Department of Medicine, Division of Endocrinology, University of Toronto, Toronto, ON, Canada; Leadership Sinai Centre for Diabetes and Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.
Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Department of Internal Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
Lancet. 2022 Dec 10;400(10368):2074-2083. doi: 10.1016/S0140-6736(22)00625-0.
Indigenous Brazilian peoples have faced an unparalleled increase in the rate of cardiovascular diseases following rapid nutritional transition to more urban diets. We aimed to conduct a systematic review and meta-analysis to evaluate the association between urbanisation (including data from Amazon rainforest deforestation) and cardiometabolic risk factors and outcomes.
In this systematic review and meta-analysis, we searched Pubmed, Embase, Web of Science, and Scopus for articles published in any language between the year 1950 and March 10, 2022. Studies conducted in Indigenous Brazilian adults that evaluated metabolic health were included. Data for deforestation was obtained by the Amazon Deforestation Monitoring Project. Cardiovascular mortality was obtained from the Brazilian Health registry. Two independent reviewers evaluated studies for risk of bias, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. The main outcomes assessed were the prevalence of obesity and related cardiometabolic risk factors among Indigenous Brazilian peoples and its association with urbanisation. Summary data were extracted from published reports for the meta-analyses. We calculated pooled estimates of the prevalence of each cardiometabolic outcome by using a random-effects model (DerSimonian-Laird method). This study is registered with the International Prospective Register of Systematic Reviews, CRD42021285480.
46 studies were identified, including a total of 20 574 adults from at least 33 Indigenous Brazilian ethnicities. Meta-analyses of the prevalence of obesity showed that there were higher rates of obesity (midwest region: 23% [95% CI 17-29]; and south region 23% [13-34]) and hypertension (south region: 30% [10-50]) in Indigenous peoples living in urban regions of Brazil, while the lowest rates of obesity (11% [95% CI 8-15]) and hypertension (1% [1-2]) were observed in those in the less urbanised (north) regions of Brazil. The prevalence of obesity was 3·5 times higher in participants living in urbanised Indigenous territories (28%) than in those living in lands with >80% native Amazon rainforest (8%). In meta-analyses that evaluated blood pressure level, there was no incremental change in blood pressure with ageing in Indigenous peoples who lived according to traditional lifestyle, in contrast to those living in urbanised regions. For Indigenous men with traditional lifestyles, systolic blood pressure changed from 109·8 mm Hg to 104·4 mm Hg between the youngest (<30 years) and the oldest (>60 years) age groups, and diastolic blood pressure changed from 69·8 mm Hg to 66·1 mm Hg. For Indigenous women with traditional lifestyles, systolic blood pressure was 100·0 mm Hg for the youngest age group with no changes for older age groups, and diastolic blood pressure was 62 mm Hg for the youngest age group with no changes for older age groups. For Indigenous men with urbanised lifestyles, systolic blood pressure changed from 117·3 mm Hg to 124·9 mm Hg between the youngest and the oldest age groups, and diastolic blood pressure changed from 72·7 mm Hg to 76·4 mm Hg. For Indigenous women with urbanised lifestyles, systolic blood pressure changed from 110·0 mm Hg to 116·0 mm Hg between the youngest and the oldest age groups, and diastolic blood pressure changed from 68·3 mm Hg to 74·0 mm Hg. For the years 1997 and 2019, the cardiovascular mortality rate in individuals living in the southeast region (the most urbanised) was 2·5 times greater than that observed in the north. Conversely, the incremental rise in cardiovascular mortality in the past two decades among Indigenous Brazilians living in the north or northeast (2·7 times increase) stands in stark contrast to the stable rates in those living in already urbanised regions.
The macrosocial changes of Indigenous peoples' traditional ways of living consequent to urbanisation are associated with an increased prevalence of adverse cardiometabolic outcomes. These data highlight the urgent need for environmental policies to ensure the conservation of the natural ecosystem within Indigenous territories, as well as the development of socio-health policies to improve the cardiovascular health of Indigenous Brazilians peoples living in urban areas.
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在经历了向更城市化的饮食快速转变后，巴西本土人民的心血管疾病发病率呈前所未有的上升趋势。本研究旨在进行系统评价和荟萃分析，以评估城市化（包括亚马逊雨林砍伐的数据）与心血管代谢风险因素和结果之间的关系。
在这项系统评价和荟萃分析中，我们检索了 Pubmed、Embase、Web of Science 和 Scopus，以获取 1950 年至 2022 年 3 月 10 日发表的任何语言的文章。纳入了评估代谢健康的巴西本土成年人的研究。通过亚马逊砍伐监测项目获取森林砍伐数据。巴西健康登记处获取心血管死亡率数据。两名独立评审员根据系统评价和荟萃分析的首选报告项目建议评估研究的偏倚风险。主要评估结果是巴西本土人民中肥胖和相关心血管代谢风险因素的流行率，及其与城市化的关系。从已发表的报告中提取荟萃分析的数据。我们使用随机效应模型（DerSimonian-Laird 方法）计算每个心血管代谢结局的患病率汇总估计值。本研究在国际前瞻性注册系统评价中注册，注册号为 CRD42021285480。
确定了 46 项研究，包括至少 33 个巴西本土民族的 20574 名成年人。荟萃分析显示，与生活在巴西城市化程度较低的北部地区（肥胖率 11%[95%CI 8-15%]和高血压率 1%[1-2%]）相比，生活在巴西城市化程度较高的中西部（肥胖率 23%[17-29%]）和南部（肥胖率 23%[13-34%]和高血压率 30%[10-50%]）地区的巴西本土人民肥胖和高血压的患病率更高。生活在城市化的原住民地区的参与者的肥胖患病率（28%）比生活在拥有>80%亚马逊雨林的原住民土地的参与者高 3.5 倍（28%）。在评估血压水平的荟萃分析中，与生活在传统生活方式的土著人民相反，生活在城市化地区的土著人民的血压随年龄的增长没有增加。对于生活方式传统的土著男性，收缩压从<30 岁的 109.8mmHg 降至>60 岁的 104.4mmHg，舒张压从 69.8mmHg 降至 66.1mmHg。对于生活方式传统的土著女性，收缩压为<30 岁的 100.0mmHg，而对于年龄较大的女性没有变化，舒张压为<30 岁的 62mmHg，而对于年龄较大的女性没有变化。对于生活方式城市化的土著男性，收缩压从<30 岁的 117.3mmHg 上升至>60 岁的 124.9mmHg，舒张压从 72.7mmHg 上升至 76.4mmHg。对于生活方式城市化的土著女性，收缩压从<30 岁的 110.0mmHg 上升至>60 岁的 116.0mmHg，舒张压从 68.3mmHg 上升至 74.0mmHg。1997 年和 2019 年，生活在东南部（最城市化）地区的个体的心血管死亡率是生活在北部地区的个体的 2.5 倍。相反，过去二十年巴西本土居民的心血管死亡率在北部或东北部（增加 2.7 倍）的急剧上升与已经城市化地区的稳定率形成鲜明对比。
城市化导致巴西本土人民传统生活方式的宏观社会变化与不良心血管代谢结局的患病率增加有关。这些数据突出表明，迫切需要制定环境政策，以确保保护原住民地区的自然生态系统，以及制定社会健康政策，以改善生活在城市地区的巴西本土人民的心血管健康。
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