Abstract
Objective
To investigate the association between various anthropometric indexes of obesity with arterial hypertension in elderly from Barbados (Bridgetown) and Cuba (Havana).
Design
Cross-sectional data were extracted from the Survey on Health, Aging and Well being in Latin America and the Caribbean (SABE).
Sample Size
In Bridgetown and Havana, respectively, 1508 and 1905 subjects (≥ 60 years) were examined, and were selected by a controlled sampling design.
Measurements
The occurrence of hypertension was assessed by self-report. Multiple measurements of adiposity were used including body mass index (BMI ≥ 28 kg/m2), waist hip ratio (WHR = > 0.95 men; > 0.80 women), waist to height ratio (W/ht. = > 0.50) and waist circumference — WCL (> 88 cm, women; > 102 cm, men) e WCOK (> 90.3 cm, women; > 91.3cm, men). Binary logistic regression analyses (Odds Ratio) were used to measure strengths of relationships.
Results
In the elderly of Bridgetown, the final design (adjusted for age, education, race, smoking, regular physical activity and diabetes) shows that, in men, WCOK and W/Ht were associated with hypertension, and in women, WCL and WCOK were the indexes associated. In the Cuban elderly, the final design shows that, with the exception of WHR, all indicators were associated with hypertension. WCOK and W/ht were the indexes most strongly associated with the outcome.
Conclusion
The explanatory power of anthropometric indicators when determining the outcome differed between men and women, as well as between cultural groups living in relative proximity (Barbadians and Cubans).
Key words: Adiposity, abdominal obesity, body mass index, aged, hypertension
Introduction
High blood pressure is a major health issue in all world regions and is one of the main risk factor for stroke, ischemic heart disease, heart attack, heart failure and kidney disease (1). Hypertension is becoming an even greater problem with the rises of life expectancy rates worldwide and the prevalence of obesity (2), which is often considered a major independent risk factor for this disorder.
In epidemiological studies, the association between hypertension and excess body fat has been determined by various anthropometric indexes. Usually, obesity is verified by the body mass index (BMI=kg/m2), which reflects the proportion of adipose tissue in body mass, not depending on body location; and by central adiposity indexes, including waist circumference (WC), waist to hip ratio (WHR) and waist to height ratio (W/ht) (3, 4, 5, 6, 7), which may more accurately identify groups at risk for the adverse health consequences of excess weight (7, 8).
Although some studies have concurred with the association of anthropometric indexes and hypertension, the results are controversial (3, 4, 5), including between genders. Some studies indicated a strong support of BMI (9), while other studies were equally supportive of WC (10), WHR (11) or W/ht (10). Among the elderly living in the tropics, this relation has not yet been largely studied and there are few studies as to the optimum anthropometric index to be used to evaluate older populations. The objective of this study was to investigate the association between several anthropometric indexes of obesity (BMI, WC, WHR and W/ht) with self-reported arterial hypertension, in elderly individuals from Cuba (Havana) and Barbados (Bridgetown), which are countries with a high aging rate (12).
Methods
Data from Barbados and Cuba were extracted from the Survey on Health, Aging and Well Being in Latin America and the Caribbean (SABE) (12), a multi-center study coordinated by the Pan- American Health Organization (PAHO) and conducted in 7 countries (Argentina, Brazil, Chile, Cuba, Mexico, Uruguay, and Barbados) during 1999-2000. The SABE protocol was approved by the ethical committees at universities in each participating country and by the Ethical Committee at the PAHO (12).
The study population consisted of individuals aged 60 years and older, men and women, residing in the cities of Bridgetown (1508 subjects) and Havana (1905 subjects).
The cross-sectional, household-based sample was of stratified, multistage, cluster sampling design of the non-institutionalized elderly population, and was generated through a multistage process by conglomerates, with stratification of the units at the highest levels of aggregation (12, 13).
Before the interview, a short cognitive questionnaire was given to all participants to establish their ability to respond to the SABE questionnaire. In cases where the person was unable to respond, the information was obtained from a proxy. Assisted interviews were conducted for 3.9% of the interviews in Bridgetown, and 9.2% in Havana. Participants not completing the anthropometric measurements were 3.9% in Barbados and 11.6% in Cuba (13).
