Bangladesh has experienced rapid economic growth and achieved major health improvements in the past decade, but malnutrition rates remain high. A nationally representative study conducted in 2011 assessed the dietary habits of 841 children 24–59 months old, 1428 children 6–14 years old, and 1412 nonpregnant, nonlactating women. The study’s objective was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then to model the potential impact of the fortification of key staple foods. The current intakes of several micronutrients—namely, iron, zinc, folate, vitamin A, and vitamin B12—were found to be insufficient to meet the needs of Bangladesh’s children and women. The fortification of rice with iron and zinc and edible oil with vitamin A has the potential to fill a significant part of the nutrient gap, as these are consumed widely and in significant amounts. Wheat flour and sugar are not as promising food vehicles in the Bangladeshi context, as they were consumed by a smaller portion of the population and in smaller amounts. In conclusion, fortification of rice and oil is recommended to address the large gap in micronutrient intakes. Malnutrition is a widespread public health problem, especially in developing countries. According to The State of Food Insecurity in the World , 870 milBangladesh is a developing country that has experienced rapid economic growth during the last 20 years, with an annual gross domestic product growth rate of 6.1% . SimultaThere are a number of factors that contribute to the high prevalence of micronutrient deficiencies, including low consumption of animal-source foods, poor bioavailability of micronutrients from plant sources, diseases and infections, food shortages, and, most importantly, a limited dietary diversity . Energy Fortification is widely recognized as being one of the most cost-effective strategies to increase regular consumption of micronutrients in a population. However, to be successful, any fortification program needs to take into account a number of parameters . First, The objective of this study was to assess dietary intakes of key micronutrients and the consumption pattern of potentially fortifiable foods, and then, based on this information, to model the potential impact of fortification of key staple foods and to assess variation in all of these foods by regions of the country. The findings of this study aim at informing the design of a fortification strategy in Bangladesh.The data presented in this paper were collected as part of a large cross-sectional nationally representative survey, the National Micronutrients Status Survey December 2011 , that waThe National Micronutrients Status Survey December 2011  used a tIn total, consumption data were gathered from 841 pre-SAC 24–59 months, 1428 SAC, and 1412 NPNL between October and December 2011. The surveyed population included pre-SAC 6–23 months old, however information on their consumption was not assessed, as they were expected to consume limited amounts of the food vehicles and therefore to benefit from fortification of staples to a limited extent only.To assess food consumption and nutrient intake of NPNL, SAC, and pre-SAC, individual 7-day semiquantitative food frequency questionnaires were used to interview NPNL, SAC, and the caregivers of pre-SAC between 24 and 59 months, taking into consideration commonly consumed foods, with special attention to vitamin A-, iron-, and zinc-rich foods. The only food that was not assessed by the semiquantitative food frequency questionnaire was oil, which was assessed at the household level. Food photographs indicating the serving size and amount in grams (g) were used to assess the quantity of consumption. Raw food weight was calculated by using appropriate conversion factors . To tranatta flour. The sugar consumption was estimated from the amount of sugar added to the foods or drinks consumed.The wheat flour products consumed by the households were separated into two categories: (1) bread, which was made industrially and bought already baked by the household and was made mainly from Maida flour; and (2) wheat flour, which was bought by the household and used to make foods within the household  and consisted mainly of For vegetable oil, the data on household monthly expenses were gathered and an average consumption was estimated for each household. Consumption estimates were extrapolated from the average per-person consumption reported in the national surveys by applying adult equivalent units (AEUs), recommended by the Food and Agriculture Organization of the United Nations (FAO), by a factor of 0.51 for children 1–3 years old, 0.71 for children 4–6 years old, 0.78 for children between 7 and 10 years old, 0.98 for boys and 0.86 for girls between 11 and 14 years, and 0.86 for women of reproductive age (14–50 years of age) .Socioeconomic status (SES) was calculated , using tFortificants and fortification levels of selected foods are presented in WHO recommended nutrient intake (RNI)  was usedData entry, including quality checks, as well as data management and analysis, was performed using SPSS software version 19. The mean consumptions among pre-SAC, SAC, and NPNL consuming rice, bread, vegetable oil, sugar, and wheat flour (excluding nonconsumers) were analyzed by one-way analysis of variance (ANOVA) (since the distribution of consumption was asymmetric) and multiple comparisons to compare strata, geographic areas, and socioeconomic status. To estimate the additional intake of the micronutrients under consideration for the fortification strategy, the mean consumption of nutrients from the fortifiable food  by age groups were calculated by multiplying the level of fortificant  with thEthical approval for this study was obtained from the Institutional Review Board (IRB) of the International Centre for Diarrhoeal Disease Research, Bangladesh  (Reference number: PR#11018). Under the IRB, the Research Review Committee provided approval on the technical aspects of the protocol, which was followed by the Ethical Review Committee giving approval for the study. The participants and/or the guardians of the participants in the study provided their written informed consent.p < 0.01 for iron and p < 0.05 for zinc). Zinc intake was higher in higher income quintiles (p < 0.001). There were no significant differences in folic acid intake between areas of residency, districts, nor socioeconomic strata. Vitamin B12 intake was significantly lower in pre-SAC from lower SES than from higher SES (p < 0.05).The consumption patterns of 841 pre-SAC, 1428 SAC, and 1412 NPNL were analyzed. The micronutrient intake estimates for five micronutrients are reported in p < 0.01) and zinc and vitamin A intakes with SES (p < 0.001 and p < 0.001). Intake of folic acid was lowest in rural areas and highest in slums (p < 0.001). Consumption of vitamin B12 was proportional with socioeconomic strata (p < 0.001).For SAC, mean iron, zinc, vitamin A, folic acid, and vitamin B12 intakes in the diet covered 23.7%, 28.0%, 50.5%, 26.2%, and 62.9% of the needs, respectively. Iron intake was correlated with the district of residency . Vitamin A intake was correlated with the district of residency (p < 0.001) and the SES (p < 0.01). Intakes of folic acid and vitamin B12 were significantly (p < 0.01) lower in rural and lower-income households and higher in slum areas and higher-income households. Vitamin B12 consumption was lower in poorer households than in wealthier households (p < 0.001).The diet of NPNL covered 12.5% of their requirements in iron, 47.4% in zinc, 75.4% in vitamin A, 29.0% in folic acid, and 45.6% in vitamin B12. Iron and zinc intakes were the highest in women from higher socioeconomic strata  was assessed for each population group. The percentages of pre-SAC, SAC, and NPNL consuming rice, bread, wheat flour, and sugar are shown in p < 0.01, p < 0.05, and p < 0.001, respectively). The pre-SAC from the lower-income families consumed more rice than the pre-SAC from the higher-income families (p < 0.001). There were no significant differences in bread consumption between regions. However, wealth had an influence on the bread consumption of pre-SAC (p < 0.01): pre-SAC from wealthier families consumed more bread. SAC consumed significantly higher amounts of wheat flour in slums and urban areas than in rural areas (p < 0.001). Pre-SAC in slums tended to consume higher amounts of wheat flour and smaller amounts in rural areas (p = 0.05). SAC and NPNL from higher-income quintiles consumed more wheat than lower-income quintiles (p < 0.001). There was a significant difference in wheat flour consumption between the divisions: wheat flour consumption was the lowest in Dhaka and in Khulna and the highest in Chittagong and Rajshahi (p < 0.001). NPNL living in slums and urban areas consumed higher amounts of sugar than NPNL living in rural areas. Sugar was consumed in higher amounts by SAC and NPNL from higher-income quintiles (both p < 0.001). Consumption also significantly differed between divisions for SAC and NPNL (both p < 0.001). SAC in Barishal consumed the most sugar, while children in Sylhet consumed the least. In Rajshahi, NPNL consumed the most sugar and NPNL in Dhaka consumed the least sugar. The average daily oil consumption was 26.4 g per capita. Oil consumption was higher in urban and slum areas than in rural areas (p < 0.001). The highest oil consumption was found in Chittagong and the lowest in Barishal (p < 0.001).The mean consumption of rice, wheat flour, bread, sugar, and oil by population group is shown in Based on mean level of consumption and recommended fortification levels, the additional intakes of iron, zinc, folic acid, and vitamin B12 , and vitAccording to the data collected from the food frequency questionnaires, iron, zinc, and vitamin A intakes were found to be lower than the requirements, highlighting the need for nutrition interventions. These findings are especially alarming since they concern population groups for whom it is critical to have an adequate nutrient intake. In fact, nutritional deficiencies during infancy and childhood can have serious and irreversible consequences that last until adulthood ,18. MoreZinc intakes in individuals from higher socioeconomic strata were higher than those in the lower strata. Women from lower socioeconomic strata tended to have lower iron intakes. This finding highlights the need to design an intervention that