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Background: The global economic burden ofDiabetes mellitus(DM) is expected to reach US$ 745 billion in 2030. The growing prevalence of the disease, mainly type 2 diabetes, is the result of population aging, nutritional transition, which include growing rates of obesity and consumption of foods high in sugar and fat. Brazil is the fourth country in the number of patients with diabetes globally and follows the global trends, with a continuous increase in prevalence. Objectives: To estimate the economic burden of DM in Brazil, including all direct and indirect costs. Methods: We used a cost-of-illness approach to calculate the total economic burden of DM. We used official healthcare-related statistics referring to 2016. Findings: We estimated the Brazilian economic burden to reach US$ 2.15 billion in 2016, of which 70.6% are indirect costs related to premature deaths, absenteeism, and early retirement. We estimate that if the rate of growth of diabetes prevalence remains in Brazil, direct and indirect costs of diabetes will more than double by 2030 (an increase of 133.4% or 6.2% per year). Conclusion: Our results are in accordance with the literature that shows that indirect costs are more relevant in low- and middle-income countries due to poorer access to health care, which result in higher mortality rates from non-communicable diseases. However, due to the potentially underestimated prevalence of diabetes in Brazil and the lack of access to nationwide private healthcare costs, we estimate costs of diabetes in Brazil to be higher than the conservative results we found. The onset of the COVID-19 pandemic is likely to result in even greater costs than what we estimated.

“Placebo tests” are normally used to support evidence of pollution impacts on health outcomes. In this study, we argue that one should be cautious to proceed with falsification tests. We examine how a large metropolitan area in Brazil copes with increased health-care demand due to high air pollution under hospital capacity constraints. Using wind as an instrument, we find that the pollution exposure increases pediatric hospitalization for respiratory diseases while the number of planned procedures decreases in public hospitals. On average, for every four additional pollution-related admissions, one elective care procedure is displaced. Urgent procedures are not displaced.

The global economic burden of (DM) is expected to reach US$ 745 billion in 2030. The growing prevalence of the disease, mainly type 2 diabetes, is the result of population aging, nutritional transition, which include growing rates of obesity and consumption of foods high in sugar and fat. Brazil is the fourth country in the number of patients with diabetes globally and follows the global trends, with a continuous increase in prevalence. To estimate the economic burden of DM in Brazil, including all direct and indirect costs. We used a cost-of-illness approach to calculate the total economic burden of DM. We used official healthcare-related statistics referring to 2016. We estimated the Brazilian economic burden to reach US$ 2.15 billion in 2016, of which 70.6% are indirect costs related to premature deaths, absenteeism, and early retirement. We estimate that if the rate of growth of diabetes prevalence remains in Brazil, direct and indirect costs of diabetes will more than double by 2030 (an increase of 133.4% or 6.2% per year). Our results are in accordance with the literature that shows that indirect costs are more relevant in low- and middle-income countries due to poorer access to health care, which result in higher mortality rates from non-communicable diseases. However, due to the potentially underestimated prevalence of diabetes in Brazil and the lack of access to nationwide private healthcare costs, we estimate costs of diabetes in Brazil to be higher than the conservative results we found. The onset of the COVID-19 pandemic is likely to result in even greater costs than what we estimated.

When examining the impacts of exposure to air pollution on health outcomes, researchers usually carry out \"placebo tests\" to provide evidence in support of their identification assumption. In general, this exercise targets health conditions seemingly unrelated to air pollution. In this study, we argue that one should proceed with caution when running such falsification tests. If healthcare infrastructure is limited, when we observe health shocks such as those driven by air pollution, the infrastructure needs to be adjusted to meet the increased demand by canceling or rescheduling elective and non-urgent procedures, for example. As a result, even health conditions seemingly unrelated to air pollution may be indirectly affected by pollution.

When a health shock hits a location, the healthcare infrastructure needs to be adjusted to meet the increased demand. This may be a challenge in developing countries because of limited hospital capacity. In this study, we examine the consequences of health shocks induced by air pollution in a megacity in the developing world: Sao Paulo, Brazil. Using daily data from 2015-2017, and an instrumental variable approach based on wind speed, we provide evidence that exposure to particulate matter (PM10) causes an increase in pediatric hospitalizations for respiratory diseases, which in turn leads to a decrease in hospital admissions for elective care – phimosis surgery and epilepsy-related procedures such as video-EEG (electroencephalograph) monitoring. Importantly, emergency procedures such as appendectomy and bone fracture repair are not affected. While strained Sao Paulo hospitals seem to absorb the increased demand induced by poor air quality, our results imply that the common practice of using health outcomes unrelated to pollution as \"placebo tests\" in studies on the effects of air pollution might be inadequate in settings with limited healthcare infrastructure. This is often the case in developing countries, where severe pollution is also ubiquitous, but also happens in deprived areas in the developed world.

Background: Global economic burden of Diabetes mellitus will reach US$ 745 billion in 2030. The growing prevalence of the disease, mainly type 2, is related to the population aging, nutritional transition, and economic growth. Brazil is the fourth country in number of patients with diabetes and also follows the global trends, with continuous increase in prevalence. In this sense, a complete assessment of the economic burden of the disease in the country, considering all direct and indirect costs, is needed. Methods: We use a cost-of-illness approach to calculate total economic burden of DM. We use recent and complete data referring to 2016. Findings: We estimate the Brazilian economic burden of US$ 2.15 billion in 2016, of which 70.6% is indirect costs related to premature deaths, absenteeism, and early retirement. Interpretation: Our results are in accordance with the literature, that shows that indirect costs are more relevant to low- and middle-income countries due to weak health services and therefore higher mortality rates from chronic diseases. Funding: This study was supported by Bloomberg Philanthropies through a sub-award agreement 5104695 between the University of North Carolina at Chapel Hill and Center for Epidemiological Studies in Nutrition and Health.

When a health shock hits a location, the healthcare infrastructure needs to be adjusted to meet the increased demand. is may be a challenge in developing countries because of limited hospital capacity. In this study, we examine the consequences of health shocks induced by air pollution in a megacity in the developing world: São Paulo, Brazil. Using daily data from 2015-2017, and an instrumental variable approach based on wind speed, we provide evidence that exposure to particulate matter (PM10) causes an increase in pediatric hospitalizations for respiratory diseases, which in turn leads to a decrease in hospital admissions for elective care – phimosis surgery and epilepsy-related procedures such as video-EEG (electroencephalograph) monitoring. Importantly, emergency procedures such as appendectomy and bone fracture repair are not affected. While strained Sao Paulo hospitals seem to absorb the increased demand induced by poor air quality, our results imply that the common practice of using health outcomes unrelated to pollution as “placebo tests'' in studies on the effects of air pollution might be inadequate in settings with limited healthcare infrastructure. This is often the case in developing countries, where severe pollution is also ubiquitous, but also happens in deprived areas in the developed world.