The anthropometric indexes (independent variables) and cut-off points used for total obesity and central adiposity were: a) body mass index (BMI = 28 kg/m2) (14) calculated with weight and height values; b) waist circumference (15) (WCL), women > 88 cm and men > 102 cm; d) waist circumference (3) (WCOK), women > 90.3 cm and men > 91.3cm; e) waist to hip (WHR), calculated with values from waist and hip circumferences, > 0.95 (men) e > 0.80 (women) (16); f) waist to height ratio (W/ht), obtained by WC and height measurements, > 0.50 (17). Weight, height, WC and hip circumference measurements were taken by trained technicians following standard protocols (12, 17, 18). The measurements were taken in triplicate (same visit) and the mean values were used in the analyses.
The occurrence of hypertension/high blood pressure (dependent variable) was assessed by the following question: “Has a doctor or nurse ever told you that you have high blood pressure?” (yes, no).
Variables of confusion tested in the models were: age (years); physical activity (yes; no), i.e. participants were asked whether they had exercised or participated in vigorous physical activity three or more times a week during the past 12 months; smoking habits (current, former, never), education (elementary, secondary, higher), race (black, non-black) and diabetes (yes, no).
Statistical procedure
Data analyses were made using The Statistical Package for Social Sciences for Windows (SPSS. 11.5, 2002, SPSS, Inc, Chicago, IL).
The chi-squared test was used for percentage comparison between categorical variables and genders.
Binary logistic regression analyses were used, stratified by gender, to determine the association between obesity indexes and arterial hypertension. Independent variables of interest to the study (BMI; WCL; WCOK; WHR e W/ht) were evaluated in the designs as categorical (dichotomic) variables.
Three designs of logistic regression were proposed for each anthropometric index, having arterial hypertension as a dependent (dichotomic) variable in all of them: 1) adjusted by age; 2) adjusted by age, education and race; 3) adjusted by age, education, race, smoking and regular physical activity (final design). In all designs, additionally, diabetes (which belongs to the causal chain) was included, with the intent of evaluating how much of the association could be explained in the presence of this covariable. Among variables of confusion, age entered the designs as a continuous variable. Education, race, smoking habits, physical activity and diabetes entered the designs as categorical variables.
Results
Mean age (± standard deviation) for the participant individuals was 72.5 ± 8.4 years (range 60-97) and 71.0 ± 8.5 years (range 60-102) for the elderly from Barbados and Cuba, respectively. Mean age for Barbadians was 71.8 ± 7.9 (range 60-95) in males and in females 73.0 ± 8.7. For Cubans, mean age was 70.2 ± 8.0 (range 60 to 96 years) and 71.6 ± 8.7, for men and women, respectively.
Table 1 shows the distribution of the elderly according to analyzed variables, gender and city/country. The prevalence of total obesity (BMI) and central adiposity (WCL, WCOK, WHR, W/ht) varied depending on the index used. For Barbadians and Cubans, the greatest frequency of central adiposity was identified by W/ht in men and by WHR in women. Women from both countries had a greater prevalence (p < 0.05) of diabetes, hypertension, non-smokers (never) and higher scores measured by BMI, WCL, WHR and W/ht (indicating obesity), when compared to men.
Table 1.
