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  • 1. Alkema, Leontine
    et al.
    Chou, Doris
    Hogan, Daniel
    Zhang, Sanqian
    Moller, Ann-Beth
    Gemmill, Alison
    Fat, Doris Ma
    Boerma, Ties
    Temmerman, Marleen
    Mathers, Colin
    Say, Lale
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. University of the Witwatersrand, Johannesburg, South Africa.
    Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10017, p. 462-474Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Millennium Development Goal 5 calls for a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed projections to show the requirements for the Sustainable Development Goal (SDG) of less than 70 maternal deaths per 100,000 livebirths globally by 2030.

    METHODS: We updated the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG) database with more than 200 additional records (vital statistics from civil registration systems, surveys, studies, or reports). We generated estimates of maternal mortality and related indicators with 80% uncertainty intervals (UIs) using a Bayesian model. The model combines the rate of change implied by a multilevel regression model with a time-series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources.

    RESULTS: We had data for 171 of 183 countries. The global MMR fell from 385 deaths per 100,000 livebirths (80% UI 359-427) in 1990, to 216 (207-249) in 2015, corresponding to a relative decline of 43·9% (34·0-48·7), with 303,000 (291,000-349,000) maternal deaths worldwide in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1·8% (0·0-3·1) in the Caribbean to 5·0% (4·0-6·0) in eastern Asia. Regional MMRs for 2015 ranged from 12 deaths per 100,000 livebirths (11-14) for high-income regions to 546 (511-652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7·5%.

    INTERPRETATION: Despite global progress in reducing maternal mortality, immediate action is needed to meet the ambitious SDG 2030 target, and ultimately eliminate preventable maternal mortality. Although the rates of reduction that are needed to achieve country-specific SDG targets are ambitious for most high mortality countries, countries that made a concerted effort to reduce maternal mortality between 2000 and 2010 provide inspiration and guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths.

    FUNDING: National University of Singapore, National Institute of Child Health and Human Development, USAID, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

  • 2. Anderson, Ian
    et al.
    Robson, Bridget
    Connolly, Michele
    Al-Yaman, Fadwa
    Bjertness, Espen
    King, Alexandra
    Tynan, Michael
    Madden, Richard
    Bang, Abhay
    Coimbra, Carlos E. A., Jr.
    Pesantes, Maria Amalia
    Amigo, Hugo
    Andronov, Sergei
    Armien, Blas
    Obando, Daniel Ayala
    Axelsson, Per
    Umeå University, Faculty of Arts, Centre for Sami Research.
    Bhatti, Zaid Shakoor
    Bhutta, Zulfi Qar Ahmed
    Bjerregaard, Peter
    Bjertness, Marius B.
    Briceno-Leon, Roberto
    Broderstad, Ann Ragnhild
    Bustos, Patricia
    Chongsuvivatwong, Virasakdi
    Chu, Jiayou
    Deji, .
    Gouda, Jitendra
    Harikumar, Rachakulla
    Htay, Thein Thein
    Htet, Aung Soe
    Izugbara, Chimaraoke
    Kamaka, Martina
    King, Malcolm
    Kodavanti, Mallikharjuna Rao
    Lara, Macarena
    Laxmaiah, Avula
    Lema, Claudia
    Taborda, Ana Maria Leon
    Liabsuetrakul, Tippawan
    Lobanov, Andrey
    Melhus, Marita
    Meshram, Indrapal
    Miranda, J. Jaime
    Mu, Thet Thet
    Nagalla, Balkrishna
    Nimmathota, Arlappa
    Popov, Andrey Ivanovich
    Poveda, Ana Maria Penuela
    Ram, Faujdar
    Reich, Hannah
    Santos, Ricardo V.
    Sein, Aye Aye
    Shekhar, Chander
    Sherpa, Lhamo Y.
    Sköld, Peter
    Umeå University, Arctic Research Centre at Umeå University.
    Tano, Sofia
    Umeå University, Faculty of Social Sciences, Umeå School of Business and Economics (USBE), Business Administration.
    Tanywe, Asahngwa
    Ugwu, Chidi
    Ugwu, Fabian
    Vapattanawong, Patama
    Wan, Xia
    Welch, James R.
    Yang, Gonghuan
    Yang, Zhaoqing
    Yap, Leslie
    Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 388, no 10040, p. 131-157Article in journal (Refereed)
    Abstract [en]

    Background: International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.

    Methods: Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.

    Findings: Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.

    Interpretation: We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.

  • 3.
    Asplund, Kjell
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Hermerén, Göran
    The need to revise the Helsinki Declaration2017In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 389, no 10075, p. 1190-1191Article in journal (Refereed)
  • 4. Beelen, Rob
    et al.
    Raaschou-Nielsen, Ole
    Stafoggia, Massimo
    Andersen, Zorana Jovanovic
    Weinmayr, Gudrun
    Hoffmann, Barbara
    Wolf, Kathrin
    Samoli, Evangelia
    Fischer, Paul
    Nieuwenhuijsen, Mark
    Vineis, Paolo
    Xun, Wei W
    Katsouyanni, Klea
    Dimakopoulou, Konstantina
    Oudin, Anna
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Modig, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Havulinna, Aki S
    Lanki, Timo
    Turunen, Anu
    Oftedal, Bente
    Nystad, Wenche
    Nafstad, Per
    De Faire, Ulf
    Pedersen, Nancy L
    Ostenson, Claes-Göran
    Fratiglioni, Laura
    Penell, Johanna
    Korek, Michal
    Pershagen, Göran
    Eriksen, Kirsten Thorup
    Overvad, Kim
    Ellermann, Thomas
    Eeftens, Marloes
    Peeters, Petra H
    Meliefste, Kees
    Wang, Meng
    Bueno-de-Mesquita, Bas
    Sugiri, Dorothea
    Krämer, Ursula
    Heinrich, Joachim
    de Hoogh, Kees
    Key, Timothy
    Peters, Annette
    Hampel, Regina
    Concin, Hans
    Nagel, Gabriele
    Ineichen, Alex
    Schaffner, Emmanuel
    Probst-Hensch, Nicole
    Künzli, Nino
    Schindler, Christian
    Schikowski, Tamara
    Adam, Martin
    Phuleria, Harish
    Vilier, Alice
    Clavel-Chapelon, Françoise
    Declercq, Christophe
    Grioni, Sara
    Krogh, Vittorio
    Tsai, Ming-Yi
    Ricceri, Fulvio
    Sacerdote, Carlotta
    Galassi, Claudia
    Migliore, Enrica
    Ranzi, Andrea
    Cesaroni, Giulia
    Badaloni, Chiara
    Forastiere, Francesco
    Tamayo, Ibon
    Amiano, Pilar
    Dorronsoro, Miren
    Katsoulis, Michail
    Trichopoulou, Antonia
    Brunekreef, Bert
    Hoek, Gerard
    Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project2014In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 383, no 9919, p. 785-795Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Few studies on long-term exposure to air pollution and mortality have been reported from Europe. Within the multicentre European Study of Cohorts for Air Pollution Effects (ESCAPE), we aimed to investigate the association between natural-cause mortality and long-term exposure to several air pollutants.