reaches the poorest segments of the population, especially for zinc and iron. These minerals are contained in a number of foods and in highest amounts in animal-source products. However, their absorption can be significantly inhibited by certain dietary components, such as phytic acid and polyphenols ,23. UnfoBased on the consumption patterns, rice is the most suitable vehicle for fortification: it is consumed regularly by the whole population, in very large and constant amounts. In fact, rice fortification could provide between 10.4 mg/day and 23.9 mg/day of additional iron, or an additional 40.5%–87.5% of the population’s RNI in iron. Rice fortification alone would be sufficient to reduce the prevalence of iron deficiency in the population. In fact, efficacy studies have shown that daily iron intakes from rice of between 13 mg and 20 mg can reduce iron deficiency and iron deficiency anemia ,26,27. RAs with rice, oil is consumed by almost all households. Oil could provide 38.3%–46.5% of the population’s vitamin A requirements, which is above the 15% minimum recommended by the International Vitamin A Consultative Group . HoweverMaida flour fortification would provide more micronutrients to pre-SAC and SAC than to NPNL. Atta flour fortification would provide more micronutrients to children living in slums and urban areas, whereas rice fortification would provide more to the rural populations. Sugar fortification with vitamin A would complement the vitamin A intakes provided by the diet and by fortified oil and would result in sufficient intakes of vitamin A among all three population age groups. However, the percentage of respondents who reported consuming sugar and the amounts consumed reported were much lower than for oil. The fortification of sugar would not benefit all population groups equally: it would benefit mostly a small segment of young children from higher socioeconomic strata.In comparison to rice and oil, the number of people consuming bread, wheat, and sugar, and the amounts consumed, are much lower. However, fortification of these food vehicles would significantly contribute to filling the gaps in current micronutrient intakes, especially if it is implemented alongside fortification of other foods  and in combination with other interventions, such as dietary diversification and supplementation. The fortification of wheat flour would provide additional amounts of iron and zinc, but also (and mostly) folate and vitamin B12. According to the results of this analysis, the simultaneous fortification of wheat flour and rice with iron would be enough to cover the needs of iron, zinc, folic acid, and vitamin B12 for pre-SAC, SAC, and NPNL, at the exception of the iron needs of NPNL. Therefore, fortification efforts need to be combined with other strategies to prevent iron deficiency. The WHO recommends three food-based strategies to fight iron deficiency: dietary diversification, food fortification, and iron supplementation. To maximize the reduction of iron deficiency prevalence among women in Bangladesh, food fortification could be combined with iron supplementation for iron-deficient women.The iron intakes might have been underestimated in our study. In fact, iron intakes were estimated based on food consumption and did not consider iron provided by groundwater. A study has shown that groundwater could provide significant amounts of iron to women in rural areas of Bangladesh . TherefoThe risk of excess intake from the fortification of multiple food vehicles is relatively low, especially given the fact that it is rare for an individual to consume all fortified products in one day. The only areas of concern would be the vitamin A intake in pre-SAC and zinc intake in pre-SAC and SAC. Some children might consume amounts of vitamin A that are close to the upper levels set for that age group. In addition, these same children have a high chance of receiving high-dose vitamin A supplements. Should the simultaneous of fortification of multiple vehicles be implemented, the risk of exceeding UL for the two micronutrients should be carefully assessed.There are four major limitations to this study. The first one is that the consumption data were assessed using a seven-day semiquantitative food frequency questionnaire. Micronutrient intakes might have been slightly over- or underestimated ,32. The In conclusion, rice and oil consumption were high, constant, and widespread across Bangladesh and therefore are the most promising food vehicles for fortification. Fortification of these two food vehicles could significantly increase the micronutrient intakes of most population groups. In order to design an optimal fortification strategy, these findings need to be complemented with a comprehensive industry and market assessment and the fortification levels adapted based on cost, technological and sensory parameters.


This study uses several bibliometric indices to explore the temporal course of publication trends regarding the bilingual advantage in executive control over a ten-year window. These indices include the number of published papers, numbers of citations, and the journal impact factor. According to the information available in their abstracts, studies were classified into one of four categories: supporting, ambiguous towards, not mentioning, or challenging the bilingual advantage. Results show that the number of papers challenging the bilingual advantage increased notably in 2014 and 2015. Both the average impact factor and the accumulated citations as of June 2016 were equivalent between categories. However, of the studies published in 2014, those that challenge the bilingual advantage accumulated more citations in June 2016 than those supporting it. Our findings offer evidence-based bibliometric information about the current state of the literature and suggest a change in publication trends regarding the literature on the bilingual advantage. In recent years, the behavioral performance of monolingual and bilingual participants during tasks related to executive control has become a theme of debate  and has Early studies on the cognitive consequences of bilingualism showed a different pattern of results. Through the first 60 years of the 20th century, most of the research on the relationship between bilingualism and cognition focused on the influence of bilingualism on the intelligence of children. In this regard, findings typically showed higher or similar scores in measures of intellectual functioning for monolingual children as compared to their bilingual counterparts . Howevei.e., inhibition, switching, and updating of information). Their results revealed null differences when bilinguals were compared to monolinguals, while a better performance trend was found for the monolingual group under some conditions of the different tasks. Moreover, the authors exposed two interesting aspects of the methodology used in studies pertaining to the BA literature: the lack of success in replicating some studies showing better performance in bilinguals, which may be due to task-dependent effects evidenced by a low convergent validity with other tasks assessing the same components of cognitive control  AND TITLE-ABS-KEY(cognitive) OR TITLE-ABS-KEY(control) OR TITLE-ABS-KEY(executive) OR TITLE-ABS-KEY(interference) AND TITLE-ABS-KEY(advantage) AND PUBYEAR > 2004 AND PUBYEAR < 2016 AND DOCTYPE(ar))”). As a result, 189 papers were retrieved.As our principal concern was to provide an overview of the current publication trends regarding the BA in healthy samples, we omitted papers that included the following features in absence of healthy groups comparisons: neurological or psychiatric disorders , script perspective , and bimodal bilingualism. Papers without a cognitive perspective  and reviews were also excluded from the analyses.e.g., reduced switch costs in bilinguals compared to monolinguals) or a conclusion in absence of specific results  involving comparisons between bilingual and monolingual groups on direct or derived behavioral measures captured by task conditions. In this vein, we counted each supporting  or challenging  behavioral information reported in the abstracts, and computed a percentage for every study. Then, we used this percentage to classify the abstract into the category it belonged , p < .0001, all discrepancies (18 cases) were resolved by discussion. The first category included all the papers that supported the bilingual advantage (SBA) with at least 80% of the behavioral information reported in the abstract pointing to the outperformance of bilinguals over monolinguals. The second category contained papers that were ambiguous regarding the bilingual advantage (ABA). In these studies, some behavioral results showed advantages for the bilingual group (in a range of 50% to 79%), while some favored their monolingual counterparts or referenced null results (in a range of 21% to 50%), or vice versa. The third category was made up of studies in which the bilingual advantage was not mentioned (NMA). Abstracts that did not mention group comparisons between monolinguals and bilinguals, and focused only on comparisons within bilingual participants  were also included in the NMA category, regardless of their position on the BA. The fourth category consisted of studies challenging the bilingual advantage (CBA), in which at least an 80% of the behavioral information reported in the abstract showed no difference between monolingual and bilingual groups, or where advantages for monolinguals were reported. Studies with abstracts that did not find a behavioral advantage for bilinguals and seemed to support the BA hypothesis based merely on neuroimaging or event-related potentials data were also placed in the CBA category. Following this criterion, 5 studies (17% of the CBA category) were classified as CBA, although the conclusions in their abstracts appeared to support the BA. Descriptive data for each category can be consulted in Each paper was classified by two independent raters into one of four exclusive categories. Although there was a strong agreement between the two raters, e.g., number of times that a given paper was cited in 2005). On the other hand, the journal impact factor (JIF) for the year of publication of each study was also considered for the bibliometric analyses.In order to compare objectively the previously described paper categories, several bibliometric indices were