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[EXTRACTO]. el presente número especial de la Revista Panamericana de Salud Pública aporta datos relevantes y actuali- zados de la Región de las Américas, abriendo camino por una senda en la que aún queda mucho trabajo por hacer para mejo- rar las medidas de control del tabaco. Además, las múltiples iniciativas de investigación descritas en este número demues- tran la enorme capacidad y colaboración presentes en la Región. Este número especial ha sido posible gracias a la cooperación de investigadores, organizaciones nacionales e internacionales, organismos intergubernamentales, puntos focales de control del tabaco en los ministerios de salud y diferentes especialistas en el control del tabaco que colaboran de forma continua para lograr los objetivos de salud.

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[EXTRACT]. This special issue applies this lens, bringing an equity focus to tobacco control measures, with particular attention paid to vulnerable groups (e.g., youth and low-income quintiles) and including a gender perspective. Further, one analysis empha- sizes the extent of environmental damage posed across the tobacco production chain, including the economic cost of tobacco products waste, and proposes policies to address this.

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This chapter explores the tension between public health protection and the freedom of commercial expression from a Commonwealth Caribbean perspective, using Barbados and Jamaica as case studies. First, it assesses the scope of the right to freedom of expression. Second, it discusses the extent to which public health protection may be invoked to restrict the right. The authors conclude that Commonwealth Caribbean states can justifiably restrict commercial speech about tobacco products and unhealthy food and beverages.

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OBJECTIVE: We examined the frequency of diabetic ketoacidosis (DKA) in cannabis users compared with nonusers in the T1D Exchange clinic registry (T1DX). RESEARCH DESIGN AND METHODS: The association between cannabis use by total substance score for cannabis (TSC) and DKA in the past 12 months was examined using a logistic regression model adjusted for potential confounders among adults in the T1DX. RESULTS: Of 932 adults with type 1 diabetes, 61 had a TSC >4, which classified them as moderate cannabis users. Adjusting for sex, age at study visit, and HbA1c, cannabis use was associated with a twofold increase in risk for DKA among adults with type 1 diabetes (odds ratio 2.5 [95% CI 1.0-5.9]). CONCLUSIONS: Cannabis use was associated with an increased risk for DKA among adults in the T1DX. Providers should inform their patients of the potential risk of DKA with cannabis use.

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[ABSTRACT]. This report examines the experiences of Small Island Developing States in the Caribbean—Barbados, Dominica, Jamaica, and in the Pacific— Fiji, Nauru, and Tonga with specific govern-mental regulatory measures to reduce the risk of obesity and associated diet-related chronic noncommunicable diseases (NCDs), as well as the obstacles and opportunities encountered. Guided by the diet-related indicators of the World Health Organization (WHO) Noncommunicable Diseases Progress Monitor 2017, the authors reviewed legislation, country reports, articles, and the databases of WHO and the World Trade Organization to identify relevant regulatory mea-sures and to establish the extent of implementation in the selected countries. Obesity prevalence ranged from 25.9% in Dominica to 41.1% in Tonga. The principal diet-related measures implemented by the selected countries were fiscal measures, such as sugar-sweetened beverage taxes and import duties to encourage greater consumption of healthy foods. Governmental action was weakest in the area of restrictions on marketing of unhealthy foods. If they are to reduce their current high rates of obesity and associated NCDs, Caribbean and Pacific states need to intensify implementation of diet-related regulatory measures, particularly in the area of marketing of unhealthy foods and beverages to children. Key implementation chal-lenges include financial and staffing constraints and the need for increased political will to counter industry opposition and to allocate adequate financial resources to keep advancing this agenda.

[RESUMEN]. Este es un informe sobre las experiencias de Barbados, Dominica, Jamaica, Fiji, Nauru y Tonga con medidas gubernamentales regulatorias específicas dirigidas a reducir el riesgo de obesidad y enfermedades no transmisibles relacionadas con la dieta y resaltar los obstáculos y oportunidades relacionados con ellas. Guiados por los indicadores relacionados con la dieta establecidos en el Monitoreo de Avances en materia de las Enfermedades no Transmisibles 2017 de la Organización Mundial de la Salud (OMS) se revisó la legislación, los informes de los países, artículos, y las bases de datos de la OMS y la Organización Mundial de Comercio para identificar las medidas regulatorias pertinentes y establecer el alcance de su implementación en los países seleccionados. La prevalencia de obesidad osciló entre el 25,9% en Dominica y el 41,1% en Tonga. Las principales medidas relacionadas con la dieta implementadas por los países seleccionados fueron medidas fiscales, como los impuestos a las bebidas azucaradas y los aranceles de importación, para alentar un mayor consumo de alimentos saludables. La acción gubernamental fue más débil en el área de restricciones en el marketing de alimentos poco saludables. Para reducir las actuales altas tasas de obesidad y enfermedades no transmisibles asociadas, los estados del Caribe y del Pacífico deben intensificar la implementación de medidas regulatorias relacionadas con la dieta, en particular en el área del marketing de alimentos y bebidas poco saludables para los niños. Los desafíos clave de la implementación incluyen limitaciones financieras y de personal y la necesidad de una mayor voluntad política para contrarrestar la oposición de la industria y asignar recursos financieros adecuados para seguir avanzando en esta agenda.