Distribution (%) of the elderly according to the analyzed variables. SABE, Bridgetown (Barbados) and Havana (Cuba) 2000
| Bridgetown (Barbados) | Havana (Cuba) | |||||
|---|---|---|---|---|---|---|
| Men | Women | P | Men | Women | P | |
| BMI | ||||||
| Normal | 70.4 | 52.9 | 87.3 | 69.3 | ||
| Obesity | 29.6 | 47.1 | 0.001 | 12.7 | 30.7 | 0.001 |
| WHR | ||||||
| Normal | 75.0 | 13.6 | 54.6 | 15.8 | ||
| Central adiposity | 25.0 | 86.4 | 0.001 | 45.4 | 84.2 | 0.001 |
| WCL | ||||||
| Normal | 81.3 | 36.8 | 83.8 | 51.4 | ||
| Central adiposity | 18.7 | 63.2 | 0.001 | 16.2 | 48.6 | 0.001 |
| WCOK | ||||||
| Normal | 54.8 | 47.2 | 56.6 | 59.4 | ||
| Central adiposity | 45.2 | 52.8 | 0.077 | 43.4 | 40.6 | 0.260 |
| W/ht | ||||||
| Normal | 28.1 | 13.9 | 30.8 | 21.3 | ||
| Central adiposity | 71.9 | 86.1 | 0.001 | 69.2 | 81.4 | 0.001 |
| Race | ||||||
| Black | 83.2 | 80.9 | 15.9 | 18.6 | ||
| Non-black | 16.8 | 19.1 | 0.251 | 84.1 | 18.6 | 0.129 |
| Education | ||||||
| Elementary | 77.2 | 78.2 | 47.4 | 61.4 | ||
| Secondary | 14.8 | 16.1 | 45.4 | 32.4 | ||
| Higher | 8.1 | 5.6 | 0.177 | 7.2 | 6.2 | 0.001 |
| Smoking | ||||||
| Current | 14.2 | 1.6 | 46.5 | 21.5 | ||
| Former | 40.0 | 7,5 | 31.2 | 15.0 | ||
| Never | 45.8 | 90.9 | 0.001 | 22.3 | 63.4 | 0.001 |
| Physical activity | ||||||
| Yes | 47.2 | 40.0 | 30,1 | 18.5 | ||
| No | 52.8 | 60.0 | 0.007 | 69.9 | 81.5 | 0.001 |
| Diabetes | ||||||
| Yes | 18.7 | 23.6 | 7.3 | 19.9 | ||
| No | 81.3 | 76.4 | 0.030 | 92.7 | 80.1 | 0.001 |
| Hypertension | ||||||
| Yes | 37.9 | 53.6 | 35.8 | 49.8 | ||
| No | 62.1 | 46.4 | 0.001 | 64.2 | 50.2 | 0.001 |
Table 2 shows the odds ratio (OR), adjusted for age, between high risk (according to anthropometric indexes) of arterial hypertension and sex. For Barbadians and Cubans of both genders, indexes BMI, WCL, WCOK and W/ht presented an association with arterial hypertension. The additional adjustment for diabetes eliminated the associations between BMI and hypertension (Barbadian men and women) and between W/ht and WCL and hypertension (Barbadian women and men, respectively).
Table 2.
Odds Ratio (OR) for hypertension according to anthropometric indexes adjusted for age. SABE, Bridgetown (Barbados), Havana (Cuba), 2000
| Bridgetown/Barbados | Havana/Cuba | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | Men CI 95% | P | OR | Women CI 95% | p | OR | Men CI 95% | p | OR | Women CI 95% | p | |
| BMI | 1.52 | 1.03-2.26 | 0.035 | 1.39 | 1.06-1.82 | 0.016 | 1.83 | 1.16-2.87 | 0.009 | 2.80 | 2.09-3.73 | 0.001 |
| BMI∗ | 1.37 | 0.91-2.06 | 0.128 | 1.27 | 0.96-1.68 | 0.095 | 1.79 | 1.13-2.83 | 0.012 | 2.85 | 2.13-3.82 | 0.001 |
| WHR | 1.28 | 0.87-1.88 | 0.215 | 1.17 | 0.79-1.71 | 0.437 | 1.37 | 1.00-1.87 | 0.050 | 0.90 | 0.64-1.27 | 0.543 |
| WHR∗ | 1.16 | 0.78-1.73 | 0.469 | 1.03 | 0.70-1.53 | 0.866 | 1.35 | 0.98-1.85 | 0.065 | 0.88 | 0.62-1.24 | 0.457 |
| WCL (cm) | 1.50 | 1.06-2.12 | 0.022 | 1.90 | 1.44-2.50 | 0.001 | 1.89 | 1.26-2.86 | 0.002 | 1.86 | 1.44-2.41 | 0.001 |
| WCL (cm)∗ | 1.34 | 0.94-1.91 | 0.103 | 1.79 | 1.34-2.37 | 0.001 | 1.87 | 1.23-2.82 | 0.003 | 1.80 | 1.39-2.33 | 0.001 |
| WCOK (cm) | 1.68 | 1.19-2.36 | 0.003 | 1.57 | 1.20-2.06 | 0.001 | 2.11 | 1.53-2.90 | 0.000 | 1.86 | 1.43-2.41 | 0.001 |
| WCOK(cm)∗ | 1.59 | 1.21-2.25 | 0.009 | 1.47 | 1.11-1.93 | 0.006 | 2.02 | 1.47-2.79 | 0.000 | 1.83 | 1.41-2.38 | 0.001 |
| W/ht | 1.80 | 1.21-2.68 | 0.004 | 1.52 | 1.09-2.25 | 0.017 | 1.91 | 1.33-2.74 | 0.000 | 1.94 | 1.41-2.65 | 0.001 |
| W/ht∗ | 1.62 | 1.16-2.46 | 0.020 | 1.40 | 0.96-2.06 | 0.056 | 1.91 | 1.33-2.74 | 0.000 | 1.84 | 1.34-2.52 | 0.001 |
OR = odds ratio; ∗ additionally adjusted for the occurrence of diabetes.