collected. On the one hand, we gathered the accumulated number of citations made to each paper through June 2016, and the number of citations made to each paper per year, which is referred to as ‘citations per year’ (in contrast to ‘accumulated citations’). Thus, ‘citations per year’ includes the raw number of citations made to each paper per year from 2005 to June 2016  were created not only in accordance with de Bruin and Della Sala , but als2) statistic. In order to examine whether a differential pattern of publication had taken place, we conducted two χ2 tests contrasting paper category and time period: one with the four paper categories, and the other considering only the SBA and CBA categories. Where appropriate, post hoc comparisons were made using the methods proposed by Beasley and Schumacker [The first set of analyses explored the distribution of the number of papers in each category  by means of the chi-square  as a function of paper category and time period. Mann-Whitney U-tests were performed separately for paper categories (SBA and CBA) and time periods (2005 to 2013 and 2014 to 2015) in order to calculate the differences between accumulated citations as of June 2016, and for the JIF. Note that a correlation analysis between the total number of citations and the year of publication showed that papers published earlier had accumulated a larger number of citations, thus providing a reliable picture of the expected trend of citations over time, r(139) = -.630, p < .0001. Moreover, the correlation between the number of accumulated citations and the JIF for the year of publication showed that papers published in high impact factor journals obtained more citations by June 2016, r(139) = .381, p < .0001. However, when considering only the papers published in 2014 in the SBA and CBA categories, the latter result was not replicated, r(20) = -.171, p = .47.The second set of analyses explored scores on the different bibliometric indices  on the SBA and CBA studies published in 2014, in order to examine the temporal citation trend following both the publication of the paper by Paap and Greenberg . A one-wp < .05 was used for all comparisons, and for all tests of simple effects involving multiple comparisons, a Bonferroni-corrected significance level of p < .05 was used.SPSS v22 statistical software was used for all statistical analyses. A significance level of 2 test, performed to observe the relationship between the number of papers published in each category  as a function of the time period (2005 to 2013 and 2014 to 2015), showed that the paper category was related to time period, with χ2 = 9.51, p = .023, and Φ = .19, revealing, as expected, an overall larger amount of studies published in 2013 and before. Interestingly, post-hoc tests revealed that the number of papers published under the CBA category was larger from 2014 onwards, compared to those published between 2005 and 2013 (p < .001). No other χ2 contrast was significant (ps > .16).The first set of analyses explored the distribution of the number of papers in each category  was also significant, with χ2 = 6.01, p = .014, and Φ = .29. As shown in 2005–2013 vs. 69% 2014–2015), while the number of SBA papers published during the same time period decreased (SBA: 60% 2005–2013 vs. 40% 2014–2015), compared to those published from 2005 to 2013 in the same categories.When considering only the SBA and CBA categories, the χ2(3) = 8.33 and p = .04. The model explained 12.6% (Nagelkerke R2) of the variance in the publication of paper categories, and correctly classified 65% of cases. Increasing the year of publication was associated with an increased probability (1.47 times) of publishing a paper under the CBA category (p = .032). However, neither the accumulated citations, nor the JIF predicted the category under which a paper was published (ps > .055).The logistic regression, performed to explore the likelihood that a paper was published under either the CBA or SBA category using bibliometric indices  as predictors, was statistically significant: χi.e., accumulated citations, JIF). The results showed no statistically significant differences between SBA and CBA categories on the accumulated number of citations as of June 2016 as determined by the Mann-Whitney test: U = 586 (Z = -0.43), p = .666. However, the Mann-Whitney test conducted to compare the accumulated number of citations gathered until June 2016 and time periods (2005 to 2013 and 2014 to 2015), showed that the accumulated number of citations until June 2016 was greater for studies published in 2013 and earlier (M = 48.86) than for studies published in 2014 and 2015 (M = 24.81), U = 215 (Z = -4.88), p < .0001. Considering the JIF for the year of publication, neither the Mann-Whitney test performed with paper category (SBA and CBA), U = 616 (Z = -0.08), p = .931, nor with time period (2005 to 2013 and 2014 to 2015), U = 537.5 (Z = -1.24), p = .214, revealed significant differences.The second set of analyses examined scores on two different bibliometric indices  = 2.88, p = .107, ηp2 = .363, meaning that the number of citations per year for the CBA category was equivalent to the SBA category. However, a within-subjects effect of year, F = 7.03, p = .003, ηp2 = .281, showed that the number of citations per year was greater in both 2015 and June 2016, when compared to 2014 (ps < .029), but similar between 2015 and June 2016 (p = 1). The interaction between paper category and year was also significant, F = 3.3, p = .048, ηp2 = .155. As shown in post hoc contrasts showed that citations per year were similar between both paper categories in 2014 and 2015 , but larger for CBA in June 2016 (p = .015).The third set of analyses explored the trend in terms of citations of SBA and CBA studies that were published in 2014. The one-way repeated-measures ANOVA conducted for citations per year included paper category (SBA and CBA) as the between-subjects factor and year (3 time points from 2014 to June 2016) as the within-subjects factor. Results did not reveal a main effect of paper category, The present study aimed to present an in-depth analysis regarding several bibliometric indices concerning the literature on bilingualism and cognitive control based on the information retrieved from 139 abstracts. We investigated the pattern of publication of four exclusive paper categories that differed in whether the behavioral information present in the study clearly supported, was ambiguous towards, did not mention, or challenged the BA hypothesis , with a particular interest in the SBA versus CBA comparison. To test the temporal progress of each paper category, we compared bibliometric indices using both two time periods (2005 to 2013 and 2014 to 2015) and three time points (ranging from 2014 to June 2016), taking the year 2014 as a cut-off point. Our findings provide an objective measure that suggests that a change has taken place in the publication trends on the BA.Data revealed that the pattern of papers published in the CBA category contrasted with that of the other three categories. In this regard, the number of studies published in 2014 and later was smaller than the number published in the previous time period (2005 to 2013) for all paper categories, except for CBA, which an increased number of studies compared to the time period spanning from 2005 to 2013. When considering only the SBA and CBA categories, this change of pattern was still present see . AlthougOther bibliometric aspects analyzed in the present study concern both the quality and impact of CBA papers in the field of bilingualism and cognitive control. The impact and quality of the studies were tested by means of the JIF and two types of citation counts: the number of accumulated citations and the mean number of citations per year. We explored whether the JIF of studies published under the SBA and CBA paper categories or the time period had an influence on publication trends. The impact factor has been found to mediate the quality and relevance of studies in areas such as medicine , where sThere were a similar number of accumulated citations for studies classified as either SBA or CBA, as of June 2016. Therefore a ‘citation bias’, which posits that positive results tend to be more cited ,35, doesSome of the following reasons might explain why there has been a change in the publication trends regarding the BA: the novelty of the results, researchers’ demands for a change of paradigm, or a decline effect in publication trends. As we have shown, results that were indifferent towards or challenged results in terms of a BA were infrequent, but they are not altogether new, as several CBA papers were already published in the 2005–2013 period ,23. ThusGiven that the study by Paap and Greenberg  has appae.g., [e.g., whether a decline effect is taking place). The main use of this procedure is to identify and characterize publication trends in terms of scientific impact and production. There are other useful methodologies more suitable to shed light to some of the issues affecting this field , such as meta-analysis [i.e., SBA and CBA). Hence, the decision to use bibliometric analysis was not trivial since it was the most appropriate method to achieve the aim of this study. Despite the previously described limitations, our results provide novel insights on the topic, and describe in a systematic fashion the current state of the literature.We would like to acknowledge some possible limitations of the current study. First, we based our entire classification criteria only in the information available in the abstracts of each included study. Although similar methods to classify abstracts have been previously adopted , some ce.g.,  showed te.g., , includianalysis . Meta-ananalysis . HoweverTaken together, the results of the present study seem to confirm the change in the publication patterns of literature on the relationship between bilingualism and cognitive control from a bibliometric perspective. We believe that this redirection of publication tendencies is being led by the need for researchers to satisfactorily incorporate their results into a more robust paradigm, and not just to comply with the BA hypothesis. Publications on enhanced cognitive control attributed to bilinguals have been rather intermittent in recent years. While some authors are able to capture this phenomenon ,45, otheS1 File(PDF)Click here for additional data file.