[RESUMO]. Este é um relatório sobre as experiências de Barbados, Dominica, Jamaica, Fiji, Nauru e Tonga com medidas específicas reguladoras do governo destinadas a reduzir o risco de obesidade e doenças não transmissíveis associadas (DNTs) relacionados à dieta e destacar os obstáculos e oportunidades que estimulam um maior uso dessas medidas. Guiados pelos indicadores relacionados à dieta estabelecido no Monitoramento de Progresso das Doenças Não Transmissíveis 2017 da Organização Mundial da Saúde (OMS), revisamos a legislação, os relatórios dos países, artigos, e as bases do dados da OMS e da Organização Mundial do Comércio para identificar as medidas reguladoras relevantes, visando reduzir o risco de obesidade e as DNTs associadas, e estabelecer o escopo de sua implementação nos países selecionados. A prevalência de obesidade variou de 25,9% na Dominica a 41,1% em Tonga. As principais medidas relacionadas à dieta implementadas pelos países selecionados foram medidas fiscais, como impostos sobre bebidas açucaradas e tarifas de importação, para incentivar maior consumo de alimentos saudáveis. A ação do governo foi mais fraca na área de restrições à comercialização de alimentos não saudáveis. Para reduzir as atuais altas taxas de obesidade e doenças não transmissíveis associadas, os países do Caribe e do Pacífico devem intensificar a implementação de medidas reguladoras relacionadas à dieta, particularmente na área da comercialização de alimentos e bebidas não saudáveis para crianças. Os principais desafios da implementação incluem restrições financeiras e de pessoal e a necessidade de maior vontade política para combater a oposição da indústria e alocar recursos financeiros adequados para continuar avançando nesta agenda.

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This report examines the experiences of Small Island Developing States in the Caribbean- Barbados, Dominica, Jamaica, and in the Pacific- Fiji, Nauru, and Tonga with specific governmental regulatory measures to reduce the risk of obesity and associated diet-related chronic noncommunicable diseases (NCDs), as well as the obstacles and opportunities encountered. Guided by the diet-related indicators of the World Health Organization (WHO) Noncommunicable Diseases Progress Monitor 2017, the authors reviewed legislation, country reports, articles, and the databases of WHO and the World Trade Organization to identify relevant regulatory measures and to establish the extent of implementation in the selected countries. Obesity prevalence ranged from 25.9% in Dominica to 41.1% in Tonga. The principal diet-related measures implemented by the selected countries were fiscal measures, such as sugar-sweetened beverage taxes and import duties to encourage greater consumption of healthy foods. Governmental action was weakest in the area of restrictions on marketing of unhealthy foods. If they are to reduce their current high rates of obesity and associated NCDs, Caribbean and Pacific states need to intensify implementation of diet-related regulatory measures, particularly in the area of marketing of unhealthy foods and beverages to children. Key implementation challenges include financial and staffing constraints and the need for increased political will to counter industry opposition and to allocate adequate financial resources to keep advancing this agenda.

Este es un informe sobre las experiencias de Barbados, Dominica, Jamaica, Fiji, Nauru y Tonga con medidas gubernamentales regulatorias específicas dirigidas a reducir el riesgo de obesidad y enfermedades no transmisibles relacionadas con la dieta y resaltar los obstáculos y oportunidades relacionados con ellas. Guiados por los indicadores relacionados con la dieta establecidos en el Monitoreo de Avances en materia de las Enfermedades no Transmisibles 2017 de la Organización Mundial de la Salud (OMS) se revisó la legislación, los informes de los países, artículos, y las bases de datos de la OMS y la Organización Mundial de Comercio para identificar las medidas regulatorias pertinentes y establecer el alcance de su implementación en los países seleccionados.La prevalencia de obesidad osciló entre el 25,9% en Dominica y el 41,1% en Tonga. Las principales medidas relacionadas con la dieta implementadas por los países seleccionados fueron medidas fiscales, como los impuestos a las bebidas azucaradas y los aranceles de importación, para alentar un mayor consumo de alimentos saludables. La acción gubernamental fue más débil en el área de restricciones en el marketing de alimentos poco saludables. Para reducir las actuales altas tasas de obesidad y enfermedades no transmisibles asociadas, los estados del Caribe y del Pacífico deben intensificar la implementación de medidas regulatorias relacionadas con la dieta, en particular en el área del marketing de alimentos y bebidas poco saludables para los niños. Los desafíos clave de la implementación incluyen limitaciones financieras y de personal y la necesidad de una mayor voluntad política para contrarrestar la oposición de la industria y asignar recursos financieros adecuados para seguir avanzando en esta agenda.