    METHODS: We used data from 22 European cohort studies, which created a total study population of 367 251 participants. All cohorts were general population samples, although some were restricted to one sex only. With a strictly standardised protocol, we assessed residential exposure to air pollutants as annual average concentrations of particulate matter (PM) with diameters of less than 2·5 μm (PM2·5), less than 10 μm (PM10), and between 10 μm and 2·5 μm (PMcoarse), PM2.5 absorbance, and annual average concentrations of nitrogen oxides (NO2 and NOx), with land use regression models. We also investigated two traffic intensity variables-traffic intensity on the nearest road (vehicles per day) and total traffic load on all major roads within a 100 m buffer. We did cohort-specific statistical analyses using confounder models with increasing adjustment for confounder variables, and Cox proportional hazards models with a common protocol. We obtained pooled effect estimates through a random-effects meta-analysis.

    FINDINGS: The total study population consisted of 367 251 participants who contributed 5 118 039 person-years at risk (average follow-up 13·9 years), of whom 29 076 died from a natural cause during follow-up. A significantly increased hazard ratio (HR) for PM2·5 of 1·07 (95% CI 1·02-1·13) per 5 μg/m(3) was recorded. No heterogeneity was noted between individual cohort effect estimates (I(2) p value=0·95). HRs for PM2·5 remained significantly raised even when we included only participants exposed to pollutant concentrations lower than the European annual mean limit value of 25 μg/m(3) (HR 1·06, 95% CI 1·00-1·12) or below 20 μg/m(3) (1·07, 1·01-1·13).

    INTERPRETATION: Long-term exposure to fine particulate air pollution was associated with natural-cause mortality, even within concentration ranges well below the present European annual mean limit value.

    FUNDING: European Community's Seventh Framework Program (FP7/2007-2011).

  • 5. Booth, Malcolm G
    et al.
    Hood, John
    Brooks, Timothy J G
    Hart, Andrew
    Umeå University, Faculty of Medicine, Department of Integrative Medical Biology (IMB), Anatomy. Glasgow Royal Infirmary, Glasgow, UK; Centre for Cell Engineering, Faculty for Biological & Life Sciences, University of Glasgow, Hillhead, Glasgow, UK.
    Anthrax infection in drug users2010In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 375, no 9723, p. 1345-1346Article in journal (Refereed)
  • 6.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lower blood pressure targets: to whom do they apply?2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10017, p. 405-406Article in journal (Refereed)
  • 7.
    Brunström, Mattias
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Thrombolysis in acute stroke2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 385, no 9976, p. 1394-1395Article in journal (Refereed)
  • 8.
    Brännström, Inger
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    Does it matter how epilepsy is considered and classified?2002In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 359, no 9315, p. 1439-Article in journal (Refereed)
  • 9.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    A transition towards a healthier global population?2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, no 10009, p. 2121-2122Article in journal (Refereed)
  • 10.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Causes of child death estimates: making use of the InterVA model2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, no 9997, p. 953-953Article in journal (Refereed)
  • 11.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre at Stellenbosch University, Stellenbosch, South Africa.
    Child mortality is (estimated to be) falling2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 388, no 10063, p. 2965-2967Article in journal (Refereed)
  • 12.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Dr Tedros Adhanom Ghebreyesus is the best candidate for WHO DG2017In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 389, no 10084, p. E6-E7Article in journal (Refereed)
  • 13.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    The UN needs joined-up thinking on vital registration2012In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 380, no 9854, p. 1643-1643Article in journal (Other academic)
  • 14.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Uncounted causes of death2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10013, p. 26-27Article in journal (Refereed)
  • 15.
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council-Wits Agincourt Unit, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Universal health coverage is needed to deliver NCD control.2018In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 391, no 10122, article id 738Article in journal (Refereed)
  • 16.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
    D'Ambruoso, Lucia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Cellular telephone networks in developing countries2008In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 371, no 9613, p. 650-Article in journal (Refereed)
  • 17.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå Centre for Global Health Research, Umeå University.
    Friberg, Peter
    Sahlgrenska University Hospital, Gothenburg.
    A proposal to add patient safety to the Stockholm Declaration - Authors'reply2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 382, no 9894, p. 765-766Article in journal (Refereed)
  • 18.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Friberg, Peter
    Swedish Society of Medicine and Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Gothenburg.
    A proposal to add patient safety to the Stockholm Declaration Reply2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 382, no 9894, p. 765-766Article in journal (Refereed)
  • 19.
    Byass, Peter
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Graham, Wendy J.
    Grappling with uncertainties along the MDG trail2011In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 378, no 9797, p. 1119-1120Article in journal (Refereed)
  • 20.
    Byass, Peter
    et al.
    Umeå University.
    Wilder-Smith, Annelies
    Umeå University. Nanyang Technol Univ, Lee Kong Chian Sch Med, Singapore .
    Utilising additional sources of information on microcephaly2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10022, p. 940-941Article in journal (Refereed)
  • 21.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Time to lower treatment BP targets for hypertension?2009In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 374, no 9689, p. 503-504Article in journal (Other academic)
  • 22.
    Carlberg, Bo
    et al.
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine.
    Lindholm, Lars Hjalmar
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Comment: Stroke and blood-pressure variation: new permutations on an old theme.2010In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 375, no 9718, p. 867-869Article in journal (Refereed)
  • 23. Dans, Antonio
    et al.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine.
    Varghese, Cherian
    Tai, E. Shyong
    Firestone, Rebecca
    Bonita, Ruth
    Non-communicable diseases in southeast Asia Reply2011In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 377, no 9782, p. 2005-2005Article in journal (Refereed)
  • 24.
    Dans, Antonio
    et al.
    Department of Medicine, College of Medicine, University of the Philippines, Manila, Philippines.
    Ng, Nawi
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Varghese, Cherian
    Western Pacific Regional Office, WHO, Manila, Philippines.
    Tai, E Shyong
    Division of Endocrinology, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
    Firestone, Rebecca
    China Medical Board and Harvard Global Equity Initiative, Cambridge, MA, USA.
    Bonita, Ruth
    School of Population Health, University of Auckland, Auckland, New Zealand.
    The rise of chronic non-communicable diseases in southeast Asia: time for action2011In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 377, no 9766, p. 680-689Article in journal (Refereed)
    Abstract [en]