Objectives. Identification of adverse effects of selective serotonin reuptake inhibitors (SSRIs) is of great importance due to their extensive use in medicine. Some studies have reported the effects of SSRIs on cognitive functions, but the results are conflicting. This study was designed to assess the effect of these drugs on cognition of patients with depression or obsessive-compulsive disorder (OCD). Methods. Patients with depression or OCD, naïve to therapy, and candidates of receiving one drug from SSRI class, voluntarily, entered this study. Mini-Mental State Examination (MMSE) test was the tool to assess their cognitive functions. MMSE scores of each patient were recorded prior to taking SSRIs and at weeks 3, 5, and 8 of drug therapy. Results. 50 patients met our inclusion criteria, with a baseline mean MMSE score of 23.94. At 3, 5, and 8 weeks of treatment, the mean scores were 22.1, 21.4, and 20.66, respectively. With a p value of <0.0001, the gradual decline was statistically significant. Conclusion. The MMSE scores of our patients showed a gradual decline over the consecutive weeks after taking SSRI drugs. It seems that the use of SSRIs in patients with depression or OCD, can cause cognitive dysfunction in the acute phase of treatment. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drug treatment of depression and obsessive-compulsive disorder (OCD). Monotherapy with this class is often recommended for patients primarily diagnosed with these conditions , 2.Despite the potential usefulness of SSRIs, they could cause unwanted side effects such as headaches, weight gain, sexual dysfunction, changes in sleep patterns, and gastrointestinal problems . OriginaThe aim of this study is to assess the effect of SSRI drugs on cognitive function of patients with depression or OCD, in acute phase of therapy. In this phase, knowledge and management of side effects are very critical for the patient's compliance to therapy, since these patients might not be motivated enough to cope with adverse effects along with their psychiatric symptoms . In manyCurrent study evaluates the patients' cognitive function, prior to taking SSRIs and throughout the acute course of their therapy.This analytic-descriptive study was conducted in a psychiatric outpatient clinic from April to September 2015. It was permitted by Ahvaz Jundishapur University of Medical Sciences ethics committee. Among patients diagnosed with depression or OCD by a board certified psychiatrist, those who currently were not under any treatment for mental or psychiatric disorders and were candidates of receiving a drug from SSRI class as monotherapy were asked to participate in this study. Inclusion criteria consisted of age between 18 and 60 years, no diagnosed cognitive impairment or mental retardation, no other comorbid disorders in Axis I, the ability to write and read, no visual or auditory impairment, no history of loss of consciousness after head trauma or brain surgery, and no history of using psychoactive drugs such as antidepressants, neuroleptics, benzodiazepines, antiepileptics, or opioids within 14 days prior to the study. Individuals with memory loss complaints in daily functioning would not be included either. If the patient developed any condition in which the use of SSRIs was contraindicated or any disability which interfered with performance of cognitive tests, he/she would be excluded from the study. In addition, patients who stopped their medication for seven consecutive days or did not adhere well with their drug therapy would be excluded. All patients signed a consent form prior to the study.Several approaches have been developed to help with the diagnosis of cognitive impairment. Some of these tests are Montreal Cognitive Assessment, DemTect, Short Test of Mental Status, Clinical Dementia Rating, and Mini-Mental State Examination (MMSE) –12. AmonThe patients' demographic data  were collected in the first visit (week 0 of therapy) and MMSE (a 30-point test) was performed at weeks 0, 3, 5, and 8 of drug therapy. Each patient's drug regimen (type of drug and dosage) remained fixed throughout this 8-week period. If for any reason the patient needed a dose reduction or increase or medication discontinuation, he/she would be excluded from the study. The response to therapy and clinical improvement of OCD/depression signs and symptoms would also be evaluated and recorded.p value of less than 0.05 were considered significant. Correlations of MMSE scores and age, sex, and level of education were analyzed by Pearson correlation test, one-way ANOVA test, and paired sample t-test, respectively.The data were analyzed using repeated measures one-way ANOVA. Results with a Fifty patients  participated in this study (50% diagnosed with depression and 50% with OCD). They all completed the study and we had no dropout patients. All of them showed signs of response to treatment of their psychiatric disorder at week 8. In order to analyze the correlation of level of education with MMSE scores, we grouped the patients into six different groups. Nine patients were in the elementary group (under 6 years of education), seven were in the middle school group (7–11 years), and 16 patients had a high school diploma. The number of patients with a bachelor, masters, or Ph.D. degree was 11, 6, and 1, respectively. The prescribed drugs for patients were paroxetine (52%), Zoloft (28%), fluoxetine (12%), and citalopram (8%).p value of less than 0.0001, the patients' MMSE scores lowered significantly from their baseline.p value = 0.4) nor during it . MMSE scores among male and female patients had a similar decline trend, when week 8 of treatment was compared with the baseline . Level of education showed no significant correlation with decline of cognitive function .Correlation of age and MMSE scores was also assessed and the results showed no significant relationship between them, neither prior to therapy  .Our data show that in patients with OCD or depression and those who are naïve to SSRI therapy, a gradual decline in their memory function can develop within the first 8 weeks of initiation of drug treatment with SSRIs. This decline did not have a relationship with the patient's age or gender, nor his/her level of education. We suggest further follow-up studies of these patients to identify the persistence of memory loss. Our results were obtained via MMSE test and regardless of the specific drug or disorder. We hope that soon other cognitive function tests would be valid and reliable for Iranian population.


Primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH) and immunoglobulin G4 related cholangitis represent the major autoimmune liver diseases (AILD). However, the relationship between AILD incidence and socioeconomic development levels is yet to be explored.P=0.082). However, in Europe, a significantly positive correlation existed between the PBC incidence and HDI . No statistical correlation between PSC incidence and HDI was observed . The incidence of AIH revealed a positive correlation with the national HDI both globally  and in Europe . Moreover, the PBC incidence demonstrated a positive correlation with the health index , but a negative correlation with the education index . Moreover, the income index presented a positive correlation with both the PSC incidence  and the AIH incidence .A total of 43 studies were included. There was a positive but not significant correlation between the PBC incidence and HDI on a global level  was applied as an indicator for socioeconomic development. HDI data were obtained and calculated based on the 2014 Human Development Report. Pearson coefficient and linear regression analysis were conducted to estimate the correlation between incidence and HDI.There is positive association between the national incidence of AILD and the socioeconomic status, as measured by HDI. In less-developed countries, the incidence of AILD, especially PBC and AIH, might be less common. Autoimmune liver diseases (AILD) cover a spectrum of primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC), autoimmune hepatitis (AIH) and immunoglobulin G4 (IgG4) related cholangitis. These are all relatively rare diseases but result in significant morbidity and mortality. A considerable proportion of patients with AILD eventually progress to end-stage liver disease. In Europe, AILD represent a major indication for liver transplantation. As complex disorders, AILD develop from the interactions between a variety of genetic and environmental factors –3. UntilPrevious epidemiological studies have reported that the incidence of AILD varies over time and space . It is wAmong the 43 enrolled studies, 22 reported the incidence of PBC –26, whilPrimary characteristics of the enrolled studies including first author, publication year, research period, country, continent, criteria of disease identification, incidence  and HDI were summarized in Table The national incidence of AILD varied among the studies performed in different countries or during different study periods. A relatively higher incidence of disease was associated with a higher national HDI. However, the included studies were generally conducted in countries with higher socioeconomic development. A total of 28 studies were performed in countries with very high HDI, 14 in high HDI countries, and one in medium HDI country. Few studies investigated the incidence of AILD in less developed countries with medium or low HDI.P = 0.082] , r = 0.348, ] Figure , Table 2] Figure .P = 0.044]. The relationship between the HDI and PBC incidence in Asia, North America or Australia was impossible to be identified due to the limited number of studies involved.In subgroup analysis for geographic location (continent), Figure P = 0.706)  or in North America .There was no correlation between the PSC incidence and the national HDI  Figure , Table 2P = 0.014] , r = 0.638, ] Figure , Table 2] Figure . LimitedP = 0.074) .Studies investigating the PBC incidence were classified into three groups based on the fact if they were conducted in very high, high or medium HDI countries. ANOVA analysis revealed no significant difference among the groups  Figure . CountriP = 0.847 by unpaired t test) , high HDI countries had no difference of PSC incidence   Figure .P = 0.017 by unpaired t test) , significantly higher than in countries with high HDIs   Figure .P = 0.036], but showed a negative correlation with the education index . There was a positive correlation between the PSC incidence and the income index . In terms of AIH, the incidence also presented a positive correlation with the income index .We further evaluated the correlations between the incidence of AILD and the three dimensions of HDI Table . InteresThis study revealed that socioeconomic development, as indicated by the HDI, might have a positive correlation with the incidence of PBC and AIH. Countries with very high HDI tended to have a higher incidence of PBC and AIH compared to countries with high or medium HDI. In addition, the economic status, as indicated by GNI per capita (income index of HDI), had a positive correlation with the incidence of PSC and AIH. We additionally found some association between national incidence of AILD and the socioeconomic status.It has been commonly recognized that AILD, mainly consisted of PBC, PSC and AIH, develops as a result from the influence of multiple genes in combination with currently undefined environmental factors. Environmental risk factors might be very complex, but are regarded to trigger the disease onset. PBC is a female predominant liver disease. A controlled interview-based study in the United States revealed that a history of urinary tract infections, cigarette smoking, use of hormone replacement therapies, or frequent use of nail polish were associated with an increased risk for PBC . On the In this study, a comprehensive review is presented, covering all available relevant studies that report the incidence of AILD without restriction of geographic region or language. On a global level, there was a positive but not significant correlation between PBC incidence and HDI. When excluding the study by Ngu et al conducted in New Zealand , whose PA deep analysis on the three dimensions of HDI has been performed. Interestingly, a high GNI per capita had a close association with PSC and AIH prevalence. Furthermore, a higher PBC incidence was related with a higher life expectancy at birth and a lower mean and expected years of schooling. These results summarized in our study might offer clues to the pathogenesis of AILD.It is the first time a research was conducted, investigating the relationship between the AILD incidence and socioeconomic development. The HDI was selected as the measurement tool because of its worldwide acceptance in international comparisons of development levels. Another strength of this study is that we set up rigorous inclusion criteria, including only population-based studies with definite diagnosis of AILD. Population-based surveys have higher validity because everyone in the at-risk population, or a random sample of the population, is accounted for.Nevertheless, a few limitations of this study must be taken into consideration. First of all, the review of AILD epidemiology was confined to Europe, North America, Asia and Australia, due to limited data in Africa and Oceania. Secondly, different areas within a country usually have different development levels. However, HDI is the summary of the average socioeconomic status of a country. Moreover, some studies were conducted in a specific region or a single province of a country, which resulted in an uneven distribution of incidence data. Thirdly, we failed to make subgroup analyses according to gender, ethnicity or region , on account of the insufficient data. In some way, different populations in an area might have variations in the disease incident rates.In summary, we have demonstrated a potentially positive relationship between the national incidence of AILD and HDI. This study provides for the first time the evidence that in areas with higher development levels, AILD might be more prevalent, and offers a distinctive perspective on the global epidemiological status of AILD. A more robust and comprehensive analysis is required for further more epidemiological investigations in other continents and based on more detailed information.For the purpose of this paper, only studies were included with definite criteria for the diagnosis of autoimmune liver disease. The diagnostic criteria for PBC included: (i) clinical presentation; (ii) elevated serum level of alkaline phosphatase of liver origin for more than 6 months; (iii) presence of serum anti-mitochondrial antibodies (≥1:40); (iv) histological characteristics of florid bile duct lesions. Criteria (ii) and (iii) were diagnostic for PBC, and criteria (iv) confirmed the diagnosis.The identification of PSC was based on increased serum levels of alkaline phosphatase and γ-glutamyltranspeptidase not otherwise explained, when magnetic resonance cholangiography (MRC) or endoscopic retrograde cholangiography (ERC) demonstrated bile duct changes with multifocal strictures and segmental dilatations. Secondary causes of sclerosing cholangitis and other cholestatic disorders were excluded.AIH was diagnosed based on the combination of clinical, biochemical  and histological conditions according to the reported criteria –50.The HDI is a compound measure of average achievement in three key dimensions of human development: a long and healthy life , being knowledgeable (education index: mean and expected years of schooling) and having a decent standard of living  per capita).http://hdr.undp.org/en/data). The average HDI over the research period was calculated, and was defined as the HDI for each study. We hypothesized that HDI progressed linearly in a short period of time and estimated the missing HDI data based on the available data. According to the 2014 Human Development Report (HDR 2014), quartiles of HDI distribution were defined as follows: very high human development (HDI ≥ 0.800), high human development (0.700 ≤ HDI< 0.800), medium human development (0.550 ≤HDI< 0.700), and low human development (HDI < 0.550).The HDI data were obtained from the United Nations Development Programme database  AND .Only studies that present incidence of PBC, PSC or AIH with a definite diagnosis in an adult population were included. Non population-based surveys were disqualified, such as those only enrolled patients in a particular hospital or participants taking part in a particular health plan.Two investigators independently completed eligibility evaluation and data extraction. Disagreement was solved by discussion with the third investigator. A total of 1708 records were identified through basic search. 1652 publications were excluded after screening through titles and abstracts. Further eligibility evaluation resulted in the exclusion of nine studies because of the absence of data about HDI or disease incidence, and an additional exclusion of four studies because they were not adult population-based. Finally, a total of 43 surveys were included in this study.P value of less than 0.05 was considered as statistically significant.All statistical analysis was performed by SPSS 21.0 . Associated data was plotted using GraphPad Prism . Kolmogorov–Smirnoff test was conducted to examine the normal distribution of variables. Correlations between the incidence of AILD and HDI were obtained by Pearson coefficient ; in cases of skewed distributions of variables, the Spearman coefficient was applied. In addition, a linear regression analysis was conducted. One-way analysis of variance (ANOVA) or an unpaired t-test was used to compare disease incidence in groups with different socioeconomic development. A


