Majid Ezzati

Publications of Majid Ezzati

• The Age Associations of Blood Pressure, Cholesterol and Glucose: Analysis of Health Examination Surveys from International Populations.

  Authors: Gitanjali M Singh, Goodarz Danaei, Pamela M Pelizzari, John K Lin, Melanie J Cowan, Gretchen A Stevens, Farshad Farzadfar, Young-Ho Khang, Yuan Lu, Leanne M Riley, Stephen S Lim, Majid Ezzati

  Circulation. 04/2012;

  BACKGROUND: The age-association of cardiovascular disease (CVD) may be partially because its metabolic risk factors tend to rise with age. Few studies have analyzed age-associations of multipleBACKGROUND: The age-association of cardiovascular disease (CVD) may be partially because its metabolic risk factors tend to rise with age. Few studies have analyzed age-associations of multiple metabolic risks in the same population, especially in nationally representative samples. We examined worldwide variations in the age associations of systolic blood pressure (SBP), total cholesterol (TC), and fasting plasma glucose (FPG). METHODS AND RESULTS: We used individual records from 83 nationally or sub-nationally representative health examination surveys in 52 countries to fit a linear model to risk factor data between ages 30-64 years for SBP and FPG, and between 30-54 years for TC. We report the cross-country variation of the slope and intercept of this relationship. We also assessed non-linear associations in older ages. Between 30 and 64 years of age, SBP increased by 1.7-11.6 mmHg per ten years of age and FPG increased by 0.8-20.4 mg/dL per ten years of age in different countries and in the two sexes. Between 30 and 54 years of age, TC increased by 0.2-22.4 mg/dL per ten years of age in different surveys and in the two sexes. For all risk factors and in most countries, risk factor levels rose more steeply among women than among men, especially for TC. On average, there was a flattening of age-SBP relationship in older ages; TC and FPG age associations reversed in older ages, leading to lower levels in older ages than in middle ages. CONCLUSIONS: The rise with age of major metabolic CVD risk factors varies substantially across populations, especially for FPG and TC. TC rises more steeply in high-income countries and FPG in the Oceania countries, the Middle East, and the US. The SBP age association had no specific income or geographical pattern.

• The exposure of infants and children to carbon monoxide from biomass fuels in The Gambia: a measurement and modeling study.

  Authors: Kathie L Dionisio, Stephen R C Howie, Francesca Dominici, Kimberly M Fornace, John D Spengler, Simon Donkor, Osaretin Chimah, Claire Oluwalana, Readon C Ideh, Bernard Ebruke, Richard A Adegbola, Majid Ezzati

  Journal of exposure science & environmental epidemiology. 12/2011; 22(2):173-81.

  Smoke from biomass fuels is a risk factor for pneumonia, the leading cause of child death worldwide. Although particulate matter (PM) is the metric of choice for studying the health effects ofSmoke from biomass fuels is a risk factor for pneumonia, the leading cause of child death worldwide. Although particulate matter (PM) is the metric of choice for studying the health effects of biomass smoke, measuring children's PM exposure is difficult. Carbon monoxide (CO), which is easier to measure, can be used as a proxy for PM exposure. We measured the exposure of children ≤5 years of age in The Gambia to CO using small, passive, color stain diffusion tubes. We conducted multiple CO measurements on a subset of children to measure day-to-day exposure variability. Usual CO exposure was modeled using a mixed effects model, which also included individual and household level exposure predictors. Mean measured CO exposure for 1181 children (n=2263 measurements) was 1.04±1.46 p.p.m., indicating that the Gambian children in this study on average have a relatively low CO exposure. However, 25% of children had exposures of 1.3 p.p.m. or higher. CO exposure was higher during the rainy months (1.33±1.62 p.p.m.). Burning insect coils, using charcoal, and measurement done in the rainy season were associated with higher exposure. A parsimonious model with fuel, season, and other PM sources as covariates explained 39% of between-child variation in exposure and helped remove within-child variability.

• Effectiveness of diabetes and hypertension management by rural primary health-care workers (Behvarz workers) in Iran: a nationally representative observational study.

  Authors: Farshad Farzadfar, Christopher J L Murray, Emmanuela Gakidou, Thomas Bossert, Hengameh Namdaritabar, Siamak Alikhani, Ghobad Moradi, Alireza Delavari, Hamidreza Jamshidi, Majid Ezzati

  Lancet. 12/2011; 379(9810):47-54.