    Southeast Asia faces an epidemic of chronic non-communicable diseases, now responsible for 60% of deaths in the region. The problem stems from environmental factors that promote tobacco use, unhealthy diet, and inadequate physical activity. Disadvantaged populations are the hardest hit, with death rates inversely proportional to a country's gross national income. Families shoulder the financial burden, but entire economies suffer as well. Although attempts to control non-communicable diseases are increasing, more needs to be done. Health-care systems need to be redesigned to deliver chronic care that is founded on existing primary health-care facilities, but supported by good referral systems. Surveillance of key modifiable risk factors is needed to monitor the magnitude of the problem and to study the effects of interventions. All branches of government and all sectors of society have to get involved in establishing environments that are conducive to healthy living. The Association of Southeast Asian Nations is in a unique position to make a united stand against chronic non-communicable diseases in the region. Inaction will affect millions of lives-often, the lives of those who have the least.

  • 25. Di Cesare, Mariachiara
    et al.
    Bentham, James
    Stevens, Gretchen A.
    Zhou, Bin
    Danaei, Goodarz
    Lu, Yuan
    Bixby, Honor
    Cowan, Melanie J.
    Riley, Leanne M.
    Hajifathalian, Kaveh
    Fortunato, Lea
    Taddei, Cristina
    Bennett, James E.
    Ikeda, Nayu
    Khang, Young-Ho
    Kyobutungi, Catherine
    Laxmaiah, Avula
    Li, Yanping
    Lin, Hsien-Ho
    Miranda, J. Jaime
    Mostafa, Aya
    Turley, Maria L.
    Paciorek, Christopher J.
    Gunter, Marc
    Ezzati, Majid
    Abdeen, Ziad A.
    Hamid, Zargar Abdul
    Abu-Rmeileh, Niveen M.
    Acosta-Cazares, Benjamin
    Adams, Robert
    Aekplakorn, Wichai
    Aguilar-Salinas, Carlos A.
    Ahmadvand, Alireza
    Ahrens, Wolfgang
    Ali, Mohamed M.
    Alkerwi, Ala'a
    Alvarez-Pedrerol, Mar
    Aly, Eman
    Amouyel, Philippe
    Amuzu, Antoinette
    Andersen, Lars Bo
    Anderssen, Sigmund A.
    Andrade, Dolores S.
    Anjana, Ranjit Mohan
    Aounallah-Skhiri, Hajer
    Ariansen, Inger
    Aris, Tahir
    Arlappa, Nimmathota
    Arveiler, Dominique
    Assah, Felix K.
    Avdicova, Maria
    Azizi, Fereidoun
    Babu, Bontha V.
    Balakrishna, Nagalla
    Bandosz, Piotr
    Banegas, Jose R.
    Barbagallo, Carlo M.
    Barcelo, Alberto
    Barkat, Amina
    Barros, Mauro V.
    Bata, Iqbal
    Batieha, Anwar M.
    Batista, Rosangela L.
    Baur, Louise A.
    Beaglehole, Robert
    Ben Romdhane, Habiba
    Benet, Mikhail
    Bernabe-Ortiz, Antonio
    Bernotiene, Gailute
    Bettiol, Heloisa
    Bhagyalaxmi, Aroor
    Bharadwaj, Sumit
    Bhargava, Santosh K.
    Bhatti, Zaid
    Bhutta, Zulfiqar A.
    Bi, HongSheng
    Bi, Yufang
    Bjerregaard, Peter
    Bjertness, Espen
    Bjertness, Marius B.
    Bjorkelund, Cecilia
    Blake, Margaret
    Blokstra, Anneke
    Bo, Simona
    Bobak, Martin
    Boddy, Lynne M.
    Boehm, Bernhard O.
    Boeing, Heiner
    Boissonnet, Carlos P.
    Bongard, Vanina
    Bovet, Pascal
    Braeckman, Lutgart
    Bragt, Marjolijn C. E.
    Brajkovich, Imperia
    Branca, Francesco
    Breckenkamp, Juergen
    Brenner, Hermann
    Brewster, Lizzy M.
    Brian, Garry R.
    Bruno, Graziella
    Bueno-de-Mesquita, H. B(as)
    Bugge, Anna
    Burns, Con
    Cabrera de Leon, Antonio
    Cacciottolo, Joseph
    Cama, Tilema
    Cameron, Christine
    Camolas, Jose
    Can, Gunay
    Candido, Ana Paula C.
    Capuano, Vincenzo
    Cardoso, Viviane C.
    Carvalho, Maria J.
    Casanueva, Felipe F.
    Casas, Juan-Pablo
    Caserta, Carmelo A.
    Castetbon, Katia
    Chamukuttan, Snehalatha
    Chan, Angelique W.
    Chan, Queenie
    Chaturvedi, Himanshu K.
    Chaturvedi, Nishi
    Chen, Chien-Jen
    Chen, Fangfang
    Chen, Huashuai
    Chen, Shuohua
    Chen, Zhengming
    Cheng, Ching-Yu
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    Willeit, Johann
    Wojtyniak, Bogdan
    Wong, Jyh Eiin
    Wong, Tien Yin
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    Wu, Frederick C.
    Wu, JianFeng
    Wu, Shou Ling
    Xu, Haiquan
    Xu, Liang
    Yamborisut, Uruwan
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    Yardim, Nazan
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    You, Qi Sheng
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    Zimmermann, Esther
    Zuniga Cisneros, Julio
    Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 387, no 10026, p. 1377-1396Article in journal (Refereed)
    Abstract [en]

    Background Underweight and severe and morbid obesity are associated with highly elevated risks of adverse health outcomes. We estimated trends in mean body-mass index (BMI), which characterises its population distribution, and in the prevalences of a complete set of BMI categories for adults in all countries.

    Methods We analysed, with use of a consistent protocol, population-based studies that had measured height and weight in adults aged 18 years and older. We applied a Bayesian hierarchical model to these data to estimate trends from 1975 to 2014 in mean BMI and in the prevalences of BMI categories (<18.5 kg/m(2) [underweight], 18.5 kg/m(2) to <20 kg/m(2), 20 kg/m(2) to <25 kg/m(2), 25 kg/m(2) to <30 kg/m(2), 30 kg/m(2) to <35 kg/m(2), 35 kg/m(2) to <40 kg/m(2), = 40 kg/m(2) [morbid obesity]), by sex in 200 countries and territories, organised in 21 regions. We calculated the posterior probability of meeting the target of halting by 2025 the rise in obesity at its 2010 levels, if post-2000 trends continue.