Walkability was measured using nine items selected from the Chinese version of the abbreviated Neighborhood Environment Walkability Scales (NEWS) and NEWS for Chinese Seniors. Outcomes were walking time, physical activity, wellbeing , and loneliness. The mean age of the participants was 71.7 ± 7.8 years. Walkability was positively associated with walking time  but not with physical activity. After adjusting for socio-demographic characteristics, health conditions, lifestyle, and negative life events, those who perceived their neighborhoods as walkable had higher scores for life satisfaction (p = 0.002) and happiness (p = 0.002), and lower scores for loneliness (p = 0.019), compared with those who perceived their neighborhoods as less walkable. However, perceived neighborhood walkability was not associated with sense of purpose and meaning in life. Among components of walkability, land use mix-access, infrastructure and safety for walking, and traffic safety showed the strongest associations with the measures of wellbeing. The results of this study support the importance of neighborhood walkability for health behavior and wellbeing of older adults. The wellbeing of older adults may be enhanced through the improvement of land use mix-access, infrastructure for walking, and traffic safety.This study examined the cross-sectional associations between perceived neighborhood walkability and walking time, physical activity, wellbeing, and loneliness, and examined which components of walkability were most strongly associated with better wellbeing and less loneliness in older adults. Participants were community-dwelling Chinese adults aged 60+ ( As worldwide life expectancy increases, the issue of maintaining wellbeing at an advanced age is growing in importance, as evidence suggests that active engagement with life and positive wellbeing are protective factors for health as people age ,2,3,4. SNeighborhood environments are being increasingly recognized as factors that influence health and wellbeing. Neighborhoods designed to be more walkable can encourage residents to walk more and may promote physical activity and social connectedness, which in turn has beneficial effects on health and wellbeing, particularly in older people. This is because older people may be more susceptible to neighborhood effects due to a combination of increasing frailty, functional decline  and dimiAlthough research supports the importance of neighborhood walkability for health and wellbeing, this line of research is still in its infancy, and the role of walkability on subjective wellbeing has been relatively unstudied. Previous studies have mostly been conducted in Western countries; it is still not known whether walkability has any role in the wellbeing of Hong Kong Chinese, who live in much denser environments in terms of population and destinations, and who may differ significantly from Caucasians in terms of culture and lifestyle. In this study, we examined the associations of walkability with walking time, physical activity, subjective wellbeing, and loneliness. We also aimed to examine which components of walkability were most strongly associated with better wellbeing and less loneliness in older adults.http://www1.map.gov.hk/gih3/view/index.jsp). Major roads and waterways served as barriers to movement and communication and therefore served as logical boundaries of the neighborhood.To examine the relationship between neighborhood characteristics, health, wellbeing, and loneliness, a survey was conducted in two selected districts of Hong Kong, including Sha Tin and Tai Po. The two districts are located in the New Territories of Hong Kong, with their population estimated at 659,794 and 303,926 in 2016, respectively . They weThree hundred and one community-dwelling Chinese adults aged 60 years and older were recruited in the survey between June and August 2017. Participants were recruited by placing recruitment notices in housing estates and elderly community centres. Several talks were also given at the centres explaining the purpose and interviews to be carried out. An age-stratified sample of volunteers was recruited, so that approximately 50% of the participants would be aged 60–69, 30% would be aged 70–79, and 20% would be aged 80 years and older, according to the age structure of the mid-year population (aged 60 years and older) of Hong Kong, 2016. To be eligible, participants needed to be aged 60 years and older, able to walk, and able to speak Cantonese. A team of trained research assistants administered the questionnaire for each participant face-to-face. The initial phase of the study did not collect data on walkability. Therefore, we excluded 120 participants whose walkability data was not available, yielding a study of 181 participants  for analysis in the present study. All participants gave written consent, and the study was approved by the Survey and Behavioral Research Ethics Committee of the Chinese University of Hong Kong (026-16). The study was performed in compliance with the declaration of Helsinki.Perceived neighborhood walkability was measured using items selected from the Chinese version of the abbreviated Neighborhood Environment Walkability Scale (Chinese NEWS-A)  and NEWSA panel of experts from the fields of geriatric medicine, public health, and urban planning reviewed Chinese NEWS-A and NEWS-CS, and developed a reduced version to measure perceived neighborhood walkability. The reduced version has a total of nine items: two items from land use mix-access, one item from street connectivity, three items from infrastructure and safety for walking, one item from aesthetics, one item from pedestrian traffic safety, and one item from safety from crime. The reduced version was scored using the original 4-point scoring system from 1 (strongly disagree) to 4 (strongly agree). The total walkability score was computed by taking the average of the nine items, where items 2, 8, and 9 were reverse scored. Possible scores range from 1 to 4, with 1 meaning less walkable and 4 meaning more walkable.r = 0.420–0.723). With the exception of the aesthetics sub-scale, there is no difference between the mean score of each item of the two versions (p = 0.284–0.609)  and the Chinese NEWS-A (0.652) were similar. In addition, correlations between individual items of the reduced version and the corresponding items of the Chinese NEWS-A were moderate to moderately-strong (4–0.609) .Walking in the past seven days was measured with two separate items extracted from the Physical Activity Scale for the Elderly (PASE) ,17. PartPhysical activity was measured using two separate items. Participants were asked how frequently they carried out physical activity  and the duration of these sessions . Time spent on physical activity (hours/week) was calculated by multiplying the frequency and the median values of the duration categories. Physical activity was defined as any physical activities for sport, exercise or recreation, including hiking, but not walking nor shopping. Examples for physical activities were given, including Tai Chi, jogging, hiking, swimming and using the fixed fitness equipment in fitness stations located in parks designed specifically for seniors.Subjective wellbeing was quantified in terms of life satisfaction, happiness, and sense of purpose and meaning in life. Life satisfaction was measured with a single item, “Overall, how satisfied are you with life as a whole these days?” which participants rated on a scale from 0 as “not at all satisfied” to 10 as “completely satisfied” . HappineSocio-demographic characteristics , health conditions (number of doctor-diagnosed chronic diseases and number of prescribed medications), and lifestyle  were collected. Participants were also asked to report the occurrence of any of the seven negative life events extracted from the Holmes and Rahe Stress Scale in the past year. These include the serious illness or accident of spouse/partner, death of spouse/partner/other close relative/close friend, separation from child/close friend/other relative upon whom participant depends, given up important hobby or activity, serious financial trouble and/or move or change in residence , and thep value of less than 0.05 was considered statistically significant. Estimates based on fewer than 30 observations are considered unreliable. All statistical analyses were performed using the statistical package SPSS, version 24 .We grouped the participants based on tertiles of the walkability score: lowest (<3.1), middle (3.1–3.6), and highest (>3.6). Participants’ characteristics, walking time, and physical activity levels were compared across tertiles of the walkability score using analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. Tests for trends were also performed as appropriate. Multivariable linear regression models were used to investigate the associations of perceived neighborhood walkability with life satisfaction, happiness, sense of purpose and meaning in life, and loneliness, which were treated as continuous variables. To examine which components of walkability were most strongly associated with measures of subjective wellbeing and loneliness, the response “strongly disagree,” “disagree,” “agree,” and “strongly agree” were coded into three dummy variables with “strongly agree” as the reference category  and “strongly disagree” as the reference category  and the regression models were repeated. Each model was analyzed with adjustment for individual characteristics . All statistical tests were two sided. A p = 0.007, p for trend = 0.003), lived more often in private high-rise housing (p < 0.001), and had longer length of residence (p = 0.006) than those in the middle and lowest tertiles.The descriptive characteristics of the study population according to walkability tertiles are reported in p = 0.001, p for trend < 0.001). The pattern remained significant after adjusting for age, sex, marital status, education, employment, income, type of housing, length of residence, number of doctor-diagnosed chronic diseases, number of prescribed medications, smoking, alcohol intake, and negative life events. However, walkability was not associated with physical activity.p = 0.002) and happiness (p = 