some countries, children aged 5 years started with healthier height or BMI than the global median and, in some cases, as healthy as the best performing countries, but they became progressively less healthy compared with their comparators as they grew older by not growing as tall (eg, boys in Austria and Barbados, and girls in Belgium and Puerto Rico) or gaining too much weight for their height (eg, girls and boys in Kuwait, Bahrain, Fiji, Jamaica, and Mexico; and girls in South Africa and New Zealand). In other countries, growing children overtook the height of their comparators (eg, Latvia, Czech Republic, Morocco, and Iran) or curbed their weight gain (eg, Italy, France, and Croatia) in late childhood and adolescence. When changes in both height and BMI were considered, girls in South Korea, Vietnam, Saudi Arabia, Turkey, and some central Asian countries (eg, Armenia and Azerbaijan), and boys in central and western Europe (eg, Portugal, Denmark, Poland, and Montenegro) had the healthiest changes in anthropometric status over the past 3·5 decades because, compared with children and adolescents in other countries, they had a much larger gain in height than they did in BMI. The unhealthiest changes—gaining too little height, too much weight for their height compared with children in other countries, or both—occurred in many countries in sub-Saharan Africa, New Zealand, and the USA for boys and girls; in Malaysia and some Pacific island nations for boys; and in Mexico for girls. Interpretation The height and BMI trajectories over age and time of school-aged children and adolescents are highly variable across countries, which indicates heterogeneous nutritional quality and lifelong health advantages and risks

    Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants.

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    BACKGROUND: Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. METHODS: We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. FINDINGS: The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. INTERPRETATION: Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. FUNDING: WHO

    Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

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    Background Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories. Methods We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age. Findings The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran. Interpretation Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings. Copyright (C) 2021 World Health Organization; licensee Elsevier
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