When an additional adjustment was made for education and race (Table 3), it was observed that the direction of associations was only modified concerning BMI (female Barbadians) and WHR (male Cubans) and was similar to the previous design (adjusted only for age). The additional adjustment for diabetes eliminated the associations between W/ht (women) and BMI (men) and hypertension in the Barbadian elderly.
Table 3.
Odds Ratio (OR) for hypertension according to anthropometric indexes adjusted for age, education and race. SABE, Bridgetown (Barbados), Havana (Cuba), 2000
| Bridgetown/Barbados | Havana/Cuba | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | Men CI 95% | p | OR | Women CI 95% | p | OR | Men CI 95% | p | OR | Women CI 95% | p | |
| BMI | 1.52 | 1.02-2.52 | 0.038 | 1.30 | 0.98-1.73 | 0.060 | 1.96 | 1.24-3.11 | 0.004 | 2.77 | 2.06-3.72 | 0.000 |
| BMI∗ | 1.35 | 0.89-2.04 | 0.150 | 1.27 | 0.96-1.69 | 0.094 | 1.93 | 1.21-3.08 | 0.006 | 2.83 | 2.11-3.81 | 0.000 |
| WHR | 1.25 | 0.84-1.84 | 0.258 | 1.14 | 0.77-1.68 | 0.528 | 1.42 | 1.03-1.96 | 0.030 | 0.95 | 0.67-1.35 | 0.788 |
| WHR∗ | 1.12 | 0.75-1.69 | 0.557 | 1.02 | 0.77-1.68 | 0.921 | 1.40 | 1.01-1.94 | 0.040 | 0.93 | 0.65-1.32 | 0.687 |
| WCL (cm) | 1.60 | 1.12-2.28 | 0.009 | 1.84 | 1.39-2.24 | 0.001 | 2.03 | 1.34-3.09 | 0.001 | 1.94 | 1.50-2.52 | 0.000 |
| WCL (cm)∗ | 1.44 | 1.00-2.08 | 0.048 | 1.75 | 1.31-2.32 | 0.001 | 2.01 | 1.31-3.07 | 0.001 | 1.88 | 1.44-2.45 | 0.000 |
| WCOK (cm) | 1.68 | 1.19-2.37 | 0.003 | 1.75 | 1.24-2,47 | 0.001 | 2.20 | 1.59-3.05 | 0.000 | 1.95 | 1.50-2.55 | 0.000 |
| WCOK(cm)∗ | 1.53 | 1.11-2.26 | 0.010 | 1.66 | 1.16-2.37 | 0.005 | 2.10 | 1.51-2.93 | 0.000 | 1.93 | 1.47-2.52 | 0.000 |
| W/ht | 1.84 | 1.22-2.75 | 0.004 | 1.51 | 1.09-2.23 | 0.041 | 2.07 | 1.43-2.99 | 0.000 | 2.16 | 1.56-2.99 | 0.000 |
| W/ht ∗ | 1.62 | 1.08-2.47 | 0.020 | 1.45 | 0.94-2.09 | 0.098 | 2.06 | 1.42-2.99 | 0.000 | 2.05 | 1.48-2.85 | 0.000 |
OR = odds ratio; ∗ additionally adjusted for the occurrence of diabetes.
Table 4 shows the odds ratio (OR) for hypertension according to anthropometric indexes, adjusted for age, education, race, smoking, and regular physical activity. For the elderly of Barbados, the final design (additionally adjusted for diabetes) shows that, in men, indexes WCOK and W/Ht were associated with hypertension, and in women, associated indexes were WCL and WCOK. W/ht values higher than 0.50 (for men) resulted in an increase of 61% (OR = 1.61) in the risk of developing hypertension; in comparison, WCL values equal or higher than 88 cm in women resulted in an increase of 76% (OR = 1.77) probability for arterial hypertension. The probability of having hypertension was 2.8 times greater among Cuban women with a BMI = 28, compared to women with BMI < 28. For Cuban men, indexes BMI, WCL, WCOK, and W/ht were associated similarly to arterial hypertension.
