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Our aim was to consolidate the evidence on the epidemiology of obesity into a conceptual model of the 'obesity transition'. Illustrative examples from the thirty most populous countries, representing 77•5% of the world's population, were used. Stage 1 of the obesity transition is characterised by a higher prevalence in women compared to men, in those with higher compared to lower socioeconomic status, and adults compared to children. Many countries in South Asia and sub-Saharan Africa are at this stage. In Stage 2, there is a large increase in the prevalence among adults, a smaller increase among children, and a narrowing of the gender gap and socioeconomic differences among women. Many Latin American and Middle Eastern countries are at this stage. High-income East Asian countries are also at this stage, albeit with a much lower prevalence of obesity. Stage 3 occurs when the prevalence of obesity among those with lower socioeconomic status surpasses that among those with higher socioeconomic status and plateaus in obesity may be observed among women with high socioeconomic status and children. Most European countries are currently at this stage. There are too few signs of countries entering into the proposed final stage of declining obesity prevalence to determine demographic patterns. This conceptual model is intended to provide guidance to researchers and policymakers in identifying the current stage of

89Background: Evidence from nationally representative studies in low-and middle-income 90 countries (LMICs) on where patients are lost in the hypertension care continuum is sparse. This 91 information, however, is essential for the effective design and targeting of health services 92 interventions, and to assess progress in improving hypertension care. This study aimed to 93 determine the cascade of hypertension care in 44 LMICs -and its variation between countries 94 and population groups -by dividing the progression from need to successful treatment into 95 discrete stages and measuring the losses at each stage. 96 Methods:We pooled individual-level population-based data collected between 2005 and 2016 97 from 44 LMICs. Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or 98 diastolic BP ≥90 mmHg or reporting use of medication for hypertension. Among those with 99 hypertension, we calculated the proportion who had i) ever had their BP measured, ii) been 100 diagnosed, iii) been treated, and iv) achieved control. We disaggregated the hypertension care 101 cascade by age, sex, education, household wealth quintile, body mass index, smoking status, 102 country, and region. We used linear regression to predict -separately for each cascade step -a 103 country's performance based on gross domestic product (GDP) per capita, allowing us to identify 104 countries whose performance fell outside of the 95% prediction interval. 105 Findings: 1,100,507 participants were included of whom 192,441 (17.5%) had hypertension. 106 73.6% (95% CI, 72.9 -74.3) of those with hypertension ever had their BP measured, 39.2% 107 (95% CI, 38.2 -40.3) were diagnosed, 29.9% (95% CI, 28.6 -31.3) received treatment, and 108 10.3% (95% CI, 9.6 -11.0) achieved control. Countries in Latin America and the Caribbean 109 generally achieved the highest performance, while those in sub-Saharan Africa performed worst. 110 Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on Funding: Harvard McLennan Family Fund 122 Research in context 123

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Summary This study evaluated global trends in ultraprocessed food and drink (UPFD) volume sales/capita and associations with adult body mass index (BMI) trajectories. Total food/drink volume sales/capita from Euromonitor for 80 countries (2002‐2016) were matched to mean adult BMI from the NCD Risk Factor Collaboration (2002‐2014). Products were classified as UPFD/non‐UPFD according to the NOVA classification system. Mixed models for repeated measures were used to analyse associations between UPFD volume sales/capita and adult BMI trajectories, controlling for confounding factors. The increase in UPF volume sales was highest for South and Southeast Asia (67.3%) and North Africa and the Middle East (57.6%), while for UPD, the increase was highest for South and Southeast Asia (120.0%) and Africa (70.7%). In 2016, baked goods were the biggest contributor to UPF volume sales (13.1%‐44.5%), while carbonated drinks were the biggest contributor to UPD volume sales (40.2%‐86.0%). For every standard deviation increase (51 kg/capita, 2002) in UPD volume sales, mean BMI increased by 0.195 kg/m2 for men (P < .001) and 0.072 kg/m2 for women (P = .003). For every standard deviation (40 kg/capita, 2002) increase in UPF volume sales, mean BMI increased by 0.316 kg/m2 for men (P < .001), while the association was not significant for women. Increases in UPFD volume sales/capita were positively associated with population‐level BMI trajectories.

Background The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach. Methods and findings We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given (“treated”), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%–9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%–5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%–78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys. Conclusions The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured.