    Findings We used 1698 population-based data sources, with more than 19.2 million adult participants (9.9 million men and 9.3 million women) in 186 of 200 countries for which estimates were made. Global age-standardised mean BMI increased from 21.7 kg/m(2) (95% credible interval 21.3-22.1) in 1975 to 24.2 kg/m(2) (24.0-24.4) in 2014 in men, and from 22.1 kg/m(2) (21.7-22.5) in 1975 to 24.4 kg/m(2) (24.2-24.6) in 2014 in women. Regional mean BMIs in 2014 for men ranged from 21.4 kg/m(2) in central Africa and south Asia to 29.2 kg/m(2) (28.6-29.8) in Polynesia and Micronesia; for women the range was from 21.8 kg/m(2) (21.4-22.3) in south Asia to 32.2 kg/m(2) (31.5-32.8) in Polynesia and Micronesia. Over these four decades, age-standardised global prevalence of underweight decreased from 13.8% (10.5-17.4) to 8.8% (7.4-10.3) in men and from 14.6% (11.6-17.9) to 9.7% (8.3-11.1) in women. South Asia had the highest prevalence of underweight in 2014, 23.4% (17.8-29.2) in men and 24.0% (18.9-29.3) in women. Age-standardised prevalence of obesity increased from 3.2% (2.4-4.1) in 1975 to 10.8% (9.7-12.0) in 2014 in men, and from 6.4% (5.1-7.8) to 14.9% (13.6-16.1) in women. 2.3% (2.0-2.7) of the world's men and 5.0% (4.4-5.6) of women were severely obese (ie, have BMI = 35 kg/m(2)). Globally, prevalence of morbid obesity was 0.64% (0.46-0.86) in men and 1.6% (1.3-1.9) in women.

    Interpretation If post-2000 trends continue, the probability of meeting the global obesity target is virtually zero. Rather, if these trends continue, by 2025, global obesity prevalence will reach 18% in men and surpass 21% in women; severe obesity will surpass 6% in men and 9% in women. Nonetheless, underweight remains prevalent in the world's poorest regions, especially in south Asia. 

  • 26. Friberg, Peter
    et al.
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Blomstedt, Yulia
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Beaglehole, Robert
    Bonita, Ruth
    Stordalen, Gunhild
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Public and global engagement with global health2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 381, no 9883, p. 2066-2066Article in journal (Refereed)
    Abstract [en]

    Global health is widely regarded as being grounded in public and global engagement. But much of the process of global health is dominated by Northern institutions, expert groups, think-tanks, high-level meetings, and the like. Indeed, the exponential growth of global health in the past decade may soon turn into terminal decline unless truly global and broad-based ownership of the concept can be achieved.

  • 27. Fullman, Nancy
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    Murray, Christopher J. L.
    Lozano, Rafael
    Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 20162018In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 391, no 10136, p. 2236-2271Article in journal (Refereed)
    Abstract [en]

    Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016.

    Methods: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0–100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita.

    Findings: In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8–98·1) in Iceland, followed by 96·6 (94·9–97·9) in Norway and 96·1 (94·5–97·3) in the Netherlands, to values as low as 18·6 (13·1–24·4) in the Central African Republic, 19·0 (14·3–23·7) in Somalia, and 23·4 (20·2–26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1–93·6) in Beijing to 48·0 (43·4–53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6–68·8) in Goa to 34·0 (30·3–38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries.

    Interpretation: GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view—and subsequent provision—of quality health care for all populations.

  • 28. Gasparrini, Antonio
    et al.
    Guo, Yuming
    Hashizume, Masahiro
    Lavigne, Eric
    Zanobetti, Antonella
    Schwartz, Joel
    Tobias, Aurelio
    Tong, Shilu
    Rocklöv, Joacim
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Forsberg, Bertil
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Leone, Michela
    De Sario, Manuela
    Bell, Michelle L
    Guo, Yue-Liang Leon
    Wu, Chang-Fu
    Kan, Haidong
    Yi, Seung-Muk
    de Sousa Zanotti Stagliorio Coelh, Micheline
    Saldiva, Paulo Hilario Nascimento
    Honda, Yasushi
    Kim, Ho
    Armstrong, Ben
    Mortality risk attributable to high and low ambient temperature: a multicountry observational study2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, no 9991, p. 369-375Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although studies have provided estimates of premature deaths attributable to either heat or cold in selected countries, none has so far offered a systematic assessment across the whole temperature range in populations exposed to different climates. We aimed to quantify the total mortality burden attributable to non-optimum ambient temperature, and the relative contributions from heat and cold and from moderate and extreme temperatures.

    METHODS: We collected data for 384 locations in Australia, Brazil, Canada, China, Italy, Japan, South Korea, Spain, Sweden, Taiwan, Thailand, UK, and USA. We fitted a standard time-series Poisson model for each location, controlling for trends and day of the week. We estimated temperature-mortality associations with a distributed lag non-linear model with 21 days of lag, and then pooled them in a multivariate metaregression that included country indicators and temperature average and range. We calculated attributable deaths for heat and cold, defined as temperatures above and below the optimum temperature, which corresponded to the point of minimum mortality, and for moderate and extreme temperatures, defined using cutoffs at the 2·5th and 97·5th temperature percentiles.

    FINDINGS: We analysed 74 225 200 deaths in various periods between 1985 and 2012. In total, 7·71% (95% empirical CI 7·43-7·91) of mortality was attributable to non-optimum temperature in the selected countries within the study period, with substantial differences between countries, ranging from 3·37% (3·06 to 3·63) in Thailand to 11·00% (9·29 to 12·47) in China. The temperature percentile of minimum mortality varied from roughly the 60th percentile in tropical areas to about the 80-90th percentile in temperate regions. More temperature-attributable deaths were caused by cold (7·29%, 7·02-7·49) than by heat (0·42%, 0·39-0·44). Extreme cold and hot temperatures were responsible for 0·86% (0·84-0·87) of total mortality.

    INTERPRETATION: Most of the temperature-related mortality burden was attributable to the contribution of cold. The effect of days of extreme temperature was substantially less than that attributable to milder but non-optimum weather. This evidence has important implications for the planning of public-health interventions to minimise the health consequences of adverse temperatures, and for predictions of future effect in climate-change scenarios.

    FUNDING: UK Medical Research Council.