Table 4.
Odds Ratio (OR) for hypertension according to anthropometric indexes adjusted for age, education, race, smoking and physical activity. SABE, Bridgetown (Barbados), Havana (Cuba), 2000
| Bridgetown/Barbados | Havana/Cuba | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | Men CI 95% | p | OR | Women CI 95% | p | OR | Men CI 95% | p | OR | Women CI 95% | p | |
| BMI | 1.51 | 1.01-2.31 | 0.042 | 1.31 | 0.99-1.74 | 0.054 | 1.89 | 1.19-3.00 | 0.007 | 2.75 | 2.04-3.70 | 0.001 |
| BMI∗ | 1.34 | 0.88-2.10 | 0.161 | 1.28 | 0.96-1.71 | 0.083 | 1.86 | 1.16-2.98 | 0.010 | 2.83 | 2.09-3.82 | 0.001 |
| WHR | 1.02 | 0.98-2.03 | 0.251 | 1.12 | 0.76-1.66 | 0.551 | 1.40 | 1.02-1.94 | 0.040 | 0.97 | 0.68-1.38 | 0.885 |
| WHR∗ | 1.14 | 0.76-1.89 | 0.523 | 1.02 | 0.68-1.51 | 0.933 | 1.38 | 1.00-1.91 | 0.052 | 0.95 | 0.67-1.35 | 0.775 |
| WCL (cm) | 1.56 | 1.08-2.82 | 0.016 | 1.85 | 1.39-2.45 | 0.001 | 1.98 | 1.30-3.02 | 0.002 | 1.88 | 1.44-2.45 | 0.001 |
| WCL (cm)∗ | 1.41 | 0.98-2.59 | 0.063 | 1.76 | 1.32-2.34 | 0.001 | 1.96 | 1.28-3.00 | 0.002 | 1.84 | 1.41-2.40 | 0.001 |
| WCOK (cm) | 1.71 | 1.12-2.37 | 0.002 | 1.81 | 1.28-2.56 | 0.001 | 2.15 | 1.54-3.00 | 0.001 | 1.91 | 1.46-2.50 | 0.001 |
| WCOK(cm)∗ | 1.60 | 1.21-2.21 | 0.010 | 1.72 | 1.20-2.46 | 0.003 | 2.06 | 1.47-2.88 | 0.001 | 1.90 | 1.45-2.49 | 0.001 |
| W/ht | 1.84 | 1.22-2.88 | 0.003 | 1.62 | 1.09-2.39 | 0.041 | 2.01 | 1.38-2.93 | 0.001 | 2.05 | 1.47-2.85 | 0.001 |
| W/ht ∗ | 1.62 | 1.08-2.47 | 0.020 | 1.40 | 0.94-2.09 | 0.098 | 2.01 | 1.38-2.95 | 0.001 | 1.97 | 1.41-2.74 | 0.001 |
OR = odds ratio; ∗ additionally adjusted for the occurrence of diabetes
Discussion
To our knowledge, this is the first population-household-based study that examined Cuban and Barbadian elderly to investigate the association between various anthropometric indexes of obesity with hypertension. The information was collected by trained personnel, using a questionnaire and standardized instruments. The large representative sample of individuals aged 60 years and older strengthened the delineation of the analyses and suggests that these findings could be extrapolated to the overall elderly population of Bridgetown and Havana.
Results have shown that the prevalence of obesity varied depending on the anthropometric index used. In the Cuban elderly (both genders) and in the Barbadian women, the frequency of total obesity (BMI = 28) was lower than what was obtained by central adiposity indexes. In men and women from both cities, respectively W/ht and WHR were the indexes showing the highest prevalence of central adiposity. These data suggest a difference in the obesity indexes' diagnostic capability when used to evaluate men and women.
Various cut-off points have been proposed for different populations and age groups (3, 17, 19, 20). Cut-off points for WCOK were proposed specifically for the Barbadian elderly (3) and the results of this present study show that they can also be applied in Cubans, in the association with hypertension. In this study, WCOK had a smaller strength of association than WCL, for Barbadian women, noticing that cut-off points for WCOK are lower and higher, respectively for men and women, than for WCL.
