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1. Availability and affordability of blood pressure-lowering medicines and the effect on blood pressure control in high-income, middle-income, and low-income countries: an analysis of the PURE study data

Author

Marjan W Attaei, MA, Rasha Khatib, PhD, Prof Martin McKee, DSc, Prof Scott Lear, PhD, Prof Gilles Dagenais, MD, Ehimario U Igumbor, PhD, Khalid F AlHabib, MD, Prof Manmeet Kaur, PhD, Lanthe Kruger, PhD, Prof Koon Teo, PhD, Fernando Lanas, MD, Khalid Yusoff, MD, Aytekin Oguz, MD, Prof Rajeev Gupta, PhD, Afzalhussein M Yusufali, MD, Ahmad Bahonar, MD, Prof Raman Kutty, MD, Prof Annika Rosengren, MD, Prof Viswanathan Mohan, DSc, Prof Alvaro Avezum, PhD, Prof Rita Yusuf, PhD, Prof Andrzej Szuba, PhD, Sumathy Rangarajan, MSc, Clara Chow, PhD, Prof Salim Yusuf, DPhil, S Yusuf, S Rangarajan, K K Teo, C K Chow, M O'Donnell, A Mente, D Leong, A Smyth, P Joseph, S Islam, M Zhang, W Hu, C Ramasundarahettige, G Wong, L Dayal, A Casanova, M Dehghan, G Lewis, A Aliberti, A Reyes, A Zaki, B Lewis, B Zhang, D Agapay, D Hari, E Milazzo, E Ramezani, F Hussain, F Shifaly, I Kay, J Rimac, J Swallow, L Heldman, M(a) Mushtaha, M(o) Mushtaha, M Trottier, N Aoucheva, N Kandy, P Mackie, R Solano, S Chin, S Ramacham, S Shahrook, S Trottier, T Tongana, W ElSheikh, J Lindeman, M McQueen, K Hall, J Keys, X Wang, J Keneth, A Devanath, R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, J Dejesus, W Elsheikh, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, JiaXuan, Hu Bo, Sun Yi, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Deng Qing, Cheng Xiaoru, He Xinye, Li Jian, Li Juan, Liu Xu, Ren Bing, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, BianRongwen, TianXiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gómez-Arbeláez, JF Arguello, R Dueñas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar, AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, A Dans, HU Co, JT Sanchez, L Pudol, C Zamora-Pudol, LAM Palileo-Villanueva, MR Aquino, C Abaquin, SL Pudol, ML Cabral, W Zatonski, A Szuba, K Zatonska, R Ilow#, M Ferus, B Regulska-Ilow, D Różańska, M Wolyniec, KF AlHabib, A Hersi, T Kashour, H Alfaleh, M Alshamiri, HB Altaradi, O Alnobani, A Bafart, N Alkamel, M Ali, M Abdulrahman, R Nouri, A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Boström, U Lindblad, P Langkilde, A Gustavsson, M Andreasson, M Snällman, L Wirdemann, K Pettersson, E Moberg, K Yeates, J Sleeth, K Kilonzo, A Oguz, AAK Akalin, KBT Calik, N Imeryuz, A Temizhan, E Alphan, E Gunes, H Sur, K Karsidag, S Gulec, Y Altuntas, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, and R Mapanga

Subjects
Public aspects of medicine, RA1-1270
Abstract

Background: Hypertension is considered the most important risk factor for cardiovascular diseases, but its control is poor worldwide. We aimed to assess the availability and affordability of blood pressure-lowering medicines, and the association with use of these medicines and blood pressure control in countries at varying levels of economic development. Methods: We analysed the availability, costs, and affordability of blood pressure-lowering medicines with data recorded from 626 communities in 20 countries participating in the Prospective Urban Rural Epidemiological (PURE) study. Medicines were considered available if they were present in the local pharmacy when surveyed, and affordable if their combined cost was less than 20% of the households' capacity to pay. We related information about availability and affordability to use of these medicines and blood pressure control with multilevel mixed-effects logistic regression models, and compared results for high-income, upper-middle-income, lower-middle-income, and low-income countries. Data for India are presented separately because it has a large generic pharmaceutical industry and a higher availability of medicines than other countries at the same economic level. Findings: The availability of two or more classes of blood pressure-lowering drugs was lower in low-income and middle-income countries (except for India) than in high-income countries. The proportion of communities with four drug classes available was 94% in high-income countries (108 of 115 communities), 76% in India (68 of 90), 71% in upper-middle-income countries (90 of 126), 47% in lower-middle-income countries (107 of 227), and 13% in low-income countries (nine of 68). The proportion of households unable to afford two blood pressure-lowering medicines was 31% in low-income countries (1069 of 3479 households), 9% in middle-income countries (5602 of 65 471), and less than 1% in high-income countries (44 of 10 880). Participants with known hypertension in communities that had all four drug classes available were more likely to use at least one blood pressure-lowering medicine (adjusted odds ratio [OR] 2·23, 95% CI 1·59–3·12); p