  • 29.
    Gothefors, Leif
    et al.
    Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics.
    Blenkharn, I
    Clostridium butyricum and necrotising enterocolitis.1978In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 1, no 8054, p. 52-3Article in journal (Refereed)
  • 30. Graham, Wendy
    et al.
    Woodd, Susannah
    Byass, Peter
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa .
    Filippi, Veronique
    Gon, Giorgia
    Virgo, Sandra
    Chou, Doris
    Hounton, Sennen
    Lozano, Rafael
    Pattinson, Robert
    Singh, Susheela
    Diversity and divergence: the dynamic burden of poor maternal health2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 388, no 10056, p. 2164-2175Article, review/survey (Refereed)
    Abstract [en]

    Maternal health is a big issue and is central to sustainable development. Each year, about 210 million women become pregnant and about 140 million newborn babies are delivered-the sheer scale of maternal health alone makes maternal well being and survival vital concerns. In this Series paper, we adopt primarily a numerical lens to illuminate patterns and trends in outcomes, but recognise that understanding of poor maternal health also warrants other perspectives, such as human rights. Our use of the best available evidence highlights the dynamic burden of maternal health problems. Increased diversity in the magnitude and causes of maternal mortality and morbidity between and within populations presents a major challenge to policies and programmes aiming to match varying needs with diverse types of care across different settings. This diversity, in turn, contributes to a widening gap or differences in levels of maternal mortality, seen most acutely in vulnerable populations, predominantly in sub-Saharan Africa. Strong political and technical commitment to improve equity-sensitive information systems is required to monitor the gap in maternal mortality, and robust research is needed to elucidate major interactions between the broad range of health problems. Diversity and divergence are defining characteristics of poor maternal health in the 21st century. Progress on this issue will be an ultimate judge of sustainable development.

  • 31. Horton, Richard
    et al.
    Beaglehole, Robert
    Bonita, Ruth
    Raeburn, John
    McKee, Martin
    Wall, Stig
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    From public to planetary health: a manifesto2014In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 383, no 9920, p. 847-847Article in journal (Other academic)
  • 32. Hussein, Julia
    et al.
    Braunholtz, David
    D'Ambruoso, Lucia
    Immpact, University of Aberdeen, UK.
    Maternal health in the year 2076: correspondence2008In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 371, no 9608, p. 203-4Article in journal (Refereed)
  • 33. Imseeh, Sawsan
    et al.
    Mikki, Nahed
    Ghandour, Rula
    Giacaman, Rita
    Norberg, Margareta
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Jerden, Lars
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Stenlund, Hans
    Husseini, Abdullatif
    Self-care and glycaemic control: a cross-sectional study2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 382, p. 19-19Article in journal (Other academic)
  • 34.
    Israelsson, Leif A
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Abdominal incision closure: small but important bites2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, no 10000, p. 1216-1218Article in journal (Other academic)
  • 35.
    Janlert, Urban
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
    Long working hours: an avoidable cause of stroke?2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, no 10005, p. 1710-1711Article in journal (Refereed)
  • 36. Kamali, A
    et al.
    Quigley, M
    Nakiyingi, J
    Kinsman, John
    Medical Research Council Programme on AIDS, Uganda.
    Kengeya-Kayondo, J
    Gopal, R
    Ojwiya, A
    Hughes, P
    Carpenter, L M
    Whitworth, J
    Syndromic management of sexually-transmitted infections and behaviour change interventions on transmission of HIV-1 in rural Uganda: a community randomised trial.2003In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 361, no 9358, p. 645-52Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Treatment of sexually-transmitted infections (STIs) and behavioural interventions are the main methods to prevent HIV in developing countries. We aimed to assess the effect of these interventions on incidence of HIV-1 and other sexually-transmitted infections.

    METHODS: We randomly allocated all adults living in 18 communities in rural Uganda to receive behavioural interventions alone (group A), behavioural and STI interventions (group B), or routine government health services and community development activities (group C). The primary outcome was HIV-1 incidence. Secondary outcomes were incidence of herpes simplex virus type 2 (HSV2) and active syphilis and prevalence of gonorrhoea, chlamydia, reported genital ulcers, reported genital discharge, and markers of behavioural change. Analysis was per protocol.

    FINDINGS: Compared with group C, the incidence rate ratio of HIV-1 was 0.94 (0.60-1.45, p=0.72) in group A and 1.00 (0.63-1.58, p=0.98) in group B, and the prevalence ratio of use of condoms with last casual partner was 1.12 (95% CI 0.99-1.25) in group A and 1.27 (1.02-1.56) in group B. Incidence of HSV2 was lower in group A than in group C (incidence rate ratio 0.65, 0.53-0.80) and incidence of active syphilis for high rapid plasma reagent test titre and prevalence of gonorrhoea were both lower in group B than in group C (active syphilis incidence rate ratio, 0.52, 0.27-0.98; gonorrhoea prevalence ratio, 0.25, 0.10-0.64).

    INTERPRETATION: The interventions we used were insufficient to reduce HIV-1 incidence in rural Uganda, where secular changes are occurring. More effective STI and behavioural interventions need to be developed for HIV control in mature epidemics.

  • 37. Kelly, F J
    et al.
    Sandström, Thomas
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Pulmonary Medicine.
    Air pollution, oxidative stress, and allergic response2004In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 363, no 9403, p. 95-96Article in journal (Refereed)
  • 38. Kivimäki, Mika
    et al.
    Jokela, Markus
    Nyberg, Solja T
    Singh-Manoux, Archana
    Fransson, Eleonor I
    Alfredsson, Lars
    Bjorner, Jakob B
    Borritz, Marianne
    Burr, Hermann
    Casini, Annalisa
    Clays, Els
    De Bacquer, Dirk
    Dragano, Nico
    Erbel, Raimund
    Geuskens, Goedele A
    Hamer, Mark
    Hooftman, Wendela E
    Houtman, Irene L
    Jöckel, Karl-Heinz
    Kittel, France
    Knutsson, Anders
    Koskenvuo, Markku
    Lunau, Thorsten
    Madsen, Ida E H
    Nielsen, Martin L
    Nordin, Maria
    Umeå University, Faculty of Social Sciences, Department of Psychology. Stress Research Institute, Stockholm University, Stockholm, Sweden .
    Oksanen, Tuula
    Pejtersen, Jan H
    Pentti, Jaana
    Rugulies, Reiner
    Salo, Paula
    Shipley, Martin J
    Siegrist, Johannes
    Steptoe, Andrew
    Suominen, Sakari B
    Theorell, Töres
    Vahtera, Jussi
    Westerholm, Peter J M
    Westerlund, Hugo
    O'Reilly, Dermot
    Kumari, Meena
    Batty, G David
    Ferrie, Jane E
    Virtanen, Marianna
    Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603 838 individuals2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 386, no 10005, p. 1739-1746Article in journal (Refereed)
    Abstract [en]