IMPORTANCE Understanding how diabetes and hypertension prevalence varies within a country as large as India is essential for targeting of prevention, screening, and treatment services. However, to our knowledge there has been no prior nationally representative study of these conditions to guide the design of effective policies. OBJECTIVE To determine the prevalence of diabetes and hypertension in India, and its variation by state, rural vs urban location, and individual-level sociodemographic characteristics. DESIGN, SETTING, AND PARTICIPANTS This was a cross-sectional, nationally representative, population-based study carried out between 2012 and 2014. A total of 1 320 555 adults 18 years or older with plasma glucose (PG) and blood pressure (BP) measurements were included in the analysis. EXPOSURES State, rural vs urban location, age, sex, household wealth quintile, education, and marital status. MAIN OUTCOMES AND MEASURES Diabetes (PG level Ն126 mg/dL if the participant had fasted or Ն200 mg/dL if the participant had not fasted) and hypertension (systolic BPՆ140 mm Hg or diastolic BPՆ90 mm Hg). RESULTS Of the 1 320 555 adults, 701 408 (53.1%) were women. The crude prevalence of diabetes and hypertension was 7.5% (95% CI, 7.3%-7.7%) and 25.3% (95% CI, 25.0%-25.6%), respectively. Notably, hypertension was common even among younger age groups (eg, 18-25 years: 12.1%; 95% CI, 11.8%-12.5%). Being in the richest household wealth quintile compared with being in the poorest quintile was associated with only a modestly higher probability of diabetes (rural: 2.81 percentage points; 95% CI, 2.53-3.08 and urban: 3.47 percentage points; 95% CI, 3.03-3.91) and hypertension (rural: 4.15 percentage points; 95% CI, 3.68-4.61 and urban: 3.01 percentage points; 95% CI, 2.38-3.65). The differences in the probability of both conditions by educational category were generally small (Յ2 percentage points). Among states, the crude prevalence of diabetes and hypertension varied from 3.2% (95% CI, 2.7%-3.7%) to 19.9% (95% CI, 17.6%-22.3%), and 18.0% (95% CI, 16.6%-19.5%) to 41.6% (95% CI, 37.8%-45.5%), respectively. CONCLUSIONS AND RELEVANCE Diabetes and hypertension prevalence is high in middle and old age across all geographical areas and sociodemographic groups in India, and hypertension prevalence among young adults is higher than previously thought. Evidence on the variations in prevalence by state, age group, and rural vs urban location is critical to effectively target diabetes and hypertension prevention, screening, and treatment programs to those most in need.

Background Evidence on where in the hypertension care process individuals are lost to care, and how this varies among states and population groups in a country as large as India, is essential for the design of targeted interventions and to monitor progress. Yet, to our knowledge, there has not yet been a nationally representative analysis of the proportion of adults who reach each step of the hypertension care process in India. This study aimed to determine (i) the proportion of adults with hypertension who have been screened, are aware of their diagnosis, take antihypertensive treatment, and have achieved control and (ii) the variation of these care indicators among states and sociodemographic groups. Methods and findings We used data from a nationally representative household survey carried out from 20 January 2015 to 4 December 2016 among individuals aged 15–49 years in all states and union territories (hereafter “states”) of the country. The stages of the care process—computed among those with hypertension at the time of the survey—were (i) having ever had one’s blood pressure (BP) measured before the survey (“screened”), (ii) having been diagnosed (“aware”), (iii) currently taking BP-lowering medication (“treated”), and (iv) reporting being treated and not having a raised BP (“controlled”). We disaggregated these stages by state, rural–urban residence, sex, age group, body mass index, tobacco consumption, household wealth quintile, education, and marital status. In total, 731,864 participants were included in the analysis. Hypertension prevalence was 18.1% (95% CI 17.8%–18.4%). Among those with hypertension, 76.1% (95% CI 75.3%–76.8%) had ever received a BP measurement, 44.7% (95% CI 43.6%–45.8%) were aware of their diagnosis, 13.3% (95% CI 12.9%–13.8%) were treated, and 7.9% (95% CI 7.6%–8.3%) had achieved control. Male sex, rural location, lower household wealth, and not being married were associated with greater losses at each step of the care process. Between states, control among individuals with hypertension varied from 2.4% (95% CI 1.7%–3.3%) in Nagaland to 21.0% (95% CI 9.8%–39.6%) in Daman and Diu. At 38.0% (95% CI 36.3%–39.0%), 28.8% (95% CI 28.5%–29.2%), 28.4% (95% CI 27.7%–29.0%), and 28.4% (95% CI 27.8%–29.0%), respectively, Puducherry, Tamil Nadu, Sikkim, and Haryana had the highest proportion of all adults (irrespective of hypertension status) in the sampled age range who had hypertension but did not achieve control. The main limitation of this study is that its results cannot be generalized to adults aged 50 years and older—the population group in which hypertension is most common. Conclusions Hypertension prevalence in India is high, but the proportion of adults with hypertension who are aware of their diagnosis, are treated, and achieve control is low. Even after adjusting for states’ economic development, there is large variation among states in health system performance in the management of hypertension. Improvem...