  Non-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system canNon-communicable diseases and their risk factors are leading causes of disease burden in Iran and other middle-income countries. Little evidence exists for whether the primary health-care system can effectively manage non-communicable diseases and risk factors at the population level. Our aim was to examine the effectiveness of the Iranian rural primary health-care system (the Behvarz system) in the management of diabetes and hypertension, and to assess whether the effects depend on the number of health-care workers in the community. We used individual-level data from the 2005 Non-Communicable Disease Surveillance Survey (NCDSS) for fasting plasma glucose (FPG) and systolic blood pressure (SBP), body-mass index, medication use, and sociodemographic variables. Data for Behvarz-worker and physician densities were from the 2006 Population and Housing Census and the 2005 Outpatient Care Centre Mapping Survey. We assessed the effectiveness of treatment on FPG and SBP, and associations between FPG or SBP and Behvarz-worker density with two statistical approaches: a mixed-effects regression analysis of the full NCDSS sample adjusting for individual-level and community-level covariates and an analysis that estimated average treatment effect on data balanced with propensity score matching. NCDSS had data for 65,619 individuals aged 25 years or older (11,686 of whom in rural areas); of these, 64,694 (11,521 in rural areas) had data for SBP and 50,202 (9337 in rural areas) had data for FPG. Nationally, 39·2% (95% CI 37·7 to 40·7) of individuals with diabetes and 35·7% (34·9 to 36·5) of those with hypertension received treatment, with higher treatment coverage in women than in men and in urban areas than in rural areas. Treatment lowered mean FPG by an estimated 1·34 mmol/L (0·58 to 2·10) in rural areas and 0·21 mmol/L (-0·15 to 0·56) in urban areas. Individuals in urban areas with hypertension who received treatment had 3·8 mm Hg (3·1 to 4·5) lower SBP than they would have had if they had not received treatment; the treatment effect was 2·5 mm Hg (1·1 to 3·9) lower FPG in rural areas. Each additional Behvarz worker per 1000 adults was associated with a 0·09 mmol/L (0·01 to 0·18) lower district-level average FPG (p=0·02); for SBP this effect was 0·53 mm Hg (-0·44 to 1·50; p=0·28). Our findings were not sensitive to the choice of statistical method. Primary care systems with trained community health-care workers and well established guidelines can be effective in non-communicable disease prevention and management. Iran's primary care system should expand the number and scope of its primary health-care worker programmes to also address blood pressure and to improve performance in areas with few primary care personnel. None.

• What has made the population of Japan healthy?

  Authors: Nayu Ikeda, Eiko Saito, Naoki Kondo, Manami Inoue, Shunya Ikeda, Toshihiko Satoh, Koji Wada, Andrew Stickley, Kota Katanoda, Tetsuya Mizoue, Mitsuhiko Noda, Hiroyasu Iso, Yoshihisa Fujino, Tomotaka Sobue, Shoichiro Tsugane, Mohsen Naghavi, Majid Ezzati, Kenji Shibuya

  Lancet. 08/2011; 378(9796):1094-105.

  People in Japan have the longest life expectancy at birth in the world. Here, we compile the best available evidence about population health in Japan to investigate what has made the Japanese peoplePeople in Japan have the longest life expectancy at birth in the world. Here, we compile the best available evidence about population health in Japan to investigate what has made the Japanese people healthy in the past 50 years. The Japanese population achieved longevity in a fairly short time through a rapid reduction in mortality rates for communicable diseases from the 1950s to the early 1960s, followed by a large reduction in stroke mortality rates. Japan had moderate mortality rates for non-communicable diseases, with the exception of stroke, in the 1950s. The improvement in population health continued after the mid-1960s through the implementation of primary and secondary preventive community public health measures for adult mortality from non-communicable diseases and an increased use of advanced medical technologies through the universal insurance scheme. Reduction in health inequalities with improved average population health was partly attributable to equal educational opportunities and financial access to care. With the achievement of success during the health transition since World War 2, Japan now needs to tackle major health challenges that are emanating from a rapidly ageing population, causes that are not amenable to health technologies, and the effects of increasing social disparities to sustain the improvement in population health.

• National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants.

  Authors: Goodarz Danaei, Mariel M Finucane, Yuan Lu, Gitanjali M Singh, Melanie J Cowan, Christopher J Paciorek, John K Lin, Farshad Farzadfar, Young-Ho Khang, Gretchen A Stevens, Mayuree Rao, Mohammed K Ali, Leanne M Riley, Carolyn A Robinson, Majid Ezzati

  Lancet. 06/2011; 378(9785):31-40.