0.002), and lower levels of loneliness (p = 0.019), after adjusting for the same list of covariates. However, walkability was not associated with sense of purpose and meaning in life.p < 0.05), but not with sense of purpose and meaning in life. Street connectivity was positively associated with happiness (p < 0.05) but not with life satisfaction or sense of purpose and meaning in life. Infrastructure and safety for walking was positively associated with happiness , but not with life satisfaction or sense of purpose and meaning in life. Aesthetics was positively associated with happiness (p = 0.025). Traffic safety was associated with each measure of wellbeing . Safety from crime was positively associated with happiness (p = 0.046) but not with life satisfaction or sense of purpose and meaning in life. No associations were observed between any of the walkability components and loneliness after multivariable adjustments.This study examined the associations between perceived neighborhood walkability and walking time, physical activity, subjective wellbeing, and loneliness in older Chinese adults. The results showed that perceived neighborhood walkability was positively associated with walking time, but not with physical activity. Perceived neighborhood walkability was significantly associated with better life satisfaction, happiness, and less loneliness, with land use mix-access, infrastructure for walking, and traffic safety showing the strongest associations.To date, several studies have investigated the relationship between perceptions of neighborhood environment characteristics and walking behaviors, as walking is the dominant physical activity carried out by older adults during their leisure time. These studies, however, were predominantly conducted in Western countries, where the built environment can differ substantially from Asian regions, particularly Hong Kong, which is one of the most densely populated cities in the world. Using a subjectively measured walkability, we found that participants who lived in the most walkable neighborhood reported more weekly hours of walking than those who lived in the least walkable neighborhood. This finding adds further evidence to the findings of previous studies showing that neighborhood walkability, either objectively  or subjectively measured, is positively associated with walking time ,24.Although walkability was associated with walking time, our findings did not find any association between perceived walkability and physical activity . This finding is consistent with previous studies done on Australian and Belgian older adults, where walkability was not associated with any measures of recreational physical activity ,25. FindOur findings also indicated that walkability was associated with better life satisfaction, happiness, and less loneliness. This finding is consistent with previous studies linking walkability with perceived quality of life  and deprThis study also examined which components of walkability were most strongly associated with better wellbeing and less loneliness in older adults. We found that all components were associated with at least one measure of wellbeing, with land use mix-access, infrastructure for walking, and traffic safety showing the strongest associations. These results are consistent with the findings in the literature. For example, a Gallup study has also found that convenient public transportation and easy access to cultural and leisure facilities shows the strongest correlation with happiness . HoweverOur finding with regard to the association between walkability and loneliness was also significant, after adjusting for covariates. This is an important finding because loneliness is highly prevalent among older adults, with a significant impact on elderly health and wellbeing . PreviouOur findings are relevant to policymakers, assisting them in the development of walkable neighborhoods. Walkability involves more than just providing sidewalks—the walking environment should also be comfortable and healthy so that the benefits of walking can be maximized . In highThere are some limitations to this study. Because of the cross-sectional nature of the study, no temporal or causal relationships can be assessed. The results were subject to selection bias as sociable people might be more likely to participate in this study. In addition, due to the small sample size, mediation analyses were not performed. Finally, this study used the measure of perceived neighborhood walkability; objective measures of walkability such as block size and street widths are needed regarding how the neighborhood walkability affects wellbeing in older adults. In spite of these limitations, the strengths of this study include the use of a reduced version of the NEWS tested for reliability, the use of different aspects of subjective wellbeing including life satisfaction, happiness, sense of purpose and meaning in life, and loneliness, and the inclusion of socio-demographic characteristics, health status, lifestyle, and negative life events in the analyses.The results of this study support the importance of neighborhood walkability for the health behavior and wellbeing of older adults. The wellbeing of older adults may be enhanced through the improvement of land use mix-access, infrastructure for walking, and traffic safety. Future studies on walkability will need to combine perceived neighborhood walkability together with objective measurements of neighborhood environmental quality to better understand the role of neighborhood walkability on health and wellbeing in older adults, and to examine what are the mechanisms through which older adults perceive more satisfaction, happiness, and meaning, and less loneliness in their life.


WHO has set a voluntary target of 80% availability of affordable essential medicines, including generics, to treat major non-communicable diseases (NCDs), in the public and private sectors of countries by 2025. We undertook a secondary analysis of data from 30 surveys in low- and middle-income countries, conducted from 2008–2015 using the World Health Organization (WHO)/Health Action International (HAI) medicine availability and price survey methodology, to establish a baseline for this target.Data for 49 medicines (lowest priced generics and originator brands) to treat cardiovascular diseases (CVD), diabetes, chronic obstructive pulmonary diseases (COPD) and central nervous system (CNS) conditions were analysed to determine their availability in healthcare facilities and pharmacies, their affordability for those on low incomes (based on median patient prices of each medicine), and the percentage of medicines that were both available and affordable. Affordability was expressed as the number of days’ wages of the lowest-paid unskilled government worker needed to purchase 30 days’ supply using standard treatment regimens. Paying more than 1 days’ wages was considered unaffordable.In low-income countries, 15.2% and 18.9% of lowest-priced generics met WHO’s target in the public and private sectors, respectively, and 2.6% and 5.2% of originator brands. In lower-middle income countries, 23.8% and 23.2% of lowest priced generics, and 0.8% and 1.4% of originator brands, met the target in the public and private sectors, respectively. In upper-middle income countries, the situation was better for generics but still suboptimal as 36.0% and 39.4% met the target in public and private sectors, respectively. For originator brands in upper-middle income countries, none reached the target in the public sector and 13.7% in the private sector. Across the therapeutic groups for lowest priced generics, CVD medicines in low-income countries (11.9%), and CNS medicines in lower-middle (10.2%) and upper-middle income countries (33.3%), were least available and affordable in the public sector. In the private sector for lowest priced generics, CNS medicines were least available and affordable in all three country income groups .This data, which can act as a baseline for the WHO target, shows low availability and/or poor affordability is resulting in few essential NCD medicines meeting the target in low- and middle-income countries. In the era of Sustainable Development Goals, and as countries work to achieve Universal Health Coverage, increased commitments are needed by governments to improve the situation through the development of evidence-informed, nationally-contextualised interventions, with regular monitoring of NCD medicine availability, patient prices and affordability. Attention is growing on preventing and treating non-communicable diseases (NCDs) which, according to the World Health Organization (WHO) are now the world’s biggest killers . Over 36Following the Political Declaration on NCDs, adopted by the UN General Assembly in 2011, WHO published its Global Action Plan for the Prevention and Control of NCDs 2013–2020 (GAP), which was endorsed by the World Health Assembly in 2013 ,5. IncluNCDs are different to acute diseases in that most require uninterrupted, life-long treatment. To help achieve this, NCD medicines must be both available in facilities when needed and affordable, especially for those on low-incomes. Using savings, borrowing money or selling assets to pay for healthcare, a common occurrence in low-income countries , is not In the GAP, medicine affordability was not defined, which is not surprising as it is not straightforward. However, the measure used by WHO and HAI in their methodology to measure medicine prices, availability and affordability   and poor affordability of medicines to treat a range of NCDs including cardiovascular diseases, diabetes, psychiatric disorders, asthma and epilepsy –12,16. IStudies to date using WHO/HAI data have considered availability and affordability separately. But, as noted in the GAP, to improve access medicines must be both available in facilities and affordable for all who need them. Therefore, in this study, we looked at the combined availability and affordability of medicines to treat four major NCDs (cardiovascular disease (CVD), diabetes, chronic obstructive pulmonary diseases (COPD), and central nervous system conditions (CNS)) to ascertain the extent to which they met WHO’s target.The WHO/HAI methodology is a facility-based survey of the availability and patient price of 50 medicines to treat communicable and non-communicable diseases, in a minimum of six geographic or administrative areas in a sample of medicine outlets in the public sector, private sector, and other sectors . Data arData is collected from five medicine outlets per sector per survey area. The selection of the outlets uses a multistage clustered approach, as described by Cameron et al . Survey International Drug Price Indicator Guide. A