    Background: Long working hours might increase the risk of cardiovascular disease, but prospective evidence is scarce, imprecise, and mostly limited to coronary heart disease. We aimed to assess long working hours as a risk factor for incident coronary heart disease and stroke. Methods: We identified published studies through a systematic review of PubMed and Embase from inception to Aug 20, 2014. We obtained unpublished data for 20 cohort studies from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium and open-access data archives. We used cumulative random-effects meta-analysis to combine effect estimates from published and unpublished data. Findings: We included 25 studies from 24 cohorts in Europe, the USA, and Australia. The meta-analysis of coronary heart disease comprised data for 603 838 men and women who were free from coronary heart disease at baseline; the meta-analysis of stroke comprised data for 528 908 men and women who were free from stroke at baseline. Follow-up for coronary heart disease was 5.1 million person-years (mean 8.5 years), in which 4768 events were recorded, and for stroke was 3.8 million person-years (mean 7.2 years), in which 1722 events were recorded. In cumulative meta-analysis adjusted for age, sex, and socioeconomic status, compared with standard hours (35-40 h per week), working long hours (>= 55 h per week) was associated with an increase in risk of incident coronary heart disease (relative risk [RR] 1.13, 95% CI 1.02-1.26; p=0.02) and incident stroke (1.33, 1.11-1.61; p=0.002). The excess risk of stroke remained unchanged in analyses that addressed reverse causation, multivariable adjustments for other risk factors, and different methods of stroke ascertainment (range of RR estimates 1.30-1.42). We recorded a dose-response association for stroke, with RR estimates of 1.10 (95% CI 0.94-1.28; p=0.24) for 41-48 working hours, 1.27 (1.03-1.56; p=0.03) for 49-54 working hours, and 1.33 (1.11-1.61; p=0.002) for 55 working hours or more per week compared with standard working hours (p(trend)<0.0001). Interpretation: Employees who work long hours have a higher risk of stroke than those working standard hours; the association with coronary heart disease is weaker. These findings suggest that more attention should be paid to the management of vascular risk factors in individuals who work long hours.

  • 39. Kivimäki, Mika
    et al.
    Nyberg, Solja T
    Batty, G David
    Fransson, Eleonor I
    Heikkilä, Katriina
    Alfredsson, Lars
    Bjorner, Jakob B
    Borritz, Marianne
    Burr, Hermann
    Casini, Annalisa
    Clays, Els
    De Bacquer, Dirk
    Dragano, Nico
    Ferrie, Jane E
    Geuskens, Goedele A
    Goldberg, Marcel
    Hamer, Mark
    Hooftman, Wendela E
    Houtman, Irene L
    Joensuu, Matti
    Jokela, Markus
    Kittel, France
    Knutsson, Anders
    Koskenvuo, Markku
    Koskinen, Aki
    Kouvonen, Anne
    Kumari, Meena
    Madsen, Ida Eh
    Marmot, Michael G
    Nielsen, Martin L
    Nordin, Maria
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine.
    Oksanen, Tuula
    Pentti, Jaana
    Rugulies, Reiner
    Salo, Paula
    Siegrist, Johannes
    Singh-Manoux, Archana
    Suominen, Sakari B
    Väänänen, Ari
    Vahtera, Jussi
    Virtanen, Marianna
    Westerholm, Peter Jm
    Westerlund, Hugo
    Zins, Marie
    Steptoe, Andrew
    Theorell, Töres
    Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data2012In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 380, no 9852, p. 1491-1497Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Published work assessing psychosocial stress (job strain) as a risk factor for coronary heart disease is inconsistent and subject to publication bias and reverse causation bias. We analysed the relation between job strain and coronary heart disease with a meta-analysis of published and unpublished studies. METHODS: We used individual records from 13 European cohort studies (1985-2006) of men and women without coronary heart disease who were employed at time of baseline assessment. We measured job strain with questions from validated job-content and demand-control questionnaires. We extracted data in two stages such that acquisition and harmonisation of job strain measure and covariables occurred before linkage to records for coronary heart disease. We defined incident coronary heart disease as the first non-fatal myocardial infarction or coronary death. FINDINGS: 30 214 (15%) of 197 473 participants reported job strain. In 1·49 million person-years at risk (mean follow-up 7·5 years [SD 1·7]), we recorded 2358 events of incident coronary heart disease. After adjustment for sex and age, the hazard ratio for job strain versus no job strain was 1·23 (95% CI 1·10-1·37). This effect estimate was higher in published (1·43, 1·15-1·77) than unpublished (1·16, 1·02-1·32) studies. Hazard ratios were likewise raised in analyses addressing reverse causality by exclusion of events of coronary heart disease that occurred in the first 3 years (1·31, 1·15-1·48) and 5 years (1·30, 1·13-1·50) of follow-up. We noted an association between job strain and coronary heart disease for sex, age groups, socioeconomic strata, and region, and after adjustments for socioeconomic status, and lifestyle and conventional risk factors. The population attributable risk for job strain was 3·4%. INTERPRETATION: Our findings suggest that prevention of workplace stress might decrease disease incidence; however, this strategy would have a much smaller effect than would tackling of standard risk factors, such as smoking. FUNDING: Finnish Work Environment Fund, the Academy of Finland, the Swedish Research Council for Working Life and Social Research, the German Social Accident Insurance, the Danish National Research Centre for the Working Environment, the BUPA Foundation, the Ministry of Social Affairs and Employment, the Medical Research Council, the Wellcome Trust, and the US National Institutes of Health.

  • 40. L, Abarca-Gómez
    et al.
    Forsner, Maria
    Högskolan Dalarna.
    M, Ezzati
    Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults.2017In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 390, no 10113, p. 2627-2642, article id S0140-6736(17)32129-3Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Underweight, overweight, and obesity in childhood and adolescence are associated with adverse health consequences throughout the life-course. Our aim was to estimate worldwide trends in mean body-mass index (BMI) and a comprehensive set of BMI categories that cover underweight to obesity in children and adolescents, and to compare trends with those of adults.

    METHODS: We pooled 2416 population-based studies with measurements of height and weight on 128·9 million participants aged 5 years and older, including 31·5 million aged 5-19 years. We used a Bayesian hierarchical model to estimate trends from 1975 to 2016 in 200 countries for mean BMI and for prevalence of BMI in the following categories for children and adolescents aged 5-19 years: more than 2 SD below the median of the WHO growth reference for children and adolescents (referred to as moderate and severe underweight hereafter), 2 SD to more than 1 SD below the median (mild underweight), 1 SD below the median to 1 SD above the median (healthy weight), more than 1 SD to 2 SD above the median (overweight but not obese), and more than 2 SD above the median (obesity).

