Management of Noncommunicable Disease Risk Factors among Venezuelans Affected by the Humanitarian Crisis.

다국어 초록 (Multilingual Abstract)

Humanitarian crises are increasingly longer in duration and more common. At the end of 2020, over 55 million people were internally displaced worldwide: 48 million due to conflict and violence and 7 million due to natural disasters. Globally, people affected by humanitarian crises are especially vulnerable to exacerbated chronic health conditions due to disrupted health services, irregular medication access, and unpredictable food supplies. As such, humanitarian aid and global health actors have become increasingly concerned with the management of noncommunicable diseases (NCDs) in these widespread and prolonged crises. Venezuela is a unique case as its nutritional context has changed dramatically in the past 10 years due to political turmoil and massive inflation. Prior to the crisis, the burden of cardiometabolic diseases including type 2 diabetes (T2D), hypertension, and obesity were documented to be increasing over time, particularly in urban areas. Over the past few years, however, the NCD burden has been especially hard to quantify, as the Venezuelan government has stopped publishing national statistics since 2016. To better understand the prevalence of cardiometabolic diseases on a national scale, a group of Venezuelan researchers conducted the first nationally representative survey of health called EVESCAM (Estudio Venezolano de Salud Cardio-Metabolica) from 2014-2017 and conducted a follow-up study in 2018-2020. My dissertation uses EVESCAM data to document the management of cardiometabolic diseases among Venezuelans affected by the humanitarian crisis who were not displaced. It also seeks to understand how modifiable risk factors may play a role in management and prevention, to inform future research, interventions, and policy in fragile contexts. Paper One describes the dietary intake of Venezuelans using baseline EVESCAM measurements (2014-2017). My co-authors and I conducted a survey-weighted, nationally representative analysis of dietary, sociodemographic, and clinical data from Venezuelans ≥20 years of age (n=3,402) to understand the prevalence of risk factors for cardiometabolic diseases in this population. Despite a high prevalence of cardiometabolic diseases, adults in Venezuela had not experienced a nutrition transition as observed elsewhere in Latin America. Dietary diversity was low and traditional foods (e.g., arepas and cheese) were still widely consumed, whereas Western foods (e.g., sugar-sweetened beverages) were consumed infrequently.Paper Two compares multimorbidity patterns in Venezuela with Mexico and US Hispanics using three nationally representative datasets: baseline EVESCAM (2014-2017), the 2016 Mexican National Health and Nutrition Survey (ENSANUT), and Hispanics in the 2015-2016 and 2017-2018 U.S. National Health and Nutrition Examination Surveys (NHANES). To compare multimorbidity between these three settings, we conducted logistic regression to understand the role of sociobehavioral factors in odds of multimorbidity and visualized patterns of multimorbidity using the prevalence of the most common two- or three-disease combinations in each country. We found that even during a humanitarian crisis, multimorbidity prevalence among Venezuelans in EVESCAM was lower than that of Hispanics in the US NHANES sample. Paper Three examines changes in diabetes management during the crisis in Venezuela. We first documented the status of type-2 diabetes management in baseline EVESCAM (2014-2017) using the continuum of care framework. We then assessed changes in health system performance over time, from 2014-2017 to 2018-2020. Finally, the association between sociodemographic characteristics and care continuum stage was quantified. Care continua included up to six stages: all diabetes; diagnosed; treated; achieved glycaemic control; achieved blood pressure, cholesterol, and glycaemic control; and achieved aforementioned control plus non-smoking. This study was among the first longitudinal continuum of care analyses for diabetes and documented that while treatment rates declined substantially in Venezuela, management of diabetes was not as severely impacted as expected among individuals in EVESCAM during this humanitarian crisis. Together, these three papers show a variety of quantitative methods to describe and document the state of NCD care in Venezuela, providing important lessons on how NCD management fared in a unique but generalizable crisis setting. Chapter Five highlights the strengths and limitations of this dissertation, as well as the implications of this work and directions for future research.