minimum of four patient prices per medicine per sector are needed for inclusion in the analysis.Data is analysed by sector. Availability, reported as the percentage of outlets where the medicine was in stock on the day of data collection, takes into account the level of outlet in the public sector that is permitted to stock each medicine. Prices are expressed as medians in local currency, and as a ratio to median supplier prices (or the median buyer price when no supplier price is given) listed in Management Sciences for Health’s (MSH) Affordability is based on median patient prices (originator brand and lowest priced generics) of each medicine in local currency for a standard treatment regimen, and expressed as the number of days’ wages needed by the lowest-paid unskilled government worker to purchase 30 days’ supply of the medicine to treat NCDs, and 7 days’ supply for medicines to treat communicable diseases. Where a medicine is not available or there are less than four price points, affordability is not assessed.Data for the secondary analysis were obtained from 30 surveys undertaken in low-income and middle-income countries from 2008 to early 2015 using the WHO/HAI methodology, and published on the WHO/HAI price database . Based oFour groups of NCDs were included in the analysis i.e. CVD, diabetes, COPD, and CNS conditions i.e. psychoses, anxiety, depression, epilepsy and Parkinson’s Disease. These had the greatest amount of data in the WHO/HAI database. A preliminary analysis identified the most surveyed medicines in each therapeutic group which, when combined, covered at least 80% of data points within the group.For each survey, only medicines on the National Essential Medicines List (NEML) at the time of the survey were selected for the secondary analysis. For Haiti there was no NEML at the time of the survey, however, it was published the following year so this was used to identify which survey medicines were essential. For Lebanon, an updated NEML was published a few months after this survey so that was used to identify the essential medicines. In total, 18 medicines to treat CVD, 7 to treat diabetes, 9 to treat COPD, and 15 CNS medicines  were included in the secondary analysis .GAP lists medicines needed to provide basic, cost-effective primary healthcare i.e. 6 CVD medicines , two products to treat diabetes (metformin and insulin), and two inhalers (bronchodilator and steroid). We used an expanded list (including CNS medicines) in our analysis as they were selected nationally to be surveyed hence considered important.The basis of all analyses was the availability and/or affordability of individual medicines in each survey. Data were not aggregated in the few surveys where two strengths or two dosage forms of the same medicine were surveyed, or by country.Two surveys (Tanzania and Uganda) did not collect data for originator brands of the survey medicines. In some other surveys, data on originator brands or generics of some medicines were not collected as marketing authorisation had not been granted in the country. In these cases, the originator brand or lowest priced generic was excluded from the analyses. As well, Tanzania and Uganda was excluded from the analysis of availability of any product type.Data were stratified by World Bank income levels to low-income countries, lower-middle income countries and upper-middle income countries. Within each income group, the median percentage availability across the basket of medicines in each therapeutic group, and across all the medicines, was calculated for originator brands and generics, separately and combined, in the public and private sectors.The median number of days’ wages to purchase standard treatments was calculated across the basket of medicines in each therapeutic group, and across all medicines. The combined availability and affordability was then determined to identify the percentage of medicines within a therapeutic group, and across all medicines, with 80% or greater availability and requiring 1 days’ wages or less to purchase standard treatments or supplied free-of-charge in the public sector.Whether low availability was the sole cause for not achieving the WHO target, or poor affordability, or both low availability and poor affordability, was then assessed for each therapeutic group per sector.All the primary data for each medicine in the analysis is available in the WHO/HAI price database i.e. percentage availability, median patient price in local currency  and the number of days’ wages needed by the lowest-paid unskilled government worker to purchase 30 days’ supply .In all three country income groups, the median availability of generics did not exceed 80% for any therapeutic group in the public sector and only for CVD medicines in the private sector of lower-middle income countries (85.8%) and upper-middle income countries (86.7%) as shown in In the public sector, median availability of originator brands across all medicines was 0% in all three country income groups. In the private sector, overall availability of originator brands was 3.2%, 10% and 53.3% in low-, lower-middle and upper-middle income countries, respectively.In low-income countries, the median availability of any product type (originator brands and generics) across all medicines was 43.3% and 66.7% in the public and private sectors, respectively. In lower-middle income countries, median availability for any product type was 57.6% and 68.6% in the public and private sectors respectively. In upper-middle income countries, median availability for any product type was similar to the less wealthy countries in the public sector (60.2%) but much higher in the private sector (90.0%). For any product type, median availability was less than 80% for all four therapeutic groups in the public sector. In the private sector, availability was 80% or higher for CVD (82.9%) and COPD (83.3%) medicines in low-income countries, CVD (88.6%) in lower-middle income countries, and all four therapeutic groups in upper-middle income countries.Based on the median number of days’ wages needed to purchase treatments, buying lowest-priced generics in the public sector requires no more than 1 days’ wage in each therapeutic groups, except for COPD and CNS medicines in lower-middle income countries which require 1.4 days’ wages . In the In all three country groups, originator brands were less affordable than lowest-priced generics in both sectors. Originator brands of CNS medicines were least affordable requiring 12 and 9 days’ wages to purchase 30 days’ supply in the public and private sectors respectively of lower-middle income countries. Note: the analysis for originator brands in the public sector is based on only a few data points per therapeutic group.The percentage of essential medicines with 80% or greater availability and requiring no more than 1 days’ wages to purchase treatments (or supplied free-of-charge in the public sector) was low in all three country groupings as shown in Across all medicines, very few originator brands met the target in low-income countries  and lower-middle income countries (0.8% and 1.4%). In upper-middle income countries, no originator brands met the target in the public sector, and 13.7% in the private sector.Where the WHO target was not meet, we identified whether the cause was solely low availability, solely poor affordability, or both low availability and poor affordability . In the In the above analyses, medians across medicines have been used. Our analysis shows that low availability and/or poor affordability is resulting in few essential NCD medicines meeting WHO’s target in low- and middle-income countries. Lowest priced generics achieving the target in the public sector ranged from 15.2% in low-income countries to 36.0% in upper-middle income countries. In the private sector, the range was similar at 18.9% in low-income countries to 39.4% in upper-middle income countries. These unacceptably low levels are likely to be contributing to the high morbidity and premature mortality from NCDs seen in developing countries.Despite its strengths, the WHO/HAI methodology has some limitations as outlined by Cameron et al. (1) MediThis is the first analysis of combined NCD medicine availability and affordability, and establishes a baseline for assessing future performance against the WHO target. In the era of Sustainable Development Goals, and countries working to achieve Universal Health Coverage, this baseline data shows that increased commitments are needed by governments and others to improve access to essential NCD medicines. Firstly, countries need to survey the availability, price and affordability of NCD medicines to identify target-gaps, then ascertain the determinants of low availability and/or poor affordability. From this, evidence-informed policies and interventions are needed that are fully implemented and enforced, and their impact monitored on a regular basis. While some of the interventions listed below have been subject to rigorous evaluation, the results may well depend on the country or environment when studied. This highlights the importance of continued monitoring and evaluation of policy interventions aimed at improving access to essential medicines.The GAP and other documents , 19–21 oWhatever policies and interventions are used nationally, price transparency is vital as it empowers governments when procuring medicines, healthcare providers when prescribing, and, most importantly, patients when buying medicines. Governments should publish their tender prices, and ensure their citizens are easily able to compare patient prices. Likewise, governments should publicly report stock-outs.As part of the plan to monitor the NCD indicators and targets, WHO and partner organisations should include availability, price and affordability of essential NCD medicines in all national surveys and monitoring work to be able to report on these critical indicators.Momentum to improve access to medicines should build in response to the Sustainable Development Goals (SDGs), Universal Health Coverage (UHC) goals and other initiatives. Priority must be given to essential medicines to treat NCDs. It is hoped that these opportunities, along with the implementation of the WHO Global Plan of Action, will result in much needed improvement in access to NCD medicines in low- and middle-income countries.This paper demonstrates that it is possible to measure access to NCD medicines in a robust way. If countries plan to implement the SDGs, UHC, and NCD goals they will need to measure and evaluate their performance. Many options exist for countries to meet these targets. Monitoring and evaluation of their actions will be crucial to learn from successes and failures that will occur.