Este é um relatório sobre as experiências de Barbados, Dominica, Jamaica, Fiji, Nauru e Tonga com medidas específicas reguladoras do governo destinadas a reduzir o risco de obesidade e doenças não transmissíveis associadas (DNTs) relacionados à dieta e destacar os obstáculos e oportunidades que estimulam um maior uso dessas medidas. Guiados pelos indicadores relacionados à dieta estabelecido no Monitoramento de Progresso das Doenças Não Transmissíveis 2017 da Organização Mundial da Saúde (OMS), revisamos a legislação, os relatórios dos países, artigos, e as bases do dados da OMS e da Organização Mundial do Comércio para identificar as medidas reguladoras relevantes, visando reduzir o risco de obesidade e as DNTs associadas, e estabelecer o escopo de sua implementação nos países selecionados.A prevalência de obesidade variou de 25,9% na Dominica a 41,1% em Tonga. As principais medidas relacionadas à dieta implementadas pelos países selecionados foram medidas fiscais, como impostos sobre bebidas açucaradas e tarifas de importação, para incentivar maior consumo de alimentos saudáveis. A ação do governo foi mais fraca na área de restrições à comercialização de alimentos não saudáveis. Para reduzir as atuais altas taxas de obesidade e doenças não transmissíveis associadas, os países do Caribe e do Pacífico devem intensificar a implementação de medidas reguladoras relacionadas à dieta, particularmente na área da comercialização de alimentos e bebidas não saudáveis para crianças. Os principais desafios da implementação incluem restrições financeiras e de pessoal e a necessidade de maior vontade política para combater a oposição da indústria e alocar recursos financeiros adequados para continuar avançando nesta agenda.

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OBJECTIVE: Treatment of severe hypoglycemia with loss of consciousness or seizure outside of the hospital setting is presently limited to intramuscular glucagon requiring reconstitution immediately prior to injection, a process prone to error or omission. A needle-free intranasal glucagon preparation was compared with intramuscular glucagon for treatment of insulin-induced hypoglycemia. RESEARCH DESIGN AND METHODS: At eight clinical centers, a randomized crossover noninferiority trial was conducted involving 75 adults with type 1 diabetes (mean age, 33 ± 12 years; median diabetes duration, 18 years) to compare intranasal (3 mg) versus intramuscular (1 mg) glucagon for treatment of hypoglycemia induced by intravenous insulin. Success was defined as an increase in plasma glucose to ≥70 mg/dL or ≥20 mg/dL from the glucose nadir within 30 min after receiving glucagon. RESULTS: Mean plasma glucose at time of glucagon administration was 48 ± 8 and 49 ± 8 mg/dL at the intranasal and intramuscular visits, respectively. Success criteria were met at all but one intranasal visit and at all intramuscular visits (98.7% vs. 100%; difference 1.3%, upper end of 1-sided 97.5% CI 4.0%). Mean time to success was 16 min for intranasal and 13 min for intramuscular (P < 0.001). Head/facial discomfort was reported during 25% of intranasal and 9% of intramuscular dosing visits; nausea (with or without vomiting) occurred with 35% and 38% of visits, respectively. CONCLUSIONS: Intranasal glucagon was highly effective in treating insulin-induced hypoglycemia in adults with type 1 diabetes. Although the trial was conducted in a controlled setting, the results are applicable to real-world management of severe hypoglycemia, which occurs owing to excessive therapeutic insulin relative to the impaired or absent endogenous glucagon response.

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OBJECTIVE: Diabetic ketoacidosis (DKA) in children and adolescents with established type 1 diabetes is a major problem with considerable morbidity, mortality, and associated costs to patients, families, and health care systems. We analyzed data from three multinational type 1 diabetes registries/audits with similarly advanced, yet differing, health care systems with an aim to identify factors associated with DKA admissions. RESEARCH DESIGN AND METHODS: Data from 49,859 individuals <18 years with type 1 diabetes duration ≥1 year from the Prospective Diabetes Follow-up Registry (DPV) initiative (n = 22,397, Austria and Germany), the National Paediatric Diabetes Audit (NPDA; n = 16,314, England and Wales), and the T1D Exchange (T1DX; n = 11,148, U.S.) were included. DKA was defined as ≥1 hospitalization for hyperglycemia with a pH <7.3 during the prior year. Data were analyzed using multivariable logistic regression models. RESULTS: The frequency of DKA was 5.0% in DPV, 6.4% in NPDA, and 7.1% in T1DX, with differences persisting after demographic adjustment (P < 0.0001). In multivariable analyses, higher odds of DKA were found in females (odds ratio [OR] 1.23, 99% CI 1.10-1.37), ethnic minorities (OR 1.27, 99% CI 1.11-1.44), and HbA1c ≥7.5% (≥58 mmol/mol) (OR 2.54, 99% CI 2.09-3.09 for HbA1c from 7.5 to <9% [58 to <75 mmol/mol] and OR 8.74, 99% CI 7.18-10.63 for HbA1c ≥9.0% [≥75 mmol/mol]). CONCLUSIONS: These multinational data demonstrate high rates of DKA in childhood type 1 diabetes across three registries/audits and five nations. Females, ethnic minorities, and HbA1c above target were all associated with an increased risk of DKA. Targeted DKA prevention programs could result in substantial health care cost reduction and reduced patient morbidity and mortality.

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