Several factors may also influence the development of hypertension in obese individuals: activation of the sympathetic nervous system and the renin-angiotensin–aldosterone system; endothelial dysfunction and renal functional abnormalities (21). Studies with different populations and age groups appear to indicate that, independently from the anthropometric index used, excess body fat is one of the main risk factors associated with hypertension, as well as central adiposity, which is considered an additional predictor for the occurrence of the disorder (4, 6, 9, 11).
These results indicate that the associations of anthropometric indexes with hypertension differed between men and women and between Barbadians and Cubans. Results have also shown that the addition of education and race to the design only modified the association between BMI and hypertension for Barbadian women, whilst the variables smoking and physical activity did not alter the associations. Differences in hypertension prevalence in black and non-black individuals have been explained by genetic differences (22) and historical, cultural, and socioeconomic factors, which in turn may influence lifestyle and access to health care (23). Although there are differences in the proportion of blacks and non-blacks, and in the politic and economic systems between the two countries, which can have consequences in lifestyle, social environment (including educational and economical opportunities, as well as work conditions) and access to health care, such factors did not affect the associations of this study.
Diabetes is an extremely common co-morbidity of hypertension and its inclusion as a variable in the regression designs did not prevent the anthropometric indexes from significantly associating with the outcome variable, although the strength of association was diminished. An exception occurred in Barbadian men, concerning BMI and WCL. In the final design, additionally adjusted for diabetes, hypertension was only associated, in Barbados, with WCOK and W/ht in men and with WCL and WCOK in women. For male and female Cubans, indexes BMI, WCL, WCOK, and W/ht were associated with hypertension.
In older population, few studies have compared the anthropometric indexes with hypertension and the findings are not consistent. In a cross-sectional study made with Polish subjects (= 70 years), the importance of obesity (BMI = 30 kg/m2) in hypertension was noticed to be partially dependent on gender, and turned out to be essential for women, but not for men (24). The study carried out by Redón et al. (6), involving 6262 Spanish individuals (60 years and older), showed a strong influence of BMI and WC (= 88cm for women or = 102 cm for men) in the prevalence of hypertension.
It is worth remembering that it has been reported that frequently used anthropometric indexes in epidemiological studies (BMI, WC, WHR and W/ht) measure body fat with different results in different populations (19). Genetic differences in body composition and lifestyles of the individuals (e.g. food ingestion and physical activity pattern), makes a comparison between studies difficult.
One of the possible limitations of this study was the use of self-reported information concerning the occurrence of arterial hypertension. However, this type of information is considered valid for estimating the prevalence of hypertension in the population (25) and makes it possible to identify those who have been diagnosed some time in their lives, albeit omits those who are unaware of having hypertension. Another limiting aspect is related with the cross-sectional delineation, which does not allow a cause-and-effect relation between obesity and hypertension to be established.
In summary, an independent and direct relationship of obesity and central adiposity with hypertension has been observed in the elderly of Bridgetown and Havana. However, the explanatory power of anthropometric indexes for determining the outcome differed between Barbadians and Cubans. For the elderly of Barbados, both WCL and W/ht were significantly associated with hypertension; whilst for men the impact of W/ht over hypertension was greater, WC was the best index for women. Among Cubans (men and women), indexes BMI, WCL, WCOK and W/ht had the highest level of association with hypertension, and BMI and WCOK (for women and men, respectively) were the indexes with the highest impact.
The results presented here show the importance of measuring central adiposity indexes in elderly individuals. Such measurements could initially be used as a screening tool and may contribute to a timely identification of hypertension. Healthy lifestyle strategies, such as increasing the amount of physical activity and eating healthily, should be stimulated and encouraged, as both strategies can help reduce obesity and central adiposity.
Acknowledgment: The SABE Survey in Barbados was funded by the Caribbean Development Bank, the Pan American Health Organization, the Chronic Disease Research Centre Appeal Fund, and the Caribbean Health Research Council. In Cuba it was partially funded by the Population Center of the National Institute of Statistics and the Ministry of Health. The authors also wish to acknowledge the elderly people who participated in the SABE survey.
Financial disclosure: None of the authors had any financial interest or support for this paper.
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