Published
2017
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2. Association of dietary nutrients with blood lipids and blood pressure in 18 countries: a cross-sectional analysis from the PURE study

Author

Andrew Mente, Mahshid Dehghan, Sumathy Rangarajan, Matthew McQueen, Gilles Dagenais, Andreas Wielgosz, Scott Lear, Wei Li, Hui Chen, Sun Yi, Yang Wang, Rafael Diaz, Alvaro Avezum, Patricio Lopez-Jaramillo, Pamela Seron, Rajesh Kumar, Rajeev Gupta, Viswanathan Mohan, Sumathi Swaminathan, Raman Kutty, Katarzyna Zatonska, Romaina Iqbal, Rita Yusuf, Noushin Mohammadifard, Rasha Khatib, Nafiza Mat Nasir, Noorhassim Ismail, Aytekin Oguz, Annika Rosengren, Afzalhussein Yusufali, Edelweiss Wentzel-Viljoen, Thandi Puoane, Jephat Chifamba, Koon Teo, Sonia S Anand, Salim Yusuf, S Yusuf, S Rangarajan, K K Teo, C K Chow, M O'Donnell, A Mente, D Leong, A Smyth, P Joseph, A Merchant, S Islam, M Zhang, W Hu, C Ramasundarahettige, G Wong, S Bangdiwala, L Dyal, A Casanova, M Dehghan, G Lewis, A Aliberti, A Arshad, A Reyes, A Zaki, B Lewis, B Zhang, D Agapay, D Hari, E Milazzo, E Ramezani, F Hussain, F Shifaly, G McAlpine, I Kay, J Lindeman, J Rimac, J Swallow, L Heldman, M(a) Mushtaha, M(o) Mushtaha, M Trottier, M Riggi, N Aoucheva, N Kandy, P Mackie, R Solano, S Chin, S Ramacham, S Shahrook, S Trottier, T Tongana, W ElSheikh, Y Iyengar, M McQueen, K Hall, J Keys, X Wang, J Keneth, A Devanath, R Diaz, A Orlandini, B Linetsky, S Toscanelli, G Casaccia, JM Maini Cuneo, O Rahman, R Yusuf, AK Azad, KA Rabbani, HM Cherry, A Mannan, I Hassan, AT Talukdar, RB Tooheen, MU Khan, M Sintaha, T Choudhury, R Haque, S Parvin, A Avezum, GB Oliveira, CS Marcilio, AC Mattos, K Teo, J Dejesus, W Elsheikh, G Dagenais, P Poirier, G Turbide, D Auger, A LeBlanc De Bluts, MC Proulx, M Cayer, N Bonneville, S Lear, D Gasevic, E Corber, V de Jong, I Vukmirovich, A Wielgosz, G Fodor, A Pipe, A Shane, F Lanas, P Seron, S Martinez, A Valdebenito, M Oliveros, Li Wei, Liu Lisheng, Chen Chunming, Wang Xingyu, Zhao Wenhua, Zhang Hongye, Jia Xuan, Hu Bo, Bo Jian, Zhao Xiuwen, Chang Xiaohong, Chen Tao, Chen Hui, Deng Qing, Cheng Xiaoru, He Xinye, Li Jian, Li Juan, Liu Xu, Ren Bing, Wang Wei, Wang Yang, Yang Jun, Zhai Yi, Zhu Manlu, Lu Fanghong, Wu Jianfang, Li Yindong, Hou Yan, Zhang Liangqing, Guo Baoxia, Liao Xiaoyang, Zhang Shiying, Bian Rongwen, Tian Xiuzhen, Li Dong, Chen Di, Wu Jianguo, Xiao Yize, Liu Tianlu, Zhang Peng, Dong Changlin, Li Ning, Ma Xiaolan, Yang Yuqing, Lei Rensheng, Fu Minfan, He Jing, Liu Yu, Xing Xiaojie, Zhou Qiang, P Lopez-Jaramillo, PA Camacho Lopez, R Garcia, LJA Jurado, D