    FINDINGS: Regional change in age-standardised mean BMI in girls from 1975 to 2016 ranged from virtually no change (-0·01 kg/m2 per decade; 95% credible interval -0·42 to 0·39, posterior probability [PP] of the observed decrease being a true decrease=0·5098) in eastern Europe to an increase of 1·00 kg/m2 per decade (0·69-1·35, PP>0·9999) in central Latin America and an increase of 0·95 kg/m2 per decade (0·64-1·25, PP>0·9999) in Polynesia and Micronesia. The range for boys was from a non-significant increase of 0·09 kg/m2 per decade (-0·33 to 0·49, PP=0·6926) in eastern Europe to an increase of 0·77 kg/m2 per decade (0·50-1·06, PP>0·9999) in Polynesia and Micronesia. Trends in mean BMI have recently flattened in northwestern Europe and the high-income English-speaking and Asia-Pacific regions for both sexes, southwestern Europe for boys, and central and Andean Latin America for girls. By contrast, the rise in BMI has accelerated in east and south Asia for both sexes, and southeast Asia for boys. Global age-standardised prevalence of obesity increased from 0·7% (0·4-1·2) in 1975 to 5·6% (4·8-6·5) in 2016 in girls, and from 0·9% (0·5-1·3) in 1975 to 7·8% (6·7-9·1) in 2016 in boys; the prevalence of moderate and severe underweight decreased from 9·2% (6·0-12·9) in 1975 to 8·4% (6·8-10·1) in 2016 in girls and from 14·8% (10·4-19·5) in 1975 to 12·4% (10·3-14·5) in 2016 in boys. Prevalence of moderate and severe underweight was highest in India, at 22·7% (16·7-29·6) among girls and 30·7% (23·5-38·0) among boys. Prevalence of obesity was more than 30% in girls in Nauru, the Cook Islands, and Palau; and boys in the Cook Islands, Nauru, Palau, Niue, and American Samoa in 2016. Prevalence of obesity was about 20% or more in several countries in Polynesia and Micronesia, the Middle East and north Africa, the Caribbean, and the USA. In 2016, 75 (44-117) million girls and 117 (70-178) million boys worldwide were moderately or severely underweight. In the same year, 50 (24-89) million girls and 74 (39-125) million boys worldwide were obese.

    INTERPRETATION: The rising trends in children's and adolescents' BMI have plateaued in many high-income countries, albeit at high levels, but have accelerated in parts of Asia, with trends no longer correlated with those of adults.

    FUNDING: Wellcome Trust, AstraZeneca Young Health Programme.

  • 41. Lewycka, Sonia
    et al.
    Mwansambo, Charles
    Rosato, Mikey
    Kazembe, Peter
    Phiri, Tambosi
    Mganga, Andrew
    Chapota, Hilda
    Malamba, Florida
    Kainja, Esther
    Newell, Marie-Louise
    Greco, Giulia
    Pulkki-Brännström, Anni-Maria
    Skordis-Worrall, Jolene
    Vergnano, Stefania
    Osrin, David
    Costello, Anthony
    Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial2013In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 381, no 9879, p. 1721-35Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi.

    METHODS: We did a 2×2 factorial, cluster-randomised trial in 185,888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126.

    FINDINGS: We monitored outcomes of 26,262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0.93, 0.64-1.35) and MMR (0.54, 0.28-1.04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0.85, 0.59-1.22) and MMR (0.48, 0.26-0.91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0.26, 0.10-0.70), and NMR by 41% (0.59, 0.40-0.86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1.09, 0.40-2.98, and 1.38, 0.75-2.54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0.82, 0.67-1.00) and an improvement in EBF rates (2.42, 1.48-3.96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0.64, 0.48-0.85) but no effect on EBF (1.18, 0.63-2.25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1.05, 0.82-1.36) and an increase in EBF (5.02, 2.67-9.44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons.

    INTERPRETATION: Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.

  • 42.
    Lindholm, Lars-Hjalmar
    et al.
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
    Carlberg, Bo
    Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Medicine.
    Samuelsson, Ola
    Betablockers for the treatment of primary hypertension: Authors' reply2006In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 367, no 9506, p. 210-Article in journal (Other academic)
  • 43.
    Lorentzon, Ronny
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine.
    Nordström, Peter
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine.
    Pettersson, Ulrika
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Sports Medicine.
    The Achilles heel of exercise.2000In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 355, no 9218, p. 1909-10; author reply 1911Article in journal (Refereed)
  • 44.
    Löfgren, Jenny
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Kadobera, Daniel
    Forsberg, Birger C.
    Mulowooza, Jude
    Wladis, Andreas
    Nordin, Pär
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
    Surgery in district hospitals in rural Uganda-indications, interventions, and outcomes2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 385, p. 18-18Article in journal (Other academic)
    Abstract [en]

    Background: There is a vast unmet need for surgical interventions in resource scarce settings. The poorest 2 billion people share 3·5% of the world's operations. The highest burden of surgical disease is seen in Africa where surgery could avert many deaths. Prospective studies investigating interventions, indications, and outcomes including perioperative mortality rates (POMR) after surgery are scant. The aim of the study was to describe the situation of surgery in a low-income setting in sub-Saharan Africa. Methods: In this descriptive, facility-based study, data were prospectively collected in questionnaires by 41 staff employed at two hospitals (Iganga General Hospital and Buluba Mission Hospital) in eastern Uganda during 4 months (major surgeries) and 3 months (minor surgeries) in 2011. Data included patient characteristics, interventions, indications for surgery, and in-hospital mortality after surgery. Descriptive statistical methods were used to analyse the data. Findings: 2701 patients underwent 2790 surgical interventions. Of these, 1051 patients underwent major surgery, which corresponds to a major surgery rate of 224·8 per 100 000 population. Most patients undergoing major surgery were women (n=923, 88%). Pregnancy related complications (n=747, 66%) leading to caesarean section (n=496, 47%) and evacuation (n=244, 22%) or gynaecological conditions (n=114, 10%) were common indications for surgery. General surgery interventions registered were herniorrhaphy (n=103, 9%), explorative laparotomy (n=60, 5%), and appendicectomy (n=31, 3%). Overall, the POMR was 0·6% (16 deaths); for major surgery it was 1·3% (14 deaths) and for minor surgeries it was 0·1% (two of 1650 patients). High POMR were seen following explorative laparotomy (13·3%, eight deaths) and caesarean section (0·8%, four deaths). Of the 510 babies delivered through caesarean section, 59 (12%) were still born or died before discharge. Interpretation: Rates of surgery are low in the study setting compared with in high-income settings where surgical rates exceed 11 000 per 100 000 population. POMR are high after exploratory laparotomy and caesarean section. Although very detailed, a larger study could be undertaken to investigate the situation in other settings. Underlying reasons leading to death and quality of surgical care should be investigated further so that POMR can be reduced in this setting.