  Data for trends in glycaemia and diabetes prevalence are needed to understand the effects of diet and lifestyle within populations, assess the performance of interventions, and plan health services.Data for trends in glycaemia and diabetes prevalence are needed to understand the effects of diet and lifestyle within populations, assess the performance of interventions, and plan health services. No consistent and comparable global analysis of trends has been done. We estimated trends and their uncertainties in mean fasting plasma glucose (FPG) and diabetes prevalence for adults aged 25 years and older in 199 countries and territories. We obtained data from health examination surveys and epidemiological studies (370 country-years and 2·7 million participants). We converted systematically between different glycaemic metrics. For each sex, we used a Bayesian hierarchical model to estimate mean FPG and its uncertainty by age, country, and year, accounting for whether a study was nationally, subnationally, or community representative. In 2008, global age-standardised mean FPG was 5·50 mmol/L (95% uncertainty interval 5·37-5·63) for men and 5·42 mmol/L (5·29-5·54) for women, having risen by 0·07 mmol/L and 0·09 mmol/L per decade, respectively. Age-standardised adult diabetes prevalence was 9·8% (8·6-11·2) in men and 9·2% (8·0-10·5) in women in 2008, up from 8·3% (6·5-10·4) and 7·5% (5·8-9·6) in 1980. The number of people with diabetes increased from 153 (127-182) million in 1980, to 347 (314-382) million in 2008. We recorded almost no change in mean FPG in east and southeast Asia and central and eastern Europe. Oceania had the largest rise, and the highest mean FPG (6·09 mmol/L, 5·73-6·49 for men; 6·08 mmol/L, 5·72-6·46 for women) and diabetes prevalence (15·5%, 11·6-20·1 for men; and 15·9%, 12·1-20·5 for women) in 2008. Mean FPG and diabetes prevalence in 2008 were also high in south Asia, Latin America and the Caribbean, and central Asia, north Africa, and the Middle East. Mean FPG in 2008 was lowest in sub-Saharan Africa, east and southeast Asia, and high-income Asia-Pacific. In high-income subregions, western Europe had the smallest rise, 0·07 mmol/L per decade for men and 0·03 mmol/L per decade for women; North America had the largest rise, 0·18 mmol/L per decade for men and 0·14 mmol/L per decade for women. Glycaemia and diabetes are rising globally, driven both by population growth and ageing and by increasing age-specific prevalences. Effective preventive interventions are needed, and health systems should prepare to detect and manage diabetes and its sequelae. Bill & Melinda Gates Foundation and WHO.

• Household and community poverty, biomass use, and air pollution in Accra, Ghana.

  Authors: Zheng Zhou, Kathie L Dionisio, Raphael E Arku, Audrey Quaye, Allison F Hughes, Jose Vallarino, John D Spengler, Allan Hill, Samuel Agyei-Mensah, Majid Ezzati

  Proceedings of the National Academy of Sciences of the United States of America. 06/2011; 108(27):11028-33.

  Many urban households in developing countries use biomass fuels for cooking. The proportion of household biomass use varies among neighborhoods, and is generally higher in low socioeconomic statusMany urban households in developing countries use biomass fuels for cooking. The proportion of household biomass use varies among neighborhoods, and is generally higher in low socioeconomic status (SES) communities. Little is known of how household air pollution varies by SES and how it is affected by biomass fuels and traffic sources in developing country cities. In four neighborhoods in Accra, Ghana, we collected and analyzed geo-referenced data on household and community particulate matter (PM) pollution, SES, fuel use for domestic and small-commercial cooking, housing characteristics, and distance to major roads. Cooking area PM was lowest in the high-SES neighborhood, with geometric means of 25 (95% confidence interval, 21-29) and 28 (23-33) μg/m(3) for fine and coarse PM (PM(2.5) and PM(2.5-10)), respectively; it was highest in two low-SES slums, with geometric means reaching 71 (62-80) and 131 (114-150) μg/m(3) for fine and coarse PM. After adjustment for other factors, living in a community where all households use biomass fuels would be associated with 1.5- to 2.7-times PM levels in models with and without adjustment for ambient PM. Community biomass use had a stronger association with household PM than household's own fuel choice in crude and adjusted estimates. Lack of regular physical access to clean fuels is an obstacle to fuel switching in low-income neighborhoods and should be addressed through equitable energy infrastructure.

• Falling behind: life expectancy in US counties from 2000 to 2007 in an international context.