Gómez-Arbeláez, JF Arguello, R Dueñas, S Silva, LP Pradilla, F Ramirez, DI Molina, C Cure-Cure, M Perez, E Hernandez, E Arcos, S Fernandez, C Narvaez, J Paez, A Sotomayor, H Garcia, G Sanchez, T David, A Rico, P Mony, M Vaz, A V Bharathi, S Swaminathan, K Shankar AV Kurpad, KG Jayachitra, N Kumar, HAL Hospital, V Mohan, M Deepa, K Parthiban, M Anitha, S Hemavathy, T Rahulashankiruthiyayan, D Anitha, K Sridevi, R Gupta, RB Panwar, I Mohan, P Rastogi, S Rastogi, R Bhargava, R Kumar, J S Thakur, B Patro, PVM Lakshmi, R Mahajan, P Chaudary, V Raman Kutty, K Vijayakumar, K Ajayan, G Rajasree, AR Renjini, A Deepu, B Sandhya, S Asha, HS Soumya, R Kelishadi, A Bahonar, N Mohammadifard, H Heidari, K Yusoff, TST Ismail, KK Ng, A Devi, NM Nasir, MM Yasin, M Miskan, EA Rahman, MKM Arsad, F Ariffin, SA Razak, FA Majid, NA Bakar, MY Yacob, N Zainon, R Salleh, MKA Ramli, NA Halim, SR Norlizan, NM Ghazali, MN Arshad, R Razali, S Ali, HR Othman, CWJCW Hafar, A Pit, N Danuri, F Basir, SNA Zahari, H Abdullah, MA Arippin, NA Zakaria, I Noorhassim, MJ Hasni, MT Azmi, MI Zaleha, KY Hazdi, AR Rizam, W Sazman, A Azman, R Khatib, U Khammash, A Khatib, R Giacaman, R Iqbal, A Afridi, R Khawaja, A Raza, K Kazmi, A Dans, HU Co, JT Sanchez, L Pudol, C Zamora-Pudol, LAM Palileo-Villanueva, MR Aquino, C Abaquin, SL Pudol, ML Cabral, W Zatonski, A Szuba, K Zatonska, R Ilow, M Ferus, B Regulska-Ilow, D Rózanska, M Wolyniec, KF AlHabib, A Hersi, T Kashour, H Alfaleh, M Alshamiri, HB Altaradi, O Alnobani, A Bafart, N Alkamel, M Ali, M Abdulrahman, R Nouri, A Kruger, H H Voster, A E Schutte, E Wentzel-Viljoen, FC Eloff, H de Ridder, H Moss, J Potgieter, AA Roux, M Watson, G de Wet, A Olckers, JC Jerling, M Pieters, T Hoekstra, T Puoane, E Igumbor, L Tsolekile, D Sanders, P Naidoo, N Steyn, N Peer, B Mayosi, B Rayner, V Lambert, N Levitt, T Kolbe-Alexander, L Ntyintyane, G Hughes, R Swart, J Fourie, M Muzigaba, S Xapa, N Gobile, K Ndayi, B Jwili, K Ndibaza, B Egbujie, A Rosengren, K Bengtsson Boström, A Gustavsson, M Andreasson, M Snällman, L Wirdemann, K Yeates, J Sleeth, K Kilonzo, A Oguz, N Imeryuz, Y Altuntas, S Gulec, A Temizhan, K Karsidag, KBT Calik, AAK Akalin, OT Caklili, MV Keskinler, AN Erbakan, AM Yusufali, W Almahmeed, H Swidan, EA Darwish, ARA Hashemi, N Al-Khaja, JM Muscat-Baron, SH Ahmed, TM Mamdouh, WM Darwish, MHS Abdelmotagali, SA Omer Awed, GA Movahedi, H Al Shaibani, RIM Gharabou, DF Youssef, AZS Nawati, ZAR Abu Salah, RFE Abdalla, SM Al Shuwaihi, MA Al Omairi, OD Cadigal, R.S. Alejandrino, J Chifamba, L Gwaunza, G Terera, C Mahachi, P Murambiwa, T Machiweni, and R Mapanga