  • 45.
    MacMahon, Stephen
    et al.
    George Institute for International Health, University of Sydney, Sydney, Australia.
    Alderman, Michael H.
    Albert Einstein College of Medicine, Yeshiva University, New York, USA.
    Lindholm, Lars H
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Family Medicine.
    Liu, Lisheng
    Chinese Academy of Medical Sciences, Fu Wai Hospital, Beijing, China.
    Sanchez, Ramiro A
    Instituto de Cardiologia y Cirugia Cardiovascular, Universidad “Dr René G Favaloro”, Buenos Aires, Argentina.
    Seedat, Yackoob K
    Nelson R Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa.
    Blood-pressure-related disease is a global health priority.2008In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 371, no 9623, p. 1480-1482Article in journal (Refereed)
  • 46. Massad, Eduardo
    et al.
    Bezerra Coutinho, Francisco Antonio
    Wilder-Smith, Annelies
    Lee Kong Chian School of Medicine, Singapore.
    The olympically mismeasured risk of Zika virus in Rio de Janeiro: authors' reply2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 388, no 10045, p. 658-659Article in journal (Other academic)
  • 47. Massad, Eduardo
    et al.
    Coutinho, Francisco Antonio Bezerra
    Wilder-Smith, Annelies
    Lee Kong Chian School of Medicine, Singapore.
    Is Zika a substantial risk for visitors to the Rio de Janeiro Olympic Games?2016In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 388, no 10039, p. 25-25Article in journal (Other (popular science, discussion, etc.))
  • 48. Mayosi, Bongani M
    et al.
    Flisher, Alan J
    Lalloo, Umesh G
    Sitas, Freddy
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health. MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
    Bradshaw, Debbie
    The burden of non-communicable diseases in South Africa2009In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 374, no 9693, p. 934-947Article in journal (Refereed)
    Abstract [en]

    15 years after its first democratic election, South Africa is in the midst of a profound health transition that is characterised by a quadruple burden of communicable, non-communicable, perinatal and maternal, and injury-related disorders. Non-communicable diseases are emerging in both rural and urban areas, most prominently in poor people living in urban settings, and are resulting in increasing pressure on acute and chronic health-care services. Major factors include demographic change leading to a rise in the proportion of people older than 60 years, despite the negative effect of HIV/AIDS on life expectancy. The burden of these diseases will probably increase as the roll-out of antiretroviral therapy takes effect and reduces mortality from HIV/AIDS. The scale of the challenge posed by the combined and growing burden of HIV/AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-effectiveness in the primary and secondary prevention of such diseases within populations and health services. We urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess, and implement integrated care interventions for chronic infectious and non-communicable diseases.

  • 49. Mayosi, Bongani M
    et al.
    Flisher, Alan J
    Lalloo, Umesh G
    Sitas, Freddy
    Tollman, Stephen M
    Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences. Univ Witwatersrand, Sch Publ Hlth, MRC, Wits Rural Publ Hlth & Hlth Transit Res Unit Agin, Johannesburg, South Africa.
    Bradshaw, Debbie
    Transmissible cancer in Africa reply2009In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 374, no 9707, p. 2052-2053Article in journal (Other academic)
  • 50. Ngandu, Tiia
    et al.
    Lehtisalo, Jenni
    Solomon, Alina
    Levälahti, Esko
    Ahtiluoto, Satu
    Antikainen, Riitta
    Bäckman, Lars
    Hänninen, Tuomo
    Jula, Antti
    Laatikainen, Tiina
    Lindström, Jaana
    Mangialasche, Francesca
    Paajanen, Teemu
    Pajala, Satu
    Peltonen, Markku
    Rauramaa, Rainer
    Stigsdotter-Neely, Anna
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Strandberg, Timo
    Tuomilehto, Jaakko
    Soininen, Hilkka
    Kivipelto, Miia
    A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial2015In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 385, no 9984, p. 2255-2263Article in journal (Refereed)
    Abstract [en]

    Background Modifiable vascular and lifestyle-related risk factors have been associated with dementia risk in observational studies. In the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), a proof-of-concept randomised controlled trial, we aimed to assess a multidomain approach to prevent cognitive decline in at-risk elderly people from the general population.

    Methods In a double-blind randomised controlled trial we enrolled individuals aged 60-77 years recruited from previous national surveys. Inclusion criteria were CAIDE (Cardiovascular Risk Factors, Aging and Dementia) Dementia Risk Score of at least 6 points and cognition at mean level or slightly lower than expected for age. We randomly assigned participants in a 1: 1 ratio to a 2 year multidomain intervention (diet, exercise, cognitive training, vascular risk monitoring), or a control group (general health advice). Computer-generated allocation was done in blocks of four (two individuals randomly allocated to each group) at each site. Group allocation was not actively disclosed to participants and outcome assessors were masked to group allocation. The primary outcome was change in cognition as measured through comprehensive neuropsychological test battery (NTB) Z score. Analysis was by modified intention to treat (all participants with at least one post-baseline observation). This trial is registered at ClinicalTrials.gov, number NCT01041989.

    Findings Between Sept 7, 2009, and Nov 24, 2011, we screened 2654 individuals and randomly assigned 1260 to the intervention group (n=631) or control group (n=629). 591 (94%) participants in the intervention group and 599 (95%) in the control group had at least one post-baseline assessment and were included in the modified intention-to-treat analysis. Estimated mean change in NTB total Z score at 2 years was 0.20 (SE 0.02, SD 0.51) in the intervention group and 0.16 (0.01, 0.51) in the control group. Between-group difference in the change of NTB total score per year was 0.022 (95% CI 0.002-0.042, p=0.030). 153 (12%) individuals dropped out overall. Adverse events occurred in 46 (7%) participants in the intervention group compared with six (1%) participants in the control group; the most common adverse event was musculoskeletal pain (32 [5%] individuals for intervention vs no individuals for control).

    Interpretation Findings from this large, long-term, randomised controlled trial suggest that a multidomain intervention could improve or maintain cognitive functioning in at-risk elderly people from the general population.

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