  Authors: Sandeep C Kulkarni, Alison Levin-Rector, Majid Ezzati, Christopher Jl Murray

  Population health metrics. 06/2011; 9(1):16.

  ABSTRACT: The United States health care debate has focused on the nation's uniquely high rates of lack of insurance and poor health outcomes relative to other high-income countries. Large disparitiesABSTRACT: The United States health care debate has focused on the nation's uniquely high rates of lack of insurance and poor health outcomes relative to other high-income countries. Large disparities in health outcomes are well-documented in the US, but the most recent assessment of county disparities in mortality is from 1999. It is critical to tracking progress of health reform legislation to have an up-to-date assessment of disparities in life expectancy across counties. US disparities can be seen more clearly in the context of how progress in each county compares to international trends. We use newly released mortality data by age, sex, and county for the US from 2000 to 2007 to compute life tables separately for each sex, for all races combined, for whites, and for blacks. We propose, validate, and apply novel methods to estimate recent life tables for small areas to generate up-to-date estimates. Life expectancy rates and changes in life expectancy for counties are compared to the life expectancies across nations in 2000 and 2007. We calculate the number of calendar years behind each county is in 2000 and 2007 compared to an international life expectancy time series. Across US counties, life expectancy in 2007 ranged from 65.9 to 81.1 years for men and 73.5 to 86.0 years for women. When compared against a time series of life expectancy in the 10 nations with the lowest mortality, US counties range from being 15 calendar years ahead to over 50 calendar years behind for men and 16 calendar years ahead to over 50 calendar years behind for women. County life expectancy for black men ranges from 59.4 to 77.2 years, with counties ranging from seven to over 50 calendar years behind the international frontier; for black women, the range is 69.6 to 82.6 years, with counties ranging from eight to over 50 calendar years behind. Between 2000 and 2007, 80% (men) and 91% (women) of American counties fell in standing against this international life expectancy standard. The US has extremely large geographic and racial disparities, with some communities having life expectancies already well behind those of the best-performing nations. At the same time, relative performance for most communities continues to drop. Efforts to address these issues will need to tackle the leading preventable causes of death.

• How many deaths are attributable to smoking in the United States? Comparison of methods for estimating smoking-attributable mortality when smoking prevalence changes.

  Authors: Shefali Oza, Michael J Thun, S Jane Henley, Alan D Lopez, Majid Ezzati

  Preventive medicine. 06/2011; 52(6):428-33.

  The number of smoking-attributable deaths is commonly estimated using current and former smoking prevalences or lung cancer mortality as an indirect metric of cumulative population smoking. NeitherThe number of smoking-attributable deaths is commonly estimated using current and former smoking prevalences or lung cancer mortality as an indirect metric of cumulative population smoking. Neither method accounts for differences in the timing with which relative risks (RRs) for different diseases change following smoking initiation and cessation. We aimed to develop a method to account for time-dependent RRs. We used birth cohort lung cancer mortality and its change over time to characterize time-varying cumulative smoking exposure. We analyzed data from the American Cancer Society Cancer Prevention Study II to estimate RRs for disease-specific mortality associated with current and former smoking, and change in RRs over time after cessation. When lung cancer was used to measure cumulative smoking exposure, 254,700 male and 227,000 female deaths were attributed to smoking in the US in 2005. A modified method in which RRs for different diseases decreased at different rates after cessation yielded similar but slightly lower estimates [251,900 (male) and 221,100 (female)]. The lowest estimates resulted from the method based on smoking prevalence [225,800 (male) and 163,700 (female)]. Although all methods estimated a large number of smoking attributable deaths, future efforts should account for temporal changes in smoking prevalence and in accumulation/reversibility of disease-specific risks.

• Altitude, life expectancy and mortality from ischaemic heart disease, stroke, COPD and cancers: national population-based analysis of US counties.

  Authors: Majid Ezzati, Mara E M Horwitz, Deborah S K Thomas, Ari B Friedman, Robert Roach, Timothy Clark, Christopher J L Murray, Benjamin Honigman

  Journal of epidemiology and community health. 03/2011;