Subjects
Male, medicine.medical_specialty, Apolipoprotein B, Endocrinology, Diabetes and Metabolism, Blood lipids, Blood Pressure, 030204 cardiovascular system & hematology, 03 medical and health sciences, chemistry.chemical_compound, 0302 clinical medicine, Endocrinology, High-density lipoprotein, Risk Factors, Diabetes mellitus, Internal medicine, Internal Medicine, medicine, Dietary Carbohydrates, Humans, 030212 general & internal medicine, chemistry.chemical_classification, biology, Cholesterol, business.industry, medicine.disease, Dietary Fats, Lipids, Diet, Cross-Sectional Studies, chemistry, Cardiovascular Diseases, Saturated fatty acid, biology.protein, lipids (amino acids, peptides, and proteins), Apolipoprotein A1, Female, business, Biomarkers, Polyunsaturated fatty acid
Abstract

Summary Background The relation between dietary nutrients and cardiovascular disease risk markers in many regions worldwide is unknown. In this study, we investigated the effect of dietary nutrients on blood lipids and blood pressure, two of the most important risk factors for cardiovascular disease, in low-income, middle-income, and high-income countries. Methods We studied 125 287 participants from 18 countries in North America, South America, Europe, Africa, and Asia in the Prospective Urban Rural Epidemiology (PURE) study. Habitual food intake was measured with validated food frequency questionnaires. We assessed the associations between nutrients (total fats, saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, carbohydrates, protein, and dietary cholesterol) and cardiovascular disease risk markers using multilevel modelling. The effect of isocaloric replacement of saturated fatty acids with other fats and carbohydrates was determined overall and by levels of intakes by use of nutrient density models. We did simulation modelling in which we assumed that the effects of saturated fatty acids on cardiovascular disease events was solely related to their association through an individual risk marker, and then compared these simulated risk marker-based estimates with directly observed associations of saturated fatty acids with cardiovascular disease events. Findings Participants were enrolled into the study from Jan 1, 2003, to March 31, 2013. Intake of total fat and each type of fat was associated with higher concentrations of total cholesterol and LDL cholesterol, but also with higher HDL cholesterol and apolipoprotein A1 (ApoA1), and lower triglycerides, ratio of total cholesterol to HDL cholesterol, ratio of triglycerides to HDL cholesterol, and ratio of apolipoprotein B (ApoB) to ApoA1 (all p trend trend trend =0·0014]). Higher intakes of total fat, saturated fatty acids, and carbohydrates were associated with higher blood pressure, whereas higher protein intake was associated with lower blood pressure. Replacement of saturated fatty acids with carbohydrates was associated with the most adverse effects on lipids, whereas replacement of saturated fatty acids with unsaturated fats improved some risk markers (LDL cholesterol and blood pressure), but seemed to worsen others (HDL cholesterol and triglycerides). The observed associations between saturated fatty acids and cardiovascular disease events were approximated by the simulated associations mediated through the effects on the ApoB-to-ApoA1 ratio, but not with other lipid markers including LDL cholesterol. Interpretation Our data are at odds with current recommendations to reduce total fat and saturated fats. Reducing saturated fatty acid intake and replacing it with carbohydrate has an adverse effect on blood lipids. Substituting saturated fatty acids with unsaturated fats might improve some risk markers, but might worsen others. Simulations suggest that ApoB-to-ApoA1 ratio probably provides the best overall indication of the effect of saturated fatty acids on cardiovascular disease risk among the markers tested. Focusing on a single lipid marker such as LDL cholesterol alone does not capture the net clinical effects of nutrients on cardiovascular risk. Funding Full funding sources listed at the end of the paper (see Acknowledgments).

Published
2017

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