  Background There is a substantial variation in life expectancy across US counties, primarily owing to differentials in chronic diseases. The authors' aim was to examine the association of lifeBackground There is a substantial variation in life expectancy across US counties, primarily owing to differentials in chronic diseases. The authors' aim was to examine the association of life expectancy and mortality from selected diseases with altitude. Methods The authors used data from the National Elevation Dataset, National Center for Heath Statistics and US Census. The authors analysed the crude association of mean county altitude with life expectancy and mortality from ischaemic heart disease (IHD), stroke, chronic obstructive pulmonary disease (COPD) and cancers, and adjusted the associations for socio-demographic factors, migration, average annual solar radiation and cumulative exposure to smoking in multivariable regressions. Results Counties above 1500 m had longer life expectancies than those within 100 m of sea level by 1.2-3.6 years for men and 0.5-2.5 years for women. The association between altitude and life expectancy became non-significant for women and non-significant or negative for men in multivariate analysis. After adjustment, altitude had a beneficial association with IHD mortality and harmful association with COPD, with a dose-response relationship. IHD mortality above 1000 m was 4-14 per 10 000 people lower than within 100 m of sea level; COPD mortality was higher by 3-4 per 10 000. The adjusted associations for stroke and cancers were not statistically significant. Conclusions Living at higher altitude may have a protective effect on IHD and a harmful effect on COPD. At least in part due to these two opposing effects, living at higher altitude appears to have no net effect on life expectancy.

• National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5·4 million participants.

  Authors: Goodarz Danaei, Mariel M Finucane, John K Lin, Gitanjali M Singh, Christopher J Paciorek, Melanie J Cowan, Farshad Farzadfar, Gretchen A Stevens, Stephen S Lim, Leanne M Riley, Majid Ezzati

  Lancet. 02/2011; 377(9765):568-77.

  Data for trends in blood pressure are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes.Data for trends in blood pressure are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. However, few worldwide analyses of trends in blood pressure have been done. We estimated worldwide trends in population mean systolic blood pressure (SBP). We estimated trends and their uncertainties in mean SBP for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (786 country-years and 5·4 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean SBP by age, country, and year, accounting for whether a study was nationally representative. In 2008, age-standardised mean SBP worldwide was 128·1 mm Hg (95% uncertainty interval 126·7-129·4) in men and 124·4 mm Hg (123·0-125·9) in women. Globally, between 1980 and 2008, SBP decreased by 0·8 mm Hg per decade (-0·4 to 2·2, posterior probability of being a true decline=0·90) in men and 1·0 mm Hg per decade (-0·3 to 2·3, posterior probability=0·93) in women. Female SBP decreased by 3·5 mm Hg or more per decade in western Europe and Australasia (posterior probabilities ≥0·999). Male SBP fell most in high-income North America, by 2·8 mm Hg per decade (1·3-4·5, posterior probability >0·999), followed by Australasia and western Europe where it decreased by more than 2·0 mm Hg per decade (posterior probabilities >0·98). SBP rose in Oceania, east Africa, and south and southeast Asia for both sexes, and in west Africa for women, with the increases ranging 0·8-1·6 mm Hg per decade in men (posterior probabilities 0·72-0·91) and 1·0-2·7 mm Hg per decade for women (posterior probabilities 0·75-0·98). Female SBP was highest in some east and west African countries, with means of 135 mm Hg or greater. Male SBP was highest in Baltic and east and west African countries, where mean SBP reached 138 mm Hg or more. Men and women in western Europe had the highest SBP in high-income regions. On average, global population SBP decreased slightly since 1980, but trends varied significantly across regions and countries. SBP is currently highest in low-income and middle-income countries. Effective population-based and personal interventions should be targeted towards low-income and middle-income countries. Funding Bill & Melinda Gates Foundation and WHO.

• National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9·1 million participants.

  Authors: Mariel M Finucane, Gretchen A Stevens, Melanie J Cowan, Goodarz Danaei, John K Lin, Christopher J Paciorek, Gitanjali M Singh, Hialy R Gutierrez, Yuan Lu, Adil N Bahalim, Farshad Farzadfar, Leanne M Riley, Majid Ezzati

  Lancet. 02/2011; 377(9765):557-67.

  Excess bodyweight is a major public health concern. However, few worldwide comparative analyses of long-term trends of body-mass index (BMI) have been done, and none have used recent national healthExcess bodyweight is a major public health concern. However, few worldwide comparative analyses of long-term trends of body-mass index (BMI) have been done, and none have used recent national health examination surveys. We estimated worldwide trends in population mean BMI. We estimated trends and their uncertainties of mean BMI for adults 20 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (960 country-years and 9·1 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean BMI by age, country, and year, accounting for whether a study was nationally representative. Between 1980 and 2008, mean BMI worldwide increased by 0·4 kg/m(2) per decade (95% uncertainty interval 0·2-0·6, posterior probability of being a true increase >0·999) for men and 0·5 kg/m(2) per decade (0·3-0·7, posterior probability >0·999) for women. National BMI change for women ranged from non-significant decreases in 19 countries to increases of more than 2·0 kg/m(2) per decade (posterior probabilities >0·99) in nine countries in Oceania. Male BMI increased in all but eight countries, by more than 2 kg/m(2) per decade in Nauru and Cook Islands (posterior probabilities >0·999). Male and female BMIs in 2008 were highest in some Oceania countries, reaching 33·9 kg/m(2) (32·8-35·0) for men and 35·0 kg/m(2) (33·6-36·3) for women in Nauru. Female BMI was lowest in Bangladesh (20·5 kg/m(2), 19·8-21·3) and male BMI in Democratic Republic of the Congo 19·9 kg/m(2) (18·2-21·5), with BMI less than 21·5 kg/m(2) for both sexes in a few countries in sub-Saharan Africa, and east, south, and southeast Asia. The USA had the highest BMI of high-income countries. In 2008, an estimated 1·46 billion adults (1·41-1·51 billion) worldwide had BMI of 25 kg/m(2) or greater, of these 205 million men (193-217 million) and 297 million women (280-315 million) were obese. Globally, mean BMI has increased since 1980. The trends since 1980, and mean population BMI in 2008, varied substantially between nations. Interventions and policies that can curb or reverse the increase, and mitigate the health effects of high BMI by targeting its metabolic mediators, are needed in most countries. Bill & Melinda Gates Foundation and WHO.

• National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3·0 million participants.

  Authors: Farshad Farzadfar, Mariel M Finucane, Goodarz Danaei, Pamela M Pelizzari, Melanie J Cowan, Christopher J Paciorek, Gitanjali M Singh, John K Lin, Gretchen A Stevens, Leanne M Riley, Majid Ezzati

  Lancet. 02/2011; 377(9765):578-86.

  Data for trends in serum cholesterol are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes.Data for trends in serum cholesterol are needed to understand the effects of its dietary, lifestyle, and pharmacological determinants; set intervention priorities; and evaluate national programmes. Previous analyses of trends in serum cholesterol were limited to a few countries, with no consistent and comparable global analysis. We estimated worldwide trends in population mean serum total cholesterol. We estimated trends and their uncertainties in mean serum total cholesterol for adults 25 years and older in 199 countries and territories. We obtained data from published and unpublished health examination surveys and epidemiological studies (321 country-years and 3·0 million participants). For each sex, we used a Bayesian hierarchical model to estimate mean total cholesterol by age, country, and year, accounting for whether a study was nationally representative. In 2008, age-standardised mean total cholesterol worldwide was 4·64 mmol/L (95% uncertainty interval 4·51-4·76) for men and 4·76 mmol/L (4·62-4·91) for women. Globally, mean total cholesterol changed little between 1980 and 2008, falling by less than 0·1 mmol/L per decade in men and women. Total cholesterol fell in the high-income region consisting of Australasia, North America, and western Europe, and in central and eastern Europe; the regional declines were about 0·2 mmol/L per decade for both sexes, with posterior probabilities of these being true declines 0·99 or greater. Mean total cholesterol increased in east and southeast Asia and Pacific by 0·08 mmol/L per decade (-0·06 to 0·22, posterior probability=0·86) in men and 0·09 mmol/L per decade (-0·07 to 0·26, posterior probability=0·86) in women. Despite converging trends, serum total cholesterol in 2008 was highest in the high-income region consisting of Australasia, North America, and western Europe; the regional mean was 5·24 mmol/L (5·08-5·39) for men and 5·23 mmol/L (5·03-5·43) for women. It was lowest in sub-Saharan Africa at 4·08 mmol/L (3·82-4·34) for men and 4·27 mmol/L (3·99-4·56) for women. Nutritional policies and pharmacological interventions should be used to accelerate improvements in total cholesterol in regions with decline and to curb or prevent the rise in Asian populations and elsewhere. Population-based surveillance of cholesterol needs to be improved in low-income and middle-income countries. Bill & Melinda Gates Foundation and WHO.

• Correction: the preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors.

  Authors: Goodarz Danaei, Eric L Ding, Dariush Mozaffarian, Ben Taylor, Jürgen Rehm, Christopher J L Murray, Majid Ezzati

  PLoS medicine. 01/2011; 8(1).

  [This corrects the article on p. e1000058 in vol. 6.].

• Correction: the promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States.

  Authors: Goodarz Danaei, Eric B Rimm, Shefali Oza, Sandeep C Kulkarni, Christopher J L Murray, Majid Ezzati

  PLoS medicine. 01/2011; 8(2).

  [This corrects the article on p. e1000248 in vol. 7.].

• National and subnational mortality effects of metabolic risk factors and smoking in Iran: a comparative risk assessment.

  Authors: Farshad Farzadfar, Goodarz Danaei, Hengameh Namdaritabar, Julie Knoll Rajaratnam, Jacob R Marcus, Ardeshir Khosravi, Siamak Alikhani, Christopher Jl Murray, Majid Ezzati

  Population health metrics. 01/2011; 9(1):55.

  ABSTRACT: Mortality from cardiovascular and other chronic diseases has increased in Iran. Our aim was to estimate the effects of smoking and high systolic blood pressure (SBP), fasting plasma glucoseABSTRACT: Mortality from cardiovascular and other chronic diseases has increased in Iran. Our aim was to estimate the effects of smoking and high systolic blood pressure (SBP), fasting plasma glucose (FPG), total cholesterol (TC), and high body mass index (BMI) on mortality and life expectancy, nationally and subnationally, using representative data and comparable methods. We used data from the Non-Communicable Disease Surveillance Survey to estimate means and standard deviations for the metabolic risk factors, nationally and by region. Lung cancer mortality was used to measure cumulative exposure to smoking. We used data from the death registration system to estimate age-, sex-, and disease-specific numbers of deaths in 2005, adjusted for incompleteness using demographic methods. We used systematic reviews and meta-analyses of epidemiologic studies to obtain the effect of risk factors on disease-specific mortality. We estimated deaths and life expectancy loss attributable to risk factors using the comparative risk assessment framework. In 2005, high SBP was responsible for 41,000 (95% uncertainty interval: 38,000, 44,000) deaths in men and 39,000 (36,000, 42,000) deaths in women in Iran. High FPG, BMI, and TC were responsible for about one-third to one-half of deaths attributable to SBP in men and/or women. Smoking was responsible for 9,000 deaths among men and 2,000 among women. If SBP were reduced to optimal levels, life expectancy at birth would increase by 3.2 years (2.6, 3.9) and 4.1 years (3.2, 4.9) in men and women, respectively; the life expectancy gains ranged from 1.1 to 1.8 years for TC, BMI, and FPG. SBP was also responsible for the largest number of deaths in every region, with age-standardized attributable mortality ranging from 257 to 333 deaths per 100,000 adults in different regions. Management of blood pressure through diet, lifestyle, and pharmacological interventions should be a priority in Iran. Interventions for other metabolic risk factors and smoking can also improve population health.

• Cost-effectiveness of treatment and endoscopic surveillance of precancerous lesions to prevent gastric cancer.

  Authors: Jennifer M Yeh, Chin Hur, Karen M Kuntz, Majid Ezzati, Sue J Goldie

  Cancer. 06/2010; 116(12):2941-53.

  Although surveillance for Barrett esophagus and other gastrointestinal precancerous conditions is recommended, no analogous guidelines exist for gastric lesions. The objective of this study was toAlthough surveillance for Barrett esophagus and other gastrointestinal precancerous conditions is recommended, no analogous guidelines exist for gastric lesions. The objective of this study was to estimate the clinical benefits and cost-effectiveness of treatment and endoscopic surveillance to prevent gastric cancer. The authors developed a state-transition decision model for a cohort of US men with a recent incidental diagnosis of gastric precancerous lesions (dysplasia, intestinal metaplasia, or atrophy). Strategies included 1) no surveillance or treatment and 2) referral for surveillance and treatment, and varied by surveillance frequency (none, every 10 years, every 5 years, or every year) and treatment modality for dysplastic and cancerous lesions (surgery or endoscopic mucosal resection [EMR]). The term "post-treatment surveillance" was restricted to surveillance of individuals after treatment. Data were based on published literature and databases. Outcomes included lifetime gastric cancer risk, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios. For a cohort of men with dysplasia aged 50 years, the lifetime gastric cancer risk was 5.9%. EMR with annual surveillance reduced the lifetime cancer risk by 90% and cost $39,800 per quality-adjusted life year (QALY). Addition of post-treatment surveillance every 10 years provided little incremental benefit ( approximately 5%) but cost >$1 million per QALY. Results were most sensitive to surgical risks and the proportion of lesions completely removed with EMR. For intestinal metaplasia, surveillance every 10 years reduced lifetime cancer risk by 61% and cost $544,500 per QALY. EMR with surveillance every 1 to 5 years for gastric dysplasia was promising for secondary cancer prevention and had a cost-effectiveness ratio that would be considered attractive in the United States. Endoscopic surveillance of less advanced lesions did not appear to be cost-effective, except possibly for immigrants from high-risk countries.

• Within-neighborhood patterns and sources of particle pollution: mobile monitoring and geographic information system analysis in four communities in Accra, Ghana.

  Authors: Kathie L Dionisio, Michael S Rooney, Raphael E Arku, Ari B Friedman, Allison F Hughes, Jose Vallarino, Samuel Agyei-Mensah, John D Spengler, Majid Ezzati

  Environmental health perspectives. 05/2010; 118(5):607-13.

  Sources of air pollution in developing country cities include transportation and industrial pollution, biomass and coal fuel use, and resuspended dust from unpaved roads. Our goal was to understandSources of air pollution in developing country cities include transportation and industrial pollution, biomass and coal fuel use, and resuspended dust from unpaved roads. Our goal was to understand within-neighborhood spatial variability of particulate matter (PM) in communities of varying socioeconomic status (SES) in Accra, Ghana, and to quantify the effects of nearby sources on local PM concentration. We conducted 1 week of morning and afternoon mobile and stationary air pollution measurements in four study neighborhoods. PM with aerodynamic diameters <or= 2.5 microm (PM2.5) and <or= 10 microm (PM10) was measured continuously, with matched global positioning system coordinates; detailed data on local sources were collected at periodic stops. The effects of nearby sources on local PM were estimated using linear mixed-effects models.Results: In our measurement campaign, the geometric means of PM2.5 and PM10 along the mobile monitoring path were 21 and 49 microg/m3, respectively, in the neighborhood with highest SES and 39 and 96 microg/m3, respectively, in the neighborhood with lowest SES and highest population density. PM2.5 and PM10 were as high as 200 and 400 microg/m3, respectively, in some segments of the path. After adjusting for other factors, the factors that had the largest effects on local PM pollution were nearby wood and charcoal stoves, congested and heavy traffic, loose dirt road surface, and trash burning. Biomass fuels, transportation, and unpaved roads may be important determinants of local PM variation in Accra neighborhoods. If confirmed by additional or supporting data, the results demonstrate the need for effective and equitable interventions and policies that reduce the impacts of traffic and biomass pollution.

• Health benefits of interventions to reduce greenhouse gases.

  Authors: Majid Ezzati, Hsien-Ho Lin

  Lancet. 03/2010; 375(9717):804; author reply 804.

• Air pollution in Accra neighborhoods: spatial, socioeconomic, and temporal patterns.

  Authors: Kathie L Dionisio, Raphael E Arku, Allison F Hughes, Jose Vallarino, Heather Carmichael, John D Spengler, Samuel Agyei-Mensah, Majid Ezzati

  Environmental science & technology. 03/2010; 44(7):2270-6.

  This study examined the spatial, socioeconomic status (SES), and temporal patterns of ambient air pollution in Accra, Ghana. Over 22 months, integrated and continuous rooftop particulate matter (PM)This study examined the spatial, socioeconomic status (SES), and temporal patterns of ambient air pollution in Accra, Ghana. Over 22 months, integrated and continuous rooftop particulate matter (PM) monitors were placed at a total of 11 residential or roadside monitoring sites in four neighborhoods of varying SES and biomass fuel use. PM concentrations were highest in late December and January, due to dust blown from the Sahara. Excluding this period, annual PM(2.5) ranged from 39 to 53 microg/m(3) at roadside sites and 30 to 70 microg/m(3) at residential sites; mean annual PM(10) ranged from 80 to 108 microg/m(3) at roadside sites and 57 to 106 microg/m(3) at residential sites. The low-income and densely populated neighborhood of Jamestown/Ushertown had the single highest residential PM concentration. There was less difference across traffic sites. Daily PM increased at all sites at daybreak, followed by a mid-day peak at some sites, and a more spread-out evening peak at all sites. Average carbon monoxide concentrations at different sites and seasons ranged from 7 to 55 ppm, and were generally lower at residential sites than at traffic sites. The results show that PM in these four neighborhoods is substantially higher than the WHO Air Quality Guidelines and in some cases even higher than the WHO Interim Target 1, with the highest pollution in the poorest neighborhood.

• Association between Tobacco Smoking and Active Tuberculosis in Taiwan: Is There Really an Association?

  Authors: Hsien-Ho Lin, Majid Ezzati, Megan Murray

  American journal of respiratory and critical care medicine. 02/2010; 181(3):291.